Urinary tract infection (UTI) is a common infection in patients with multiple sclerosis (MS) and can be associated with increased morbidity and mortality. A review published in Multiple Sclerosis and Allied Disorders provided a comprehensive overview of the risk factors, prevalence, management, and complications of urinary tract infections in this patient population
MS is the most common neurological disease in young adults, with a prevalence of 1 in 1,000 people in the US.1,2 There is an increased risk of infections, including urinary tract infections, respiratory infections of the skin, and opportunistic infections. The data suggest that infections are the most common comorbidities following a diagnosis of MS, reported in 80% of patients
Approximately 50% to 80% of MS patients report urinary symptoms associated with an increased risk of urinary tract infections, morbidity, and mortality.2-5 In a study of over 15,000 MS patients from the US and UK, the risk urinary or kidney infections was twice as high in people with MS as in people without MS.6 In addition, people with MS may be more likely to develop complications from severe infections as the risk of hospitalization for an infection was also high found to be significantly higher in this group.
The most common bacteria responsible for urinary tract infections in patients with MS were Escherichia coli, group B streptococci, Klebsiella pneumoniae, Proteus mirabilis, and coagulase-negative staphylococci. 1
Multiple sclerosis is associated with an increased risk of developing a neurogenic bladder due to discoordination between the brainstem centers and the sacral parts of the spinal cord.4 Bragadin and colleagues reported a high prevalence of lower urinary tract symptoms in patients with MS, including positioning or emptying symptoms that are associated with an increased risk of urinary tract infections.7
Patients with MS with significant disabilities, especially those who are independent and need assistance with personal activities of daily living, have greater difficulty with maintaining adequate hydration, regular bathing, and perineal hygiene. They are more prone to urinary tract infections due to urinary obstruction, high bladder pressure, bladder stones, and catheters
Morbidity and mortality
It has been suggested to increase the activation of the immune response after infection to increase the risk of MS relapse during a urinary tract infection.1 While there are no studies to assess the specific risk of relapse after a urinary tract infection, the Possibility of increased risk of relapse after urinary tract infection based on other studies suspected types of infection. However, a recent literature search of publications in English and French conducted under the French Multiple Sclerosis Society’s guidelines for clinical practice on Urinary Tract Infections and MS concluded that urinary tract infections were not associated with an increased risk of MS. Relapse or persistent worsening of the disability. On the other hand, febrile UTIs have been found to be associated with an increased risk of temporary worsening of disability in patients with MS.9 A study by Fitzgerald and colleagues showed that UTIs are relatively rare at the time of a suspected MS relapse in both hospitals as well as outpatient Patient population. 10
Urinary tract infection is a leading cause of hospital stays in MS patients and accounts for approximately 30% to 50% of hospital stays in these patients.1 Patients with MS who are hospitalized for UTIs are more likely to be men, the elderly with progressive MS, and significant disability.
In addition, a history of UTI was found to be associated with decreased survival. Data suggest that UTI was the leading cause of death in MS patients, accounting for 8% of deaths in this patient population, compared with just 2% of deaths in the general population. The increase in deaths from urinary tract infections was greater in MS deaths in men than in women, although urinary tract infections had an important impact on deaths from MS in both sexes.11 However, others said this was most likely more likely to be due to the severity of MS than Association 3
Diagnosing a urinary tract infection can be difficult in people with MS. While the infection may be associated with clinical symptoms such as fever, urgency, increased frequency, incontinence, and hematuria, MS patients do not necessarily have the classic symptoms described in the general population.1 In addition, the urgency, frequency modification, and incontinence of MS dysfunction can occur and be present in patients with MS who do not have an infection.
The gold standard for UTI diagnosis is the urine culture of specimens obtained from either a clean-catch midstream sample, an indwelling urethral catheter, or a suprapubic aspiration from a suprapubic catheter.1 In addition, the Acute Cystitis Symptom Score, a validated self-report The questionnaire for diagnosing acute cystitis in women is a sensitive and specific tool for distinguishing urinary tract infections from other urogenital diseases. 12
- Asymptomatic bacteriuria – Studies have shown no clinical efficacy in pharmacological treatment of inpatients with asymptomatic bacteriuria with MS. Treatment of asymptomatic bacteriuria can induce resistant strains of bacteria. Therefore, it is exceptionally considered for patients with recurrent acute urinary tract infections prior to treatment for urinary tract infection, pregnancy or immunosuppression
- Symptomatic Urinary Tract Infection – Broad spectrum antibiotics are recommended for patients with MS who have been diagnosed with urinary tract infection based on local patterns of microbial susceptibility, and can be adjusted later based on urinary culture result.13 Patients with relapsed MS should receive corticosteroid therapy may not be canceled got UTI.1
- Urinary tract infection prophylaxis – Prophylactic antibiotics, urinary irrigation, and cranberry extract have not been effective in preventing urinary tract infections in patients with MS.1 Additional studies are needed to provide data on the effectiveness of probiotics. In patients with neurogenic bladder, the choice of catheter type and pharmacological treatment of the neurogenic bladder with oxybutynin, tolterodine, trospium, or propiverine may reduce the risk of urinary tract infections.13 In refractory cases, injection of botulinum toxin into the detrusor muscle may be considered.
While the risk of urinary tract infection during treatment for MS has not been specifically studied, there are several studies that suggest that drugs used to treat MS may have an impact on the risk of urinary tract infections. A 2016 study by Wilkenmann and colleagues reported that long-term treatment with interferons or glatiramer acetate posed a low risk of infection, while natalizumab, dimethyl fumarate, and fingolimod were associated with an increased risk of opportunistic infections, including urinary tract infections. 14 data showed this risk for serious infections in patients with MS treated with rituximab was higher compared to natalizumab and fingolimod, and this remained significant compared to patients treated with interferon beta and glatiramer acetate.15
Awareness of urinary tract infections in MS patients is critical for early diagnosis, treatment and infection prophylaxis in this population. “Urinary tract infections are a major risk and problem in MS patients. The high prevalence, hospitalization and mortality rates of urinary tract infections in MS are of concern, such as the cause-consequence relationship between urinary tract infections and corticosteroid use in outbreaks,” said Medeiros Junior et al.1 “Therefore, further studies are needed to thoroughly analyze every nuance of this important comorbidity [patients with] MS. “1
1. Medeiros Junior WLG, Demore CC, Mazaro LP et al. Urinary Tract Infection in Patients with Multiple Sclerosis: An Overview. Mult Scler Relat Disord. 2020; 46: 102462. doi: 10.1016 / j.msard.2020.102462
2. Nicholas R, Young C, Friede T. Bladder symptoms in multiple sclerosis: a review of the pathophysiology and management. Expert opinion Drug Saf. 2010; 9 (6): 905- 915. doi: 10.1517 / 14740338.2010.501793
3. Jick SS, Li L, Falcone GJ, Vassilev ZP, Wallander MA. Multiple sclerosis epidemiology: results of a large observational study in the UK. J Neurol. 2015; 262 (9): 2033- 2041. doi: 10.1007 / s00415-015-7796-2
4. Fowler CJ, Panicker JN, Drake M et al. A British consensus on the treatment of the bladder for multiple sclerosis. Postgrad Med J. 2009; 85 (1008): 470-6. 477. doi: 10.1136 / jnnp.2008.159178
5. Nikseresht A, Salehi H, Foroughi AA, Nazeri M. Association between urinary symptoms and urinary tract infection in patients with multiple sclerosis. Glob J Health Sci. 2016; 8 (4): 253- 259. doi: 10.5539 / gjhs.v8n4p253
6. Persson R., Lee S., Yood MU, et al. Infections in Patients Diagnosed with Multiple Sclerosis: A Multi-Database Study. Mult Scler Relat Disord. 2020; 41: 101982. doi: 10.1016 / j.msard.2020.101982
7. Bragadin MM, Motta R, Uccelli MM, et al. Lower urinary tract dysfunction in patients with multiple sclerosis: a residual analysis after voiding 501 cases. Mult Scler Relat Disord. 2020; 45: 102378. doi: 10.1016 / j.msard.2020.102378
8. Li V., Barker N, Curtis C et al. Prevention and treatment of hospitalization for urinary tract infections in patients with multiple sclerosis. Mult Scler Relat Disord. 2020; 45: 102432. doi: 10.1016 / j.msard.2020.102432
9. Donzé C, Papeix C, Lebrun-Frenay C. Urinary Tract Infections and Multiple Sclerosis: Recommendations from the French Society for Multiple Sclerosis. Rev. Neurol (Paris). 2020; 176 (10): 804- 822. doi: 10.1016 / j.neurol.2020.02.011
10. Fitzgerald KC, Cassard LA, Fox SR, Probasco JC, Cassard SD, Mowry EM. The prevalence and usefulness of screening for urinary tract infections at the time of suspected relapse in multiple sclerosis. Mult Scler Relat Disord. 2019; 35: 61- 66. doi: 10.1016 / j.msard.2019.06.038
11. Harding K, Zhu F, Alotaibi M, Duggan T, Tremlett H, Kingwell E. Analysis of the Multiple Cause of Death in Multiple Sclerosis: A Population-Based Study. Neurology. 202094 (8): e820-e829. doi: 10.1212 / WNL.0000000000008907
12. Alidjanov JF, Naber KG, Abdufattaev UA, Pilatz A, Wagenlehner FME. Reassessment of Symptom Score for Acute Cystitis, a Self-Reported Questionnaire. Part I. Development, diagnosis and differential diagnosis. Antibiotics. 2018; 7 (1): 6. doi: 10.3390 / antibiotics7010006
13. European Association for Urology. Urological infections. https://uroweb.org/guideline/urological-infections/. Accessed February 20, 2020.
14. Winkelmann A, Löbermann M, Reisinger EC, Hartung HP, Zettl UK. Disease-modifying therapies and infection risks in multiple sclerosis. Nat Rev Neurol. 2016; 12 (4): 217- 233. doi: 10.1038 / nrneurol.2016.21
15. Luna G., Alping P., Burman J., et al. Risks of infection in patients with multiple sclerosis treated with fingolimod, natalizumab, rituximab, and injectable therapies. JAMA Neurol. 2020; 77 (2): 184-1. 191. doi: 10.1001 / jamaneurol.2019.3365