Evaluation of 3 methods of bladder irrigation to treat bacteriuria in persons with neurogenic bladder

Abstract

Background/objective: We conducted a randomized, double-blind comparison of twice daily bladder irrigation using 1 of 3 different solutions in community-residing persons with neurogenic bladder who used indwelling catheters to evaluate efficacy in treatment of bacteriuria.

Methods: Eighty-nine persons with bacteriuria were randomized to irrigate their bladders twice daily for 8 weeks with 30 mL of (a) sterile saline, (b) acetic acid, or (c) neomycin-polymyxin solution. Urinalysis, cultures, and antimicrobial susceptibility tests were performed at baseline and weeks 2, 4, and 8 to determine the extent to which each of the solutions affected numbers and types of bacteria, urinary pH, urinary leukocytes, and generation of antimicrobial-resistant organisms.

Results: Bladder irrigation was well tolerated with the exception of 3 participants who had bladder spasms. None of the 3 irrigants had a detectable effect on the degree of bacteriuria or pyuria in 52 persons who completed the study protocol. A significant increase in urinary pH occurred in all 3 groups. No significant development of resistance to oral antimicrobials beyond what was observed at baseline was detected.

Conclusions: Bladder irrigation was generally well tolerated for 8 weeks. No advantages were detected for neomycin-polymyxin or acetic acid over saline in terms of reducing the urinary bacterial load and inflammation. We cannot recommend bladder irrigation as a means of treatment for bacteriuria in persons with neurogenic bladder.

Figure 1. Distribution of bacterial groups isolated in urine cultures from 52 participants before and after completion of 8 weeks of bladder irrigation. There was no difference over time (P ≥ 0.10) for any bacterial group except Enterococcus spp (P = 0.0006).

Figure 2. Occurrence of Enterococcus spp in each bladder irrigation group over time. There was a significant increase in the total numbers of persons harboring these organisms over time (P = 0.005) and within the neo-mycin-polymyxin group (P = 0.02).

Figure 3. Occurrence of MRSA in the 3 bladder irrigation groups stratified across 4 data collection points showing no significant increase over time (P ≥ 0.37).

Figure 4. Occurrence of gram-negative bacilli resistant to ampicillin, ciprofloxacin, trimethoprim-sulfamethoxazole, or cephalosporins in 3 bladder irrigation groups stratified across 4 data collection time-points showing no significant increases over time (P ≥ 0.11).

Figure 5. Occurrence of MDR gram-negative bacilli in 3 bladder irrigation groups stratified across 4 data collection points showing no significant increases over time (P ≥ 0.41).

Figure 6. Median numbers of urinary leukocytes stratified according to bladder irrigation group and data collection points showing persistence of high level pyuria throughout the study. No significant increases were observed in any group (P ≥ 0.6).

Figure 7. Mean urinary pH stratified according to bladder irrigation group and data collection points showing significant changes over the course of the study in all 3 groups (P = 0.01).