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Bacteriuria in Chronically Paralyzed Dogs

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In today’s VETgirl online veterinary CE podcast, we review bacteriuria in dogs with chronic paralysis. Unfortunately, the majority of small animal clinicians have dealt with their fair share of the dachshund or other poor pup presenting with paraplegia secondary to intervertebral disk disease (IVDD) or other diseases. In the midst of the numerous difficult conversations that such cases require, the risk of future urinary tract infections (UTIs) is likely not the first thing to come to mind. Yet in humans, UTIs and sepsis are a serious concern with paralysis. In dogs with chronic paralysis, how do we handle the urinalysis with bacteriuria? It can be difficult to determine the clinical implications of such a finding, yet in the age of antimicrobial stewardship, many clinicians are seeking guidance on when to treat such a patient with antibiotics. Therefore, in a study entitled “The frequency and clinical implications of bacteriuria in chronically paralyzed dogs”, the authors investigate chronically paralyzed dogs to determine the frequency of bacteriuria, the presence of clinical signs associated with bacteriuria, and the survival rate in such patients.

This was a retrospective, observational study performed at the North Carolina State College of Veterinary Medicine. Medical records for dogs with chronic paraplegia were evaluated, all of which had been previously evaluated for participation in clinical trials. In order to be included, dogs must have had a history of an acute, severe injury to the thoracolumbar spinal cord over 3 months prior to enrollment. Additionally, they must have failed to recover the ability to walk or perception of pain, and had at least one documented urine culture. The investigators performed a thorough extraction of data from the medical records, including extensive patient information, details regarding the spinal cord injury, surgical information, and data regarding urinalysis and urine culture results. In this study, a definition for UTI was bacterial growth > 10^5 CFU/mL, and pyuria was defined as > 5 WBCs per high-power field. A body temperature greater than 102.5F (39C) was considered a fever.

In total, 47 dogs met the inclusion criteria and had their medical records reviewed for the study. The dogs were approximately half male and half female, and not surprisingly, dachshunds were the most highly represented breed in this group. In the majority of cases, the cause of paraplegia was intervertebral disk disease (IVDD), followed by vertebral fracture and/or luxation. So let’s find out about those urine cultures! Well of these 47 dogs, 75% (35 dogs) had at least one urine culture that was positive for growth. That’s a big number, though perhaps not entirely surprising for clinicians who have managed chronically paralyzed patients. Just under a third of dogs (13/47) had recurrent positive urine cultures. While the range of urine cultures performed on each dog ranged from 1 to 28, the median was 3, with a grand total of 251 cultures performed overall. Of all 251 cultures, 56% were positive. E. Coli was the most common organism cultured, and nearly 10% of these cultures showed antibiotic resistant organisms.

Now in humans with spinal cord injuries, UTIs are a potential cause of septicemia and increased mortality. When differentiating a true UTI from asymptomatic bacteriuria, numerous diagnostic and clinical variables are taken into account. Not surprisingly, the presence of fever and/or pyuria are two important factors, which is one reason these authors paid particular attention to body temperature and the presence of pyuria in this population, along with other clinical symptoms. In this group, there was no statistically significant association between the presence of a fever and positive versus negative urine cultures. However, pyuria was significantly associated with positive urine cultures.

The authors also assessed two more subjective variables that can be helpful in such cases, which were cloudiness of the urine and the presence of a foul odor. Given that these are changes that may be identified at home by an owner, this VETgirl found them to be helpful additions to this study. Unfortunately since reporting of a foul odor was not standard in the medical record, the authors were unable to assess a statistical association between odor and urine culture results. That said, in the 44 records where a foul odor was reported, 38% did have positive bacterial growth, half of which were E. Coli. Overall, no significant difference in cloudiness was observed between the positive and negative urine cultures. Some of you may be wondering how bacteriuria affected survival in this population. Now importantly, these authors only had survival data available for 35 dogs, but of those 35, there was no significant difference in survival between dogs with bacteriuria versus those without. Unlike in dogs without spinal cord injuries, sex did not significantly affect the occurrence of bacteriuria in this population, nor did age at onset of paraplegia or duration of paraplegia.

The authors acknowledge various limitations of this study, largely related to its retrospective nature. For instance, some dogs had gaps in the information available in their medical record; treatment varied between dogs; and certain dogs were lost to follow-up. The authors also mention that because their inclusion criteria dictates dogs must have had at least one urine culture, this may have skewed results towards dogs with bacteriuria as they may have been more likely to have a culture performed.

With all that in mind, what can we take away from this VETgirl podcast? Well, these findings suggest that bacteriuria and recurrent bacteriuria are common in dogs with chronic paraplegia, and this complication should be openly discussed with owners. In this population, no significant association was made between the presence of bacteriuria and survival, and while the presence of a fever or urine cloudiness were not shown to be significantly associated with bacterial growth, the presence of pyuria was associated with positive culture results. Now this study did not evaluate or make recommendations regarding the use of antimicrobial therapy for bacteriuria in dogs with chronic paraplegia, but hopefully additional studies will be performed to provide guidance in this area. The authors do recommend routine monitoring of patient history, physical examination, urinalysis, and urine culture in dogs suffering from chronic paralysis.

References:
1. Rafatpanah Baigi S, Vaden S, Olby NJ. The frequency and clinical implications of bacteriuria in chronically paralyzed dogs. J Vet Intern Med. 2017;31:1790-1795.

Abbreviations:
IVDD – Intervertebral disk disease
UTI – Urinary tract infection

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