Overall, 9,447 Veterans with SCI/D were seen for an annual evaluation in FY18 and FY19 were included in this study. The majority were male (96%), White 66%), and had an American Spinal Injury Association Impairment Scale (AIS) D grade SCI (43%). The most common etiology of SCI was motor vehicle collision (25%). Those with AIS D grade SCI or unclassified SCI were generally older than those with AIS A-C grade SCI. Additionally, there was a small but significant difference in socioeconomic status between the groups. (Table 1)
Table 1
Patient demographics by neurologic level of injury, N = 9447
| Tetraplegia AIS A-C | Paraplegia AIS A-C | All AIS D | Not classified | p-value |
N = 9447 | N = 1644 | N = 2263 | N = 4042 | N = 1498 | n |
Age, median (range) | 62 (21–91) | 63 (22–97) | 67 (19–100) | 68 (20–101) | < 0.01 |
Male gender (%) | 1593 (96.9) | 2172 (96.0) | 3872 (95.8) | 1432 (95.6) | 0.21 |
Race/Ethnicity (%) | | | | | |
White | 1065 (64.8) | 1602 (70.8) | 2578 (63.8) | 968 (64.6) | < 0.01 |
Non-Latino Black | 401 (24.4) | 392 (17.3) | 1078 (26.7) | 340 (22.7) | |
Other | 178 (10.8) | 269 (11.9) | 386 (9.6) | 190 (12.7) | |
Etiology of Injury (%) | | | | | |
Motor vehicle collision | 636 (38.7) | 911 (40.3) | 705 (17.5) | 73 (4.9) | < 0.01 |
Fall | 316 (19.2) | 340 (15.0) | 790 (19.5) | 48 (3.2) | |
Other | 692 (42.1) | 1012 (44.7) | 2547 (63.0) | 1377 (91.9) | |
Co-morbidity index score, mean (SD) | 2.06 (1.4) | 2.06 (1.4) | 2.37 (1.6) | 2.61 (1.8) | < 0.01 |
Bladder management (%) | | | | | |
Evidence of catheter use | 709 (43.1) | 1113 (49.2) | 800 (19.8) | 467 (31.2) | < 0.01 |
No evidence of catheter use | 935 (56.9) | 1150 (50.8) | 3242 (80.2) | 1031 (68.8) | |
Rurality Score (% rural) | 451 (27.4) | 741 (32.7) | 1098 (27.2) | 417 (27.8) | < 0.01 |
GeoScore, mean (SD) | 99.9 (15.8) | 99.5 (14.8) | 98.7 (15.3) | 99.0 (15.1) | 0.03 |
AIS – American Spinal Injury Association Impairment Scale |
SD – Standard Deviation |
The classification of patients by urine testing and culture results is shown in Fig. 1. Just over half (54%) of the cohort received a urine culture during their annual exam visit, of whom 57% (2910) had a positive culture. Of those with a positive culture, 13% received antibiotics within 7 days of the annual exam encounter, compared to 6% of those with negative cultures and 5% of those that did not receive a culture at all.
Figure 2 shows the microbiology of cultures obtained and breakdown of antibiotic use in the cohort. E. coli was the most common isolate on culture (32% of cultures), followed by K. pneumoniae (19% of cultures) and E. faecalis (17% of cultures). (Fig. 2, panel A.) Additionally, 44% of cultures grew more than one organism. (Fig. 2, panel B.) The most prescribed antibiotic in the cohort was nitrofurantoin, followed by ciprofloxacin and doxycycline. (Fig. 2, panel C.) Finally, 19% of participants who received antibiotics were prescribed a course for less than 7 days, while 38% were prescribed a course for 7–10 days, 6% were prescribed a course for 11–14 days, and 37% were prescribed a course of antibiotics for more than 14 days. (Fig. 2, panel D.)
The results of multivariable logistic regression analysis demonstrated several demographic and clinical characteristics that were associated with receiving a urine culture during the annual evaluation. (Table 2) Black (vs White) patients were more likely to have a urine culture performed (OR: 1.29; 95% CI: 1.15–1.43), as well as participants with an AIS-D grade SCI versus those with tetraplegia AIS A-C (OR: 2.04; 95% CI: 1.77–2.35). Conversely, older age, higher comorbidity index score, not having any evidence of catheter use for bladder management, and not receiving antibiotics within 7 days of the annual exam encounter were all significantly associated with a reduced likelihood of receiving a urine culture during the annual exam. (Table 2)
Table 2
Association of demographic and clinical characteristics with receipt of urine culture during annual evaluation.
| Unadjusted OR (95% CI) | p-value | Adjusted OR (95% CI) | p-value |
Age | 0.99 (0.991–0.999) | < 0.01 | 0.995 (0.991–0.999) | 0.01 |
Race | | | | |
White | Reference | | Reference | |
Black | 1.29 (1.04–1.26) | 0.26 | 1.29 (1.15–1.43) | < 0.01 |
Other | 1.15 (1.0-1.32) | 0.31 | 1.1 (0.91–1.29) | 0.35 |
Ethnicity | | | | |
Non-Hispanic | Reference | | Reference | |
Hispanic | 0.94 (0.81–1.09) | 0.04 | 1.04 (0.88–1.24) | 0.64 |
Unknown | 1.28 (1.05–1.55) | 0.01 | 1.26 (0.98–1.61) | 0.07 |
Gender | | | | |
Male | Reference | | Reference | |
Female | 1.07(0.87–1.32) | 0.50 | 1.07 (0.84–1.35) | 0.60 |
Neurologic Level of Injury | | | | |
Tetraplegia AIS A-C | Reference | | Reference | |
Paraplegia AIS A-C | 1.19 (1.05–1.36) | < 0.01 | 1.10 (0.94–1.28) | 0.23 |
AIS D | 0.93 (0.83–1.05) | 0.71 | 2.04 (1.77–2.35) | < 0.01 |
Not Classified | 0.71 (0.62–0.82) | < 0.01 | 1.08 (0.90–1.28) | 0.41 |
Etiology of Injury | | | | |
Motor Vehicle Collision | Reference | | Reference | |
Fall | 0.90 (0.79–1.02) | 0.38 | 0.93 (0.80–1.08) | 0.33 |
Other | 0.72 (0.66–0.80) | < 0.01 | 0.89 (0.79–1.01) | 0.07 |
Comorbidity Index | 0.94 (0.92–0.96) | < 0.01 | 0.91 (0.88–0.94) | < 0.01 |
Bladder Management | | | | |
Catheter | Reference | | Reference | |
No Catheter | 0.11 (0.10–0.12) | < 0.01 | 0.11 (0.10–0.12) | < 0.01 |
Antibiotics Prescribed within 7 Days of AE | | | | |
Yes | Reference | | Reference | |
No | 0.51 (0.45–0.59) | < 0.01 | 0.60 (0.50–0.73) | < 0.01 |
Several of the demographic and clinical characteristics analyzed were also associated with antibiotic use within 7 days of the annual examination encounter. (Table 3) A higher comorbidity index score was associated with increased odds of receiving antibiotics within 7 days of the annual exam (OR: 1.06; 95% CI: 1.01–1.11). However, Black participants or those with unknown ethnicity were less likely to receive antibiotics than their White, non-Hispanic peers. Additionally, not having any evidence of catheter use for bladder management, having an organism identified on culture that was not one of the top three organisms identified on culture overall, and not receiving a urine culture during the annual examination encounter were significantly associated with a reduced likelihood of receiving a prescription for antibiotics within 7 days of the annual evaluation.
Table 3
Association of demographic and clinical characteristics with prescription for antibiotics within 7 days of the annual evaluation.
| Unadjusted OR (95% CI) | p-value | Adjusted OR (95% CI) | p-value |
Age | 1.00 (0.99-1.0) | 0.71 | 1.00 (0.99–1.01) | 0.40 |
Race | | | | |
White | Reference | | Reference | |
Black | 0.71 (0.61–0.84) | 0.01 | 0.70 (0.59–0.83) | < 0.01 |
Other | 0.81 (0.64–1.01) | 0.69 | 0.84 (0.66–1.07) | 0.16 |
Ethnicity | | | | |
Non-Hispanic | Reference | | Reference | |
Hispanic | 1.12 (0.89–1.40) | 0.05 | 1.06 (0.80–1.40) | 0.69 |
Unknown | 0.72 (0.51–1.02) | 0.03 | 0.51 (0.32–0.82) | 0.01 |
Gender | | | | |
Male | Reference | | Reference | |
Female | 1.41(1.05–1.88) | 0.02 | 1.22 (0.84–1.76) | 0.29 |
Neurologic Level of Injury | | | | |
Tetraplegia AIS A-C | Reference | | Reference | |
Paraplegia AIS A-C | 1.08 (0.90–1.30) | < 0.01 | 1.16 (0.92–1.47) | 0.20 |
AIS D | 0.67 (0.56–0.81) | < 0.01 | 1.01 (0.80–1.28) | 0.92 |
Not Classified | 0.83 (0.67–1.03) | 0.38 | 1.11 (0.83–1.47) | 0.48 |
Etiology of Injury | | | | |
Motor Vehicle Collision | Reference | | Reference | |
Fall | 0.82 (0.66-1.00) | 0.16 | 0.97 (0.77–1.25) | 0.83 |
Other | 0.87 (0.75–1.01) | 0.54 | 1.03 (0.86–1.20) | 0.80 |
Comorbidity Index | 1.05 (1.01–1.09) | 0.02 | 1.06 (1.01–1.11) | 0.03 |
Bladder Management | | | | |
Catheter | Reference | | Reference | |
No Catheter | 0.47 (0.42–0.54) | < 0.01 | 0.68 (0.57–0.82) | < 0.01 |
Organism Identified on Culture in Top 3 | | | | |
Yes | Reference | | Reference | |
No | 0.42 (0.37–0.47) | < 0.01 | 0.48 (0.41–0.57) | < 0.01 |
Urine Culture During AE | | | | |
Yes | Reference | | Reference | |
No | 0.51 (0.45–0.59) | < 0.01 | 0.62 (0.51–0.75) | < 0.01 |