I ORAL PRESENTATIONS

Topic 1: Infection and Isolation in SCI
Chair: Kurt Naber, William Donovan

Introduction Lectures:
EMERGING BACTERIAL RESISTANCE IN UROGENITAL INFECTIONS
K. Naber
Department of Urology, Hospital St. Elisabeth, Straubing, Germany

Many of the pathogens creating therapeutic problems because of emerging resistance
are also causing urogenital infections, such as Pseudomonas, Acinetobacter,
Enterococcus, Staphylococcus species and several species of Enterobacteriaceae,
such as E. coli, Klebsiella, Enterobacter, and Citrobacter. In the past mostly these
problems were solved by developing new and more potent antimicrobial substances.
After a time of rapid detection of different new antibiotic classes in the 1940s upto the
1960s, such as sulfonamides, betalactams, tetracyclines, aminoglycosides, macrolides,
glycopeptides, and quinolones, modifications of the known molecules were
mainly used to overcome the resistance problem. The development of new antibiotic
classes, however, became more and more difficult even though the biochemical
methods have improved very much in the meantime. Therefore other intelligent
strategies have to be followed even more strictly, such as hygienic measurements,
screening of risk groups for early detection of multiresistant pathogens (“detect and
destroy”), improved antibiotic policy and if possible vaccination. This is, however, not
an easy task in a global world, where also pathogens are not stopped by any border.

ISOLATION OF INDIVIDUALS WITH SCI– PSYCHOLOGICAL POINT OF VIEW
W. Strubreither

Management of MRSA and other infections includes immediate isolation of the patient.
Long periods of isolation are considered to be psychologically detrimental. This public
opinion is the result of experiences, which have been reported by prisoners of war or
explorers when subject to isolated conditions or the result of laboratory studies
involving bedrest and social isolation. It has previously been seen that isolation, or
perceptual or sensory deprivation, may lead to some abnormal thought or perceptual
occurrences. Additional information on altered sensory environments is available from
research into hospitalized patients. There are reports that many patients on intensive
care units experienced a fluctuating state of consciousness, characterised by fatigue,
distraction, confusion, disorientation, agitation, and ultimately, depression. It is stated,
that altered sensory environment could produce changes in affect, cognition, and
perception. Reported effective changes included fear, anxiety, depression, and rapid
mood changes, but also non- compliance behaviour. Also observed is the set in of pain
or even hallucinations.

But it seems that the reactions of spinal cord injured patients are atypical and do not
correspond to other patients. Indications to this statement are found in papers concerning
the reactions of MRSA- positive patients. These papers show a higher level of
depressive and anxious symptoms amongst isolated MRSA- positive patients who
have no spinal cord injuries. There was also no correlation between length of hospitalization
or isolation and the outcome measures. On the other hand, MRSA positive
patients with spinal cord injuries feel more angry than non- isolated SCI- patients, but
do not have significant higher scores in depression or anxiety. It is seen that the difference
between the psychological well- being of isolated MRSA positive SCI- pa-tients
and non- isolated SCI- patients is not as great as might have been expected. Patients
feel that rehabilitation is affected, but the situation may be improved by providing more
space and a better view onto the ward.

1/1 Spinal cord injury induced immune depression syndrome (SCI-IDS)

Jan M. Schwab, Tino Riegger, Sabine Conrad, Hermann J. Schluesener, Hans-
Peter Kaps, Andreas Badke, Christopher Baron, Jutta Gerstein, Klaus Dietz,
Mahdi Abdizahdeh, Hans-Peter Kaps
Institute of Brain Research, University of Tuebingen, Medical School, Calwer
Str. 3, 72072 Tuebingen, BG Trauma Center, Dept. Spinal Cord Injury,
Tuebingen

Infections are among the leading causes of death in spinal cord injured patients and
are associated with hampered wound healing, prolonged hospitalization and impaired
neurological recovery. Here, we have analyzed fluctuations of immune cell populations
following spinal cord injury (SCI) by FACS analysis from acute until chronic stages. In
humans, a rapid and drastic decrease of CD14+ monocytes (<50% of control level),
CD3+ T-lymphocytes (<20%, p<0.0001) and CD19+ B-lymphocytes (<30%, p=0.0009)
and MHC class II (HLA-DR)+ cells (< 30%, p<0.0001) is evident within 24 hours after
spinal cord injury reaching minimum levels within the first week compared to controls.
Experimental SCI of rats not receiving methylprednisolone induced - likewise –
depletion of ED9+ monocytes (<65%), CD3+ T-lymphocytes (< 30 %, p=0.0066), CD45
RA+ B-lymphocytes (< 45%, p<0.0001), MHC class II (< 40%, p=0.0003) and OX-62+
dendritic cells (< 55%, p=0.0052) within the first week after SCI. We demonstrate that
spinal cord injury induces early onset of immune suppression and secondary immune
deficiency (SCI-IDS) independent of methylprednisolone therapy. SCI induced immune
alterations persisted until chronic stages. Our data recommend immediate preventive
antibiotic treatment already within 24 hours to decrease mortality, costs (time of
hospitalization) and improve neurologic outcome following SCI.

2/1 The frequency of bacteriuria and urinary tract infection in 249 spinal
cord injured.
Karin Pettersson1, Olof Jonsson1, Ingela Berrum-Svennung1, Peter Asplund2,
Ann-Katrin Karlsson1
Institute of Clinical Neuroscience, Göteborg, Sweden

The occurrence of resistant bacterias is increasing. At our SCI Unit in Göteborg,
Sweden urinary cultures are performed on all patients twice weekly. In a retrospective
chart review of 249 SCI patients we investigated the frequency of bacteriuria, bacterial
species and treatment related to emptying regime, age and sex. 7.812 urinary cultures
were evaluated.

38 % of the cultures showed bacteriuria, (C:41 %, Th:38 %, L+S:33%). The age and
sex distribution was equal. 30 % of the positive cultures were treated with an equal
distribution according to level of lesion, sex and age. Bacteriuria was found in 33 % of
the subjects who recovered normal micturition, 37 % of the CIC, 40 % in the mixed
regime and 55 % of the CAD group. The bacteriuria was treated in 24 % of the normal,
32 % of the CIC , 34 % in the mixed and 25 % of the CAD group. The most common
bacterial species were enterococcus (29 %) Klebsiella (23 %) and E.Coli (18 %).
MRSA was found in 1,5 % of the cultures. By regular culturing of urine we could treat
according to pattern of resistance and the creation of resistant bacterias might be
avoided.

3/1 An Outbreak of Methicillin Resistant Staphylococcus (MRSA) in a
Spinal Cord Unit

V. Geng, B.Klesse, M. Baumberger
Swiss Paraplegic Centre, CH, 6207 Nottwil

Objectives
To carry out epidemiological study on an outbreak caused by MRSA colonization in a
spinal cord unit in a period of 2 month in autumn 2004

Material and Methods
Outbreakinvestigation with epidemiologic, microbiologic and molecular biologic
methods were used to find out the source and the route of transmission. After
identifying two patients with a hospital acquired MRSA colonization on the same unit
the outbreak management started with screening patients, personal and the
environment. All the patients on the ward the outbreak took place, were screened by
nasal, axillaries, rectal swabs and microbiological culture from wounds and urine. The
healthcare professionals on the unit were screened by nasal swabs and control from
the skin flora on hands.

Results
The outbreak of MRSA colonization occurred in 9 patients (n=26) and in 9 health care
professionals (n= 160). The results of the environment survey showed the colonization
from a notebook used for patient documentation on the spinal cord unit. Costs of the
outbreak were about 250.000 Euro.

Conclusions
Infection control and a continuous investigation for hand hygiene and disinfection are
necessary. Also equipment like notebooks could be a source for hospital acquired
colonization or infections.

Keywords
MRSA, Outbreak, Infection Control, Notebook

4/1 Anterior decompression and tricortical iliac bone grafting for
tuberculosis of spine

Fazlul Hoque, Atiar Rahman, Umme Kulsum
Centre for the Rehabilitation of the Paralysed (CRP)

Study Design: To evaluate the role of anterior decompression and reconstruction of
the resultant gap with bone graft for spinal tuberculosis.

Objectives: (1) To evaluate the neurological recovery. (2) To evaluate the bony
interbody fusion by tricortical auotologus iliac bone graft.

Setting: Centre for the Rehabilitation of the Paralysed (CRP), Savar, Dhaka.

Method: Twenty-three patients, 21 paraplegics and 2 tetreplegics, with active
tuberculosis of the spine were treated by anterior debridement, decompression and
interbody fusion by tricortical auotologus iliac bone graft.

Results: Out of 23 patients 19 had a mean follow up of 27 months. At this follow up
fourteen patients had complete neurological recovery and 5 complete paraplegia
(ASIA-A) cases recovered to functionally useful neurological stages. All 19 cases have
neurological recovery to some degree except one late stage complete paraplegic
(ASIA-A) case. There were no major complications or instances of graft resorption and
failure except one graft slippage.

Conclusion: The initial results of our series are encouraging. We believe anterior
decompression and stabilization of spinal column with autologous iliac bone graft has a
better neurological outcome and less chance of residual kyphosis. Tricortical
autologous iliac bone grafts are suitable options for the treatment of spinal tuberculosis.

5/1 Results of decompression & spinal stabilization by bone graft along
with instrumentations in Pott’s paraplegia

Md.Shah Alam
SSMC &Mitford hospital.,Dhaka, Bangladesh.

Introduction: Tuberculosis in the skeletal system is always secondary. Maximum cases
can be managed conservatively.

Method & materials: A total of 15 cases of Pott’s paraplegia were treated by surgical
treatment after giving anti-tubercular drugs. 9 were male and 6 were female. Age of the
patients was from 15to 48 years and mean age was 32.5.Maximum cases were treated
by surgical intervention when patients were not improving during conservative
treatment .Common side of involvement of tubercular lesion was in this series in dorsolumber
region. Decompression of the spinal cord along with stabilization of spine was
done by bone graft with instrumentations. Instrumentations actually enhance in fusion
and prevents further deformities. Direct antero-lateral decompression done by
thoracotomy in 7 cases and retroperitoneal drainage done in 3 cases, 4 cases by
costotransversectomy, and in 1 case by mid line posterior approach.

Results: Maximum cases were improved immediately after surgery.1 patient presented
to us with discharging sinus and his improvement was little bit slowly in comparison
with other cases. Every patient was advised to use braces for 3 to 6 months.

Conclusion: Surgical treatment is always rewarding in tubercular patients. Pott’s
disease when does not improve by conservative treatment in that case surgery has got
tremendous role.

6/1 Amyloidosis Revisited. A Sequale of Chronic Infection in Adult SCIPatients

B. Singhal, A. Graham
National Spinal Injuries, Stoke Mandeville Hospital, Aylesbury, Buckinghamshire,
U.K HP21 8AL

Amyloidosis is rare diseases characterised by extra cellular protein deposit in various
tissues and vital organs of the body, which often leads to severe, and debilitating
chronic health problem and death.

Method:
Retrospective scrutiniisation of five case notes with amyloidosis in SCI patients.
We report 5 cases of amyloidosis treated in the NSIC over the period of time. The
commonest cause is a result of repetitive urinary tract infection and infected chronic
pressure sores. (Reference 1). The actual incidence of amyloidosis in SCI population is
unknown. Renal amyloidosis is associated with increased mortality in haemodialysis
patients. (Reference 2)

Results:
Three of the patients died due to end stage renal diseases and gram-negative
septicaemia. They all had iron deficiency anaemia and low serum ferritin consistent
with previous observations (Reference 3). Causes for amyloidosis in 5 of them was
chronic infection, 2 pressures sore related, 1 infected total hip replacement, 2 recurrent
urinary tract infection (incomplete bladder emptying). All had proteinuria and showed
clinical signs of nephrotic syndrome. Three had positive rectal biopsy for amyloid and
two had positive renal biopsy for amyloid.

Conclusion:
The case reports remind us of this fatal pathology in SCI population .The emphasis of
management still lies in prevention. There is some hope in the form of high-dose
melphalan with stem cell support (Reference 4). More research is required to look
into this fatal disease. Optimisation of bladder management and prompt treatment of
pressure sores is key to prevention

References:
(1)Barton CH, Vaziri ND, Paraplegia.22 (1): 31-41.1984 Feb
(2) Sengul.S, Arat Z, Odemir FN; Artificial organs28 (9): 846-52,2004 Sep
(3) Vaziri ND, Mirhamdi MK; Journal Of American Paraplegia Society, 6(1): 3-6.1983 Jan
(4) Comenzo RL; Current Treatment Options in Oncology.1 (1): 83-9,2000 Apr

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