**1. Introduction**

Infectious complications are supposed to be an important cause of morbidity and mortality in patients with spinal cord injury (SCI). Infectious diseases may lead to death and several

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complications such as prolonged hospital stay and increased cost of management of patients. Several organs may be affected and problems in these organs can be even more important than the primary event. The types of infections in these patients are different and related to several factors. Inabilities to changing position or ineffective cough, using several necessary devices, prolonged hospitalization, and several other factors, in patients with SCI, predispose them to different types of infections. Inability to walk, sit, or change position may lead to pressure ulcers, skin and soft tissue infection, and osteomyelitis. Reduced tissue perfusion increases the spinal cord-injured patient's susceptibility to pressure ulcers [1] during the acute and rehabilitation phases, most frequently over bony prominences such as the sacrum, tuber ischii, heel, malleolus, and trochanter [2]. Physical and psychosocial elements such as nutrition, past history of pressure ulcers, and social supports can be important in developing ulcers [3]. Ineffective cough and retained pulmonary secretion may lead to pneumonia. Most of the patients need intubation in the course of hospitalization that predisposes them to ventilator-associated pneumonia. Ventilator-associated pneumonia is the most frequent nosocomial infection in patients receiving mechanical ventilation and contributes to a longer intensive care unit stay and high morbidity and mortality [4, 5]. Use of high doses of corticosteroid for management of some patients with SCI can increase the risk of infection. In those patients who need surgical intervention, the operation time is usually prolonged. Sometimes, the use of an external device is mandatory for fixation of unstable vertebral column. The SCI patients may develop bloodstream infection during the hospital admission. During bloodstream infection occurrence in an SCI population, multidrug-resistant organisms are frequent [6]. ICU-acquired bloodstream infection in the intensive care unit is still associated with a high mortality rate. The increase of antimicrobial drug resistance makes its treatment increasingly challenging. ICU bloodstream infection is associated with a 40% increase in the risk of 30-day mortality, particularly if the early antimicrobial therapy is not adequate [7]. Paying attention to antibiotic therapy is important in SCI patients. Antibiotic resistance is of great concern for both infection control and the treatment of infectious diseases. Drug-resistant pathogens, such as methicillin-resistant *Staphylococcus aureus* (MRSA), *Pseudomonas aeruginosa*, *Acinetobacter* and extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae, are associated with inappropriate antibiotic treatment that resulted in adverse outcomes. In addition, unnecessary use of broad-spectrum antibiotics for patients with non-drug-resistant pathogens increases mortality [8].

multifactorial, including reduced sensation of classical UTI symptoms, incomplete bladder emptying, frequent catheterizations, or chronic urinary tract catheters [10]. The rate of UTI in an SCI patient is 2.5 episodes in patient per year. UTI is the second leading cause of mortality in SCI patients [11]. Patients with SCI who have urinary catheters have an increased risk of UTI. Urinary tract infection can be important and can cause serious complications including

Infectious Complications after Spinal Cord Injury http://dx.doi.org/10.5772/intechopen.72783 93

Using Foley catheter is usually accompanied with colonization of microorganisms and infection [12]. Bacterial biofilm formation of Foley catheter can cause cystitis [10]. About 80% of UTIs follow urinary catheter insertion. Nitrofurazone-coated and silver alloycoated catheters can decrease asymptomatic bacteriuria during short-term (<30 days) use in comparison with latex or silicon catheters. The risk of infection is higher with long-term catheterization, and it is safe to remove it early after surgery. Latex and silicone catheters have the same infection rates, but Foley catheters cause more symptomatic bacteriuria and UTI than intermittent catheterizations. Changing the drainage bags and adding antiseptic solution to bags cannot prevent UTI in patients [13]. There are several risk factors for UTI in SCI patients. Reflux of vesicoureteral, postvoiding residuals, outlet obstruction, urinary tract stones, and bladder overdistension [14]. These patients are exposed to antibiotics because of frequent infections that may be an important risk factor for resistant microorganism infection [15]. Today, UTI may be difficult to treat in SCI patients because of antibiotic-resistant organisms. The SCI patients are also colonized by resistant organisms because of recurrent and prolonged hospitalization [16]. The main causative agent of UTI in SCI population is usually derived from the patient's flora. The indwelling catheter has a great role in infection and the duration of catheterization is the most important risk factor. If the patient carries a catheter more than 30 days, the risk of infection with multiple organisms will increase. Although short-term catheterization can be risk factor for bacteriuria, it is usually asymptomatic and often by a single microorganism [17]. It is better to use hydrophilic-coated catheter for intermittent catheterization in SCI patients during acute inpatient rehabilitation. These kinds of catheters can postpone the development of UTI. They also reduce the incidence of bacteriuria and infection. Reduction of complications and treatment costs and preventing the emergence of antibiotic-resistant organisms are other benefits of hydrophilic-coated catheters [18]. Substitution of indwelling catheter with intermittent catheterization during the rehabilitation phase will reduce development of UTI [9]. The unitary catheter should work in a closed system so that no organism can enter the system. It is also important to reduce the duration of catheterization. Sometimes intermittent catheterization, condom sheet catheter, and suprapubic catheters may substitute indwelling catheterization to reduce the risk of infection [17]. Intermittent catheterization is safe and is advised to prevent UTI in SCI patients. Condom sheet catheter can be used in patients who are able to urinate and there is no pathology or injury in urethra. In some patients, where using condom sheet catheter or intermittent catheterization is not suitable or possible, the physician may decide to use suprapubic catheter. The physicians should be aware of these two points that SCI patients may not have the classic symptoms of UTI and urinary infection

sepsis and septic shock if it is not diagnosed and treated.

may cause urologic complications [15].

These can be the risk factors for developing infections in SCI patients. In this chapter, the cause of infections, predisposing factors, diagnosis, management, and prevention will be discussed.
