**5. Pyuria**

from the upper layers of the biofilm circulating in the fluid medium, urine in this case, and attempting to adhere to a new substrate which is more conducive to their growth. These

The specificity of individuals with SCI is that asymptomatic bacteriuria is usually present and the sensory disorder results in the lack of a clear symptom of urinary tract infection. The clinician should carefully evaluate the patient to decide whether a positive urine culture reveals infection or is an asymptomatic bacteriuria. Additionally, fever should not be attributed to urinary tract infection if the only positive point is bacteriuria unless other possible causes of fever are excluded. Approximately 45% of feverish conditions in these patients are thought to be due to urinary tract infections [59]. Other causes are respiratory infections as well as thromboembolic events. The septic condition in quadriplegic patients may also occur as hypothermia [60]. Approximately 10% of febrile episodes may be the result of a temperature control malfunction and not an infection [61]. The coexistence of elevated CRP and routine serum test values should be considered. UTI is accompanied by a specimen of urine blisters with microbes above 10<sup>5</sup> CFU/ml, and symptoms such as fever, back pain in the lumbar region of the kidney, upper urinary tract infection, and if the patient has a sensation at this level, urinary urgency and increased spasticity. A characteristic symptom is the reduction of cystic functional capacity and the aggravation of overactive bladder syndrome, in the case of a neurogenic overactive detrusor, or the discontinuation of response to previously well-regulated treatment for increased extravasation activity. The incidence of urinary tract infections in SCI patients is 2.5 episodes per patient per year. Bacteremia and sepsis occur in 1% of SCI patients [62]. The urinary system is considered to be the most common source of bacteremia [62, 63]. Bacteremia in SCI patients is accompanied by 90% fever, 17% hypotension, and death rate of about 15%. [62, 63]. Approximately 20–25% of episodes are characterized by polymicrobial infections. Bacteriemia is more common in quadriplegic patients and in patients with complete SCI [64]. Urogenital tube manipulations are considered as risk factors for bacteremia [65].

Urinary tract colonization often follows colonization of the urogenital tract, perineum or urethra with enteropathogenic microorganisms [66, 67]. In a study of 15 adult men with SCI and other neurogenic urinary dysfunctions, the normal flora of the perineum, penis and urethra regions was compared with the flora of 10 control men without neurogenic urinary disorders [68]. The predominant microorganisms with respect to the control group were Grampositive granules and diphtheroids. In the individuals with the neurogenic urinary disorder, the microorganisms isolated from the skin flora include species such as Enterobacteriaceae, Pseudomonas, Acinetobacter, and Enterococcus [68]. In addition, other studies of individuals with SCI as compared to non-injured patients, the presence of *E.coli* microorganisms

detachable bacteria can cause systemic infection [53, 58].

66 Microbiology of Urinary Tract Infections - Microbial Agents and Predisposing Factors

**3. Clinical symptoms**

**4. Microbiology—urine culture**

The significance of pyuria in neurogenic patients in combination with the use of intermittent catheterization or permanent catheter is often difficult to assess. Changing the Foley catheter in symptomatic patients causes an increase in the leucocytes without affecting the microbial strain or the number of colonies [71]. Positive urine culture (105 CFU/ml colonies), with the presence of >50 leucocytes per field of vision, is associated with an increased risk of fever. In addition, Gram-positive microorganisms such as *Staphylococcus epidermidis* and *Streptococcus faecalis* are accompanied by a small number of leukocytes despite the occurrence of a large number of colonies, while Gram-negative microorganisms are accompanied by significant pyuria [72]. According to the above significant pyuria is associated with the presence of catheters, infection with Gram-negative microorganisms, as well as bacterial tissue filtration.
