In the symptomatic child with neurogenic bladder at risk for urinary tract infection (UTI), urine culture should be performed regardless of the results of urinalysis, recommended Catherine S. Forster, MD , of Cincinnati Children’s Hospital Medical Center, and her associates.

In a general pediatric population, studies have found that certain uropathogens – such as Enterococcus species, Klebsiella species, and Pseudomonas aeruginosa – are less likely to be associated with pyuria than Escherichia coli.

But children with neurogenic bladders who require clean intermittent catheterization (CIC) often have chronic urethral inflammation, and this “may confound the association between pyuria and uropathogens,” the investigators said

According to the guidelines of the Infectious Disease Society of America guidelines for the diagnosis of catheter-associated UTI, pyuria is not considered diagnostic of UTI in patients who require CIC.

Children with neurogenic bladder requiring CIC often have bacteriuria and often undergo urinalyses to determine if empirical antibiotics are warranted until urine culture results are available. “Although timely initiation of antibiotics can prevent the progression of infection and decrease the risk of renal scars, unnecessary antimicrobial agents contribute to the emergence of bacterial resistance,” Dr. Forster and her associates said.

So the researchers designed a study to find out if the presence of pyuria was associated with particular uropathogens in children with neurogenic bladders.

In an analysis of 2,420 urinalysis and urine culture results from EHRs between Jan.1, 2008, and Dec. 31, 2014, for patients aged 18 years and younger with neurogenic bladders requiring CIC, the most frequently isolated uropathogen was E. coli (37%), followed by Enterococcus species (14%), Klebsiella species (11%), and various other uropathogen species (38%).

In children needing CIC for neurogenic bladder, growth of Enterococcus species on urine culture was linked with lower odds of both microscopic pyuria (0.44) and leukocyte esterase (0.45).

“With these results, we suggest that the current markers of UTI evidenced on urinalysis and urine microscopy are insufficient for predicting bacteriuria in this population,” Dr. Forster and her colleagues said, leading to their recommendation to perform a culture in symptomatic children with neurogenic bladders irrespective of urinalysis results.

Dr. Forster received a research grant from the National Institutes of Health. The investigators said they had no relevant conflicts of interest.

SOURCE: Forster CS et al. Pediatrics. 2018;141(5):e20173006.


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