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Antibiotic prophylaxis for urinary tract infections in children with spina bifida on intermittent catheterization
Bas Zegers1, Cuno Uiterwaal, Jan Kimpen
1Department of Pediatrics, Wilhelmina Children's Hospital, Utrecht, The Netherlands. b.zegers@mmc.nl
Insights
Stopping antibiotic prophylaxis for children with spina bifida undergoing clean intermittent catheterization (CIC) did not increase urinary tract infections (UTIs). However, discontinuing prophylaxis led to more asymptomatic bacteriuria and UTIs in some patients.
Area of Science:
- Pediatric Urology
- Infectious Diseases
- Nephrology
Background:
- Antibiotic prophylaxis is commonly used in children with spina bifida using clean intermittent catheterization (CIC) to prevent urinary tract infections (UTIs).
- The necessity and safety of long-term low-dose antibiotic chemoprophylaxis in this population require further investigation.
Purpose of the Study:
- To evaluate the hypothesis that discontinuing low-dose antibiotic chemoprophylaxis does not increase the incidence of UTIs in children with spina bifida.
- To identify patient subgroups who may safely discontinue antibiotic prophylaxis.
Main Methods:
- A randomized controlled trial involving 176 patients with spina bifida was conducted.
- Patients were assigned to either continue or discontinue low-dose chemoprophylaxis for 18 months.
- Urine samples were analyzed biweekly for leukocyturia and bacteriuria using dipsticks and cultures.
Main Results:
- Discontinuation of chemoprophylaxis led to significantly higher rates of asymptomatic bacteriuria (IRR 1.23) and UTIs (IRR 1.44).
- The number needed to harm for UTIs was 2.2, indicating one extra UTI per two patients discontinuing prophylaxis annually.
- Factors predicting successful discontinuation included male gender and a low pre-study UTI rate. 43% of patients in the discontinuation group switched back to prophylaxis.
Conclusions:
- Low-dose antibiotic prophylaxis can be safely discontinued in select children with spina bifida on CIC.
- Particular candidates for discontinuation include males, patients with a history of infrequent UTIs, and those without vesicoureteral reflux.
Purpose:
Antibiotic prophylaxis (low dose chemoprophylaxis) has been prescribed since the introduction of clean intermittent catheterization in children with spina bifida. We hypothesized that stopping low dose chemoprophylaxis does not increase the number of urinary tract infections in these patients.
Materials And Methods:
A total of 176 patients with spina bifida participated in a randomized controlled trial (ISRCTN trial number 56278131) of either continuation or discontinuation of low dose chemoprophylaxis. During the 18-month study period biweekly urine samples were evaluated for leukocyturia and bacteriuria with dipsticks and cultures. Asymptomatic significant bacteriuria (positive culture results without clinical symptoms) and urinary tract infections (significant bacteriuria with clinical symptoms and leukocyturia) were analyzed.
Results:
Discontinuation of low dose chemoprophylaxis resulted in higher rates of asymptomatic significant bacteriuria (incidence rate ratio 1.23, 95% CI 1.08-1.40, p = 0.002) and urinary tract infection (IRR 1.44, 95% CI 1.13-1.83, p = 0.003). For urinary tract infection the number needed to harm was 2.2, that is if 2 patients discontinued low dose chemoprophylaxis for a year, 1 extra urinary tract infection would result. Febrile urinary tract infection occurred once in every 30 patient-years and slightly more often in the discontinuation group (relative risk 2.0, 95% CI 0.38-10.6, p = 0.4). Of 88 patients allocated to discontinuation of low dose chemoprophylaxis 38 (43%) switched back to chemoprophylaxis. The urinary tract infection rate was nonsignificantly higher in the presence of vesicoureteral reflux. Male gender and a low pre-study rate of urinary tract infection predicted successful discontinuation.
Conclusions:
Patients with spina bifida on clean intermittent catheterization and antibiotic prophylaxis for urinary tract infections can safely discontinue this prophylaxis, in particular males, patients with low urinary tract infection rates and patients without vesicoureteral reflux.
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