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Discontinuation of Antimicrobial Prophylaxis (AP) in Children With Spina Bifida: A Case Series Analysis
Kevin G Couloures1, Michael Anderson2, Michael Machiorlatti2
1Yale School of Medicine, New Haven, Connecticut, USA.
Insights
Selective Treatment (ST) using catheterization and bowel management significantly reduced urinary tract infections (UTIs) in children with spina bifida, decreasing the need for antimicrobial prophylaxis (AP) and improving renal function.
Area of Science:
- Pediatric Nephrology
- Urology
- Infectious Diseases
Background:
- Spina bifida patients have a high risk of urinary tract infections (UTIs).
- Antimicrobial prophylaxis (AP) can reduce symptomatic UTIs but promotes antimicrobial resistance.
- Bladder emptying and constipation management are alternative UTI prevention strategies.
Purpose of the Study:
- To evaluate if a Selective Treatment (ST) regimen, emphasizing catheterization and bowel management, can reduce the need for AP in children with spina bifida.
- To assess the impact of ST on UTI incidence and renal function compared to AP.
Main Methods:
- A case series analysis of 67 pediatric spina bifida patients was conducted.
- Routine AP was replaced with clean-catch catheterization and a daily bowel regimen (ST).
- UTI incidence, renal function (creatinine clearance/GFR), and antibiotic resistance patterns were retrospectively reviewed.
Main Results:
- The mean number of UTIs decreased from 8.7 on AP to 1.0 on ST.
- No infections on ST required intravenous antibiotics due to resistance, unlike 5 infections on AP.
- A significant improvement in Glomerular Filtration Rate (GFR) was observed when switching from AP to ST.
Conclusions:
- Antimicrobial prophylaxis (AP) is ineffective in preventing UTIs in spina bifida patients and contributes to resistant organisms.
- Discontinuing AP and adhering to a catheterization regimen (ST) improved susceptibility to oral antimicrobials and preserved renal function.
- Selective Treatment (ST) with catheterization and bowel management is a viable alternative to AP for UTI prevention and renal protection in spina bifida.
Background:
Spina bifida increases the risk for urinary tract infections (UTI). Antimicrobial prophylaxis (AP) reduces symptomatic UTI's but selects resistant organisms. Measures to ensure regular and complete emptying of the bladder combined with treatment of constipation reduce the risk for UTI.
Objectives:
Demonstrate that close adherence to a catheterization regimen in children with spina bifida (Selective Treatment - ST) reduces the need for antimicrobial prophylaxis.
Methods:
Case series analysis of pediatric spina bifida clinic patients where routine antimicrobial prophylaxis was replaced by clean-catch catheterization and daily bowel regimen (ST). Retrospective chart review of 67 children (mean entry age: 24 months, median age: 4 months; 32 Males, 35 Females) enrolled between 1986 - 2004. Mean follow-up was 128.6 months (range 3 - 257 months). Asymptomatic and symptomatic UTI incidences were noted on AP and ST protocols. Creatinine clearance at study entry and follow-up was calculated by the age appropriate method. A multivariable regression model with delta Glomerular Filtration Rate (GFR) as the dependent variable, independent sample t-test and Wilcoxon rank sum were performed with SAS v. 9.2.
Results:
The mean number of infections while on AP was 8.7 (95% CI 5.72, 11.68) and was 1.0 on ST (95% CI 0.48, 1.43). 5 infections on the AP protocol required intravenous (IV) antibiotics due to resistance to oral therapy, but none on ST. Comparing change in GFR between both protocols (AP vs. ST) found a significant difference in the change of GFR by treatment protocol.
Conclusions:
AP did not prevent UTIs and resulted in more resistant organisms requiring IV antibiotics. Discontinuing AP allowed the return of susceptibility to oral antimicrobials and significantly improved GFR in those children who had previously been on AP. Adherence to a catheterization regimen with prompt treatment of symptomatic UTI conserved renal function and prevented selection of resistant organisms.
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