Amikacin bladder instillation as prophylaxis for recurrent urinary tract infections in a child with neurogenic...

Recurrent symptomatic urinary tract infections (rUTIs) in pediatric patients with neurogenic bladder and chronic kidney disease can be particularly difficult to manage with an appropriate prophylaxis and treatment, especially when caused by multidrug-resistant organisms. Intravesical aminoglycoside instillation may provide a safe renal-sparing prophylactic option.

A 9-year-old female with neurogenic bladder due to voiding dysfunction, stage 2 chronic kidney disease and bilateral hydronephrosis, who presented with high-grade fever, flank pain and vomiting. She had had 3 hospitalizations for multi-drug resistant urinary tract infections (MDR-UTIs) in the past 6 months, despite previous use of oral prophylaxis. Initially, she was receiving sulfamethoxazole/trimethoprim, then switched to nitrofurantoin for 6 months. The urine culture grew Klebsiella pneumoniae (ESBL-producing), with sensitivity to amikacin, meropenem and imipenem. The patient was treated with intravenous meropenem for 14 days, with both clinical and microbiological resolution. To minimize the chance of recurrence, a prophylaxis regimen started as intravesical amikacin instillation (250 mg in 50 mL normal saline) via self-intermittent catheterization - daily for 2 weeks, alternate days for 10 weeks, and finally twice weekly for 12 weeks. At 2-week follow-up visit, she was additionally started on prophylactic sulfamethoxazole/trimethoprim. Approximately 18 months follow-up after discharge, the patient remained asymptomatic with no further UTIs.

This case report provides useful information on effective long-term prophylaxis of multi-drug resistant recurrent urinary tract infection or rUTI, using intravesical amikacin in a child with neurogenic bladder and renal injury. Utilizing specific protocols for dosage standardization and prospective studies to assess the safety and effectiveness would be beneficial.