Bladder Plate Flora and Resistance Patterns in Children with Exstrophy-Epispadias Spectrum and Exposed Urothelium at Primary Closure
Elizabeth B. Roth, MD1, Travis Groth, MD1, Jennifer Frazier, MPH2, Bryan S. Sack, MD3, Dana A. Weiss, MD2, Aseem R. Shukla, MD2, Joseph G. Borer, MD3, Douglas A. Canning, MD2, Michael E. Mitchell, MD1, John V. Kryger, MD1.
1Children's Hospital of Wisconsin, Milwaukee, WI, USA, 2Children's Hospital of Philadelphia, Philadelphia, PA, USA, 3Boston Children's Hospital, Boston, MA, USA.
Background: Evidence-based antibiotic guidelines for bladder exstrophy and epispadias repair do not exist as little is known about the flora of exposed urothelium in this population. It is also unknown whether delayed closure presents increased risk for colonization of the exposed urothelium or increased chance of colonization with resistant organisms that might impact success of the repair.
Materials and Methods: Bladder plate cultures were performed using standard wound culture swabs on 28 consecutive exstrophy-epispadias patients with exposed urothelium above the level of the external urethral sphincter at each participating institution between November 2014 and March 2017. All cultures were performed on the date of surgery under general anesthesia prior to surgical prep. Clinical diagnosis and preoperative antibiotic use were collected by chart review. All cultures were analyzed by the clinical microbiology lab using a semiquantitative methodology and cultures were considered positive if they grew one or more dominant organisms or organisms inconsistent with typical skin flora. Cultures were examined for enteric pathogens, Staphylococcal species including S. aureus, Streptotoccal species and anaerobic isolates when available. Cultures where one or more organisms exhibited resistance to the standard institutional antibiotic panel were considered positive for evidence of antibiotic resistance. Descriptive analysis was performed of available culture data. Univariate and bivariate analyses of age at surgery compared to positive cultures and cultures with resistant organisms were performed using non-parametric testing for univariate comparisons and simple logistic regression for bivariate comparisons. All tests were two-tailed with significance set at 0.05.
Results: Of the 28 patients, 25 had classic bladder exstrophy, 1 had cloacal exstrophy and 2 had penopubic epispadias. Median age at surgery was 80 days (range 6-288 days) and 4/25 (16%) of patients received daily prophylactic antibiotics prior to surgery. Cultures were positive in 22 patients (79%) with Staphylococcal species present in 12 (43%), enteric pathogens present in 11 (39%) and Streptococcal species present in 5 (18%). Fifteen patients (54%) grew organisms with resistance to one or more antibiotics. Anaerobic culture data was available for 21 patients, 9 of whom (43%) had growth of anaerobic organisms. Patients on prophylaxis had higher rates of resistance at surgery (75% vs 48%) but this was not significant. Positive cultures and resistance were not significantly different between early surgery (<75 days of age) or delayed surgery (>75 days). Older age at surgery appeared to have a small protective effect on having positive cultures (OR 0.985 (0.969-1.001) per day of age) or resistant cultures (OR 0.986 (0.970-1.002) per day of age) but this was not significant.
Conclusions: The majority of patients demonstrated growth of one or more organisms colonizing the bladder plate at the time of surgical repair, with over half of patients demonstrating antibiotic resistance. Older age does not appear to be a risk factor for either positive cultures or antibiotic resistance and may be protective. Overall, the results support that a delayed approach to bladder closure does not appear to increase the bacterial flora or resistance on the exposed urothelium at the time of surgery.
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