Antibiotic bladder instillations decrease symptomatic urinary tract infections in neurogenic bladder patients on clean intermittent catheterization
Kathy Huen, MD, Lucia Chen, BS, MS, Farnoosh Nik-Ahd, BA, Steven Lerman, MD, Jennifer Singer, MD.
UCLA, Los Angeles, CA, USA.
Urinary tract infections (UTIs) are common in patients with neurogenic bladder (NGB) performing clean intermittent catheterization (CIC). The effectiveness of strategies for UTI prevention in this population, including oral antibiotic prophylaxis and bladder irrigations, have conflicting evidence. We hypothesize that daily neomycin-polymyxin (Neosporin) or gentamicin bladder instillations reduce the rate of symptomatic UTIs in this population.
We retrospectively reviewed the records of all-age patients cared for in the UCLA pediatric urology clinic with NGB on CIC having symptomatic UTIs and on daily intravesical instillations of Neosporin or gentamicin between Dec 2013 and Oct 2017. Symptomatic UTIs were defined by patient complaints of cloudy/foul-smelling urine, fevers, chills, increase in bladder spasms, pain, leakage and with a positive urine culture. Multidrug resistant (MDR) organisms were those resistant to two or more classes of antibiotics. Primary outcomes were rates of symptomatic UTIs, emergency department (ED) visits for UTI, inpatient hospitalizations for UTI, MDR status of UTI organisms, and discontinuation of oral antibiotic prophylaxis. Count-based outcomes were analyzed using mixed-effects Poisson regression, with a random effect to account for within-patient correlation. Dichotomous outcomes were assessed using McNemar’s test for paired data.
52 patients with a median age of 14.5 years and 192 distinct urine cultures were identified. All patients were followed at least 6 months following initiation of antibiotic bladder instillations; 84% had at least one-year post-instillation data available. Most common etiologies of NGB were spina bifida (38.5%), cloacal exstrophy (11.5%) and posterior urethral valves (9.6%). 69.2% of patients had at least one urological reconstruction, the most common being appendicovesicostomy (44.2%) and enterocystoplasty (40.4%). 90.4% and 9.6% of patients received Neosporin and gentamicin instillations, respectively. 3/52 patients (5.7%) converted to gentamicin instillation for failure to suppress infections on Neosporin. Median age at instillation initiation was 13 years and median instillation duration of 3.8 years. The most prevalent organism pre- and post-instillation was Escherichia coli (40.4%) and Enterococcus (15.4%), respectively.
The frequency of symptomatic UTIs after initiating intravesical antibiotic instillation was reduced by 58% [incidence rate ratio (IRR) 0.42, 95% confidence interval (CI) 0.31 to 0.56; p<0.001] in a multivariate model adjusted for race, gender, and prior urinary tract reconstruction, with an absolute reduction of a median of 2 UTI episodes [interquartile range range (IQR) 1,4] to 1 episode (IQR 0,2, p<0.001). There was also a reduction in ED visits (IRR 0.44, 95% CI 0.29 to 0.69; p<0.001; adjusted). There was a non-statistically significant trend towards a decreased frequency of inpatient hospitalizations for UTIs (IRR 0.63, 95% CI 0.38 to 1.02; p=0.06; adjusted). Fewer patients received oral antibiotic prophylaxis after initiation of antibiotic instillations (65.4% vs. 48.1%, p<0.001). There was no significant change in MDR status of UTI organisms with instillations (pre-instillation 60% vs. post instillation 40.4%, p=0.48).
Antibiotic bladder instillations decrease frequency of symptomatic UTIs, reduce frequency of ED visits for UTI, and reduce need for oral antibiotic prophylaxis in patients with NGB on CIC. There was no increase in MDR UTI organisms with initiation of intravesical antibiotic instillation.
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