Prospective Evaluation of a Pediatric Urodynamics Protocol with Targeted Urine Cultures
Rachel Shannon, MPH, Theresa Meyer, MS, RN, CPN, Dawn Diaz-Saldano, APN, MSN, CPNP, Liza Beilke, DNP, APRN, CPNP, Devon C. Snow-Lisy, MD, Sameer J. Patel, MD, Ilina Rosoklija, MPH, Emilie K. Johnson, MD, MPH, Elizabeth B. Yerkes, MD.
Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.
Background Recent prospective analysis of an institutional urodynamics (UDS) urine culture (UCx) protocol demonstrated a high rate of asymptomatic bacteriuria (39%). However, the rate of symptomatic post-UDS UTI was <1% with no identifiable predictors, casting doubt on the utility of UCx at time of catheterization for UDS. The protocol was thus modified to restrict UCx to a targeted subset of patients. This study aims to evaluate the modified protocol to determine if restricting UCx during UDS increased the rate of symptomatic post-UDS UTI.
Methods The UDS protocol at one freestanding children’s hospital was modified in 7/2019 to restrict formerly routine UCx during UDS to only patients <2 years old and not on clean intermittent catheterization (CIC), and to those with symptomatic UTI in prior 30 days, multi-drug resistant or vancomycin-resistant Enterococcus infection, or immunosuppression. A check-in call was made 48-72 hours after UDS, and those without symptoms only received antibiotic treatment for positive UCx if they did not use CIC. A prospective study of patients undergoing UDS 7/2019 - 6/2020 was undertaken. Clinical history, UCx results, and follow-up were documented. The primary outcome was symptomatic post-UDS UTI, defined as positive UCx ≥10^4 CFU/mL and fever ≥38.5◦C or new urinary symptoms of pain (flank, abdominal, or with catheterization), gross hematuria, fever, cloudy or foul-smelling urine, urgency, or frequency within 7 days of UDS. Data were analyzed using descriptive statistics, Mann Whitney test, and Fisher’s exact test.
Results 533 patients underwent 601 UDS (309/601=51% female, 324/601=54% White, 187/601=31% Hispanic, median age 8 years [range 0-28]). The primary indication was most commonly myelomeningocele (MMC) (34%), fatty filum (18%), lipomyelomeningocele (LMM) (10%), tethered cord (7%), or posterior urethral valves (5%). 21% had diagnosed vesicoureteral reflux (VUR) before UDS. Most (44%) used CIC, 37% used diapers, and 18% voided volitionally. Of 601 UDS, 204 (34%) were accompanied by UCx. Of 204 UCx, 72 (35%) were positive, predominantly with E. coli (38/72=53%) or Klebsiella (10/72=14%). Patients with positive UCx were older (median 2.6 years vs. median 1.2 years, p<0.00001), and more likely to have MMC or LMM (47% vs. 30%, p=0.0146), use CIC (53% vs. 15%, p<0.00001), and have VUR (26% vs. 13%, p=0.0208). 20% (20/105) of UCx from patients <2 years with no CIC use were positive. Only three patients (5%) developed symptomatic post-UDS UTI. Two of these patients had UCx with UDS, 1 positive and 1 negative. The 3 patients did not have appreciable similarities regarding UDS indication, bladder management, age, sex, or VUR, and none had UTI symptoms at the time of UDS or prior 30 days.
Conclusions Risk of symptomatic post-UDS UTI remained very low (<1%) after restricting UCx during UDS to a targeted subset of patients, with no identifiable predictors. Only 1% (1/72) of positive UCx were associated with symptomatic post-UDS UTI, underscoring the lack of utility of UCx during UDS. Refinement of the UDS protocol is indicated, which may include discontinuation of UCx in all groups or observation of asymptomatic positive UCx in infants that do not use CIC.
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