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Evaluating the utility of routine urine culture and antibiotic treatment in children undergoing OnabotulinumtoxinA injection
Hannah Agard Bachtel, MD1, Hunter Flores, MS2, Bridget Park, MS2, Soo Jeong Kim, MD1, Susan L. Jarosz, DO1, Paul F. Austin, MD1, Chester J. Koh, MD1, Nicolette K. Janzen, MD1.
1Texas Children's Hospital/Baylor College of Medicine, Houston, TX, USA, 2Baylor College of Medicine, Houston, TX, USA.

BACKGROUND: OnabotulinumtoxinA (Botox) is used as treatment for refractory idiopathic and neurogenic detrusor overactivity in children. Many patients perform intermittent self-catheterization and therefore have higher rates of asymptomatic bacteriuria, which may increase their risk of symptomatic urinary tract infection (UTI) following treatment. Multiple injections are often needed due to the short-term efficacy of onabotulinumtoxinA treatment, and this may also increase the risk of UTI. The goal of this study is to evaluate whether a sterile urine is necessary to decrease the risk of symptomatic postoperative UTI in patients undergoing intradetrusor Botox injection.
METHODS: A retrospective review of all patients undergoing intradetrusor Botox injection at our institution from January 2014 to October 2021 was performed. Demographic data, clinical characteristics, antibiotic treatment and urine culture results were collected. A positive urine culture was defined as > 103 CFU/ml in growth of any uropathogenic bacteria. Our primary outcome was the development of a symptomatic UTI within 14 days of the procedure.
RESULTS: A total of 103 patients underwent 158 treatments with onabotulinumtoxinA. The overall incidence of symptomatic postoperative UTI was 3%. Patients with asymptomatic bacteriuria had a greater incidence of symptomatic postoperative UTI compared to those with sterile urine, but the difference was not significant (3.8% vs 0%, p=0.57). Obtaining a urinalysis or urine culture prior to surgery did not affect the incidence of symptomatic postoperative UTI (p=0.54). The number needed to treat with antibiotics to prevent one symptomatic postoperative UTI was 27. Prior history of a multi-drug resistant UTI was a significant risk factor in the development of symptomatic postoperative UTI (p=0.048).
CONCLUSIONS: The risk of symptomatic UTI following OnabotulinumtoxinA injection in children is low. The presence of sterile urine at the time of surgery does not significantly decrease the risk of symptomatic postoperative UTI. Routine treatment of asymptomatic bacteriuria results in a large number of patients receiving unnecessary antibiotics. Patients with a prior history of multi-drug resistant UTI are at increased risk of symptomatic postoperative UTI and may benefit from pre-operative urine testing and treatment.


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