Urinary Tract Infection In Children With Spina Bifida And Spinal Cord Injury

Obumneke Amadi, MPH(c)KKI/Ferguson FellowJULY 2013

Spina Bifida What is Spina Bifida: Spina Bifida literally means “split spine.” Spina Bifida happens when a baby is in the womb and the spinal column does not close all of the way3 Types of SB:• Occult Spinal Dysraphism• Spina Bifida Occulta• Myelomeningocele

Epidemiology Of Spina Bifida

• 1 out of 1,000 infants in us born with Spina Bifida

• 90-95% of babies born with Spina Bifida are born to parents with no family history of Spina Bifida

• Most common in girls than boys

• Most common neural tube defect

SOURCE: What is Spina Bifida? - Spina Bifida Association Retrieved from www.spinabifidaassociation.org

Spina Bifida(diagram)

Spinal Cord Injury

What is Spinal Cord Injury A spinal cord injury begins with a sudden, traumatic blow to the spine that fractures or dislocates vertebrae.

Types of SCI

• Complete

• Incomplete

Source: Spinal Cord Injury (2013). National Institutes of Health. Retrieved from www.ninds.nih.gov/disorders/sci

Epidemiology Of Spinal Cord Injury• It is estimated that the annual incidence of spinal cord

injury is approximately 40 cases per million population in the U. S. or approximately 12,000 new cases each year

-the average age at injury was 28.7 years-most injuries occur between the ages of 16 and 30-80.6% of spinal cord injuries occur among males-most common cause of SCI is falls, followed by acts of violence

Source: Spinal Cord Injury Facts and Figures at a Glance(2012) - National Spinal. Retrieved from https://www.nscisc.uab.edu

Spinal Cord

Urinary Tract Infection(UTI)What is UTI:

• UTI occurs when organisms in bladder cause infection

▫ >10,000 CFU in a catheterized sample▫ >100,000 CFU in clean catch

AND Fever Dysuria (painful urination) Frequency Back pain White blood cells in the urine

• Bacteria are the most common cause of UTIs.

Source: Urinary Tract Infections in Adults(2011). National Kidney andUrologic: Retrieved from kidney.niddk.nih.gov/kudiseases/pubs/utiadult

Epidemiology of UTIIncidence and PrevalenceIncidence• Females: 1,200 cases per 100,000 persons annually

• Males: 30 cases per 100,000 persons annually

Prevalence

• Females: 1,000 to 4,000 cases per 100,000 persons

• Males: <100 cases per 100,000 persons

source: Urinary Tract Infection(2012).Elsevier: https://www.clinicalkey.com/topics/urology/urinary-tract-infection.html

Organisms Associated With UTI• E coli (is the most common causing 75-90% of

UTI)• Klebsiella species• Proteus species• Enterococcus species• Staphylococcus saprophyticus• Staph aureus• Fungal in immune compromised patients

Risk Factors1. Bacterial virulence

2. Host factors :Anatomical:• Abnormal insertion of ureters in the bladder.• Urinary tract obstruction caused by phimosis, meatal

stenosis • Indwelling catheter

Functional: • *Neurogenic bladder in spina bifida patients and spinal

cord injuryImmunologic • Immune deficiency

Catheter

Urinary Tract

Antibiotic Sensitivity Antibiotic sensitivity is the susceptibility of bacteria to antibiotics. The AST test is usually carried out to determine which antibiotic will be most successful in treating a bacterial infection in vivo. Testing for antibiotic sensitivity is often done by the Kirby-Bauer method. The ranges include:• Susceptible: organisms exposed to antibiotic with a high

likelihood of therapeutic success.• Intermediate : organisms exposed to antibiotic with an

uncertain therapeutic effect.• Resistant: organisms are able to survive after exposure to one or

more antibiotics

Antibiotic Sensitivity/Medication• Kirby-Bauer method Disc:

MedicationThese are the common Antibiotics used to treat UTI, they prevent complications of infections such as kidney damage. Most antibiotics come in pill or liquid form

Source:Antibiotics for Urinary Tract Infections (UTIs)(2013). Retrived from Health-Encyclopedia - Kaiser Permanente.htm

Generic Name Brand Name

Ciprofloxacin Cipro

AmoxicillinAmoxil, Augmentin,others

NitrofurantoinFuradantin, Macrobid, Macrodantin

Sulfamethoxazole with Trimethoprim Bactrim, Septra

Purpose and Objectives

• The purpose of the study was to examine organisms associated with UTI in the population of children with SB and SCI who were treated in out-patient and in-patient settings

• Public health significance: Knowledge of the causative organisms associated with UTI in patients with SB and SCI is of public health significance to promote appropriate use of antibiotics and reduce kidney damage

Hypothesis•Children with spinal cord injury and spina

bifida have a larger variety of organisms causing UTI than in the general population

•Organisms causing UTI in Children with spinal cord injury and spina bifida will have more resistance

Method• A retrospective record review was conducted to extract data

from medical records and a pre-existing data base of in-patients and out-patients with SB and SCI who were diagnosed with UTI.

• Medical records from 2010-2013 were reviewed

• Data on demographics (e.g., gender, age, and race/ethnicity), medical condition, medication, and organism responsible for UTI, organism antibiotic resistance, hospital status input & output will be obtained.

• Chi square analysis was done to determine if there were statistically significant differences in the organisms infecting children with SCI versus SB.

Demographic (N=31)Characteristics n (%) Mean (SD)Gender (Male) 16 (52)Age (Years) 16.8 (7.8)Race White 17 (55) African American 10 (32) American Indian 3 (10) Other 1 (3)Ethnicity Hispanic 1 (3)

Organisms Infecting Patients with SB/SCISB/SCI General PopulationE. Coli (35%) E. Coli (75-90%)E. Faecalis (25%) E. Faecalis (2.15%)Klebsiella sp.(13%) Staph sp (6.45%)Staph sp. (10%) Klebsiella sp (1.07%)

There were no statistically significant differences in the organisms infecting children with SCI compared to SB (Pearson chi2 (5) =7.1803; P = 0.0208).

Antibiotic Susceptibility PatternRates for antibiotic sus/1

inter/2

resis/3

AMPICILLIN 14 0 13AMP. SUBACTAM 13 0 6PIPER)TAZO 19 0 2CEFAZOLIN 17 1 3CEFOXITIN 17 0 6CEFRIAXONE 18 0 2CEFEPIME 20 0 2AZTREONAM 18 2 2MER0PENEM 19 0 2 ERTAPENEM 18 0 2TRIMETH_SULFA 16 0 3TETRACYCLINE 12 3 13GENTAMICIN 18 0 2TOBRAMYCIN 17 1 3AMIKACIN 19 1 1CIPORFLOXACIN 17 0 5

NITROFURANTOIN 18 2 3OXACILLIN 0 0 2VANCOMYCIN 7 0 0

TOTAL 297 10 72 379AMPICILL

IN

AMP. SUBACTA

M

PIPER)TA

ZO

CEFAZO

LIN

CEFOXITI

N

CEFRIAXONE

CEFEP

IME

AZTREO

NAM

MER0PEN

EM

ERTA

PENEM

TRIM

ETH_SU

LFA

TETRACYC

LINE

GENTA

MICIN

TOBRAMYC

IN

AMIKACIN

CIPORFLOXACIN

NITROFU

RANTOIN

OXACILLIN

VANCOMYCIN

0

5

10

15

20

25

sus/1

inter/2

resis/3

Conclusion And Public Health Significance

• E. coli is the leading cause of UTI in our study. • Contrary to the study’s of hypothesis, the susceptibility of the

bacteria to commonly used antibiotics is good.• It is also recommended that proper sensitivity testing of Urinary

tract infection causing organisms should be undertaken to guide the management of UTIs until the development of conclusive local guidelines to therapy.

• Using antibiotic susceptibility data assists pediatric providers in using appropriate first line antibiotics when children present with symptoms of urinary tract infection.

Strengths And WeaknessesStrength• Study of specialized

underserved population of children

• Increased knowledge of the organisms causing UTI in patients with SB and SCI

Weakness• Small sample size• Limited access to lab work

in out patient population• Limited generalizability

Reference• Abdelaziz Elamin(n.d).Urinary tract infection in children. Retreived from

www.pitt.edu/~super7/43011-44001/43861.ppt

• Mohamad Fakih(n.d).Appropriate Urinary Catheter Use And Management Retrieved from http://www.catheterout.org

• Urinary Tract Infection(2012).Elsevier: https://www.clinicalkey.com/topics/urology/urinary-tract-infection.html

• Urinary Tract Infections in Adults(2011). National Kidney andUrologic: Retrieved from kidney.niddk.nih.gov/kudiseases/pubs/utiadult

• What is Spina Bifida?(2012).Retrieved from www.spinabifidaassociation.org

• Spinal Cord Injury Facts and Figures at a Glance(2012) - National Spinal. Retrieved from https://www.nscisc.uab.edu

• Spinal Cord Injury (2013). National Institutes of Health. Retrieved from www.ninds.nih.gov/disorders/sci

Acknowlegement

•CDC Ferguson Fellowship program•Kennedy krieger institue – mentors•Dr H.Belcher