Urinary Tract Infection In Children With Spina Bifida And

Spinal Cord Injury

Obumneke Amadi, MPH(c)KKI/Ferguson Fellow

JULY 2013

Spina Bifida(SB) What is SB: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 wayTypes of SB:• Occult Spinal Dysraphism : Infants with this have a dimple in their lower back• Spina Bifida Occulta: It is often called “hidden Spina Bifida” because about 15 percent of

healthy people have it and do not know it. However, pain and neurological symptoms may occur

• Spina Bifida Cystica: is the most severe form of Spina Bifida. It happens when parts of the spinal cord and nerves come through the open part of the spine. It causes nerve damage and other disabilities

Epidemiology Of Spina Bifida• 1 out of 1,000 infants in us born with SB• 90-95% of babies born with SB are born to parents with no family history of SB• Most common in girls than boys• Most common neural tube defect(NTD)• Occurs most frequently in birth defect that results to disability

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

Spina Bifida(diagram)

Spinal Cord Injury(sci)What is SCI: A spinal cord injury usually begins with a sudden, traumatic blow to the spine that fractures or dislocates vertebrae. The damage begins at the moment of injury when displaced bone fragments, disc material, or ligaments bruise or tear into spinal cord tissueTypes of SCI:• Complete - A complete injury is indicated by a total lack of sensory and motor function

below the level of injury. People who survive a spinal cord injury will most likely have medical complications such as chronic pain and bladder and bowel dysfunction, in-addition to respiratory and heart problems. Successful recovery depends upon how well these chronic conditions are handled day to day.

• Incomplete - the ability of the spinal cord to convey messages to or from the brain is not completely lost. People with incomplete injuries retain some motor or sensory function below the injury

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 (SCI), not including those who

die at the scene of the accident, 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, and most injuries occurred between the ages of 16 and 30-80.6% of spinal cord injuries occurred among males-most common cause of SCI is falls, followed by acts of violence (primarily gunshot wounds).

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

Spinal Cord (diagram)

Urinary Tract Infection(UTI)

What is UTI:• Is the finding of microorganisms in bladder urine including fungi, viruses, and bacteria.

Bacteria are the most common cause of UTIs. This occurs as a result of bacterial invasion of the bladder due to the ascending infection from perianal contaminates, usually the bowel flora such as Escherichia coli.

• Bacteria infection of the bladder with UTI is more like to occur in infrequent or incomplete voiding.

• ICD-9 code : 599.0

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

Urinary Tract(diagram)

Epidemiology of UTIIncidence and prevalenceIncidence• Females: 1,200 cases per 100,000 persons annually• Males: 30 cases per 100,000 persons annuallyPrevalence• Females: 1,000 to 4,000 cases per 100,000 persons• Males: <100 cases per 100,000 personsDemographicsAge• Among infants up to 6 months of age, UTI is more common in boys than girls• Among persons between 1 and 65 years of age, UTI predominantly occurs in female patients, presumably

because of the anatomy of the female urethra, which allows bacteria to access the urinary tract relatively easily

• Among persons over age 65, bacteriuria affects men and women roughly equally (approximately 40Gender• UTI is more frequent in females than in males• Uncircumcised male infants have a higher incidence of UTI than female infants.

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

Risk Factors1. Bacterial virulence i.e. Extremely infectious2. Host factors :Anatomical• abnormal insertion of ureters in the bladder.• Urinary tract obstruction caused by phimosis, meatal stenosis

• Indwelling catheterFunctional : such as neurogenic bladder in spina bifida patients, and inappropriate detrusor muscle contractions Immunologic : in immune deficiency

Hospital Acqiured UTI• Catheter-associated infections (CAUTI)comprise 80% of these cases• UTIs account for 40% of all hospital-acquired infections• Catheter-risk of bacteriuria increases risk of bacteriuria increases each day of use:• Per day: 5% Per day: 5%• 1 week: 25%• 1 th 100%

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

Catheter(Diagram)

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

InvestigationLAB STUDIES:Urine cultures are sent to the laboratory for Interpretation: • A clean-catch urine sample with more than 100,000 colony-forming units (CFU) of a single

organism is classic criteria for UTI.• a clean-catch specimen that reports any growth. If the specific gravity of the urine was low,

60,000-80,000 CFU may be significant.• Lower colony counts may be significant if present on a repeat culture. Contamination with

perenial flora may mask an existing UTI

Source: Abdelaziz Elamin(n.d).Urinary tract infection in children. Retreived from www.pitt.edu/~super7/43011-44001/43861.ppt

Culture• Suprapubic aspiration >1,000 cfu/ml• Cath >10,000 cfu/ml• Clean catch>100,000 cfu/ml

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:

MedicationGeneric Name Brand Name

ciprofloxacin Cipro

levofloxacin Levaquin

nitrofurantoinFuradantin, Macrobid, Macrodantin

sulfamethoxazole with trimethoprim Bactrim, Septra

These are the common Antibiotics used to treat UTI, they prevent complications of infections 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

Research Public health significance:• The prevalence of (UTI) in (SB) and (SCI) is on the rise in children and has become a Public

health significance on measures to find prevention of (UTI) which causes heart disease, kidney damage and death as a result of renal failure if left untreated.

• National Hospital Ambulatory Medical care survey, stated that UTI caused nearly 7 million physicians visits and 1 million EMS visits, leading to 100,000 hospitalizations.

• The retrospective study was to find secondary prevention of the known Bacteria and antibiotic vaccine to stop UTI infection through comparing data between SB and SCI Inpatient and Outpatient children

• Outcome: In a samll population of 35.The most common bacteria was E.coli (n= 12, 39%), followed by E.faecalis (n=9; 29%), Staph sp.(n=4;13%), Klebsiella sp. (n= 3;10%), Pseudomonas sp.(n=2; 6%) and Proteus sp. (n=1, 3%). Chi square analysis was done to determine if there were statistically significant differences in the organisms infecting children with SCI versus SB. There were no statistically significant differences in the organisms infecting children with SCI compared to SB (Pearson chi2 (5) =7.1803; P = 0.0208). Data on antibiotic susceptibility patterns for children with spinal bifida and spinal cord injury presented a total number of susceptibility (n-307), intermediate(n-10) and resistance(n-76). The most used medication is Cipro followed by Bactrim and Cefixime.

Conclusion• Urinary tract infection is preventable in the hospital by practicing a required level of aseptic

techniques in catheter use by the care givers and also through inspection of equipment and materials used for the purpose.

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