Source:

Forster
CS
,
Shaikh
N
,
Hoberman
A
, et al
.
Uropathogens and pyuria in children with neurogenic bladders
.
Pediatrics
.
2018
;
141
(
5
):
e20173006
; doi:
https://doi.org/10.1542/peds.2017-3006

Investigators from the Cincinnati Children’s Hospital Medical Center and Children’s Hospital of Pittsburgh conducted a retrospective cohort study to assess the relationship between pyuria and type of uropathogen in children with neurogenic bladders who require clean intermittent catheterization (CIC). Eligible patients were identified using electronic medical records. Eligibility criteria included (a) age ≤18 years, (b) diagnosis of neurogenic bladder (defined using ICD-9 codes), (c) a positive urine culture (defined as ≥10,000 CFU/mL on a specimen obtained by catheter) with concurrent urinalysis performed at the study institution between 2008 and 2014, and (d) having undergone CIC during the study period (determined using manual review of medical records). Demographic, clinical, and laboratory data were abstracted from the medical record.

The primary exposure variables were the presence of pyuria, defined as ≥5 urinary white blood cells per high-powered field, and leukocyte esterase (LE) on urinalysis. The primary outcome was the uropathogen isolated from the positive urine culture. Investigators used logistic regression to determine the association between uropathogens and positive LE and pyuria after controlling for potential demographic and clinical characteristics.

There were 2,420 positive urine cultures with concurrent urinalyses included in the analysis. Of these, 1,907 (79%) had pyuria. The most frequently isolated uropathogen was Escherichia coli (37%), followed by Enterococcus (14%) and Klebsiella (11%). Compared to growth of E coli on urine culture, the growth of Enterococcus was associated with decreased odds of pyuria (adjusted OR [aOR], 0.66; 95% CI, 0.47–0.91) and LE on urinalysis (aOR, 0.63; 95% CI, 0.47–0.86). Compared to growth of E coli on urine culture, the growth of Klebsiella was associated with increased odds of LE on urinalysis (aOR, 3.14; 95% CI, 1.67–6.60).

The investigators conclude that in children with neurogenic bladders who require CIC, Enterococcus may grow on urine culture despite no pyuria or LE on urinalysis.

Dr Singer has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.

Compared to the general population, patients with neurogenic bladders who require CIC are at increased risk of UTI. However, the diagnosis and management of UTI in these patients remains somewhat of a conundrum. The Infectious Diseases Society of America guidelines recommend treatment only for patients with symptomatic UTI; however, patients with neurogenic bladder are less likely to have classic UTI symptoms. Urinalysis and urine microscopy have been used to screen patients at risk for UTI; however, as the current investigators point out, the presence of pyuria and LE in this population may be unreliable markers for the presence of UTI. Even the role of urine culture has been questioned in this population because patients with neurogenic bladder are likely to have bacterial colonization and...

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