We analyzed a database of 2420 urine cultures from all children with neurogenic bladder who performed clean-intermittent catheterization at a single center from 2008-2014. We exclude urine cultures that had no bacterial growth, growth of mixed organisms, or growth of a fungus, and cultures without a concurrent UA. On the bivariate analysis, we found male gender, bladder exstrophy, presence of a Mitrofanoff, and vesicoureteral reflux (VUR) were all positively associated with pyuria. Multivariate analysis showed that growth of Enterococcus was associated with significantly lower odds of pyuria (Odds ratio: 0.66 (0.47-0.91) for cultures with more than 10,000 colony-forming units per milliliter (CFU/mL); 0.44 (0.30-0.64) for cultures with more than 100,000 CFU/mL) while controlling for age, gender, etiology of neurogenic bladder, presence of a Mitrofanoff, presence of hydronephrosis, and VUR. We also found that hydronephrosis and VUR were both associated with significantly increased odds of pyuria in both analyses, while cloacal malformation, tethered cord, and growth of Proteus were all associated with increased odds of pyuria only in the analysis that included cultures with >100,000 CFU/mL.
This data suggests that the presence of Enterococcus in the urine is associated with a decreased odd of pyuria in children with neurogenic bladders. However, it is important to note that we did not attempt to differentiate between UTI and asymptomatic bacteriuria in this study. While pyuria lacks specificity for the diagnosis of UTI in children with neurogenic bladders, it is possible that the lack of differentiation between UTI and asymptomatic bacteriuria in this work is confounding the results. Further, the clinical applicability of these results is difficult to ascertain. While we do not want to advocate for routine urine cultures in every patient with a neurogenic bladder, as over testing will likely lead to overtreatment, especially with clinicians who have less experience in managing this patient population. However, in patients in whom there is a high degree of suspicion for UTI, but have a UA without pyuria, we would suggest obtaining a urine culture to assess for the presence of Enterococcus.
Written by: Catherine S. Forster, MD, MS, Pediatric Hospitalist, Children's National Medical Center
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