title: Discontinuation of Antimicrobial Prophylaxis (AP) in Children With Spina Bifida: A Case Series Analysis.
abstract: BACKGROUND
  Spina bifida increases the risk for urinary tract infections (UTI). Antimicrobial prophylaxis (AP) reduces symptomatic UTI's but selects resistant organisms. Measures to ensure regular and complete emptying of the bladder combined with treatment of constipation reduce the risk for UTI.
  
  
  OBJECTIVE
  Demonstrate that close adherence to a catheterization regimen in children with spina bifida (Selective Treatment - ST) reduces the need for antimicrobial prophylaxis.
  
  
  METHODS
  Case series analysis of pediatric spina bifida clinic patients where routine antimicrobial prophylaxis was replaced by clean-catch catheterization and daily bowel regimen (ST). Retrospective chart review of 67 children (mean entry age: 24 months, median age: 4 months; 32 Males, 35 Females) enrolled between 1986 - 2004. Mean follow-up was 128.6 months (range 3 - 257 months). Asymptomatic and symptomatic UTI incidences were noted on AP and ST protocols. Creatinine clearance at study entry and follow-up was calculated by the age appropriate method. A multivariable regression model with delta Glomerular Filtration Rate (GFR) as the dependent variable, independent sample t-test and Wilcoxon rank sum were performed with SAS v. 9.2.
  
  
  RESULTS
  The mean number of infections while on AP was 8.7 (95% CI 5.72, 11.68) and was 1.0 on ST (95% CI 0.48, 1.43). 5 infections on the AP protocol required intravenous (IV) antibiotics due to resistance to oral therapy, but none on ST. Comparing change in GFR between both protocols (AP vs. ST) found a significant difference in the change of GFR by treatment protocol.
  
  
  CONCLUSIONS
  AP did not prevent UTIs and resulted in more resistant organisms requiring IV antibiotics. Discontinuing AP allowed the return of susceptibility to oral antimicrobials and significantly improved GFR in those children who had previously been on AP. Adherence to a catheterization regimen with prompt treatment of symptomatic UTI conserved renal function and prevented selection of resistant organisms.
authors.affiliation: Yale School of Medicine, New Haven, Connecticut, USA.
authors.forename: Kevin G
authors.initials: KG
authors.lastname: Couloures
authors.affiliation: The University of Oklahoma Health Sciences Center, Oklahoma City, USA.
authors.forename: Michael
authors.initials: M
authors.lastname: Anderson
authors.affiliation: The University of Oklahoma Health Sciences Center, Oklahoma City, USA.
authors.forename: Michael
authors.initials: M
authors.lastname: Machiorlatti
authors.affiliation: Yale School of Medicine, New Haven, Connecticut, USA.
authors.forename: Olivera
authors.initials: O
authors.lastname: Marsenic
authors.affiliation: Keck School of Medicine of USC, Los Angeles, California, USA.
authors.forename: Lawrence
authors.initials: L
authors.lastname: Opas
keywords: Antimicrobial Drug Resistance; Cohort Series; Spina Bifida; Urinary Catheterization; Urinary Tract Infection