Uropathogens and Pyuria in Children With Neurogenic Bladders

BACKGROUND: A recent study revealed that specific uropathogens are associated with lower odds of pyuria in a general pediatrics population. Children with neurogenic bladders who require clean intermittent catheterization (CIC) frequently have pyuria. Our objective with this study was to determine if an association exists between pyuria and type of uropathogen in CIC-dependent children.

METHODS: We obtained urinalysis and urine culture results from electronic medical records from January 2008 through December 2014 for patients ≤18 years of age with neurogenic bladders managed at a single institution. Cultures without concurrent urinalyses were excluded from analysis, as were cultures that yielded no growth, fungal growth, or growth of unidentified mixed organisms. We used logistic regression to determine the association of pyuria and leukocyte esterase with specific uropathogens.

RESULTS: We included 2420 cultures in this analysis. The growth of Enterococcus on urine culture was associated with lower odds of both pyuria and leukocyte esterase. In contrast, the growth of more than 100 000 colony-forming units per milliliter of Proteus mirabilis was associated with increased odds of both pyuria and leukocyte esterase, and the growth of Pseudomonas aeruginosa was associated with increased odds of leukocyte esterase but not pyuria. Certain etiologies of neurogenic bladder, such as bladder exstrophy and cloacal malformations, were also associated with increased odds of pyuria compared with neurogenic bladder due to myelomeningocele.

CONCLUSIONS: In children with neurogenic bladders who require CIC, Enterococcus may grow in urine culture without pyuria or positive leukocyte esterase. Accordingly, urine cultures should be obtained in symptomatic children, regardless of urinalysis results.

Abbreviations:

CI — 

confidence interval

CIC — 

clean intermittent catheterization

ICD-9 — 

International Classification of Diseases, Ninth Revision

UTI — 

urinary tract infection

VUR — 

vesicoureteral reflux

What’s Known on This Subject:

The growth of Enterococcus in urine culture is associated with lower odds of pyuria in children with a normal genitourinary tract. Children with neurogenic bladders who require clean intermittent catheterization frequently have pyuria, which may confound this association.

What This Study Adds:

Enterococcus in urine culture from children with neurogenic bladders is associated with lower odds of pyuria. In a symptomatic child, urine culture should be performed regardless of the urinalysis results.

Children with neurogenic bladders who require clean intermittent catheterization (CIC) frequently have bacteriuria. Routine urinalysis is often used at the point of care to diagnose a urinary tract infection (UTI). In a general pediatric population, specific uropathogens (eg, Enterococcus species, Klebsiella species, and Pseudomonas aeruginosa) were less likely to be associated with pyuria than Escherichia coli.1 However, children with neurogenic bladders who require CIC frequently have chronic urethral inflammation, which may confound the association between pyuria and uropathogens.2 Therefore, we sought to determine if the presence of pyuria was associated with specific uropathogens in children with neurogenic bladders.