621 INCIDENCE OF UTI AND REFLUX IN A NICU SETTING

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MODIFICATIONS IN TECHNIQUE LEADING TO IMPROVED SUCCESS OF ROBOTIC EXTRAVESICAL URETERAL REIMPLANATION

PREDICTING FACTORS OF BREAKTHROUGH INFECTION IN CHILDREN WITH PRIMARY VESICOURETERAL REFLUX

Kyle Kiriluk*, Alexandre Rosen, Marcelo Orvieto, Mohan Gundeti, Chicago, IL

INTRODUCTION AND OBJECTIVES: Many pediatric urologists still favor using of prophylactic antibiotics to treat children with vesicoureteral reflux. But, breakthrough infection sometimes occurs and causes significant morbidity resulting renal scarring. So, we tested whether abnormal renal scan and other factors are predictive of breakthrough infection using univariate analyses. METHODS: We retrospectively reviewed the medical records of 163 consecutive children who were diagnosed with vesicoureteral reflux between 1997 and 2010. Clinical parameters for the statistical analysis included form of presentation, gender, age, VUR grade, laterality, presence of intrarenal reflux, class of antibiotic drug, and presence of abnormal renal scan by Dimercapto-succinic acid (DMSA). Clinical parameters used for prognostic factors were established by univariate analyses. Fisher’s exact test and unpaired t test were done using SPSS (SPSS ver. 12.0 (SPSS Inc., Chicago,IL, USA)). RESULTS: Breakthrough infection developed in 61 children (48.0%). A total of 58 children (45.7%) had abnormal renal scans. Time to development of breakthrough infection was significantly longer in girls (9.0 ⫾ 8.2 months) than in boys (5.8 ⫾ 4.8 months, p⬍0.05). On univariate analysis, the most predicting factor for breakthrough infection was abnormal renal scan (p⫽0.062). The second predicting factor was higher reflux grades (p⫽0.071). In patients with abnormal renal scans, there was significant difference between patients younger than 1 year and those 1 year old or older. Mean ⫾ SD age at diagnosis of VUR with breakthrough infection (1.14 ⫾ 3.14) was significantly less than without breakthrough infection (5.05 ⫾ 3.31, p⬍0.01). There was also significant difference between patients with bilateral and unilateral reflux. CONCLUSIONS: Our data showed that abnormal renal scan is the most predicting factor for breakthrough infection. Parents and physicians should aware that these patients are at risk for breakthrough urinary tract infection, potentially leading to renal damage.

INTRODUCTION AND OBJECTIVES: While initial series have reported high failure rates, success of robotic assisted laparoscopic extravesical ureteral reimplantation (RALUR) has now approached that of open surgery. Improved success is often accredited to increased experience without indicating any improvement to technique. We review the outcomes of our first patients to have RALUR and analyze success based on changes in our technique that have occurred over time. METHODS: Between November 2008 and June 2011, a single surgeon, MSG, performed RALUR on a total of 22 patients (35 ureters) with vesicoureteral reflux (VUR). Retrospective analysis of our prospectively maintained database was performed. Only patients with successful completion of RALUR and postoperative voiding cystourethrogram (VCUG) were included in analysis. Success was defined as complete resolution of VUR on VCUG. The surgical technique for RALUR and subsequent modifications were placed into the following categories: Use of simple interrupted stitches and detrussoraphy length (DL) of 3 cm (1), Running stitch with DL of 4 cm (2), Running stitch, incorporation of ureteral adventitia with detrussoraphy closure, and DL of 5 cm (3) (Figure1). RESULTS: 20 patients (8 unilateral and 12 bilateral ureters) fit inclusion criteria. On preoperative VCUG, 12 ureters had grade 3 and 18 ureters grade 4 VUR. In patients with bilateral VUR, one had unilateral grade 1 and one had unilateral grade 2 VUR. Average age at surgery was 5.2 years (range 2.8 – 7.9 years). Mean operative time was 193 minutes for unilateral and 216 minutes for bilateral surgery. Average length of stay was 2.2 days (range 1 to 4 days). One patient was discharged with a catheter for transient urinary retention. No patient required readmission after discharge. Overall, resolution of VUR was seen in 25 of 32 ureters (78%). Resolution of VUR based on surgical technique was 8 of 13 ureters (62%), 6 of 8 ureters (75%), and 11 of 11 ureters (100%) for techniques 1, 2, and 3 respectively. Average follow up was 337 days (range 98 to 889 days). De novo postoperative hydronephrosis was seen in 9 ureters (28%) and resolved in all cases. CONCLUSIONS: Improvement in surgical technique including use of a running stitch, incorporation of ureteral adventitia into closure of detrussoraphy and increasing DL have helped in improving our success of RALUR.

jae shin park*, daegu, Korea, Republic of

Univariate analyses of factors predicting breakthrough infection Univariate Analysis (p-value) Abnormal vs normal renal scan 0.062 Reflux grade l/ll vs. lV/V

0.071

Laterality(unilat. vs bilat.)

0.192

Febrile vs. afebrile presentation

0.131

Age younger than 1yr vs 1yr or older

0.189

Male vs femal Gender

0.984

Present vs. absent intrarenal reflux

0.218

Source of Funding: none

621 INCIDENCE OF UTI AND REFLUX IN A NICU SETTING Douglas Coplen*, Akshaya Vachharajani, Tasnim Najaf, Erica Traxel, Paul Austin, Saint Louis, MO

Source of Funding: None

INTRODUCTION AND OBJECTIVES: Urinary tract infections (UTI) are a cause of bacterial infection in up to 7% of febrile infants and children. Hydronephrosis and vesicoureteral reflux(VUR) are risk factors for febrile UTI. Ultrasound (US) identifies obstruction but is not sensitive or specific in the detection of VUR. The AAP guidelines (2011) for infants 2-24 months of age recommend a VCUG only if the US is abnormal. We evaluated US findings and the incidence of reflux in premature neonates with a history of UTI identified during hospitalization in a NICU. METHODS: We retrospectively reviewed the records of all NICU admissions during a 5 year period (2006-2010) at a tertiary care children’s hospital. UTI was defined as ⬎ 10000 bacteria on a catheterized urine sample. Concomitant blood culture results were tabulated

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in infants with a UTI. Gender, race, birth weight, estimated gestational age, indications for urine culture, and congenital anomalies were recorded for each infant. During this period an US and VCUG were recommended in all infants with a UTI. US images were reviewed. Renal dilation was categorized using the Society for Fetal Urology classification. VUR was graded using the International Reflux classification. RESULTS: There were 3518 (1481 females and 2037 males) unique NICU admissions during the five year time period. UTI was identified in 110 infants (3%). There were 21 females (1.4%) and 89 males (4.4%) with UTI. None of the males was circumcised. Median gestational age was 27 weeks (mean 31 weeks) in those with UTI (range 23-40 weeks). US and VCUG findings in neonates with UTI are shown in table 1. Reflux was grade II in six neonates, grade III in 4, grade IV in 2 with grade 2 dilation, and grade V in one with grade 3 dilation. CONCLUSIONS: Anatomic abnormalities are uncommon in neonates with a UTI. None had obstruction and high grade reflux was identified in only 3 infants (3%). This population is instead at increased risk for UTI for other reasons, such as their naı¨ve immune status, comorbidities related to prematurity, and the presence of invasive monitoring and vascular access. In concordance with recent AAP guidelines a VCUG may not be required in all neonates with a history of UTI. While US is a poor predictor of VUR high grade reflux is rare in neonates with a normal US.We propose a judicious policy reserving VCUG studies for NICU neonates with UTI and upper tract abnormalities identified on US. US findings normal

# neonates 73

# with reflux 4 (5%)

grade 1

8

5 (62%)

grade 2

26

3 (12%)

grade 3

2

0

grade 4

1

1 (100%)

Source of Funding: None

622 OCCULT MEGARECTUM: A COMMONLY UNRECOGNIZED CAUSE OF ENURESIS Irina Stanasel*, Gordon McLorie, Anthony Atala, Steve Hodges, Winston-Salem, NC INTRODUCTION AND OBJECTIVES: O’Regan et al. proved constipation was a commonly unrecognized cause of enuresis in 1986. In that study, constipation was defined as abnormal rectal distention. Modern recommendations focus on clinical signs, such as hard or rare stools, to define constipation. However, this definition fails to account for a group of children who have megarectum without clinically obvious functional constipation. We hypothesize that occult megarectum remains a commonly unrecognized cause of enuresis, and that treating megarectum in children with this type of constipation will cure enuresis in most children. METHODS: A retrospective review of 30 consecutive patients seen in our clinic with a chief complaint of nocturnal enuresis was performed, with an analysis of the results of their plain abdominal radiographs. The results of the studies were based on a novel method termed the rectal to pelvic outlet ratio (RPOR), and Leech criteria. These results were compared to the reported constipation history per ICCS guidelines, which recommends asking parents and children if the child’s bowel movements occur less often than every other day, and if the stool consistency is hard. Patients diagnosed with megarectum were treated with laxatives with the goal of restoring normal rectal tone. RESULTS: All patients demonstrated rectal distention by RPOR ratio, while 80% were constipated by Leech criteria. Only 10% of the patient or families reported clinical symptoms of constipation. All the adolescent patients in our study, and 80% of the younger patients, were cured of enuresis with laxative therapy.

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CONCLUSIONS: Occult megarectum remains a commonly undiagnosed cause of nocturnal enuresis. Abdominal radiographs represent a simple, noninvasive method to diagnose megarectum, and may improve the treatment of nocturnal enuresis. Source of Funding: None

623 URINE CULTURE UTILIZATION AND BROAD-SPECTRUM ANTIBIOTIC PRESCRIPTION FOR PEDIATRIC URINARY TRACT INFECTION: GUIDELINES VERSUS PRACTICE PATTERNS Hillary Copp*, San Francisco, CA; Jenny Yiee, Los Angeles, CA; Alexandria Smith, Janet Hanley, Santa Monica, CA; Christopher Saigal, Urologic Diseases in America, Los Angeles, CA INTRODUCTION AND OBJECTIVES: Broad-spectrum antibiotics are frequently prescribed in the outpatient treatment of pediatric urinary tract infection (UTI). As a key step in decreasing the emergence of antimicrobial resistance the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America recommend tailoring of empiric antibiotic therapy based on urine culture results. No study has characterized the concurrent use of urine cultures with empiric broadspectrum antibiotic prescription in the treatment of pediatric UTI. METHODS: We used Innovus i3, a claims database with longitudinal data from 2002-2007. We examined children ⬍18 years who had a broad-spectrum antibiotic prescribed for an outpatient UTI. Amoxicillin-clavulanate, quinolones, macrolides, and second- and thirdgeneration cephalosporins were classified as broad-spectrum antibiotics. We evaluated trends in obtaining urine cultures with broad-spectrum prescription and performed multivariable logistic regression to assess for factors associated with obtaining a urine culture with broadspectrum prescription for UTI. RESULTS: Urine culture was performed in 62% of the 10,318 UTI visits for which a broad-spectrum antibiotic was prescribed. The proportion of urine cultures obtained among broad-spectrum UTI visits decreased during the study period from 67% to 58% (p⬍0.001). On multivariable analysis age (2-5 years: OR 1.3, 95%CI 1.1-1.5 and 6-12 years: OR 1.4, 95%CI 1.2-1.6 compared with age 13-17 years); history of UTI (OR 1.1, 95%CI 1.0-1.2); presence of congenital urologic anomaly (OR 1.2, 95%CI 1.0-1.4); and physician specialty (pediatricians: OR 2.4, 95%CI 2.2-2.7 compared with family physicians/internists) were independent predictors of performing a urine culture with broad-spectrum antibiotic prescription. Males (OR 0.8, 95%CI 0.7-0.9) and patients from the Northeast (OR 0.8, 95%CI 0.7-0.9), Midwest (OR 0.9, 95%CI 0.8-0.9), and West (OR 0.7, 95%CI 0.6-0.8) compared with the South were less likely to have urine cultures obtained when prescribed broad-spectrum antibiotics. CONCLUSIONS: Providers often do not obtain urine cultures when prescribing broad-spectrum antibiotics and the occurrence of this practice has decreased overtime. Important differences in practice patterns were observed based on patient sex, geographic location, and physician specialty. These findings support the need for interventions to promote guideline-based practices for empiric broad-spectrum antibiotic treatment of pediatric UTI. Source of Funding: NIH NIDDK (Urologic Diseases in America)

624 BROAD-SPECTRUM ANTIBIOTIC PRESCRIBING PATTERNS IN OUTPATIENT PEDIATRIC URINARY TRACT INFECTION Hillary Copp*, San Francisco, CA; Jenny Yiee, Los Angeles, CA; Alexandria Smith, Janet Hanley, Santa Monica, CA; Christopher Saigal, Urologic Diseases in America, Los Angeles, CA INTRODUCTION AND OBJECTIVES: Ambulatory care physicians often prescribe broad-spectrum antibiotics for the treatment of pediatric urinary tract infection (UTI). However, most UTIs are susceptible to narrower-spectrum alternatives. Few studies have examined factors that are associated with broad-spectrum antibiotic prescribing practices for pediatric UTI.