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Postoperative catheterization and prophylactic antimicrobials in children with hypospadias
POSTOPERATIVE CATHETERIZATION PROPHYLACTIC ANTIMICROBIALS
AND
IN
CHILDREN WITH HYPOSPADIAS ISAAC
SHOHET,
MORDECHAI
M.D. ALAGAM,
M.D.
RAPHAEL SHAFIR, M.D. HAGGAI TSUR, M.D. BERNARD
COHEN,
F.R.C.P.E.
From the Chaim Sheba Medical of Medicine, Tel Aviv University,
Center, Sackler School Tel Hashomer, Israel
ABSTRACT-A prospective study of 78 children who underwent 84 operations for correction of hypospadias was done. Of these, 54 had a transperineal indwelling Foley catheterfor ten days after surgery and 30, a transurethral catheter. Forty-five randomly selected children received prophylactic antimicrobial therapy (sulfamethoxazole), and the remaining 39 children served as controls. Incidence of urinary tract infection was significantly higher in the control group (10 of 39) as compared with the treated group (3 of 45) in spite of the higher incidence of vesicoureteral reflux in the treated group. This suggests that prophylactic antimicrobial treatment may prevent urinary tract infection from prolonged indwelling catheterization.
Hypospadias is one of the most common anomalies of the urogenital tract: its incidence ranges from 1 to 3.3 per 1,000 live births.’ Following surgical repair of hypospadias, an indwelling urinary catheter is inserted for a period of seven to ten days.2 Prolonged bladder catheterization is associated with an increased rate of urinary tract infections.3 Several authors have advocated the use of prophylactic antimicrobials in these patients. 4 No data are available concerning prolonged catheterization in children after hypospadias repair. During the last two and one-half years 84 operations for the correction of hypospadias were performed in Chaim Sheba Medical Center. In a prospective study we examined the incidence of urinary tract infection in catheterized children to determine the value of prophylactic antimicrobials. Material
pospadias were included in the study. Prophylactic antimicrobials were given to 41 children after 45 operations (Group A) (Table I). Treatment was started with sulfamethoxazole on the first postoperative day up to the third day after the catheter was removed. No prophylactic treatment was given to the remaining 37 children after 39 operations (Group B). During operation under sterile conditions an indwelling latex Foley catheter was introduced with a gravity closed-drainage system. The catheter was left for ten days. Catheter was inserted by transperineal approach in 50 children following 54 operations of either second stage Browne method or a one-stage repair. Transurethral procedure was used in 28 children who underwent 30 operations of first stage repair. Urine specimens were cultured on admission and on postoperative days 2, 3, 5, 6, 8, and 10. Catheter urine cultures were considered positive if more than lo4 organisms per milliliter were found. Children with positive urine cultures preoperatively were excluded from the
and Methods
Seventy-eight patients who underwent eighty-four operations for the correction of hy-
UROLOGY
/
OCTOBER
1983
/
VOLUME
XXII,
NUMBER
4
391
TABLE I.
Clinical
Comparison
between treated and control groups No Prophylactic Treatment Group B
Prophylactic Antimicrobials Group A
Data
Number of children Number of operations Transperineal catheterization: operations Transurethral catheterization: operations Urinary tract infections Reflux Total With infections Urinary complaints Fever Leukocvtosis
41 45
37 39
29
24
16 3
15
9 1 0 0 1
2 0 0 4 5
10
TABLE II.
Organisms isolated from children in Group A (prophylactic antimicrobials) and Group B (controls)
Case No.
Age (Year)
Group 1 2 3
A
Group 1 2 3 4 5 6 7 8 9 10
B
10 9 4
4.5 12 4 2 4.5 3.5 3 4 2.5 5
Method of Catheter Insertion Transperineal Transperineal Transurethral
Transurethral Transurethral Transurethral Transperineal Transperineal Transperineal Transperineal Transperineal Transperineal Transurethral
study. Bacterial identification was performed by standard methods. Urines for culture were obtained under sterile conditions and following meticulous cleansing of the junction between the catheter and the drainage tube. Catheter care consisted of twice daily cleansing of the insertion area and irrigations four times daily. Blood cultures were obtained according to study protocol from patients who had rectal fever more than 38.5’ C. All children underwent intravenous pyelography and a micturating cystourethrography prior to surgery. Vesicoureteral reflux was found in 11 children who had 11 operations.
392
Day of Postcatheterization Positive Cultures
IVP and Cystourethrography Normal Normal Reflux (Grade
5 9 10
Organisms Isolated E. coli Klebsiella E. coli
sp .
II)
Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal
5
E. coli Klebsiella sp. E. coli E. coli E. coli Klebsiella sp. I? aeruginosa S. fecalis (Group E. coli E. coli
5 8 8 8 8 8 8 10 10
D)
Results No significant difference in age was observed between Groups A and B (4.82 f SD = 2.03 and 4.73 f SD = 2.33, respectively). Type of surgery, hospital personnel, quality of catheter care, and type of catheterization were similar in both groups. None of the children with Foley catheter had postoperative purulent discharge at the insertion area. The incidence of positive cultures throughout hospitalization was significantly higher in Group B: 10 of 39 when compared with Group A: 3 of 45 (P < 0.05 by chi square analysis) (Table II). Cultures that were taken on second
UROLOGY
/
OCTOBER1983
/
VOLUMEXXII,NUMBER4
and third day after catheterization were all negative. One child in Group A and 2 children in Group B had positive urine cultures on postoperative day 5 while the other 11 children acquired bacteriuria on postcatheterization days 8 and 10. The most commonly isolated pathogen was Escherichia coli. Urine cultures of Group A grew E , coli in 2 children and Klebsiella species in 1. In Group B, 6 children had E, coli, 2 Klebsiella species, 1 Pseudomonas aeruginosa, and 1 Streptococcus fecalis (Group D) in their urine cultures. Eleven children showed evidence of vesicoureteral reflux on cystourethrography; 2 in Group B and 9 in Group A. In one child with vesicoureteral reflux in Group A only, bacteriuria developed, while the other 10 children had negative urine cultures. In only 4 cases did fever appear to be helpful in the diagnosis of urinary tract infection in catheterized children. Four children with urinary tract infections in Group B and none in Group A had elevated temperature. Leukocytosis (white cell count more than 10,000 mm3) was encountered in 6 children with urinary tract infection; 5 in Group B and 1 in Group A. There were no urinary complaints of infection in the catheterized patients. The transperineal procedure for inserting the Foley catheter was used in 22 children following 24 operations in Group B and in 28 children following 29 operations in Group A. Transurethral procedure was used in 15 children following 15 operations in Group B and in 13 children following 16 operations in Group A. There was no significant difference between the two procedures in the tendency to acquire bacteriuria. Blood cultures which were obtained from patients who had fever above 38.5” C were all negative. Routine clinical examination and urine culture tests done one week after hospital discharge showed no sign of postoperative urinary tract infection in any of the children.
catheter and the mucosa.g Nonsterile disconnection of the catheter and the drainage bag or bacterial contamination of the drainage system may also increase the incidence of urinary tract infection, suggesting that retrograde intraluminal spread of organisms may occur.1o Most authors advocate the use of prophylactic antimicrobials in prolonged catheterization in adults.3.4 The value of prophylactic treatment in children after hypospadias repair surgery had not yet been studied. Our results suggest that a course of prophylactic antimicrobials in these children reduces significantly the incidence of urinary tract infections with lower overall rate as well as a lower average daily incidence. Our observed rate of bacteriuria was 26 per cent, with an incidence of 6.1 per cent per day of catheterization in Group B and 6.7 per cent with an incidence of 1.8 per cent per day of catheterization in Group A. On the basis of our data, we recommend that prophylactic antimicrobials be given to every child with an indwelling catheter after hypospadias repair surgery. Urine specimen cultures must be submitted from all patients several times during the catheterization period. Children with bacteriuria should be treated with a specific antimicrobial as soon as possible. Tel Hashomer, Israel (DR. SHOHET) References 1. Schaffer AA, and Erbes J: Hypospadias, Am J Surg 79: 183 (1950). 2. Cecil AB: Modern treatment of hypospadias, Tr Am Genitoiurin Surg 43: 148 (1951). 3. Shapiro SR, Santamarina A, and Harrison JH: Catheterassociated urinary tract infections: incidence and a new approach to prevention, J Urol 112: 659 (1974). 4. Britt MR, et al: Antimicrobial prophylaxis for catheterassociated bacteriuria, Antimicrob Agents Chemother 11: 240 (1977). 5. Martin CM, and Bookrajian EN: Bacteriuria prevention after indwelling urinary catheterization: a controlled study, Arch Intern Med 110: 703 (1962). 6. Bupont HL, and Spink WW: Infections due to gram negative organisms: an analysis of 860 patients with bacteremia at the University of Minnesota Medical Center 19581966, Medicine 48: 307 (1962). 7. Martin CM, Vaquer F, and Meyers MS: Prevention of gram negative rod bacteriuria associated with indwelling urinary tract catheterization, Antimicrob Agents Chemother 3: 617 (1963). 8. Helmolz HF: Determination of the bacterial content of the urethra. J Ural 64: 158 (1950). 9. Kass EH, and Schneiderman LJ: Entry of bacteria into the urinary tracts of patients with inlying catheters, N Engl J Med 256: 556 (1957). 10. Kumin CM, and McCormack RC: Prevention of catheter induced urinary tract infections by sterile closed drainage, ibid 274: 1155 (1966).
Comment Indwelling bladder catheters have long been associated with high incidence of urinary tract infection and resulting complications.5-7 Catheterization acquired bacteriuria is usually due to the introduction into the bladder of micro-organisms colonizing the distal urethra and the perineum during or after the insertion.* It has been postulated that bacteria enter the bladder through a thin fluid space between the
UROLOGY
/
OCTOBER
1983
/
VOLUME
XXII,
NUMBER
4
393
AND
IN
CHILDREN WITH HYPOSPADIAS ISAAC
SHOHET,
MORDECHAI
M.D. ALAGAM,
M.D.
RAPHAEL SHAFIR, M.D. HAGGAI TSUR, M.D. BERNARD
COHEN,
F.R.C.P.E.
From the Chaim Sheba Medical of Medicine, Tel Aviv University,
Center, Sackler School Tel Hashomer, Israel
ABSTRACT-A prospective study of 78 children who underwent 84 operations for correction of hypospadias was done. Of these, 54 had a transperineal indwelling Foley catheterfor ten days after surgery and 30, a transurethral catheter. Forty-five randomly selected children received prophylactic antimicrobial therapy (sulfamethoxazole), and the remaining 39 children served as controls. Incidence of urinary tract infection was significantly higher in the control group (10 of 39) as compared with the treated group (3 of 45) in spite of the higher incidence of vesicoureteral reflux in the treated group. This suggests that prophylactic antimicrobial treatment may prevent urinary tract infection from prolonged indwelling catheterization.
Hypospadias is one of the most common anomalies of the urogenital tract: its incidence ranges from 1 to 3.3 per 1,000 live births.’ Following surgical repair of hypospadias, an indwelling urinary catheter is inserted for a period of seven to ten days.2 Prolonged bladder catheterization is associated with an increased rate of urinary tract infections.3 Several authors have advocated the use of prophylactic antimicrobials in these patients. 4 No data are available concerning prolonged catheterization in children after hypospadias repair. During the last two and one-half years 84 operations for the correction of hypospadias were performed in Chaim Sheba Medical Center. In a prospective study we examined the incidence of urinary tract infection in catheterized children to determine the value of prophylactic antimicrobials. Material
pospadias were included in the study. Prophylactic antimicrobials were given to 41 children after 45 operations (Group A) (Table I). Treatment was started with sulfamethoxazole on the first postoperative day up to the third day after the catheter was removed. No prophylactic treatment was given to the remaining 37 children after 39 operations (Group B). During operation under sterile conditions an indwelling latex Foley catheter was introduced with a gravity closed-drainage system. The catheter was left for ten days. Catheter was inserted by transperineal approach in 50 children following 54 operations of either second stage Browne method or a one-stage repair. Transurethral procedure was used in 28 children who underwent 30 operations of first stage repair. Urine specimens were cultured on admission and on postoperative days 2, 3, 5, 6, 8, and 10. Catheter urine cultures were considered positive if more than lo4 organisms per milliliter were found. Children with positive urine cultures preoperatively were excluded from the
and Methods
Seventy-eight patients who underwent eighty-four operations for the correction of hy-
UROLOGY
/
OCTOBER
1983
/
VOLUME
XXII,
NUMBER
4
391
TABLE I.
Clinical
Comparison
between treated and control groups No Prophylactic Treatment Group B
Prophylactic Antimicrobials Group A
Data
Number of children Number of operations Transperineal catheterization: operations Transurethral catheterization: operations Urinary tract infections Reflux Total With infections Urinary complaints Fever Leukocvtosis
41 45
37 39
29
24
16 3
15
9 1 0 0 1
2 0 0 4 5
10
TABLE II.
Organisms isolated from children in Group A (prophylactic antimicrobials) and Group B (controls)
Case No.
Age (Year)
Group 1 2 3
A
Group 1 2 3 4 5 6 7 8 9 10
B
10 9 4
4.5 12 4 2 4.5 3.5 3 4 2.5 5
Method of Catheter Insertion Transperineal Transperineal Transurethral
Transurethral Transurethral Transurethral Transperineal Transperineal Transperineal Transperineal Transperineal Transperineal Transurethral
study. Bacterial identification was performed by standard methods. Urines for culture were obtained under sterile conditions and following meticulous cleansing of the junction between the catheter and the drainage tube. Catheter care consisted of twice daily cleansing of the insertion area and irrigations four times daily. Blood cultures were obtained according to study protocol from patients who had rectal fever more than 38.5’ C. All children underwent intravenous pyelography and a micturating cystourethrography prior to surgery. Vesicoureteral reflux was found in 11 children who had 11 operations.
392
Day of Postcatheterization Positive Cultures
IVP and Cystourethrography Normal Normal Reflux (Grade
5 9 10
Organisms Isolated E. coli Klebsiella E. coli
sp .
II)
Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal
5
E. coli Klebsiella sp. E. coli E. coli E. coli Klebsiella sp. I? aeruginosa S. fecalis (Group E. coli E. coli
5 8 8 8 8 8 8 10 10
D)
Results No significant difference in age was observed between Groups A and B (4.82 f SD = 2.03 and 4.73 f SD = 2.33, respectively). Type of surgery, hospital personnel, quality of catheter care, and type of catheterization were similar in both groups. None of the children with Foley catheter had postoperative purulent discharge at the insertion area. The incidence of positive cultures throughout hospitalization was significantly higher in Group B: 10 of 39 when compared with Group A: 3 of 45 (P < 0.05 by chi square analysis) (Table II). Cultures that were taken on second
UROLOGY
/
OCTOBER1983
/
VOLUMEXXII,NUMBER4
and third day after catheterization were all negative. One child in Group A and 2 children in Group B had positive urine cultures on postoperative day 5 while the other 11 children acquired bacteriuria on postcatheterization days 8 and 10. The most commonly isolated pathogen was Escherichia coli. Urine cultures of Group A grew E , coli in 2 children and Klebsiella species in 1. In Group B, 6 children had E, coli, 2 Klebsiella species, 1 Pseudomonas aeruginosa, and 1 Streptococcus fecalis (Group D) in their urine cultures. Eleven children showed evidence of vesicoureteral reflux on cystourethrography; 2 in Group B and 9 in Group A. In one child with vesicoureteral reflux in Group A only, bacteriuria developed, while the other 10 children had negative urine cultures. In only 4 cases did fever appear to be helpful in the diagnosis of urinary tract infection in catheterized children. Four children with urinary tract infections in Group B and none in Group A had elevated temperature. Leukocytosis (white cell count more than 10,000 mm3) was encountered in 6 children with urinary tract infection; 5 in Group B and 1 in Group A. There were no urinary complaints of infection in the catheterized patients. The transperineal procedure for inserting the Foley catheter was used in 22 children following 24 operations in Group B and in 28 children following 29 operations in Group A. Transurethral procedure was used in 15 children following 15 operations in Group B and in 13 children following 16 operations in Group A. There was no significant difference between the two procedures in the tendency to acquire bacteriuria. Blood cultures which were obtained from patients who had fever above 38.5” C were all negative. Routine clinical examination and urine culture tests done one week after hospital discharge showed no sign of postoperative urinary tract infection in any of the children.
catheter and the mucosa.g Nonsterile disconnection of the catheter and the drainage bag or bacterial contamination of the drainage system may also increase the incidence of urinary tract infection, suggesting that retrograde intraluminal spread of organisms may occur.1o Most authors advocate the use of prophylactic antimicrobials in prolonged catheterization in adults.3.4 The value of prophylactic treatment in children after hypospadias repair surgery had not yet been studied. Our results suggest that a course of prophylactic antimicrobials in these children reduces significantly the incidence of urinary tract infections with lower overall rate as well as a lower average daily incidence. Our observed rate of bacteriuria was 26 per cent, with an incidence of 6.1 per cent per day of catheterization in Group B and 6.7 per cent with an incidence of 1.8 per cent per day of catheterization in Group A. On the basis of our data, we recommend that prophylactic antimicrobials be given to every child with an indwelling catheter after hypospadias repair surgery. Urine specimen cultures must be submitted from all patients several times during the catheterization period. Children with bacteriuria should be treated with a specific antimicrobial as soon as possible. Tel Hashomer, Israel (DR. SHOHET) References 1. Schaffer AA, and Erbes J: Hypospadias, Am J Surg 79: 183 (1950). 2. Cecil AB: Modern treatment of hypospadias, Tr Am Genitoiurin Surg 43: 148 (1951). 3. Shapiro SR, Santamarina A, and Harrison JH: Catheterassociated urinary tract infections: incidence and a new approach to prevention, J Urol 112: 659 (1974). 4. Britt MR, et al: Antimicrobial prophylaxis for catheterassociated bacteriuria, Antimicrob Agents Chemother 11: 240 (1977). 5. Martin CM, and Bookrajian EN: Bacteriuria prevention after indwelling urinary catheterization: a controlled study, Arch Intern Med 110: 703 (1962). 6. Bupont HL, and Spink WW: Infections due to gram negative organisms: an analysis of 860 patients with bacteremia at the University of Minnesota Medical Center 19581966, Medicine 48: 307 (1962). 7. Martin CM, Vaquer F, and Meyers MS: Prevention of gram negative rod bacteriuria associated with indwelling urinary tract catheterization, Antimicrob Agents Chemother 3: 617 (1963). 8. Helmolz HF: Determination of the bacterial content of the urethra. J Ural 64: 158 (1950). 9. Kass EH, and Schneiderman LJ: Entry of bacteria into the urinary tracts of patients with inlying catheters, N Engl J Med 256: 556 (1957). 10. Kumin CM, and McCormack RC: Prevention of catheter induced urinary tract infections by sterile closed drainage, ibid 274: 1155 (1966).
Comment Indwelling bladder catheters have long been associated with high incidence of urinary tract infection and resulting complications.5-7 Catheterization acquired bacteriuria is usually due to the introduction into the bladder of micro-organisms colonizing the distal urethra and the perineum during or after the insertion.* It has been postulated that bacteria enter the bladder through a thin fluid space between the
UROLOGY
/
OCTOBER
1983
/
VOLUME
XXII,
NUMBER
4
393