Urinary Tract Infection in Pediatric Patients on Clean Intermittent Catheterization via a Mitrofanoff port with Reused Catheters - Any Association with Catheter Sterility?

OBJECTIVE: The objective of this study is to find out whether the reused catheters for clean intermittent catheterization (CIC) are colonized before insertion and its association with urinary tract infection (UTI).
MATERIALS AND METHODS: This is a study conducted on 28 pediatric surgery patients who are on CIC via a Mitrofanoff port and who were reusing catheters, in a tertiary care private medical college hospital for 6-month period. Catheters to be used for the next catheterization were sent for culture along with urine culture. A questionnaire was utilized to assess CIC practice and UTI.
RESULTS: Diseases of patients were: neurogenic bladder and exstrophy-epispadias and posterior urethral valve. Twenty-one of them had an augmented bladder. Hydronephrosis was present in ten and vesicoureteral reflux (VUR) in five. Their mean duration of CIC was 5.3 years. Of 28 catheter tip samples, 16 catheters were colonized with organism. Of the 28 urine culture samples, 17 cultures were positive and all were asymptomatic except one. Of the 16 positive catheter samples, only 9 had positive urine culture; four of them had grown different organisms and five of them had the same organism, and even in these five, single organism was seen only in three. Urine culture grew Gram-negative organism in 85%, but catheter grew Gram-positive organism in 46%. No difference was found in the variables between both groups such as hydronephrosis, VUR, and augmented bladder.
CONCLUSION: Reused catheters were colonized in 57% of the study patients, but reused catheter may not be the cause of culture positivity or UTI in the study population. Copyright:

INTRODUCTION

Clean intermittent catheterization (CIC) is the preferred method of bladder emptying in children who need life term catheterization for structural or functional bladder diseases such as exstrophy–epispadias complex or neurogenic bladder when emptying is not possible or incomplete. CIC introduced by Lapides et al. in 1972 was a game changer in the treatment of patients with incomplete bladder emptying.[1] Lapides strongly believed Campbell's observation “that urinary retention rather than catheterization is the thing to be feared.”[1] The technique of CIC is used in all age groups including infants and has become an important therapeutic tool in pediatric urology. Patients do catheterization through the urethra or through continent catheterizable port as in Mitrofanoff.

CIC is a clean but not an aseptic technique, where catheter is inserted several times a day and removed to drain the bladder by the patient or by the caregiver. It involves ordinary handwashing and using cleansed reusable catheters or disposable catheters.[2] Various types of catheters are available for catheterization, and they are made of rubber, latex, or polyvinyl chloride. These catheters are not intended for reuse by the manufacturers. Methods of cleaning the catheter for reuse described in the literature include simple washing, washing in soap, 70% alcohol solution, boiling, microwave sterilization.[34]

These patients who are on CIC are prone to bacteriuria whether they are using single-use catheter or reusing catheter. Urinary tract infection (UTI) in these patients were thought to be due to internal factors rather than by catheter contamination during CIC.[1] In India, CIC patients are using catheters made of polyvinyl chloride available as infant feeding tube or Nel Cath. They do catheterization once in 3–4 h with a set of catheters used serially. As patients are reusing the catheters, they were advised to reuse dry catheters from, a set of catheters for a period of time. Catheters are washed with water and air-dried between uses.

In India, reusing catheters for intermittent catheterization is mainly driven by financial issues. There are not many studies to show whether the reused catheters by CIC patients cause any UTI in them. A descriptive study was conducted to find out whether the reused catheters used for CIC are colonized with organisms before insertion in the patient. If colonized, to find out whether there is any association with the UTI and the underlying disease.

MATERIALS AND METHODS

This is a study conducted in PSG Institute of Medical Sciences and Research, a tertiary care private medical college hospital, in South India. The Institutional Ethical Board approval was obtained (IRB number: 16/157). The study period was from June to December 2017. The study population was pediatric surgery patients who are on intermittent catheterization through continent stoma and who are reusing the catheters. They were enrolled when they came for regular follow-up. They were included if they were on CIC for >3 months and on regular CIC. Patients using new catheters every time for catheterization and those on CIC for <3 months were excluded from the study.

Good CIC practice was defined as change of a set of catheters (8–10) once in 3 months and the use of dry catheters by the patient or the caregiver. The catheter was identified as the cause of UTI when there is growth of >15 colonies/plate from the catheter with the same organism grown in significant amount in urine and the patient having symptoms of UTI at the time of collection.

Patients who were eligible to participate in the study were approached. Informed consent was obtained from those who were willing to participate and were enrolled in the study. None of the study patients were on antibiotic prophylaxis whether they have vesicoureteral reflux (VUR) or not. The catheter which is supposed to be used for the next catheterization was collected. The tip of the catheter (length of 5–7 cm) was sent in sterile culture bottle to the microbiology department. A questionnaire was used to assess CIC practice and history of UTI. Case details were documented from the case record of the patient. During the same visit, serum creatinine, urine microscopy, urine culture, and sensitivity were done as part of regular follow-up protocol. The results were collected and analyzed.

RESULTS

A total number of patients studied were 28. Fourteen of them were males and 14 of them were females. The mean age of study population was 11.85 years (standard deviation [SD]: 5.73). The primary conditions of the patients were neurogenic bladder (8 patients), exstrophy–epispadias complex (9 patients), posterior urethral valve (5 patients), and others (6 patients), which include cloaca, ureterocele, duplex system, and urethral injury.

Twenty-one patients had augmented bladders because of their primary condition. Hydronephrosis was seen in 10 of 28 which was mild in 8 units and moderate to severe in 7 units. Hydronephrosis was unilateral in 5 patients and bilateral in 5 patients. VUR was seen in 5 of 28 patients. All reflux were unilateral, and it was Grade II in 2 patients and Grade III in 3 patients. The mean serum creatinine of the study patients was 0.69 mg/dl (SD: 0.34).

The mean duration of CIC was 5.3 years (SD: 3.88). All the study patients are on CIC through Mitrofanoff port (n = 28). Majority of the patients were using feeding tube (17 patients), and 11 of them were using Nel Cath for CIC. The set of catheters used by each patient varies between 2 and 25 catheters, with a mean of 8.72 catheters. Time interval to change a set of catheters varied from 7 days to 2 years in our study population, with a mean period of 2.8 months. Majority of them were using dry catheters (77%).

Of 28 catheter samples studied, 16 catheters (57%) were colonized with organism and 12 did not grow any organism. Of the 28 urine culture samples, 17 cultures (60.7%) were positive with significant colony counts and 11 were negative. Of the 17 culture-positive patients, all were asymptomatic except one who had febrile UTI with urinary symptoms. Only that child with the UTI was treated with appropriate antimicrobial. When the relation between colonized catheter and positive urine culture was analyzed, it was found [Chart 1] that of the 16 positive catheter samples, 7 had negative urine culture and 9 had positive urine culture. Of the nine samples with positive urine culture, four grew different organisms in culture compared to catheter and five had the same organism which was Escherichia coli (E. coli). Even in these five who grew the same organism, mixed growth was seen in two and single organism was seen only in three [Table 1]. There is no statistical significant association between catheter colonization group and urine culture-positive group (Chi-square test with Yates's continuity correction = 0.028075, df: 1, P = 0.867). In the catheter-negative group of 12 patients, urine culture was positive in 8 and one of them had symptomatic UTI.

Chart 1

Relationship of positive catheter and urine culture. Mixed growth – Escherichia coli along with some other organisms, Pure culture – only Escherichia coli

Table 1

Organism grown when both catheter tip and urine culture were positive (n=9)

S. No	Catheter tip organism	Urine culture organism	Organism b/w groups
1	E. coli	E. coli (ESBL)	Same in pure culture (1-3)
2	E. coli	E. coli (ESBL)
3	E. coli	E. coli
4	E. coliEnterococcusMS CONS	E. coli (ESBL)	But as part of mixed flora (4-5)
5	E. coliK. pneumoniae	E. coliEnterococcus
6	K. pneumoniaeE. faecalis	E. coli	Different (6-9)
7	MSSA	P. aeruginosa
8	MS CONS	E. coli (ESBL)
9	K. pneumoniae	E. coli (ESBL)

E. coli: Escherichia coli, K. pneumoniae: Klebsiella pneumoniae, MSSA: Methicillin-sensitive S. aureus, MS CONS: Methicillin-sensitive coagulase-negative staphylococci, E. faecalis: Enterococcus faecalis, P. aeruginosa: Pseudomonas aeruginosa,E. coli (ESBL): Extended-spectrum beta-lactamase-positive E. coli, S. aureus: Staphylococcus aureus

The distribution of organism in urine culture was predominantly Gram-negative organism (85%) (E. coli – 14, Enterococcus faecalis – 3, Pseudomonas aeruginosa – 1, Proteus mirabilis – 1, and Klebsiella pneumoniae – 1), but in catheter colonization, Gram-negative organism was present only 54% and Gram-positive organism grew in 46% (Staphylococcus aureus – 6, E. faecalis – 5, E. coli – 5, K. pneumoniae – 3, P. aeruginosa – 3, and Acinetobacter baumannii – 2) [Chart 2]. However, there is no statistically significant difference between Gram-negative and Gram-positive organism status of the urine culture and catheter groups (Chi-square test with Yates's continuity correction = 3.465, df = 1, P = 0.063). E. coli was the predominant organism grown in urine culture samples (85%), but the catheter was colonized predominantly with S. aureus and Enterococcus, followed by E. coli.

Chart 2

Distribution of organism in urine culture and catheter culture in clean intermittent catheterization patients

Other factors which could have contributed to urine culture positivity such as hydronephrosis, VUR, and augmented bladder patients were analyzed [Table 2]. No difference was found in the variables as VUR and augmented bladder between both the urine culture-positive and urine culture-negative groups. However, hydronephrosis was (54%) in the culture-negative group compared to 23% in the culture-positive group. Hydronephrosis being more in the culture-negative group, it was considered not significant.

Table 2

Other factors which could affect culture positivity

	Urine culture positive (n=17), n (%)	Urine culture negative (n=11), n (%)
Hydronephrosis	23	54
Vesicoureteral reflux	18	18
Augmented bladder	76	73

Frequency of urinary tract infection in clean intermittent catheterization patients

The overall magnitude of the problem of symptomatic UTI happening in these patients on CIC was also looked into using questionnaire and case documents. UTI was seen in 7 of 28 patients over a period of 5.3 years of CIC (i.e., 148 patient years). Six of them had a single episode of UTI and one had two episodes. Five of these patients had risk factors for UTI as persisting hydronephrosis or VUR. These patients who had UTI had good CIC practice except one.

DISCUSSION

This study shows that reused catheters were colonized in 16 of 28 patients (57%), but the catheter may not be the cause of culture positivity or UTI in the study population. This is because of the following reasons: only 3 of 28 had grown the same single organism in both catheter and urine culture; the catheter had grown Gram-positive organism in a significant 46% of patients and urine culture had grown predominantly Gram-negative organism (85% of patients); urine culture was positive in patients whose catheter did not grow any organism; and the only symptomatic UTI patient in the study group was in the catheter-negative group.

The relationship between reused and single use of catheters with respect to UTIs is being continuously debated in CIC patients. Limited data show that using a new sterile catheter for each void does not decrease the frequency of bacteriuria in patients on CIC.[3] Kiddoo et al. from Canada compared reused polyvinyl catheters and single-use hydrophilic catheters regarding UTI in a randomized crossover four-center trial with two treatment periods of 24 weeks each, consisting of single-use hydrophilic-coated catheter and multiple-use polyvinyl chloride catheter. It had 45 patients in each arm, and the study was conducted between 2009 and 2012. They found more UTI in the single-use group (mean ± SD person weeks of UTI was 3.42 ± 4.67 in the single-use hydrophilic-coated catheter group and 2.20 ± 3.23 in the multiple-use polyvinyl chloride catheter group (P < 0.001)). They concluded that there is a lack of evidence to state that UTI is affected by multiuse PVC catheter or single-use hydrophilic catheter.[3]

All 28 in the study were on Mitrofanoff CIC. Mitrofanoff port is a part of all our augments (n = 21). In patients who require long-term CIC, even if they do not need augment, we provide Mitrofanoff port to facilitate painless CIC.

This study also brings out that these patients who are on CIC have significant number of urine culture positivity (60.7%) but asymptomatic except one. This is consistent with the literature that states that approximately 70% of patients who perform CIC have bacteriuria.[5] Asymptomatic patients in the current study were not treated with antimicrobial. The 1992 National Institute on Disability and Rehabilitation Research statement,[6] with updated support from the 2011 American Academy of Pediatrics UTI guideline states that bacteriuria/positive culture is not clinically relevant unless accompanied by symptoms.[7] Culture positivity was seen on those with or without hydronephrosis, reflux, and augmented status of the bladder in the current study.

The current study shows that the predominant organism grown in the urine culture in the study population was E. coli (85%), and the literature also reiterates that E. coli is the most common organism cultured in patients on CIC.[4] Lucas et al. have shown that E. coli was the dominant organism (60%) in culture-positive CIC patients.[8] However, the catheter colonization in the present study group was dominated by S. aureus and E. faecalis, followed by E. coli. A study done by Jennifer L. Chan et al. on adequacy of sanitization and storage of catheters for intermittent use after washing and microwave sterilization showed that catheter grew Gram-positive cocci and rods, presumably Staphylococcus and Bacillus species, and they also concluded that catheter may not be the cause of UTI in these patients in spite of its reuse.[4]

We presume that these patients on CIC are likely to suffer from more episodes of UTI as they are catheterizing the bladder so many times a day over many years even with residual hydronephrosis or VUR in some. Contrary to this assumption, the current study shows that these patients on CIC had few episodes of UTI (8 episodes in 28 patients) in 148 patient years of CIC. Catheter may not be the cause of symptomatic UTI happened over the years of CIC as 6 of 7 patients with UTI had good CIC practice and they had other risk factors for UTI such as hydronephrosis and VUR. Enrollment of small number of patients in the study and absence of control group was a major limitation of the study.

CONCLUSION

Reused catheters were colonized in 57% of our patients, but reused catheter may not be the cause of culture positivity or UTI in our study population. We need to study larger population before concluding that catheter colonization has nothing to do with UTI in CIC patients. If catheter may not be the cause of UTI, reusing catheters is acceptable as it reduces the cost of CIC which is very important for Indian population and adds less damage to the environment. This study also brings out that a significant number of these patients on CIC have urine culture positivity, but they are asymptomatic and require no antimicrobial treatment. It is heartening to know that these patients on CIC infrequently suffer from symptomatic UTI over long years of CIC.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.