Urological care for children with spina bifida: Individual, tailored and without antibiotic prophylaxis

In our SPIN UTI study, we have focused on the urological problems, urinary tract infections and Quality of Life in spina bifida children. For eighteen months, we have analyzed the diagnosing, treatment and prevention of urinary tract infections in 176 children with spina bifida from Utrecht and Leuven and their Quality of Life.

We have evaluated the European protocols for prevention, evaluation and treatment of urinary tract infections and urological care for children with spina bifida. We have concluded from this survey that there is no consensus in urological care.

We have evaluated the accuracy of home testing with a leukocyte esterase test and a dip slide urine culture. This study reveals that a negative esterase test in home setting properly excludes bacteriuria and urinary tract infection: when the esterase test is negative, there is no indication for culture or antibiotic treatment.

We have also evaluated the value of antibiotic prophylaxis for prevention of urinary tract infections in our cohort. Biweekly urine samples were evaluated using a leukocyte esterase test and agar plated urine culture. Non-febrile urinary tract infections occurred more often in the discontinuation group, statistically significant, but clinically not relevant: prophylaxis has to be administered for more than 2 years to prevent one urinary tract infection. A significant number of patients switched back to prophylaxis because of recurrent urinary tract infections. We recommend that antibiotic prophylaxis should only be continued in spina bifida children with a high rate of febrile urinary tract infections.

The nearly 5,000 bacterial cultures in our study enabled us to evaluate the influence of stopping antibiotic prophylaxis on the bacterial resistance pattern. Overall, our study showed a decrease in bacterial resistance to commonly used antibiotics once prophylaxis is stopped. When the use of prophylaxis is necessary, trimethoprim has the least negative influence on bacterial resistance. Oral antibiotic treatment is adequate for urinary tract infections in clinically not-ill children. In our cohort, nitrofurantoin is first choice medication for a non-febrile urinary tract infection without prophylaxis.

We evaluated the Quality of Life in our cohort with the KINDL-R questionnaire on the domains of physical and emotional well-being, self-esteem, family, friends and school. Compared to healthy controls, both the children and their parents have significantly lower Quality of Life scores. Patients have higher scores than their parents. Severity of morbidity is poorly correlated with perceived Quality of Life, and should not be used to estimate a patients well-being.

In our study we have shown that there is no current consensus on nephro-urological care in patients with spina bifida. Proper urological care can be improved by implementing our findings: 1. antibiotic prophylaxis is only warranted in children with frequently recurring urinary tract infections, 2. bacterial susceptibility to commonly used therapeutic antibiotics is higher when refraining from every day antibiotic prophylaxis, 3. exclusion of a suspected urinary tract infection can be done at home with a simple leukocyte esterase test, and 4. individual repetitive assessment of Quality of Life ensures tailored counseling and psychosocial care in spina bifida.