FREQUENCY
OF URINARY TRACT INFECTION IN CHILDREN WITH CEREBRAL PALSY

Authors:
Rahida Karim, Jahanzeb Khan Afridi, Ahmad Saud Dar, Muhammad Batoor Zaman,
Afnan Amjad,

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ABSTRACT

Background: Cerebral
palsy (CP) occurs in about 2.0–2.5 per 1000 live births. Rates have remained
fairly stable over the past 40 years. In many children, the cause of CP is
unknown. A child with cerebral palsy is having a difficulty in neuromotor
control, a nonprogressive brain lesion, and an injury to the brain that
occurred before it was fully matured. The morbidity associated with CP
comprises of seizure disorders, mental retardation, abnormalities of vision,
problems with respiratory muscle, and lower urinary tract dysfunctions.
Possible reasons for the propensity to urinary tract infections include
vesicoureteral reflux and incomplete bladder emptying resulting from detrusor
hyperreflexia and detrusor sphincter dyssynergia.

 

Materials and
Methods: this study was conducted
in the department of pediatrics Hayatabad Medical Complex, Peshawar from
01.01.2016 to 31.12.2016. Through a descriptive cross-sectional study design, a
total of 113 children with cerebral palsy, selected in a consecutive sampling
and med-stream urine specimen was collected for urine culture to detect UTI.

 

Results: The
mean age group of the sample was 7.8 + 3.6
years. 68.1% of the sample was male and 31.9%
were female gender. In our study, UTI was recorded in 32.7% of patients
with more propensities towards age group above 5 years (p 5 to 10 years and 30.1% of patients were in the age group >
10 to 15 years. (Table 1)

While distributing the patients with regards to gender, we
observed that in our study 68.1% of the sample was male and 31.9% were female
gender. (Table 2)

Form
all the patients, a mid stream specimen of urine was collected in sterile
container and was sent to hospital laboratory for detection of UTI which is
defined where Urine analysis showed greater than or equal to 2-5 WBCs or 15
bacteria per high power field (HPF) in centrifuged urine sediment and the urine
culture showing growth of more than 105 organisms per ml of urine.
In our study, UTI was recorded in 32.7% of patients. (Table 3)

While we stratified UTI with regards to age groups, we observed
that the difference was statistically significant after applying chi square
test with a p value of 5 to 10 years

41

36.3

>10 to 15 years

34

30.1

Total

113

100.0

 

Gender

Frequency

Percent

 

Male

77

68.1

Female

36

31.9

Total

113

100.0

 

Table
3; FREQUENCY OF URINARY TRACT INFECTION (n=113)

UTI

Frequency

Percent

 

Yes

37

32.7

No

76

67.3

Total

113

100.0

 

Table
4; AGE GROUP WISE STRATIFICATION OF UTI (n=113)

 

Urinary Tract Infection

P Value

Yes

No

Age Groups

Up to 5 years

0

38

5 to 10 years

29

12

70.7%

29.3%

>10 to 15 years

8

26

23.5%

76.5%

Total

37

76

32.7%

67.3%

 

Table
5; GENDER GROUP WISE STRATIFICATION OF UTI (n=113)

 

Urinary Tract Infection

P Value

Yes

No

Gender of the patient

Male

23

54

0.34

29.9%

70.1%

Female

14

22

38.9%

61.1%

Total

37

76

32.7%

67.3%

 

DISCUSSION

Acute urinary tract infection
(UTI) is common in children. By the age of seven years, 8.4%of girls and 1.7%
of boys will have suffered at least one episode9. Death is now a
rare complication but hospitalization is frequently required (40%),
particularly in infancy. Transient damage to the kidneys occurs in about 40% of
children affected and permanent damage occurs in about 5%10
sometimes even following a single infection. Symptoms are systemic rather than
localized in early childhood and consist of fever, lethargy, anorexia, and
vomiting. UTI is caused by Escherichia coli in over 80% of cases11
and treatment consists of a course of antibiotics.

Children who have had one
infection are at risk of further infections. Recurrent UTI occurs in up to 30%12.
The risk factors for recurrent infection are vesicoureteric reflux (VUR),
bladder instability and previous infections11, 13. Recurrence of UTI
occursmore commonly in girls than boys12.

Febrile urinary tract infections have the highest incidence during the first year
of life in both sexes, whereas nonfebrile urinary tract infections occur predominantly
in girls older than 3 years14. After infancy, urinary tract infections confined to the
bladder are generally accompanied by localized symptoms and are easily treated. In
contrast, the presence of fever increases the probability of kidney involvement
(sensitivity, 53 to 84%; specificity, 44 to 92%)15 and is associated with an increased
likelihood of underlying nephrourologic abnormalities and a greater risk of consequent
renal scarring. Kidney
scarring related to urinary tract infection has been considered a cause of
substantial long-term
morbidity16. Thus, children with proven infections have been intensively evaluated and
treated, and they have often undergone surgery or have received long-term antibiotic
prophylaxis.15 Such approaches have been questioned17.18.
A number of trials have
been conducted or are under way to determine optimal approaches to the assessment and management
of initial febrile urinary tract infections and subsequent interventions for them.

In our study, we studied the
frequency of UTI in children presenting with cerebral palsy and fever. We
observed it to be 32.7% with equal propensity of either gender towards UTI.
Studies reporting the incidence and prevalence of UTI in children have varied
by population, sampling method, and diagnostic criteria. Rates therefore vary
widely, from 0.25% in a small UK GP study19 to 13.5% in a
hospital-based study of febrile infants20.

Ozturk et
al. in Turkey has reported 32.5% frequency of UTI21 which
is comparable to present study 32.7%, but is much higher than the respective
7.4% and 2.2% reported
by Reid and Borzyskowski in London22 and Hellquist et al. in North
Carolina23. The discrepancies in frequency of UTI in latter two
studies22 ,23 may be due to the prior use of antibiotics, although
not reported in our study. CP subjects more frequently had symptoms and signs
of UTI, history of constipation and enuresis, prior history of UTI, urinalyses
findings and culture proven UTI than their age and sex matched comparators
without CP. Similar findings have also been reported by Ozturk et al. in Turkey21.

Parents and siblings have to carry Cerebral palsy from one
place to other, because of difficulty in mobility and both manually propelled
or electrically powered wheelchairs are often beyond the reach of these
families. The are neglected children who stay supine for prolonged period of
time, with the majority developing pressure source on occiputs and buttocks and
prolonged smearing by their faeces due to poor personal hygiene may increase
risk of UTI. Few of them may be urinary continent but due to poor mobility, UTI
may develop easily following urinary retention resulting from difficulty in
getting to the toilets to micturate.  Poor
water intake due to immobility results in kidney stones which may predispose to
UTI24. In addition some of these children have high burden of
pinworms25 which may be linked to higher risk of UTI. Poorly mobile
CP children had propensity to develop constipation which also contributes to
higher risk of UTI in this group of children. Furthermore, the propensity to
developing constipation in poorly mobile CP children may also have contributed to
the higher risk of UTI in this group of children.

We
found that all the CP children with UTI are over-five in our study. Majority of
the CP patients are over five (65%) were recruited in our study. So these
findings may probably result from recruitment bias. When CP patients come for
follow up in our clinics we should review symptoms of UTI as it presents
symptomatically, it should be confirmed and treated in order to prevent its
potential complications.

 

CONCLUSION

We concluded from this study
that severe immobility in CP children is responsible for high prevalence of
UTI, therefore efforts should be made for effective physiotherapy, so that CP
children can attain maximum mobility and independence.

 

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