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FREQUENCY
OF URINARY TRACT INFECTION IN CHILDREN WITH CEREBRAL PALSY

 

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

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STRUCTURED
ABSTRACT

 

Introduction:
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

 

 

TABLE 2

GENDER-WISE
DISTRIBUTION OF SAMPLE (n=113)

 

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.

The frequency of UTI of 32.7% found
in the present
study is comparable to the 32.5% reported by Ozturk et al. in Turkey21, 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. Although not reported in
our study, antibiotics had been used prior to presentation of the CP patients in the latter two
studies22, 23 and may possibly
explain the discrepancies in the frequency of the UTI. Furthermore, the symptoms and signs
of UTI, a history of
constipation, enuresis, a prior history of UTI, urinalyses findings, and culture proven UTI
were significantly more frequent
in subjects with cerebral palsy than their age- and sex-matched comparators without
cerebral palsy. Similar findings
have also been reported by Ozturk et al. in Turkey21.

Children with cerebral palsy who
often have to be carried from one place to the other by their siblings or their
parents because of difficulty in mobility and both manually propelled or
electrically powered wheelchairs are often beyond the reach of these families.
Often, these children are neglected and, stationed supine in one place for a
long time, with the majority developing pressure sores on the occiputs and the
buttocks and the poor personal hygiene resulting from prolonged smearing by
their faeces may increase the risk of UTI. Also, because of poor mobility, UTI
may develop easily following urinary retention resulting from the difficulty in
getting to the toilets to micturate in a few that may be urinary continent.
Closely linked to the poor mobility are the poor water intake and the resultant
risk of kidney stones whichmay predisposing these children to UTI24.
In addition, a high burden of pinworms seen in some of these children25
may be linked to a higher risk of UTI. 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.

In our study, we found that all the
C Psubjects with UTI are over-five children. These findings may probably result
from recruitment bias as more CP patients that are over five (65%) were
recruited in our study. Furthermore, UTI presents more symptomatically, and
therefore all efforts should be put in place to review symptoms of UTI among
the CP patients when they come for follow-up in our clinics in order to confirm
and treat a UTI and thus prevent its potential complications.

 

CONCLUSION

 

The
present study would sum up to indicate that there is a high prevalence of UTI among our
children with CP, which
may be due to severe immobility. Therefore, concerted efforts should be put in
place for effective physiotherapy
aimed at attaining the greatest possible mobility and
independence among
our children with CP.

 

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