¹Professor, ²Associate Professor, ³Junior Resident, Department of Pediatrics, Swami Ramanand Teerth Rural Government Medical College, Ambajogai, Beed, Maharashtra, INDIA.

Email: avinashsanap26@gmail.com

OBSERVATIONS AND RESULTS

Among the total 62 patients, 35(56.45%) patients were males and 27 (43.54%) were females. 70.96% children of CP were found in the age group of 2-10 years with mean age of patients was 8.53±3.83 years, ranged from 2-18 years. However, the distribution of age group of CP cases was statistically similar in male and female with p value of 0.421 as shown in table 1.

Table 1: Distribution of the Study subjects according to Age and gender

From the table 2, it was observed that spastic CP was the commonest physiological type of CP 56 (90.32%). Among the spastic group, quadriplegia was 53.22%, diplegia 22.58%, double hemiplegia 12.90% and monoplegia 1.61%. The malnutrition was more with female (92.59%) compared to male (85.71%) with p value of 0.234. Majority of children were grade I (46.77%) malnourished followed by grade II malnutrition (29.03%) whereas 11.29% patients had normal nutritional status. The prematurity was (54.83%) commonest cause of CP.

Table 2: Clinical type of CP, Nutrition status of patients and causes of CP

Regarding the degree of gross motor dysfunction, maximum patients (35; 56.45%) had mild dysfunction including 13 (20.96%) with grade 1 and 22 (35.48%) with grade 2. Moderate to severe motor dysfunction was seen in 27 (43.54%) including 10(16.12%) with grade 3, 07 (11.29%) with grade 4, and 10 (16.12%) with grade 5 as depicted in figure 1. For intellectual disability Binet Kamat Test of Intelligence was used, among the 54 children with CP whose ages were between 3 and 18 years, maximum number of children had mild intellectual disability 28 (51.85%) followed by moderate intellectual disability 16 (29.62%) and 10 children had severe disability (18.51%).

Figure 1: Distribution of cases according gross motor dysfunction Figure 2: Distribution of patients according to presenting symptoms

Most of the patients had symptom of frequency of urination 32 (51.61%) followed by history of constipation and enuresis as shown in figure 2.

Table 3 presented urinalyses findings among subjects with CP and which showed urine culture proven UTI in 20 cases. Thus, the prevalence of UTI among children with CP was 32.25%, of them 20.96% (13 cases) were male and 11.29% (7 cases) were female. The maximum number of UTI positive cases were observed in 5-7 years age group (25%) followed by 8-10 years (20%).

Table 3: Urinalyses findings among subjects with cerebral palsy

Out of 62 cases, 3 cases had asymptomatic bacteriuria. Thus, the prevalence of asymptomatic bacteruria in children with CP was 4.8%. Of the 07 females examined (UTI positive), 2 (28.57%) had AUTI while 1 (7.69%) of the 13 males had significant bacteriuria. The most common organisms causing UTI in CP children was escherichia coli (45%) followed by Strept. Faecalis isolated in 20% children. From figure 3 it was observed that the escherichia coli were isolated from majority of male (46.15%) and female (42.85%) subjects.

Figure 3: Organisms causing urinary tract infection in cerebral palsy

Table 4 shows the antimicrobial sensitivity pattern of organisms causing UTI in CP. The major isolates i.e. Escherichia coli and Streptococcus faecalis were 100% sensitive to ceftriaxone, amoxiclav, nitrofurantoin, cotrimoxazole, ciprofloxacin, ofloxacin and sparfloxacin but less sensitive to gentamicin and streptomycin while resistant to tetracycline (0%) and nalidixic acid (0%).

Table 4: Antimicrobial sensitivity pattern of organisms causing UTI in CP

E. coli: Escherichia coli, Staph. aureus: Staphylococcus aureus, Strept. faecalis: Streptococcus faecalis.

In bivariate analysis, older children (>5 years), moderate to severe motor disability, dysuria, constipation, flank/abdominal pain, significant haematuria, significant pyuria and significant microscopic pyuria, were found to be significantly associated with UTI (𝑃 values <0.05) (Table 5 and 6). However, in univariate regressionanalysis only moderate to severe gross motor dysfunctionpredicts the risk of UTI (OR = 53.72, 95% CI, 2.31-1332.00, 𝑃 value 0.018), (Table 7).

Table 5: Bivariate analysis: Association between some characteristics of subjects with CP and presence of UTI

Table 6: Urinalyses findings among subjects with CP and the relationship with UTI

Table 7: Predictors of UTI among the children with cerebral palsy

DISCUSSION

Children with CP suffer from multiple problems and potential disabilities such as mental retardation, epilepsy, feeding difficulties, vision, and hearing impairments. Screening for these conditions should be part of the initial assessment.¹⁰ Also, children with CP may present with lower urinary tract dysfunction which increases their risk for UTI and it is a challenging yet common clinical condition. In developed countries special adaptive equipment’s such as walkers, poles, standing frames and electronic wheel chairs are available to help in ambulation of CP children. However, in developing countries like India such facilities are lacking which limits mobility and hence increases the susceptibility to UTI. Furthermore, no local study is published regarding UTI in CP patients and we found an international study reported 38.5% prevalence of UTI in children with CP.²² Hence the present study was conducted in 62 patients to find out the prevalence and predictors of UTI among central Indian children with CP. Urinalyses findings showed that the urine culture proven UTI in 32.25% of cases with CP and this prevalence is under the values reported by developed countries. However, authors from developed countries report an increase of 2.2-32.5% of UTIs among patients with CP.^11,12 Few studies reported low prevalence rates of UTI in CP patients^13,14; moreover, other several studies documented high prevalence rates.^8,11 These disparities may be due to the non-uniformity of study designs and the possibility of different forms of bias in these studies. More importantly, the definition of UTI adopted by the investigators may also have contributed to the absence of unanimity in the findings. Furthermore, the frequency of UTI of 32.25% found in the present study is comparable to the 32.5% reported by Ozturk et al. in Turkey,¹¹ but is much higher than the respective 7.4% and 2.2% reported by Reid and Borzyskowski in London¹² and Hellquist et al.¹⁵ It was observed that the maximum numbers of our UTI positive cases were (20.96%) males with a male to female ratio of 1.8: 1 and most of were found in 5-7 years age group (25%) followed by 8-10 years (20%), 2-4 years (20%) and 11-13 years (15%). In age group of 14-16 and 17-18 years 10% cases each. These findings are correlated with the previous studies.^{14,16, and17} Diagnosis of asymptomatic bacteriuria is made by urine culture. Either a properly collected clean-catch specimen or a catheterized specimen is acceptable. The Infectious Diseases Society of America (IDSA) has established criteria for diagnosing asymptomatic bacteriuria.¹⁸ Out of 62 cases, 03 cases had asymptomatic bacteriuria. Thus, the prevalence of asymptomatic bacteriuria in children with CP was 4.8%. These findings are comparable with the other studies.^8,17Escherichia coli have been shown to account for up to 75% of UTIs in all paediatric age groups followed by Klebsiella spp., Proteus spp., and Pseudomonas spp.¹⁹ As may be expected, Escherichia coli were also the commonest isolates (45%) among our subjects with CP. Strept. Faecalis isolated in 20% children, Staphylococcus aureus in 3 (15%), while Proteus spp. and Klebsiella spp. were isolated in 2 (10%) children each. All the 3 children with Staphylococcus aureus isolate also presented with fever. Similar findings are reported in previous studies.^{7,8,11, and 14} Various studies had shown that Escherichia coli are becoming highly resistant to the first line empirical antimicrobials for UTI, including cotrimoxazole, amoxicillin, nitrofuratoin and nalidixic acid. Its preserved sensitivity to the quinolones and ceftriaxone and gentamicin may be explained by the fact that the quinolones are rarely prescribed for children and the parenteral routes of ceftriaxone and gentamicin reduce the abuse of these two antibiotics. Although in vitro resistance may not necessarily mean in vivo resistance.^20,21 In current study, the major isolates, Escherichia coli, were 100% sensitive to ceftriaxone, amoxiclav, nitrofurantoin, cotrimoxazole, ciprofloxacin, ofloxacin and sparfloxacin but less sensitive to gentamicin (66.66%) and Streptomycin (55.55%) as well as were resistant to tetracycline (0%) and nalidixic acid (0%). Streptococcus faecalis were 100% sensitive to ceftriaxone, amoxiclav, nitrofurantoin, ciprofloxacin, ofloxacin and sparfloxacin and less sensitive to gentamicin (75%), streptomycin, cotrimoxazole (50%) but resistant to tetracycline and nalidixic acid. Staphylococcus aureus is 100% sensitive to ceftriaxone, amoxiclav, nitrofurantoin, ciprofloxacin, ofloxacin and sparfloxacin and less sensitive to cotrimoxazole (66.66%), gentamicin (33.33%) and resistant to streptomycin, nalidixic acid and tetracycline. Proteus spp. 100% sensitive to ceftriaxone, nitrofurantoin, ciprofloxacin, ofloxacin and sparfloxacin, less sensitive to gentamicin, streptomycin and amoxiclav (50%), resistant to nalidixic acid tetracycline, cotrimoxazole. Klebsiella spp. 100% sensitive to ceftriaxone, cotrimoxazole, nitrofurantoin, ciprofloxacin, ofloxacin, sparfloxacin and gentamicin, less sensitive to amoxiclav (50%) and resistant to nalidixic acid, streptomycin, tetracycline. These findings are in accordance with the study done by Anígilájé et al.⁸ and Ryakitimbo. et al.¹⁴ Abdominal ultrasound scan among the 20 CP children with UTI revealed no renal parenchymal abnormality. In 3 female children there were bladder wall thickness, irregularity of the bladder wall, and residual urine. Anígilájé et al.⁸ found similar results. To our knowledge, Silva et al.¹⁷ study is the first study to examining ultrasound assessment of BWT in a population with CP. The overall mean BWT was 2.30±0.79 mm. There was also no significant variation in BWT between children with and without LUTD, or between patients who could walk and patients who could not. We found out the predictors of urinary tract infections: In bivariate analysis, older children (>5 years), moderate to severe motor disability, dysurias, constipation, flank/abdominal pain, significant haematuria, significant pyuria and significant microscopic pyuria, were found to be significantly associated with UTI (p values <0.05). However, in univariate regression analysis only moderate to severe gross motor dysfunction predicts the risk of UTI (OR = 53.72, 95% CI, 2.31-1332.00, p value 0.018). These results are comparable with the study conducted by Anígilájé et al.⁸

CONCLUSION

As per findings of present study the frequency of urinary tract infection among children with cerebral palsy was 32.25% and this incidence was significantly higher in male child. The prevalence of asymptomatic bacteriuria in children with cerebral palsy was 4.8%. So, it is important to screen these children for urine examination as a baseline investigation in all the cerebral palsy patients presenting to hospital (both indoor and outdoor departments) and also regular follow up required to minimize the urinary complications.

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