Childhood Kidney Diseases

Korean Society of Pediatric Nephrology (대한소아신장학회)
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Breakthrough Urinary Tract Infection: A Clinical Study of Experience of a Single Center

예방적 항생제 사용중에 발생한 요로감염: 단일 병원에서 경험한 임상연구

  • Bae, Sang-In (Department of Pediatrics, Pusan National University Collese of Medicine) ;
  • Cheon, Chong-Kun (Department of Pediatrics, Pusan National University Collese of Medicine) ;
  • Kim, Su-Young (Department of Pediatrics, Pusan National University Collese of Medicine)
  • 배상인 (부산대학교 의학전문대학원 소아과학교실) ;
  • 전종근 (부산대학교 의학전문대학원 소아과학교실) ;
  • 김수영 (부산대학교 의학전문대학원 소아과학교실)
  • Received : 2010.09.22
  • Accepted : 2010.10.18
  • Published : 2010.10.31
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Abstract

Purpose : It has been a common medical practice to use prophylactic antibiotics to prevent recurrent urinary tract infections (UTI) in high risk situations such as urinary tract obstruction, vesicoureteral reflux, neurogenic bladder, or urinary stones. But sometimes, we meet difficult situation of breakthrough infections (BI) which might cause new or progressive renal scarring. The clinical characteristics of children contracting breakthrough UTI experienced in a single center were studied. Methods : The study was done retrospectively through medical records of 150 pediatric patients who had been cared in pediatric and urologic clinics of Pusan National University Hospital from Jan. 2001 till June 2006 and had prophylactic antibiotics to prevent recurrent UTI. Results : The starting age of prophylactic antibiotics of 150 patient was 1-76 months, and median age was 5 months. The BI developed 61 times in 43 patients (28.7%), 1.5 times per 100 patient-months. The BI occurred more frequently in patients with higher grade of VUR, and in the cases with abnormal DMSA scan. Co-trimoxazole was more effective than 2nd and 3rd generation cephalosporins to prevent UTI. The distribution of causative organisms was more diverse than usual UTI. The causative organisms were sensitive to the antibiotics used for prophylaxis in 29.5%, and resistant in 59.1%. After experience of BI, 40 percents of patients went to the surgical treatment including endoscopic injection of Deflux, 35% to new antibiotics for prophylaxis, 26% remain on the same antibiotics as the previous one. Conclusion : Based on our study results, preexisting renal scar might be one of the factors which should be considered in favor of early surgical interventions of VUR. Poor compliance and wrong selection of antibiotics such as cephalosporins are important underlying causes of breakthrough UTIs.

목 적 : 소아에서 여러 가지 원인으로 반복적 요로감염의 위험성을 줄이기 위한 예방적 항생제 투여시, 새로운 내성균의 출현으로 요로 감염이 재발하게 되는 소위 돌파 감염(breakthrough infection)이 있게 되면 그에 의한 새로운 신 반흔 형성이 문제가 된다. 하지만 지금까지 국내에서 돌파 감염의 임상양상에 대한 보고는 드물었으므로 저자는 본 병원에서 실제 예방적으로 사용하고 있는 항생제의 실태와 그에 따른 돌파 감염의 임상 양상을 알아보고자 본 연구를 시행하였다. 방 법 : 약 5년 6개월간 부산대학교병원 소아과에서 요로감염의 재발을 방지하기 위하여 예방적 항생제를 사용한 150명의 환자를 대상으로 돌파감염의 양상에 대하여 차트와 검사결과를 후향적으로 조사하였다. 결 과 : 예방적 항생제 투여를 시작한 연령 범위는 1-76개월, 중간 연령은 5개월이었으며, 돌파감염은 총 43례(28.7%)에서 61회 발생하였고 발생빈도는 환자 100 patient-months당 1.5회였다. 방광 요관 역류로 예방적 항생제를 사용한 경우, 역류의 정도에 따른 돌파감염의 발생빈도는 grade I-II에서 18.5%, grade III에서 21.1%, grade IV-V에서 41.7%로써 grade가 높을수록 높았으나 통계적 유의성은 없었다(P=0.06). 또한 항생제 사용 전실시한 DMSA 스캔에서 이상이 있었던 경우가 이상이 없었던 경우보다 쉽게(47.3% vs 14.7%) 요로감염이 발생하였다. 돌파 감염의 원인균은 대장균에 의한 경우가 가장 많았지만(29.5%), 일반적인 요로 감염에서 보다 다양한 균주에 의해 고른 분포로 요로 감염이 발생하였다. 사용한 예방적 항생제 중 co-trimoxazole을 사용한 경우가 2세대, 3세대 세파로스포린을 사용한 경우보다 요로감염의 예방에 효과적이었으며(P=0.0386, P=0.0128), 항생제 감수성 검사 결과 27.3%는 사용 중인 예방적 항생제에 감수성이 있었고 59.1%는 저항성을 보였다. 돌파 감염이 발생한 환아 중 39.5%에서 수술적 치료로 바꾸었으며 34.9%에서 항생제를 변경하였고 25.6%에서는 종래의 항생제를 계속 사용하였다. 결 론 : 신 반흔이 있는 경우는 돌파 감염이 쉽게 일어나므로 내시경적인 방법 등을 포함한 수술적 치료의 선택에 고려되어져야하며, 돌파 감염을 방지하기 위해 환자의 항생제 투여의 순응도를 고려해야 하며 세파로스포린 같은 항생제 사용은 자제해야 할 것으로 사료된다.

Keywords

References

  1. Elder JS. Urinary tract infection. In: Kligman RM, Behman RE, Jenson HB, Stanton BF, editors. Nelson Textbook of Pediatrics. 18th ed. Philadelphia:W.B. Saunders Co, 2007: 2223-8.
  2. Dai B, Liu Y, Jia J, Mei C. Long-term antibiotics for the prevention of recurrent urinary tract infection in children: a systematic review and meta-analysis. Arch Dis Child 2010;95:499-508. https://doi.org/10.1136/adc.2009.173112
  3. Ansari MS. Prophylactic antibiotics in vesicoureteric reflux: Evidence-based analysis. Indian J Urol 2009;25:276-7. https://doi.org/10.4103/0970-1591.52926
  4. Cheng C, Tsai M, Huang Y, Su L, Tsau Y, Lin C, et al. Antibiotic resistance patterns of community-acquired urinary tract infections in children with vesicoureteral reflux receiving prophylactic antibiotic therapy. Pediatrics 2008;122:1212-7. https://doi.org/10.1542/peds.2007-2926
  5. Birmingham Reflux Study Group. Prospective trial of operative versus non-operative treatment of severe vesicoureteric reflux in children: five years observation. Br Med J 1987;295:237-41. https://doi.org/10.1136/bmj.295.6592.237
  6. Tamminen-Mo bius T, Brunier E, Ebel KD, Lebowitz R, Olbing H, Seppanen U, et al. Cessation of vesicoureteral reflux for five years in infants and children allocated to medical treatment. The International Reflux Study in Children. J Urol 1992; 148;1662- 8. https://doi.org/10.1016/S0022-5347(17)36997-5
  7. Weiss R, Duckett J, Spitzer A. Results of a randomized clinical trial of medical versus surgical management of infants and children with grades III and IV primary vesicoureteral reflux (United States) (The International Reflux Study in Children). J Urol 1992;148: 1667-73. https://doi.org/10.1016/S0022-5347(17)36998-7
  8. Brendstrup L, Hjelt K, Petersen KE, Petersen S, Andersen EA, Daugbjerg PS, et al. Nitrofurantoin versus trimethoprim prophylaxis in recurrent urinary tract infection in children. A randomized double-blind study. Acta Pediatr Scand 1990;79:1225-4.
  9. Smith EM, Elder JS. Double antimicrobial prophylaxis in girls with breakthrough urinary tract infections. Urology 1994;43:708-12. https://doi.org/10.1016/0090-4295(94)90190-2
  10. Savage DC, Howie G, Adler K. Controlled trial of therapy in covert bacteriuria of childhood. Lancet 1975;1:358-61.
  11. Stansfeld JM. Duration of treatment for urinary tract infections in children. Br Med J 1975;3:65-6. https://doi.org/10.1136/bmj.3.5975.65
  12. Smellie JM, Katz G, Gruneberg RN. Controlled trial of prophylactic treatment in childhood urinary-tract infection. Lancet 1978; 2:175-8.
  13. Cardiff-Oxford Bacteriuria Study Group. Sequelae of covert bacteriuria in schoolgirls. A four-year follow-up study. Lancet 1978; 1:889-93.
  14. Elder JS, Peters CA, Arant BS Jr, Ewalt DH, Hawtrey CE, Hurwitz RS, et al. Pediatric Vesicoureteral Reflux Guidelines Panel summary report on the management of primary vesicoureteral reflux in children. J Urol 1997;157:1846-51. https://doi.org/10.1016/S0022-5347(01)64882-1
  15. Craig JC, Simpson JM, Williams GJ. Antibiotic prophylaxis and recurrent urinary tract infection in children. N Engl J Med 2009;361:1748-59. https://doi.org/10.1056/NEJMoa0902295
  16. Garin EH, Olavarria F, Garcia Nieto V, Valenciano B, Campos A, Young L. Clinical significance of primary vesicoureteral reflux and urinary antibiotic prophylaxis after acute pyelonephritis: A multicenter, randomized, controlled study. Pediatrics 2006;117:626-32. https://doi.org/10.1542/peds.2005-1362
  17. Wheeler DM, Vimalachandra D, Hodson EM, Roy LP, Smith GH, Craig JC. Interventions for primary vesicoureteric reflux. Cochrane Database Syst Rev 2004, Issue 3. Art No.: CD001532.
  18. Hansson S, Dhamey M, Sigstrom O, Sixt R, Stokland E, Wennerstrom M, et al. Dimercapto- succinic acid scintigraphy instead of voiding cystourethrography for infants with urinary tract infection. J Urol 2004;172: 1071-3. https://doi.org/10.1097/01.ju.0000135337.71154.60
  19. Jodal U, Koskimies O, Hanson E. Infection pattern in children with vesicoureteral reflux randomly allocated to operation or longterm antibacterial prophylaxis. J Urol 1992; 148:1650-2. https://doi.org/10.1016/S0022-5347(17)36994-X
  20. Smellie JM, Barratt TM, Chantler C. Medical versus surgical treatment in children with severe bilateral vesicoureteral reflux and bilateral nephropathy: a randomised trial. Lancet 2001;357:1329-33. https://doi.org/10.1016/S0140-6736(00)04520-7
  21. Capozza N, Caione P. Dextranomer/hyaluronic acid copolymer implantation for vesicoureteral reflux: a randomized comparison with antibiotic prophylaxis. J Pediatr 2002; 140:230-4. https://doi.org/10.1067/mpd.2002.121380
  22. Hodson EM, Wheeler DM, Smith GH, Craig JC, Vimalachandra D. Interventions for primary vesicoureteric reflux. Cochrane Database of Systematic Reviews 2007, Issue 3. Art No. : CD001532. DOI 10.1002/146518 58.cd001532.pub3.
  23. Hellerstein S, Nickell E. Prophylactic antibiotics in children at risk for urinary tract infection. Pediatr Nephrol 2002;17:506-10. https://doi.org/10.1007/s00467-002-0899-x
  24. Szlyk GR, Williams SB, Majd M, Belman AB, Rushton HG. Incidence of new renal parenchymal inflammatory changes following breakthrough urinary tract infection in patients with vesicoureteral reflux treated with antibiotic prophylaxis: evaluation by 99m- Technetium dimercapto-succinic acid renal scan. J Urol 2003;170:1566-8. https://doi.org/10.1097/01.ju.0000085962.68246.ce