ABSTRACT ‘Asymptomatic bacteriuria’ (ASB) is isolation of a specified quantitative count of bacteria in an appropriately collected urine specimen obtained from a person without symptoms or signs referable to urinary infection. Catheterized specimens are less likely to be contaminated compared with voided specimens; therefore, positive cultures of catheterized specimens are more likely to reflect true bladder bacteriuria even with low colony counts. The common pathogens for ASB are Escherichia coli, Klebsiella and Streptococcus spp. Pasteurella spp. was not previously reported as an ASB agent. ASB is important for pregnant women, children, individuals with obstructive uropathy, chronic renal failure and neutropenia, before the urologic procedures and after renal transplantation. Treatment of ASB is required for above situations. We report an 11-year-old-girl with neurogenic bladder who made clean intermittent catheterization and had Pasteurella aerogenes as an ASB agent. asymptomatic bacteriuria, neurogenic bladder, Pasteurella aerogenes INTRODUCTION Asymptomatic bacteriuria (ASB) is reproduction of the same bacterial strain taken from two urine specimens without fever and local symptoms such as dysuria and hematuria in at least 24 h interval at the rate of ≥100 000 cfu/ml . Production of microorganism in the catheterized urine specimen is more significant, as it will reduce the risk of contamination. ASB is common and its prevalence changes according to age, gender and existence of urinary system anomaly . The most common microorganisms are Escherichia coli, Klebsiella and Streptococcus spp, respectively [3, 4]. To our knowledge, the microorganism of Pasteurella species, especially Pasteurella aerogenes, has never been reported as an ASB agent. We described an 11-year-old girl with P. aerogenes as an ASB agent who made clean intermittent catheterization (CIC) owing to neurogenic bladder. CASE REPORT An 11-year-old girl, followed up owing to neurogenic bladder, applied to provide urine culture before urodynamic evaluation. She had no complaints. Her medical history revealed that she had recurrent upper-urinary-tract infections and positive urine cultures with E. coli and one time with Klebsiella pneumoniae. According to the voiding cystourethrogram, the fourth-degree vesicoureteral reflux and a neurogenic bladder were determined. She underwent an ureteroneocystostomy surgery and had daytime enuresis. She had CIC for the past 6 months. Her systemic examination was normal. In her urinalysis, the density and pH were normal and the nitrite was negative. No bacteria or leukocytes were seen in microscopy. In complete blood count, white blood cells = 6500/mm3 (5.0–14.5 × 103/mm3), Hb = 12.8 g/dl (11.5–12.5 g/dl), hematocrit = 38.3% (34–37%), MCV = 88 fl, thrombocytes = 349 000/mm³ (150–400× 103/mm3); in the serum biochemistry, liver and kidney function tests and electrolytes were within normal limits. C-reactive protein and erythrocyte sedimentation rate were within normal limits. In the catheterized urinary specimen, 100 000 cfu/ml P. aerogenes was detected with Phoenix 100 (BD, USA) full-automatic system. Renal ultrasonography was normal. Because she had no complaints, the urine culture was repeated. The same microorganism was reproduced in the same numbers of colony also in the second culture and it was accepted that she had ASB. The history was repeated and then it was learnt that her family were keeping an injured rabbit, they had found on the road, for almost 1 week. Ten-day ampicillin treatment was started because there was urological structural abnormality and she had CIC. In the post-treatment control urine and urine culture evaluation, it was observed that 100 000 cfu/ml P. aerogenes reproduction continued. Complete blood count and acute phase reactants were repeated and found to be within normal limits. The patient whose ASB clinic continued received a 10-day ampicillin-sulbactam treatment and no reproduction was observed in the control urine culture at the end of the treatment. DISCUSSION The same microorganism reproduced in the same number of colony in the catheterized urine culture specimens taken from the patient in a 24-h interval and when she had the complaint of ASB. ASB has great significance especially in pregnant women, children, obstructive uropathy, chronic renal failure, diabetes, neutropenia and before urologic intervention . CIC is the intermittent bladder emptying of a patient with urinary dysfunction . In this patient group, symptomatic urinary system infections and ASB are the most common complications. The prevalence of ASB has been reported to change between 23% and 89% among patients having spinal cord injury and using intermittent catheter . Our patient was in the pediatric age group, had urinary tract anomaly and used intermittent catheter. In a study, the urine cultures of 112 asymptomatic patients, having spina bifida and performing CIC, were evaluated, and in 45 of these patients, a positive culture result was obtained. In terms of reproducing microorganisms, the most common ones are E. coli, Klebsiella and Streptococcus spp, respectively . The Pasteurella species has never been defined as an ASB agent. Pasteurella are gram negative, nonmotile, facultatively anaerobic coccobacilli that inhabit the oral cavity and gastrointestinal tract of many animals . Organisms grow in culture including sheep blood and chocolate agar but not usually on MacConkey agar media. Most strains are catalase, oxidase and indole positive and produce acid from sucrose. For most Pasteurella spp, the principal reservoir is in animals (dog, cat, pigs and a wide variety of domestic and wild animals). Pasteurella aerogenes is more associated with pigs and hamsters. Bites, claws or licks of these animals generally result in localized infections in humans . The factors that affect patients’ defense system adversely like immunosuppression, malignity, malnutrition, trauma, intravenous drug addiction, diabetes mellitus, atherosclerosis, chronic renal failure, chronic liver disease and long-term systemic steroid use can pave the way for severe systemic infections like septicemia, meningitis, peritonitis, endocarditis or osteomyelitis, thereby causing the infection to show a fatal course . Pasteurella spp also has symptomatic urinary tract infections defined especially with the sub-group Pasteurella multocida. Hubbert and Rosen showed that 5 of 253 pasteurella infections (unrelated with animal contact) were from urine specimen. Komorowski and Farmer defined two urinary tract infections linked to P. multocida. One of them was a 15-year-old male patient with chronic renal failure and ileal loop, and the other one was a 26-year-old patient with cervical carcinoma complicated with vesicoureteral reflux and renal failure [11, 12]. But, P. aerogenes was not previously reported as an ASB and urinary tract infection agent. In majority of the Pasteurella spp-related urinary tract infections, there are medical or urologic anomalies. Our patient had neurogenic bladder. Although there is no clear information regarding how pasteurella species cause urinary tract infections, chronic diseases and structural anomalies of urinary tracts are known to be risk factors . The determination of P. multocida agent in a patient who had urinary tract infection and no history of animal clawing and biting, and the same P. multocida in that patient’s cat showed enough zoonotic transmission and animal contact . Consequently, the presence of underlying structural urologic anomalies and especially the diseases impairing the host immune defense is important. In this case, the microorganism was thought to be inoculated to the urogenital system through catheter owing to the rabbit’s licking the patient’s hands. The first drug to be chosen in pasteurella infections should be Penicillin. However, ampicillin, amoxicillin-clavulanate, cefuroxime, cefpodoxime, trimethoprim-sulfamethoxazole, doxycycline and quinolones are other effective agents. In this case, the 10-day ampicillin-sulbactam treatment was given and no reproduction was seen in the control culture. Preventive aspects are important. The first point is avoidance of pets in homes with immuno-compromised individuals. The patients must wash hands strictly when they manage CIC drainage procedures. Storage of catheters must be made safely. In conclusion, it should be remembered that zoonotic transmission is important in patients with underlying urologic anomaly, and in immunosuppressed patients, it is required to be careful about animal contact, and symptomatic or asymptomatic atypical microorganisms other than usual infection agents may reproduce in these patients. REFERENCES 1 Wagenlehner FM, Naber KG, Weidner W. Asymptomatic bacteriuria in elderly patients: significance and implications for treatment. Drugs Aging 2005; 22: 801– 7. Google Scholar CrossRef Search ADS PubMed 2 Nicolle LE, Bradley S, Colgan R, et al. Infectious diseases society of america guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis 2005; 40: 643– 54. Google Scholar CrossRef Search ADS PubMed 3 Zegers BS, Uiterwaal CC, Verpoorten CC, et al. Home screening for bacteriuria in children with spina bifida and clean intermittent catheterization. BMC Infect Dis 2012; 12: 264. 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Journal of Tropical Pediatrics – Oxford University Press
Published: Feb 1, 2018
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