Marei Mahmoud Marei, Jackson Raef, Keene David J B
Department of Paediatric Urology and Bladder Exstrophy, The Royal Manchester Children's Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom; Cairo University, Faculty of Medicine (Kasr Alainy), Department of Paediatric Surgery, Cairo University Children's Hospitals, Cairo, Egypt.
Department of Paediatric Urology and Bladder Exstrophy, The Royal Manchester Children's Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom.
J Pediatr Urol. 2021 Feb;17(1):65.e1-65.e11. doi: 10.1016/j.jpurol.2020.08.007. Epub 2020 Aug 19.
Little has been reported to date on the instillation of antimicrobials directly into the bladder in children. Children with complex urinary tract anomalies struggle frequently with recurrent urinary tract infections (UTI), with frequent emergence of antibiotic resistance. Gentamicin bladder instillation to treat and prevent UTI was described in children since 2006.
We adopted gentamicin bladder instillation in 2016 and evaluate herein our intermediate-term experience with it.
This study is a retrospective review of a prospectively initiated database and a clinical audit of our practice. The gentamicin bladder instillation was employed in 24 cases. A treatment regime was initiated for symptomatic documented UTI when resistance patterns precluded an oral alternative (14 cases), avoiding hospitalisation for parenteral antibiotics. A prophylaxis regime (19 cases-including 9 of the 14 who received an initial treatment regime) followed at least one breakthrough UTI while receiving oral prophylactic antibiotics. Two instillation volumes (8 mg gentamicin in 20 mL 0.9% NaCl or 20 mg gentamicin in 50 mL 0.9% NaCl) were used to suit different bladder capacities. The irrigation is given twice a day for 7 days in the treatment regime or once a day, every other day, in the prophylactic regime. Gentamicin serum levels (all cases) and audiology/audiometry testing (17/24 cases) were checked to assess the safety of this method.
The median age when either the treatment course or prophylaxis regime was started was 3.8 years. The treatment regime was 86% successful (12/14) to suppress an acute UTI. The mean duration of prophylaxis was 252 days (median: 256 days). The percentage of patients on the prophylactic regime who had no breakthrough UTI was 58%. No serum gentamicin was detectable secondary to the intravesical instillation. No attributable cases of sensorineural hearing loss were detected. Gentamicin resistance emerged in one case (4.16%).
Intravesical administration was feasible via various routes for a spectrum of complex lower urinary tract abnormalities (see Summary Figure). Concerns regarding systemic absorption, nephrotoxicity or ototoxicity were investigated and safety ensured. Limitations include being a small series of non-identical pathologies, albeit categorically similar and being a single-arm study, however, statistical significance was proven descriptively and analytically.
In selected cases and with the appropriate specialist support and logistics, intravesical gentamicin instillation is well-tolerated and safe to treat and/or prevent urinary tract infections in pateints with complex bladder conditions and lower urinary tract pathologies.
迄今为止，关于直接向儿童膀胱内灌注抗菌药物的报道较少。患有复杂尿路异常的儿童经常反复发生尿路感染（UTI），且抗生素耐药性频繁出现。自2006年以来，已有关于庆大霉素膀胱灌注治疗和预防儿童UTI的描述。
我们于2016年采用庆大霉素膀胱灌注，并在此评估我们的中期经验。
本研究是对前瞻性建立的数据库进行回顾性分析以及对我们的实践进行临床审计。对24例患者采用庆大霉素膀胱灌注。当耐药模式排除口服替代药物时，对有症状记录的UTI启动治疗方案（14例），避免因使用胃肠外抗生素而住院。在接受口服预防性抗生素治疗时，至少出现一次突破性UTI后启动预防方案（19例，包括接受初始治疗方案的14例中的9例）。使用两种灌注量（20 mL 0.9%氯化钠中含8 mg庆大霉素或50 mL 0.9%氯化钠中含20 mg庆大霉素）以适应不同的膀胱容量。治疗方案中每天灌注两次，共7天；预防方案中每天一次，隔日进行。检查庆大霉素血清水平（所有病例）和听力/听力测定测试（17/24例）以评估该方法的安全性。
开始治疗疗程或预防方案时的中位年龄为3.8岁。治疗方案抑制急性UTI的成功率为86%（12/14）。预防的平均持续时间为252天（中位数：256天）。接受预防方案且未出现突破性UTI的患者百分比为58%。膀胱内灌注后未检测到血清庆大霉素。未检测到可归因的感音神经性听力损失病例。1例（4.16%）出现庆大霉素耐药。
对于一系列复杂的下尿路异常，膀胱内给药可通过多种途径实现（见总结图）。对全身吸收、肾毒性或耳毒性的担忧进行了调查并确保了安全性。局限性包括病例数少且病理情况不完全相同，尽管分类上相似且为单臂研究，然而，通过描述性和分析性方法证明了统计学意义。
在特定病例中，在适当的专家支持和后勤保障下，膀胱内灌注庆大霉素耐受性良好，对于患有复杂膀胱疾病和下尿路病变的患者，治疗和/或预防尿路感染是安全的。
