Institutional Outcomes of Immediate vs Delayed or No Clean Intermittent Catheterization in Infant Neurogenic Bladder

Abstract

BACKGROUND: Timing of clean intermittent catheterization (CIC) in infants with neurogenic lower urinary tract dysfunction (NLUTD) remains uncertain. We compared 12-month infectious and renal-bladder ultrasound (RBUS) outcomes in infants started on CIC within 30 days of life versus those managed without neonatal CIC. METHODS: Single-center ambispective cohort of 221 infants with NLUTD (June 2017 to January 2025). Primary analysis compared immediate CIC (≤ 30 days; n = 53) versus non-immediate management (n = 168). Secondary descriptive analyses stratified non-immediate management into never CIC (n = 116) and delayed CIC initiation (> 30 days; n = 52). Outcomes through 12 months included bacteriuria, symptomatic UTI, febrile UTI counts, baseline and follow-up RBUS findings, Kaplan-Meier time to first symptomatic UTI, and an exploratory multivariable Cox model (interpreted as associative given confounding by indication and time-varying escalation). RESULTS: Immediate CIC infants had higher neurologic risk (upper motor neuron phenotype 79% vs 33%) and more antibiotic prophylaxis exposure (57% vs 32%). Bacteriuria was higher with immediate CIC (43% vs 24%; RR 1.78, 95% CI 1.18-2.67), consistent with catheter-associated colonization and increased detection. Symptomatic UTI incidence was similar in the primary comparison (47% vs 38%; RR 1.24, 95% CI 0.88-1.75). In secondary three-group analyses, delayed CIC had the highest symptomatic UTI rate (73% delayed vs 47% immediate vs 22% never) and higher febrile UTI counts, with shorter time to first symptomatic UTI on Kaplan-Meier analysis. Follow-up RBUS abnormalities (bladder wall thickening/irregularity, ureteral dilatation, and reported renal scarring) were most frequent in delayed CIC infants; however, these findings are limited by longer imaging follow-up and likely confounded by indication. Circumcision status among males did not differ by CIC timing in either the primary or three-group comparisons. CONCLUSIONS: In this institutional cohort, immediate CIC was associated with increased bacteriuria consistent with colonization without higher symptomatic UTI rates in the primary comparison. Associations between delayed CIC initiation and worse infectious and imaging outcomes likely reflect reactive escalation (time-varying exposure) and baseline non-exchangeability rather than a causal effect of "delay." Findings support risk-adapted CIC initiation and symptom-based UTI diagnosis to promote antimicrobial stewardship.