Background Catheter associated urinary tract infection(CAUTI) is a common device-acquired infection and represent a potentially harmful reservoir of resistant uropathogens. Guidelines recommend limitation of catheter use, aseptic catheter insertion, sterile equipment, strict hand hygiene, use of smallest catheter possible and maintenance of a closed drainage system.

Klebsiella Pneumoniae is a non-mobile aerobic rod causing a large spectrum of hospital-acquired infections, especially pneumonia or urinary tract infections (UTI), developing intrinsic resistance genes. Treating multi drug resistant(MDR) gram negative pathogens becomes a challenge for the caregiver.

Vesicoureteral reflux(VUR) consists of backflow of urine from the bladder into the ureters. It can be primary or secondary due to abnormal lower urinary tract function and elevated intravesical pressure. Post void residual(PVR) is a hallmark of detrusor underactivity(DUA) in children.

Case Presentation Summary We present the case a three years old boy, hospitalized for viral encephalitis, undergoing artificial respiratory support and urine catheterization for 6 weeks. Neurological status was hypotonic cerebral palsy and secondary urine incontinence in a previously toilet trained child.

First febrile UTI developed two days after removing urine catheter. High resistant Klebsiella pn. (ESBL+, AAC(3)-II) was treated with a ten-day course of Cephtriaxone and Amikacin. Clinical response to treatment was good with sterile urine culture after 96 hours. After treatment, the child had asymptomatic bacteriuria with MDR Klebsiella pn. in spite of rigorous local hygiene, proper hydration and oral Fosfomycin. Second febrile UTI was accompanied by febrile seizures, and urine culture was positive with MDR Klebsiella (+ESBL or +HL AmpC, Carbapenem impermeability). Treatment with high dose Meropenem (40mg/kg/dose) for twelve days was successful. Third febrile UTI occurred five days after finishing treatment with same MDR Klebsiella strain. Once again, fourteen-day high dose Meropenem course was successful. Fourth febrile UTI with Escherichia Coli occurred two weeks later and was treated successfully with ten-day course of Ciprofloxacin.

Ultrasound examination revealed normal kidneys and bladder, while voiding cystography was evocative for bilateral VUR and post void residual.

Neurologic status improved over a three-month period from almost complete hypotonic palsy to mild hypotonic paraplegia.

Discussions Long hospitalization and prolonged urine catheterization increase the risk of CAUTI. High dose Meropenem remains efficient in treating MDR Klebsiella strains. Recurrent UTI should be further investigated for presence of VUR.

Neurological damage, like hypotonic cerebral palsy can be associated with underactive bladder and detrusor underactivity.