Loading

JSM Renal Medicine

Urinary Tract Infection and Antimicrobial Susceptibility Pattern Associated with Asymptomatic Bacteriuria in those Receiving Clean Intermittent Catheterization for Neurogenic Bladder

Research Article | Open Access Volume 2 | Issue 2 |

  • 1. Department of Pediatrics, The Ohio State University, USA
  • 2. Section of Urology, Nationwide Children’s Hospital, USA
  • 3. Center for Microbial Pathogenesis at the Research Institute, Nationwide Children’s Hospital, USA
  • 4. Department of Urology, The Ohio State University, USA
  • 5. Department of Urology, Cincinnati Children’s Hospital, USA
+ Show More - Show Less
Corresponding Authors
Elizabeth Lucas, Division of complex HealthCare, Nationwide Children’s Hospital, 700 Children’s Drive, Columbus, Ohio, USA, Tel: 614-722-5808; Fax: 614-355- 5395;
Abstract

Clean intermittent catheterization (CIC) is a frequently performed procedure on patients with neurogenic bladder to assist with voiding and is associated with bacteriuria. Due to this bacteriuria, this patient population is frequently subjected to multiple courses of antibiotics, whether appropriate or not and often become colonized with multi-drug resistant organisms. Choosing appropriate empirical antibiotics is a clinical dilemma when encountering these patients at the beginning of an illness. We reviewed antimicrobial susceptibility patterns of urine cultures for 50 myelomeningocele patients over the course of 1 year. Data for 192 organisms was available for analysis and E. coli was the most commonly recovered organism. Using univariate analysis we sought to detect differences identifying subjects who were most likely to be colonized with resistant E. coli strains versus those subjects that had susceptible strains. Though the probability of resistance is higher than that in the community, it did not proportionately increase with olderage, increased duration of clean catheterization, or related to route of catheterization. Decisions for empirical therapy ought to be guided by individual patient’s previous culture results with particular attention to colonization with resistant organisms, but broad spectrum coverage may not be necessary in all patients utilizing clean intermittent catheterization.

Citation

Lucas E, Singh C, Baxter C, Risser R, Mohamed AZ, et al. (2017) Urinary Tract Infection and Antimicrobial Susceptibility Pattern Associated with Asymptomatic Bacteriuria in those Receiving Clean Intermittent Catheterization for Neurogenic Bladder. JSM Renal Med 2(2): 1012.

Keywords

•    Urinary catheter
•    Bacteriuria
•    Uropathogen

INTRODUCTION

Clean intermittent catheterization (CIC) is often employed in patients with neurogenic bladder secondary to spina bifida or spinal dysraphism for normal voiding of the bladder. Due to the frequency of catheterization, patients often present with bacteriuria [1], with the prevalence ranging from 70% [1] to 85% [2]. As these patients are typically non-sensate, they often are classified as episodes of asymptomatic bacteriuria (ABU). While antimicrobial treatment is not associated with elimination of ABU or reduction in urinary tract infection (UTI) [3], antimicrobials are administered when febrile UTI is encountered. Choosing appropriate antimicrobial therapy for the coliforms is emphasized and local susceptibility patterns typically guide selection for clinicians [4]. However, prior exposure to antimicrobials, as frequently occurs in this population for various indications, alters sensitivity patterns. This problem makes it difficult to choose appropriate empirical antimicrobial therapy at the onset of illness in this population, but is essential to minimize morbidity related to UTI [5]. Hence, we sought to prospectively study the incidence of asymptomatic bacteriuria, antimicrobial sensitivity pattern and potential predictive factors for antimicrobial resistance in a cohort of patients with neurogenic bladder on regular CIC for bladder management.

METHODS

Patients

Consecutive patients with neurogenic bladder secondary to myelomeningocele on regular CIC 4-6 times a day were consented to participate in a prospective randomized trial to study the effect of catheter type on the microbiological milieu of the bladder [6]. Informed consent was obtained by a trained provider both verbally and with a written explanation of the study. The study protocol was approved by the Institutional Review Board for human studies (OHRP Assurance No. FWA00002860) at Nationwide Children’s Hospital (IRB number: IRB12-00269) and registered at clinicaltrials.gov (NCT01305681). All those with recent or foreseeable change in the catheterization pattern or preferences due to surgeries, outstation trips or transition from caregiver catheterization to self catheterization were excluded. Other exclusion criteria include antimicrobial chemoprophylaxis and treatment for UTI within the past two weeks. An intended sample size of 50 was achieved over a period of ten months (June 2011 to March 2012). At the beginning of the study period, a clean catheterized sample of urine was obtained using a new catheter. The specimen was transported within one hour to the microbiology department. In addition to the clinical and microbiological information that was obtained as a part of the study, the sensitivity pattern was obtained whenever there was a growth of a potential pathogen. The ChildLab at Nationwide Children’s Hospital processed all urine samples per standard protocols plating to sheep blood and MacConkey agar biplates using calibrated loops [7]. Cultures were incubated for a minimum of 16 hours at 35° C in ambient air and quantitation of significant pathogens provided as colonies per milliliter of urine. Isolated colonies were identified to the genus and species level, as appropriate, using standard biochemical or automated identification tests (Vitek 2, bioMerieux. Durham, NC). Sensitivity was determined using disc diffusion method. Demographic data and clinical information pertaining to voiding and urinary infections were obtained.

Statistical analysis was performed using the Prism® software package (GraphPad, La Jolla, CA) and SPSS Statistics® (IBM, Armonk, NY). Descriptive statistics were used for demographic data and reports of resistance patterns, and the univariate analysis to compare the three E. coli cohorts used an ordinary one way ANOVA.

Definitions

“Bacteriuria” in this population is not well defined, since colonization is known to occur with intermittent catheterization. Previously used definition of >104 colony-forming units or more obtained by bladder catheterization was used to define significant bacteriuria [8]. Febrile Urinary Tract Infection was defined as a positive urine culture result with fever >101 degree Fahrenheit, abdominal pain, change in continence pattern or change in color or odor of urine [1]. Those who had febrile UTI more than once were categorized as recurrent UTI [9]. Enterobacteriaceae and other bacteria known to cause UTI were categorized as potential pathogens. Lactobacilli, corynebacterium, coagulase negative staphylococci and other bacteria that are not clinically relevant were categorized as non-pathogens [4]. Significant bacteriuria associated with non-susceptibility to at least one agent in one or more antimicrobial categories was categorized as colonization with resistant pathogen [10]. Multidrug resistant organisms (MDRO) were defined according to the CDC’s definition: acquired non-susceptibility to at least one agent in one or more antimicrobial categories [11].

In our patient cohort analysis, we divided patients up based on the susceptibility pattern of their recovered E. coli species. Patients who only grew E. coli species that were pan-sensitive to all antimicrobials tested were included in the “sensitive” cohort. Conversely, a “resistant” cohort was comprised of patients who grew E. coli species that were resistant to first line therapies ampicillin and co-trimoxazole PLUS drug resistance to another drug class. If patients grew E. coli species with intermediate resistance, like resistance to ampicillin only or resistance to another class of antimicrobials, that patient was included in the “mixed” cohort. If a patient grew multiple strains of E. coli of varying susceptibility patterns during the study period, the assignment to cohort followed the most resistant strain available. For example, if a patient grew a strain resistant to ampicillin, cotrimoxazole, and a cephalosporin in one culture and another entirely sensitive E. coli strain in a later culture, the patient was included in the resistant cohort. Our practice when choosing empirical therapy is that the presence of a previous multidrug resistant organism influences a clinician to select a more broad spectrum agent.

RESULTS

230 patients from our myelomeningocele clinic were assessed for eligibility. 116 patients were excluded on the basis of: (i) presentation with active UTI, (ii) ongoing antimicrobial chemoprophylaxis for recurrent UTI or vesicoureteral reflux (iii) scheduled urinary tract surgery during study period, (iv) or poor compliance with CIC. 64 patients declined to participate; the remaining 50 patients consented to participate (Figure 1). The demographic parameters are given in (Table 1).

In total, 286 species were recovered from 184 urine samples. 29 collected samples did not demonstrate any growth and were considered culture-negative. Of the 286 species evaluated, antibiotic susceptibility was determined for 192 species (Figure 1). The sensitivity pattern of the predominant pathogens associated with urinary tract infection is given in (Table 2). E. coli was the most commonly recovered species and more than half (N = 53) were resistant to at least one typical first line therapy, ampicillin or co-trimoxazole. 47 species demonstrated resistance to antibiotics beyond first line therapies and 16 of those qualified as multidrug resistant strain, with resistance to ampicillin, co-trimoxazole, and another class of antimicrobial agent. An additional 9 Pseudomonas species were recovered but their sensitivity patterns are so different from other gut coliforms they were not included in the table. Another 21 various potentially pathogenic species are also not included in the table due to their small numbers, but those sensitivity patterns are reported in our [Supplemental Table 1].

To evaluate for factors that may identify myelomeningocele patients at risk for carriage of multidrug resistant strains, we examined three cohorts of patients. E. coli is the most commonly recovered uropathogen from all UTI patients and was the most commonly recovered potential uropathogen from our patient population, thus we chose to use this species to compare groups. 46 participants had at least one strain of E. coli recovered during the study period. Of the remaining 4 participants, 2 patients had culture negative results at all time points and 2 patients did not grow an E. coli species. The first cohort of participants includes 16 strains of E. coli obtained from 9 unique patients that demonstrated resistance to ampicillin, co-trimoxazole, and another drug class.The second cohort includes 33 strains of E. coli that were sensitive to all antibiotics tested obtained from 16 unique patients. The final cohort demonstrated mixed susceptibility patterns for 27 strains of E. coli from 15 unique patients. We examined these three cohorts for potential risk factors listed in (Table 3). We compare cohorts in terms of age, sex, and total duration of catheterization (in years). We further examined whether subjects employed night drainage (the practice of leaving a catheter in place overnight to allow emptying of the bladder), whether they had previous undergone bladder augmentation, and whether they performed catheterization through the urethra or a surgically created channel in the abdomen called the Mitrofanoff procedure. Univariate analysis did not find any statistically significant difference between cohorts to identify potential risk factors for carriage of MDROs (Table 3).

DISCUSSION

Bacteriuria is often encountered in neurogenic bladder patients who require clean catheterization for bladder emptying and the incidence is one of the highest among populations studied. Though bacteriuria is usually asymptomatic, UTI can occur, and urologists continue to debate on the appropriate metrics for diagnosis of infection in this population [12-14]. It is our practice to focus on objective symptoms like fever, systemic illness, with turbid or malodorous urine, lower abdominal pain or change in continence pattern when diagnosing a UTI in this population. Diagnosis of pyelonephritis in patients with myelomeningocele tends to be even more challenging due to sensory impairment, body habitus and the higher prevalence of asymptomatic bacteriuria. Antimicrobials are frequently administered in this group to treat recurrent UTI, to eliminate bacteriuria or following a febrile episode with positive culture and no other localizable infection. However, antimicrobial prophylaxis has been proven to be ineffective in eradicating bacteriuria in this group of patients [15,16], and repeated exposure to antimicrobials is known to be associated with increased risk of resistance [5]. Recurrent UTI and treatment with beta-lactam antibiotics within the preceding three months has been noted to increase the risk of infection with resistant organisms in the community [17]. Treatment with antimicrobial agents like co-trimoxazole results in higher incidence of Enterobacteraceae resistant to co-trimoxazole [18]. With this change in susceptibility pattern, knowledge of the microbial pattern seen in this select group of patients will enable initiating the most appropriate antimicrobial when indicated, while awaiting the sensitivity results. Factors that determine the choice of antimicrobial include severity of the infection, renal function, sensitivity patterns in the community, and prior infection’s antimicrobial pattern.

One recent retrospective study sought to identify risk factors associated with UTI in myelomeningocele patients with neurogenic bladder and found that younger age and suprasacral cord lesions had a higher association with frequent UTIs. Interestingly, the authors found that increasing age was associated with decreasing odds of UTI [19]. Over the 12 months of follow up during our trial, our patient population collectively experienced only 2 UTIs, which is a similar rate found in other reports [20,21]. With such low numbers, we were unable to compare resistance patterns or risk factors for MDROs among patients with active urinary tract infections. Comparing culture results to identify risk factors is a difficult task, as potential uropathogens are so varied in susceptibility patterns. For this reason, we focused on E. coli, an organism that 92% of our study population grew, so we could sort participants into specific cohorts based on their susceptibility pattern of particular strains. We hypothesized that older age and longer duration of catheterization would lead to acquisition of more MDROs, due to likely exposure to more courses of antimicrobial agents. However, in our patient population, prevalence of bacteriuria or a resistant pattern did not correlate with increasing age or duration of catheterization. Despite the low rate of UTIs in our population during the study period, the resistance to co-trimoxazole and ampicillin was found to be high [Table 2].

Our study does have some important limitations to consider. Our study numbers are small and we had strict inclusion criteria, excluding patients with poor CIC compliance. It is possible that patients with improved adherence to CIC have generally lower carriage rates of MDROs. We also excluded patients on antimicrobial prophylaxis and only tracked antimicrobial use in relation to UTIs, so it is possible the urinary culture results were affected by antimicrobials prescribed for indications other than UTI.

Therefore, when empirical antimicrobial treatment is initiated prior to availability of the sensitivity report, it is prudent to review individual patients’ previous urine cultures for guidance. Though the probability of resistance to typical first line antimicrobial agents is higher than that of the community, it does not seem to proportionately increase with the duration of being on clean catheterization or age. Decisions for empirical therapy ought to be made with consideration of the individual patient’s previous culture results with particular attention to colonization with resistant organisms, but broad spectrum coverage may not be necessary in all patients utilizing clean intermittent catheterization.

Table 1: Patient demographics.

Patient Demographics  
Sex
     Male
     Female
22
28
Age 0.92-42 years
(Median: 10.5 years)
Years of catheterization 0.5 – 30 years
(Median: 6.75 years)
Route of catheterization
 Urethra
Mitrofanoff
40 (80%)
10 (20%)
Bladder augmentation 12 (24%)
Night time drainage 12 (24%)
# of UTIs in past 2 years 0-15 episodes
(mean: 2)
Abbreviations UTI: Urinary Tract Infection

Table 2: Sensitivity patterns for commonly recovered organisms.
1. Due to intrinsic properties, Enterococcus species have a limited susceptibility pattern and our laboratory only reports results for Ampicillin, 
Vancomycin, and Dalfopristin/quinupristin. 
2. Klebsiella species all have instrinsic resistance to ampicillin. 

  S: all Antibiotics R: to Amp R: to co-trimoxazole R: Other Antibiotics R: to Amp, Co-trimoxazole, and other Antibiotics
E.coli (N: 94) 46 33 20 47 16
Proteus sp. (N: 16) 1 4 3 14 0
Enterobac-teraceae sp. (N: 11) 0 10 1 10 1
Enterococcus sp. (N: 25) 2 1 N/A¹ 22 N/A¹
Klebsiella sp. (N: 15) 0 15² 4 12 4
Abbreviations S: Sensitive; R: Resistant; Amp: Ampicillin, sp: Species, N/A: Not Applicable

Table 3: Comparison between patients with a resistant E. coli species was found and those with a susceptible E. coli species.

Factor Resistant E. coli N: 9 Sensitive E. coli N:15
Age (years) 2-25 
Median: 13
11 months-31 
Median: 11
Sex Male: 3
Female: 6
Male: 6
Female: 9
Duration of catheterization (years) 2-25
Median: 12
11 months – 27 
years
Median: 7
Number of recurrent UTIs in the past 2 years 0-4
Median: 1 
0-10
Median: 1
Overnight drainage (N of patients) 2 3
Augmentation (N of patients) 2 5
Route of catheterization (N of patients) Mitrofanoff: 3
Urethra: 6
Mitrofanoff: 3
Urethra: 12
Abbreviations: N: number; UTI: urinary tract infection

Supplemental Table 1: Sensitivity patterns for all remaining less commonly recovered organisms.

  N of isolates S: to all Abx tested R to TMP SMX and amp R to other Abx R to Abx other than TMP SMX and/ or amp S to any abx tested
Aerococcussp 1 0 0 0 1 1
Acinetobacter sp 1 0 0 0 1 1
Bacillus sp 1 1 0 0 0 0
Brevundimonassp 1 0 0 0 1 1
Citrobactersp 4 0 1 1 2 4
Lactose fermenting GNR 1 0 0 0 1 1
Providencia sp 2 0 0 0 2 2
Pseudomonas sp 9 1 0 0 4 8
Shewanellaputrifaciens 1 0 0 0 1 1
Staphylococcus sp 8 1 0 0 6 8
Streptococcus sp 2 1 0 0 0 1
Abbreviations: N: Number; S: Sensitive; R: Resistant; Abx: Antibiotics; TMP-SMX: Co-trimoxazole; Amp: Ampicillin; sp: species

 

ACKNOWLEDGEMENT

This study was supported by Astra Tech Corporation.

REFERENCES

1. Schlager TA, Dilks S, Trudell J, Whittam TS, Hendley JO. Bacteriuria in children with neurogenic bladder treated with intermittent catheterization: natural history. J Pediatr. 1995; 126: 490-496.

2. Ottolini MC, Shaer CM, Rushton HG, Majd M, Gonzales EC, Patel KM. Relationship of asymptomatic bacteriuria and renal scarring in children with neuropathic bladders who are practicing clean intermittent catheterization. J Pediatr. 1995; 127: 368-372.

3. Maynard FM, Diokno AC. Urinary infection and complications during clean intermittent catheterization following spinal cord injury. J Urol. 1984; 132: 943-946.

4. Roberts KB. Urinary tract infection: clinical practice guideline for the diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months. Pediatrics. 2011;128: 595-610.

5. Paschke AA, Zaoutis T, Conway PH, Xie D, Keren R. Previous antimicrobial exposure is associated with drug-resistant urinary tract infections in children. Pediatrics. 2010; 125: 664-672.

6. Lucas EJ, Baxter C, Singh C, Mohamed AZ, Li B, et al. Comparison of the microbiological milieu of patients randomized to either hydrophilic or conventional PVC catheters for clean intermittent catheterization. J Pediatr Urol. 2016; 12: 172.

7. Garcia LS IH. Clinical microbiology procedures handbook. Second ed. Washington DC: ASM Press; 2007.

8. Hellerstein S. Recurrent urinary tract infections in children. Pediatr Infect Dis. 1982; 1: 271-281.

9. Craig JC, Simpson JM, Williams GJ, Lowe A, Reynolds GJ, McTaggart SJ, et al. Antibiotic prophylaxis and recurrent urinary tract infection in children. N Engl J Med. 2009; 361: 1748-1759.

10. Conway PH, Cnaan A, Zaoutis T, Henry BV, Grundmeier RW, Keren R. Recurrent urinary tract infections in children: risk factors and association with prophylactic antimicrobials. JAMA. 2007; 298: 179- 186.

11. Siegel JD, Rhinehart E, Jackson M, Chiarello L. Healthcare Infection Control Practices Advisory C. Management of multidrug-resistant organisms in health care settings, 2006. Am J Infect Control. 2007; 35: 165-193.

12. Elliott SP, Villar R, Duncan B. Bacteriuria management and urological evaluation of patients with spina bifida and neurogenic bladder: a multicenter survey. J Urol. 2005; 173: 217-220.

13. Madden-Fuentes RJ1, McNamara ER, Lloyd JC, Wiener JS, Routh JC, Seed PC, et al. Variation in definitions of urinary tract infections in spina bifida patients: a systematic review. Pediatrics. 2013; 132: 132- 139.

14. Zegers BS, Winkler-Seinstra PL, Uiterwaal CS, de Jong TV, Kimpen JL, de Jong-de Vos van Steenwijk CC. Urinary tract infections in children with spina bifida: an inventory of 41 European centers. Pediatr Nephrol. 2009; 24: 783-788.

15. Schlager TA, Anderson S, Trudell J, Hendley JO. Nitrofurantoin prophylaxis for bacteriuria and urinary tract infection in children with neurogenic bladder on intermittent catheterization. J Pediatr. 1998; 132: 704-708.

16. Zegers B, Uiterwaal C, Kimpen J, van Gool J, de Jong T, Winkler Seinstra P, et al. Antibiotic prophylaxis for urinary tract infections in children with spina bifida on intermittent catheterization. J Urol. 2011; 186: 2365-2370.

17. Hoban DJ, Nicolle LE, Hawser S, Bouchillon S, Badal R. Antimicrobial susceptibility of global inpatient urinary tract isolates of Escherichia coli: results from the Study for Monitoring Antimicrobial Resistance Trends (SMART) program: 2009-2010. Diagn Microbiol Infect Dis. 2011; 70: 507-511.

18. Murray BE, Rensimer ER, DuPont HL. Emergence of high-level trimethoprim resistance in fecal Escherichia coli during oral administration of trimethoprim or trimethoprim--sulfamethoxazole. N Engl J Med. 1982; 306: 130-135.

19. Chaudhry R, Balsara ZR, Madden-Fuentes RJ, Wiener JS, Routh JC, Seed P, et al. Risk Factors Associated With Recurrent Urinary Tract Infection in Neurogenic Bladders Managed by Clean Intermittent Catheterization. Urology. 2017; 102: 213-218.

20. Kiddoo D, Sawatzky B, Bascu CD, Dharamsi N, Afshar K, Moore KN. Randomized Crossover Trial of Single Use Hydrophilic Coated vs Multiple Use Polyvinylchloride Catheters for Intermittent Catheterization to Determine Incidence of Urinary Infection. J Urol. 2015; 194: 174-179.

21. Prieto J, Murphy CL, Moore KN, Fader M. Intermittent catheterisation for long-term bladder management. Cochrane Database Syst Rev. 2014; 9: 006008.

Received : 01 May 2017
Accepted : 29 Jun 2017
Published : 02 Jul 2017
Journals
Annals of Otolaryngology and Rhinology
ISSN : 2379-948X
Launched : 2014
JSM Schizophrenia
Launched : 2016
Journal of Nausea
Launched : 2020
JSM Internal Medicine
Launched : 2016
JSM Hepatitis
Launched : 2016
JSM Oro Facial Surgeries
ISSN : 2578-3211
Launched : 2016
Journal of Human Nutrition and Food Science
ISSN : 2333-6706
Launched : 2013
JSM Regenerative Medicine and Bioengineering
ISSN : 2379-0490
Launched : 2013
JSM Spine
ISSN : 2578-3181
Launched : 2016
Archives of Palliative Care
ISSN : 2573-1165
Launched : 2016
JSM Nutritional Disorders
ISSN : 2578-3203
Launched : 2017
Annals of Neurodegenerative Disorders
ISSN : 2476-2032
Launched : 2016
Journal of Fever
ISSN : 2641-7782
Launched : 2017
JSM Bone Marrow Research
ISSN : 2578-3351
Launched : 2016
JSM Mathematics and Statistics
ISSN : 2578-3173
Launched : 2014
Journal of Autoimmunity and Research
ISSN : 2573-1173
Launched : 2014
JSM Arthritis
ISSN : 2475-9155
Launched : 2016
JSM Head and Neck Cancer-Cases and Reviews
ISSN : 2573-1610
Launched : 2016
JSM General Surgery Cases and Images
ISSN : 2573-1564
Launched : 2016
JSM Anatomy and Physiology
ISSN : 2573-1262
Launched : 2016
JSM Dental Surgery
ISSN : 2573-1548
Launched : 2016
Annals of Emergency Surgery
ISSN : 2573-1017
Launched : 2016
Annals of Mens Health and Wellness
ISSN : 2641-7707
Launched : 2017
Journal of Preventive Medicine and Health Care
ISSN : 2576-0084
Launched : 2018
Journal of Chronic Diseases and Management
ISSN : 2573-1300
Launched : 2016
Annals of Vaccines and Immunization
ISSN : 2378-9379
Launched : 2014
JSM Heart Surgery Cases and Images
ISSN : 2578-3157
Launched : 2016
Annals of Reproductive Medicine and Treatment
ISSN : 2573-1092
Launched : 2016
JSM Brain Science
ISSN : 2573-1289
Launched : 2016
JSM Biomarkers
ISSN : 2578-3815
Launched : 2014
JSM Biology
ISSN : 2475-9392
Launched : 2016
Archives of Stem Cell and Research
ISSN : 2578-3580
Launched : 2014
Annals of Clinical and Medical Microbiology
ISSN : 2578-3629
Launched : 2014
JSM Pediatric Surgery
ISSN : 2578-3149
Launched : 2017
Journal of Memory Disorder and Rehabilitation
ISSN : 2578-319X
Launched : 2016
JSM Tropical Medicine and Research
ISSN : 2578-3165
Launched : 2016
JSM Head and Face Medicine
ISSN : 2578-3793
Launched : 2016
JSM Cardiothoracic Surgery
ISSN : 2573-1297
Launched : 2016
JSM Bone and Joint Diseases
ISSN : 2578-3351
Launched : 2017
JSM Bioavailability and Bioequivalence
ISSN : 2641-7812
Launched : 2017
JSM Atherosclerosis
ISSN : 2573-1270
Launched : 2016
Journal of Genitourinary Disorders
ISSN : 2641-7790
Launched : 2017
Journal of Fractures and Sprains
ISSN : 2578-3831
Launched : 2016
Journal of Autism and Epilepsy
ISSN : 2641-7774
Launched : 2016
Annals of Marine Biology and Research
ISSN : 2573-105X
Launched : 2014
JSM Health Education & Primary Health Care
ISSN : 2578-3777
Launched : 2016
JSM Communication Disorders
ISSN : 2578-3807
Launched : 2016
Annals of Musculoskeletal Disorders
ISSN : 2578-3599
Launched : 2016
Annals of Virology and Research
ISSN : 2573-1122
Launched : 2014
Journal of Muscle Health
ISSN : 2578-3823
Launched : 2016
JSM Genetics and Genomics
ISSN : 2334-1823
Launched : 2013
JSM Anxiety and Depression
ISSN : 2475-9139
Launched : 2016
Clinical Journal of Heart Diseases
ISSN : 2641-7766
Launched : 2016
Annals of Medicinal Chemistry and Research
ISSN : 2378-9336
Launched : 2014
JSM Pain and Management
ISSN : 2578-3378
Launched : 2016
JSM Women's Health
ISSN : 2578-3696
Launched : 2016
Clinical Research in HIV or AIDS
ISSN : 2374-0094
Launched : 2013
Journal of Endocrinology, Diabetes and Obesity
ISSN : 2333-6692
Launched : 2013
Journal of Substance Abuse and Alcoholism
ISSN : 2373-9363
Launched : 2013
JSM Neurosurgery and Spine
ISSN : 2373-9479
Launched : 2013
Journal of Liver and Clinical Research
ISSN : 2379-0830
Launched : 2014
Journal of Drug Design and Research
ISSN : 2379-089X
Launched : 2014
JSM Clinical Oncology and Research
ISSN : 2373-938X
Launched : 2013
JSM Bioinformatics, Genomics and Proteomics
ISSN : 2576-1102
Launched : 2014
JSM Chemistry
ISSN : 2334-1831
Launched : 2013
Journal of Trauma and Care
ISSN : 2573-1246
Launched : 2014
JSM Surgical Oncology and Research
ISSN : 2578-3688
Launched : 2016
Annals of Food Processing and Preservation
ISSN : 2573-1033
Launched : 2016
Journal of Radiology and Radiation Therapy
ISSN : 2333-7095
Launched : 2013
JSM Physical Medicine and Rehabilitation
ISSN : 2578-3572
Launched : 2016
Annals of Clinical Pathology
ISSN : 2373-9282
Launched : 2013
Annals of Cardiovascular Diseases
ISSN : 2641-7731
Launched : 2016
Journal of Behavior
ISSN : 2576-0076
Launched : 2016
Annals of Clinical and Experimental Metabolism
ISSN : 2572-2492
Launched : 2016
Clinical Research in Infectious Diseases
ISSN : 2379-0636
Launched : 2013
JSM Microbiology
ISSN : 2333-6455
Launched : 2013
Journal of Urology and Research
ISSN : 2379-951X
Launched : 2014
Journal of Family Medicine and Community Health
ISSN : 2379-0547
Launched : 2013
Annals of Pregnancy and Care
ISSN : 2578-336X
Launched : 2017
JSM Cell and Developmental Biology
ISSN : 2379-061X
Launched : 2013
Annals of Aquaculture and Research
ISSN : 2379-0881
Launched : 2014
Clinical Research in Pulmonology
ISSN : 2333-6625
Launched : 2013
Journal of Immunology and Clinical Research
ISSN : 2333-6714
Launched : 2013
Annals of Forensic Research and Analysis
ISSN : 2378-9476
Launched : 2014
JSM Biochemistry and Molecular Biology
ISSN : 2333-7109
Launched : 2013
Annals of Breast Cancer Research
ISSN : 2641-7685
Launched : 2016
Annals of Gerontology and Geriatric Research
ISSN : 2378-9409
Launched : 2014
Journal of Sleep Medicine and Disorders
ISSN : 2379-0822
Launched : 2014
JSM Burns and Trauma
ISSN : 2475-9406
Launched : 2016
Chemical Engineering and Process Techniques
ISSN : 2333-6633
Launched : 2013
Annals of Clinical Cytology and Pathology
ISSN : 2475-9430
Launched : 2014
JSM Allergy and Asthma
ISSN : 2573-1254
Launched : 2016
Journal of Neurological Disorders and Stroke
ISSN : 2334-2307
Launched : 2013
Annals of Sports Medicine and Research
ISSN : 2379-0571
Launched : 2014
JSM Sexual Medicine
ISSN : 2578-3718
Launched : 2016
Annals of Vascular Medicine and Research
ISSN : 2378-9344
Launched : 2014
JSM Biotechnology and Biomedical Engineering
ISSN : 2333-7117
Launched : 2013
Journal of Hematology and Transfusion
ISSN : 2333-6684
Launched : 2013
JSM Environmental Science and Ecology
ISSN : 2333-7141
Launched : 2013
Journal of Cardiology and Clinical Research
ISSN : 2333-6676
Launched : 2013
JSM Nanotechnology and Nanomedicine
ISSN : 2334-1815
Launched : 2013
Journal of Ear, Nose and Throat Disorders
ISSN : 2475-9473
Launched : 2016
JSM Ophthalmology
ISSN : 2333-6447
Launched : 2013
Journal of Pharmacology and Clinical Toxicology
ISSN : 2333-7079
Launched : 2013
Annals of Psychiatry and Mental Health
ISSN : 2374-0124
Launched : 2013
Medical Journal of Obstetrics and Gynecology
ISSN : 2333-6439
Launched : 2013
Annals of Pediatrics and Child Health
ISSN : 2373-9312
Launched : 2013
JSM Clinical Pharmaceutics
ISSN : 2379-9498
Launched : 2014
JSM Foot and Ankle
ISSN : 2475-9112
Launched : 2016
JSM Alzheimer's Disease and Related Dementia
ISSN : 2378-9565
Launched : 2014
Journal of Addiction Medicine and Therapy
ISSN : 2333-665X
Launched : 2013
Journal of Veterinary Medicine and Research
ISSN : 2378-931X
Launched : 2013
Annals of Public Health and Research
ISSN : 2378-9328
Launched : 2014
Annals of Orthopedics and Rheumatology
ISSN : 2373-9290
Launched : 2013
Journal of Clinical Nephrology and Research
ISSN : 2379-0652
Launched : 2014
Annals of Community Medicine and Practice
ISSN : 2475-9465
Launched : 2014
Annals of Biometrics and Biostatistics
ISSN : 2374-0116
Launched : 2013
JSM Clinical Case Reports
ISSN : 2373-9819
Launched : 2013
Journal of Cancer Biology and Research
ISSN : 2373-9436
Launched : 2013
Journal of Surgery and Transplantation Science
ISSN : 2379-0911
Launched : 2013
Journal of Dermatology and Clinical Research
ISSN : 2373-9371
Launched : 2013
JSM Gastroenterology and Hepatology
ISSN : 2373-9487
Launched : 2013
Annals of Nursing and Practice
ISSN : 2379-9501
Launched : 2014
JSM Dentistry
ISSN : 2333-7133
Launched : 2013
Author Information X