| Abstract|| |
This is a retrospective study of 82 children with urinary tract infection (UTI) evaluated for the prevalence of vesicoureteral reflux at a community hospital in Riyadh, Saudi Arabia from 1997 to 2000. There were 73 (89%) girls and nine (11%) boys; 58 (71%) were at an age between 1-5 years, 15 (18%) were between 0-1year and nine (11%) were more than 5 years of age. All patients were documented to have UTI by history and laboratory investigations. There were 29 patients (35%) who had acute pyelonephritis at the initial clinical presentation and 53 (65%) had recurrent UTI. Escherichia coli was the isolated bacterium from urine in 79(96.4%) patients. Thirty-four (41.5%) patients had vesicoureteral reflux (VUR); 17 (50%) had it bilaterally and 14 (41%) had renal scarring. There were 9/82 (11%) patients who had renal scarring without reflux. Twenty-six (77%) of the VUR patients had mild to moderate reflux (grade 1-3) and eight (23%) had severe reflux (grade 4-5). Two patients with bilateral reflux had mild to moderate reflux on one side and severe reflux on the other. The age of the patients with VUR was below one year in 11 (32%), between 1 year and 5 years in 21(62%), and between 6 and 12 years in two (6%) patients. There were 11/ 29 (38%) patients with acute pyelonephritis who had reflux. Follow-up of the VUR patients showed that reflux disappeared without surgical intervention in 15 (44%), improved in two (6%) to lower grade and worsened in two (6%) to higher grade. Seven (20.5%) patients underwent ureteral reimplantation; all of them had recurrent UTI and were more than one year of age. While on chemoprophylaxis, two (28%) of the reimplanted patients developed breakthrough infections and the remaining five (72%) had a radiological picture of chronic pyelonephritis. None of the study patients developed new scars, hypertension or renal failure during follow-up; the duration of followup was from 5 months to 3 1/2 years and only seven (20.5%) patients had less than one-year follow-up. We conclude that Saudi children with UTI below 7 years of age have high incidence of reflux and scarring especially in patients presenting with acute pyelonephritis. A multi center study is needed to evaluate the size of the problem and its complications in the Saudi children besides screening of the siblings of patients with reflux.
Keywords: Urinary tract infection, Saudi, Vesicoureteral reflux.
|How to cite this article:|
Al-Ibrahim AA, Girdharilal RD, Jalal MC, Alghamdy AH, Ghazal YK. Urinary Tract Infection and Vesicoureteral Reflux in Saudi Children. Saudi J Kidney Dis Transpl 2002;13:24-8
|How to cite this URL:|
Al-Ibrahim AA, Girdharilal RD, Jalal MC, Alghamdy AH, Ghazal YK. Urinary Tract Infection and Vesicoureteral Reflux in Saudi Children. Saudi J Kidney Dis Transpl [serial online] 2002 [cited 2020 Jan 19];13:24-8. Available from: http://www.sjkdt.org/text.asp?2002/13/1/24/33198
| Introduction|| |
Urinary tract infection (UTI) is among the most common acute bacterial infections of childhood. Although most children have an excellent prognosis, there is a risk of serious complications in a small group with vesicoureteral reflux. ,,,,,
Vesicoureteral reflux (VUR) can be found in 30-40% of both boys and girls with UTI. Scarring after acute pyelonephritis occurs in 10-15% of cases, especially with repeated infections. Due to its renal injury, VUR is a major cause of hypertension during childhood and end-stage renal failure in patients less than 30 years of age. ,,, Early and correct diagnosis, and prophylactic antibiotic treatment is frequently recommended to prevent complications. 
This retrospective study attempts to determine the prevalence of the problem and its outcome in the Saudi children.
| Patients and Methods|| |
The records of 99 children with urinary tract infection seen at the nephrology department of the Sulaimania Children's Hospital in Riyadh, Saudi Arabia, in the period from January 1997 to June 2000 were reviewed. Seventeen patients were excluded from the study because of inadequate data.
Patients with recurrent UTI were referred to the nephrology clinic and patients with pyelonephritis were admitted and managed in the nephrology unit. Detailed history and clinical examination were obtained. Results of the previous episodes of infection were reviewed. All patients had complete blood count, renal function tests, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), urinalysis, urine culture and sensitivity. Ultrasound of kidneys and urinary tract was done for all patients irrespective of their age. Voiding cystourethrogram (VCUG) was done in patients below the age of 5 years, four weeks after the documentation of negative urine culture. Patients above five years had VCUG only if there were abnormal ultrasound findings. Intravenous pyelography (IVP) was also performed in case of abnormal ultrasound findings. Prophylactic antibiotics were prescribed for all the study patients during the performance of the imaging studies.
DMSA nuclear scan to detect scarring was done in all the patients with recurrent UTI or pyelonephritis three months after the remission of the acute episode. The VCUG was repeated annually in patients with documented vesicoureteral reflux. VUR was graded as per the international reflux study classification. DMSA scanning was performed annually in patients with documented scars, patients with persistent reflux in the annual VCUG and patients after each episode of acute pyelonephritis.
Acute pyelonephritis was diagnosed on the basis of clinical presentation of high-grade fever, laboratory evidence of leucocytosis, high ESR, raised CRP, and positive urine culture.
The patients were followed-up every three months and weight, height and blood pressure were recorded. Laboratory investigations included urinalysis, urine culture and sensitivity, and renal function tests. The parents were educated about the illness and necessity of the patients' hygiene. In some cases, school authorities were also involved.
| Results|| |
The study included 82 evaluable patients. There were 73 (89%) girls and nine (11%) boys; 58 (71%) were at an age between 1-5 years, 15 (18%) were between 0-1year and nine (11%) were more than 5 years of age. The duration of follow-up was from 5 months to 3 1/2 years and only seven (20.5%) patients had less than one-year follow-up.
All patients were documented to have UTI by history and laboratory investigations. There were 29 patients (35%) who had acute pyelonephritis at the initial clinical presentation and 53 (65%) had recurrent UTI.
Escherichia More Details coli (E. coli) was isolated in urine culture of 79 (96.4%) patients, Klebsiella pneumoniae in two (2.4%) and Pseudomonas species in one (1.2%).
The antibiotics used for treatment and chemoprophylaxis included Nitrofurantoin in 37 (45%) patients, Nalidixic acid in 27 (33%), Cotrimoxazol in 13 (16%) and Amoxicillin in 5 (6%); Cotrimoxazol was switched to other antibiotics after few months of therapy due to the resistance and/or the breakthrough infections with E. coli, while Amoxicillin was used for patients below three months of age
Congenital abnormalities were detected in only six patients; duplex kidneys in two, bladder diverticula in two, hypoplastic dysplastic kidneys in one and horseshoe kidney in one. None of these patients had VUR.
Thirty-four (41.5%) patients had VUR; 17 (50%) had it bilaterally (41% in the left side, and 9% in the right side) and 14 (41%) had renal scarring. Distribution of VUR in relation to age and sex is shown in [Table - 1]. There were 23 (67%) VUR patients with history of recurrent UTI (28% had an average of seven attacks/year before referral) and 11 (32%) had acute pyelonephritis at time of referral.
Twenty-six (77%) of the VUR patients had mild to moderate reflux (grade 1-3) and eight (23%) had severe reflux (grade 4-5); two patients with bilateral reflux had mild to moderate reflux on one side and severe reflux on the other, [Table - 2]. Scar alone was detected in nine patients out of 82 (11%); five of them presented with a history of recurrent UTI, and four with acute pyelonephritis.
At the time of the first referral almost all of the patients had no radiological investigations, and no chemoprophylaxis; they were not aware of the sequelae of their illness. There was an average delay of 13.5 hours in treatment from the time of presentation in patients with reflux as compared to 3.5 hours in patients without reflux.
During follow-up, VUR resolved in 15 (44%) of patients within 2-3 years, improved in two (6%) to lower grade and worsened in two (6%) to higher grade. Seven (20.5%) patients underwent uretral reimplantation; all of them had recurrent UTI and were more than one year of age. While on chemoprophylaxis, two (28%) of the reimplanted patients developed breakthrough infections and the remaining five (72%) had a radiological picture of chronic pyelonephritis. None of the study patients developed new scars, hypertension or renal failure during follow-up.
| Discussion|| |
Although most children with UTI have an excellent prognosis there is a risk of serious sequelae, which should be considered by physicians, parents and patients. In this study, 98% of our patients were less than 5 years of age and females prevailed among the patients with UTI even in the neonatal period, a finding similar to what was reported elsewhere in Saudi Arabia. E. coli was the most common organism isolated in urine culture of 96.4% of patients, similar to what was reported in the literature. ,,,,,
VUR was detected in 41% of our patients, which is higher than the 32.9% in the Singaporean children  and 29.5% Libyan children,  but slightly lower than the 45% in the study of 29 Saudi children.  These differences are not likely to be significant.
There is high incidence of VUR in patients below five years of age (94%) as compared to 59% in an earlier study from Saudi Arabia.  Of those patients with VUR, 32% were below one year of age, almost similar to the incidence reported by others,  with more males in our study (36%) than the 13% reported in other studies.  VUR was also detected in 6% of our patients between the ages of 5-12 years. Though this is a small percentage, it cannot be ignored especially that VCUG was not done in all the patients above five years of age.
Scarring was detected in 41% of our patients with recurrent UTI and acute pyelonephritis, which is higher than the percentage of 37% reported in a recent study. 
In our study, acute pyelonephritis was associated with increased incidence of VUR (38%) and scarring (45%), which was higher than the 10-15% incidence reported elsewhere.  This is also higher than the percentages reported in recurrent acute pyelonephritis where 38% of VUR patients had scarring.  In our study, delayed management by an average of 13.5 hours in cases of acute pyelonephritis might have contributed to scarring, whereas initiation of treatment within 3.5 hours resulted in no sequalae.
Half of the patients in our study had bilateral reflux compared to 40% in the more recent studies, ,,, but the majority had mild to moderate degree (77%) and 94% of them had spontaneous resolution within 1-2 year follow-up as compared to 61-92% in other studies. ,
In our study, the patients who had uretral reimplantation because of VUR were more than one year of age and required continuous chemoprophylaxis, which was not always successful.
Hypertension and new scar formation or resolution of scars and renal impairment were not detected in our patients, which may be due to the short duration of follow-up.
We tried to screen the siblings of the patients with reflux but because of the large number of siblings in each family and overload of patients we could not proceed as recommended by others.[ 14]
We conclude that VUR is common among the Saudi children with recurrent UTI and age below seven years. It is more common in girls than boys, with high incidence of reflux and scarring especially in patients with acute pyelonephritis, which might be due to delay in management. A great effort is needed to reduce the incidence by early diagnosis and effective early management of acute and recurrent urinary tract infections. A multi center study is needed to evaluate the size of the problem and its complications in the Saudi children as well as screening of the siblings of patients with reflux.
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Alia Abdulrahim Al-Ibrahim
Consultant Pediatric Nephrologist, Suleimania Children’s Hospital, P.O. Box 59046, Riyadh 11525
[Table - 1], [Table - 2]