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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2009  |  Volume : 20  |  Issue : 1  |  Page : 135-139
Empirical treatment for pediatric urinary tract infection and resistance patterns of uropathogens, in Queen Alia hospital and prince A'Isha military center - Jordan


Department of Pediatric Nephrology, King Hussien Medical Center, Amman, Jordan

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   Abstract 

We conducted this retrospective study to identify the most appropriate oral antibiotic as empiric treatment of urinary tract infection according to resistance patterns of uropathogens among children treated at Queen Alia Military Hospital and Prince A`isha Bent Al-Hussein Military Center from January 2006 to April 2007. Urine cultures for isolated microorganism and their anti­biotic susceptibility in patients below the age of 14 years treated as outpatient were reviewed. Out of 3820 cultures, 529 isolates were found, E coli was the most frequent organism. Resistance to Ampicillin, sulfamethoxazole, and trimethoprim (TMP-SMZ) was common, and multidrug-resistant (MDR) among E. coli isolates was 59.9%. Knowledge of patterns of resistance at each institution helps in deciding empiric therapy for UTI. Pretreatment urine culture should be performed and followed up for the continuation of the treatment.

Keywords: Empirical treatment, Urinary tract infection, resistance of uropathogens, multidrug resistance, pediatric, Jordan

How to cite this article:
Al-Mardeni RI, Batarseh A, Omaish L, Shraideh M, Batarseh B, Unis N. Empirical treatment for pediatric urinary tract infection and resistance patterns of uropathogens, in Queen Alia hospital and prince A'Isha military center - Jordan. Saudi J Kidney Dis Transpl 2009;20:135-9

How to cite this URL:
Al-Mardeni RI, Batarseh A, Omaish L, Shraideh M, Batarseh B, Unis N. Empirical treatment for pediatric urinary tract infection and resistance patterns of uropathogens, in Queen Alia hospital and prince A'Isha military center - Jordan. Saudi J Kidney Dis Transpl [serial online] 2009 [cited 2019 Nov 14];20:135-9. Available from: http://www.sjkdt.org/text.asp?2009/20/1/135/44724

   Introduction Top


Urinary tract infection (UTI) is defined as bac­teriauria along with urinary symptoms. [1] Epi­demiology of UTI during childhood varies by age, gender and other factors. UTI commonly affects boys during the first year of life, [2] but thereafter 3-5% of girls, [2],[3],[4] of the girls are affec­ted, increasing to 10% by the teenage years. [5]

Nearly 40% of children with UTI will have ra­diological abnormalities as reflux and hydro­nephrosis. [6] Early recognition and prompt treat­ment of UTI prevents development of pyelo­nephritis, urosepsis, and late sequelae such as renal scarring or renal failure. Recent reports highlight the problem of resistant uropathogens and its influence on empiric therapy, [7],[8],[9],[10] such as high prevalence of trimethoprim-sulfamethoxazole resistance in the community worldwide. [10],[11],[12],[13]

This retrospective study was conducted to identify UTI due to resistant microbes among children and evaluate empiric antibiotic therapy.


   Methods Top


This retrospective study was conducted in two complementary hospitals- Queen Alia Hospital and Prince A ` isha Center at pediatric outpatient clinics during the period from January 2006 to April 2007.

Lab records of all urine cultures for patients below the age of 14 years were reviewed re­gardless of the method of urine collection. Posi­tive cultures were analyzed, and antimicrobial susceptibility results were reviewed according to the types of microorganisms. Antimicrobial susceptibility was tested with agar diffusion (DAD) following the Minimal Inhibitory Con­centration methods described by the National Committee for Clinical Laboratory Standards (NCCLS) included ampicillin, combination of sulfamethoxazole and trimethoprim (TMP-SMZ), cephalexin, gentamicin, nalidixic acid, ceftria­xone, and nitrofurantoin. We excluded all posi­tive cultures that belonged to the same patient within the previous six months of a urine cul­ture report to eliminate any possibility of recur­rent UTI. Multidrug-resistant (MDR) was de­fined as antimicrobial resistance of a micro­organism to three or more antibiotics.


   Statistical analysis Top


SPSS 13 for windows was used for statistical analysis. Chi-Square as well as fisher's exact test were used to compare categorical variables. P value < 0.05 was considered as statistically significant.


   Results Top


Out of 3820 reviewed results of cultures, only 529 cultures were positive and included in this study; 432 (81.7%) were females.  Escherichia More Details coli was the causative agent in 81.1 % of the cases, while other frequently grown microorga­nisms included Proteus, Klebsiella, Citrobacter and Enterococci, [Table 1]. UTI due to E. coli was more common in females.

Among the non-E. coli UTI, Proteus and Klebsiella represented (74.0%) of the total; Proteus was the most common in females, whereas Klebsiella was more prevalent in, [Table 2].

[Table 3] shows the overall resistance pattern of cultured microorganisms to commonly used antibiotics, while [Table 4] shows that 257 of 429 (59.9%) isolates of E.coli were MDR.


   Discussion Top


Management of infants and children with acute UTI must be undertaken with four major goals in mind: proper documentation of the diagnosis, identification of anatomical abnormalities and such children be followed for a number of years, and antibiotic therapy should be given for a mi­nimum of 3 to 7 days in children with uncom­plicated UTI and for 10 days or longer in those with suspected or proved pyelonephritis. [14]

Frequently cultured organisms isolated in UTIs belong to the family of gram-negative, facul­tative anaerobic bacilli Enterobacteriaceae. [15] 90% of all community-acquired urinary tract infections, and more than 30% of nosocomially acquired UTIs are caused by E coli. [16],[4] Accor­ding to the demographic data, females are affec­ted more often than males due to anatomical differences. [17] In our study we also found E. coli as the commonest organism (81.1 %) cultured. Similarly it was also common in females (81.7%)

Empiric antibiotic therapy for UTI is based on the knowledge of the predominant pathogens and their antimicrobial susceptibility in the area of practice, [22],[23] age, clinical severity, location of infection, presence of structural abnormalities, and allergy to certain antibiotics. [24]

Antibiotic resistance has become an important factor to be considered in the treatment of in­fections. Resistance is more common institutio­nalized, and hospitalized patients. E. coli resis­tance has been progressing for more than a decade. [9] Resistance to TMP-SMZ was found to be higher in toddlers and pre-teens while resis­tance to Nitrofurantoin increased as patient age increased in one of the study. 7 Epidemiology and resistance patterns of bacterial pathogens in pediatric UTI show large interregional variabi­lity and rates of bacterial resistances are chan­ging due to different antibiotic treatment. [8],[18]

Most of the resistance was accounted for by the Non-E. coli uropathogens which is in gene­ral agreement with scattered reports on the increasing resistance of uropathogens. [19],[20],[21]

In our institutions TMP-SMZ and Cephalexin is used as empirical treatment for uncomplica­ted urinary tract infections in children because of their tolerability, availability, spectrum of ac­tivity against suspected uropathogens, and favo­rable pharmacokinetic profiles, in agreement with the American Academy of Pediatrics opi­nion. [25] On the other hand this study revealed a high bacterial resistance to E. coli and Non-E. coli- for oral antibiotics: Ampicillin, TMP-SMZ, Nalidixic acid and Cephalexin (81.9%, 73.5%, 49.0% and 39.5% respectively), possibly due to the easy access to antibiotics in general in pri­vate pharmacies and poor compliance.

Nitrofurantoin was associated with the lowest level of resistance 20.7 %, possibly due to its multiple mechanisms of action. [9] Side effects of nitrofurantion are minimal and may include gas­tric intolerance malaise, cough, and dyspnea and its use should be encouraged to counter the increasing bacterial resistance.

The prevalence of MDR among E. coli iso­ lates was high and 59.9% of isolates (257 of 429) were resistant to three or more anti­microbials [Table 4]. MDR was significantly high especially when compared with (20.6%) in Spain [26] and (7.1%) in the United States. [27] (30%) of E. coli were resistant to Nitrofurantoin and Ceftriaxone also. This pattern suggest possible co-selection of antimicrobial resistance media­ted by MDR plasmids and important implica­tions for the selection of empiric therapy of infections caused by E. coli.

Uropathogens resistances to injectable antibio­tics were the lowest, 21.6 % for Ceftriaxone and 21.0 % for Gentamicin due to their use only in severe cases.

In conclusion, treatment of UTI in pediatric patients generally begins with a broad-spectrum antibiotics, and its recommendations should base on individual hospitals urine culture and sensi­tivity results The results of the present study suggest that prevalence of MDR E. coli was alarmingly high and the most appropriate first line oral antibiotic for empiric treatment of uri­nary tract infection at our center was Nitrofu­rantoin and Cephalexin as second line agent. Antibacterial resistance patterns should be up­dated to ensure proper empiric treatment of UTI.[Table 5]

 
   References Top

1.Zelikovic I, Adelman RD, Nancarrow PA. Urinary tract infections in children: an update. West J Med 1992;157:554-61.  Back to cited text no. 1  [PUBMED]  [FULLTEXT]
2.Hellerstein S. Antibiotic treatment for urinary tract infections in Pediatric patients. Minerva Pediatr 2003;55(5):395-406.  Back to cited text no. 2    
3.Klein JO, Long SS. Bacterial infections of the urinary tract. In: Remington JS, Klein JO, eds. Infectious diseases of the fetus and newborn infant. 4th ed. Philadelphia: Saunders, 1995: 925-34.  Back to cited text no. 3    
4.Elder JS. Urologic disorders in infants and chil­dren. In: Behrman RE, Kliegman RM, Jenson HB, eds. Nelson Textbook of Pediatrics. 17th ed. Philadelphia. PA: W.B.Saunders; 2004: 1785-90  Back to cited text no. 4    
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7.Gaspari RJ. Antimicrobial Susceptibility Patterns of Pediatric Uropathogens; Data from the Surveillance Network Academic Emergency Medicine2005;10(5):433-4  Back to cited text no. 7    
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10.Zhanel GG, Karlowsky JA, Harding GK, et al. A Canadian national surveillance study of urinary tract isolates from outpatients: Compa­ison of the activities of trimethoprim-sulfame­thoxazole, ampicillin, mecillinam, nitrofurantoin, and ciprofloxacin. Antimicrob Agents Chemother 2000;44:1089-92.  Back to cited text no. 10  [PUBMED]  [FULLTEXT]
11.Brown PD, Freeman A, Foxman B. Prevalence and predictors of trimethoprim-sulfamethoxazole resistance among uropathogenic Escherichia Coli isolates in Michigan. Clin Infect Dis 2002; 34:1061-6.  Back to cited text no. 11  [PUBMED]  [FULLTEXT]
12.Huovinen, P. Increases in rates of resistance to trimethoprim. Clin Infect Dis 1997;24(Suppl. 1):S63-6  Back to cited text no. 12    
13.Goettsch W, van Pelt W, Nagelkerke N, et al. Increasing resistance to fluoroquinolones in Escherichia coli from urinary tract infections in The Netherlands. J Antimicrob Chemother 2000;46:223-8  Back to cited text no. 13  [PUBMED]  [FULLTEXT]
14.Zorc JJ. Diagnosis and management of pediatric urinary tract infections. Clin Microbiol Rev 2005;18(2):417-22.  Back to cited text no. 14    
15.Donald P, Bartkowski DO. Recognizing UTIs in infants and children: Early treatment prevents permanent damage. Postgrad Med 2001;109:1.  Back to cited text no. 15    
16.Bingen E. Escherichia coli virulence factors in pediatric urinary tract infection. Arch Pediatr 1998;5(Suppl3):279S-81S.  Back to cited text no. 16    
17.Nakhjavani FA, Mirsalehian A, Hamidian M, Kazemi B, Mirafshar M, Jabalameli F Anti­microbial Susceptibility Testing for Escherichia coli Strainsto Fluoroquinolones, in Urinary Tract Infections. Iranian J Publ Health 2007; 36:89-92.  Back to cited text no. 17    
18.Ghazi A. Co-Trimoxazole in the Empiric Treat­ment of Urinary Tract Infection. Palestinian Medical Journal. 2005;2:2.  Back to cited text no. 18    
19.Ladhani S, Gransden W. Increasing antibiotic resistance among urinary tract isolates. Arch Dis Child 2003;88:444-5.  Back to cited text no. 19  [PUBMED]  [FULLTEXT]
20.Santen SA, Altieri MF. Pediatric urinary tract infection. Emerg Med Clin North Am 2001; 19:675-90.  Back to cited text no. 20  [PUBMED]  
21.Right SW, Wren KD, Haynes ML. Trimethoprim­sulfamethoxazole resistance among urinary coliform isolates. J Gen Intern Med 1999; 14:606-9.  Back to cited text no. 21    
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23.Shao HF, Wang WP, Zhang XW, Li ZD. Distribution and resistance trends of pathogens from urinary Tract infections and impact on management. Zhonghua Nan Ke Xue 2003; 9(9):690-6.  Back to cited text no. 23    
24.Anthony P, Brian J. Review of urinary tract infection. US Pharm 2006; 31:6.  Back to cited text no. 24    
25.American Academy of Pediatrics. Subcommittee on Urinary Tract Infection. Practice parameter: Diagnosis, treatment, and evaluation of urinary tract infection in infants and young children. Pediatrics 1999;103:843-52.  Back to cited text no. 25    
26.Oteo J, Lazaro E, de Abajo FJ, Baquero F, Campos J; Spanish members of EARSS1. Antimicrobial-resistant Invasive Escherichia coli, Spain. Emerging Infectious Diseases www.cdc.gov/eid 2005;11(4).  Back to cited text no. 26    
27.Sahm DF, Thorensberry C, Mayfield DC, Jones ME, Karlowsky JA. Multidrug resistance urinary tract isolates of Escherichia coli: Prevalence and patient demographics in the United States in 2000. Antimicrob Agents Chemother 2001;45:1402-6.  Back to cited text no. 27    

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Correspondence Address:
Reham Issa Al-Mardeni
Pediatric Specialist at King Hussien Medical Center, and Fellow in Pediatric Nephrology Division, Amman
Jordan
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PMID: 19112236

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]

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    Abstract
    Introduction
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    Statistical analysis
    Results
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