| 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 2013 May 22];20:135-9. Available from: http://www.sjkdt.org/text.asp?2009/20/1/135/44724
| Introduction|| |
Urinary tract infection (UTI) is defined as bacteriauria along with urinary symptoms.  Epidemiology of UTI during childhood varies by age, gender and other factors. UTI commonly affects boys during the first year of life,  but thereafter 3-5% of girls, ,, of the girls are affected, increasing to 10% by the teenage years. 
Nearly 40% of children with UTI will have radiological abnormalities as reflux and hydronephrosis.  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, ,,, such as high prevalence of trimethoprim-sulfamethoxazole resistance in the community worldwide. ,,,
This retrospective study was conducted to identify UTI due to resistant microbes among children and evaluate empiric antibiotic therapy.
| Methods|| |
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|| |
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|| |
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|| |
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. 
Frequently cultured organisms isolated in UTIs belong to the family of gram-negative, facultative anaerobic bacilli Enterobacteriaceae.  90% of all community-acquired urinary tract infections, and more than 30% of nosocomially acquired UTIs are caused by E coli. , According to the demographic data, females are affected more often than males due to anatomical differences.  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, , age, clinical severity, location of infection, presence of structural abnormalities, and allergy to certain antibiotics. 
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.  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. ,
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. ,,
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.  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.  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  and (7.1%) in the United States.  (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]
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Reham Issa Al-Mardeni
Pediatric Specialist at King Hussien Medical Center, and Fellow in Pediatric Nephrology Division, Amman
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]