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RENAL DATA FROM ASIA-AFRICA |
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| Year : 2012 | Volume
: 23
| Issue : 3 | Page : 629-634 |
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| Co-existence of urinary tract infection and malaria among children under five years old: A report from Benin City, Nigeria |
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PO Okunola1, MO Ibadin1, GE Ofovwe1, G Ukoh2
1 Department of Child Health, University of Benin Teaching Hospital, Benin City, Nigeria
2 Department of Pharmaceutical Microbiology, University of Benin, Benin City, Nigeria
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| Date of Web Publication | 7-May-2012 |
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 Abstract | | |
Children with fever are a majority in the various emergency rooms all over the world, and especially in the tropics. Most in sub-Saharan Africa will be treated for malaria, whether confirmed or not. It therefore follows that some of the morbidities other than malaria may go undiagnosed. The comorbidities with malaria that may have similar presentation among under-fives therefore are difficult to detect, and diseases like respiratory tract infections and urinary tract infections (UTI) are left to debilitate affected children. The exact burden of UTI co-existing with malaria in Nigeria remains ill defined. This study looks at the co-existence of UTI in under- fives with a primary diagnosis of malaria. Well-nourished children aged less than five years with confirmed malaria seen at the Children Emergency Room of the University of Benin Teaching Hospital were recruited into a prospective cross-sectional study between June and August 2006. The prevalence of UTI was 9% (27 of 300 children), with those aged less than 24 months comprising the majority. The uropathogens isolated included Staphylococcus aureus (55.6%), Escherichia coli (29.6%) and Kleibsiella pneumonia (14.8%). The isolates demonstrated high in vitro sensitivity to clavulanic acid-potentiated amoxicillin, ciprofloxacin and gentamicin, but were resistant to other commonly used antibiotics like amoxicillin and co-trimoxazole. The study indicates that UTI is a silent comorbidity in children aged less than 5 years with malaria and there is a need to evaluate these children in order to prevent the long-term morbidity of chronic renal diseases.
How to cite this article:
Okunola P O, Ibadin M O, Ofovwe G E, Ukoh G. Co-existence of urinary tract infection and malaria among children under five years old: A report from Benin City, Nigeria. Saudi J Kidney Dis Transpl 2012;23:629-34 |
How to cite this URL:
Okunola P O, Ibadin M O, Ofovwe G E, Ukoh G. Co-existence of urinary tract infection and malaria among children under five years old: A report from Benin City, Nigeria. Saudi J Kidney Dis Transpl [serial online] 2012 [cited 2013 May 19];23:629-34. Available from: http://www.sjkdt.org/text.asp?2012/23/3/629/95860 |
| Introduction | |  |
Urinary tract infection (UTI) is defined by the presence of pure bacterial growth in the urinary tract in numbers in excess of set values determined by the method of urine collection. [1],[2],[3] UTI is a leading cause of morbidity in children, especially those less than five years old. Other than fever, UTI in young children is characterized by the absence of specific symptoms. [4] Unfortunately, fever as a symptom is common to other childhood infections including malaria and respiratory infections. Furthermore, UTI is known to co-exist with these common childhood diseases. [5] Malaria is the leading cause of morbidity and mortality, particularly in sub-Saharan Africa. In malaria-endemic countries in Africa, 25-40% (average 30%) of all outpatient clinic visits are for malaria. In the same countries, between 20 and 50% of all hospital admissions are due to malaria and its complications. [6] In Benin City, Nigeria, up to 63% of under-fives, presenting with fever of acute onset without localizing signs of infection, had malaria. [7] Diagnosis of malaria is commonly based on clinical features only as most facilities in developing countries lack the requisite laboratory back-up. Therefore, the child presenting in such facilities with fever would almost invariably be managed for malaria without recourse to identifying the underlying cause or ascertaining its coexistence with other morbidities, including UTI. Thus, cases of UTI and other morbidities could be missed. Also, when malaria and UTI co-exist, the features manifested by the child would most likely be interpreted as malaria, and it is unlikely that the child with positive smear for malaria will be investigated further for UTI or other morbidities. Therefore, the prevalence of these comorbidities would be under-estimated and under-reported. [8],[9] UTI has been reported in patients with malaria, and prevalence rates of up to 13.3% have been reported in children with malaria aged three months to 12 years. [10]
The consequences of missed diagnosis and inadequate treatment of UTI have been reported by several authors. The conditions include reflux nephropathy, hypertension, chronic renal failure and end-stage renal disease, encountered later in life. [11],[12],[13] The need to identify cases of UTI, either alone or in co-existence with other morbidities, cannot be over-emphasized.
However, the magnitude of the problem of UTI co-existing with malaria, particularly in malaria-endemic areas, is uncertain. Also unknown are the characteristics of such UTIs in terms of bacterial etiology and in vitro sensitivity to antimicrobial agents. The study therefore was conducted to identify the following: prevalence of malaria, UTI comorbidity, organisms responsible for such coexisting UTI and their antibiotic sensitivity pattern.
| Patients and Methods | | |
This prospective, cross-sectional and descriptive study was carried out at the Children's Emergency Room (CHER) of the University of Benin Teaching Hospital (UBTH), Benin City, between June and August 2006. The age of the study subjects was between six and 59 months. All patients had confirmed diagnosis of malaria based on demonstration of malarial parasitemia, and were recruited consecutively in the CHER. Children with the following features were excluded: (a) exposure to antibiotics within ten days preceding the evaluation; (b) history of urinary tract structural abnormalities as determined from their medical records or patients whose symptoms suggest abnormalities of the urinary tract; (c) male subjects with recurrent UTI; (d) urologic manipulations such as catheterization carried out within 72 h preceding the evaluation; (e) pre-existing conditions known to be associated with immunosuppression, such as protein-energy malnutrition, sickle cell anemia, malignancies, human immunodeficiency virus infection/acquired immunodeficiency syndrome; and (f) ultimate management for other morbidities instead of malaria and/or UTI, such as bronchopneumonia.
Evaluation For each child, a detailed history was obtained with emphasis on fever, symptoms referable to the urinary tract (i.e., dysuria, frequency, urgency, loin pain, abdominal pain, diarrhea and enuresis), use of antibiotics, previous urologic manipulations and radiologic investigations. This was followed by thorough physical examination with a view to identifying signs suggestive of UTI, malaria and other morbidities in the patients.
Laboratory Methods
All the subjects were investigated with full blood count and blood smear for malaria parasites, and appropriate urine samples were collected for analysis. Hemoglobin genotype is routinely done for children in CHER. All patients with proven UTI were managed with appropriate antibiotics or co-amoxiclav or ceftriaxone in the interim, [11] in consonance with the unit protocol.
All urine samples were evaluated within one hour of collection. Where this was not possible, the specimens were stored at 4-8°C in a refrigerator for a period not exceeding 12 h. [16] All specimens were examined uncentrifuged and subjected to microscopy and culture and sensivity. [17],[18] Identification of bacterial species was done using biochemical methods as described by Chessebrough. [19] Microscopic urinalyses and culture was performed according to standard laboratory procedures. Diagnosis of UTI was based on pure growth of bacteria in excess of set values based on the specimen analyzed. [1],[2],[3]
Malaria Parasite Smear
Thick and thin films were made from each blood sample. The thick and thin films were prepared by the methods as described in a WHO monograph, and Giemsa staining was applied to them. The species identification and parasite density were determined semi-quantitatively as described earlier. [20]
| Data Analysis | | |
Data analysis was done using SPSS 11 for Windows and means and standard deviations (with ranges) were calculated for parametric values. Percentages and proportions were calculated for non-parametric values. Sub-stratification of the subjects was based on age, gender and degree of parasitemia. The prevalence of UTI in these sub-groups was compared. Degrees of association were assessed using the Chi squared test, and P-values less than 0.05 were regarded as significant.
| Results | | |
A total of 334 patients were recruited consecutively for the study. Thirty (8.9%) were excluded because of prior use of antibiotics and four (1.2%) due to incomplete data. Of the remaining 300 patients evaluated, urine samples were collected through suprapubic aspiration in 133 patients (44.3%) and, in 167 (55.7%), mid-stream urine samples were collected. About 95% of the samples collected through suprapubic aspiration were in children less than 24 months, while 62.9% of the mid-stream urine samples were obtained from children older than 24 months. Five (1.7%) of the study subjects had severe malaria (criterion being severe anemia). The 300 patients were made up of 154 males (51.3%) and 146 females (48.7%), giving a male to female ratio of 1.1:1. [Table 1] shows the age and gender distribution of the study population. The mean age of the subjects was 24.9 ± 14.78 months.
Prevalence of urinary tract infection
Twenty-seven of the 300 patients (9.0%) evaluated had growth of a single bacterial pathogen. Of these 27 patients, 16 were females (59.3%) and 11 were males (40.7%). Thus, the gender prevalence of UTI in males was 7.2%, or 11 / 154 , and 11.0% or 16 / 164 in females. There was no significant gender difference in the prevalence of UTI (χ2 = 0.954, P = 0.05). The distribution of UTI among the age cohorts is shown in [Table 2]. Eighteen of the 189 children (9.5%) aged 24 months and below had UTI in comparison with 9 / 111 (8.1%) seen in those above the age of 24 months. [Table 3] shows the relationship between malaria parasite density and incidence of UTI. One hundred and twenty-eight (42.6%) of the study subjects had a parasite density of 1+, 153 (51%) had 2+ while 19 (6.3%) had 3+; none had 4+. There was a positive correlation between malaria parasite density and prevalence of UTI (r = 0.98). | Table 2: Prevalence of concomitant urinary tract infection according to age group.
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 | Table 3: Relationship between incidence of urinary tract infection and malaria parasite density.
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Bacterial isolates
Staphylococcus aureus was isolated in 15 subjects (55.6%) with UTI, Escherichia More Details coli in eight (29.6%) and Kleibsiella pneumoniae in four (14.8%).
Among the samples obtained from supra-pubic aspiration, five each (45.0%) grew Staphylococcus aureus and Escherichia coli  e (9.0%) grew Kleibsiella pneumoniae. All the isolates were highly sensitive to ciprofloxacin, co-amoxiclav and gentamicin but highly resistant to co-trimoxazole, chloramphenicol and amoxicillin. The in vitro sensitivity pattern to selected antibiotics is shown in [Table 4]. All 27 patients with co-existing UTI were commenced on co-amoxiclav empirically, and this was reviewed when the sensitivity reports were received. They all responded to treatment, response being defined as resolution of fever and any other symptom(s) within 72 h of the commencement of anti-malarials/antibiotics and culture-negative urine specimen after antibiotic therapy.
Patient follow-up
The patients were followed-up on a monthly basis for three months, with a repeat urine culture performed at each follow-up visit. Fifteen (55.6%) of the patients were seen on all three occasions, while 18 (68.7%) came on two visits; others were lost to follow-up after the first visit.
| Discussion | | |
The study further corroborates the findings as documented in other reports that malaria in children can co-exist with UTI. [9],[10],[21] The prevalence of UTI in this study was 9%, which is lower than that of Okwara et al, [10] who in 2004 recorded 13.3% in Kenya among children aged 3 months to 12 years. The higher value in Okwara's study may be accounted for by the fact that a disproportionately higher number of young infants were included in this study, and the incidence of bacterial infections including UTI are noted to be higher in the younger age group. [22],[23] An earlier study by Musa et al [9] in Benin City reported a prevalence of 6% in their sub-population with malaria, a figure that is lower than what is recorded in this study. It is uncertain why this variation was seen in prevalence rates between the two studies carried out on comparable age groups from the same center. On the other hand, the prevalence figure in this study is markedly lower than the 24% reported by Phillips et al [21] in children older than six years with severe malaria. However, the study population and morbidity pattern in this study is different from that reported by Phillips et al. Although the subset with severe malaria in this study is too small to warrant inter-group comparison, it is nonetheless an established fact that bacterial co-infection is higher in subjects with severe malaria. [21] Therefore, the higher prevalence may be ascribed to pronounced immunosuppression, which could be more marked in severe malaria. [14],[15],[21],[24] The implications of our findings are not far fetched. Approximately one in every ten children under five years of age, managed for parasitologically proven malaria, had concomitant UTI, which could only be detected through concerted efforts. Non-detection implies that such covert morbidity would be untreated. Untreated and poorly managed UTI is known to predispose to hypertension, renal scaring and chronic renal insufficiency (CRI) in later life. [10]
The prevalence of UTI among subjects with malaria was higher in children less than 24 months old, and this observation is comparable to the report of Musa et al. [9] This trend may be ascribed to the fact that the younger child has some immuneincompetence that predisposes him to increased incidence of infection, including UTI. [9],[23],[25]
Staphylococcus aureus was the most common bacterial isolate in this study, which is different from other studies that noted predominance of Escherichia coli as the most common bacterial cause of UTI. [10],[26] The predominance of Staphylococcus aureus in our study could imply that there is an increased predisposition to gram-positive infections in children with malaria or there is a changing pattern of uropathogens. However, this is an area that will require further investigation. The spectrum of isolates in this study is narrow, as only three organisms were isolated. A similar trend was noted by Musa et al in Benin in 2003. [9] Chances are that these were the only uropathogens involved in the UTI or that rarer organisms could not be identified, granted the constraints of sourcing specialized media needed for isolation of such fastidious organisms in resource-poor countries. Nonetheless, the spectrum of organisms found among this cohort is similar to what is obtainable for the general population, implying that malaria co-existing with UTI is not due to any special group of organism(s).
The in vitro sensitivity of isolates was high to three of the antibiotics used in testing, namely ciprofloxacin, co-amoxiclav and gentamicin, but very low to other commonly used antibiotics such as amoxicillin and co-trimoxazole. This observation is in accordance with the findings of Musa et al [9] and other authors in Nigeria, [25],[26] who noted the emergence of resistance of uropathogens to commonly used antibiotics. The high incidence of resistance of common urinary pathogens to amoxicillin and co-trimoxazole may be due to the indiscriminate use of these antibiotics. It is of note that ciprofloxacin is of limited value because of untoward effects, particularly in children. Additionally, gentamicin can be used only parenterally thus limiting its utility for out-patient care. Co-amoxiclav may therefore be the rational empirical choice for UTI in such subjects, particularly in the study locale. It may nonetheless be argued that in vitro sensitivity patterns may not necessarily reflect the in vivo situation, as some of these drugs attain high concentrations in the bladder. Further studies may be required to fully ascertain their values in the treatment of UTI.
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Correspondence Address:
M O Ibadin
Department of Child Health, University of Benin Teaching Hospital, Benin City
Nigeria
[Table 1], [Table 2], [Table 3], [Table 4] |
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