RENAL DATA FROM THE ARAB WORLD
|Year : 2020 | Volume
| Issue : 1 | Page : 200-208
|Incidence, risk factors and causative bacteria of urinary tract infections and their antimicrobial sensitivity patterns in toddlers and children: A report from two tertiary care hospitals
Ezzat K Amin1, Ali M Abo Zaid1, Abd El Rahman I. Kotb1, Mohamed A El-Gamasy2
1 Department of Pediatrics, Faculty of Medicine, Zagazig University, Zagazig, Egypt
2 Department of Pediatrics, Tanta University Hospital, Tanta, Gharbia, Egypt
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|Date of Submission||03-Jan-2019|
|Date of Decision||25-Feb-2019|
|Date of Acceptance||26-Feb-2019|
|Date of Web Publication||3-Mar-2020|
| Abstract|| |
Urinary tract infection (UTI) is one of the most common bacterial infections among children. It is noted that the risk of renal damage from UTI is the greatest in children younger than five years, thus early diagnosis and prompt treatment are important. The aim of this study was to assess the incidence of UTI in children attending pediatric outpatient clinics in Zagazig and Tanta University Hospitals as tertiary care hospitals. Furthermore, we attempted to determine related risk factors, isolate the organisms that cause UTI in children, and study their antibiotic susceptibility patterns. This cross-sectional descriptive study was conducted on 1200 toddlers and children, (754 boys and 446 girls) aged between 30 months and seven years attending the pediatric outpatient clinics of Zagazig and Tanta University Hospitals. All patient groups were subjected to full medical history, physical examination, dipstick analysis by using both nitrite and leukocyte esterase (LE) detectors, microscopic examinations, and urine culture for cases with the positive LE, positive nitrite dipstick test for urine or positive for both LE and nitrite. The incidence of UTI among children included in the current study was 7%. Positive LE was seen in 112 (9.3%), nitrite positivity was seen in 94 (7.8%), and both LE and nitrite positivity in 34 (2.8%). Escherichia coli was the most common organism. Cefotaxime and amikacin were the most common sensitive antibiotics to the isolates.
|How to cite this article:|
Amin EK, Abo Zaid AM, I. Kotb AE, El-Gamasy MA. Incidence, risk factors and causative bacteria of urinary tract infections and their antimicrobial sensitivity patterns in toddlers and children: A report from two tertiary care hospitals. Saudi J Kidney Dis Transpl 2020;31:200-8
|How to cite this URL:|
Amin EK, Abo Zaid AM, I. Kotb AE, El-Gamasy MA. Incidence, risk factors and causative bacteria of urinary tract infections and their antimicrobial sensitivity patterns in toddlers and children: A report from two tertiary care hospitals. Saudi J Kidney Dis Transpl [serial online] 2020 [cited 2020 Apr 4];31:200-8. Available from: http://www.sjkdt.org/text.asp?2020/31/1/200/279941
| Introduction|| |
Even though urinary tract infection (UTI) is one of the most common bacterial infections among children, it is uncommonly recorded in urine screening in school students.
Approximately, 2% of boys and 8% of girls are affected at the age of seven years. UTI in children is a significant source of morbidity. It is noted that the risk of renal damage from UTI is the greatest in children younger than five years, thus early diagnosis and prompt treatment are important.
Factors predisposing children to UTI include congenital and functional abnormalities, and accurate diagnosis is important to ensure that adequate therapy and proper follow-up is given to prevent future complications.,
Seeking laboratory confirmation of the diagnosis requires the initial stage of collecting an uncontaminated urine sample and this is a challenge in infants and children who are not toilet trained.
The use of dipstick test decreases patient’s time and money and may also help in the earlier initiation of treatment. Although culture is a gold standard for the diagnosis of UTI, it has some disadvantages. Urine culture takes at least 48 h, and a well-equipped laboratory and trained staff are required to give a reliable result. On the other hand, dipstick tests have the advantage of being rapid and easy to carry out and can be performed in small laboratories by laboratory technicians.
Knowledge of the epidemiology (incidence and prevalence) of UTI among different subgroups of children can help clinicians in selecting children who would benefit from further diagnostic testing. Using prevalence rates as an estimate of the prior probability of disease is the first step in evidence-based practice. In children with low pretest probability of disease, routine diagnostic testing is not necessary. In fact, in such children, the random approach to diagnostic testing might lead to more harm than benefit. In contrast, in children with a high pretest probability of disease, routine diagnostic testing would be appropriate.
| Objective|| |
The aim of this work was to study the incidence of UTI in children attending the pediatric outpatient clinic in Zagazig and Tanta University Hospitals, as tertiary care hospitals. Furthermore, it was attempted to determine the related risk factors, isolate the organisms that cause UTI in children, and study the antibiotic susceptibility patterns of the isolates.
| Subjects and Methods|| |
Design of the study
This cross-sectional descriptive study was conducted from November 2017 to November 2018 at the outpatient clinics of Zagazig and Tanta University Hospitals, both are tertiary care hospitals.
This study was carried out on 1200 children, (754 males and 446 females) from 2.5 to 7 years old attending the pediatric outpatient clinics.
Children were selected in a random manner provided they met the following criteria:
- Age, 2.5-7 years old.
○Live in Sharkia, Gharbia, Behera, Kafr- Elsheick, and Menufia Governorates and attended the pediatric outpatient clinics in Zagazig and Tanta University Hospitals, both tertiary care hospitals.
- Age <2 years old and >7 years
- A child with urinary catheter-associated UTI
- A child diagnosed with congenital anomalies of the kidneys or urinary tract
- Previous surgery of the genitourinary tract (except circumcision in male children)
- A child with a history of chronic renal disease and the presence of an immuno- compromising condition (e.g., human immunodeficiency virus, malignancy, use of chronic corticosteroids, or other immuno- suppressive agents). The purpose of the study was explained to the parents of the study children.
All children included in the study were subjected to the following:
- Detailed history taking, with special focus on the presence of urological manifestations (dysuria, loin pain, frequency, supra-pubic pain, change of the color of urine, and enuresis), treatment with certain drugs for a long period, past or family history of renal diseases
- Full clinical examination, with special focus on weight, height, and abdominal examination for renal mass or fullness of renal angles
- Urine samples were collected from the children by midstream clean-catch technique, in sterile cups. Complete urine analysis was performed on these urine specimens by microscopic examination of the centrifuged sample for pus cells, white blood cells, and red blood cells morphology. Dipsticks analysis by using both esterase and nitrate detectors was performed
- Urine culture was performed in cases with positive leukocyte esterase (LE) dipstick, positive nitrite dipstick or positive for both LE, and nitrite dipstick test in urine.
| Statistical Analysis|| |
All data were collected, tabulated, and statistically analyzed using IBM SPSS Statistics for Windows version 20.0 (IBM Corp., Armonk, NY, USA) and MedCalc 13 for windows (MedCalc Software bvba, Ostend, Belgium).
Statistical analysis was performed using the Chi-square test for comparing numerical parameters.
| Results|| |
The incidence of UTI among the studied toddlers and children included in the current study was 84 (7%). [Table 1] shows that there was statistically significant difference between the studied groups regarding risk factors for UTI including uncircumcised males, positive family history of UTI, recurrent UTI, nocturnal enuresis, constipation, and prolonged use of antibiotics. [Table 1] also shows that there was statistically significant difference between males and females in relation to prevalence of UTI, where the prevalence in females was 54.8% (46 females from 84 one has UTI), while the prevalence in males was 45.2% (38 males from 84 patients with UTI) (P <0.05).
|Table 1: Risk factors for urinary tract infection in the studied toddlers and children.|
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[Table 2] and [Figure 1] summarize laboratory results of the current study showing that 112 children (9.3%) were positive by dipstick for LE and 94 (7.8%) were positive for nitrite; combined LE and nitrite positivity was seen in 34 (2.8%).
|Table 2: Validity of multistick method for diagnosing urinary tract infection.|
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|Figure 1: Summary of laboratory results of the current study showing that children with dipstick leukocyte esterase positive were 112 (9.3%), nitrite positive were 94 (7.8%), and both leukocyte esterase and nitrite positive were 34 (2.8%).|
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Regarding the validity of the positive LE dipstick test, sensitivity was 73.8%, specificity was 95.5%, negative predictive value was 98%, positive predictive value was 55.4%, and overall accuracy was 94%.
Regarding the validity of positive nitrite dipstick test, sensitivity was 66.7%, specificity was 96.6%, negative predictive value was 97.5%, positive predictive value was 59.6%, and overall accuracy was 94.5%.
As regards the validity of combined positive LE and nitrite, sensitivity was 40.5%, specificity was 100%, negative predictive value was 95.7%, positive predictive value was 100%, and overall accuracy was 95.8%.
[Figure 2] summarizes the organisms causing UTI in our studied patients. Escherichia More Details coli was the most common organism that causes UTI in children in our study.
|Figure 2: Summary of the causative organisms causing urinary tract infection in our studied patients; Escherichia coli was the most common organism in our study.|
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[Table 3] summarizes patterns of bacterial susceptibility to antimicrobials; cefotaxime and amikacin were the most common antibiotics sensitive to the isolates.
| Discussion|| |
This study was an attempt to determine the incidence of UTI, microbial pathogens implicated in UTI and their antibiotic susceptibility patterns in children attending the pediatric outpatient clinics at Zagazig and Tanta University hospitals, both tertiary care hospitals. The total number of children included in this study was 1200 aged 2.5-7 years; 754 children (62.8%) were males and 446 (37 %) were females, 358 (30%) were from urban areas and 842 (70 %) were from rural areas.
This study showed that the incidence of UTI in toddlers and children attended the pediatric outpatient clinics at Zagazig and Tanta University hospitals was 7%. Similar to our results, Mohammed et al, in Giza gover- norate in Egypt found that the prevalence of UTI in 1000 apparently healthy school-going children, 552 boys (55.2%) and 448 girls (44.8%), was 6%.
In the study of Durmišević-Serdarević et al, in Bosnia, found that UTI was present in 352 children (6.5%), including 114 boys (32.4%) and 238 girls (67.6%).
In the study of Shaikh et al, the overall prevalence of UTI in older children (<19 years) with or without fever was reported to be 7.8%.
In a study in Nnewi in Nigeria, the prevalence of significant bacteriuria among pediatric patients attending Nnamdi Azikiwe University Teaching Hospital was 8%. This study showed that there was the high incidence of UTI among the female gender (66.67%) than the male gender (33.33%).
In another study in Menoufiya Governorate in Egypt, of 500 children, 314 (62.8%) were males and 186 (37.2%) were females and the prevalence of UTI among children aged 3-12 years attending the pediatric outpatient clinic in Menoufia University Hospital was 4.8%. However, this was not in agreement with the study of El Masry et al, in Sohag Governorate in Egypt, where the prevalence of UTI among primary school children from five primary schools in different parts of the Sohag Governorate, was 0.6% for the initial urinary screening and 0.5% for the second screening.
El-Gamasy et al, reported that the antibiotics which were commonly used in their pediatric patients with UTI such as trime- thoprim/sulfamethoxazole, ampicillin, and cephalexin did not seem to be appropriate for the empirical treatment of community-acquired UTI because of its very high rate of resistance and added that regular monitoring by complete urinalysis is required.
Results of the current study shows that there was statistically significant difference between males and females in relation to prevalence of UTI, where the prevalence of UTI in female 54.8% (46 females from 84 one has UTI) while the prevalence of UTI in male 45.2% (38 males from 84 one has UTI) (P =0.014), the highest number of cases (31%) was found among females in the age group five to seven years than among males (28.6%) in the age group two to four years. Similar to our results, Mohammed et al reported a higher prevalence of UTI occurred in girls (11.4%) than boys (1.6%), with statistically significant difference between males and females in relation to the prevalence of UTI. In the study of El-Shafie et al, there was statistically significant difference between males and females in relation to the prevalence of UTI among the screened children.
Results of the current study showed statistically significant difference between risk factors such as uncircumcised males, family history of UTI, recurrent UTI, enuresis, and constipation and prevalence of UTI, and statistically significant higher difference between prolonged uses of antibiotics in relation to the prevalence of UTI.
In the study of Sawalha, nocturnal enuresis was highly significantly correlated with the prevalence of UTI (P = 0.035), whereas in the study of Safarinejad, the overall prevalence of enuresis was 6.8%, the prevalence of urinary tract pathology was 2.9% among enuretics which indicates high association between UTI and nocturnal enuresis. In the study of Afridi et al, circumcised males appear to be at lower risk for developing UTI perhaps because of low peri-urethral and urethral bacterial colonization; this may be due to the small number of males included in the study.
In the study of Isa et al, they reported that there was a statistically significant difference between bedwetting and UTI. However, the association between UTI and previous history of UTI was insignificant (P >0.05). The study of Hossain et al showed that female gender (P <0.05), constipation (P <0.001), not taking anthelmintic (P <0.001), lack of toilet training (P <0.001), and inadequate water intake (P <0.01) were significant risk factors for UTI in children.
Similar to our results, El-Shafie et al found that the sensitivity of the dipstick test was 82.6%, specificity was 98.9%, positive predictive value was 79.1%, and negative predictive value was 99.1%. Hence, the dipstick is a good negative test rather being a good positive test for the detection of UTI. However, in the study of Najeeb et al, found that the combined sensitivity of LE and nitrite was 75.74%, whereas specificity was 68.90%. He concluded that urine dipstick test may be considered for rapid urinalysis to diagnose UTI.
In the study of Laosu-Angkoon, it was found that the sensitivity of LE test was 63.6% while the combined LE and nitrite test were 66.7%. They concluded that the dipstick test can be used as a rapid diagnostic tool in detecting UTI and to prevent potential sequelae such as hypertension and renal scarring.
The study of Taneja et al found that the combined sensitivity of LE and nitrite was 79.6%, while sensitivity and specificity of LE were 73.5% and 58.5%, respectively, and for nitrite was 57.1% and 78.7%, respectively. He concluded that for the faster diagnosis of UTI, dipstick tests for LE and nitrite tests should be added in routine laboratory practices.
The study of Abdelhamid found that LE sensitivity was 85.8%, specificity 54.1%, positive predictive value 45.9%, and negative predictive value was 91.2%. Nitrite sensitivity was 79.3%, specificity was 66.3%, positive predictive value was 73.9%, and negative predictive value was 88.9%. LE and nitrite sensitivity was 71.2%, specificity was 100.00%, positive predictive value was 100% and negative predictive value was 79.4%.
Results of the current study show that accor- ding to culture, the most common infecting organism was E. coli that represents 76.2% followed by Klebsiella pneumonia (9.5%), Enterococcus fecalis (7.1%), Proteus mirabilis (4.8%), and coagulase-negative Staphylococci (2.4%).
Similar to our results, Lehrasab et al reported that the most common organisms responsible for UTI found were E. coli (47.6%) followed by Klebsiella (23.2%) and Proteus (10%); Staphylococcus was found in 7.3% and Enterobacter in 7.3% of the children. The remaining (4.6%) were effected with other organisms.
The study of Abdelhamid shows that the infecting organism was E. coli in 62.5%, Klebsiella in 12.5%, E. fecalis in 16.7%, and coagulase-negative staphylococci in 8.3%. In the study of Dada and Aruwa, the predominant bacterial isolate was E. coli (56.8%), followed by S. aureus (18.9%), Klebsiella spp. (16.2%) and P. aeruginosa (8.1%).
In the study of Afridi et al, the most common urinary pathogens isolated were E. coli (63%), K. pneumoniae (8%) and P. mirabilis (8%). Other pathogens included Pseudomonas aerogenosa (7%), Staphylococcus aureus and Citrobacter in 5% each, and Enterobacter and coliform 2%, each. In the study of El-Shafie et al, the most common organism found in UTI cases was E. coli (62 %) followed by E. fecalis (17.3%), K. pneumonia (10.3%), and coagulase- negative staphylococci (10.4 %).
Results of the current study show that according to antibiotic sensitivity, 24 patients (28.6%) were sensitive to cefotaxime, 22 (26.2%) were sensitive to amikacin, 12 (14.3%) were sensitive to amoxicillin and clavulanic acid, six (7.1%) were sensitive to ceftriaxone, six (7.1%) were sensitive to co- trimoxazole, six (7.1%) were sensitive to imipenem, four (4.8%) were sensitive to ciprofloxacin, and four (4.8%) were sensitive to nitrofurantoin. Similar to our study, according to antibiotic sensitivity, 62.5% of the patients were sensitive to cefotaxime, 25% were sensitive to amikacin and 12.5% were sensitive to amoxicillin and clavulanic acid.
In the study of Wu et al, the most common uropathogen in primary and recurrent UTI was E. coli and cefazolin was the drug of choice for treating such infections in children. In the study of Afridi et al, sensitivity of different urinary organisms isolated was the highest to amikacin (82%) followed by meropenem (75%), tazocin (61%), and sulzone (58%). In the study of Sharma et al, most of the organisms were highly sensitive to nitrofurantoin and amikacin. Sensitivity to quinolones and third-generation cephalosporins varied according to the organism. E. coli was 100% sensitive to nitrofurantoin and sensitive to ofloxacin, cefotaxim, and amikacin in 94.4%, 94.7%, and 94.7%, respectively. E. coli was resistant to ampicillin in 91.6%, co-trimoxazole in 66.6%, and nalidixic acid in 63.6%.
We conclude that the incidence of UTI in our study was 7%. Risk factors for UTI in children in our study were uncircumcised males, prolonged use of antibiotics, family history of UTI, recurrent UTI, enuresis, and constipation. E. coli was the most common organism that caused UTI in children in our study. Cefotaxime and amikacin were the most common antibiotics sensitive to the isolates. Further studies must be performed in a larger population in Egypt to help in the determination of local causative organisms and preventive measures to decrease the prevalence of UTI.
| Study Limitations|| |
Our study was small sample-sized, not covering large population size but may help in meta-analysis studies.
Conflict of interest: None declared.
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Mohamed A El-Gamasy
Department of Pediatrics, Tanta University Hospital, Tanta, Gharbia
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]
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