Diagnosis and management of pediatric urinary tract infections

Enhanced quantitative urine culture technique, a slight modification, in detecting under-diagnosed pediatric urinary tract infection

Objectives

The pediatric urinary tract infection (UTI) often remains under-diagnosed or neglected owing to non-specific clinical presentations, patients failing to describe the actual situation and of clinical practice in diagnosis. The study was aimed to determine the etiologies of UTI in children with enhanced quantitative urine culture (EQUC) technique.

Results

Of enrolled 570 pediatric urine samples, the significant growth positivity was higher in EQUC 92 (16.15%) compared to standard urine culture (SUC) 73 (12.80%) technique. 20.6% of the significant isolates as detected with EQUC were missed on the SUC technique. The age group, in range 1–4 years, was more prone to the infection, where E. coli was the commonest pathogen. EQUC detected, probably all isolates, contributing UTI i.e. multidrug-resistant (MDR), extensive drug-resistant (XDR), and extended-spectrum β-lactamase (ESBL) producers, as some of them skipped on the SUC technique. Of total organisms isolated from EQUC, 46% were ESBL producer, 56.5% were MDR, and 1.4% were XDR. However, 40.5% ESBL, 44% MDR but no XDR detected on SUC. Hence a simple modification on conventional culture protocol could be a crucial modification for the detection of etiologies, contributing UTI, and hence to reduce inapt antimicrobial burden.

Synergistic evaluation of AgO2 nanoparticles with ceftriaxone against CTXM and blaSHV genes positive ESBL producing clinical strains of Uro-pathogenic E. coli

The silver oxide nanoparticles (AgO₂-NPs) were synthesised using silver foil as a new precursor in wet chemical method. X-ray diffraction analysis shows crystallographic structures of AgO₂-NPs with crystallite size of 35.54 nm well-matched with standard cubic structure. Scanning electron microscopy analysis clearly shows the random distribution of spherical-shaped nanoparticles. Energy dispersive X-ray analysis confirmed the purity of the samples as it shows no impurity element. Fourier transforms infra-red analysis confirmed the formation of AgO₂-NPs with the presence of Ag-O-Ag stretching bond. All the techniques also confirmed the loading of ceftriaxone drug on the surface of AgO₂-NPs. This study also described the effect of AgO₂-NPs having synergistic activity with β lactam antibiotic i.e. ceftriaxone against ESBL generating Escherichia coli (E. coli). Among isolated strains of E. coli, 60.0% were found to be ESBL producer. The synergistic activities of AgO₂-NPs with ceftriaxone suggest that these combinations are effective against MDR-ESBL E. coli strains as evident by increase in zone sizes. The present study observed rise in MDR-ESBL E. coli with polymorphism of blaCTXM and blaSHV causing UTI infections in Pakistani population. The antibiotic and AgO₂-NPs synergistic effect can be used as an efficient approach to combat uro-pathogenic infections.

Clinical, etiological and antimicrobial susceptibility profile of pediatric urinary tract infections in a tertiary care hospital of Nepal

Background

Urinary tract infection (UTI) is one of most common pediatric infections. The study was designed to assess the clinical profile, common bacterial microorganisms causing UTI and their antimicrobial susceptibility patterns at B. P. Koirala Institute of Health Sciences (BPKIHS) hospital.

Methods

This is a prospective cross-sectional study conducted at Department of Microbiology and Infectious Diseases for 6 months (January to June 2018). A total of 1962 non-repetitive urine specimens (midstream, nappy pad, catheter aspirated) of pediatric patients (0–14 years age) suspected of UTI were obtained in the Microbiology laboratory. Clinical data was obtained from requisition form and hospital software. Culture and bacterial identification was done by using standard microbiological guidelines. Antimicrobial susceptibility testing was done by Kirby-Bauer disc diffusion method following clinical and laboratory standards institute (CLSI) guidelines. Resistance to methicillin and vancomycin were confirmed by calculating minimum inhibitory concentration using broth dilution method.

Results

Among 1962 samples, 314 (16%) were positive for bacterial infection. Fever, irritability and poor feeding was the most common symptoms in neonates while older children presented with fever and urinary symptoms. E. coli was reported the most common etiological agent (53%), followed by Enterococcus faecalis (22%), Klebsiella pneumoniae (7%) and Staphylococcus aureus (7%). Multidrug resistant (MDR) isolates accounted for 32% of isolates, while 5% were extensively drug resistant (XDR). Fourty percentage of gram-negative bacilli were ESBL producer, 38% of S. aureus were methicillin resistant Staphylococcus aureus (MRSA) and 5% E. faecalis were vacomycin resistant enterococci (VRE). E coli was highly resistant to Ampicillin (87%), Ceftriaxone (62%) and Ofloxacin (62%). Amikacin (11% resistance) and Nitrofurantoin (5% resistance) are the most effective drugs for gram-negative bacilli (GNB) while vancomycin and linezolid are functional against gram-positive cocci.

Conclusions

High-level antimicrobial resistance was observed in pediatric UTI with alarming incidence superbugs like MDR, XDR, ESBL and MRSA. Regular surveillance should be carried out to determine the local prevalence of organisms and antimicrobial susceptibilities in order to guide the proper management of children.

Urinary tract infections in children: an overview of diagnosis and management

Urinary tract infections (UTIs) are a common and potentially serious bacterial infection of childhood. History and examination findings can be non-specific, so a urine sample is required to diagnose UTI. Sample collection in young precontinent children can be challenging. Bedside dipstick tests are useful for screening, but urine culture is required for diagnostic confirmation. Antibiotic therapy must be guided by local guidelines due to increasing antibiotic resistance. Duration of therapy and indications for imaging remain controversial topics and guidelines lack consensus. This article presents an overview of paediatric UTI diagnosis and management, with highlights of recent advances and evidence updates.

Urinary Tract Infection in Children

BACKGROUND

Urinary Tract Infection (UTI) is a common infection in children. Prompt diagnosis and appropriate treatment are very important to reduce the morbidity associated with this condition.

OBJECTIVE

To provide an update on the evaluation, diagnosis, and treatment of urinary tract infection in children.

METHODS

A PubMed search was completed in clinical queries using the key terms "urinary tract infection", "pyelonephritis" OR "cystitis". The search strategy included meta-analyses, randomized controlled trials, clinical trials, observational studies, and reviews. The search was restricted to English literature and the pediatric age group. Patents were searched using the key terms "urinary tract infection" "pyelonephritis" OR "cystitis" from www.google.com/patents, http://espacenet.com, and www.freepatentsonline.com.

RESULTS

Escherichia coli accounts for 80 to 90% of UTI in children. The symptoms and signs are nonspecific throughout infancy. Unexplained fever is the most common symptom of UTI during the first two years of life. After the second year of life, symptoms and signs of pyelonephritis include fever, chills, rigor, flank pain, and costovertebral angle tenderness. Lower tract symptoms and signs include suprapubic pain, dysuria, urinary frequency, urgency, cloudy urine, malodorous urine, and suprapubic tenderness. A urinalysis and urine culture should be performed when UTI is suspected. In the work-up of children with UTI, physicians must judiciously utilize imaging studies to minimize exposure of children to radiation. While waiting for the culture results, prompt antibiotic therapy is indicated for symptomatic UTI based on clinical findings and positive urinalysis to eradicate the infection and improve clinical outcome. The choice of antibiotics should take into consideration local data on antibiotic resistance patterns. Recent patents related to the management of UTI are discussed.

CONCLUSION

Currently, a second or third generation cephalosporin and amoxicillin-clavulanate are drugs of choice in the treatment of acute uncomplicated UTI. Parenteral antibiotic therapy is recommended for infants ≤ 2 months and any child who is toxic-looking, hemodynamically unstable, immunocompromised, unable to tolerate oral medication, or not responding to oral medication. A combination of intravenous ampicillin and intravenous/intramuscular gentamycin or a third-generation cephalosporin can be used in those situations. Routine antimicrobial prophylaxis is rarely justified, but continuous antimicrobial prophylaxis should be considered for children with frequent febrile UTI.

Pediatric Urinary Tract Infection as a Cause of Outpatient Clinic Visits in Southern Ethiopia: A Cross Sectional Study

Background

Failure to timely diagnose and treat urinary tract infections is associated with grave long term consequences. The objectives of this study included assessing the proportion and predictors of Urinary Tract Infection (UTI) as a cause of pediatric outpatient department (OPD) visits and determining common uropathogens with antimicrobial susceptibility pattern.

Methods

A cross sectional study was conducted from May to September 2015 among children of less than 15 years old at a tertiary center in Hawassa, Ethiopia. Children who fulfilled predefined eligibility criteria were recruited to undergo urine culture and urine analysis.

Results

A total of 863 children visited the OPD during the study period among which 269(31.2%) fulfilled the predefined eligibility criteria. Urine culture was positive for 74/269(27.5%) of the clinically suspected children. Male uncircumcision (adjusted odds ratio (aOR) 3.70; 95% CI 1.34–10.16) and under nutrition (aOR 5.41; 95%CI 2.64–11.07) were independent predictors of culture positivity. More than 5 WBC per high power field (aOR 4.7, 95% CI 1.8–12.7) on microscopy, urine PH > 5.0 (aOR 2.6, 95%CI 1.2–5.8), and positive leukocyte esterase (aOR 9.9, 95%CI 4.1–25.7) independently predicted positive growth on urine culture. Escherichia coli (34/74, 45.9%) and Klebsiella spp (18/74, 24.3%) were the most frequent isolates. High resistance was noted against amoxicillin (70.6%) and cotrimoxazole (97.1%) by E. coli.

Conclusion

UTI accounted for a tenth of total OPD visits. Commonly used first line antibiotics showed high level resistance to common etiologies of UTI. UTI should be suspected in febrile children, and antibiograms should be done to tailor prescription of antibiotics.

Prevalence and Antimicrobial Susceptibility of Bacterial Uropathogens Isolated from Pediatric Patients at Yekatit 12 Hospital Medical College, Addis Ababa, Ethiopia

BACKGROUND

Urinary tract infection (UTI) is considered as the most common bacterial infection seen among the pediatric patients.

OBJECTIVE

This study was carried out in order to determine the prevalence of urinary tract infection in pediatric patients, identify bacterial uropathogens responsible for the infection, and study the antibiotic sensitivity patterns of bacterial isolates.

MATERIALS AND METHODS

A cross-sectional study designed and conducted from January to April 2014. Clean-voided midstream urine specimens were obtained from 384 pediatric patients less than or equal to 15 years in sterile universal bottles. Urine collected from each patient was inoculated onto CLED and blood agar plates using a calibrated inoculating loop with a capacity of 0.001 ml. Inoculated plates were incubated for 24-48 hours at 37°C at inverted position aerobically. Bacterial isolates were indentified and characterized by Gram stain and by using an array of standard routine biochemical tests. The antimicrobial susceptibility test was carried out by using the Kirby-Bauer disc diffusion method. Frequency distribution tables were used to describe the findings. Logistical regression was also used to estimate crude odds ratio (COR) with 95% confidence interval (CI) of positive responses to the different variables, and P values less than 0.05 were taken as statistically significant.

RESULT

In this study, a total of 384 patients (199 males and 185 females) aged less than or equal to 15 years from whom urine samples were collected were enrolled. Of these patients, 61 (15.9%) had significant bacteriuria. Of the 185 females, 36 (19.5%) came up with positive cultures, while 25 (12.6%) of the 199 males had significant bacteriuria, and the largest number of study subjects were below the age of 3 years, and the largest positive culture was obtained from this age group, accounting for 35 (57.4%.) out of 61 positive cultures. Bacterial species belonging to six genera were isolated and identified from 61 positive cultures, and the genera were Escherichia, Klebsiella, Staphylococcus, Proteus, Acinetobacter, and Enterococcus. E. coli was isolated in 28 cases (49.5 %), followed by Klebsiella spp. in 17 cases (27.9%), Staphylococcus spp. in 5 patients (8.2%.) (S. aureus in one and coagulase-negative staphylococci in 4 cases), Enterococcus in 7 cases (11.5%), Proteus spp. in 3 cases (4.9%), and Acinetobacter in one case (1.6%). Of the bacterial isolates, E. coli was found out to be the most common pathogen followed by Klebsiella spp. Furthermore, E. coli and Klebsiella spp. were the most common pathogens in female patients accounting for 71.4% and 64.7%, respectively. Regarding susceptibility tests, E. coli and Klebsiella spp. were not 100% susceptible to any of the 11 antibiotics tested. Acinetobacter spp. had 100% resistance to three antibiotics: gentamicin (GN), trimethoprim-sulfamethoxazole (SXM), and augmentin (AMP). But they were 100% susceptible to ciprofloxacin (CIP), cefuroxime (CXM), norfloxacin (NOR), and ceftazidime (CAZ). On the contrary, Proteus spp. was 100% sensitive to all drugs except to nitrofurantoin. Species of Enterococcus had resistance of 71.4% to chloramphenicol (C) and 85.7% to both SXM and erythromycin. S. aureus was 100% susceptible to almost all drugs, while coagulase-negative staphylococci were not as susceptible as S. aureus. Multidrug resistance to two or more drugs was observed in 73.7% of the bacterial isolates.

CONCLUSION

This study determined the prevalence of urinary tract infection in pediatric patients and highlighted the major bacterial uropathogens involved in UTI for the first time in the country. Furthermore, bacterial pathogen species and their frequency was consistent with the usually reported pattern, with E. coli being the most common organism isolated in cases of urinary tract infections followed by Klebsiella spp. Most of the bacterial isolates were multidrug resistant, and it is therefore suggested that appropriate antimicrobials should be administered to reduce the risk of multidrug resistant organisms developing and avert ineffectiveness of antibiotics. This condition indicates that antibiotic selection should be based on knowledge of the local prevalence of bacterial organisms and antibiotic sensitivities rather than empirical treatment. The present study indicated that ciprofloxacin (CIP), ceftazidime (CAZ), cefotaxime (CTX), cefuroxime (CXM), clindamycin (DA), and ceftriaxone (CRO) were the best antibiotics for the treatment of Gram-negative and Gram-positive bacterial uropathogens, respectively, in the study area relatively.

A systematic review of parents' experiences and information needs related to their child's urinary tract infection

OBJECTIVE

As a first step toward the development of an animated video and infographic to increase parents' knowledge of pediatric urinary tract infections (UTIs), we conducted a systematic review of their experiences and information needs.

METHODS

We searched Ovid Medline, Ovid PsycINFO, CINAHL, and ProQuest Dissertations and Theses Global for studies published in 2000 or thereafter. We appraised quality using the Mixed Methods Appraisal Tool. We summarised the quantitative data narratively and the qualitative data thematically.

RESULTS

We identified 1493 records and included four. Sample size ranged from 20 to 2726 parents. The children ranged from <1 to 12 years old and had experienced one to >10 UTIs. Parents were not always aware of UTI symptoms and generally received little information. Parents sought information online, and desired it via other means. Some parents were not confident in healthcare providers' (HCPs') knowledge of UTIs. Inadequate information about diagnostic tests sometimes resulted in fear and non-compliance.

CONCLUSIONS

From the limited literature, it appears that parents would like information about prevention, diagnosis, treatment, and prognosis, but do not always consider HCPs good information sources.

PRACTICE IMPLICATIONS

Care providers should communicate information in ways that suit parents' self-identified needs.

Is vaginal reflux associated with urinary tract infection in female children under the age of 36 months?

Purpose

To determine the relationship between vaginal reflux (VR) and urinary tract infection (UTI) in female children aged <36 months.

Methods

A single center retrospective study was performed for 191 girls aged <36 months, with a diagnosis of febrile UTI, who underwent a voiding cystourethrography (VCUG) for assessment of vesicoureteral reflux (VUR) at Sanggye Paik Hospital. Fifty-one girls, who underwent VCUG for assessment of congenital hydronephrosis or renal pelvis dilatation, without a UTI, formed the control group. The correlation between the presence and grade of VR and UTI was evaluated.

Results

The prevalence rate of VR was higher in the UTI (42.9%) than control (13.7%) group (P<0.05), with a higher VR severity grade in the UTI (mean, 0.64) than control (mean, 0.18) group (P<0.05). On subanalysis with age-matching (UTI group: n=126, age, 5.28±2.13 months; control group: n=22, age, 4.79±2.40 months; P=0.33), both VR prevalence (43.65% vs. 18.18%, P<0.05) and grade (0.65 vs. 0.22, P<0.05) remained higher in the UTI than control group. Presence and higher grade of VR were associated with UTI recurrence (P<0.05). VR was correlated to urosepsis (P<0.05). The renal defect rate of patients with VR (VR [+]/VUR [+]) was not different from that of patients without VR (74% vs. 52%, P=0.143) in the VUR group; however, it was higher than that of VR (+)/VUR (-) patients (74% vs. 32%, P=0.001). If a child with VR (+)/VUR (+) is exposed to a UTI, the risk of renal defect increases.

Conclusion

Occurrence of VR is associated with UTI recurrence and urosepsis in pediatric female patients.

Functional variants in intercellular adhesion molecule-1 and toll-like receptor-4 genes are more frequent in children with febrile urinary tract infection with renal parenchymal involvement

AIM

We studied the functional polymorphisms of intercellular adhesion molecule-1 (ICAM-1) and toll-like receptor-4 (TLR-4) genes and risk of acute pyelonephritis (APN) in children attending Assiut University Children's Hospitals, Egypt, from 2011 to 2015.

METHODS

Urinary tract infections (UTIs) were diagnosed in 380 children: 98 had APN and 282 had lower UTIs. Four single-nucleotide polymorphisms in ICAM-1 and TLR-4 genes were genotyped in all subjects: ICAM-1 rs1799969 Gly241Arg, ICAM-1 rs5498 Glu469Lys, TLR-4 rs4896791 Thr399Ile and TLR-4 rs4896790 Asp299Gly.

RESULTS

Patients with APN were significantly more likely to have AA genotype of the ICAM-1 rs5498 (1462 A/G) polymorphism (p = 0.04) than children with lower UTIs and the TLR-4 Asp299Gly GG genotype (p = 0.002) and G allele (p = 0.006) than healthy controls. The association with the ICAM-1 Glu469Lys (1462A/G) was less evident. The GG genotype was associated with a modest relative risk of 1.4 (p = 0.1) of developing APN, but was not an independent odds ratio, at 1.2 (p = 0.48).

CONCLUSION

Functional variants in ICAM-1 and TLR-4 genes were increasingly common in children with febrile UTIs with renal parenchymal involvement, but the ICAM-1 Glu469Lys (1462A/G) association was less evident. TLR4 Asp299Gly might independently increase renal parenchymal infection rather than renal scarring.

Febrile urinary-tract infection due to extended-spectrum beta-lactamase-producing Enterobacteriaceae in children: A French prospective multicenter study

Objectives

To assess the management of febrile urinary-tract infection (FUTIs) due to extended-spectrum β-lactamase–producing Enterobacteriaceae (ESBL-E) in children, the Pediatric Infectious Diseases Group of the French Pediatric Society set up an active surveillance network in pediatric centers across France in 2014.

Materials and methods

We prospectively analysed data from 2014 to 2016 for all children < 18 years old who received antibiotic treatment for FUTI due to ESBL-E in 24 pediatric centers. Baseline demographic, clinical features, microbiological data and antimicrobials prescribed were collected.

Results

301 children were enrolled in this study. The median age was 1 year (IQR 0.02–17.9) and 44.5% were male. These infections occurred in children with history of UTIs (27.3%) and urinary malformations (32.6%). Recent antibiotic use was the main associated factor for FUTIs due to ESBL-E, followed by a previous hospitalization and travel history. Before drug susceptibility testing (DST), third-generation cephalosporins (3GC) PO/IV were the most-prescribed antibiotics (75.5%). Only 13% and 24% of children received amikacine alone for empirical or definitive therapy, respectively, whereas 88.7% of children had isolates susceptible to amikacin. In all, 23.2% of children received carbapenems in empirical and/or definitive therapy. Cotrimoxazole (24.5%), ciprofloxacin (15.6%) and non-orthodox clavulanate–cefixime combination (31.3%) were the most frequently prescribed oral options after obtaining the DST. The time to apyrexia and length of hospital stay did not differ with or without effective empirical therapy.

Conclusions

We believe that amikacin should increasingly take on a key role in the choice of definitive therapy of FUTI due to ESBL-E in children by avoiding the use of carbapenems.

Gene Therapy for Adenosine Deaminase Deficiency: A Comprehensive Evaluation of Short- and Medium-Term Safety

Loss of adenosine deaminase activity leads to severe combined immunodeficiency (ADA-SCID); production and function of T, B, and natural killer (NK) cells are impaired. Gene therapy (GT) with an autologous CD34⁺-enriched cell fraction that contains CD34⁺ cells transduced with a retroviral vector encoding the human ADA cDNA sequence leads to immune reconstitution in most patients. Here, we report short- and medium-term safety analyses from 18 patients enrolled as part of single-arm, open-label studies or compassionate use programs. Survival was 100% with a median of 6.9 years follow-up (range, 2.3 to 13.4 years). Adverse events were mostly grade 1 or grade 2 and were reported by all 18 patients following GT. Thirty-nine serious adverse events (SAEs) were reported by 15 of 18 patients; no SAEs were considered related to GT. The most common adverse events reported post-GT include upper respiratory tract infection, gastroenteritis, rhinitis, bronchitis, oral candidiasis, cough, neutropenia, diarrhea, and pyrexia. Incidence rates for all of these events were highest during pre-treatment, treatment, and/or 3-month follow-up and then declined over medium-term follow-up. GT did not impact the incidence of neurologic/hearing impairments. No event indicative of leukemic transformation was reported.

Bacterial isolates and their antimicrobial susceptibility patterns among pediatric patients with urinary tract infections

OBJECTIVE

Urinary tract infection is a common pediatric problem with the potential to produce long-term morbidity. Therefore, appropriate diagnosis and prompt treatment is required. However, studies about magnitude of uropathogenicity and antimicrobial resistance pattern of pediatric urinary tract infection (UTI) are lacking in resource limited countries including Ethiopia. This study was aimed to determine bacterial isolates, antimicrobial susceptibility pattern among pediatric patients with UTI.

MATERIAL AND METHODS

A cross- sectional study was conducted. Pathogenic bacterial isolates were identified by culture and biochemical methods following standard procedures. Antimicrobial susceptibility testing of the isolates for commonly used antibiotics was done using the standard disc diffusion method on Muller Hinton agar. Associations between dependent and independent variables were measured using chi-square test and within 95% confidence interval. P values <0.05 were considered as statistically significant.

RESULTS

A total of 310 pediatric patients were included in the study, and 82 (26.45%) bacterial isolates were detected. Gram- negative bacteria were predominant etiologic agents of UTI in this study. E. coli was the most frequently occurring pathogen (n=45; 54.88%) followed by S. aureus and P.aeruginosa (n=8; 9.75% for both), P. vulgaris, P.aeruginosa (n=4; 4.88%, for both) and Enterococcus species (n=3; 3.66%). All K. pneumoniae, P. mirabilis, and K. ozanae straines were 100% resistance to ampicillin, followed by P. aeruginosa (87.5%) and E. coli (69%). While all Gram- positive bacterial isolates were 100% sensitive to ciprofloxacin. Malnutrition, history of catherization and previous history of UTI were independently associated with UTI (p=0.000).

CONCLUSION

There was a high prevalence of uropathogenic bacteria and drug resistance particularly to ampicillin (72%) and tetracycline (37.80%). This condition indicates that antibiotic selection should be based on knowledge of the local prevalence of bacterial organisms and antibiotic sensitivities rather than empirical treatment.

Impact of cytokine genetic polymorphisms on the risk of renal parenchymal infection in children

BACKGROUND

Acute pyelonephritis is associated with renal scarring in up to 30% of patients. Renal scarring may cause significant long-term morbidity. The pathogenesis of acute pyelonephritis remains unclear, although it involves interaction among uroepithelium, the immune system cells, and the locally produced cytokines. That some UTI-prone children develop acute pyelonephritis, and eventually renal parenchymal scarring, suggests a genetic role. Interleukin-6, interleukin-8, chemokine receptor-1 (CXCR1), and tumor necrosis factor-alpha (TNFα), the key regulators of the host immune responses, are proteins whose secretion is controlled by genes. We postulated that functional polymorphic variants of their genes might have a role in APN susceptibility.

OBJECTIVES

We sought to investigate a possible association of the common functional polymorphisms in genes encoding IL-6, IL-8, CXCR1, and TNFα with the risk of APN in children.

METHODS

Urine culture was used to diagnose 300 children with UTI, of mean age of 51.31 ± 37.4 months (2-180 months). 99Tc-DMSA scans diagnosed 86 children with APN. Follow-up scans identified new renal scars in 18 children. Six functional single-nucleotide polymorphisms (SNPs) in genes encoding IL-6, IL-8, CXCR1, and TNFα were genotyped in all subjects (IL-6 rs1800795 (-174G/C), IL-6 rs1800796 (-572G/C), IL-8 rs2227306 (781C/T), IL8 rs4073 (-251A/T), CXCR1 rs2234671 (2607G/C), and TNFα rs1800629 (-308G/A)).

RESULTS

TT genotype of IL-8 -251A/T polymorphism was significantly higher in APN patients (26.7%) than those with lower UTI (11.7%, p = 0.01) and control individuals (12.2%, p = 0.002). T allele was significantly more common in APN than in lower UTI (p = 0.025) and was significantly more common in APN (46%) than in the controls (p = 0.001). Similarly, TT genotype of IL-8 781C/T polymorphism was significantly more common in APN patients (31.4%) than those with lower UTI (17.3%, p = 0.003) and the controls (14.3%, p = 0.001). T allele was significantly more common in APN (55%) than lower UTI (40%, p = 0.005) and controls (37%, p = 0.001). However, IL-8 -251A/T and +781C/T SNPs did not qualify as an independent risk for parenchymal infection (OR 1.9, 95% CI 0.68-2.6, p = 0.13 and OR 2.3, 95% CI 0.89-3.7, p = 0.091, respectively). Lower UTI did not differ from the controls. The frequency of the genotypes and alleles of IL-6, CXCR1, and TNFα SNPs did not differ significantly among the different groups of the study.

CONCLUSION

IL-8 -251A/T and +781C/T SNPs are associated with susceptibility to renal parenchymal infection in children and could be implicated in APN risk. However, none of these variants could clearly and independently predict this risk.

Characterization of the urinary microbiota of elderly women and the effects of type 2 diabetes and urinary tract infections on the microbiota

Evidence shows that urine has complex bacterial profiles with considerable variation between individuals. Aging and age-related conditions can lead to the changes to the composition of urine, which means that the available nutrition for bacteria in the bladder changes with age. We explored the characteristics of the urinary microbiota of elderly women and whether these are associated with age-related conditions such as diabetes and urinary tract infections. An elderly and a non-elderly cohort of women were included. Magnetic beads were used to isolate bacterial genomic DNA, which was analyzed based on the V3-V4 hypervariable region of the 16S rRNA gene. There were significant differences between the elderly and non-elderly regarding thirteen genera of bacteria. For example, the relative abundance of Lactobacillus was dramatically reduced in the elderly compared with the non-elderly; it also decreased with age in the elderly cohort and it was not correlated with urine pH. The relative abundance of Peptococcus increased with age in the elderly while the abundance of Bifidobacteria decreased with age. The abundance of Escherichia coli was the same in the two cohorts, and it increased with water intake and was not associated with urinary tract infection events. Higher levels of Lactobacillus (including Lactobacillus iners) in the elderly were associated with diabetes, and lower levels of Peptoniphilus and Dialister were correlated with asymptomatic bacteriuria. The urinary microbiota of women is affected by ageing, type 2 diabetes mellitus and asymtomatic bacteriuria.

The clinical diagnosis and management of urinary tract infections in children and adolescents

Urinary tract infections (UTI) are one of the most common and serious bacterial infections encountered by paediatricians and primary care physicians. Although the diagnosis and management of UTI appear simplistic, they remain among the most contentious issues in paediatrics. In part, UTI controversies stem from the absence of classic clinical symptoms, inappropriate urine specimen collection, modified urinary tract imaging recommendations, and diverse treatment and prevention strategies. Recently published guidelines and large clinical trials have attempted to clarify UTI diagnostic and management strategies. In this manuscript, we review the diagnosis and management of acute and recurrent UTI in the paediatric and adolescent populations.

Urinary Tract Infection in Children: Management in the Era of Antibiotic Resistance-A Pediatric Urologist's View

CONTEXT

Antibiotic resistance to uropathogens has grown significantly worldwide. Today, pediatric urologist experience a situation that needs appropriate action because urinary tract infections are one of the most common bacterial infections in children.

OBJECTIVE

In this overview we aimed at presenting the clinical aspects of antibiotic usage in pediatric urology. Our intention was to take part of the important debate regarding future management of bacterial resistance against antibiotics.

EVIDENCE ACQUISITION

We searched PubMed for the terms: [UTI in children], [Recurrent UTI in children], and [Antibiotic resistance in UTI]. When using these terms, we found a numerous amount (3875) of published clinical articles related to the topic. By means of an overview, we chose not to focus on a specific condition but to an overall understanding of the problems related to pediatric urology in general.

EVIDENCE SYNTHESIS

We found that usage of antibiotics has had an unquestionable benefit to reduce the morbidity and mortality related to urinary tract infections in childhood. However, recent studies suggest that early exposure to antibiotics in childhood might have negative systemic effects related to neurocognitive function, body metabolism, and fat distribution. In addition to increased resistance to common antimicrobial agents, it has resulted in increased costs and inadequate effect in severe infections. This calls for changes in the clinical management of urinary pathogens in pediatric urology.

CONCLUSIONS

As the prevalence of antibiotic resistance grows, pediatric urologists have a key role in managing its consequences and its prevention.

PATIENT SUMMARY

In this overview we looked at the consequences of antibiotic usage treating urinary tract infections in childhood. We found that the prevalence of antibiotic resistance has grown. We concluded that decision-makers must know about the short- and long-term effects of antibiotic usage in children. When we understand the development of antibiotic resistance better, we can build up prevention strategies.

Incidence and risk factors of urinary tract infection in very low birth weight infants

OBJECTIVES

To describe the incidence and associated risk factors of urinary tract infection (UTI) in very low birth weight (VLBW) infants and to determine the value of diagnostic imaging studies after the first UTI episode before discharge from the neonatal intensive care unit (NICU).

METHODS

VLBW infants born during 2003-2012 were reviewed for UTI. In a nested case-control study, potential risk factors of UTI were compared between infants with UTI (cases) versus birth weight and gestational age matched controls. Renal ultrasonography (USG) and voiding cystourethrography (VCUG) results were reviewed in cases.

RESULTS

During the study period, 54.7% of urine culture specimens were collected by sterile methods. 3% (45/1,495) of VLBW infants met the study definition for UTI. UTI was diagnosed at mean postnatal age of 33.1±22.9 days. There was no significant difference in gender, ethnicity, antenatal steroid exposure, blood culture positive sepsis, ionotropic support, respiratory support and enteral feeding practices between cases and controls. Cases had a significantly higher cholestasis compared to controls (22% vs. 9% ; p = 0.03). However, cholestasis was not a significant predictor of UTI in the adjusted analysis [adjusted OR 2.38 (95% CI 0.84 to 6.80), p = 0.11]. Cases had higher central line days, parenteral nutrition days, total mechanical ventilation days, chronic lung disease, and length of stay compared to controls. Renal USG was abnormal in 37% and VCUG was abnormal in 17% of cases.

CONCLUSIONS

The incidence of UTI in contemporary VLBW infants is relatively low compared to previous decades. Since no significant UTI predictors could be identified, urine culture by sterile methods is the only reliable way to exclude UTI. The majority of infants with UTI have normal renal anatomy. UTI in VLBW infants is associated with increased morbidity and length of stay.

Antibacterial resistance patterns of pediatric community-acquired urinary infection: Overview

BACKGROUND

Urinary tract infection (UTI) is common in children. The aim of this study was therefor to construct a guide for the empirical antibiotic treatment of community-acquired UTI by investigating the etiology and antimicrobial resistance patterns of uropathogens and analyzing the epidemiological and clinical patient characteristics.

METHODS

A total of 158 children with positive urine culture were included in the study. Antibiotic susceptibility testing was performed with Vitek 2 Compact for 28 commonly used antimicrobials.

RESULTS

Mean age was 3.36 ± 3.38 years (range, 45 days-15 years). Escherichia coli (60.1%), and Klebsiella spp. (16.5%) were the most common uropathogens. For all Gram-negative isolates, a high level of resistance was found against ampicillin/sulbactam (60.1%), trimethoprim/sulfamethoxazole (44.2%), cefazolin (36.2%), cefuroxime sodium (33.5%), and amoxicillin/clavulanate (31.5%). A low level of resistance was noted against cefepime (8.7%), ertapenem (4.6%), norfloxacin (1.3%), and meropenem (0.7%). There was no resistance against amikacin.

CONCLUSIONS

There is high antibiotic resistance in children with UTI. The patterns of uropathogen antimicrobial resistance vary in susceptibility to antimicrobials depending on region and time. Thus, the trends of antibiotic susceptibility patterns should be analyzed periodically to select the appropriate regimen for UTI treatment.

Early infant male circumcision: Systematic review, risk-benefit analysis, and progress in policy

AIM

To determine whether recent evidence-based United States policies on male circumcision (MC) apply to comparable Anglophone countries, Australia and New Zealand.

METHODS

Articles in 2005 through 2015 were retrieved from PubMed using the keyword "circumcision" together with 36 relevant subtopics. A further PubMed search was performed for articles published in 2016. Searches of the EMBASE and Cochrane databases did not yield additional citable articles. Articles were assessed for quality and those rated 2+ and above according to the Scottish Intercollegiate Grading System were studied further. The most relevant and representative of the topic were included. Bibliographies were examined to retrieve further key references. Randomized controlled trials, recent high quality systematic reviews or meta-analyses (level 1++ or 1+ evidence) were prioritized for inclusion. A risk-benefit analysis of articles rated for quality was performed. For efficiency and reliability, recent randomized controlled trials, meta-analyses, high quality systematic reviews and large well-designed studies were used if available. Internet searches were conducted for other relevant information, including policies and Australian data on claims under Medicare for MC.

RESULTS

Evidence-based policy statements by the American Academy of Pediatrics (AAP) and the Centers for Disease Control and Prevention (CDC) support infant and later age male circumcision (MC) as a desirable public health measure. Our systematic review of relevant literature over the past decade yielded 140 journal articles that met our inclusion criteria. Together, these showed that early infant MC confers immediate and lifelong benefits by protecting against urinary tract infections having potential adverse long-term renal effects, phimosis that causes difficult and painful erections and "ballooning" during urination, inflammatory skin conditions, inferior penile hygiene, candidiasis, various sexually transmissible infections in both sexes, genital ulcers, and penile, prostate and cervical cancer. Our risk-benefit analysis showed that benefits exceeded procedural risks, which are predominantly minor, by up to 200 to 1. We estimated that more than 1 in 2 uncircumcised males will experience an adverse foreskin-related medical condition over their lifetime. Wide-ranging evidence from surveys, physiological measurements, and the anatomical location of penile sensory receptors responsible for sexual sensation strongly and consistently suggested that MC has no detrimental effect on sexual function, sensitivity or pleasure. United States studies showed that early infant MC is cost saving. The evidence supporting early infant MC has further strengthened since the positive AAP and CDC reviews.

CONCLUSION

Affirmative MC policies are needed in Australia and New Zealand. Routine provision of accurate, unbiased education, and access in public hospitals, will maximize health and financial benefits.

High rates of multidrug resistance among uropathogenic Escherichia coli in children and analyses of ESBL producers from Nepal

Background

Emergence of Extended-spectrum beta-lactamase producing Escherichia coli causing urinary tract infections (UTI) among pediatric patients is an increasing problem worldwide. However, very little is known about pediatric urinary tract infections and antimicrobial resistance trend from Nepal. This study was conducted to assess the current antibiotic resistance rate and ESBL production among uropathogenic Escherichia coli in pediatric patients of a tertiary care teaching hospital of Nepal.

Methods

A total of 5,484 urinary tract specimens from children suspected with UTI attending a teaching hospital of Nepal over a period of one year were processed for the isolation of bacterial pathogens and their antimicrobial susceptibility testing. Escherichia coli (n = 739), the predominant isolate in pediatric UTI, was further selected for the detection of ESBL-production by phenotypic combination disk diffusion test.

Results

Incidence of urinary tract infection among pediatric patients was found to be 19.68% and E coli (68.4%) was leading pathogen involved. Out of 739 E coli isolates, 64.9% were multidrug resistant (MDR) and 5% were extensively drug resistant (XDR). Extended spectrum beta lactamase (ESBL) was detected in 288 (38.9%) of the E coli isolates.

Conclusion

Alarming rate of drug resistance among pediatric uropathogens and high rate of ESBL-producing E. coli was observed. It is extremely necessary to routinely investigate the drug resistance among all isolates and formulate strict antibiotics prescription policy in our country.

The Need for Improved Detection of Urinary Tract Infections in Young Children

BACKGROUND AND OBJECTIVES

An estimated 400,000 urinary tract infections (UTIs) are diagnosed annually in children aged <3 years in the United States; yet >50% of febrile UTIs may be missed in this population. Here, we explored possible barriers to diagnosing febrile UTIs in very young children through social research of community pediatricians.

METHODS

Following qualitative interviews, a quantitative survey was developed that included a high-risk case for febrile UTI, presented before prompting for the topic of the survey, to gauge practice of delayed testing. Factors associated with delay were explored using univariate logistic regression. The final survey link was sent to three populations via email, with the largest response from a survey sent to pediatricians in Pennsylvania, which formed the basis of our primary results.

RESULTS

Of the 218 evaluable responses, 59.6% of physicians would initially test urine in the high-risk case patient, while 21.6% would choose to continue fever reducer and follow-up in 2 days. In the knowledge-based questions, 67.5, 34.0, and 35.6% of respondents identified the correct prevalences in total population, Caucasian girls, and uncircumcised boys, respectively. Many pediatricians (59.5%) believed that delays in detection are common in clinical practice. Physicians who chose to delay testing were more likely to be female, in practice for <25 years, to underestimate prevalence of febrile UTIs and have greater number of children seen per week (all P ≤ 0.02).

CONCLUSION

Our findings support the need for improved communication and education about prevalence in higher risk populations, outcomes associated with delayed diagnosis, and optimal skills for collection of urine in young patients.

Non-therapeutic infant male circumcision. Evidence, ethics, and international law perspectives

OBJECTIVES

To review the evidence of the benefits and harms of infant male circumcision, and the legal and ethical perspectives of infant male circumcision.

METHODS

We conducted a systematic search of the literature using PubMed, EMBASE, and the Cochrane library up to June 2015. We searched the medical law literature using the Westlaw and Lexis Library law literature resources up to June 2015.

RESULTS

Male circumcision significantly reduced the risk of urinary tract infections by 87%. It also significantly reduced transmission of human immunodeficiency virus among circumcised men by 70%. Childhood and adolescent circumcision is associated with a 66% reduction in the risk of penile cancer. Circumcision was associated with 43% reduction of human papilloma virus infection, and 58% reduction in the risk of cervical cancer among women with circumcised partners compared with women with uncircumcised partners. Male infant circumcision reduced the risk of foreskin inflammation by 68%. 

CONCLUSION

Infant male circumcision should continue to be allowed all over the world, as long as it is approved by both parents, and performed in facilities that can provide appropriate sterilization, wound care, and anesthesia. Under these conditions, the benefits of infant male circumcision outweigh the rare and generally minor potential harms of the procedure.

Molecular epidemiology of carbapenem resistant gram-negative bacilli from infected pediatric population in tertiary - care hospitals in Medellín, Colombia: an increasing problem

BACKGROUND

Gram-negative bacilli are a cause of serious infections in the pediatric population. Carbapenem are the treatment of choice for infections caused by multidrug-resistant Gram-negative bacilli, but the emergence of carbapenem resistance has substantially reduced access to effective antimicrobial regimens. Children are a population vulnerable to bacterial infections and the emergence of resistance can worsen prognosis. The aim of this study is to describe the clinical and molecular characteristics of infections caused by carbapenem-resistant Gram-negative bacilli in pediatric patients from five tertiary-care hospitals in Medellín, Colombia.

METHODS

A cross-sectional study was conducted in five tertiary-care hospitals from June 2012 to June 2014. All pediatric patients infected by carbapenem-resistant Gram-negative bacilli were included. Clinical information for each patient was obtained from medical records. Molecular analyses included PCR for detection of bla VIM, bla IMP bla NDM, bla OXA-48 and bla KPC genes and PFGE and MLST for molecular typing.

RESULTS

A total of 59 patients were enrolled, most of them less than 1 year old (40.7 % n = 24), with a previous history of antibiotic use (94.9 %; n = 56) and healthcare-associated infections - predominately urinary tract infections (31.0 %; n = 18). Klebsiella pneumoniae was the most frequent bacteria (47.4 %), followed by Enterobacter cloacae (40.7 %) and Pseudomonas aeruginosa (11.9 %). For K. pneumoniae, KPC was the predominant resistance mechanism (85.7 %; n = 24) and ST14 was the most common clone (39.3 % n = 11), which included strains closely related by PFGE. In contrast, E. cloacae and P. aeruginosa were prevailing non-carbapenemase-producing isolates (only KPC and VIM were detected in 1 and 3 isolates, respectively) and high genetic diversity according to PFGE and MLST was found in the majority of the cases.

CONCLUSIONS

In recent years, increasing carbapenem-resistant bacilli in children has become in a matter of great concern. It is important to conduct systemic surveillance and take measures to prevent dissemination of multidrug-resistant bacteria.

Resistance to oral antibiotics in 4569 Gram-negative rods isolated from urinary tract infection in children

To investigate antibiotic resistance among pathogens isolated from urines in a tertiary care children's hospital in Italy. Retrospective analysis of prospectively collected data on antibiotic susceptibility of Gram-negatives isolated from urines at the Istituto Giannina Gaslini, Genoa - Italy from 2007 to 2014. Antibiotic susceptibility was evaluated. By means of CLSI criteria from 2007 to 2010, while from 2011 EUCAST criteria were adopted. Data on susceptibility to amoxicillin-clavulanate, co-trimoxazole, cefuroxime, nitrofurantoin, fosfomycin and ciprofloxacin were evaluated for Escherichia coli, while for other Enterobacteriaceae data were collected for amoxicillin-clavulanate, co-trimoxazole and ciprofloxacin and for ciprofloxacin against Pseudomonas aeruginosa. Univariate and multivariable analyses were performed for risk factors associated with resistance. A total of 4596 Gram-negative strains were observed in 3364 patients. A significant increase in the proportion of resistant strains was observed for E.coli against amoxicillin-clavulanate, cefuroxime and ciprofloxacin and for others Enterobacteriaceae against co-trimoxazole and ciprofloxacin. Resistance to nitrofurantoin and fosfomycin was very infrequent in E.coli. Logistic regression analysis showed that repeated episode of urinary tract infections was a risk factor for E.coli resistance to amoxicillin-clavulanate, co-trimoxazole and cefuroxime, while admission in one of the Units usually managing children with urinary tract malformations was significantly associated to resistance to amoxicillin-clavulanate and cefuroxime.

CONCLUSION

In conclusion the present study shows an increase in antibiotic resistance in pediatric bacteria isolated from urines in children, especially in presence of repeated episodes and/or urinary tract malformations. This resistance is worrisome for beta-lactams and cotrimoxazole, and start to increase also for fluoroquinolones while nitrofurantoin and fosfomycin still could represent useful drugs for oral treatment of these infections.

WHAT IS KNOWN

• Infections are frequent in patients with urinary tract malformations • Antibiotic prophylaxis can select for resistant pathogens What is New: • The increase in the resistance to β-lactams, co-trimoxazole or fluoroquinolones in pathogens causing urinary tract infections cause a reduction of drugs with oral formulations available for therapy • Old drugs like nitrofurantoin and fosfomycin can represent attractive compounds for oral treatment of urinary tract infections in children presence of resistance to other drug classes.

Critical evaluation of unscientific arguments disparaging affirmative infant male circumcision policy

We evaluate recent claims opposing infant male circumcision, a procedure now supported by the evidence-based policy of the American Academy of Pediatrics. We find those criticisms depend on speculative claims about the foreskin and obfuscation of the strong scientific evidence supporting pediatric policy development. An argument that circumcision should be delayed to allow a boy to make up his own mind as an adult fails to appreciate the psychological, scheduling and financial burdens later circumcision entails, so reducing the likelihood that it will occur. In contrast, early infant circumcision is convenient, safer, quicker, lower risk, healing is faster, cosmetic outcome is routinely good and the lifetime benefits accrue immediately. Benefits include reduction in urinary tract infections, inflammatory skin conditions, foreskin problems, and, when older, substantial protection against sexually transmitted infections and genital cancers in the male and his female sexual partners. Some authorities regard the failure to offer parents early infant circumcision as unethical, just as it would be unethical to fail to encourage the vaccination of children. In conclusion, the criticisms of evidence-based infant male circumcision policy are seriously flawed and should be dismissed as unhelpful to evidence-based development and implementation of pediatric policy intended to improve public health and individual wellbeing.

Value of Ultrasound in Detecting Urinary Tract Anomalies After First Febrile Urinary Tract Infection in Children

Background Urinary tract infection (UTI) is an infection that affects part of the urinary tract. Ultrasound is a noninvasive test that can demonstrate the size and shape of kidneys, presence of dilatation of the ureters, and the existence of anatomic abnormalities. The aim of the study is to estimate the value of ultrasound in detecting urinary tract anomalies after first attack of UTI. Methods This study was conducted at the Nephrology Clinic, New Children's Hospital, Faculty of Medicine, Cairo University, from August 2012 to March 2013, and included 30 children who presented with first attack of acute febrile UTI. All patients were subjected to urine analysis, urine culture and sensitivity, serum creatinine, complete blood count, and imaging in the form of renal ultrasound, voiding cysto-urethrography, and renal scan. Results All the patients had fever with a mean of 38.96°C ± 0.44°C and the mean duration of illness was 6.23 ± 5.64 days. Nineteen patients (63.3%) had an ultrasound abnormality. The commonest abnormalities were kidney stones (15.8%). Only 2 patients who had abnormal ultrasound had also vesicoureteric reflux on cystourethrography. Sensitivity of ultrasound was 66.7%, specificity was 37.5%, positive predictive value was 21.1%, negative predictive value was 81.8%, and total accuracy was 43.33%. Conclusion We concluded that ultrasound alone was not of much value in diagnosing and putting a plan of first attack of febrile UTI. It is recommended that combined investigations are the best way to confirm diagnosis of urinary tract anomalies.

A High-resolution Typing Assay for Uropathogenic Escherichia coli Based on Fimbrial Diversity

Urinary tract infections (UTIs) are one of the most common bacterial infections in humans, causing cystitis, pyelonephritis, and renal failure. Uropathogenic Escherichia coli (UPEC) is the leading cause of UTIs. Accurate and rapid discrimination of UPEC lineages is useful for epidemiological surveillance. Fimbriae are necessary for the adherence of UPEC strains to host uroepithelia, and seem to be abundant and diverse in UPEC strains. By analyzing all the possible fimbrial operons in UPEC strains, we found that closely related strains had similar types of chaperone-usher fimbriae, and the diversity of fimbrial genes was higher than that of multilocus sequence typing (MLST) genes. A typing assay based on the polymorphism of four gene sequences (three fimbrial genes and one housekeeping gene) and the diversity of fimbriae present was developed. By comparison with the MLST, whole-genome sequence (WGS) and fumC/fimH typing methods, this was shown to be accurate and have high resolution, and it was also relatively inexpensive and easy to perform. The assay can supply more discriminatory information for UPEC lineages, and have the potential to be applied in epidemiological surveillance of UPEC isolates.

Serotyping and Antimicrobial Susceptibility Pattern of Escherichia coli Isolates from Urinary Tract Infections in Pediatric Population in a Tertiary Care Hospital

Urinary tract infections (UTIs) in pediatric population are associated with high morbidity and long term complications. In recent years, there is increased prevalence of Escherichia coli (E. coli) strains producing extended spectrum β-lactamase, Amp C, and Metallo β-lactamase, making the clinical management even more difficult. This study was aimed to detect the serotypes and to determine antimicrobial susceptibility profile of E. coli isolates from urine samples of children <10 yrs old. A total of 75 pure E. coli strains isolated from patients with symptoms of UTI and colony count ≥10⁵ organisms/mL were included in the study. Antibiotic sensitivity pattern showed maximum resistance to nalidixic acid (98.7%), followed by ampicillin (97.3%), amoxi-clavulanate (96%), and fluoroquinolones (92%) while most of the isolates were found sensitive to piperacillin-tazobactam (13.3%), nitrofurantoin (5.3%), and meropenem (1.3%). 48% of the strains were ESBL producer (extended spectrum beta lactamase). 44% strains were typable withantisera used in our study and the most common serogroup was O6 (33.3%) followed by O1 (15.1%) and O15 (15.1%). To conclude, judicious use of antibiotics according to hospital antibiotic policy and infection control measures should be implemented to prevent spread of multidrug resistant organisms.

Profile of Virulence Factors in the Multi-Drug Resistant Pseudomonas aeruginosa Strains of Human Urinary Tract Infections (UTI)

Background:

Putative virulence factors are responsible for the pathogenicity of UTIs caused by Pseudomonas aeruginosa (P. aeruginosa). Resistance of P. aeruginosa to commonly used antibiotics is caused by the extreme overprescription of those antibiotics.

Objectives:

The goal of the present study was to investigate the prevalence of virulence factors and the antibiotic resistance patterns of P. aeruginosa isolates in UTI cases in Iran.

Patients and Methods:

Two hundred and fifty urine samples were collected from patients who suffered from UTIs. Samples were cultured immediately, and those that were P. aeruginosa-positive were analyzed for the presence of virulence genes using polymerase chain reaction (PCR) testing. Antimicrobial susceptibility testing (AST) was performed using the disk diffusion method.

Results:

Of the 250 urine samples analyzed, 8 samples (3.2%) were positive for P. aeruginosa. The prevalence of P. aeruginosa in male and female patients was 2.7% and 3.5%, respectively, (P = 0.035). In patients less than 10 years old, it was 4.2%, and in patients more than 55 years old, it was 4.2%. These were the most commonly infected groups. The highest levels of resistance were seen against ampicillin (87.5%), norfloxacin (62.5%), gentamycin (62.5%), amikacin (62.5%), and aztreonam (62.5%), while the lowest were seen for meropenem (0%), imipenem (12.5%), and polymyxin B (12.5%). LasB (87.5%), pclH (75%), pilB (75%), and exoS (75%) were the most commonly detected virulence factors in the P. aeruginosa isolates.

Conclusions:

It is logical to first prescribe meropenem, imipenem, and polymyxin B in cases of UTIs caused by P. aeruginosa. Medical practitioners should be aware of the presence of levels of antibiotic resistance in hospitalized UTI patients in Iran.

Update on the approach of urinary tract infection in childhood

OBJECTIVE

Urinary tract infection (UTI) is the most common bacterial infection in childhood. UTI may be the sentinel event for underlying renal abnormality. There are still many controversies regarding proper management of UTI. In this review article, the authors discuss recent recommendations for the diagnosis, treatment, prophylaxis, and imaging of UTI in childhood based on evidence, and when this is lacking, based on expert consensus.

SOURCES

Data were obtained after a review of the literature and a search of Pubmed, Embase, Scopus, and Scielo.

SUMMARY OF THE FINDINGS

In the first year of life, UTIs are more common in boys (3.7%) than in girls (2%). Signs and symptoms of UTI are very nonspecific, especially in neonates and during childhood; in many cases, fever is the only symptom.

CONCLUSIONS

Clinical history and physical examination may suggest UTI, but confirmation should be made by urine culture, which must be performed before any antimicrobial agent is given. During childhood, the proper collection of urine is essential to avoid false-positive results. Prompt diagnosis and initiation of treatment is important to prevent long-term renal scarring. Febrile infants with UTIs should undergo renal and bladder ultrasonography. Intravenous antibacterial agents are recommended for neonates and young infants. The authors also advise exclusion of obstructive uropathies as soon as possible and later vesicoureteral reflux, if indicated. Prophylaxis should be considered for cases of high susceptibility to UTI and high risk of renal damage.

Etiology and Antimicrobial Susceptibility Pattern of Pathogenic Bacteria in Children Subjected to UTI: A Referral Hospital-Based Study in Northwest of Iran

Urinary tract infection (UTI) is 1 of the most common bacterial diseases in children with a considerable resistance to antimicrobials. This 5 years prospective study was carried out to determine the frequency of isolation and antimicrobial resistance patterns of uropathogens among children subjected to urine culture at Tabriz Children Educational-Health Care Center, in the northwest of Iran. Organisms were isolated using standard culture techniques. Frequency of UTI among children examined by urine culture was 3.6%. The isolated bacteria were Escherichia coli (71.4%), followed by Klebsiella spp. (9.6%), Enterococcus spp. (6.4%), Pseudomonas aeruginosa (4.2%), Serratia spp. (4.2%), and Enterobacter spp. (4.2%). E coli resistance levels were 11% for nitrofurantoin, 15% for ciprofloxacin, 25% for nalidixic acid, and 30% to 75% for amikacin, gentamicin, ceftriaxone, ceftizoxime, cefotaxime, and co-trimoxazole. Among the tested antibiotics, ciprofloxacin, showed the highest activity (100%) against Klebsiella and P aeruginosa isolates followed by amikacin, nalidixic acid, and gentamicin. Overall, the highly active antibiotic against Gram-negative and Gram-positive organisms was amikacin and then ciprofloxacin. On the other hand, the empirical initial therapy with co-trimoxazole and third-generation cephalosporins would be inadequate for more cases of UTI in the study area. Moreover, susceptibility testing should be carried out on all clinical isolates, and the empirical antibiotic treatment changed accordingly.

The role of tissue harmonic imaging ultrasound combined with power Doppler ultrasound in the diagnosis of childhood febrile urinary tract infections

AIM

This study assessed the ability of tissue harmonic imaging ultrasound combined with power Doppler ultrasound in the detection of childhood febrile urinary tract infections in comparison with the gold standard reference method: Tc-99m dimercaptosuccinicacid renal cortical scintigraphy.

MATERIAL AND METHODS

This prospective study included 60 patients who were hospitalized with a first episode of febrile urinary tract infections. All children were examined with dimercaptosuccinicacid scan and tissue harmonic imaging ultrasound combined with power Doppler ultrasound within the first 3 days of admission.

RESULTS

Signs indicative of acute infection were observed in 29 patients according to the results of tissue harmonic imaging ultrasound combined with power Doppler ultrasound while dimercaptosuccinicacid scan revealed abnormal findings in 33 patients. The sensitivity, specificity, positive predictive value and negative predictive value of tissue harmonic imaging combined with power Doppler ultrasound using dimercaptosuccinicacid scintigraphy as the reference method in patients diagnosed with first episode febrile urinary tract infections were calculated as 57.58% (95% confidence interval: 40.81%-72.76%); 62.96% (95% confidence interval: 44.23%-78.47%); 65.52% (95% confidence interval: 52.04%-77%); 54.84% (95% confidence interval: 41.54%-67.52%); respectively.

CONCLUSIONS

Although current results exhibit inadequate success of power Doppler ultrasound, this practical and radiation-free method may soon be comprise a part of the routine ultrasonographic evaluation of febrile urinary tract infections of childhood if patients are evaluated early and under appropriate sedation.

Profile of urinary tract infections in paediatric patients

Background & objectives:

This cross-sectional study was conducted at a tertiary care centre in Puducherry, south India, with the aim of finding the profile of the paediatric urinary tract infection (UTI), bacterial pathogens involved, and also to observe vesicoureteric reflux (VUR) and renal scarring in these patients.

Methods:

A total of 524 paediatric patients ≤13 yr, suspected to have UTI, were included in the study. Urine samples were collected, processed for uropathogen isolation and antibiotic susceptibility test was performed as per the Clinical and Laboratory Standards Institute (CLSI) guidelines. Thirty two culture proven children with UTI underwent micturating cysto-urethrography (MCU) and dimercaptosuccinic acid (DMSA) scanning was done for 69 children.

Results:

of the 524 children, 186 (35.4%) had culture proven UTI with 105 (56.4%) being infants, 50 (27.4%) between 1-5 yr, 30 (16.12%) between 5-13 yr and 129 (69.35%) males. Posterior urethral valve (PUV) was noted in three, hydronephrosis in one, VUR in 18 and renal scarring in 33. VUR as well as renal scarring were more in males >1 yr of age. A significant association (P=0.0054) was noted with a combined sensitivity and specificity of these investigations being 83 and 90 per cent, respectively of the MCU and DMSA scans for detecting VUR. Escherichia coli was the most common pathogen isolated, sensitive to nitrofurantoin, followed by cefoperazone-sulbactam, aminoglycosides and meropenem.

Interpretation & conclusions:

Our results indicate that UTI varies with age and gender and extensive evaluation is required in boys under one year of age with UTI. This study also highlights the better efficacy of aminoglycosides, cefoperazone-sulbactam and nitrofurantoin in vitro compared with meropenem in Gram–negative uropathogens.

Recurrent urinary tract infections in children: Preventive interventions other than prophylactic antibiotics

Urinary tract infection (UTI) is one of the most common childhood infections. Permanent renal cortical scarring may occur in affected children, especially with recurrent UTIs, leading to long-term complications such as hypertension and chronic renal failure. To prevent such damage, several interventions to prevent UTI recurrences have been tried. The most established and accepted prevention at present is low dose long-term antibiotic prophylaxis. However it has a risk of break through infections, adverse drug reactions and also the risk of developing antibiotic resistance. The search is therefore on-going to find a safer, effective and acceptable alternative. A recent meta-analysis did not support routine circumcision for normal boys with no risk factors. Vaccinium Macrocarpon (cranberry), commonly used against UTI in adult women, is also effective in reducing the number of recurrences and related antimicrobial use in children. Sodium pentosanpolysulfate, which prevents bacterial adherence to the uroepithelial cells in animal models, has shown conflicting results in human trials. When combined with antibiotic, Lactobacillus acidophilus (LA-5) and Bifidobacterium, by blocking the in vitro attachment of uropathogenic bacteria to uroepithelial cells, significantly reduce in the incidence of febrile UTIs. Deliberate colonization of the human urinary tract of patients with recurrent UTI with Escherichia-coli (E. coli) 83972 has resulted in subjective benefit and less UTI requiring treatment. The non-pathogenic E. coli isolate NU14 DeltawaaL is a candidate to develop live-attenuated vaccine for the treatment and prevention of acute and recurrent UTI. Diagnosing and treating dysfunctional elimination syndromes decrease the incidence of recurrent UTI. A meta-analysis found the lack of robust prospective randomized controlled trials limited the strength of the established guidelines for surgical management of vesicoureteral reflux. In conclusion, several interventions, other than antibiotic prophylaxis, for the prevention of recurrent UTI have been tried and, although showing some promise, they do not provide so far a definitive effective answer. Finding suitable alternatives still requires further high quality research of those seemingly promising interventions.

Evaluation and management of recurrent urinary tract infections in children: state of the art

Urinary tract infections (UTIs) represent an important cause of febrile illness in young children and can lead to renal scarring and kidney failure. However, diagnosis and treatment of recurrent UTI in children is an area of some controversy. Guidelines from the American Academy of Pediatrics, National Institute for Health and Clinical Excellence and European Society of Paediatric Radiology differ from each other in terms of the diagnostic algorithm to be followed. Treatment of vesicoureteral reflux and antibiotic prophylaxis for prevention of recurrent UTI are also areas of considerable debate. In this review, we collate and appraise recently published literature in order to formulate evidence-based guidance for the diagnosis and treatment of recurrent UTI in children.

Urinary tract infections in children: EAU/ESPU guidelines

CONTEXT

In 30% of children with urinary tract anomalies, urinary tract infection (UTI) can be the first sign. Failure to identify patients at risk can result in damage to the upper urinary tract.

OBJECTIVE

To provide recommendations for the diagnosis, treatment, and imaging of children presenting with UTI.

EVIDENCE ACQUISITION

The recommendations were developed after a review of the literature and a search of PubMed and Embase. A consensus decision was adopted when evidence was low.

EVIDENCE SYNTHESIS

UTIs are classified according to site, episode, symptoms, and complicating factors. For acute treatment, site and severity are the most important. Urine sampling by suprapubic aspiration or catheterisation has a low contamination rate and confirms UTI. Using a plastic bag to collect urine, a UTI can only be excluded if the dipstick is negative for both leukocyte esterase and nitrite or microscopic analysis is negative for both pyuria and bacteriuria. A clean voided midstream urine sample after cleaning the external genitalia has good diagnostic accuracy in toilet-trained children. In children with febrile UTI, antibiotic treatment should be initiated as soon as possible to eradicate infection, prevent bacteraemia, improve outcome, and reduce the likelihood of renal involvement. Ultrasound of the urinary tract is advised to exclude obstructive uropathy. Depending on sex, age, and clinical presentation, vesicoureteral reflux should be excluded. Antibacterial prophylaxis is beneficial. In toilet-trained children, bladder and bowel dysfunction needs to be excluded.

CONCLUSIONS

The level of evidence is high for the diagnosis of UTI and treatment in children but not for imaging to identify patients at risk for upper urinary tract damage.

PATIENT SUMMARY

In these guidelines, we looked at the diagnosis, treatment, and imaging of children with urinary tract infection. There are strong recommendations on diagnosis and treatment; we also advise exclusion of obstructive uropathy within 24h and later vesicoureteral reflux, if indicated.

Association between UTI and urinary tract abnormalities: a case-control study in Erbil City/Iraq

OBJECTIVE

To determine the proportion of ultrasound abnormalities of the urinary system between two groups of children: affected with urinary tract infection (UTI) and unaffected (control). Further, to determine the most common microorganisms causing UTI in those children with urinary tract abnormalities.

METHODS

A case-control study was carried out in Erbil, Iraq between September and December 2012. Ultrasound examinations were carried out on 64 children affected with UTI and on 64 unaffected with UTI (control) in order to detect differences, in the presence of abnormalities, in the urinary tract between the two groups.

RESULTS

A majority (59.4%) of children affected with UTI had ultrasound abnormalities, compared with 26.6% of the control group (P<0.001). Escherichia coli was the most common microorganism in both groups, although the difference was not statistically significant. More than one half (75%) of patients with UTI were female, compared with 25% who were male (P<0.001).

CONCLUSION

More than one half of the children in the present study who presented with UTI were found to have ultrasound abnormalities. E. coli was the most common causative pathogen for children with or without ultrasound abnormalities.

Urinary tract infection: aetiology and antimicrobial resistance pattern in infants from a tertiary care hospital in northern India

INTRODUCTION

Urinary tract infection (UTI) is one of the most common bacterial infections in childhood. Present study was undertaken to determine the occurrence of the uropathogens and their antimicrobial susceptibility pattern in infants (< 1yr) suspected with UTI.

MATERIALS AND METHODS

This study was conducted in the Microbiology Department on urine samples received from infants for a period of two years from September 2011 to August 2013.

RESULTS

Culture positivity rate was found to be 15.7%. There was an overall male preponderance in cases of UTI (70.1%). Most common bacterial isolate was E.coli (45.4%) followed by Klebsiella (16.7%) and Enterococcus spp (13.2%). Isolation of candida was 21.1%, maximum from ICU (63.1%). Maximum gram negative isolates (50%) showed high resistance to gentamicin, amikacin, cefotaxime and norfloxacin while most of the isolates (5%) were found susceptible to nitrofurantoin and piperacillin-tazobactam. 45.1% of gram negative bacilli were ESBL producer. We recommend continuous monitoring of changes in bacterial pathogens causing UTI and antibiotic sensitivity in each area for effective treatment of UTI.

CONCLUSION

Since antimicrobial resistance is a major problem, such study will help in formulating a strict antibiotics prescription policy in our country.

Clinical and laboratory indices of severe renal lesions in children with febrile urinary tract infection

AIM

To evaluate the predictive value of various clinical and laboratory parameters on the identification of acute extensive and/or multifocal renal involvement in children with febrile urinary tract infections (UTI).

METHODS

The medical records of 148 children (median age: 2.4 months, range: 11 days-24 months), who were admitted during a 3-year period with a first episode of febrile UTI, were analysed. Acute dimercaptosuccinic acid scintigraphy (DMSA), clinical and laboratory parameters were evaluated.

RESULTS

Seventy six children (51%) had abnormal findings on the acute DMSA. Of them, 20 had DMSA grade 2, while 56 had grade 3 and 4. Patients with a DMSA grade 3 and 4 were more likely to have shivering (OR 3.4), white blood count (WBC) ≥ 18 000/μL (OR 2.4), absolute neutrophil count (ANC) ≥ 9300/μL (OR 4.4), C-reactive protein (CRP) ≥ 50 mg/L (OR 2.7) and procalcitonin (PCT) ≥ 1.64 ng/mL (OR diagnostic). There was a significant difference of WBC (p = 0.004), ANC, CRP and PCT levels (p < 0.001) between children with normal and grade 2 aDMSA versus those with aDMSA grade 3 and 4.

CONCLUSIONS

Shivering and elevated inflammatory markers increase the risk of acute extensive and/or multifocal kidney involvement in children with febrile UTI. Procalcitonin seems to be an excellent marker of the severity of acute parenchymal involvement.

Outpatient management of young febrile infants with urinary tract infections

OBJECTIVE

Controversy exists regarding the disposition of young febrile infants who present to emergency departments (EDs) with urinary tract infections (UTIs). In a large multicenter cohort of such patients, we aimed to determine the variation in patient disposition and clinical factors independently associated with outpatient management.

METHODS

Secondary analysis of a retrospective study of infants 29 to 60 days with fever (≥38.0°C), urinalysis finding, and culture-proven UTIs presenting to 20 North American EDs belonging to the Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics. We determined independent factors associated with outpatient management.

RESULTS

Of 1764 infants with UTIs, 132 (7.5%) were discharged home from the ED. The proportion of infants managed as outpatients varied among sites (0%-20.0%). Of the 132 infants, 29 (22.0%) were subsequently hospitalized after culture results were known, including 5 patients with bacteremia. None of the 107 patients initially discharged from the ED for whom outcomes were known had adverse events (0%; 95% CI, 0%-2.7%). On multivariable regression and generalized estimated equations analyses, only clinical site, presence of upper respiratory tract infection symptoms, absence of vomiting, and having fewer than 10 white blood cells per microliter on cerebrospinal fluid examination were independently associated with discharge from the ED. Clinical site was the factor most highly associated with outpatient management (odds ratio, 8.8; 95% confidence interval, 5.2-15.0).

CONCLUSIONS

There is substantial practice variation regarding the disposition of febrile infants 29 to 60 days of age with UTIs. Institutional practice is the strongest predictor of outpatient management. Further evidence is needed to guide the management of non-toxic-appearing young febrile infants with UTIs.

Quantitative metabolomics of urine for rapid etiological diagnosis of urinary tract infection: evaluation of a microbial-mammalian co-metabolite as a diagnostic biomarker

BACKGROUND

We have previously reported a NMR-based urinalysis for the screening of urinary tract infection (UTI) with high accuracy and reproducibility. Urinary acetic acid per creatinine was found to be a diagnostic marker of bacterial UTI with an area-under-receiver operating characteristic (ROC) curve of 0.97. In addition, we identified trimethylamine (TMA) as a human-microbial marker of Escherichia coli (EC)-associated UTI. Here, we evaluate the clinical application of NMR-based urinalysis in aiding the etiological diagnosis of bacterial UTI.

METHODS

Proton NMR spectroscopy was acquired using a Bruker 600MHz spectroscopy for 88 urine samples from patients with bacterial UTI, confirmed by urine culture. The spectra were analyzed using orthogonal partial least squares-discriminant analysis (OPLS-DA). ROC curve analysis was performed after the quantitation of the urine metabolites.

RESULTS

The TMA/creatinine (mmol/mmol) level was determined to be a specific marker for EC-associated UTI. It has an area-under-ROC=0.85 (95% confidence interval: 0.75-0.91). For the etiological diagnosis, the cutoff for 97.0% specificity was at 0.0117mmol/mmol creatinine for EC-associated UTI with a sensitivity of 66.7%. The mean of TMA/creatinine of EC is 21-fold that of non-EC.

CONCLUSIONS

The co-metabolism of TMA by EC and human cells makes TMA an ideal urine biomarker for UTI. The presence of TMA in a freshly collected sample eliminates the possibility of contamination of urine by bacteria during the collection process resulting in a positive bacterial culture result. We envisage the NMR-based urinalysis of urinary TMA that can be a useful method for the etiological diagnosis of EC-associated UTI.

Veracity and rhetoric in paediatric medicine: a critique of Svoboda and Van Howe's response to the AAP policy on infant male circumcision

In a recent issue of the Journal of Medical Ethics,Svoboda and Van Howe commented on the 2012 changein the American Academy of Pediatrics (AAP) policy on newborn male circumcision, in which the AAP stated that benefits of the procedure outweigh the risks. Svoboda and Van Howe disagree with the AAP conclusions. We show here that their arguments against male circumcision are based on a poor understanding of epidemiology,erroneous interpretation of the evidence, selective citation of the literature, statistical manipulation of data, and circular reasoning. In reality, the scientific evidence indicates that male circumcision, especially when performed in the newborn period, is an ethically and medically sound low-risk preventive health procedure conferring a lifetime of benefits to health and well-being.Policies in support of parent-approved elective newborn circumcision should be embraced by the medical,scientific and wider communities.

Circumcision rates in the United States: rising or falling? What effect might the new affirmative pediatric policy statement have?

The objective of this review was to assess the trend in the US male circumcision rate and the impact that the affirmative 2012 American Academy of Pediatrics policy statement might have on neonatal circumcision practice. We searched PubMed for the term circumcision to retrieve relevant articles. This review was prompted by a recent report by the Centers for Disease Control and Prevention that found a slight increase, from 79% to 81%, in the prevalence of circumcision in males aged 14 to 59 years during the past decade. There were racial and ethnic disparities, with prevalence rising to 91% in white, 76% in black, and 44% in Hispanic males. Because data on neonatal circumcision are equivocal, we undertook a critical analysis of hospital discharge data. After correction for underreporting, we found that the percentage had declined from 83% in the 1960s to 77% by 2010. A risk-benefit analysis of conditions that neonatal circumcision protects against revealed that benefits exceed risks by at least 100 to 1 and that over their lifetime, half of uncircumcised males will require treatment for a medical condition associated with retention of the foreskin. Other analyses show that neonatal male circumcision is cost-effective for disease prevention. The benefits of circumcision begin in the neonatal period by protection against infections that can damage the pediatric kidney. Given the substantial risk of adverse conditions and disease, some argue that failure to circumcise a baby boy may be unethical because it diminishes his right to good health. There is no long-term adverse effect of neonatal circumcision on sexual function or pleasure. The affirmative 2012 American Academy of Pediatrics policy supports parental education about, access to, and insurance and Medicaid coverage for elective infant circumcision. As with vaccination, circumcision of newborn boys should be part of public health policies. Campaigns should prioritize population subgroups with lower circumcision prevalence and a higher burden of diseases that can be ameliorated by circumcision.

Study of Aetiology and Anti-biogram of Uropathogens in Children-A Retrospective Analysis

OBJECTIVES

Urinary Tract Infections (UTIs) are the most common serious bacterial infections which are seen during infancy. The aim of the present study was to evaluate aetiology, and antimicrobial resistance patterns among infants and children who approached our hospital for treatment of UTIs.

METHODS

In this observational study which was carried out from 2007 to 2010, 1575 urine samples which were collected from children with suspected UTIs were studied. Demographic characteristics, aetiological agents and antimicrobial resistance were evaluated.

RESULTS

UTIs were more common in the 0-1 year age group, among males. Among females, UTIs were commonly seen after 2 years of life. The most common isolated pathogen was Escherichia coli spp (45.12%), followed by Klebsiella spp (18.17%) and Enterococcus spp (9.23%). Isolated pathogens were highly resistant to ampicillin, co-trimoxazole, and norfloxacin (82%-98%) and highly sensitive to gentamicin (83%),amikacin (76.5%), and nitrofurantoin (71.5%).

CONCLUSION

The most common pathogen which caused UTIs in children was E. coli spp. The isolated pathogens were highly resistant to commonly used antibiotics, ampicillin and co-trimoxazole, while they were highly sensitive to gentamicin, amikacin and nitrofurantoin. So, these antibiotics may be used as alternative drug therapies for the treatment of UTIs.