A study of the 20-year evolution of antimicrobial resistance patterns of pediatric urinary tract infections in a single center

Etiology and Oral Antibiotic Susceptibility Patterns of the First Urinary Tract Infection Episode in Infants Under 6 Months of Age: A 17-Year, Retrospective, Single-Center Study in Italy

BACKGROUND

Urinary tract infections (UTIs) are among the most common bacterial infections in children, and the antibiotic susceptibility in the youngest patients remains poorly understood. This study aimed to describe the distribution of uropathogens and their antibiotic susceptibility, focusing on oral formulations.

METHODS

Data from the first microbiological isolation, between January 2007 and December 2023, at Istituto Gaslini, in young infants (aged <6 months), were analyzed.

RESULTS

We isolated 2473 infants' first pathogen, with a median age in the sample of 2.8 months and 62.6% male. A total of 2498 bacterial isolates were identified, of which 88.8% were Gram-negative and 11.2% were Gram-positive. Escherichia coli (53%) was the most frequent isolate, followed by Klebsiella pneumoniae (12.3%) and Enterococcus spp. (9.6%). No significant differences were observed between males and females, but infants younger than 3 months exhibited a significantly different pathogen distribution compared to older infants. The pathogen distribution showed significant changes before and after 2015, with a marked increase in Klebsiella pneumoniae isolates post-2015. Escherichia coli showed increases in resistance to amoxicillin-clavulanate and ciprofloxacin after 2015.

CONCLUSIONS

Escherichia coli remains the most common uropathogen; however, Klebsiella pneumoniae has not only shown a high prevalence but also significant resistance, particularly in recent years.

Role of Gut and Urinary Microbiome in Children with Urinary Tract Infections: A Systematic Review

Background: The complex interaction between the gut and urinary microbiota underscores the importance of understanding microbial dysbiosis in pediatric urinary tract infection (UTI). However, the literature on the gut-urinary axis in pediatric UTIs is limited. This systematic review aims to summarize the current literature on the roles of gut and urinary dysbiosis in pediatric UTIs. Methods: This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A comprehensive literature search was performed across four databases, including PubMed, Web of Science, Scopus, and EMBASE. All studies published between January 2003 and December 2023 utilizing 16S rRNA sequencing to profile the gut or urinary microbiome in children with UTIs were included. Heat map visualization was used to compare microbial profiles between UTI and control cohorts. The methodological quality assessment was performed using the Newcastle-Ottawa scale (NOS). Results: Eight studies were included in this review. While five studies compared the microbiota signatures between patients and controls, three studies focused solely on the UTI cohort. Also, the gut and urinary microbiome profiles were investigated by four studies each. The consistent loss of microbiome alpha-diversity with an enrichment of specific putative pathobiont microbes was observed among the included studies. Escherichia coli consistently emerged as the predominant uropathogen in pediatric UTIs. In addition to this, Escherichia fergusonii, Klebsiella pneumoniae, and Shigella flexneri were isolated in the urine of children with UTIs, and enrichment of Escherichia, Enterococcus, Enterobacter, and Bacillus was demonstrated in the gut microbiota of UTI patients. On the contrary, certain genera, such as Achromobacter, Alistipes, Ezakiella, Finegoldia, Haemophilus, Lactobacillus, Massilia, Prevotella, Bacteroides, and Ureaplasma, were isolated from the controls, predominantly in the fecal samples. The methodological quality of the included studies was variable, with total scores (NOS) ranging from 5 to 8. Conclusions: The enrichment of specific pathobionts, such as Escherichia coli, in the fecal or urinary samples of the UTI cohort, along with the presence of core microbiome-associated genera in the non-UTI population, underscores the critical role of the gut-urinary axis in pediatric UTI pathogenesis. These findings highlight the potential for microbiome-based strategies in pediatric UTIs. Further studies with larger cohorts, standardized healthy controls, and longitudinal profiling are essential to validate these observations and translate them into clinical practice.

The Molecular Mechanisms and Therapeutic Potential of Cranberry, D-Mannose, and Flavonoids against Infectious Diseases: The Example of Urinary Tract Infections

The treatment of infectious diseases typically includes the administration of anti-infectives; however, the increasing rates of antimicrobial resistance (AMR) have led to attempts to develop other modalities, such as antimicrobial peptides, nanotechnology, bacteriophages, and natural products. Natural products offer a viable alternative due to their potential affordability, ease of access, and diverse biological activities. Flavonoids, a class of natural polyphenols, demonstrate broad anti-infective properties against viruses, bacteria, fungi, and parasites. Their mechanisms of action include disruption of microbial membranes, inhibition of nucleic acid synthesis, and interference with bacterial enzymes. This review explores the potential of natural compounds, such as flavonoids, as an alternative therapeutic approach to combat infectious diseases. Moreover, it discusses some commonly used natural products, such as cranberry and D-mannose, to manage urinary tract infections (UTIs). Cranberry products and D-mannose both, yet differently, inhibit the adhesion of uropathogenic bacteria to the urothelium, thus reducing the likelihood of UTI occurrence. Some studies, with methodological limitations and small patient samples, provide some encouraging results suggesting the use of these substances in the prevention of recurrent UTIs. While further research is needed to determine optimal dosages, bioavailability, and potential side effects, natural compounds hold promise as a complementary or alternative therapeutic strategy in the fight against infectious diseases.

Genomic surveillance for antimicrobial resistance - a One Health perspective

Antimicrobial resistance (AMR) - the ability of microorganisms to adapt and survive under diverse chemical selection pressures - is influenced by complex interactions between humans, companion and food-producing animals, wildlife, insects and the environment. To understand and manage the threat posed to health (human, animal, plant and environmental) and security (food and water security and biosecurity), a multifaceted 'One Health' approach to AMR surveillance is required. Genomic technologies have enabled monitoring of the mobilization, persistence and abundance of AMR genes and mutations within and between microbial populations. Their adoption has also allowed source-tracing of AMR pathogens and modelling of AMR evolution and transmission. Here, we highlight recent advances in genomic AMR surveillance and the relative strengths of different technologies for AMR surveillance and research. We showcase recent insights derived from One Health genomic surveillance and consider the challenges to broader adoption both in developed and in lower- and middle-income countries.

Urinary Tract Infection and Antimicrobial Resistance Patterns: 5-Year Experience in a Tertiary Pediatric Nephrology Center in the Southwestern Region of Poland

(1) Background: Urinary tract infections (UTIs) are among the most common infections in the pediatric population. This study aimed to analyze the urine culture results and antimicrobial patterns over the last 5 years in children diagnosed with UTI. (2) Methods: Retrospective analysis of medical records of 242 patients hospitalized in the Pediatric Nephrology Department diagnosed with a UTI in the years 2018-2022. (3) Results: The most common causative agent was E. coli, responsible for 64% of UTIs, followed by Klebsiella spp. (16%), Pseudomonas spp. (6%), Enterobacter spp. (4%), Proteus spp. (4%), and Enterococcus spp. (3%). Non-E. coli UTIs were significantly more frequently observed in patients with congenital anomalies of the kidney and urinary tract or neurogenic bladder and patients receiving antibiotic prophylaxis. For the whole study period, 32% of E. coli were resistant to amoxicillin/clavulanic acid, 23.3% to trimethoprim/sulfamethoxazole, 12.2% to ciprofloxacin, and 4.4% to nitrofurantoin. During 2018-2022, the prevalence of E. coli resistant to amoxicillin/clavulanic acid varied from 16.7% to 41.2%, and resistance to cefuroxime increased four times (from 4% in 2018 to 16.7% in 2022). Starting in 2021, all isolated E. coli strains were classified as susceptible-increased exposure or resistant to cefuroxime. (4) Conclusion: Managing pediatric UTIs remains challenging in clinical practice. The choice of optimal empiric treatment should be considered following local recommendations and individual risk factors assessment and require careful dosage adjustment. Observed changes in antimicrobial resistance indicated the need for frequent updating of local recommendations for the management of pediatric patients with UTIs.

Antibiotic resistance in bloodstream isolates from high-complexity paediatric units in Madrid, Spain: 2013-2021

BACKGROUND

Antimicrobial resistance (AMR) has become a significant challenge in high-complexity healthcare settings.

AIM

To evaluate the prevalence of AMR in bloodstream isolates from high-complexity paediatric units in Spain over a nine-year period.

METHODS

A retrospective observational multicentre study was conducted in three tertiary hospitals, analysing bloodstream isolates from patients aged <18 years admitted to the paediatric intensive care, neonatology, and oncology-haematology units between 2013 and 2021. Demographics, antimicrobial susceptibility, and resistance mechanisms were analysed in two periods (2013-2017 and 2017-2021).

FINDINGS

In all, 1255 isolates were included. AMR was more prevalent in older patients and those admitted to the oncology-haematology unit. Multidrug resistance was observed in 9.9% of Gram-negative bacteria (GNB); 20.0% of P. aeruginosa vs 8.6% of Entero-bacterales (P < 0.001), with an increase in Enterobacterales from 6.2% to 11.0% between the first and the second period (P = 0.021). Difficult-to-treat resistance was observed in 2.7% of GNB; 7.4% of P. aeruginosa vs 1.6% of Enterobacterales (P < 0.001), with an increasing trend in Enterobacterales from 0.8% to 2.5% (P = 0.076). Carbapenem resistance among Enterobacterales increased from 3.5% to 7.2% (P = 0.029), with 3.3% producing carbapenemases (67.9% VIM). Meticillin resistance was observed in 11.0% of S. aureus and vancomycin resistance in 1.4% of Enterococcus spp., with both rates remaining stable throughout the study period.

CONCLUSION

This study reveals a high prevalence of AMR in high-complexity paediatric units. Enterobacterales showed a concerning increasing trend in resistant strains, with higher rates among older patients and those admitted to oncology-haematology units.

Nitrofuran Derivatives Cross-Resistance Evidence-Uropathogenic Escherichia coli Nitrofurantoin and Furazidin In Vitro Susceptibility Testing

The treatment of urinary tract infections is usually empirical. For example, nitrofuran derivatives, mainly nitrofurantoin (but also furazidin), are used in Eastern Europe. A significant problem is the assessment of the usefulness of furazidin, as there are no standards for susceptibility testing. Additionally, a high percentage of strains resistant to nitrofurantoin should prompt caution when choosing furazidin in therapy. This study aimed to answer the question of whether it is possible to use nitrofurantoin susceptibility for furazidin drug susceptibility analyses and if there is any cross-resistance in the nitrofuran derivatives group. One hundred E. coli clinical isolates, obtained from the Central Teaching Hospital of the Medical University of Lodz, were cultured from positive urine samples. For susceptibility testing, microdilution and disk diffusion methods, following EUCAST guidelines, were used. The results showed that the MICs of furazidin were equal to or lower than those of nitrofurantoin in 89% of the tested strains. The MIC50/90 values for furazidin were two times lower than those for nitrofurantoin. Positive correlations were found between MICs and growth inhibition zones for both antibiotics. Based on the obtained data and previous studies, it was assumed that the transfer of susceptibility testing results from nitrofurantoin to furazidin is acceptable due to cross-resistance in nitrofuran derivatives.

Antibiotic Drug Resistance Pattern of Uropathogens in Pediatric Patients in Pakistani Population

The common prevalent diseases in the age of 0 to 6 are related to urinary tract infections. If not properly diagnosed, they will lead to urological and nephrological complications. Uropathogens are developing resistance against most drugs and are harder to treat. A study was done on the inpatients and outpatients of the two hospitals located in Lahore. A total of 39,750 samples that were both male and female were collected. Escherichia and Klebsiella were found in 234 samples based on biochemical characterization, growth on CLED agar, and white blood cell/pus cell (WBC) microscopy. In comparison to males, female samples had a higher number of uropathogens (1:1.29). From the samples of Shaikh Zayed Hospital (SZH), the ratio of Klebsiella to Escherichia (1:1.93) was reported, while this ratio was 1.84:1 from the Children Hospital (CH). The incidence of UTI was higher in the month of September. Randomly selected Escherichia and Klebsiella were verified via a 16S rRNA sequence. Antibiotic resistance profiling of isolated bacterial strains was done against 23 antibiotics. The most efficient antibiotics against Klebsiella and Escherichia were colistin sulphate (100% sensitivity against bacteria from CH; 99.3% against strains from SZH) and polymyxin B (100% sensitivity against strains from SZH; 98.8% against strains from CH). Sensitivity of the total tested strains against meropenem (74%, SZH; 70% CH), Fosfomycin (68%, SZH; 73% CH strains), amikacin (74% SZH; 55% CH), and nitrofurantoin (71% SZH;67% CH) was found, Amoxicillin, ampicillin, and cefuroxime showed 100 to ≥90% resistance and are the least effective.