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

Insights into Hospitalized Children with Urinary Tract Infections: Epidemiology and Antimicrobial Resistance Patterns in Israel-A Single Center Study

Background: The escalating resistance of uropathogens in pediatric febrile urinary tract infection (F-UTI) is a global concern. This study examined changing trends in F-UTI epidemiology and resistance patterns among Israeli pediatric inpatients over a decade. Methods: Demographic, clinical, and laboratory data for children between 3 months and 18 years old with febrile UTI from 2010 to 2021 were retrieved from electronic medical records. Results: A total of 761 cases of F-UTI were identified (702 females, mean age 43 months). Escherichia coli was the most common pathogen (85.9%), followed by Pseudomonas aeruginosa (3.5%) and Klebsiella pneumoniae (3.4%). Compared with the non-complicated UTI group, the complicated UTI group had significantly higher rates of Pseudomonas aeruginosa (5.3% vs. 1.0%, p = 0.002) and Klebsiella pneumoniae (4.6% vs. 1.6%, p = 0.03). Antibiotic resistance analysis revealed significant differences between the groups: resistance to cephalexin was higher in the complicated UTI group (19.3%) compared with the non-complicated UTI group (13.4%, p = 0.03). Notably, relatively low resistance rates were observed for ceftriaxone (4.4%) and gentamicin (6.0%). Over time, a significant decreasing trend in resistance to ampicillin was observed (slope = -0.0193, p = 0.011). No significant trends were found for trimethoprim-sulfamethoxazole, cephalexin, amoxicillin-clavulanic acid, ceftriaxone, and cefuroxime. Conclusions: Significant differences in pathogen distribution and resistance patterns between complicated UTI and non-complicated UTI groups highlight the need for continuous resistance monitoring and adherence to local guidelines. For the treatment of severe community F-UTI, ceftriaxone could be a reasonable option for first-onset F-UTI. Further studies are needed to implement antibiotic stewardship and optimize usage.

Antibiotic Stewardship and Treatment of Uncomplicated Urinary Tract Infection (UTI) in Children and Adolescents in the Emergency Department of a Community Hospital

A retrospective, cross-sectional study of children with suspected urinary tract infections (UTIs) 3 months to 18 years of age who had a urinalysis and urine culture (UC) during an emergency department (ED) visit between 2019 and 2020 was performed. Chi-square, Fisher exact, and independent samples T tests were used as appropriate. Median age was 6.6 years (interquartile range = 3.3-12.4). Urinalysis positivity was 92.8%, of which 81.9% of children were prescribed a first-line antibiotic. First-line antibiotic use was 82.7%. Positive UC rate was 84.7%, with 84% receiving a first-line antibiotic (P = .025). The correlation between a positive urinalysis and a positive UC was 80.8% (P < .001). Change of antibiotics based on the uropathogen of positive UCs was 6.3% (P < .001). The urinalysis and UC guided the diagnosis and treatment of UTIs. First-line antibiotics can be safely administered in the ED and prescribed for positive urinalyses. Studies are needed to evaluate the discontinuation of antibiotics with negative UCs as part of antibiotic stewardship initiatives.

Urologic practice patterns of pediatricians: a survey from a large multisite pediatric care center

Objective

To evaluate the practice patterns of pediatricians as they relate to common urologic concerns.

Materials and methods

An anonymous 15-question survey was created and distributed to all pediatricians at our institution, a large multisite care center. This study was deemed exempt by the institutional review board.

Results

55 of the 122 (45%) providers queried responded. 93% of the participants were female, and 7.3% were male. 55% recommended testicular self-examination at adolescence, while 39% did not recommend at any age. 78% stated that they were "Fairly confident" in the exam for undescended testicle (UTD). One-third referred patients with UDT to a subspecialist upon recognition at birth, 13% at 3 months of age, and 28% at 6 months of age. 10% reported obtaining a VCUG after the first febrile urinary tract infection (UTI), 26% after the second, and 36% only if there were abnormal findings on renal ultrasound. 28% of providers reported that they refer to pediatric urology after the initial febrile UTI. 19% provided antibiotics for UTI symptoms alone with negative urinalysis and urine culture.

Conclusions

Despite established guidelines, practice patterns varied among pediatricians. Pediatricians typically followed the AAP's guidelines regarding VCUGs (62%), with only a few adhering to urologic recommendations (9%). Despite the consistency between AAP and AUA guidelines regarding the age at which to refer a patient for cryptorchidism, about 70% of practitioners referred patients too early or too late. Harmonized, consolidated guidelines between pediatricians and pediatric urologists would improve patient care and efficiency of the healthcare system.

Conflicting views of physicians and surgeons concerning pediatric urinary tract infection: a comparative review

BACKGROUND

A first febrile urinary tract infection (UTI) is a common condition in children, and pathways of management have evolved over time.

OBJECTIVE

To determine the extent to which pediatricians and surgeons differ in their investigation and management of a first febrile UTI, and to evaluate the justifications for any divergence of approach.

MATERIALS AND METHODS

A literature search was conducted for papers addressing investigation and/or management following a first febrile UTI in children published between 2011 and 2021. Searches were conducted on Medline, Embase, and the Cochrane Controlled Trials Register. To be eligible for inclusion, a paper was required to provide recommendations on one or more of the following: ultrasound (US) and voiding cystourethrogram (VCUG), the need for continuous antibiotic prophylaxis and surgery when vesicoureteral reflux (VUR) was detected. The authorship required at least one pediatrician or surgeon. Authorship was categorized as medical, surgical, or combined.

RESULTS

Pediatricians advocated less imaging and intervention and were more inclined to adopt a "watchful-waiting" approach, confident that any significant abnormality, grades IV-V VUR in particular, should be detected following a second febrile UTI. In contrast, surgeons were more likely to recommend imaging to detect VUR (p<0.00001), and antibiotic prophylaxis (p<0.001) and/or surgical correction (p=0.004) if it was detected, concerned that any delay in diagnosis and treatment could place the child at risk of kidney damage. Papers with combined authorship displayed intermediate results.

CONCLUSION

There are two distinct directions in the literature regarding the investigation of an uncomplicated first febrile UTI in a child. In general, when presented with a first febrile UTI in a child, physicians recommend fewer investigations and less treatment, in contrast to surgeons who advocate extensive investigation and aggressive intervention in the event that imaging detects an abnormality. This has the potential to confuse the carers of affected children.

Estimated Roles of the Carrier and the Bacterial Strain When Methicillin-Resistant Staphylococcus aureus Decolonization Fails: a Case-Control Study

Methicillin-resistant Staphylococcus aureus (MRSA) is a common bacterial pathogen that frequently colonizes healthy individuals, with potential to cause invasive infection. In Denmark, to keep the prevalence low, MRSA carriers are recommended to undergo decolonization treatments, but achieving decolonization is challenging. Knowledge about the factors contributing to decolonization is scarce. We aimed to identify bacterial genome and clinical factors influencing MRSA decolonization. We identified all new MRSA patients above 2 years of age within the Hvidovre catchment area, Copenhagen, Denmark, in 2017 and 2018. Carriers were defined as chronic carriers (cases) if they were MRSA positive after two or more treatments and as nonchronic carriers (controls) if they were MRSA free after the first or second treatment. Using whole-genome sequencing (WGS), we constructed a pangenome of bacterial strains. With the incorporation of bacterial genome and clinical patient data, machine learning and multivariate analyses were performed to determine the factors associated with decolonization. A total of 477 MRSA carriers were included. An age of ≥13 years was significantly associated with nonchronic carriage. We identified 278 bacterial genetic features that were statistically significantly associated with chronic carriage (P < 0.05 by Fisher's exact test). Chronic MRSA carriage was predicted with 68% accuracy using a combination of bacterial genome data and patient clinical data. Decolonization success is multifactorial. Apart from the 68% predicted accuracy found in this study, we estimate that the remaining 32% is a result of host factors and microbiome composition. IMPORTANCE Carriage of methicillin-resistant Staphylococcus aureus (MRSA) and other multiresistant bacteria is a prerequisite for infection and transmission. Successful decolonization treatment removes these risks. We aimed to identify bacterial genome and host clinical factors that influence MRSA decolonization to estimate the roles of the carrier and the bacterial strain, respectively, when decolonization fails. The long-term goal, beyond this study, is to optimize decolonization success, minimize MRSA transmission, and, ultimately, improve the quality of life of MRSA carriers.

Urinary tract infections in children: building a causal model-based decision support tool for diagnosis with domain knowledge and prospective data

BACKGROUND

Diagnosing urinary tract infections (UTIs) in children in the emergency department (ED) is challenging due to the variable clinical presentations and difficulties in obtaining a urine sample free from contamination. Clinicians need to weigh a range of observations to make timely diagnostic and management decisions, a difficult task to achieve without support due to the complex interactions among relevant factors. Directed acyclic graphs (DAG) and causal Bayesian networks (BN) offer a way to explicitly outline the underlying disease, contamination and diagnostic processes, and to further make quantitative inference on the event of interest thus serving as a tool for decision support.

METHODS

We prospectively collected data on children present to ED with suspected UTIs. Through knowledge elicitation workshops and one-on-one meetings, a DAG was co-developed with clinical domain experts (the Expert DAG) to describe the causal relationships among variables relevant to paediatric UTIs. The Expert DAG was combined with prospective data and further domain knowledge to inform the development of an application-oriented BN (the Applied BN), designed to support the diagnosis of UTI. We assessed the performance of the Applied BN using quantitative and qualitative methods.

RESULTS

We summarised patient background, clinical and laboratory characteristics of 431 episodes of suspected UTIs enrolled from May 2019 to November 2020. The Expert DAG was presented with a narrative description, elucidating how infection, specimen contamination and management pathways causally interact to form the complex picture of paediatric UTIs. Parameterised using prospective data and expert-elicited parameters, the Applied BN achieved an excellent and stable performance in predicting Escherichia coli culture results, with a mean area under the receiver operating characteristic curve of 0.86 and a mean log loss of 0.48 based on 10-fold cross-validation. The BN predictions were reviewed via a validation workshop, and we illustrate how they can be presented for decision support using three hypothetical clinical scenarios.

CONCLUSION

Causal BNs created from both expert knowledge and data can integrate case-specific information to provide individual decision support during the diagnosis of paediatric UTIs in ED. The model aids the interpretation of culture results and the diagnosis of UTIs, promising the prospect of improved patient care and judicious use of antibiotics.

Emerging Role of Microbiome in the Prevention of Urinary Tract Infections in Children

The microbiome of the urinary tract plays a significant role in maintaining health through the impact on bladder homeostasis. Urobiome is of great importance in maintaining the urothelial integrity and preventing urinary tract infection (UTI), as well as promoting local immune function. Dysbiosis in this area has been linked to an increased risk of UTIs, nephrolithiasis, and dysfunction of the lower urinary tract. However, the number of studies in the pediatric population is limited, thus the characteristic of the urobiome in children, its role in a child's health, and pediatric urologic diseases are not completely understood. This review aims to characterize the healthy urobiome in children, the role of dysbiosis in urinary tract infection, and to summarize the strategies to modification and reshape disease-prone microbiomes in pediatric patients with recurrent urinary tract infections.

The change of antibiotic susceptibility in febrile urinary tract infection in childhood and adolescence during the last decade

Purpose

The purpose of this study was to clarify the pattern of antibiotic resistance in pediatric urinary tract infections (UTIs).

Materials and Methods

We analyzed the data of entire urine culture tests and antibiotic susceptibility tests performed on hospitalized patients for febrile UTI at the Uijeongbu St. Mary’s Hospital during 2010–2020. A retrospective analysis was performed using medical records of urine culture results and antibiotic susceptibility results in patients with UTIs.

Results

We performed urine cultures from 2,491 patients, and identified bacterial types in 1,651 cases. We found that the resistance rates to ampicillin, ampicillin/sulbactam, cefazolin, gentamicin, piperacillin, tobramycin, and trimethoprim/sulfamethoxazole were already over 20% in 2010. The resistance rates to many other antibiotics also steadily increased over time. Among the antibiotics tested in 2020, only amikacin, cefoxitin, imipenem, piperacillin/tazobactam, and tigecycline showed the resistance rates below 20%. Noticeably, ciprofloxacin also showed an increase in the resistance rate from 7.3% in 2010 (S 139 vs. R 11) to 27.78% in 2019 (S 104 vs. R 40) and even over 30% (33.96%) in 2020 (S 35 vs. R 18).

Conclusions

Antibiotic resistance is a serious problem in pediatric UTIs. In the treatment of pediatric UTIs, more caution is needed in the use of antibiotics. It may be necessary to apply appropriate antibiotic management programs such as antibiotics steward program for pediatric patients. Failure of a proper response strategy coping with antibiotic resistance may accelerate the resistance crisis.

Antibiotic Resistance in Paediatric Febrile Urinary Tract Infections

Febrile urinary tract infection (UTI) is currently considered the most frequent cause of serious bacterial illness in children in the first 2 years of life. UTI in paediatrics can irreversibly damage the renal parenchyma and lead to chronic renal insufficiency and related problems. To avoid this risk, an early effective antibiotic treatment is essential. Moreover, prompt treatment is mandatory to improve the clinical condition of the patient, prevent bacteraemia, and avoid the risk of bacterial localization in other body sites. However, antibiotic resistance for UTI-related bacterial pathogens continuously increases, making recommendations rapidly outdated and the definition of the best empiric antibiotic therapy more difficult. Variation in pathogen susceptibility to antibiotics is essential for the choice of an effective therapy. Moreover, proper identification of cases at increased risk of difficult-to-treat UTIs can reduce the risk of ineffective therapy. In this review, the problem of emerging antibiotic resistance among pathogens associated with the development of paediatric febrile UTIs and the best potential solutions to ensure the most effective therapy are discussed. Literature analysis showed that the emergence of antibiotic resistance is an unavoidable phenomenon closely correlated with the use of antibiotics themselves. To limit the emergence of resistance, every effort to reduce and rationalise antibiotic consumption must be made. An increased use of antibiotic stewardship can be greatly effective in this regard.

Antibiotic Resistance Patterns of Uropathogens Causing Urinary Tract Infections in Children with Congenital Anomalies of Kidney and Urinary Tract

Background: Urinary tract infections (UTI) are common in children worldwide. Congenital anomalies of kidney and urinary tract (CAKUT) increase the risk of UTI and consequently antibiotic resistance. Antibiotic resistance represents an important public health issue worldwide. We aimed to evaluate the local trend in terms of bacterial uropathogen resistance in the western part of Romania in children with CAKUT and UTI. Methods: 252 children with CAKUT were admitted to our hospital over a five-year period. Of them, 91 developed at least one UTI episode, with a total number of 260 positive urine cultures. We collected data about age at diagnosis of CAKUT, sex, origin environment, type and side of CAKUT, number of UTIs, type of uropathogen, and uropathogens antibiotic resistance. Results: Distribution of uropathogens was Escherichia coli (38.84%), Klebsiella spp. (21.15%), Enterococcus spp. (15.76%), Proteus spp. (8.07%), Pseudomonas spp. (8.07%), Enterobacter spp. (2.3%), other Gram-negative bacteria (2.3%), and other Gram-positive bacteria (3.45%). High antibiotic resistance was detected for ampicillin, amoxicillin, and second-generation cephalosporins. Escherichia coli presented high resistance for cefepime and ceftriaxone. Pseudomonas spp. remained susceptible to amikacin, quinolones, and colistin. Vancomycin, teicoplanin, linezolid, and piperacillin/tazobactam remained effective in treating Gram-positive UTI. Conclusions: High antibiotic resistance was identified for frequently used antibiotics. Lower antibiotic resistance was observed for some broad-spectrum antibiotics. Understanding uropathogens’ antibiotic resistance is important in creating treatment recommendations, based on international guidelines, local resistance patterns, and patient particularities.

[Urinary tract infections in a pediatric setting: Bacterial ecology and antibiotic susceptibility at the Pediatric Teaching Hospital Charles-de-Gaulle in Ouagadougou (Burkina Faso)]

INTRODUCTION

Urinary tract infection is the second most common bacterial infection in children, after respiratory tract infection. The objective of this work was to study the bacterial ecology and antibiotic susceptibility of germs isolated during childhood urinary tract infections at the Paediatric University Hospital Charles-de-Gaulle in Ouagadougou.

PATIENTS AND METHOD

This was a descriptive retrospective study covering the period from July 1^st, 2010 to June 30, 2015, including 141 children from 0 to 15 years old hospitalized in the medical paediatrics department for a urinary tract infection.

RESULTS

The hospital frequency of urinary tract infection was 0.7%. The mean age of the patients was 43.1 months. Female patients accounted for 57.4%, a sex-ratio of 0.7. Gram-negative bacilli were often involved (67.4%) with Escherichia Coli and Klebsiella in 35.5% and 22% of cases respectively. The main Gram-positive bacteria were staphylococci (15.5%), enterococci (11.3%) and streptococci (5.6%). Enterobacteriaceae isolated were sensitive to netilmicin (80%), chloramphenicol (76.4%), and furan (82.6%). All strains of staphylococcus were susceptible to furan, gentamicin, chloramphenicol and cefixime. In 66.7% of cases, the isolated strains of staphylococcus were resistant to amoxicillin.

CONCLUSION

Urinary tract infection is a common problem in pediatrics. Its management must be early and adequate based on knowledge of the bacterial ecology in order to reduce the risk of long-term renal complications.

Evaluation of urinalysis and urine culture in children with first-time urinary tract infection

OBJECTIVE

This study aimed to review results of urinalysis with flow cytometry technique at the time of diagnosis of urinary tact infection (UTI), and to determine uropathogenes with their antibiotic resistance patterns in children with first-time UTI.

MATERIAL AND METHODS

This single-centered, retrospective, cross-sectional study was conducted from January 2015 to December 2017. The study included 361 children with a first-time UTI diagnosis. Age, gender, results of automated urinalysis, urine culture results were recorded.

RESULTS

Mean ages of children were 55.8±50.7 months. E. coli was the most common isolated microorganism followed by K. pneumoniae, Proteus, Enterococcus, and P. aeroginosa. Median count of pyuria was 44 leukocyte/mm3 (range:0-2954/mm3). Median count of pyuria in female and male patients were 53 and 22 leukocyte/mm3, respectively (p=0047). A total of 98 patients (27.1%) had no pyuria. Proportion of pyuria in female and male patients were 81.2% and 76%, respectively (p>0.05). Mean age of patients with and without pyuria were 59±52 months and 46±44months, respectively (p<0.05). According to uropathogen, there was pyuria at the ratio of 60% in Pseudomonas, 62.5% in Enterococcus spp, 66.7% in Proteus, 78.3% in Klebsiella, and 82.7% in E. coli. Children with UTI induced by E. coli had resistance ratios of 30.5% and 22.4% to cefixime and ceftiaxone, respectively. Children with UTI by Klebsiella spp had resistance ratios of 47.8% and 39.1% to cefixime and ceftriaxone, respectively.

CONCLUSION

E. coli was the most common uropathogen in children with first-time UTI. Pyuria may be lacking according to age, gender, and type of uropathogene. Pyuria level was higher in females. In addition, ceftriaxone and cefixime resistance is increasing making ampirical treatment choices limited.

Trends in Incidence of Urinary Tract Infection in Mainland China from 1990 to 2019

Purpose

Urinary tract infection (UTI) is the second-most-common type of infection in China. This study aimed to determine the long-term trends in the incidence of UTI in Mainland China between 1990 and 2019.

Materials and Methods

Data were extracted from the Global Burden of Disease Study 2019 and were analyzed with the age–period–cohort framework.

Results

The net drift in the incidence of UTI was –0.37% (95% CI: –0.40%, –0.35%) in males and –0.25% (95% CI: –0.29%, –0.20%) in females. For males, the local drift was lower than 0 (P<0.05) among those younger than 90 years. For females, the local drift was lower than 0 (P<0.05) among those younger than 60 years and higher than 0 (P<0.05) in those aged 65–79 years. In the same birth cohort, the incidence of UTI was higher in females than in males in all age groups (P<0.05). The period relative risk (RR) showed a decreasing pattern after 2005 in both sexes. The cohort RR showed a downward trend of the birth cohort after 1905 for males and 1960 for females.

Conclusion

The incidence has increased significantly among older females over the past 30 years. It is necessary to develop a comprehensive intervention plan for reproductive health services covering females and males of all ages.

Evaluation of Antibiotic Prescribing Practices and Antimicrobial Sensitivity Patterns in Urinary Tract Related Infectious Diseases in Pediatric Patients

Complications of urinary tract infections (UTIs) like kidney failure and septicaemia develop once infections spread from the upper urinary tract to other parts of the body by haematogenous dissemination and they pose great health and economic burden to the countries. This retrospective study was conducted among 132 patients with bacterial UTIs in the inpatient department of tertiary care hospital in Abha, Saudi Arabia. During the study period, Escherichia coli (E. coli) and Klebsiella pneumonia (K. pneumonia) along with other 15 different bacteria were isolated. A significant difference (P < 0.05) was observed between the male and female children population in different age groups. We observed fever (84.09%) as a major symptom (P < 0.05), and seizure (9%) was reported as a major concomitant condition among UTI cases. Around 31.82% of E. coli was found to be the most common uropathogens in pediatric cases followed by 25% in K. pneumoniae. E. coli was observed to be more susceptible (92.86%) to amikacin, ceftriaxone, levofloxacin, ertapenem, gentamycin, meropenem, piperacillin-tazobactam, tigecycline, and ceftazidime. However, meropenem, tigecycline, and amikacin were observed to be effective in 100% of cases of K. pneumoniae. Meanwhile, cephalosporins were the most commonly prescribed drug category among different classes of drugs. Almost 99% of pediatric cases, based on their age, were admitted to the ward, and drugs were administered intravenously. We concluded that microbiology laboratory evidence on the causative organisms and choice of treatment together allows tailoring appropriate treatment regimens in conjunction with clinical experiences.

Resistance to Antibiotics of Uropathogen Bacteria Isolated From Urine and Blood in Pediatric Cancer Patients: A Single Center, 12-year Study

Resistant pathogens have become a major healthcare problem in children with cancer, causing different kinds of infections such as the bloodstream ones, most common, and most frequently described and the urinary tract ones, of which less data are available. We analyzed and compared the proportions, and the trends of resistance in pathogens isolated from blood and urines in children with cancer followed in IRCCS Istituto Giannina Gaslini, Genova, Italy, from January 2007 to December 2018. Overall, 345 strains detected in urines and 282 in bloodstream infections were analyzed. Enterobacteriales were the most frequently isolated pathogens. During the study period in urines, there was a significant increase of resistance to ceftazidime, ciprofloxacin, piperacillin/tazobactam, and trimethoprim-sulfamethoxazole, but pathogens from blood were significantly more frequently resistant to amikacin, piperacillin/tazobactam, and combination therapy piperacillin/tazobactam+amikacin, even if with a decreasing trend during the study period. These data confirm the importance of surveillance of isolated microorganism and antibiotic resistance in cancer children.

A novel screening method for pediatric urinary tract infection using ordinary diapers

Urinary tract infection (UTI) is one of the most common bacterial infections in children. The symptoms of UTI in young children are nonspecific, therefore urine should be examined whenever UTI cannot be ruled out. In clinical settings, however, collecting urine from children who are not toilet trained is sometimes difficult, presenting a challenge in UTI management. Here, we developed a “diaper UTI test”, which enables the quick detection of pyuria in ordinary diapers, and investigated its sensitivity and specificity in a clinical study. The diaper UTI test is based on a leukocyte esterase reaction. Reagent was prepared in liquid form so that it can be absorbed by disposable diapers, where it will produce a violet color in the presence of pyuria. For the clinical study, we enrolled children younger than 3 years with potential UTI who underwent bladder catheterization for urine culture and urinalysis. Of the 65 children included, 21 were diagnosed with UTI. The sensitivity and specificity of the diaper UTI test were 90.5% (95% CI 69.6–98.8) and 93.2% (95% CI 81.3–98.6), respectively. Because of its convenience and good sensitivity, the diaper UTI test may be useful in the screening of pediatric UTI.

Antimicrobial Resistance and Genotyping of Bacteria Isolated from Urinary Tract Infection in Children in an Iranian Referral Hospital

Introduction

Urinary tract infection (UTI) is one of the most common bacterial infections in childhood, and the increasing rate of antibiotic resistance to the commonly prescribed antimicrobial agents against it has become a major concern. The aim of this study was to determine the antibiotic resistance and genotyping of bacteria isolated from urine cultures in patients referred to the Children’s Medical Center, Tehran, Iran.

Methods

During the 1-year period, antimicrobial susceptibility profiles of strains isolated from patients with UTI were determined. Typing of the isolates causing nosocomial infections was performed by random amplified polymorphic DNA (RAPD) analysis, and the results were analyzed by Gelcompar II software.

Results

In this study, 203 children (130 girls and 73 boys) were included. The patients’ age ranged from 1 day to 16 years (IQR average=4 months to 4 years). The most frequent isolated organisms were Escherichia coli (118 isolates, 58%), followed by Klebsiella pneumoniae (30 isolates, 15%). Sixty-two strains (18 strains of E. coli, 13 strains of K. pneumoniae, 11 strains of Enterococcus faecium, and five strains of Burkholderia cepacia complex) had criteria of nosocomial infection. A high resistance rate to trimethoprim-sulfamethoxazole (69%) and cefotaxime (60%) was reported in E. coli and K. pneumoniae strains, respectively. Pseudomonas aeruginosa strains showed high sensitivity to amikacin (100%). All E. faecium strains were susceptible to trimethoprim-sulfamethoxazole (100%), and 23% of the strains were resistant to vancomycin. The analysis of RAPD-typing revealed the presence of three clusters in E. coli, two clusters in E. faecium, and one clone in K. pneumoniae. Besides, four out of five isolates of B. cepacia complex had more than 90% genetic similarity.

Conclusion

The most frequent isolated pathogen was E. coli, and an increasing rate of antibiotic resistance to the commonly prescribed antimicrobial agents such as trimethoprim/sulfamethoxazole and cephalosporins was observed. Moreover, the results of this study showed the presence of clones with ≥80% similarity in E. coli, K. pneumoniae, E. faecium, and B. cepacia complex isolates; therefore, the transmission of nosocomial infections from one patient to another or one ward to another is probable.

Treatment outcome and predictors of poor clinical response in extensively drug-resistant gram-negative urinary tract infection among children: A single-institution experience

INTRODUCTION

Extensively drug-resistant (XDR) is defined as isolates sensitive only to two or fewer antimicrobial categories. This paper aims to present the treatment outcome and identify factors associated with poor clinical response among children with XDR gram-negative urinary tract infection (UTI).

METHODS

This is a retrospective cohort conducted at a tertiary pediatric hospital from January 2014 to June 2017. All patients diagnosed with culture-proven XDR gram-negative UTI were identified and analyzed. Descriptive statistics were used to summarize demographic and clinical characteristics. Patients were categorized according to treatment outcomes: success vs. failure. Univariate analysis and multivariate logistic regression were used to assess statistical differences between the groups and determined patient variables that are predictive of poor response. Odds ratio (OR) and corresponding 95% confidence interval (CI) were generated.

RESULTS

A total of 29 (19.2%) XDR gram-negative pediatric UTIs were identified within the 42-month study period. No significant differences were noted in demographic characteristics between the groups. Treatment outcome of XDR gram-negative UTI patients showed that combination therapy with colistin had the highest success rate (40.9%), followed by non-colistin (36.4%) and combination therapy without colistin (22.7%). However, univariate analysis showed no significant difference among the different treatment groups (p=0.65). On multivariate logistic regression, receiving immunosuppressant and the presence of indwelling urinary catheters were independent predictors of poor clinical response among pediatric patients with XDR gram-negative UTI (OR 19.44, 95% CI 1.50-251.4, p=0.023 and OR 20.78, 95% CI 1.16-371.28, p=0.039; respectively).

CONCLUSIONS

The treatment success rate of XDR gram-negative pediatric UTI ranged from 22.7-36.4%. This finding emphasizes the need to advocate antibiotic stewardship to prevent further increase in XDR UTIs. Indwelling urinary catheters and receipt of immunosuppressants are associated with poor clinical outcome.

Short-term antibiotic exposure affected the type and resistance of uropathogens similar to long-term antibiotic prophylaxis in children hospitalised for urinary tract infections

AIM

We investigated the impact of any antibiotic exposure on unusual and resistant pathogens in children with a urinary tract infection (UTI).

METHODS

This was a retrospective cohort study of 695 children (54% female) hospitalised with 711 UTI episodes at Heraklion University Hospital, Greece, from January 2007 to December 2017. Three groups were studied: no previous antibiotic exposure, ongoing prophylaxis and short-term exposure to antibiotics in the last six months.

RESULTS

The median age at hospitalisation was 0.8 years (range 25 days to 15.9 years). Previous short-term exposure and prophylaxis were important determinants of non-Escherichia coli (E. coli) (OR 2.05, 95% CI 1.25-3.36, P = .0017 and OR 3.84, 95% CI 2.32-6.34, P < .0001, respectively) and extended-spectrum beta-lactamase-positive uropathogens (OR 2.43, 95% CI 1.36-4.32, P = .0025 and OR 2.63, 95% CI 1.31-5.33, P = .0070, respectively). Short-term antibiotics in the last 30 days or intravenous antibiotics were mostly associated with non-E. coli pathogens (OR 6.71 and OR 2.55, respectively). The most important determinants of E. coli resistance were short-term antibiotics for ampicillin (OR 2.58) and prophylaxis for cotrimoxazole (OR 2.64).

CONCLUSION

Recent short-term exposure to antibiotics and ongoing prophylaxis both had a significant impact on the type and resistance of uropathogens.

Optimal Antibiotics at Hospital Discharge for Children With Urinary Tract Infection

OBJECTIVES

Antibiotic stewardship at hospital discharge is an area of need. We assessed the rate of optimal antibiotic prescriptions at hospital discharge, on the basis of urine culture and susceptibility data, for children diagnosed with a urinary tract infection (UTI).

METHODS

We conducted a retrospective study of patients ≤18 years of age who were admitted to a general pediatrics service at a freestanding children's hospital during 2017 with a diagnosis of UTI and received an antibiotic prescription at discharge. For the primary analysis, optimal antibiotic at hospital discharge was determined by evaluating if the cultured urinary pathogen was susceptible to the prescribed antibiotic and if the antibiotic was the narrowest-spectrum option available. Secondary objectives included assessment of antibiotic dosing accuracy and description of antibiotic treatment duration.

RESULTS

A total of 78 cases were included. Sixty-eight (83%) cases were caused by cefazolin-susceptible Escherichia coli and Klebsiella species. Thirty-one (40%) cases had a discharge antibiotic prescription that was determined to be optimal. Of the 47 (60%) cases that were suboptimal, 44 (94%) were considered to be excessively broad spectrum. In 3 (6%) cases, the causative organism was nonsusceptible to the prescribed antibiotic. Ten (13%) discharge antibiotic prescriptions had inaccurate dosing and/or frequency.

CONCLUSIONS

Missed opportunities for narrow-spectrum antibiotic selection at hospital discharge for pediatric UTIs frequently occurred. In particular, higher-generation cephalosporins and ciprofloxacin were often prescribed for cephalexin-susceptible cases. Antibiotic stewardship attention, specifically at hospital discharge for pediatric UTIs, is likely to have a high impact.

Association of Antibiotic Treatment Duration With Recurrence of Uncomplicated Urinary Tract Infection in Pediatric Patients

Background: Gaps and inconsistencies in published information about optimal antibiotic treatment duration for uncomplicated urinary tract infection (UTI) in pediatric patients pose a dilemma for antibiotic stewardship. Objective: Evaluate the association of antibiotic treatment duration with recurrence rates in children with new-onset cystitis or pyelonephritis. Methods: Retrospective cohort analysis of patients aged 2 to 17 years with new-onset cystitis or pyelonephritis and without renal/anatomical abnormality was conducted using Truven Health MarketScan Database for 2013-2015. Results: Of 7698 patients, 85.5% had cystitis, 14.3% pyelonephritis. Duration of antibiotic treatment was as follows: 3 to 5 days for cystitis (20.4%) or 7 (33.6%), 10 (44.2%), or 14 (1.8%) days for any UTI. Recurrence occurred in 5.5% of patients. Covariates associated with increased recurrence risk included pretreatment antibiotic exposure (odds ratio [OR] = 1.29; 95% CI = 1.06-1.57), pyelonephritis on diagnosis date (OR = 1.44; 95% CI = 1.03-2.00), follow-up visit during antibiotic treatment (OR = 3.21; 95% CI = 2.20-4.68), parenteral antibiotic (OR = 1.89; 95% CI = 1.33-2.69), and interaction of pyelonephritis diagnosis with nitrofurantoin monotherapy (OR = 3.68; 95% CI = 1.20-11.29). After adjustment for covariates, the association between duration of antibiotic treatment and recurrence was not significant (compared with 7 days: 10 days: OR = 1.07, 95% CI = 0.85-1.33; 14 days: OR = 0.89, 95% CI = 0.45-1.78). Conclusions and Relevance: Antibiotic treatment duration was not significantly associated with recurrence of uncomplicated UTI in a national pediatric cohort. Results provide support for shorter-course treatment, consistent with antimicrobial stewardship efforts.

Relationship between urinalysis findings and responsible pathogens in children with urinary tract infections

BACKGROUND

Pyuria, presence of bacteria, leukocyte esterase, and nitrite positivity in urinalysis should be considered together, and simultaneous urine culture test should be performed in the diagnostic evaluation of urinary tract infection (UTI). The absence of pyuria in urinalysis cannot exclude UTI in patients with suggestive clinical findings.

OBJECTIVE

It was aimed to assess relationship between urinalysis tests and uropathogen and to evaluate antibiotic resistance in children.

METHODS

The study included patients (aged 0-18 years) with significant uropathogen growth in urine culture tests. The patients' data regarding age, gender, results of urine microscopy, urine culture, and antibiogram were recorded retrospectively.

RESULTS

Overall, 705 patients (562 girls, 143 boys) with significant growth in urine culture test were included. Median age was 72 months among girls and 12 months among boys. Most common uropathogens were Escherichia coli (79.6%) and Klebsiella pneumoniae (8.2%). E. coli was more commonly among girls (87%) and Klebsiella spp. among boys (53.3%). Pyuria was positive in urinalysis in 75% of patients. Pyuria presence was more common in patients with E.coli or Proteus spp. (80.6% and 71.4%, respectively) than those with Enterococcus spp. and Klebsiella spp. (52.0% and 53.3%, respectively). In culture antibiogram tests, ampicillin resistance was 100% in Klebsiella oxytoca and Enterobacter spp. and 72% in E. coli strains. No ceftriaxone resistance was observed in K. oxytoca, Citrobacter spp., Pseudomonas aeruginosa, and Enterobacter spp.

DISCUSSION

Most UTIs were seen in older girls. Pyuria might be lacking in UTIs associated to Klebsiella spp. and Enterococcus spp., and absence of pyuria may not exclude UTI in patients with compatible clinical findings. Ceftriaxone is still an option in empirical treatment; unnecessary use of third-generation cephalosporins should be avoided, particularly in infections other than UTI.

CONLUSIONS

It was found that E. coli more commonly caused leukocyturia, leukocyte esterase positivity, and pyuria; that pyuria might be lacking in UTIs associated to Klebsiella spp. and Enterococcus spp. and that pyuria was more prevalent among girls. It is though that urine culture tests should be performed in children with suspected UTI even in the absence of pyuria because lack of pyuria may lead delay in diagnosis and treatment as well as renal scar formation.