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Towards a deeper understanding of the vaginal microbiota. Nat Microbiol 2022; 7:367-378. [PMID: 35246662 DOI: 10.1038/s41564-022-01083-2] [Citation(s) in RCA: 73] [Impact Index Per Article: 36.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 02/03/2022] [Indexed: 12/30/2022]
Abstract
The human vaginal microbiota is a critical determinant of vaginal health. These communities live in close association with the vaginal epithelium and rely on host tissues for resources. Although often dominated by lactobacilli, the vaginal microbiota is also frequently composed of a collection of facultative and obligate anaerobes. The prevalence of these communities with a paucity of Lactobacillus species varies among women, and epidemiological studies have associated them with an increased risk of adverse health outcomes. The mechanisms that drive these associations have yet to be described in detail, with few studies establishing causative relationships. Here, we review our current understanding of the vaginal microbiota and its connection with host health. We centre our discussion around the biology of the vaginal microbiota when Lactobacillus species are dominant versus when they are not, including host factors that are implicated in shaping these microbial communities and the resulting adverse health outcomes. We discuss current approaches to modulate the vaginal microbiota, including probiotics and vaginal microbiome transplants, and argue that new model systems of the cervicovaginal environment that incorporate the vaginal microbiota are needed to progress from association to mechanism and this will prove invaluable for future research.
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Meena J, Thomas CC, Kumar J, Raut S, Hari P. Non-antibiotic interventions for prevention of urinary tract infections in children: a systematic review and meta-analysis of randomized controlled trials. Eur J Pediatr 2021; 180:3535-3545. [PMID: 34156540 DOI: 10.1007/s00431-021-04091-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 04/22/2021] [Accepted: 04/25/2021] [Indexed: 11/28/2022]
Abstract
A considerable proportion of children experience a recurrence of urinary tract infection (UTI) following the first episode. While low-dose antibiotic prophylaxis has been the mainstay for the prevention of UTI, recent evidence raised concerns over their efficacy and safety. Hence, we aim to systematically synthesize evidence on the efficacy and safety of non-antibiotic prophylactic interventions for UTI. Using keywords related to study population (children) and intervention (non-antibiotic), we searched CENTRAL, Embase, PubMed, and Web of Science for randomized controlled trials (RCTs) published until August 2020. RCTs comparing any non-antibiotic interventions with placebo/antibiotics for prevention of UTIs in children were considered eligible. We used a random-effect model to provide pooled estimates. Sixteen trials evaluating 1426 participants were included. Cranberry was as effective as antibiotic prophylaxis (RR: 0.92; 95% CI: 0.56-1.50) but better than placebo/no therapy (RR: 0.48; 95% CI: 0.28-0.80) in reducing UTI recurrence. Probiotic therapy was more effective in reducing UTI recurrence (RR: 0.52; 95% CI: 0.29-0.94) when compared with placebo. While probiotic therapy was not better than antibiotics prophylaxis in preventing UTI (RR: 0.82; 95% CI: 0.56-1.21), they have a lower risk of antibiotic resistance (RR: 0.38; 95% CI: 0.21-0.69).Conclusion: Cranberry products and probiotics are the two non-antibiotic interventions that have been chiefly evaluated, reduce the risk of UTI recurrence when compared with placebo in children with a normal urinary tract. The findings from this systematic review suggest that while cranberry and probiotics may be used, there is a definite need to identify better and more acceptable non-antibiotic interventions. What is Known: • Efficacy of the low-dose antibiotic is controversial in preventing UTI and it is associated with increase in the risk of antimicrobial resistance. • Non-antibiotic interventions such as cranberry products are effective in preventing UTI recurrence in adults. What is New: • Cranberry products are effective in reducing the recurrence of UTI in children with normal urinary tract. • Low-quality evidence suggests that probiotics can be a potential prophylactic measure to reduce recurrence of UTI in the pediatric population.
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Affiliation(s)
- Jitendra Meena
- Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | | | - Jogender Kumar
- Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sumantra Raut
- Division of Pediatric Nephrology, Department of Pediatrics, NRS Medical College & Hospital, Kolkata, India
| | - Pankaj Hari
- Division of Nephrology, Department of Pediatrics, ICMR Center for Advanced Research in Nephrology, All India Institute of Medical Sciences, New Delhi, India.
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Suh W, Kim BN, Kang HM, Yang EA, Rhim JW, Lee KY. Febrile urinary tract infection in children: changes in epidemiology, etiology, and antibiotic resistance patterns over a decade. Clin Exp Pediatr 2021; 64:293-300. [PMID: 33076637 PMCID: PMC8181017 DOI: 10.3345/cep.2020.00773] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 09/18/2020] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Understanding the epidemiology and prevalence of febrile urinary tract infection (fUTI) in children is important for risk stratification and selecting appropriate urine sample collection candidates to aid in its diagnosis and treatment. PURPOSE This study aimed to analyze the epidemiology, etiology, and changes in antibiotic susceptibility patterns of the first fUTI in children. METHODS This retrospective observational cohort study included children younger than 19 years of age who were diagnosed and treated for their first fUTI in 2006-2016. Electronic medical records were analyzed and radiologic images were evaluated. RESULTS A total of 359 patients (median age, 5.1 months; interquartile range, 3.0-10.5 months) fit the inclusion criteria; of them, 78.0% (n=280) were younger than 12 months old. The male to female ratio was 5.3:1 for patients aged 0-2 months, 2.1:1 for those 3-5 months, and 1.6:1 for those 6-11 months. Beyond 12 months of age, there was a female predominance. Escherichia coli was the leading cause (83.8%), followed by Enterococcus species (6.7%), and Klebsiella pneumoniae (3.6%). Significant yearly increases in the proportions of multidrug-resistant strains (P<0.001) and extended-spectrum beta-lactamase (ESBL) producers (P<0.001) were observed. In patients with vesicoureteral reflux (VUR), the overall recurrence rate was 53.6% (n=15). A significantly higher recurrence rate was observed when the fUTI was caused by an ESBL versus non-ESBL producer (75.0% vs. 30.0%, P=0.03). CONCLUSION fUTI was most prevalent in children younger than 12 months of age and showed a female predominance in patients older than 12 months of age. The proportion of ESBL producers causing fUTI is increasing. Carbapenems, rather than noncarbapenems, should be considered for treating fUTI caused by ESBL-producing enteric gram-negative rods to reduce short-term recurrence rates in children with VUR.
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Affiliation(s)
- Woosuck Suh
- Departments of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Bi Na Kim
- Departments of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hyun Mi Kang
- Departments of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Eun Ae Yang
- Departments of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jung-Woo Rhim
- Departments of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Kyung-Yil Lee
- Departments of Pediatrics, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Yim HE, Han KD, Kim B, Yoo KH. Impact of early-life weight status on urinary tract infections in children: a nationwide population-based study in Korea. Epidemiol Health 2020; 43:e2021005. [PMID: 33445823 PMCID: PMC8060518 DOI: 10.4178/epih.e2021005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 12/28/2020] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVES We aimed to evaluate the association between early-life weight status and urinary tract infection (UTI) risk in children. METHODS A nationwide study was conducted using Korean National Health Screening (NHS) data and National Health Insurance Service data. A sample cohort was selected using data from the 2014 and 2015 NHS for infants and children (4-71 months) and followed up until the end of 2017. Participants were divided into 4 groups (underweight, normal weight, overweight, and obese) based on the weight-for-age (< 2 years) or body mass index (≥ 2 years). Hazard ratios (HRs) with 95% confidence intervals (CIs) for developing UTIs, cystitis, and acute pyelonephritis (APN) were calculated using a Cox proportional hazard model. RESULTS Of 1,653,106 enrolled children, 120,142 (7.3%) developed UTIs, cystitis, and APN during follow-up. The underweight, overweight, and obese groups had higher risks of UTIs than the reference group after adjusting for age, sex, birth weight, and preterm birth. Between 2 years and 6 years of age, boys with underweight had a high risk of UTI and APN, while girls with overweight and obesity revealed elevated risks of UTIs, cystitis, and APN. The HRs for APN in boys with underweight and in girls with obesity were 1.46 (95% CI, 1.03 to 2.07) and 1.41 (95% CI, 1.13 to 1.75), respectively, after adjusting for age, sex, birth weight, and preterm birth. The incidence of APN did not decrease with age in underweight and obese children aged 2-6 years. CONCLUSIONS Children with underweight, overweight, and obesity may be at high risk for UTIs.
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Affiliation(s)
- Hyung Eun Yim
- Department of Pediatrics, Korea University Ansan Hospital, Ansan, Korea.,Department of Pediatrics, Korea University College of Medicine, Seoul, Korea
| | - Kyung Do Han
- Department of Statistics and Actuarial Science, Soongsil University, Seoul, Korea
| | - Bongseong Kim
- Department of Statistics and Actuarial Science, Soongsil University, Seoul, Korea
| | - Kee Hwan Yoo
- Department of Pediatrics, Korea University College of Medicine, Seoul, Korea.,Department of Pediatrics, Korea University Guro Hospital, Seoul, Korea
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Pennesi M, Amoroso S, Bassanese G, Pintaldi S, Giacomini G, Barbi E. Frequency of urinary tract infection in children with antenatal diagnosis of urinary tract dilatation. Arch Dis Child 2020; 105:260-263. [PMID: 31462436 DOI: 10.1136/archdischild-2019-317637] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 07/31/2019] [Accepted: 08/08/2019] [Indexed: 11/04/2022]
Abstract
BACKGROUND Neonates with congenital urinary tract dilatation (UTD) may have an increased risk of urinary tract infections (UTI). At present, the management of these patients is controversial and the utility of continuous antibiotic prophylaxis (CAP) remains uncertain as the literature presents contradicting evidence. The aim of this observational study was to assess UTI occurrence in children with prenatal diagnosis of urinary collecting system dilatation without antibiotic prophylaxis. METHODS Between June 2012 and August 2016, we evaluated the incidence of UTI and the clinical and ultrasonography evolution in 407 children with a prenatally diagnosed UTD. All subjects underwent two prenatal ultrasounds scans (USs) at 20 weeks and 30 weeks of gestation and within 1 month of birth. Patients with a confirmed diagnosis of UTD underwent US follow-up at 6, 12 and 24 months of life. According to the UTD classification system stratify risk, after birth UTD were classified into three groups: UTD-P1 (low risk group), UTD-P2 (intermediate risk group), and UTD-P3 (high risk group). Voiding cystourethrogram was performed in all patients who presented a UTI and in those with UTD-P3. No patient underwent CAP. RESULTS Postnatal US confirmed UTD in 278 out of 428 patients with the following rates: UTD-P1 (126), UTD-P2 (95) and UTD-P3 (57). During postnatal follow-up, 6.83% patients presented a UTI (19 out of 278). Eleven out of 19 had vesicoureteral reflux (VUR), and other four were diagnosed with obstructive uropathy and underwent surgical correction. Five patients presented a UTI reinfection. CONCLUSION The occurrence of UTI in patients with urinary collecting system dilatation was low. The recent literature reports an increased selection of multirestistant germs in patients with VUR exposed to CAP. This study constitutes a strong hint that routine continuous antibiotic prophylaxis could be avoided in patients with UTD.
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Affiliation(s)
- Marco Pennesi
- Department of Pediatrics, Institute for Maternal and Child Health-IRCCS "Burlo Garofolo", Trieste, Italy
| | - Stefano Amoroso
- Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy
| | - Giulia Bassanese
- Center for Pediatrics and Adolescent Medicine, University of Heidelberg, Heidelberg, Germany
| | - Stefano Pintaldi
- Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy
| | - Giulia Giacomini
- Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy
| | - Egidio Barbi
- Department of Pediatrics, Institute for Maternal and Child Health-IRCCS "Burlo Garofolo", Trieste, Italy.,Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy
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Ammenti A, Alberici I, Brugnara M, Chimenz R, Guarino S, La Manna A, La Scola C, Maringhini S, Marra G, Materassi M, Morello W, Nicolini G, Pennesi M, Pisanello L, Pugliese F, Scozzola F, Sica F, Toffolo A, Montini G. Updated Italian recommendations for the diagnosis, treatment and follow-up of the first febrile urinary tract infection in young children. Acta Paediatr 2020; 109:236-247. [PMID: 31454101 PMCID: PMC7004047 DOI: 10.1111/apa.14988] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 08/22/2019] [Accepted: 08/23/2019] [Indexed: 12/21/2022]
Abstract
AIM Our aim was to update the recommendations for the diagnosis, treatment and follow-up of the first febrile urinary tract infection in young children, which were endorsed in 2012 by the Italian Society of Pediatric Nephrology. METHODS The Italian recommendations were revised on the basis of a review of the literature published from 2012 to October 2018. We also carried out an ad hoc evaluation of the risk factors to identify children with high-grade vesicoureteral reflux or renal scarring, which were published in the previous recommendations. When evidence was not available, the working group held extensive discussions, during various meetings and through email exchanges. RESULTS Four major modifications have been introduced. The method for collecting urine for culture and its interpretation has been re-evaluated. We have reformulated the algorithm that guides clinical decisions to proceed with voiding cystourethrography. The suggested antibiotics have been revised, and we have recommended further restrictions of the use of antibiotic prophylaxis. CONCLUSION These updated recommendations have now been endorsed by the Italian Society of Pediatric Nephrology and the Italian Society for Pediatric Infectivology. They can also be used to compare other recommendations that are available, as a worldwide consensus in this area is still lacking.
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Affiliation(s)
- Anita Ammenti
- Pediatric Polyspecialistic GroupPoliambulatorio Medi‐SaluserParmaItaly
| | - Irene Alberici
- Department of Woman and Child's HealthUniversity of PadovaPadovaItaly
| | | | - Roberto Chimenz
- Pediatric Nephrology and Dialysis UnitDepartment of PediatricsG. Martino HospitalUniversity of MessinaMessinaItaly
| | - Stefano Guarino
- Department of WomanChild and of General and Specialized SurgeryUniversità degli Studi della Campania L. VanvitelliNaplesItaly
| | - Angela La Manna
- Department of WomanChild and of General and Specialized SurgeryUniversità degli Studi della Campania L. VanvitelliNaplesItaly
| | - Claudio La Scola
- Nephrology and Dialysis UnitDepartment of PediatricsAzienda Ospedaliero Universitaria Sant'Orsola‐MalpighiBolognaItaly
| | | | - Giuseppina Marra
- Pediatric NephrologyDialysis and Transplant UnitFondazione Ca'Granda, IRCCS Policlinico di MilanoMilanoItaly
| | | | - William Morello
- Pediatric NephrologyDialysis and Transplant UnitFondazione Ca'Granda, IRCCS Policlinico di MilanoMilanoItaly
| | | | - Marco Pennesi
- Department of PediatricsInstitute for Child and Maternal HealthIRCCS Burlo GarofoloTriesteItaly
| | | | | | | | | | | | - Giovanni Montini
- Pediatric NephrologyDialysis and Transplant UnitFondazione Ca'Granda, IRCCS Policlinico di MilanoMilanoItaly
- Giuliana and Bernardo Caprotti Chair of PediatricsDepartment of Clinical Sciences and Community HealthUniversity of MilanoMilanoItaly
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Maduemem KE, Rodriguez YD, Fraser B. How Sensitive are Dipstick Urinalysis and Microscopy in Making Diagnosis of Urinary Tract Infection in Children? Int J Prev Med 2019; 10:62. [PMID: 31198497 PMCID: PMC6547774 DOI: 10.4103/ijpvm.ijpvm_353_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Accepted: 09/27/2017] [Indexed: 11/04/2022] Open
Abstract
Background Urinary tract infection (UTI) is a common reason for referral to the emergency department (ED) especially in unwell infants. Upper UTIs are particularly at risk of significant complications later in life. Rapid dipstick urinalysis and microscopy are often used in unwell children as a screening tool to guide early diagnosis and treatment. This study aims to evaluate the sensitivity of dipstick urinalysis and microscopy in the diagnosis of UTI. Methods A retrospective review of children aged 16 years and below with positive urine culture (UC) over a 3-year period was done. The results of urine dipstick and microscopy were compared with the positive UC and sensitivities calculated. Results Dipstick urinalysis and microscopy of 262 children were studied. Female-to -male ratio of 1.8:1. Median age was 0.79 (range: 0.02-15.95) years. The sensitivity of nitrite, blood, and leukocyte esterase (LE) were 0.54, 0.74, and 0.86 (95% confidence interval [CI] = 0.46-0.62, 0.68-0.80, and 0.82-0.91), respectively. The sensitivity of pyuria of ≥100 cells/mm3 was 0.92 (95% CI = 0.89-0.95). The presence of any of the 3 dipstick parameters increased the sensitivity to 0.97 (95% CI = 0.95-0.99). The lowest sensitivity 0.49 (95% CI = 0.40-0.58) was found with combined positive LE and nitrite. There was a significant comparison between positive LE dipstick test and pyuria (P = 0.000004). Conclusions Dipstick urinalysis may not be reliable in ruling out UTI in children. However, considering both positive dipstick and pyuria will be more useful in making the diagnosis.
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Affiliation(s)
| | | | - Brian Fraser
- Department of Paediatrics, Cork University Hospital, Cork, Ireland
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Anigilaje EA. A Putative Role of Apolipoprotein L1 Polymorphism in Renal Parenchymal Scarring Following Febrile Urinary Tract Infection in Nigerian Under-Five Children: Proposal for a Case-Control Association Study. JMIR Res Protoc 2018; 7:e156. [PMID: 29903699 PMCID: PMC6024104 DOI: 10.2196/resprot.9514] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 03/23/2018] [Accepted: 04/10/2018] [Indexed: 01/13/2023] Open
Abstract
Background Although urinary tract infection (UTI) resolves with prompt treatment in a majority of children, some children, especially those aged less than 5 years, also develop renal parenchymal scarring (RPS). RPS causes high blood pressure that may lead to severe chronic kidney disease and end-stage renal disease (ESRD). Although the risk of UTI is higher in white children than in black children, it is unknown whether RPS is more common in white children than in black children as data are scarce in this regard. A common genetic predisposition to kidney disease in African Americans and the sub-Saharan African blacks is the possession of apolipoprotein L1 (APOL1). APOL1 risk variants regulate the production of APOL1. APOL1 circulates in the blood, and it is also found in the kidney tissue. While circulating, APOL1 kills the trypanosome parasites; an increased APOL1 in kidney tissues, under the right environmental conditions, can also result in the death of kidney tissue (vascular endothelium, the podocytes, proximal tubules, and arterial cells), which, ultimately, is replaced by fibrous tissue. APOL1 may influence the development of RPS, as evidence affirms that its expression is increased in kidney tissue following UTI caused by bacteria. Thus, UTI may be a putative environmental risk factor responsible for APOL1-induced kidney injury. Objective The aim of this proposal was to outline a study that seeks to determine if the possession of two copies of either G1 or G2 APOL1 variant increases the risk of having RPS, 6 months following a febrile UTI among Nigerian under-five children. Methods This case-control association study seeks to determine whether the risk of RPS from febrile UTI is conditional on having 2 APOL1 risk alleles (either G1 or G2). Cases will be children with a confirmed RPS following a febrile UTI. Controls will be age-, gender-, and ethnic-matched children with a febrile UTI but without RPS. Children with vesicoureteral reflux and other congenital anomalies of the urinary tract are to be excluded. Association between predictor variables (ethnicity, APOL1 G1 or G2, and others) and RPS will be tested at bivariate logistic regression analyses. Predictors that attained significance at a P value of ˂.05 will be considered for multiple logistic regressions. Likelihood-based tests will be used for hypothesis testing. Estimation will be done for the effect size for each of the APOL1 haplotypes using a generalized linear model. Results The study is expected to last for 3 years. Conclusions The study is contingent on having a platform for undergoing a research-based PhD program in any willing university in Europe or elsewhere. The findings of this study will be used to improve the care of African children who may develop RPS following febrile UTI. Registered Report Identifier RR1-10.2196/9514
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Affiliation(s)
- Emmanuel Ademola Anigilaje
- Nephrology Unit, Department of Paediatrics, College of Health Sciences, University of Abuja, Abuja, Nigeria
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Ayelign B, Abebe B, Shibeshi A, Meshesha S, Shibabaw T, Addis Z, Gelaw A, Dagnew M. Bacterial isolates and their antimicrobial susceptibility patterns among pediatric patients with urinary tract infections. Turk J Urol 2018; 44:62-69. [PMID: 29484230 PMCID: PMC5821286 DOI: 10.5152/tud.2017.33678] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Accepted: 09/05/2017] [Indexed: 11/22/2022]
Abstract
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.
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Affiliation(s)
- Birhanu Ayelign
- Department of Biochemistry, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Betelehem Abebe
- Department of Clinical Laboratory services, University of Gondar Hospital, Gondar, Ethiopia
| | - Adugna Shibeshi
- Department of Clinical Laboratory services, University of Gondar Hospital, Gondar, Ethiopia
| | - Sosina Meshesha
- Department of Clinical Laboratory services, University of Gondar Hospital, Gondar, Ethiopia
| | - Tewodros Shibabaw
- Department of Biochemistry, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Zelalem Addis
- Departments of Medical Microbiology, School of Biomedical and Laboratory Sciences, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Aschalew Gelaw
- Departments of Medical Microbiology, School of Biomedical and Laboratory Sciences, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Mulat Dagnew
- Departments of Medical Microbiology, School of Biomedical and Laboratory Sciences, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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Patwardhan V, Kumar D, Goel V, Singh S. Changing prevalence and antibiotic drug resistance pattern of pathogens seen in community-acquired pediatric urinary tract infections at a tertiary care hospital of North India. J Lab Physicians 2017; 9:264-268. [PMID: 28966488 PMCID: PMC5607755 DOI: 10.4103/jlp.jlp_149_16] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
AIMS AND OBJECTIVES The aim and objective of this study was to assess the temporal changes in the microbiological profiles and antimicrobial resistance patterns of uropathogens in pediatric community-acquired UTI. MATERIALS AND METHODS This is a retrospective analysis of data collected over a Scattered period of 5 years. The baseline data collected were from January to December 2009, and the second period considered for comparison was from January to December 2014. Urine specimens from children (<17 years) suspected of UTI were cultured by a semi-quantitative method on cysteine lactose electrolyte-deficient medium. Antibiotic sensitivity was put up by Kirby-Bauer disc diffusion method as per the Clinical and Laboratory Standard Institute guidelines. RESULTS In the year 2009, 340 of 2104 (16.15%) urine specimens yielded significant colony count, whereas in 2014, it was 407 of 2212 (18.39%) (P = 0.051). Escherichia coli was the predominant pathogen and was significantly more prevalent in girls than in boys (P < 0.0001) during both periods. There was a significant overall increase in resistance to ampicillin (from 40.29% to 58.72%), amoxyclav (from 26.17% to 40.54%), nitrofurantoin (from 28.82% to 39.06%), and norfloxacin (from 30% to 41.42%). However, the maximum increase in the resistance was noted for co-trimoxazole from 35.58% in 2009 to 63.39% in 2014 (P = 0.0000058). The prevalence of extended-spectrum beta-lactamases (ESBLs) has also significantly increased from 21.7% to 33.16% (P = 0.0045). CONCLUSION Although E. coli remains the prime pathogen in pediatric UTI, the prevalence of resistance has dramatically increased over the 5-year study period. Our study highlights the emergence of community-acquired ESBL-producing uropathogens in children proclaiming treatment challenges.
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Affiliation(s)
- Vrushali Patwardhan
- Division of Clinical Microbiology and Molecular Medicine, Department of Laboratory Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Dinesh Kumar
- Division of Clinical Microbiology and Molecular Medicine, Department of Laboratory Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Varun Goel
- Division of Clinical Microbiology and Molecular Medicine, Department of Laboratory Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Sarman Singh
- Division of Clinical Microbiology and Molecular Medicine, Department of Laboratory Medicine, All India Institute of Medical Sciences, New Delhi, India
- Address for correspondence: Dr. Sarman Singh, Division of Clinical Microbiology and Molecular Medicine, Department of Laboratory Medicine, All India Institute of Medical Sciences, New Delhi - 110 029, India. E-mail:
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Whittle SB, Williamson KC, Russell HV. Incidence and risk factors of bacterial and fungal infection during induction chemotherapy for high-risk neuroblastoma. Pediatr Hematol Oncol 2017; 34:331-342. [PMID: 29200325 PMCID: PMC7185719 DOI: 10.1080/08880018.2017.1396386] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
UNLABELLED High-risk neuroblastoma is an aggressive childhood cancer with poor outcomes. Treatment begins with an induction phase comprised of intense multi-agent chemotherapy with the goal of maximally reducing tumor bulk. Given the high intensity of induction chemotherapy, neutropenic fever and infectious complications are common; however, the actual incidence is difficult to determine from clinical trial reports. We performed a retrospective review of infection-related complications in 76 children treated for high-risk neuroblastoma at Texas Children's Hospital. Medical records were reviewed for demographics, febrile neutropenia (FN) episodes, presence, and type of bacterial and fungal infections, and potential risk factors for infection. Fifty-seven percent of patients developed one or more serious bacterial or fungal infections during induction chemotherapy. Additionally, over 75% of patients had at least one admission for FN. Risk factors for developing any infection included female sex, MYCN amplification, and having Medicaid. Patients with external central venous catheters and those requiring parenteral nutrition had higher rates of bacteremia or fungemia. Each cycle, 50% were readmitted for either FN or infection. The overall burden of infectious complications was high, with 70% having two or more unplanned admissions for infection or FN. The incidence of febrile neutropenia and serious bacterial and fungal infections during induction chemotherapy for high-risk neuroblastoma is high. Most patients had at least two additional hospitalizations for infectious complications. Risk factors including female sex, MYCN amplification, payer status, and type of central access were associated with higher rates of infection in this cohort. ABBREVIATIONS CLABSI Central line associated blood stream infection; CTCAE Common Terminology Criteria for Adverse Events; FN Febrile neutropenia; ANC Absolute neutrophil count; TPN Total parenteral nutrition.
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Affiliation(s)
- Sarah B. Whittle
- Department of Pediatrics, Section of Hematology-Oncology, Texas Children’s Cancer and Hematology Centers, Baylor College of Medicine, Houston, TX
| | - Kaitlin C. Williamson
- Department of Pediatrics, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX
| | - Heidi V. Russell
- Department of Pediatrics, Section of Hematology-Oncology, Texas Children’s Cancer and Hematology Centers, Baylor College of Medicine, Houston, TX
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12
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Classification of pediatric urinary tract dilation: the new language. Pediatr Radiol 2017; 47:1109-1115. [PMID: 28779200 DOI: 10.1007/s00247-017-3883-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Revised: 02/27/2017] [Accepted: 04/28/2017] [Indexed: 10/19/2022]
Abstract
The multidisciplinary consensus on the classification of prenatal and postnatal urinary tract dilation (UTD classification system) was created to unify the language used to describe urinary tract dilation on antenatal and postnatal ultrasound examinations and thereby facilitate communication among providers and improve outcomes research. The background and new classification system are described in this review, with imaging examples.
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Contribution of urinary tract infection to the burden of febrile illnesses in young children in rural Kenya. PLoS One 2017; 12:e0174199. [PMID: 28323886 PMCID: PMC5360311 DOI: 10.1371/journal.pone.0174199] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Accepted: 03/06/2017] [Indexed: 12/03/2022] Open
Abstract
Introduction The clinical features of UTI in young children may not localize to the urinary tract and closely resemble other febrile illnesses. In malaria endemic areas, a child presenting with fever is often treated presumptively for malaria without investigation for UTI. Delayed or inadequate treatment of UTI increases the risk of bacteremia and renal scarring in young children and subsequently complications as hypertension and end stage renal disease in adulthood. Methods A cross-sectional study was carried out in a hospital in western Kenya. Inpatients and outpatients 2 months to five years with axillary temperature ≥37.5°C and no antibiotic use in the previous week were enrolled between September 2012 and April 2013. Urine dipstick tests, microscopy, and cultures were done and susceptibility patterns to commonly prescribed antibiotics established. UTI was defined as presence of pyuria (a positive urine dipstick or microscopy test) plus a positive urine culture. Results A total of 260 subjects were recruited; 45.8% were female and the median age was 25months (IQR: 13, 43.5). The overall prevalence of UTI was 11.9%. Inpatients had a higher prevalence compared to outpatients (17.9% v 7.8%, p = 0.027). UTI co-existed with malaria but the association was not significant (OR 0.80, p = 0.570). The most common organisms isolated were Escherichia coli (64.5%) and Staphylococcus aureus (12.9%) and were sensitive to ciproflaxin, cefuroxime, ceftriaxone, gentamycin and nitrofurantoin but largely resistant to more commonly used antibiotics such as ampicillin (0%), amoxicillin (16.7%), cotrimoxazole (16.7%) and amoxicillin-clavulinate (25%). Conclusion Our study demonstrates UTI contributes significantly to the burden of febrile illness in young children and often co-exists with other infections. Multi-drug resistant organisms are common therefore choice of antimicrobial therapy should be based on local sensitivity pattern.
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Easterbrook B, Capolicchio JP, Braga LH. Antibiotic prophylaxis for prevention of urinary tract infections in prenatal hydronephrosis: An updated systematic review. Can Urol Assoc J 2017; 11:S3-S11. [PMID: 28265307 DOI: 10.5489/cuaj.4384] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION While continuous antibiotic prophylaxis (CAP) is currently recommended to prevent urinary tract infections (UTIs) in infants with prenatal hydronephrosis (HN), this recommendation is not evidence-based. The objective of this study was to systematically determine whether CAP reduces UTIs in the HN population. METHODS Applicable trials were identified through an electronic search of MEDLINE (1946-2015), EMBASE (1980-2016), CINAHL (1982-2016), and CENTRAL (1993-2016) and through a hand search of American Urological Association (AUA) (2012-2015) and European Society for Pediatric Urology (ESPU) (2012-2015) abstracts, as well as reference lists of included trials. The search strategy was not limited by language or year of publication. Eligible studies compared CAP to no CAP in patients with antenatal HN, <2 years of age, and reported development of UTI and HN grades. Two independent reviewers performed title and abstract screening, full-text review, and quality appraisal. RESULTS Of 1518 citations screened, 11 were included, contributing 3909 patients for final analysis. Of these, four (36%) were considered high-quality when assessed by the Newcastle Ottawa Scale. Meta-analysis of the non-randomized trials (n=10) provided similar pooled UTI rates, regardless of CAP use: 9.9% (95% confidence interval [CI] 8.4-11.4%) for CAP and 7.5% (95% CI 6.4-8.6%) for no CAP. CONCLUSIONS This systematic review and meta-analysis suggests there may be value in providing CAP to infants with high-grade HN; however, due to the very low-quality data from non-randomized studies, important clinical variables, such as circumcision status, were unable to be assessed.
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Affiliation(s)
- Bethany Easterbrook
- McMaster Pediatric Surgery Research Collaborative, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - John-Paul Capolicchio
- Division of Urology, Montreal Children's Hospital, McGill University Health Centre, Montreal, QC, Canada
| | - Luis H Braga
- Department of Surgery, Division of Urology, McMaster University, Hamilton, ON, Canada
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15
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Lellig E, Apfelbeck M, Straub J, Karl A, Tritschler S, Stief CG, Riccabona M. [Urinary tract infections in children]. Urologe A 2017; 56:247-262. [PMID: 28154883 DOI: 10.1007/s00120-016-0316-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Urinary tract infections (UTI) are the most common bacterial infections in children. The symptoms are not very specific and range from abdominal pain, poor feeding to nocturnal urinary incontinence. The technique of collecting urine plays an important role for securing the diagnosis. The best way to obtain urine in non-toilet-trained children is catheterization or suprapubic bladder aspiration. In toilet-trained children midstream urine is an acceptable alternative after cleaning the foreskin or labia. In the case of an infection a prompt empirical antibiotic therapy is necessary to reduce the risk of parenchymal scarring of the kidneys. There are different approaches to diagnose vesicoureteral reflux in different countries. The commonly used standard approach in Germany is voiding cystourethrography. In the case of reflux dimercaptosuccinic acid (DMSA) scintigraphy should be performed additionally to exclude renal scarring (bottom-up approach).
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Affiliation(s)
- E Lellig
- Urologische Klinik und Poliklinik, Ludwig-Maximilians-Universität München, Campus Großhadern, Marchioninistr. 15, 81377, München, Deutschland.
| | - M Apfelbeck
- Urologische Klinik und Poliklinik, Ludwig-Maximilians-Universität München, Campus Großhadern, Marchioninistr. 15, 81377, München, Deutschland.
| | - J Straub
- Urologische Klinik und Poliklinik, Ludwig-Maximilians-Universität München, Campus Großhadern, Marchioninistr. 15, 81377, München, Deutschland
| | - A Karl
- Urologische Klinik und Poliklinik, Ludwig-Maximilians-Universität München, Campus Großhadern, Marchioninistr. 15, 81377, München, Deutschland
| | - S Tritschler
- Urologische Klinik und Poliklinik, Ludwig-Maximilians-Universität München, Campus Großhadern, Marchioninistr. 15, 81377, München, Deutschland
| | - C G Stief
- Urologische Klinik und Poliklinik, Ludwig-Maximilians-Universität München, Campus Großhadern, Marchioninistr. 15, 81377, München, Deutschland
| | - M Riccabona
- Urologische Klinik und Poliklinik, Ludwig-Maximilians-Universität München, Campus Großhadern, Marchioninistr. 15, 81377, München, Deutschland
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Ward CS, Huang TW, Herrera JA, Samaco RC, Pitcher MR, Herron A, Skinner SA, Kaufmann WE, Glaze DG, Percy AK, Neul JL. Loss of MeCP2 Causes Urological Dysfunction and Contributes to Death by Kidney Failure in Mouse Models of Rett Syndrome. PLoS One 2016; 11:e0165550. [PMID: 27828991 PMCID: PMC5102405 DOI: 10.1371/journal.pone.0165550] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Accepted: 10/13/2016] [Indexed: 11/19/2022] Open
Abstract
Rett Syndrome (RTT) is a neurodevelopmental disorder characterized by loss of acquired skills during development, autonomic dysfunction, and an increased risk for premature lethality. Clinical experience identified a subset of individuals with RTT that present with urological dysfunction including individuals with frequent urinary tract infections, kidney stones, and urine retention requiring frequent catheterization for bladder voiding. To determine if urologic dysfunction is a feature of RTT, we queried the Rett Syndrome Natural History Study, a repository of clinical data from over 1000 individuals with RTT and found multiple instances of urological dysfunction. We then evaluated urological function in a mouse model of RTT and found an abnormal pattern of micturition. Both male and female mice possessing Mecp2 mutations show a decrease in urine output per micturition event. Furthermore, we identified signs of kidney failure secondary to urethral obstruction. Although genetic strain background significantly affects both survival and penetrance of the urethral obstruction phenotype, survival and penetrance of urethral obstruction do not directly correlate. We have identified an additional phenotype caused by loss of MeCP2, urological dysfunction. Furthermore, we urge caution in the interpretation of survival data as an endpoint in preclinical studies, especially where causes of mortality are poorly characterized.
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Affiliation(s)
- Christopher S. Ward
- Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, United States of America
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX 77030, United States of America
- Jan and Dan Duncan Neurological Research Institute, Texas Children’s Hospital, Houston, TX 77030, United States of America
| | - Teng-Wei Huang
- Program in Developmental Biology, Baylor College of Medicine, Houston, TX 77030, United States of America
| | - José A. Herrera
- Program in Translational Biology and Molecular Medicine, Baylor College of Medicine, Houston, TX 77030, United States of America
| | - Rodney C. Samaco
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX 77030, United States of America
- Program in Translational Biology and Molecular Medicine, Baylor College of Medicine, Houston, TX 77030, United States of America
- Jan and Dan Duncan Neurological Research Institute, Texas Children’s Hospital, Houston, TX 77030, United States of America
| | - Meagan R. Pitcher
- Program in Translational Biology and Molecular Medicine, Baylor College of Medicine, Houston, TX 77030, United States of America
| | - Alan Herron
- Center for Comparative Medicine, Baylor College of Medicine, Houston, TX 77030, United States of America
| | - Steven A. Skinner
- Greenwood Genetic Center, Greenwood, SC 29646, United States of America
| | - Walter E. Kaufmann
- Greenwood Genetic Center, Greenwood, SC 29646, United States of America
- Boston Children’s Hospital, Boston, MA 02115, United States of America
| | - Daniel G. Glaze
- Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, United States of America
| | - Alan K. Percy
- University of Alabama, Birmingham, Birmingham, AL 35294, United States of America
| | - Jeffrey L. Neul
- Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, United States of America
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX 77030, United States of America
- Program in Developmental Biology, Baylor College of Medicine, Houston, TX 77030, United States of America
- Program in Translational Biology and Molecular Medicine, Baylor College of Medicine, Houston, TX 77030, United States of America
- Jan and Dan Duncan Neurological Research Institute, Texas Children’s Hospital, Houston, TX 77030, United States of America
- * E-mail:
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Andrés-Jensen L, Jørgensen FS, Thorup J, Flachs J, Madsen JL, Maroun LL, Nørgaard P, Vinicoff PG, Olsen BH, Cortes D. The outcome of antenatal ultrasound diagnosed anomalies of the kidney and urinary tract in a large Danish birth cohort. Arch Dis Child 2016; 101:819-24. [PMID: 27217581 DOI: 10.1136/archdischild-2015-309784] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Accepted: 04/29/2016] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Antenatal ultrasound diagnosed anomalies of the kidney and urinary tract (AUDAKUT) are reported in 0.3%-5% on prenatal ultrasound (US) and 0.3%-4.5% on postnatal US. The anterior-posterior diameter of the renal pelvis (APD) is an essential measurement. Series with low threshold values of APD prenatally and postnatally will include healthy infants. It is important to avoid follow-up of such infants. INTERVENTIONS In 2006, new Danish guidelines for AUDAKUT were introduced. AIM OF STUDY Investigations of incidences and type of AUDAKUT based on Danish guidelines, including long-term follow-up. DESIGN Cohort study. SETTING Copenhagen University Hospital Hvidovre and Copenhagen University Hospital Rigshospitalet, Denmark. PATIENTS Consecutive cases with AUDAKUT in the second and third trimesters, which were either terminated before 22 completed weeks of gestation or born in the 8-year period January 2006-December 2013. Patients were followed until June 2014. RESULTS 50 193 live born children and 24 terminated fetuses (0.05%) were included. The prevalence of AUDAKUT was only 0.39% prenatally, 0.29% at first postnatal US and 0.22% at the end of follow-up, including terminated cases. The greater the prenatal and postnatal APD, the higher risk of febrile urinary tract infection (fUTI) and surgical intervention, and lower probability of resolution. 25% of the identified patients had fUTI and/or surgery. CONCLUSIONS We recommend threshold values of APD at least 10 mm in the third trimester and in general at least 12 mm at first postnatal US for intensive follow-up. In this largest to date unselected birth cohort of AUDAKUT, the incidences of clinically significant AUDAKUT were in the lowest range of those previously published.
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Affiliation(s)
- Liv Andrés-Jensen
- Department of Paediatrics, Copenhagen University Hospital Hvidovre, Copenhagen, Denmark
| | - Finn Stener Jørgensen
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, Copenhagen University Hospital Hvidovre, Copenhagen, Denmark Faculty of Health Science, University of Copenhagen, Copenhagen, Denmark
| | - Jorgen Thorup
- Faculty of Health Science, University of Copenhagen, Copenhagen, Denmark Department of Paediatric Surgery, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Julie Flachs
- Department of Paediatrics, Copenhagen University Hospital Hvidovre, Copenhagen, Denmark
| | - Jan Lysgaard Madsen
- Department of Clinical Physiology and Nuclear Medicine, Centre for Functional and Diagnostic Imaging and Research, Copenhagen University Hospital Hvidovre, Copenhagen, Denmark
| | - Lisa Leth Maroun
- Department of Pathology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Pernille Nørgaard
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, Copenhagen University Hospital Hvidovre, Copenhagen, Denmark
| | - Pablo Gustavo Vinicoff
- Department of Radiology and Ultrasound, Copenhagen University Hospital Hvidovre, Copenhagen, Denmark
| | - Beth Härstedt Olsen
- Department of Radiology and Ultrasound, Copenhagen University Hospital Hvidovre, Copenhagen, Denmark
| | - Dina Cortes
- Department of Paediatrics, Copenhagen University Hospital Hvidovre, Copenhagen, Denmark Faculty of Health Science, University of Copenhagen, Copenhagen, Denmark
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Urinary tract infection pattern in adult women followed from childhood. Pediatr Nephrol 2016; 31:1107-11. [PMID: 26879801 DOI: 10.1007/s00467-016-3342-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Revised: 01/29/2016] [Accepted: 01/29/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND The aim of this study was to describe the pattern of urinary tract infection (UTI) and bladder function in women who had experienced recurrent UTI in childhood, with and without consequent renal damage, and followed for three to four decades. METHODS A population-based cohort of women who had been followed from the first UTI in childhood and previously studied at a median age of 27 years was studied at a median age of 41 years. Renal damage was evaluated by (99m)Tc-dimercaptosuccinic acid scan. Clinical data were collected on the pattern of recurrent UTIs and bladder function. RESULTS A total of 86 women were investigated, of whom 58 had suffered renal damage and 28 were without. Febrile UTI in adulthood had occurred in 22 patients, once in 15 women and twice or more in seven women. There was a change in the infection pattern over time, evident already in childhood, that was characterized by a decrease in UTI frequency and a shift from febrile to non-febrile infections. A significant association was found between renal damage and febrile UTI (p = 0.046), and between abnormal bladder function and recurrent non-febrile UTI (p = 0.002). There was no relationship between persisting vesicoureteral reflux (VUR) and proneness to either symptomatic UTI (p = 0.99) or febrile UTI in adulthood (p = 0.14). CONCLUSIONS Among this study cohort there was a continuously decreasing rate of febrile UTI in adulthood. Persisting VUR was not related to UTI in adulthood. Abnormal bladder function was related to non-febrile UTI but not to febrile UTI.
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Lüthje P, Brauner A. Novel Strategies in the Prevention and Treatment of Urinary Tract Infections. Pathogens 2016; 5:E13. [PMID: 26828523 PMCID: PMC4810134 DOI: 10.3390/pathogens5010013] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Revised: 08/05/2015] [Accepted: 01/21/2016] [Indexed: 01/15/2023] Open
Abstract
Urinary tract infections are one of the most common bacterial infections, especially in women and children, frequently treated with antibiotics. The alarming increase in antibiotic resistance is a global threat to future treatment of infections. Therefore, alternative strategies are urgently needed. The innate immune system plays a fundamental role in protecting the urinary tract from infections. Antimicrobial peptides form an important part of the innate immunity. They are produced by epithelial cells and neutrophils and defend the urinary tract against invading bacteria. Since efficient resistance mechanisms have not evolved among bacterial pathogens, much effort has been put into exploring the role of antimicrobial peptides and possibilities to utilize them in clinical practice. Here, we describe the impact of antimicrobial peptides in the urinary tract and ways to enhance the production by hormones like vitamin D and estrogen. We also discuss the potential of medicinal herbs to be used in the prophylaxis and the treatment of urinary tract infections.
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Affiliation(s)
- Petra Lüthje
- Department of Microbiology, Tumor and Cell Biology, Division of Clinical Microbiology, Karolinska Institutet and Karolinska University Hospital, Stockholm SE-171 76, Sweden.
| | - Annelie Brauner
- Department of Microbiology, Tumor and Cell Biology, Division of Clinical Microbiology, Karolinska Institutet and Karolinska University Hospital, Stockholm SE-171 76, Sweden.
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20
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Fuente MÁ, Costa TS, García BS, Serrano MA, Alonso MS, Luján EA. Practical approach to screen vesicoureteral reflux after a first urinary tract infection. Indian J Urol 2014; 30:383-6. [PMID: 25378818 PMCID: PMC4220376 DOI: 10.4103/0970-1591.142055] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Introduction: Vesicoureteral reflux (VUR) is a common pediatric urologic disorder. After the first urinary tract infection (UTI), imaging studies are recommended, starting with a renal ultrasound (RUS). Voiding cystourethrography (VCUG) and dimercaptosuccinic acid (DMSA) scan are the other main radiologic studies used to detect VUR. We evaluated the use of RUS as a screening method for VUR in children below 2 years of age, in order to avoid unnecessary VCUG. Materials and Methods: Medical records and imaging studies of infants (<2 years) who had their first UTI in a 6 year period were retrospectively reviewed. We evaluated the sensitivity, specificity, and negative predictive values of RUS and DMSA for diagnosing VUR. Results: Among 155 children (51% males) with their first UTI, 148 RUS were performed, 128 VCUG and 29 DMSA. VUR was detected in 21% patients; 14.5% low grade and 6.5% high grade. One hundred and twenty-one patients underwent both RUS and VCUG, 101 RUS were normal and 20 abnormal. Of the normal RUS 98% had no or low grade VUR. Among those with an abnormality on RUS 30% had high grade VUR (P < 0.001). Conclusions: After the first UTI in infants (<2 years) RUS is a good screening method for VUR. Among such shildren with a normal RUS, we do not recommend VCUG or DMSA. In our opinion, VCUG should be performed only in patients with abnormal findings in RUS or in recurrent UTI.
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Affiliation(s)
| | - Talía Sainz Costa
- Department of Pediatrics, Hospital Clínico San Carlos, Madrid, Spain
| | | | | | | | - Esther Aleo Luján
- Department of Pediatrics, Hospital Clínico San Carlos, Madrid, Spain
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McMullen JA, Mahant S, DeGroot JM, Stephens D, Parkin PC. Predictors of long length of stay in infants hospitalized with urinary tract infection. Hosp Pediatr 2014; 4:291-7. [PMID: 25318111 DOI: 10.1542/hpeds.2014-0020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Urinary tract infection (UTI) is the most common serious bacterial infection in infants. To use resources optimally, factors contributing to costs through length of stay (LOS) must be identified. This study sought to identify clinical and health system factors associated with long LOS in infants with UTI. METHODS Using a case-control design, we included infants <6 months old hospitalized with UTI. Cases had LOS ≥96 hours; controls had LOS <96 hours. Clinical and health system variables were extracted from medical records. Cases and controls were compared by using comparative statistics and multiple logistic regression analysis. RESULTS Cases (n = 71) and controls (n = 71) did not differ by gender; cases were more likely to be younger (4.2 vs 7.1 weeks, P = .04), born preterm (13% vs 3%, P = .03), have known genitourinary disease (17% vs 4%, P = .01), an ultrasound (85% vs 68%, P = .02) or voiding cystourethrogram (VCUG) (61% vs 34%, P = .001) ordered, longer wait for VCUG (53 vs 27 hours, P = .002), consult requested (54% vs 10%, P < .001), and longer duration of intravenous (IV) antibiotics (125 vs 62 hours, P < .001). Multiple logistic regression demonstrated that cases were more likely to be premature (odds ratio [OR] 7.6), have known genitourinary disease (OR 7.3), and have VCUG ordered in the hospital (OR 4.5). CONCLUSIONS Infants who are older, are born full term, have no genitourinary disease, receive shorter courses of IV antibiotics, and do not have a VCUG ordered have shorter stays and may be eligible for a short-stay unit. Earlier transition to oral antibiotics and delayed ordering of a VCUG may decrease LOS.
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Affiliation(s)
| | - Sanjay Mahant
- Division of Paediatric Medicine and the Paediatric Outcomes Research Team (PORT), Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada, and Child Health Evaluative Sciences, and Department of Paediatrics, Faculty of Medicine Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Julie M DeGroot
- Division of Paediatric Medicine and the Paediatric Outcomes Research Team (PORT), Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada, and
| | - Derek Stephens
- Clinical Research Sciences, SickKids Research Institute, Toronto, Ontario, Canada Dalla Lana School of Public Health, and
| | - Patricia C Parkin
- Division of Paediatric Medicine and the Paediatric Outcomes Research Team (PORT), Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada, and Child Health Evaluative Sciences, and Department of Paediatrics, Faculty of Medicine Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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22
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Swerkersson S, Jodal U, Åhrén C, Hansson S. Urinary tract infection in small outpatient children: the influence of age and gender on resistance to oral antimicrobials. Eur J Pediatr 2014; 173:1075-81. [PMID: 24623269 DOI: 10.1007/s00431-014-2289-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Revised: 02/11/2014] [Accepted: 02/16/2014] [Indexed: 11/26/2022]
Abstract
UNLABELLED Urinary tract infection (UTI) is a common bacterial disease in small children in which treatment with antimicrobials is used. The worldwide increase of bacterial resistance to these drugs is threatening the efficacy of such treatment and may increase the risk for long-term damage. The aim of this retrospective study was to analyse the development of resistance to oral antimicrobials over a 10-year period in an unselected outpatient population of small children with first-time UTI. The patient material included 494 boys and 512 girls below 2 years of age with community acquired symptomatic UTI. Escherichia coli bacteria were isolated in 96 % of girls and 89 % of boys (p < 0.0001). The overall resistance of E. coli was 14 % to trimethoprim and below 1 % to cefadroxil and nitrofurantoin. Over the 10-year period, the trimethoprim resistance of E. coli increased from 5 to 17 % but remained unchanged to cefadroxil and nitrofurantoin. E. coli resistance to trimethoprim was related to age: 11 % below and 19 % above 9 months (p < 0.01). The increase in resistance over time and with age was found only in girls. CONCLUSION The increasing resistance of E. coli to trimethoprim makes this drug less suitable for empiric treatment of UTI. Young children with UTI seem predisposed to early development of resistance. Therefore, surveillance of resistance to antimicrobials with special regard to age and gender is recommended.
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Affiliation(s)
- Svante Swerkersson
- Department of Pediatrics, Pediatric Uronephrologic Center, The Queen Silvia Children's Hospital, Sahlgrenska University Hospital, 416 85, Göteborg, Sweden,
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Alsammani MA, Ahmed MI, Abdelatif NF. Bacterial uropathogens isolates and antibiograms in children under 5 years of age. Med Arch 2014; 68:239-43. [PMID: 25568544 PMCID: PMC4240567 DOI: 10.5455/medarh.2014.68.239-243] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2014] [Accepted: 06/30/2014] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Childhood urinary infections are among the most common febrile illnesses occurring during this period with varying susceptibility to antibiotic. AIM The aim of this study was to identify uropathogens responsible to for urinarytract infection (UTIs) in children less than 5 years of age, and determine the antibiograms of the isolates to commonly used antibiotics. PATIENTS AND METHODS Hundred and four children (2 months - 5 years old) seen at the Gadarif Teaching Hospital from January 2012 and December 2013 were evaluated. A urine specimen was obtained by a plastic bag with an adhesive backing around an opening or by direct voiding into sterile container. Urine was examined microscopically and those with significant pyuria and bacteruria were further cultured and microorganisms were identified and tested for antimicrobial susceptibility. RESULTS Out of 304 children suffering from UTIs; 145(47.7%) had significant pyuria of them; 54(17.8 %) had positive bacterial growth. The frequency of sex and residency were almost the same. E. coli (42.6%) was the most common uropathogen, sensitive to ciprofloxacin (91.3%), followed by Pseudomonas aeruginosa (29.6%) sensitive to Ciprofloxacin (75%)and Norofloxacin (68.8%), Klebsiellapneumoniae (18.5%) sensitive to Ciprofloxacin and Norofloxacin and Nalidixic acid (90%) and Proteus mirabilis sensitive to Ciprofloxacin and Norofloxacin (90%), Amoxicillin / clavulanic acid (Augmentin(80%). CONCLUSION The most common uropathogens were E. coli, Pseudomonas aeruginosa,Klebsiellapneumoniae, and Proteus mirabilis. Ciprofloxacin is the recommended initial empirical therapy while awaiting the culture and sensitivity results.
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Affiliation(s)
- Mohamed Alkhatim Alsammani
- Department of Medical Biochemistry, College of Applied Medical Sciences, Qassim University, Bahri, Sudan
| | - Mohamed Issa Ahmed
- Department of Medical Biochemistry, College of Applied Medical Sciences, Qassim University, Bahri, Sudan
| | - Nahla Farouk Abdelatif
- Department of Medical Biochemistry, College of Applied Medical Sciences, Qassim University, Bahri, Sudan
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Abstract
OBJECTIVES The objective of this study was (1) to determine the reliability of urinalysis (UA) for predicting urinary tract infection (UTI) in febrile children, (2) to determine whether UA findings can predict Escherichia coli versus non-E. coli urinary tract infection, and (3) to determine if empiric antibiotics should be selected based on E. coli versus non-E. coli infection predictions. METHODS This was a retrospective chart review of children from 2 months to 2 years of age who presented to the emergency department with fever (rectal temperature >100.4°F) and had a positive urine culture. This study was conducted between January 2004 and December 2007. Negative UA was defined as urine white blood cell count less than 5 per high-power field, negative leukocyte esterase, and negative nitrites. Urine cultures were classified into E. coli and non-E. coli groups. These groups were compared for sex, race, and UA findings. Multivariate forward logistic regression, using the Wald test, was performed to calculate the likelihood ratio (LR) of each variable (eg, sex, race, UA parameters) in predicting UTI. In addition, antibiotic sensitivities between both groups were compared. RESULTS Of 749 medical records reviewed, 608 were included; negative UA(-) was present in 183 cases, and positive UA(+) was observed in 425 cases. Furthermore, 424 cases were caused by E. coli, and 184 were due to non-E. coli organisms. Among 425 UA(+) cases, E. coli was identified in 349 (82.1%), whereas non-E. coli organisms were present in 76 (17.9%); in contrast, in 183 UA(-) cases, 108 (59%) were due to non-E. coli organisms versus 75 (41%), which were caused by E. coli. Urinalysis results were shown to be associated with organism group (P < 0.001). Positive leukocytes esterase had an LR of 2.5 (95% confidence interval [CI], 1.5-4.2), positive nitrites had an LR of 2.8 (95% CI, 1.4-5.5), and urine white blood cell count had an LR of 1.8 (95% CI, 1.3-2.4) in predicting E. coli versus non-E. coli infections. Antibiotic sensitivity compared between UA groups demonstrated equivalent superiority of cefazolin (94.7% sensitive in UA(+) vs 84.0% in UA(-) group; P < 0.0001), cefuroxime (98.2% vs 91.7%; P < 0.001), and nitrofurantoin (96.1% vs 82.2%; P < 0.0001) in the UA(+) group. In contrast, the UA(-) group showed significant sensitivity to trimethoprim-sulfamethoxazole (82.2% vs 71.3% in UA(+); P = 0.008). CONCLUSIONS Urinalysis is not an accurate predictor of UTI. A positive urine culture in the presence of negative UA most likely grew non-E. coli organisms, whereas most UA(+) results were associated with E. coli. This study also highlighted local patterns of antibiotic resistance between E. coli and non-E. coli groups. Negative UA results in the presence of strong suspicion of a UTI suggest a non-E. coli organism, which may be best treated with trimethoprim-sulfamethoxazole. Conversely, UA(+) results suggest E. coli, which calls for treatment with cefazolin or cefuroxime.
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Urinary Measurement of Neutrophil Gelatinase Associated Lipocalin and Kidney Injury Molecule-1 Helps Diagnose Acute Pyelonephritis in a Preclinical Model. J Biomark 2013; 2013:413853. [PMID: 26317016 PMCID: PMC4437360 DOI: 10.1155/2013/413853] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2013] [Accepted: 11/06/2013] [Indexed: 11/30/2022] Open
Abstract
Background. The study assessed whether measurement of urinary biomarkers of acute kidney injury could be helpful in diagnosing acute pyelonephritis and subsequent scarring. Method. Escherichia coli J96 (0.3 mL inoculum containing 1 × 109/mL) was directly injected into the renal cortex of 3-week-old female Sprague Dawley rats (n = 20), with saline substituted in a control group (n = 10). Following the injection, urine was collected 2, 7, 14, 28, and 42 days after injection. Urinary neutrophil gelatinase associated lipocalin (NGAL), kidney injury molecule-1 (Kim-1), and interleukin-18 were quantitatively measured using enzyme-linked immunosorbent assay (ELISA). The levels of the biomarkers were adjusted for creatinine. Time course changes within a group or between the groups were compared. Correlation analysis was performed to understand the relationship between urinary levels and histological scarring. Results. Significantly elevated urinary NGAL was evident at two and seven days after injection, and Kim-1 was elevated at two days after injection. Receiver operating characteristic analyses confirmed the sensitivity of these markers at these times. No urinary marker at acute stage of APN was correlated with the amount of future scarring, negating their predictive value. Conclusion. Urinary NGAL and Kim-1 could be helpful in diagnosing febrile urinary tract infection in children.
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Abstract
In infants and young children, urinary tract infections (UTI) often present with unspecific symptoms. Appropriate techniques of urine sampling play an important role for accurate microbiological diagnosis. In infants urine sampling by bladder puncture or transurethral catheter is recommended. In young infants with suspected pyelonephritis, calculated antibiotic treatment should be initiated parenterally with a combination of a third generation cephalosporin or an aminoglycoside with ampicillin. After the age of 3-6 months group 3 oral cephalosporins can be used in uncomplicated pyelonephritis. With the first febrile UTI early sonography is recommended to provide information about renal parenchymal involvement and to exclude malformations of the kidneys and urinary tract. Strategies for the recognition of vesicoureteral reflux and renal damage are under discussion. Recently published guidelines by the American Academy of Pediatrics for the diagnosis and management of UTI in febrile children and infants aged 2-24 months will most likely influence the still pending German guidelines.
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Affiliation(s)
- R Beetz
- Zentrum für Kinder- und Jugendmedizin, Universitätsmedizin Mainz, Johannes Gutenberg- Universität, Mainz.
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Couture E, Labbé V, Cyr C. Clinical predictors of positive urine cultures in young children at risk for urinary tract infection. Paediatr Child Health 2013; 8:145-9. [PMID: 20020011 DOI: 10.1093/pch/8.3.145] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Urinary tract infections (UTIs) are a common source of bacterial infection among young febrile children. The diagnosis of UTI is challenging because the clinical presentation is not specific. OBJECTIVE To describe clinical predictors to identify young children needing urine culture for evaluation of UTI. METHODS Retrospective cohort study of all children younger than two years of age (719 hospital visits for 545 patients) suspected of having a UTI during a 12-month period. The outcome was UTI, defined as a catheterized urine culture with pure growth of 10⁴ colonies/mL or greater, or suprapubic aspiration culture with 10³ colonies/mL or greater. Candidate predictors included demographic, historical and physical examination variables. RESULTS The medical records of 545 children younger than two years of age were reviewed. Forty-six per cent were girls. Mean age was 9.1 months (SD 7 months). Four variables were found to predict UTI: absence of another source of fever on examination (odds ratio [OR]=41.6 [95% CI, 8.8 to 197.4]), foul smelling urine (OR=19.7 [95% CI, 5.7 to 68.2]), white blood cell count greater than 15,000/mm³ (OR=4.3 [95% CI, 2.0 to 9.3]), younger than six months old (OR=3.1 [95% CI, 1.3 to 7.1]). The sensitivity of an abnormal urine analysis was 0.77 (95% CI, 0.66 to 0.88) and the specificity was 0.31 (95% CI, 0.2 to 0.42). CONCLUSION An incremental increase in risk for UTI is associated with younger age (younger than six months), having a white blood cell count higher than 15,000/mm³, parental report of malodorous or foul smelling urine and the absence of an alternative source of fever. In the present patient population, obtaining a urine culture from children with at least one of these clinical predictors would have resulted in missing one UTI (2%), and 111 negative cultures (20%) would have been avoided.
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Affiliation(s)
- Elise Couture
- Département de pédiatrie, Centre hospitalier universitaire de Sherbrooke, Université de Sherbrooke, Sherbrooke (Québec)
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Lee HC, Kurtin PS, Wight NE, Chance K, Cucinotta-Fobes T, Hanson-Timpson TA, Nisbet CC, Rhine WD, Risingsun K, Wood M, Danielsen BH, Sharek PJ. A quality improvement project to increase breast milk use in very low birth weight infants. Pediatrics 2012; 130:e1679-87. [PMID: 23129071 PMCID: PMC3507251 DOI: 10.1542/peds.2012-0547] [Citation(s) in RCA: 99] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To evaluate a multihospital collaborative designed to increase breast milk feeding in premature infants. METHODS Eleven NICUs in the California Perinatal Quality of Care Collaborative participated in an Institute for Healthcare Improvement-style collaborative to increase NICU breast milk feeding rates. Multiple interventions were recommended with participating sites implementing a self-selected combination of these interventions. Breast milk feeding rates were compared between baseline (October 2008-September 2009), implementation (October 2009-September 2010), and sustainability periods (October 2010-March 2011). Secondary outcome measures included necrotizing enterocolitis (NEC) rates and lengths of stay. California Perinatal Quality of Care Collaborative hospitals not participating in the project served as a control population. RESULTS The breast milk feeding rate in the intervention sites improved from baseline (54.6%) to intervention period (61.7%; P = .005) with sustained improvement over 6 months postintervention (64.0%; P = .003). NEC rates decreased from baseline (7.0%) to intervention period (4.3%; P = .022) to sustainability period (2.4%; P < .0001). Length of stay increased during the intervention but returned to baseline levels in the sustainability period. Control hospitals had higher rates of breast milk feeding at baseline (64.2% control vs 54.6% participants, P < .0001), but over the course of the implementation (65.7% vs 61.7%, P = .049) and sustainability periods (67.7% vs 64.0%, P = .199), participants improved to similar rates as the control group. CONCLUSIONS Implementation of a breast milk/nutrition change package by an 11-site collaborative resulted in an increase in breast milk feeding and decrease in NEC that was sustained over an 18-month period.
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Affiliation(s)
- Henry C. Lee
- Division of Neonatology, Department of Pediatrics, University of California, San Francisco, San Francisco, California;,California Perinatal Quality Care Collaborative, Stanford, California
| | - Paul S. Kurtin
- Department of Quality Management, Rady Children’s Hospital, San Diego, California
| | - Nancy E. Wight
- Sharp Mary Birch Hospital for Women and Infants, San Diego, California
| | - Kathy Chance
- Children’s Medical Services Branch, California Department of Health Care Services, Sacramento, California
| | | | | | | | | | | | | | | | - Paul J. Sharek
- California Perinatal Quality Care Collaborative, Stanford, California;,General Pediatrics, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California;,Center for Quality and Clinical Effectiveness, Lucile Packard Children’s Hospital, Palo Alto, California; and
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Tramma D, Hatzistylianou M, Gerasimou G, Lafazanis V. Interleukin-6 and interleukin-8 levels in the urine of children with renal scarring. Pediatr Nephrol 2012; 27:1525-30. [PMID: 22527530 DOI: 10.1007/s00467-012-2156-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2010] [Revised: 02/20/2012] [Accepted: 03/07/2012] [Indexed: 11/30/2022]
Abstract
BACKGROUND Acute pyelonephritis (APN) is one of the most significant bacterial infections in infancy and early childhood, and can lead to permanent kidney damage and chronic renal failure. OBJECTIVE To evaluate interleukin-6 (IL-6) and interleukin-8 (IL-8) levels in the urine of children with renal scarring (RS), searching for clinical information about the immuno-inflammatory process that contributes to RS. METHODS Urine concentrations of IL-6 and IL-8 were evaluated in 50 children, 33 with RS detected after an episode of acute pyelonephritis (group A) and 17 children with a history of acute pyelonephritis, but without RS (group B). These children were divided into four groups: group A(1), 23 children with RS and vesicoureteral reflux (VUR); group A(2), 10 children with RS without VUR; group B(1), 13 children without RS and without VUR; group B(2), 4 children without RS, but with VUR. None of them had had urinary tract infection for a minimum of 6 months. To avoid dilution effects, urinary levels of IL-6 and IL-8 were expressed as the ratio of cytokine to urinary creatinine (pg/mg). RESULTS Urinary IL-8 levels were below the lower detection limit in all samples. IL-6 was detectable in the majority of children with RS and below the detection limits in the urine samples of children without RS. There were no statistically significant differences between urinary interleukin-6 levels in children with and those without VUR. There was a significant relationship between the grade of renal scars, the time passed since the last episode of acute pyelonephritis and the urinary levels of IL-6 (p < 0.0001 and p < 0.04 respectively). CONCLUSION Further experimental studies are required to demonstrate the correlation between histopathology and urinary cytokine levels.
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Affiliation(s)
- Despoina Tramma
- 4th Pediatric Department, Aristotle University of Thessaloniki, Thessaloniki, Greece.
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Felber M, Schabmann A, Inschlag N, Karesch L, Ponocny-Seliger E, Friedrich MH, Völkl-Kernstock S. Effects of parental soothing behavior on stress levels of 2-8 year old children during voiding cystourethrograms by phase of procedure. J Clin Psychol Med Settings 2012; 18:400-9. [PMID: 21969226 DOI: 10.1007/s10880-011-9260-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Using the example of a voiding cystourethrogram (VCUG), a painful radiological procedure, this study investigated whether parental soothing behavior (reassuring comments like "it's almost over" or "You're O.K." and soothing by "sh, sh") in one phase of the procedure influenced the child's distress in the following phase. The sample was comprised of 68 2-8 year-old children and the accompanying parent(s). Child and parental behavior during the VCUG was coded using a standardized rating scale (CAMPIS-R). Parental reassurance during the anticipatory phase significantly increased the child's distress of the following phase, while parental "sh, sh" significantly reduced it. Both parental behaviors showed no significant effect on the child's distress of the following phase when applied during the procedure itself. Results underline the importance of differentiating between anticipatory and procedural phases of the VCUG. Counselling methods for parents on more appropriate strategies to assist their children during procedural phases of the VCUG are necessary.
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Affiliation(s)
- Michaela Felber
- Department of Economic Psychology, Educational Psychology and Evaluation, University of Vienna, Vienna, Austria
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Salo J, Uhari M, Helminen M, Korppi M, Nieminen T, Pokka T, Kontiokari T. Cranberry juice for the prevention of recurrences of urinary tract infections in children: a randomized placebo-controlled trial. Clin Infect Dis 2011; 54:340-6. [PMID: 22100577 DOI: 10.1093/cid/cir801] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Cranberry juice prevents recurrences of urinary tract infections (UTIs) in adult women. The objective of this study was to evaluate whether cranberry juice is effective in preventing UTI recurrences in children. METHODS A double-blind randomized placebo-controlled trial was performed in 7 hospitals in Finland. A total of 263 children treated for UTI were randomized to receive either cranberry juice (n = 129) or placebo (n = 134) for 6 months. Eight children were omitted because of protocol violations, leaving 255 children for the final analyses. The children were monitored for 1 year, and their recurrent UTIs were recorded. RESULTS Twenty children (16%) in the cranberry group and 28 (22%) in the placebo group had at least 1 recurrent UTI (difference, -6%; 95% confidence interval [CI], -16 to 4%; P = .21). There were no differences in timing between these first recurrences (P = .32). Episodes of UTI totaled 27 and 47 in the cranberry and placebo groups, respectively, and the UTI incidence density per person-year at risk was 0.16 episodes lower in the cranberry group (95% CI, -.31 to -.01; P = .035). The children in the cranberry group had significantly fewer days on antimicrobials (-6 days per patient-year; 95% CI, -7 to -5; P < .001). CONCLUSIONS The intervention did not significantly reduce the number of children who experienced a recurrence of UTI, but it was effective in reducing the actual number of recurrences and related antimicrobial use.
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Affiliation(s)
- Jarmo Salo
- Department of Paediatrics, Oulu University Hospital, University of Oulu, Finland.
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Leroy S, Gervaix A. Procalcitonin: a key marker in children with urinary tract infection. Adv Urol 2011; 2011:397618. [PMID: 21274426 PMCID: PMC3026964 DOI: 10.1155/2011/397618] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2010] [Revised: 12/20/2010] [Accepted: 12/21/2010] [Indexed: 01/12/2023] Open
Abstract
Urinary tract infections (UTIs) are the most common source of bacterial infections among young febrile children. Accurate diagnosis of acute pyelonephritis (APN) and vesicoureteral reflux (VUR) is important because of their association with renal scarring, leading in the cases to long-term complications. However, the gold standard examinations for both are either DMSA scan (for APN and scar) or cystography (for VUR) and present limitations (feasibility, pain, cost, etc.). Procalcitonin, a reliable marker of bacterial infections, was demonstrated to be a good predictor of both renal parenchymal involvement in the acute phase and late renal scars. Furthermore, it was also found to be associated with high-grade VUR and was the key tool of a clinical decision rule to predict high-grade VUR in children with a first UTI. Therefore, procalcitonin may certainly be found playing a role in the complex and still debated picture of which examination should be performed after UTI in children.
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Affiliation(s)
- Sandrine Leroy
- Centre for Statistics in Medicine, Wolfson College Annexe, University of Oxford, Linton Road, Oxford OX2 6UD, UK
- Pasteur Institute, 75015 Paris, France
| | - Alain Gervaix
- Department of Pediatrics, University Hospital of Geneva, 1211 Geneva, Switzerland
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Impressive renal damage after acute pyelonephritis in a child. Pediatr Nephrol 2010; 25:1365-8. [PMID: 20157735 DOI: 10.1007/s00467-010-1461-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2009] [Revised: 12/18/2009] [Accepted: 12/29/2009] [Indexed: 10/19/2022]
Abstract
Urinary tract infection (UTI) is one of the most common bacterial infections in children, and its role in the pathogenesis of scarred kidney is debated. We report on a 7-year-old child who presented with severe UTI. The early (day 4) renal computed tomography (CT) scan showed normal-sized kidneys (110 mm on the left, 105 mm on the right), whereas the control CT scan and dimercaptosuccinic acid (DMSA) scan, performed 1 and 2 months later, respectively, showed a small scarred right kidney (60 mm) with a 12% residual function. An intermittent right vesicoureteral reflux (VUR) was diagnosed by direct isotopic cystography and then treated by Cohen vesicoureteral reimplantation. The patient remained free of infectious recurrence, hypertension, or renal function decrease. This report demonstrates that one episode of acute pyelonephritis can lead to severe renal scarring. Whereas antenatal lesions are thought to have a stronger role in the causal pathway for reflux nephropathy than is UTI in addition to VUR, this observation reminds us that UTI can truly play an important role in damaging kidneys.
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Controversies in the management of vesicoureteral reflux: the rationale for the RIVUR study. J Pediatr Urol 2009; 5:336-41. [PMID: 19570724 PMCID: PMC3163089 DOI: 10.1016/j.jpurol.2009.05.010] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2009] [Accepted: 05/13/2009] [Indexed: 11/22/2022]
Abstract
UNLABELLED The current management of vesicoureteral reflux (VUR) focuses on the prevention of urinary tract infections (UTI), with curative surgery being limited to those children that fail conservative measures. This is based on the assumption that UTIs are preventable with the use of prophylatic antibiotics, leading to reduction of renal scarring, and the possibility that VUR in children can resolve spontaneously. METHODS Review of the recent literature has demonstrated a growing concern that antibiotic prophylaxis may not lead to prevention of UTIs. Additionally, data indicate that renal scarring may not be preventable with antibiotic prophylaxis or even surgical correction of VUR. An overview of all of the current controversies is presented in this paper. RESULTS Does antibiotic prophylaxis lead to reduction in UTIs in children with VUR? To address this question, the National Institutes of Health have developed a randomized placebo-controlled study of children with VUR (the RIVUR Study), identified following the development of a UTI. CONCLUSIONS There are far reaching consequences of the results of the RIVUR Study. If antibiotic prophylaxis does not prevent UTI in children with VUR, or lead to reduction in renal scarring, does identification of VUR provide any benefits? Perhaps appropriate treatment of UTI may be all that is necessary for preserving renal function. Final answers will have to wait until the completion of this study.
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Comparing stress levels in children aged 2-8 years and in their accompanying parents during first-time versus repeated voiding cystourethrograms. Wien Klin Wochenschr 2008; 120:414-21. [PMID: 18726667 DOI: 10.1007/s00508-008-1001-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2007] [Accepted: 05/20/2008] [Indexed: 10/21/2022]
Abstract
OBJECTIVES Invasive procedures such as voiding cystourethrograms (VCUGs) cause distress in both children and their accompanying parents. The main purpose of this study was to examine whether stress levels in children and their parents differ during first-time and repeated VCUGs. The second objective was to examine the relationship between parental behavior (behavior promoting child coping and behavior promoting child distress), parental stress levels and child distress in first-time versus repeated VCUGs. METHODS In a prospective study, the distress behavior of 31 children aged 2-8 years who were undergoing a repeated VCUG was examined. A second group of 31 children who were undergoing a VCUG for the first time served as a control sample. Child and parental behavior during the VCUG was coded by three independent observers using a standardized rating scale (CAMPIS-R, Blount et al.). Children reported on their stress levels using a faces scale; parents and radiologists rated the child's distress on a visual analog scale. Similarly, parents assessed their own stress levels on a visual analog scale. RESULTS The stress levels of children undergoing a repeated VCUG do not differ from those of children undergoing a VCUG for the first time, but parental stress levels were significantly lower during repeated VCUGs. In both VCUG groups there was significant positive correlation between parental distress-promoting behavior and child distress, and between parental stress levels and child distress. Parental coping-promoting behavior showed no significant correlation with child distress or parental stress levels in either VCUG group. Parental stress levels and parental distress-promoting behavior correlated positively only for repeated VCUGs. Neither parental coping- nor distress-promoting behavior differed between first-time versus repeated VCUG groups. CONCLUSIONS Repeated VCUGs and first-time VCUGs are both highly distressing procedures for children. Even though parental stress levels are lower during repeated VCUGs, spontaneous parental behavior proves to be ineffective or even counterproductive in reducing the child's distress. Further research into efficient counseling and training methods for parents and children undergoing VCUGs is required.
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Kwok WY, de Kwaadsteniet MCE, Harmsen M, van Suijlekom-Smit LWA, Schellevis FG, van der Wouden JC. Incidence rates and management of urinary tract infections among children in Dutch general practice: results from a nation-wide registration study. BMC Pediatr 2006; 6:10. [PMID: 16584577 PMCID: PMC1450286 DOI: 10.1186/1471-2431-6-10] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2005] [Accepted: 04/04/2006] [Indexed: 05/08/2023] Open
Abstract
Background We aimed to investigate incidence rates of urinary tract infections in Dutch general practice and their association with gender, season and urbanisation level, and to analyse prescription and referral in case of urinary tract infections. Method During one calendar year, 195 general practitioners in 104 practices in the Netherlands registered all their patient contacts. This study was performed by the Netherlands Institute for Health Services Research (NIVEL) in 2001. Of 82,053 children aged 0 to 18 years, the following variables were collected: number of episodes per patient, number of contacts per episode, month of the year in which the diagnosis of urinary tract infection was made, age, gender, urbanisation level, drug prescription and referral. Results The overall incidence rate was 19 episodes per 1000 person years. The incidence rate in girls was 8 times as high as in boys. The incidence rate in smaller cities and rural areas was 2 times as high as in the three largest cities. Throughout the year, incidence rates varied with a decrease in summertime for children at the age of 0 to 12 years. Of the prescriptions, 66% were in accordance with current guidelines, but only 18% of the children who had an indication were actually referred. Conclusion This study shows that incidence rates of urinary tract infections are not only related to gender and season, but also to urbanisation. General practitioners in the Netherlands frequently do not follow the clinical guidelines for urinary tract infections, especially with respect to referral.
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Affiliation(s)
- Wing-Yee Kwok
- Department of General Practice, Erasmus MC - University Medical Center Rotterdam, PO Box 1738, 3000 DR, Rotterdam The Netherlands
| | - Marjolein CE de Kwaadsteniet
- Department of General Practice, Erasmus MC - University Medical Center Rotterdam, PO Box 1738, 3000 DR, Rotterdam The Netherlands
| | - Mirjam Harmsen
- Centre for Quality of Care Research (WOK), Radboud University Nijmegen Medical Centre, PO Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Lisette WA van Suijlekom-Smit
- Department of Paediatrics, Erasmus MC - University Medical Center/Sophia Children's Hospital, PO Box 1738, 3000 DR Rotterdam, The Netherlands
| | - François G Schellevis
- Netherlands Institute for Health Services Research (NIVEL), PO Box 1568, 3500 BN Utrechtt the Netherlands
| | - Johannes C van der Wouden
- Department of General Practice, Erasmus MC - University Medical Center Rotterdam, PO Box 1738, 3000 DR, Rotterdam The Netherlands
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Gbadegesin RA, Cotton SA, Watson CJ, Brenchley PEC, Webb NJA. Association between ICAM-1 Gly-Arg polymorphism and renal parenchymal scarring following childhood urinary tract infection. Int J Immunogenet 2006; 33:49-53. [PMID: 16426244 DOI: 10.1111/j.1744-313x.2006.00565.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Renal parenchymal scarring (RPS) following urinary tract infection (UTI) is an important cause of renal morbidity in children. Studies have shown that the intensity of the inflammatory response following infection is related to the risk of RPS. However, genetic variability in this response has not been studied. Adhesion molecules play a crucial role in leucocyte recruitment following infection, and polymorphisms have been reported in the genes for key cell adhesion molecules. We have investigated the possibility that children who develop RPS following UTI may exhibit altered genotype or allele frequencies for polymorphisms of the intercellular adhesion molecule-1 (ICAM-1) (exons 4 and 6), E-selectin (exons 2 and 4), platelet endothelial cell adhesion molecule-1 (PECAM-1) (exon 3) and CD11b (3'UTR) genes, which may predict outcome of UTI. DNA was isolated from 99 children shown to have developed RPS, 43 children with no evidence of scarring (NS) following UTI and 170 healthy controls. Genotyping was performed by restriction fragment length polymorphism (RFLP) analysis. When the RPS group was compared with the NS group, there was a significant reduction in the frequency of the ICAM-1 exon 4 A allele (10.6 vs. 21.3%, respectively, chi2 = 6.01, P = 0.014). There was no significant difference in either allele or genotype frequency for any of the other polymorphisms studied. These data suggest that the A allele of the ICAM-1 exon 4 polymorphism may protect against the risk of RPS following UTI and may participate in the regulation of the inflammatory response following UTI.
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Affiliation(s)
- R A Gbadegesin
- Department of Nephrology, Royal Manchester Children's Hospital, Pendlebury, Manchester, M27 4HA, UK
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Leroy S, Marc E, Adamsbaum C, Gendrel D, Bréart G, Chalumeau M. Prediction of vesicoureteral reflux after a first febrile urinary tract infection in children: validation of a clinical decision rule. Arch Dis Child 2006; 91:241-4. [PMID: 15890693 PMCID: PMC2065936 DOI: 10.1136/adc.2004.068205] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
AIMS To test the reproducibility of a highly sensitive clinical decision rule proposed to predict vesicoureteral reflux (VUR) after a first febrile urinary tract infection in children. This rule combines clinical (family history of uropathology, male gender, young age), biological (raised C reactive protein), and radiological (urinary tract dilation on renal ultrasound) predictors in a score, and provides 100% sensitivity. METHODS A retrospective hospital based cohort study included all children, 1 month to 4 years old, with a first febrile urinary tract infection. The sensitivities and specificities of the rule at the two previously proposed score thresholds (< or =0 and < or =5) to predict respectively, all-grade or grade > or =3 VUR, were calculated. RESULTS A total of 149 children were included. VUR prevalence was 25%. The rule yielded 100% sensitivity and 3% specificity for all-grade VUR, and 93% sensitivity and 13% specificity for grade > or =3 VUR. Some methodological weaknesses explain this lack of reproducibility. CONCLUSIONS The reproducibility of the previously proposed decision rule was poor and its potential contribution to clinical management of children with febrile urinary tract infection seems to be modest.
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Affiliation(s)
- S Leroy
- Clinical Epidemiology Unit, Department of Paediatrics, Saint-Vincent-de-Paul Hospital, AP-HP, Université Paris V, Paris, France
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Abstract
BACKGROUND Almost all newborns have phimosis, which is known as one of the risk factors for urinary infection. The present study analyzed which specific prepuce conditions correlated with the development of febrile urinary infection in Japanese male infants. METHODS The subjects consisted of 100 children, 64 boys and 36 girls, with febrile urinary infection. Prepuces were classified by their retractability in the male patients and in 714 healthy boys. RESULTS Ninety-four percent of first febrile urinary infections occurred before 7 months of age in boys, whereas only 37% of the girls had first infections by that age. The prepuce covered the external urethral meatus in 96% of the healthy boys aged 3 years or less. A gentle retraction maneuver could not uncover the urethral meatus in approximately 40% of the boys aged 0-6 months. The frequency started to decline spontaneously after that age. Male patients aged 0-6 months significantly more often had tightly covered meatus than did healthy neonates (85%vs 42%, P < 0.0001). CONCLUSIONS These findings indicate that it is specifically those boys whose external urethral meatus are tightly covered with foreskin who constitute the high-risk group for urinary infection. Awareness of this observation should help with diagnosing and managing urinary infection in young boys.
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Affiliation(s)
- Masahiro Hiraoka
- Department of Pediatrics, School of Medicine, Fukui Medical University, Matsuoka, Fukui, Japan.
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Abstract
OBJECTIVES We studied the false-positive rate of bag urine cultures in diagnosing bacteriuria in infants and examined the factors responsible for contamination. METHODS One hundred asymptomatic patients with previous urinary tract infections (UTI; age range 5-23 months; sex ratio M : F 73:27) were screened by bag urine cultures and confirmed by suprapubic aspiration or catheterization. Those producing contaminated and clean samples were interviewed with a standard questionnaire. RESULTS Sixty patients had insignificant growth and 40 had doubtful or mixed growth. After further interview and instructions, the latter group produced a second bag urine sample with negative results in 23 and positive results in 17. Among the latter, UTI was confirmed in five and excluded in 12 cases. The false-positive rate of first urine collection was 36.8%. Comparing patients with contaminated urine to those with negative urine samples, we found the former were associated with waiting for more than one void to complete urine collection, and with uncircumcised boys. Other factors did not reach statistical significance. Proper counselling and repeating a second culture reduced the overall false-positive rate to 12.6%. CONCLUSION In our population, the contamination rate of one bag urine culture was 36.8%, which is unacceptable and alternative methods need to be sought. Contamination was associated with improper collection procedures and with uncircumcised boys. Proper instructions and doing a second urine culture reduced the overall rate to 12.6%, but at the expense of delaying diagnosis and treatment.
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Affiliation(s)
- P S Li
- Department of Paediatrics, Tuen Mun Hospital, Hong Kong, China
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Kassir K, Vargas-Shiraishi O, Zaldivar F, Berman M, Singh J, Arrieta A. Cytokine profiles of pediatric patients treated with antibiotics for pyelonephritis: potential therapeutic impact. CLINICAL AND DIAGNOSTIC LABORATORY IMMUNOLOGY 2001; 8:1060-3. [PMID: 11687440 PMCID: PMC96226 DOI: 10.1128/cdli.8.6.1060-1063.2001] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Urinary tract infections are common in infants and children. Pyelonephritis may result in serious complications, such as renal scarring, hypertension, and renal failure. Identification of the timing of release of inflammatory cytokines in relation to pyelonephritis and its treatment is essential for designing interventions that would minimize tissue damage. To this end, we measured urinary cytokine concentrations of interleukin-1 beta (IL-1 beta), IL-6, and IL-8 in infants and children with pyelonephritis and in healthy children. Children that presented to our institution with presumed urinary tract infection were given the diagnosis of pyelonephritis if they had a positive urine culture, pyuria, and one or more of the following indicators of systemic involvement: fever, elevated peripheral white blood cell count, or elevated C-reactive protein. Urine samples were obtained at the time of presentation prior to the administration of antibiotics, immediately after completion of the first dose of antibiotics, and at follow up 12 to 24 h after presentation. IL-1 beta, IL-6, and IL-8 concentrations were measured by enzyme-linked immunosorbent assay. Creatinine concentrations were also determined, and cytokine/creatinine ratios were calculated to standardize samples. Differences between pre-antibiotic and follow-up cytokine/creatinine ratios were significant for IL-1 beta, IL-6, and IL-8 (P < 0.01). Differences between pre-antibiotic and control cytokine/creatinine ratios were also significant for IL-1 beta, IL-6, and IL-8 (P < 0.01). Our study revealed that the urinary tract cytokine response to infection is intense but dissipates shortly after the initiation of antibiotic treatment. This suggests that renal damage due to inflammation begins early in infection, underscoring the need for rapid diagnosis and intervention.
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Affiliation(s)
- K Kassir
- Division of Pediatric Critical Care and Harbor-UCLA Department of Pediatric Critical Care, Children's Hospital of Orange County, Orange, California 92868, USA.
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