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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 4  |  Issue : 4  |  Page : 136-140

Prevalence of infective organisms of infections of urinary tract in a sample of Arab infants and children


Assistant Professor of Pediatrics, Department of Pediatrics Faculty of Medicine, Tanta University, Tanta, Egypt

Date of Web Publication29-Dec-2017

Correspondence Address:
Dr. Mohamed Abdelaziz El-Gamasy
Al-Ashraf Street with Sultan Morad, Tanta City, Gharbia Governate
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jina.jina_21_17

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  Abstract 


Background: Infections of urinary tract were considered as the most common hospital-acquired infections in hospitalized patients. Area-specific monitoring studies aimed to assess the prevalence of causative organisms of urinary tract infections (UTIs) and their responsiveness to different available antimicrobials in a sample of Arab children, which may help the clinician to choose the correct empirical treatment. We aimed to study the type of urinary pathogens isolated from hospitalized patients with first-episode UTI in our locality and its antibiotic susceptibility pattern. Materials and Methods: Urine samples were collected from 320 clinically suspected cases of UTI from inpatient wards and outpatient clinic of Pediatric Department of Tanta University Hospital during the period from June 2016 to June 2017. The samples were tested microbiologically by standard procedures. Antibiotic susceptibility of the isolated pathogens was tested for commonly used antibiotics by disc diffusion method according to hospital policy. Results: Significant bacteriuria was present in 75% of the samples, 16.25% were sterile, and 8.75% showed insignificant bacteriuria. The most common pathogens were Escherichia coli (55%), Klebsiella spp. (26.6%), and Proteus mirabilis (14.2%). The mean susceptibility was high for amikacin (85%), ceftriaxone (82%), cefotaxime (80%), nitrofurantoin (80%), and nalidixic acid (78%) but low for ampicillin (21%), cephalexin (30%), and sulfamethoxazole + trimethoprim (37%). Conclusions: The antibiotics which are commonely used in UTIs such as trimethoprim/sulphamethoxazole,ampicillin and cephalexin are not appropriate for embrical treatment of common UTIs.This may be attributed to high rate of bacterial resistance .Regular monitering of these patients is recommended to establish reliable information about patterns of urinary pathogens aiming optimal embrical therapy for children with UTI.

Keywords: Microbiological, pediatric, urinary tract infection


How to cite this article:
El-Gamasy MA. Prevalence of infective organisms of infections of urinary tract in a sample of Arab infants and children. J Integr Nephrol Androl 2017;4:136-40

How to cite this URL:
El-Gamasy MA. Prevalence of infective organisms of infections of urinary tract in a sample of Arab infants and children. J Integr Nephrol Androl [serial online] 2017 [cited 2021 Dec 4];4:136-40. Available from: http://www.journal-ina.com/text.asp?2017/4/4/136/222066




  Introduction Top


Urinary tract infections (UTIs) are the most common nosocomial infection among hospitalized patients.[1] It occurs in 3–5% of girls and 1% of boys. In girls, the first UTI usually occurs by the age of 5 years with peaks during infancy and toilet training. After the first UTI, 60–80% of girls will develop the second UTI within 18 months. In boys, most UTIs occur during the first year of life.[2] In infancy, nonspecific manifestations such as fever, vomiting, and abdominal pain can make the diagnosis of UTI challenging. In infancy and young children, fever without localization is frequently the admitting diagnosis.[3] Recurrent UTIs are common and can lead to irreversible damage to the kidneys resulting in renal hypertension, renal scarring, and chronic renal failure.[4] It is universally accepted that UTI can be only ascertain on the basis urine microscopy and microbial culture. In almost all cases, treatment must be initiated before the final bacteriological results are available. Therefore, studies to increase our knowledge about the type of pathogens responsible for UTIs and their susceptibility patterns to antibiotic drugs are very important to help clinicians to choose the correct empirical treatment. We aimed to study the type of urinary pathogens isolated from hospitalized patients with first-episode UTI in our locality and its antibiotic susceptibility pattern.


  Materials and Methods Top


Design of the study and setting

The present cross-sectional study was conducted after approval from the Research Ethical Committee of the Tanta University Hospital and informed oral or written parental consents on 320 pediatric patients selected from the inpatient ward and outpatient clinics of Pediatric Departments from June 2016 to June 2017.

Inclusion criteria included all clinically suspected pediatric patients for UTI.

Exclusion criteria included previous history of UTI, known congenital anomalies of the kidney and urinary tract, especially on current prophylactic treatment with antibiotics.

All patients were subjected to full history taking, thorough clinical examination, especially anthropometric measurements (weight and height), and vital signs and laboratory investigations including complete urine analysis.

As urinary catheterization could lead to invading the urinary tract from outside bacteria through the bladder, affecting accuracy of the experimental bacteriological results, urine samples were collected by one of the two methods including mid-stream-clean-catch method and suprapubic bladder aspiration according to the age and compliance of patients and their families. All samples were processed using the standard microbiological procedure. Samples were processed on blood agar and MacConkey medium by standard loop method and incubated at 37°C overnight. Single organism growth of ≥100,000 colony-forming units/ml was considered as significant bacteriuria. The organisms were identified by routine methods from the samples showing significant bacteriuria. Antibiotic susceptibility of the isolated pathogens was tested for commonly used antibiotics by standard disc diffusion technique on Muller-Hinton agar as recommended by Bauer et al.[5] After 24 h, at 37°C, the zone of inhibition was measured. Antibiotic discs were obtained from Oxoid and Himedia. The results were interpreted according to the National Committee for Clinical Laboratory Standards.[6]

Statistical analysis

The collected data were tabulated and statistically analyzed using Statistical Package for the Social Sciences (SPSS) software, version 17 (SPSS Inc., Chicago, IL, USA). For quantitative data, the range and mean ± standard deviation were calculated. For qualitative data, comparison between two groups and more was done using Chi-square test. For comparison between means of two groups of parametric data of independent samples, Student t-test was used. Univariate parametric analysis of variance (ANOVA) was used for comparison between more than two means of more than two different groups (F) value of ANOVA. Significance was adopted at P < 0.05 for interpretation of results of tests of significance.[7]


  Results Top


There were 320 urine samples which were collected, 202 (84.2%) samples were collected by mid-stream-clean-catch method, 38 (15.8%) samples were obtained by suprapubic bladder aspiration.

Out of the 320 sample processed, 240 (75%) showed significant bacteriuria, 52 (16.25%) were sterile, and 28 (8.75%) showed insignificant bacteriuria.

Age and sex distributions of the culture-positive urine samples are shown in [Table 1]. From a total of 240 samples, 56 (23.3%) urine samples were from infants below 2 years, 108 (45%) were from children aged 2–6 years, and 76 (31.7%) were from those between 6 and 12 years.
Table 1: Age and sex distribution of the patients with culture positive urine samples

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Regarding sex distribution, there was statistically significant difference between the studied groups. UTIs were more common in females above the age of 2 years than in males. On the other hand, UTIs were more common in males below the age of 2 years than in females (P < 0.05).

The organisms grown on the cultures of 240 urinary samples with significant bacteriuria were as follows:  Escherichia More Details coli in 132 (54.9%), Klebsiella spp. in 64 (26.6%), Proteus mirabilis in 34 (14.2%), and Enterococcus faecalis in 10 (4.2%) [Table 2]. E. coli was the commonest isolated organism by both clean catch middle stream and suprapublic bladder aspiration (44.1% and 10.8% respectively).
Table 2: Distribution of isolated bacteria according to method of collection of urine samples

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Significant bacteriuria was present in mid-stream-clean-catch samples in 202 out of 240 samples (84.2%). This percentage was lower in suprapubic bladder aspiration collected samples (only 15.8%).

The antibiogram of isolated pathogens is shown in [Table 3] and [Figure 1]. The highest susceptibility for all isolated pathogens was for amikacin (85%), ceftriaxone (82%), cefotaxime (80%), nitrofurantoin (80%), and nalidixic acid (78%). Susceptibility was low for ampicillin (21%), cephalexin (30%), and sulfamethoxazole + trimethoprim (37%).
Table 3: Results of couture and sensitivity of urine samples of the studied patients

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Figure 1: Mean susceptibilities of each urinary pathogen in the studied patients. Amp: Ampicillin, CL: Cephalexin, CTX: Cefotaxime, CRO: Ceftriaxone, NA: Nalidixic acid, F: Nitrofurantoin, Amk: Amikacin, SXT: Sulfamethoxazole + Trimethoprim

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E. coli was most sensitive to amikacin (92%), followed by ceftriaxone (88%), cefotaxime (85%), nitrofurantoin (82%), and nalidixic acid (81%).

Klebsiella spp. was most susceptible to nitrofurantoin (86%), nalidixic acid (83%), and amikacin (81%). P. mirabilis was most sensitive to amikacin (92%), ceftriaxone (91%), and cefotaxime (90%). E. faecalis was most sensitive to nalidixic acid (100%), nitrofurantoin (80%), and cefotaxime (80%), but less susceptibility was observed for sulfamethoxazole + trimethoprim (20%), ampicillin (20%), and cephalexin (40%).


  Discussion Top


Diagnosis of UTI is a good example of the need for close cooperation between the clinician and the microbiologist. Studies have established that a normal urinalysis does not rule out UTI in children.[8] The presence of significant bacteriuria in 75% of samples indicates the significance of microbiological culture to clinch the diagnosis of UTI.

In the present study, significant bacteriuria was present in 84.2% of samples collected by mid-stream method which is greater than the results of samples collected by suprapubic aspiration (15.8%). In circumcised males, mid-stream urine is highly recommended as a reliable noninvasive procedure for diagnosis of UTI.[9] Furthermore, the American Academy of Pediatrics recognizes that the low rate of UTI in this population (0.2%–0.4%) does not justify the routine use of an invasive potentially traumatic diagnostic procedure.[10]

Insignificant bacteriuria or sterile samples were found in 25% of patients; this may be explained by prior antibiotic treatment before submitting the urine sample and other clinical conditions that may mimic UTI.

The demographic data of our patients show that females are more affected than males (n = 168 and 72, respectively), but males are affected by first-episode UTI at significantly younger age than females. The relatively high percentage (70%) of female patients in our study can be explained by the fact that in age group above 1 year of life, girls are more prone to developing UTI, in our study, the median age of the included patients was higher than other studies so most of our subjects are of girls, in younger samples (during the first year of life), the relative rate of males would probably be higher than females.

In our study, the Enterobacteriaceae group, namely, E. coli(55%), Klebsiella spp. (26.6%), and P. mirabilis (14.2%), were the most common pathogens isolated. The isolation rates of urinary pathogens are consistent with reports of the recently published studies from different countries.[11],[12],[13],[14] Enterobacteriaceae have several factors responsible for their attachment to the uroepithelium. These Gram-negative aerobic bacteria colonize the urogenital mucosa with adhesion, pili, fimbria, and P1-blood group phenotype receptors.[15]

This study shows high bacterial resistance of uropathogens to common antibiotics, namely, ampicillin, cephalexin, and sulfamethoxazole-trimethoprim (SMX/TMP) in children with first-episode UTI. In Middle East countries like Egypt, empirical antibiotic therapy is the main role for treating infections of urinary tract. They may be attributed to low socioeconomic and low cultural levels among population. The WHO guidelines indicate SMX/TMP and ampicillin as first choice for treatment of UTI in children in developing countries.[15] Our study recommends against this advice. The low susceptibility to these drugs could be due to widespread use of these antibiotics in the community for treating other common infections as otitis media and pharyngitis.[16]

According to Iranian study,[17] E. coli isolates were highly resistant to ampicillin (88%) and resistance rates to ampicillin have been reported in other countries which was 88% in India,[18] 80% in Taiwan,[19] and 47.8%–64.6% in Turkey.[20]

Ampicillin is rapidly excreted, and the duration of significant drug concentration in the urine is short. This may predispose to increased bacterial resistance when used to treat UTI. In addition, ampicillin is relatively ineffective in clearing E. coli from intestinal and vaginal mucosa which may predispose to recurrence of UTIs.[21]

Nitrofurantoin and nalidixic acid are still maintaining good activity against E. coli(82% and 81%, respectively) and Klebsiella spp. (86% and 83%, respectively). However, they are not widely used due to their rapid excretion in urine and so they fail to achieve therapeutic concentrations in blood.[8] Because of this pharmacokinetic profile, nitrofurantoin and nalidixic acid are commonly used for prophylaxis and not recommended to treat febrile infants with UTI.

Aminoglycosides and third-generation cephalosporins are considered safe in the treatment of UTI in children. E. coli was most sensitive to amikacin (92%), followed by ceftriaxone (88%) and cefotaxime (85%). Intravenous therapy should be considered in children who have failed oral therapy and continue to be febrile. These results are consistent with other recommendation for empirical therapy of UTIs. Haller et al.[22] concluded that ampicillin and aminoglycosides were appropriate empirical treatments for UTIs in hospitalized children in University Hospital of Freiburg in Germany. While Hoberman et al.[23] recommended cefixime as a first-line empirical antibiotic for outpatient therapy of community-acquired UTIs.

A limitation of the present study is that the sample size was relatively small that might not represent the whole population in our country. Another limitation is that although some bacteria are sensitive to some antibiotics in vitro according to culture and sensitivity results, they do not represent their condition inside the human tissues because the antibiotic drugs have their own pharmacokinetic, pharmacodynamic, and pharmacogenomic characteristics in vivo. Notwithstanding these limitations, the data of the present findings can be used as a basis to offer helps for pediatricians and general practitioners to adequately mange UTI in pediatrics.


  Conclusion Top


The antibiotics commonly used in UTIs such as trimethoprim/sulfamethoxazole, ampicillin, and cephalexin do not seem to be appropriate for the empirical treatment of community-acquired UTIs because of its very high rate of resistance. Since the present study was a cross-sectional study, regular monitoring by complete urinalysis including physical, chemical, microscopic, and microbiological examinations is required. In clinical practice, clean-catch mid-stream technique is the most used urinary collection method provided freshly analyzed during the first 120 min of gaining the sample. Loss of transparency of specimen may be attributed to the presence of PO4 gravels in a specimen with abnormally high pH rather than pyuria. An offensive smell may be attributed to highly concentrated urine not due to infections of urinary tract. There are many disadvantages for urine analysis by dipstick test like false interpretations of findings (+ve or –ve). Fluid balance of the diseased children can be estimated easily by osmolality of urine.

Diagnosis of simple infections of urinary tract may be easily achieved by simple tests including evaluation of leukocyte esterase and nitrite in urine samples. They may be managed empirically till the results of cultures appear. The aim of these recommendations was to establish reliable information about resistance pattern of urinary pathogens for optimal empirical therapy of patients with UTIs.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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2.
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Jahnukainen T, Chen M, Celsi G. Mechanisms of renal damage owing to infection. Pediatr Nephrol 2005;20:1043-53.  Back to cited text no. 4
    
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Bauer AW, Kirby WM, Sherris JC, Turck M. Antibiotic susceptibility testing by a standardized single disk method. Am J Clin Pathol 1966;45:493-6.  Back to cited text no. 5
    
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National Committee for Clinical Laboratory Standards. Performance Standards for Antimicrobial Disc Susceptibility Tests, M2-A7. 7th ed. Wayne, Pennsylvania, USA: NCCLS; 2000.  Back to cited text no. 6
    
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8.
Practice parameter: The diagnosis, treatment, and evaluation of the initial urinary tract infection in febrile infants and young children. American academy of pediatrics. Committee on quality improvement. Subcommittee on urinary tract infection. Pediatrics 1999;103:843-52.  Back to cited text no. 8
    
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Prais D, Straussberg R, Avitzur Y, Nussinovitch M, Harel L, Amir J, et al. Bacterial susceptibility to oral antibiotics in community acquired urinary tract infection. Arch Dis Child 2003;88:215-8.  Back to cited text no. 9
    
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Amir J, Ginzburg M, Straussberg R, Varsano I. The reliability of midstream urine culture from circumcised male infants. Am J Dis Child 1993;147:969-70.  Back to cited text no. 10
    
11.
Sharifian M, Karimi A, Tabatabaei SR, Anvaripour N. Microbial sensitivity pattern in urinary tract infections in children: A single center experience of 1,177 urine cultures. Jpn J Infect Dis 2006;59:380-2.  Back to cited text no. 11
    
12.
Keah Sh, Wee E, Chng K, Keah K. Antimicrobial susceptibility of community-acquired uropathogens in general practice. Malays Fam Physician 2007;2:64-9.  Back to cited text no. 12
    
13.
Zhanel GG, Hisanaga TL, Laing NM, DeCorby MR, Nichol KA, Palatnik LP, et al. Antibiotic resistance in outpatient urinary isolates: Final results from the North American Urinary Tract Infection Collaborative Alliance (NAUTICA). Int J Antimicrob Agents 2005;26:380-8.  Back to cited text no. 13
    
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Andrade SS, Sader HS, Jones RN, Pereira AS, Pignatari AC, Gales AC, et al. Increased resistance to first-line agents among bacterial pathogens isolated from urinary tract infections in Latin America: Time for local guidelines? Mem Inst Oswaldo Cruz 2006;101:741-8.  Back to cited text no. 14
    
15.
Lomberg H, Hanson LA, Jacobsson B, Jodal U, Leffler H, Edén CS, et al. Correlation of P blood group, vesicoureteral reflux, and bacterial attachment in patients with recurrent pyelonephritis. N Engl J Med 1983;308:1189-92.  Back to cited text no. 15
    
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Currie ML, Mitz L, Raasch CS, Greenbaum LA. Follow-up urine cultures and fever in children with urinary tract infection. Arch Pediatr Adolesc Med 2003;157:1237-40.  Back to cited text no. 16
    
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Kashef N, Djavid GE, Shahbazi S. Antimicrobial susceptibility patterns of community-acquired uropathogens in Tehran, Iran. J Infect Dev Ctries 2010;4:202-6.  Back to cited text no. 17
    
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Gupta N, Kundra S, Sharma A, Gautam V, Arora DR. Antimicrobial susceptibility of uropathogens in India. J Infect Dis Antimicrob Agents 2007;24:13-8.  Back to cited text no. 18
    
19.
Lau SM, Peng MY, Chang FY. Resistance rates to commonly used antimicrobials among pathogens of both bacteremic and non-bacteremic community-acquired urinary tract infection. J Microbiol Immunol Infect 2004;37:185-91.  Back to cited text no. 19
    
20.
Kurutepe S, Surucuoglu S, Sezgin C, Gazi H, Gulay M, Ozbakkaloglu B, et al. Increasing antimicrobial resistance in Escherichia coli isolates from community-acquired urinary tract infections during 1998-2003 in Manisa, Turkey. Jpn J Infect Dis 2005;58:159-61.  Back to cited text no. 20
    
21.
Daikos GL, Kathpalia SB, Sharifi R, Lolans VT, Jackson GG. Comparison of ciprofloxacin and beta-lactam antibiotics in the treatment of urinary tract infections and alteration of fecal flora. Am J Med 1987;82:290-4.  Back to cited text no. 21
    
22.
Haller M, Brandis M, Berner R. Antibiotic resistance of urinary tract pathogens and rationale for empirical intravenous therapy. Pediatr Nephrol 2004;19:982-6.  Back to cited text no. 22
    
23.
Hoberman A, Wald ER, Hickey RW, Baskin M, Charron M, Majd M, et al. Oral versus initial intravenous therapy for urinary tract infections in young febrile children. Pediatrics 1999;104:79-86.  Back to cited text no. 23
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]


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