Urinary infections in children

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

BACKGROUND

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

OBJECTIVE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Genome profiling of uropathogenic E. coli from strictly defined community-acquired UTI in paediatric patients: a multicentric study

BACKGROUND

Urinary tract infection (UTI) in children is a common bacterial infection. The emergence of extended-spectrum beta-lactamases (ESBLs) poses a major challenge against the treatment of uropathogens. We aimed to characterize the E. coli isolates recovered from children with UTI for their resistance profile and circulating sequence types (ST).

METHODS

Children (> 1.5-18 years of age) from different community health centres of India with symptoms of UTI were enrolled. Isolates causing significant bacteriuria were identified by Matrix-Assisted Laser Desorption Ionization Time of Flight Mass Spectrometry (MALDI-TOF MS) and tested for antimicrobial susceptibility by the automated system, VITEK-2 (Biomeriux, Durhum, US). Nineteen E. coli isolates (15 ESBL positive and 4 ESBL negative) were sequenced in Oxford Nanopore platform followed by core-genome phylogeny, accessory genome cluster analysis, identification of sequence types, mobile genetic elements, genetic antimicrobial resistance markers. The correlation between detection of antimicrobial resistance genes with phenotypic resistance profiles was also investigated.

RESULTS

Eleven percent of children had significant bacteriuria [male:female-1:1, > 50% were 11-18 years of age group]. E. coli was predominant (86%) followed by K. pneumoniae (11%). Susceptibility of E. coli was highest against fosfomycin (100%) followed by carbapenems (90.7%) and nitrofurantoin (88.8%). ST131 (15.8%) and ST167 (10.5%) found as high-risk clones with the presence of plasmid [IncFIB (63.1%), IncFIA (52.6%)], and composite transposon [Tn2680 (46.6%)] in many isolates. Few isolates coharboured multiple beta-lactamases including blaNDM-5 (33.3%), blaOXA-1 (53.3%), blaCTX-M-15 (60%) and blaTEM-4 (60%).

CONCLUSIONS

This study highlights horizontal transmission of resistance genes and plasmids in paediatric patients at community centers across the nation harbouring multidrug-resistant genes such as blaNDM-5 and blaCTX-M-15 associated with high-risk clones ST131 and ST167. The data is alarming and emphasizes the need for rapid identification of resistance markers to reduce the spread in community. To our knowledge, this is the first multicentric study targeting paediatric UTI patients from the community setting of India.

Evaluation of clinical, etiological and antimicrobial resistance profile of pediatric urinary tract infections in a secondary health care centre

Background

Urinary tract infections are common during childhood. The etiologic agents and empirical antibiotics may vary due to age and geographic area.

Objectives

This study was designed to investigate the urinary tract infection pathogens, their antibiotic resistance profile and risk factors in a sample of well-child population.

Materials and Methods

This retrospective study was conducted in the pediatric clinics of a secondary health-care centre in a one-year period. The source of data was hospital and laboratory records. Toilet trained children and adolescents aged between 5–17 years old with positive urine culture were enrolled into the study. Microbiological studies were conducted according to international guidelines.

Results

During the study 3640 urine samples were analyzed and 342(9.4%) had significant growth. Gram negative enterobacteria were the most common infectious agents. Antibiotic susceptibility tests showed low cephalosporine resistance unless ESBL was positive. Multi drug resistance was remarkable. Extended beta lactamase resistance rate was 17%. Previous history of antibiotic use before the present administration was the only significant risk factor for ESBL positivity.

Conclusion

Treating urinary tract infections may become an emerging problem soon. Unless there are risk factors, cephalosporines are good options, but if so nitrofurantoin or carbapanems should be preferred for treatment in this population.

Comparison of Primary and Recurrent Urinary Tract Infections in Children

Aim We aimed to compare the demographic and ultrasound data regarding first-episode urinary tract infections with recurrent infections in children. Methods A total of 509 children aged 0-16 years who were diagnosed to have a urinary tract infection (UTI) as confirmed with positive urinary culture tests were retrospectively investigated. A comparison of baseline parameters, responsible pathogen incidences, and ultrasound findings was made between children who had a single episode of UTI (n=418, 82.1%) with those having second or more recurrent episodes of urinary tract infection (n=91, 17.9%). Results The mean age of children with a single episode of urinary tract infection was significantly lower than those who had recurrent urinary tract infection (5.33±4.38 vs. 7.01±4.83 years, p=0.003). Incidences of Escherichia coli and Enterococcus faecalis was significantly higher in patients with recurrent urinary tract infection than those who had single episode (n=315, 75.4% vs. n=80, 87.9%, p=0.009 and n=8, 1.9% vs. n=9, 9.9%, p<0.001, respectively). An abnormal ultrasound was significantly more common in patients with recurrent urinary tract infection than those who had a single episode (n=41, 54.6% vs. n=59, 22.7%). Increased renal parenchymal echogenicity (p=0.002), bladder cystitis (p=0.01) and hydronephrosis (p<0.001) were significantly more common in patients with recurrent urinary tract infection than those who had a single episode of urinary tract infection. Conclusion Escherichia coli and Enterococcus faecalis were the most common responsible pathogens in recurrent urinary tract infections. Structural changes, such as hydronephrosis and bladder cystitis, are likely to have an important role in the etiology of children with recurrent urinary tract infection.

Risks with Gynaecological problems on the health of University Students

Objective:

To determine the risk with gynecological problems on the health of female university students.

Methods:

The study was conducted as a descriptive in university in Central Anatolia, Turkey. The research population was composed of 1305 female university students studying at a university in Central Anatolia. The study was conducted between January and March 2017. The data were collected through a questionnaire consisting of 23 questions prepared by the researchers to determine the socio-demographic characteristics of the participants and the risk with gynecological problems they encountered. Numerical and percentage statistics were used to analyze the data.

Results:

About 65.4 percent of the female students in this study previously had gynecological examination, and 38.8 percent of them were diagnosed with gynaecological problems. It was found that 87.6 percent of the female students had risk with gynecological disorders. the most common ones being dysmenorrhoea (63.2%), premenstrual syndrome (56.7%), urinary tract infection (22.4%), and polycystic ovarian syndrome (13%), respectively.

Conclusions:

It was found that nearly all the young girls had risk with gynecological problems and nearly half of them were diagnosed with different gynaecological disorders.

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

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

Urine interleukin-6, interleukin-8 and transforming growth factor β1 in infants with urinary tract infection and asymptomatic bacteriuria

INTRODUCTION

Urinary tract infection (UTI) occurs in 1.1% of girls and 1.4% of boys during the first year of life. Asymptomatic bacteriuria (ABU) is usually detected incidentally in 0.9% of girls and 2.5% of boys at this age. The aim of the study was to assess the usefulness of measurement of pro-inflammatory urine interleukin (IL)-6 and IL-8 concentrations and anti-inflammatory transforming growth factor β1 (TGF-β1) level in infants with febrile UTI, non-febrile UTI and ABU.

MATERIAL AND METHODS

A total of 35 children, mean age 6.14 ±3.47 months, were divided into three groups: group I - febrile UTI (n = 13), group II - non-febrile UTI (n = 13) and group III - ABU (n = 9). At the time of enrollment urine IL-6, IL-8, TGF-β1 and serum C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and white blood cell count (WBC) were measured. Renal ultrasound was performed in all children, 99mTc-dimercaptosuccinic acid scintigraphy (DMSA) and voiding cystourethrography in children with UTI.

RESULTS

Urine concentrations of IL-6 and IL-8 were significantly higher in febrile UTI compared to those with non-febrile UTI and ABU (p < 0.5, p < 0.01) and positively correlated with CRP, ESR and WBC (p < 0.01). Urine levels of TGF-β1 were significantly higher in children with febrile UTI compared to those with ABU (p < 0.05) and positively correlated with WBC (p < 0.01). Inflammatory changes in the DMSA scan were detected in 66.6% of children with UTI. No significant difference in frequency of an abnormal DMSA scan compared to a normal scan was found in groups with febrile and non-febrile UTI. No relations between urine cytokines, systemic inflammatory markers and changes in DMSA scan were observed. The cutoff value for detection of inflammatory changes in the DMSA scan for IL-8 was 120 pg/mg creatinine (Cr) and 40 pg/mg Cr for TGF-β1. Based on this value, the sensitivity for IL-8 was 58.3%, specificity 100% and for TGF-β1 66.7% and 83.7%, respectively.

CONCLUSIONS

We found significant differences in children with febrile UTI and ABU regarding urine IL-6, IL-8 and TGF-β1 levels. Urine cytokines and systemic inflammatory markers do not differentiate between upper and lower UTI in infants.

A Comparison of Bladder Catheterization and Suprapubic Aspiration Methods for Urine Sample Collection From Infants With a Suspected Urinary Tract Infection

This study compares 2 sampling methods for urine cultures in young infants. We analyzed data on urine samples obtained from 83 infants using 2 sources of urine: suprapubic bladder aspiration (SPA) and bladder catheterization. All specimens were subjected to both urinalysis and culture, and the results compared. Eighty-three infants with positive urine culture results obtained by bladder catheterization were subjected to SPA. Of these, only 24 (28.9%) and 20 (24%) yielded positive urine culture and abnormal urinalysis data, respectively. Samples obtained via catheterization had a high false-positive rate (71.1%). The sensitivity and specificity of urinalysis were 66.7% (95% CI, 44.68% to 84.33%) and 93.22% (95% CI, 83.53% to 98.08%), respectively. In infants younger than 12 months, SPA is the best method to avoid bacterial contamination, showing better results than transurethral catheterization.

Causative pathogens and antibiotic resistance in children hospitalized for urinary tract infection

BACKGROUND

Urinary tract infections (UTI) are one of the most common bacterial infections in children and a major cause of hospitalization. In this study we investigated the clinical characteristics, causative uropathogens; their antibiotic susceptibility and resistance patterns, treatment modalities and efficacy in children hospitalized for UTI in a tertiary care setting.

METHODS

Patients hospitalized for an upper UTI between March 2009 and July 2014 were enrolled. The urine culture-antibiogram results and accompanying urinary tract abnormalities were recorded retrospectively.

RESULTS

A total of 142 patients (104 girls, 73.2%; 38 boys, 26.8%) were enrolled. Mean patient age was 32.6 ± 4.1 months. History of recurrent UTI was present in 45.8% (n = 65), with prior hospitalization in 12.0% (n = 17). Frequency of vesicoureteral reflux was 18.3% (n = 26). Gram-negative enteric microorganisms yielded growth in all culture-positive UTI and the most common microorganism was Escherichia coli (n = 114, 80.3%). Extended spectrum beta-lactamase-producing (ESBL (+)) bacterial strains were detected in 49.3% (n = 70), with third-generation cephalosporin resistance in all and increased duration of hospitalization.

CONCLUSIONS

The prevalence of UTI with ESBL (+) bacterial strains with multi-drug resistance is increasing in the hospitalized pediatric population, therefore rational use of antibiotics is essential.

Urinary tract infection in children after cardiac surgery: Incidence, causes, risk factors and outcomes in a single-center study

Nosocomial urinary tract infection (UTI) increases hospitalization, cost and morbidity. In this cohort study, we aimed to determine the incidence, risk factors, etiology and outcomes of UTIs in post-operative cardiac children. To this end, we studied all post-operative patients admitted to the Pediatric Cardiac Intensive Care Unit (PCICU) in 2012, and we divided the patients into two groups: the UTI (UTI group) and the non-UTI (control group). We compared both groups for multiple peri-operative risk factors. We included 413 children in this study. Of these, 29 (7%) had UTIs after cardiac surgery (UTI group), and 384 (93%) were free from UTIs (control group). All UTI cases were catheter-associated UTIs (CAUTIs). A total of 1578 urinary catheter days were assessed in this study, with a CAUTI density rate of 18 per 1000 catheter days. Multivariate logistic regression analysis demonstrated the following risk factors for CAUTI development: duration of urinary catheter placement (p<0.001), presence of congenital abnormalities of kidney and urinary tract (CAKUT) (p<0.0041) and the presence of certain syndromes (Down, William, and Noonan) (p<0.02). Gram-negative bacteria accounted for 63% of the CAUTI. The main causes of CAUTI were Klebsiella (27%), Candida (24%) and Escherichia coli (21%). Resistant organisms caused 34% of CAUTI. Two patients (7%) died in the UTI group compared with the one patient (0.3%) who died in the control group (p<0.05). Based on these findings, we concluded that an increased duration of the urinary catheter, the presence of CAKUT, and the presence of syndromes comprised the main risk factors for CAUTI. Gram-negative organisms were the main causes for CAUTI, and one-third of them found to be resistant in this single-center study.

The use of intravesical hyaluronic acid for recurrent urinary tract infections in children: a case-series study

BACKGROUND

This is the first study performed to evaluate the effects of intravesical hyaluronic acid (IHA) instillation on diminishing the frequency of recurrent urinary tract infections (UTIs) in children.

METHODS

Fifteen children (10 girls, 5 boys) with recurrent UTIs were divided into two groups as either complicated (group 1) (with accompanying disorders including vesicoureteral reflux or neurogenic bladder) or uncomplicated patients (group 2). After administration of weekly four sessions of IHA therapy the patients were followed-up monthly for 2 years and classified as responsive (complete/partial) or unresponsive to treatment.

RESULTS

53.3% of the patients with recurrent UTIs were complicated. In group 1 (n = 8), complete and partial response rates were 62.5% (n = 5) and 25% (n = 2), respectively. There was no response in 12.5% (n = 1) of the cases in group 1. In group 2 (n = 7), complete and partial response rates were 71.4% (n = 5) and 14.3% (n = 1), respectively. In this group, 14.3% (n = 1) of the patients were found to be unresponsive to IHA treatment. No side effects were observed in any of the patients.

CONCLUSIONS

IHA administration is considered as an effective treatment modality which significantly reduces the prevalence of or even provides complete recovery from recurrent UTIs in childhood. Therefore, it is believed that this approach can be used as a promising alternative to widespread use of antibiotics in this patient group.

The diagnosis, evaluation and treatment of acute and recurrent pediatric urinary tract infections

Urinary tract infection (UTI) is one of the most common bacterial infections encountered by pediatricians. Currently, the diagnosis and management of acute UTI and recurrent UTI in children remain controversial. Recently published guidelines and large clinical trials have attempted to clarify UTI diagnostic and management strategies. In this manuscript, we review the diagnosis and management of acute and recurrent UTI in the pediatric population.