Urinary tract infections in the infant

Uropathogens and clinical manifestations of pyuria-negative urinary tract infections in young infants: A single center cross-sectional study

BACKGROUND

Urine leukocyte count under microscopy is one of the most frequently used routine screening tests for urinary tract infection (UTI). Nevertheless, it is observed that pyuria is lacking in 10-25% of children with UTI. This study aims to determine the factors related to pyuria-negative UTI in young infants aged under four months old.

METHOD

This retrospective cross-sectional study was conducted on 157 patients aged under 4 months old with UTI. All subjects had paired urinalysis and urine culture, which were collected via transurethral catheterization. According to the results of their urinalysis, the patients were then classified as UTI cases with pyuria and UTI cases without pyuria. The clinical characteristics and outcomes of both groups were analyzed.

RESULT

Among the 157 UTI patients, the prevalence of pyuria-negative UTI was 44%. Significant risk factors associated with pyuria-negative UTI included non-E.coli pathogens, younger age, shorter duration of fever prior to hospital visit, lower white blood cell (WBC) count upon hospital visit, and absence of microscopic hematuria.

CONCLUSIONS

We found that non-E.coli uropathogens were the strongest factor related to pyuria-negative UTI. The absence of pyuria cannot exclude the diagnosis of UTI in young infants, and it's reasonable to perform both urinalysis and urine culture as a part of the assessment of febrile or ill-looking young infants.

Prevalence and risk factors of urinary tract infection among children with bronchiolitis

BACKGROUND

The co-occurrence of bronchiolitis and urinary tract infections (UTI) in hospitalized children is associated with high morbidity and economic strain. However, due to a low prevalence (<3%) and inconsistent diagnostic criteria, there is ongoing debate regarding the necessity of systematic screening. This study estimated the prevalence of UTI among children admitted for bronchiolitis and analyzed the associated demographic and clinical factors.

METHODS

A 5-year (2016-2020) retrospective chart review was conducted among all children admitted for bronchiolitis at a referral pediatrics department in Jeddah, Saudi Arabia. UTI was diagnosed according to the American Association of Pediatrics criteria. Demographic, clinical, microbiological, and imaging data were extracted from the hospital electronic records.

RESULTS

Of the 491 cases of children with bronchiolitis, urine culture and analysis were available for 320 patients. Based on urine culture criteria alone, the prevalence of UTI was 13.1% (95% CI 9.6-17.3), and the most common pathogens included E. coli (33.3%), K. pneumoniae (23.8%), and Enterococcus faecalis (14.3%), and 13 (31.0%) of the isolates were EBSL. By considering urinalysis criteria, i.e., pyuria or nitrituria, the estimated prevalence of UTI decreased to 3.4% (1.7-6.1%), and the most common pathogens were K. pneumoniae (5/11) and E. coli (3/11), with 6/11 ESBL-producing isolates. Regurgitation associated with a higher risk of UTI compared to absence of regurgitation (5.3% versus 0.8%; p = 0.031). Urinary tract ultrasound showed high specificity (98.7-100%) and negative predictive value (97.4-97.7%) in UTI using either criterion.

CONCLUSIONS

There is a higher prevalence of UTI among children with bronchiolitis in the study center, which has several implications in screening, diagnosis, and management. Further multicenter studies are required to enhance the external validity of these findings and assess the cost-effectiveness of screening strategy at a national level.

Association Between Antibiotic Duration and Recurrence of Urinary Tract Infection in the Neonatal Critical Care Unit

OBJECTIVES

Urinary tract infection (UTI) is the most common bacterial infection in infants. Current practice guidelines suggest a treatment duration of 7 to 14 days. Suboptimal therapy may increase the risk for recurrent UTIs leading to renal scarring and possibly chronic kidney disease. The primary objective is to evaluate the duration of therapy for UTIs and its association with the incidence of recurrent UTIs in a neonatal intensive care unit (NICU). The secondary objectives are to identify the risk factors and the most common organisms for recurrent UTIs.

METHODS

Patients were identified via the diagnosis codes for UTIs and were included if admitted to the NICU and if they received antibiotics prior to hospital discharge. Patients were divided into 2 groups: antibiotic treatment for 7 days or fewer and antibiotic treatment for greater than 7 days.

RESULTS

Eighty-six infants were included in the study. Twenty-six patients received antibiotics for 7 days or fewer, and 60 for more than 7 days. In the study, the median birth weight was 977 g and the median gestational age was 27.6 weeks. There was no significant difference in the rate of recurrent UTIs between the 2 groups (p = 0.66). However, in the subgroup analysis, the incidence was higher for patients receiving antibiotic therapy for fewer than 7 days versus 7 days (p = 0.03).

CONCLUSION

There was no difference in recurrence of UTI between treatment groups (≤7 days versus >7 days), and recurrence was seen in a higher percentage of patients with a urinary tract anomaly.

Characterization of young infants with fecal carriage of multidrug-resistant Escherichia coli in Southern Taiwan

BACKGROUND

The accelerating prevalence of extended-spectrum β-lactamase (ESBL)-producing and multidrug-resistance (MDR) Escherichia coli(E. coli) become a public health challenge worldwide. This study aimed to discuss the prevalence of drug-resistant E. coli colonization and analyze its risk factors and clinical characteristics among young infants in Southern Taiwan.

METHODS

Stool samples were collected from young infants, aged less than three months, within three days of their hospitalization from September to December 2019 in a tertiary hospital. A questionnaire was designed for parents to complete. E. coli colonies were selected and analyzed for antimicrobial susceptibility. PCR-based multilocus sequence typing was to detect the presence of sequence type ST131 and blaCTX-M genes.

RESULTS

Among 100 enrolled infants, 36% had fecal carriage of E. coli isolates, of which twenty nine (80.5%) were MDR, thirteen (36.1%) were ESBL-producing isolates and five (13.8%) and ten (27.7%) were ST131 and strains carrying CTX-M-14 gene, respectively. Compared to non-ST131 and non-CTX-M-14 gene carrier, isolates of ST131 and CTX-M-14 gene carrier showed a significantly higher resistance rate to cefixime, ceftriaxone, and gentamycin, with p value all <0.05.

CONCLUSION

The prevalence of ESBL-producing and MDR E. coli fecal carriage were both high in young infants. The most common sequence type is ST131, of which all are strains carrying CTX-M-14. Further surveillance and investigation to control for the high prevalence of antimicrobial-resistant E. coli fecal carriage among infants in Taiwan are warranted.

Concentration of novel urinary tract infection biomarkers in neonates

Urinary tract infections (UTIs) are a common comorbidity in hospitalized neonates. The current UTI diagnostics have several limitations including invasive collection of urinary samples to ensure sterility, risk of contamination and lack of consensus definitions of UTI based on urine culture. Antimicrobial peptides (AMPs) have been recently utilized as novel biomarkers that can efficiently and accurately diagnose pediatric UTI. However, the concentration of AMPs in neonatal urine is not well-defined. Urine from neonates admitted to a single level IV neonatal intensive care unit was obtained to determine baseline concentration of two AMPs, Ribonuclease 7 (RNase 7) and Beta Defensin-1 (BD-1) and to define the relationship between AMP concentration and gestational age (GA). AMP levels were normalized to urine creatinine. RNase 7 and BD-1 were expressed in neonatal urine (n = 66) regardless of GA and as early as 22 weeks gestation. Urinary concentrations of both AMPs decreased as GA and birthweight increased. The overall median urinary RNase 7/UCr and BD-1/UCr values were 271 ng/mg, and 116 ng/mg, respectively. Median urinary concentrations of RNase 7/UCr for infants born at < 27, 27-32, 33-35 and ≥ 36 weeks were 569, 308, 254, and 124 ng/mg respectively. Similarly, the concentrations of BD-1/UCr at these GA were 166, 115, 108, and 14 ng/mg, respectively. Baseline neonatal urinary concentration of two AMPs (RNase 7 and BD-1) and the variation by GA were identified. This is an essential first step toward the potential utilization of AMPs in improving neonatal UTI diagnostics.

Prescribing Pattern and Efficacy of Oral Antibiotics for Pediatric Urinary Tract Infections in Japan: A Descriptive Study Using a Nationwide Claims Database

BACKGROUND

Pediatric urinary tract infections are often treated with third-generation cephalosporins; however, the increasing prevalence of Escherichia coli resistant to cephalosporins has reduced their effectiveness. Although resistance is prevalent in Asia, the prescribing patterns and clinical effectiveness of antibiotics have mostly been reported in the United States. This study aimed to describe the prescription patterns and effectiveness of oral antibiotics for treating pediatric urinary tract infections in Japan.

METHODS

This descriptive study used data from a nationwide Japanese claims database. We identified patients <6 years old with urinary tract infections who received oral antibiotics between January 2016 and December 2020. Descriptive analyses were performed to assess prescription patterns. Moreover, logistic regression analyses were conducted to estimate the odds ratios (ORs) and 95% confidence intervals (95% CIs) for treatment failure among the commonly prescribed antibiotics and patient characteristics. Treatment failure was defined as the prescription of different antibiotics within 7 days of the primary prescription.

RESULTS

Of the 4,127 patients, 2,766 (67.0%) were prescribed third-generation cephalosporins, and 347 (8.4%) were prescribed amoxicillin. Trimethoprim-sulfamethoxazole and amoxicillin-clavulanate were prescribed to 63 (1.5%) and 50 (1.2%) patients, respectively. Treatment failure was observed in 118 (2.9%) patients and more often in amoxicillin-treated patients than in cefcapene pivoxil-treated patients [OR, 2.18 (95% CI: 1.04-4.58)].

CONCLUSIONS

Third-generation cephalosporins are the most commonly prescribed antibiotics for the initial therapy of pediatric urinary tract infections in Japan. Third-generation cephalosporins are still effective in Japan, despite the high prevalence of resistance against cephalosporins.

Neonatal Cystitis Makes Adult Female Rat Urinary Bladders More Sensitive to Low Concentration Microbial Antigens

Purpose

Interstitial cystitis/bladder pain syndrome (IC/BPS) is a chronic pain disorder. Patients with IC/BPS often experience "flares" of symptom exacerbation throughout their lifetime, initiated by triggers, such as urinary tract infections. This study sought to determine whether neonatal bladder inflammation (NBI) alters the sensitivity of adult rat bladders to microbial antigens.

Methods

Female NBI rats received intravesical zymosan treatments on postnatal days P14-P16 while anesthetized; Neonatal Control Treatment (NCT) rats were anesthetized. In adults, bladder and spinal cord Toll-like receptor type 2 and 4 (TLR2, TLR4) contents were determined using ELISAs. Other rats were injected intravesically with lipopolysaccharide (LPS; mimics an E. coli infection; 25, 50, 100, or 200 μg/mL) or Zymosan (mimics yeast infection; 0.01, 0.1, 1, and 10 mg/mL) solutions on the following day. Visceromotor responses (VMRs; abdominal contractions) to graded urinary bladder distention (UBD, 10-60 mm Hg, 20s) were quantified as abdominal electromyograms (EMGs).

Results

Bladder TLR2 and TLR4 protein levels increased in NBI rats. These rats displayed statistically significant, dose-dependent, robustly augmented VMRs following all but the lowest doses of LPS and Zymosan tested, when compared with their adult treatment control groups. The NCT groups showed minimal responses to LPS in adults and minimally increased EMG measurements following the highest dose of Zymosan.

Conclusion

The microbial antigens LPS and Zymosan augmented nociceptive VMRs to UBD in rats that experienced NBI but had little effect on NCT rats at the doses tested. The greater content of bladder TLR2 and TLR4 proteins in the NBI group was consistent with increased responsiveness to their agonists, Zymosan and LPS, respectively. Given that patients with IC/BPS have a higher incidence of childhood urinary tract infections, this increased responsiveness to microbial antigens may explain the flares in symptoms following "subclinical" tract infections.

Effects of deferoxamine on intrinsic colistin resistance of Proteus mirabilis

Proteus mirabilis is a common pathogen, which is responsible for urinary tract infections. Iron is a critical element necessary for both humans and pathogens to maintain their biological functions, and iron limitation via chelator agents may be useful in the treatment of infections. The present study aimed to investigate the synergistic interactions between the iron chelator agent deferoxamine (DFO) and the antibacterial drug colistin. The minimum inhibitory concentration (MIC) values of DFO and colistin for P. mirabilis isolates were determined by broth microdilution. The checkerboard technique was used to examine the potential synergy between DFO and colistin. Furthermore, time-kill assays were used for the confirmation of synergy detected by the checkerboard assay, as well as for determining bacteriostatic and bactericidal interactions throughout a 24-h period. As expected, all P. mirabilis isolates were resistant to colistin. DFO did not inhibit P. mirabilis growth when used alone, even at very high doses (10 µg ml-1). Notably, when in combination with DFO, the MIC values of colistin were markedly reduced, and the checkerboard assay results showed synergy between colistin and DFO for all isolates. In addition, in time-kill assays, colistin + DFO exhibited synergistic activity against all strains at most time intervals and concentrations tested. Colistin + DFO showed bactericidal activity at colistin concentrations of 1xMIC and 2xMIC, although a degree of re-growth was observed in one of the strains at 12-24 h. These findings indicated that DFO has the potential for use as an adjunct to colistin through iron sequestration, thus providing synergistic activity to an antibiotic that would not normally be considered a treatment option against P. mirabilis. In vivo experiments in the future may provide useful information on the efficacy of DFO/colistin since these models effectively reflect physiological parameters.

Urinary tract infections in children from the Gulf Cooperation Council countries: a literature review (2011-2022)

Urinary tract infections (UTIs) are common healthcare-associated and community-acquired bacterial infections in children. Data on pediatric UTIs in the Gulf Cooperation Council (GCC) region (Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and the United Arab Emirates) have not been collated. Our aim is to review the published literature on the risk factors, etiology, antimicrobial susceptibility, and treatment of pediatric (aged <18 years) UTIs from healthcare and community settings in the GCC countries.

Prevalence and Clinical Significance of Urinary Tract Infection among Neonates Presenting with Unexplained Hyperbilirubinemia in Lebanon: A Retrospective Study

BACKGROUND

Neonatal jaundice is commonly seen in term and preterm newly born babies. It could be either physiologic or secondary to multiple underlying pathologies like urinary tract infection (UTI). Our main objective was to confirm the relationship between neonatal jaundice without apparent cause like hemolysis and the presence of UTI.

MATERIALS AND METHODS

We, retrospectively over a period extended from 2017 to 2020, included 496 babies admitted for elevated indirect hyperbilirubinemia for whom demographic, clinical, laboratory, and therapeutic data were collected through a detailed questionnaire.

RESULTS

Our study included 496 neonates and showed a prevalence of UTI in 8.9% of neonates. The two most common microorganisms in urine culture were Escherichia coli (65.9%) and Klebsiella pneumoniae (25.0%). A multivariate logistic analysis showed that UTI was associated with male neonates (odds ratio [OR] = 2.366, 95% confidence interval [CI]: 1.173 - 4.774; P = 0.016), history of prenatal UTI (OR = 5.378, 95% CI: 2.369 - 12.209; P <0.001), poor feeding (OR = 3.687, 95% CI: 1.570 - 8.661; P = 0.003), and positive urine culture in catheter (OR = 2.704, 95% CI: 1.255 - 5.826; P = 0.011). The mean length of stay was higher in patients with positive UTI (Median = 216 hours) compared to patients with negative UTI (Median = 48 hours) (P <0.001).

CONCLUSION

Neonatal sreening for UTI should be recommended whenever there is unexplaind early or prolonged hyperbilirubinemia with no evidence of alloimmune hemolysis or blood group incompatibility and to prevent the morbidity of urosepsis and congenital kidneys malformations.

Preterm and Term Infants Evaluated for Sepsis: Differences in Management and Clinical Outcomes

BACKGROUND AND OBJECTIVES

To describe differences in practice patterns and outcomes of young preterm versus age-matched term infants evaluated for sepsis, because evaluation and management of this group are not well defined.

METHODS

We conducted a retrospective single-center study at an academic, freestanding children's hospital of previously healthy preterm and term infants aged 0 to 60 days, who presented for initial evaluation of fever and/or hypothermia from 2014 to 2019. We classified infants by gestational age as preterm (32-36 6/7 weeks) and term (37-42 weeks) and compared diagnostic evaluation, management, and clinical outcomes.

RESULTS

Out of 363 preterm infants evaluated for sepsis, 336 met inclusion criteria; within the same study period, 2331 term infants were evaluated for sepsis, of which 600 were randomly selected and 554 were included. Clinicians performed inflammatory marker testing and chest x-rays more frequently in preterm infants 31% vs 25% (P = .034) and 50% vs 32% (P < .001), respectively. Preterm infants had a higher rate of bacteremia 5.9% vs 2.5% (P = .035), were hospitalized more frequently 72% vs 63% (P = .006), and required ICU level of care more often 32% vs 5% (P < .001) than term infants. They had lower rates of viral infections 33% vs 42% (P = .015) and no significant increased return visits. Febrile preterm and term infants, and older hypothermic preterm infants had relatively higher rates of serious bacterial infections. Hypothermic preterm infants had the longest hospitalizations.

CONCLUSIONS

Preterm infants had increased rates of bacteremia and required higher level of care compared with age-matched term infants, likely reflecting their increased risk for sepsis and other concomitant morbidities associated with preterm birth.

Effective antimicrobial therapies of urinary tract infections among children in low- and middle-income countries: A systematic review

Importance

Urinary tract infection (UTI) is one of the most common infections encountered in infancy and childhood. Despite the emerging problem of antibiotic resistance in recent years, the use of antibiotics for better management of UTIs is inevitable.

Objective

This study aims to explore the efficacy and adverse effects of the available antimicrobial agents that are used in pediatric UTIs in low- and middle-income countries (LMICs).

Methods

Five electronic databases were searched to identify relevant articles. Two reviewers independently performed screening, data extraction, and quality assessment of the available literature. Randomized controlled trials providing antimicrobial interventions in both male and female participants within the age range of 3 months to 17 years in LMICs were included.

Results

Six randomized controlled trials from 13 LMICs were included in this review (four trials explored the efficacy). Due to high heterogeneity across the studies, a meta-analysis was not performed. Other than attrition and reporting bias, the risk of bias was moderate to high due to poor study designs. The differences in the efficacy and adverse events of different antimicrobials were not found to be statistically significant.

Interpretation

This review indicates the necessity for additional clinical trials on children from LMICs with more significant sample numbers, adequate intervention periods, and study design.

Vesicoureteral Reflux Diagnosis After Hospitalization for Acute Cystitis and Pyelonephritis

Children with recurrent fevers in a short period of time need to be worked up to identify the underlying cause. Fevers in children and infants can be from many different sources. Vesicoureteral reflux (VUR) is an anatomical and physiological anomaly in children that can lead to retrograde urine flow from the bladder back into the distal ureters. This retrograde flow can cause distention, scarring, and recurrent infections including urinary tract infections (UTIs) and pyelonephritis. Identification of multiple UTIs in a short period of time should raise suspicion for a more complex pathology such as VUR and requires a more thorough workup. This workup is needed for both diagnosis and treatment. The patient in this report was seen by physicians in the emergency department, pediatric intensive care unit, nephrology, and her pediatrician. If surgery is needed, a urologist would also be involved. This report will discuss the pathophysiology of VUR and associated pathologies, diagnostic approach, medical and surgical treatment modalities, as well as prognosis.

Invasive fungal infection is associated with antibiotic exposure in preterm infants: a multi-centre prospective case-control study

BACKGROUND

Previous antibiotic exposure is an important risk factor for invasive fungal infection (IFI). Antibiotic overexposure is common in lower-income countries; however, multi-centre studies concerning IFI in relation to antibiotic exposure are scarce.

AIM

This prospective, multi-centre matched case-control study explored the correlation of IFI and antibiotic exposure in very preterm infants or very-low-birthweight infants admitted to 23 tertiary hospitals in China between 2018 and 2021.

METHODS

Using a 1:2 matched design for gestational age, birth weight and early-onset sepsis (yes/no), the risk factors between infants diagnosed with IFI and infection-free controls were compared. The antibiotic use rate (AUR) was calculated using calendar days of antibiotic therapy in the 4 weeks preceding IFI onset divided by onset day of IFI.

FINDINGS

In total, 6368 infants were included in the study, of which 90 (1.4%) were diagnosed with IFI. Median AUR, length of antibiotic therapy (LOT) and days of antibiotic therapy (DOT) within the 4 weeks preceding IFI onset were 0.90, 18 days and 30 days, respectively. Multi-variate analysis showed that a 10% increase in AUR, each additional day of DOT and LOT, and each additional day of third-generation cephalosporins and carbapenems were notably associated with IFI.

CONCLUSION

Prolonged antibiotic therapy is common before the onset of IFI, and is an important risk factor, especially the use of third-generation cephalosporins and carbapenems. Antibiotic stewardship should be urgently developed and promoted for preterm infants in order to reduce IFI in lower-income countries such as China.

Variability in antimicrobial use among infants born at <33 weeks gestational age

Excessive antimicrobial use is associated with adverse neonatal outcomes. In our cohort of 27,163 infants born at <33 weeks gestational age, the first week after birth accounted for the highest rates of antimicrobial use, and variability across sites persisted after adjustment for patient characteristics correlated with illness severity.

Can diagnostic and imaging recommendations from the 2011 AAP UTI guidelines be applied to infants <2 months of age?

INTRODUCTION

In 2011, the American Academy of Pediatrics (AAP) published guidelines regarding diagnosis and management of children 2-to-24-months-old with initial febrile urinary tract infection (fUTI). Available data were insufficient to determine whether evidence from studies of 2-to-24-month-olds applies to those <2-months-old, so they were excluded.

OBJECTIVE

This study aimed to 1) compare demographic, clinical, imaging and outcomes between patients <2-months-old and those 2-to-24-months-old hospitalized with fUTI, and 2) assess whether diagnostic and imaging recommendations of the AAP 2011 guidelines apply to those <2-months-old.

STUDY DESIGN

A cohort study of patients ≤24-months-old hospitalized at a children's hospital with fUTI from 2016 to 2018 was conducted. Data were collected via a prospectively generated electronic medical record note template, supplemented with retrospective chart review. Primary outcomes included differences in demographics, clinical presentation, urine culture results, and imaging utilization/results by age group. Secondary outcomes included surgical procedures, UTI recurrence, and 90-day all-cause readmissions and emergency department (ED) revisits. Univariate and bivariate statistics were utilized to compare age groups.

RESULTS

Overall, 137 patients were included (median age 70 days, 55.5% male [92.1% uncircumcised], 53.3% Hispanic/Latino, 89.8% 1st fUTI). There were no demographic differences between groups, except children <2-months-old were more frequently male (71.2 vs 43.6%, p = 0.002). The Summary Table compares clinical factors and imaging utilization by age. There were no differences in urinalysis or urine culture results between groups. Patients <2-months-old had shorter fever duration, lower maximum temperature, and lower white blood cell counts. Voiding cystourethrograms (VCUGs) were recommended and obtained more frequently in patients <2-months-old, but there were no differences in renal and bladder ultrasound (RBUS) or VCUG results between age groups. There were no differences in UTI recurrence (13.6% of <2-months-old vs 14.1% of 2-to-24-months-old, p = 1.00) or fUTI recurrence (13.6 vs 7.7%, p = 0.40) within 1 year, 90-day readmission (6.8 vs 6.4%, p = 1.00), or 90-day ED revisit (22.0 vs 20.5%, p = 1.00).

DISCUSSION

There were minimal differences between the <2-months-old and 2-to-24-months-old age groups in demographics, laboratory (including microbial) or imaging results, or clinical outcomes. Patients <2-months-old were more frequently male and less ill. These data support applying urinalysis and urine culture diagnostic criteria, and universal RBUS, from the AAP guidelines to patients <2-months-old. Given utilization differences, applicability of VCUG guideline recommendations requires further clarification for patients <2-months-old.

CONCLUSION

Laboratory testing and RBUS recommendations from the AAP guidelines may be safely applied to infants <2-months-old. Further studies are needed to clarify optimal VCUG recommendations.

Incidence and risk factors of urinary tract infection in neonatal sepsis

Background

Neonates with sepsis may have concurrent urinary tract infection (UTI), which may be asymptomatic or have nonspecific symptoms. Failure to diagnose UTI, resulting in a delay of appropriate therapy, has been reported to cause renal scarring, hypertension, and kidney failure among infants. This study aimed to determine the contribution of UTI to neonatal sepsis and to assess different risk factors that could be associated with UTI. This cross-sectional study was conducted at the Neonatal Intensive Care Unit (NICU) of Fayoum University Hospital, Fayoum, Egypt, between March 2018 and January 2019. Neonates of both genders from birth to the 28th day of life with clinical features of either early- or late-onset sepsis (during or after the first 3 days of life, respectively) were enrolled in this study. All neonates were subjected to complete history taking from the parents, full clinical examination, and laboratory investigations including complete blood count, C-reactive protein, blood culture, and urine culture.

Results

The current study included 100 neonates admitted to the NICU with clinical and laboratory features of sepsis. Positive blood culture (proven sepsis) was detected in 60%, and the proportion of positive urine culture (UTI) in the entire study group was 11%. The incidence of UTI was 11.7% in proven sepsis compared to 10% in suspected sepsis, and it was 16.36% in late-onset sepsis (LOS) versus 4.44% in early-onset sepsis (EOS). There was a statistically significant association between poor feeding and feeding intolerance and positive urine culture (UTI). Leukopenia and expert panel criteria score showed high sensitivity (81.80% and 90.90%, respectively) but low specificity for the diagnosis of UTI.

Conclusions

Gram-negative bacteria have been highly suspected in cases of neonatal sepsis. Poor feeding and feeding intolerance have association with positive urine culture. Finally, urine culture for sepsis was recommended especially in the late type.

In-vitro determination of antimicrobial activities of Eruca sativa seed oil against antibiotic-resistant gram-negative clinical isolates from neonates: a future prospect

Background

The aim of this study is investigate the antimicrobial effect of plant oils against bacterial strains isolated from neonatal asymptomatic bacteriuria (ABU) and to evaluate the antiseptic effect of the most potent one.

Methods

The antimicrobial effect of 17 plant oils were tested against 15- gram-negative bacterial strains recovered from cases of neonatal ABU (11 Escherichia. coli, 3 Klebsiella pneumonia, and 1 Pseudomonas aeruginosa) using the agar well diffusion method. The micro-dilution method was performed to investigate the minimum inhibitory concentrations (MIC) and the minimum bactericidal concentrations (MBC) in concentrations ranging from 1.95 μg/ml to 500 μg/ml. The evaluation of the antiseptic activity of the Eruca sativa (arugula) seed oil was investigated using time-kill assay in concentrations ranging from 50 μg/ml to 0.195 μg/ml.

Results

All tested oils showed variable antimicrobial activities against the tested strains. Arugula, wheat germ, cinnamon, parsley, dill, and onion oils were the most active oils. Among them, arugula oil was the most active oil with MIC₅₀ and MIC₉₀ were 3.9 μg/ml and 31.3 μg/ml respectively. MBC₅₀ and MBC₉₀ of arugula oil were 15.6 μg/ml and 125μg/ml respectively. The time-kill assay of arugula oil indicated that a concentration of 100 μg/ml completely killed nine of the tested strains after 10 min and reduced the CFU/ml of the rest of the strains by 3 log¹⁰ at the same time interval.

Conclusion

Arugula seed oil could be a potentially used as an antiseptic especially for neonates.

Antimicrobial utilization in very-low-birth-weight infants: association with probiotic use

OBJECTIVE

To examine the association between probiotic use and antimicrobial utilization.

STUDY DESIGN

We retrospectively evaluated very-low-birth-weight (VLBW) infants admitted to tertiary neonatal intensive care units in Canada between 2014 and 2019. Our outcome was antimicrobial utilization rate (AUR) defined as number of days of antimicrobial exposure per 1000 patient-days.

RESULT

Of 16,223 eligible infants, 7279 (45%) received probiotics. Probiotic use rate increased from 10% in 2014 to 68% in 2019. The AUR was significantly lower in infants who received probiotics vs those who did not (107 vs 129 per 1000 patient-days, aRR = 0.89, 95% CI [0.81, 0.98]). Among 13,305 infants without culture-proven sepsis or necrotizing enterocolitis ≥Stage 2, 5931 (45%) received probiotics. Median AUR was significantly lower in the probiotic vs the no-probiotic group (78 vs 97 per 1000 patient-days, aRR = 0.85, 95% CI [0.74, 0.97]).

CONCLUSION

Probiotic use was associated with a significant reduction in AUR among VLBW infants.

Prediction of Urinary Tract Infection in Neonates with Unexplained Indirect Hyperbilirubinemia

Background: Neonates with urinary tract infection  (UTI) are susceptible to higher rates of morbidity and mortality, specifically when presented with hyperbilirubinemia. Screening for UTIs in jaundiced neonates is a cost-effective strategy. The aims of this study were to investigate the pattern of UTI (prevalence, etiology, and susceptible antimicrobial agents) in neonates admitted to the NICU with unexplained indirect hyperbilirubinemia, as well as to identify early predictors of UTI in order to reduce the present morbidity and long-term consequences in NICU patients. . Methods: A cross-sectional hospital-based study that included 140 neonates diagnosed with unexplained indirect hyperbilirubinemia in the first 4 weeks of life. A questionnaire was applied to obtain demographic and clinical data. A number of laboratory parameters were assessed with clinical examination. Bacterial growth of 1 × 103 colony-forming units/mL of a single uropathogen was used to identify the existence of UTI. Multivariate analysis was used to identify the predicting factors of UTIs. Results: In the NICU group investigated, 25.7% of subjects had a culture-proved UTI. The most frequently  isolated organism was Escherichia coli. Amikacin was the most common antibiotic that the isolates were susceptible to. In multivariable logistic regression analysis, a positive urine culture was statistically associated with an increase in  WBCs  (OR= 6.90, p= 0.001), pyuria (OR= 5.55, p= 0.001), small for gestational age (OR= 4.07, p= 0.021), prolonged phototherapy duration (OR= 3.50, p= 0.034), and the presence of obstetric complications (OR= 2.92, p= 0.001). Conclusion: UTI is substantially prevalent among neonates admitted to the NICU with unexplained indirect hyperbilirubinemia. The importance of routine UTI screening (urine culture)  as part of the clinical assessment of unexplained hyperbilirubinemia was highlighted in this study, particularly in neonates with leukocytosis, pyuria, small for gestational age, prolonged phototherapy, and those born from mothers with a history of obstetric complications.  

High burden of ESBL- producing Klebsiella spp., Proteus mirabilis, Enterobacter cloacae and Pseudomonas aeruginosa in diagnosed cases of urinary tract infection in a Nigerian Teaching Hospital

Infections of the urinary tract have been on the rise globally and these are also worsened by the increasing rate of antibiotic resistance in uropathogens. This study aimed to determine the susceptibility profile of extended spectrum β-lactamase (ESBL)- producing uropathogens to selected antibiotics and their carriage of ESBL genes. Bacterial uropathogens were obtained from the urine bench of a Microbiology laboratory in a Teaching Hospital in South-West Nigeria. Susceptibility to antibiotics was tested using the disc diffusion method, while detection of ESBL production was done using the double disc synergy test (DDST). Detection of ESBL genes was performed by PCR. A total of 21 ESBL- producing uropathogens were obtained namely: Klebsiella pneumoniae (11), Klebsiella oxytoca (6), Proteus mirabilis (2), Enterobacter cloacae (1) and Pseudomonas aeruginosa (1). The resistance to antibiotics in the uropathogens was: imipenem (0%), gentamicin (38.1%), sulfamethoxazole-trimethoprim (52.4%), amoxicillin-clavulanate (61.9%), aztreonam (66.7%), ceftazidime (66.7%), tetracycline (90.5%), cefpodoxime (100%) and cefotaxime (100%). Altogether, 90.5% (19/21) of the isolates were multidrug resistant (MDR). Of the 21 uropathogens, 61.9% (13/21) carried bla CTX-M, 52.4% (11/21) carried bla TEM while bla SHV was detected in 47.6% (10/21) of the isolates. There was co-carriage of ESBL genes in 12 uropathogens. This study showed a high prevalence of multidrug resistance and a high carriage of ESBL genes in the ESBL- producing isolates obtained over the study period. There is a need for a review of antibiotic options in the treatment of UTI to clamp down on the ever-increasing tide of antibiotic resistance in uropathogens.

Evidence-based circumcision policy for Australia

The aim was (1) to perform an up-to-date systematic review of the male circumcision (MC) literature and (2) to determine the number of adverse medical conditions prevented by early MC in Australia. Searches of PubMed using "circumcision" with 39 keywords and bibliography searches yielded 278 publications meeting our inclusion criteria. Early MC provides immediate and lifetime benefits, including protection against: urinary tract infections, phimosis, inflammatory skin conditions, inferior penile hygiene, candidiasis, various STIs, and penile and prostate cancer. In female partners MC reduces risk of STIs and cervical cancer. A risk-benefit analysis found benefits exceeded procedural risks, which are predominantly minor, by approximately 200 to 1. It was estimated that more than 1 in 2 uncircumcised males will experience an adverse foreskin-related medical condition over their lifetime. An increase in early MC in Australia to mid-1950s prevalence of 85% from the current level of 18.75% would avoid 77,000 cases of infections and other adverse medical conditions over the lifetime for each annual birth cohort. Survey data, physiological measurements, and the anatomical location of penile sensory receptors responsible for sexual sensation indicate that MC has no detrimental effect on sexual function, sensitivity or pleasure. US studies found that early infant MC is cost saving. Evidence-based reviews by the AAP and CDC support early MC as a desirable public health measure. Although MC can be performed at any age, early MC maximizes benefits and minimises procedural risks. Parents should routinely be provided with accurate, up-to-date evidence-based information in an unbiased manner early in a pregnancy so that they have time to weigh benefits and risks of early MC and make an informed decision should they have a son. Parental choice should be respected. A well-trained competent practitioner is essential and local anaesthesia should be routinely used. Third party coverage of costs is advocated.

Effect of probiotics on urinary tract infections in children: A systematic review and meta-analysis

BACKGROUND

Urinary tract infections (UTIs) are the most prevalent bacterial infections that occur in children worldwide.

OBJECTIVE

This meta-analysis aims to investigate the utility of probiotics as preventive therapy in children with a UTI.

METHODS

The Web of Science, PubMed, and Scopus were searched for articles that investigated the relationship between probiotic consumption and the risk of UTIs. The quality of the articles was evaluated using the Jadad scale. The pooled odds ratio (OR) and 95% confidence interval (CI) were calculated using a random-effects model. Subgroup analyses and sensitivity analyses were also conducted. The Cochran Q test and the statistic I2 were used to evaluate heterogeneity. To determine any potential publication bias, the Egger's and Begg's tests were used.

RESULTS

In total, eleven studies were selected for systematic review and meta-analysis. Compared to children who did not receive probiotics, the OR of developing or having a recurring urinary tract infection in those who received probiotics was 0.94 (95% CI; 0.88-0.999; p-value=0.046). The Begg's and Egger's tests showed no evidence of publication bias between probiotics and the risk of developing new or recurring urinary tract infections.

CONCLUSION

Based on this systematic review and meta-analysis, probiotics could be an alternative therapy for children who are at risk of developing a UTI. They are non-pharmaceutical options and could be used as natural prophylaxis for UTIs. However, the currently published evidence does not irrefutably confirm that probiotics provide a protective effect against urinary bacterial infections. Therefore, there need to be large-scale randomized clinical trials undertaken to investigate the possible prophylaxis of probiotics.

Antibiogram of Urinary Tract Infections and Sepsis among Infants in Neonatal Intensive Care Unit

Neonatal infections including sepsis and urinary tract infections are considered among the leading causes of mortality in neonatal intensive care units (NICU). Thus, use of empiric antibiotics is very important in infected neonates and the success of this practice is mainly reliant on the availability of an up-to-date antibiogram for currently used antibiotic drugs. In this study, we aim to determine the bacteriological profile and antibiotic susceptibility pattern of bacteria isolated from blood or/and urine cultures belonging to patients at the NICU. A total of 54 urine samples were collected in the period between January 2015 and December 2019. Data of infants with positive urine and blood bacterial isolates were gathered retrospectively. The most commonly isolated bacteria from urine observed were K. pneumoniae (44%) and E. coli (39%), while Acinetobacter baumannii (33%) and K. pneumoniae (22%) predominated in neonatal blood samples. The majority of uropathogens and blood isolates exhibited low resistance to imipenem and tigecycline, respectively. These antibiotics would be recommended for future use as empirical treatment in neonates with urinary tract infections and/or sepsis. This investigation highlights the importance of surveillance studies to manage and ensure the effectiveness of treatment plan for critically ill infants.

Clinical guidelines of UTIs in children: quality appraisal with AGREE II and recommendations analysis

OBJECTIVE

To explore the current Chinese and English guidelines of urinary tract infection (UTI) in children and provide a summary of the recommendations of the guidelines.

METHODS

An electronic search was conducted on databases, including Pubmed, SinoMed, Wangfang Data, CHKD,VIP, NICE, WHO, GIN and Medliveto retrieve data of the clinical practice guidelines on UTI from the establishment of the database to June 2020. Four assessors assessed the quality of guidelines using the Appraisal of Guidelines for Research & Evaluation II (AGREE II) and evaluated the specific recommendations in guidelines.

RESULTS

(1) Nine guidelines including two from the USA (AAP and A guideline for the inpatient care of children with pyelonephritis) and the remaining from EAU/ESPU, SINEPE, KHA-CARI, CPS, ISPN, NICE and CMA-CSP were explored. (2) The AGREE II evaluation demonstrated higher scores of UTI guidelines in terms of 'scope and purpose' (72.99%±11.19%) and 'clarity of presentation' (75.62%±7.75%), whereas the average scores were lower in the aspect of 'stakeholder involvement' (35.49%±14.41%), 'rigour of development' (37.05%±10.05%), 'applicability' (37.75%±11.98%) and 'editorial independence' (43.06%±48.14%). The average scores of the guidelines were as follows: SINePe (72.57%), CMA-CSP (62.96%), EAU/ESPU (59.61%), AAP (56.86%), NICE (47.54%), CPS (40.93%), KHA-CARI (38.86%), ISPN (38.63%) and A guideline for the inpatient care of children with pyelonephritis (34.72%). (3) All the selected guidelines basically reached a consensus on urine sample retention methods in older children, the antibiotic treatment course and renal and bladder ultrasonography application but lacked a conclusion on the determination of urine culture results, the choice of voiding cystourethrography and Tc-99mdimercaptosuccinicacid, and antibiotic prophylaxis.

CONCLUSION

There remains a need to improve the quality of guidelinesfor UTI in clinical practice. Existing controversies on the current guidelines of UTI in some recommendations warrant further exploration to provide more evidence on formulating more unified and practical guidelines in the future.

ETHICS AND DISSEMINATION

No ethical approval is required for this research, as it did not include patients or patient data.

Correlation of Renal Scarring to Urinary Tract Infections and Vesicoureteral Reflux in Children

Objective

To study the association of the grade of vesicoureteral reflux (VUR) and urinary tract infections (UTI) with renal scarring at the first clinical presentation of patients who underwent antireflux surgery. Materials and methods. Between 2015 and 2020, 150 patients (194 units) who underwent antireflux surgery had dimercaptosuccinic acid (DMSA) renal scans preoperatively. Patients were classified into the nonscar and scar groups according to DMSA scan results. Moreover, cases were classified into afebrile UTI, febrile UTI, and antenatal hydronephrosis (ANH) according to the mode of presentation. We correlated the mode of presentation and the grade of VUR to the presence/absence of renal scars in both groups.

Results

The mean follow-up was 45 months preoperatively. The mode of presentation was afebrile, febrile UTIs, and antenatal hydronephrosis in (50, 14), (20, 46), and (10, 10) patients in the nonscar and scar groups, respectively. Of the 20 patients who presented ANH, 10 (50%) had scars. Clinical presentation was correlated to the presence of renal scarring and its degree. The scar group had significantly higher grades of VUR than the nonscar group (grades I–II (50 units versus 10 units), grade III (28 units versus 40 units), and grade IV–V (22 units versus 44 units) for the nonscar versus scar groups, respectively (pvalue <0.001).

Conclusion

Renal scarring is associated with higher grades of reflux and urinary tract infections. We advocate further research investigating infants who had UTIs with or without fever for early detection of reflux.

Effective antimicrobial therapies of urinary tract infection among children in low-income and middle-income countries: protocol for a systematic review and meta-analysis

INTRODUCTION

Urinary tract infection (UTI) is a frequently diagnosed infection in women and children. Treatments are often initiated with broad-spectrum antibiotics without performing any culture and sensitivity test. Inappropriate and empirical antimicrobial regimens and poor adherence to the drugs lead to the recurrence of the disease. Moreover, resistance against antibiotics in the urinary tract bacteria due to inadequate therapies is a more significant cause of concern. This systematic review will explore the different antimicrobial options for treating UTIs in children and compare their effectiveness.

METHODS AND ANALYSIS

Four electronic databases MEDLINE, Cochrane Central Register of Controlled Trials, Scopus and Web of Science will be searched in February 2022 to find relevant studies. After the initial screening by two independent review authors, the selected articles will go through the full-text evaluation to filter the inclusion criteria. Using an appropriate tool, the risk of bias will also be assessed by two independent review authors. The review results showing the treatment effects of different antimicrobials will be presented as a narrative synthesis, and a meta-analysis will be conducted if applicable. Assessment of heterogeneity between studies, assessment of publication bias, and sensitivity analysis will also be performed.

ETHICS AND DISSEMINATION

The study protocol of this systematic review has been approved by the institutional review board of North South University. The dissemination of the results will be conducted in the form of scientific publication in a peer-reviewed journal and presentations in different regional and international conferences.

PROSPERO REGISTRATION NUMBER

CRD42021260415.

Infant Escherichia coli urinary tract infection: is it associated with meningitis?

OBJECTIVES

Determine the prevalence of coexisting bacterial meningitis (BM) and sterile cerebrospinal fluid (CSF) with raised white cell count relative to age ('pleocytosis') in the presence of Escherichia coli urinary tract infection (UTI), with the addition of CSF E. coli PCR analysis.

DESIGN

Single-centre, retrospective cohort study.

SETTING

Tertiary paediatric hospital.

PARTICIPANTS

Children aged 8 days to 2 years, with a pure growth of E. coli from urine and a CSF sample taken within 48 hours of a positive urine culture between 1 January 2014 and 30 April 2019.

MAIN OUTCOME MEASURE

Prevalence of coexisting E. coli BM with UTI, defined as a pure growth E. coli from urine and a CSF culture with pure growth E. coli and/or positive E. coli PCR.

RESULTS

1903 patients had an E. coli UTI, of which 314 (16%) had a CSF sample taken within 48 hours. No cases of coexisting E. coli BM were identified. There were 71 (23%) cases of pleocytosis, 57 (80%) of these had PCR analysis, all of which were E. coli PCR not detected. Patients aged 1-6 months accounted for 72% of all lumbar punctures (LPs).

CONCLUSION

The risk of E. coli UTI and coexisting E. coli BM is low. There is potential to reduce the number of routine LPs in infants with a diagnosis of E. coli UTI with the greatest impact in children up to 6 months of age. CSF E. coli PCR can help further reduce post-test probability of BM in the setting of pleocytosis.

Prevalence, aetiology, antimicrobial susceptibility testing, and predictors of urinary tract infection among neonates with clinical sepsis: a cross-sectional study

Background

Urinary tract infection (UTI) is the most common and life-threatening bacterial infection among neonates. This study aimed to determine the prevalence, aetiology, and susceptible antimicrobial agents among neonates with UTI.

Methods

This was a cross-sectional analytical hospital-based study that included 152 neonates with clinical sepsis who were admitted at Dodoma regional referral hospital from January to June 2020. Bacterial growth of 1 × 103 colony forming units/mL of a single uropathogen was used to define the presence of UTI. Statistical analysis was performed using SPSS version 23.0 and multivariate analysis was used to determine the predicting factors of UTI. P <0.05 was regarded statistically significant.

Results

The prevalence of UTI was 18.4% (28/152). Klebsiella pneumoniae 64.3% (18/28) and Enterobacter spp. 35.7% (10/28) were the bacterial agents isolated. The bacterial isolates were 90%, and 60% sensitive to ciprofloxacin and amikacin, respectively. Low Apgar score (AOR = 12.76, 95% CI = 4.17–39.06, p<0.001), prolonged labour (AOR = 5.36, 95% CI = 1.28–22.52, p = 0.022), positive urine nitrite test (AOR = 26.67, 95% CI = 7.75–91.70, p<0.001), and positive leucocyte esterase test (AOR = 6.64, 95% CI = 1.47–29.97, p = 0.014) were potential predictors of UTI.

Conclusion

The prevalence of UTI confirmed by urine culture among neonates that were included in the present study indicates that this problem is common in the population where the study was conducted. Klebsiella pneumoniae and Enterobacter spp. were the uropathogens which were isolated. Ciprofloxacin, nitrofurantoin, and amikacin were sensitive to the isolated uropathogens.

Clinical and Microbial Etiology Characteristics in Pediatric Urinary Tract Infection

BACKGROUND

Urinary tract infection (UTI) is a common occurrence in children. UTI and urological malformations are intimately linked. However, whether urinary tract malformations affect the clinical features of pediatric UTI remains unclear. The purpose of this study was to characterize the clinical features and microbial etiology of UTI in children.

METHODS

We retrospectively reviewed the records of 741 patients with UTI treated at the Chongqing Medical University Affiliated Children's Hospital between 2015 and 2020. Patients with and without urological malformations were compared using propensity score matching (PSM).

RESULTS

Escherichia coli was the most common causative microorganism of UTI, accounting for 40.5% of infections. One hundred twenty-two patients (16.5%) had urological malformations. PSM identified 122 matched pairs of patients with or without urological malformations. The proportion of patients with UTI caused by atypical microorganisms was significantly higher in patients with urological malformations (P = 0.048). Children with urological malformations showed longer duration of intravenous antibiotic treatment (P = 0.010), higher cost of treatment (P < 0.001), and higher prevalence of recurrence (23.8 vs. 10.7%, P < 0.001), compared with the normal group.

CONCLUSION

Children with urological malformations are more likely to develop UTI with atypical microorganisms. Appropriate imaging examination and urine culture are strongly recommended for the diagnosis and management of pediatric UTI.

Practice Summary of Antimicrobial Therapy for Commonly Encountered Conditions in the Neonatal Intensive Care Unit: A Canadian Perspective

Neonates are highly susceptible to infections owing to their immature cellular and humoral immune functions, as well the need for invasive devices. There is a wide practice variation in the choice and duration of antimicrobial treatment, even for relatively common conditions in the NICU, attributed to the lack of evidence-based guidelines. Early decisive treatment with broad-spectrum antimicrobials is the preferred clinical choice for treating sick infants with possible bacterial infection. Prolonged antimicrobial exposure among infants without clear indications has been associated with adverse neonatal outcomes and increased drug resistance. Herein, we review and summarize the best practices from the existing literature regarding antimicrobial use in commonly encountered conditions in neonates.

Pediatric urology research in 2020: A bibliometric analysis of the top 100 most cited articles

BACKGROUND

Pediatric Urology deals with genitourinary diseases. Present study aimed to collect the top-cited article in Pediatric Urology in order to define the most debated and studied topics.

METHODS

The journals reported in "Urology & Nephrology" category of the 2019 edition of Journal Citation Reports, together with the most relevant journals of "Transplantation," "Pediatrics," and "Surgery" categories, were browsed. The articles of interest in Pediatric Urology with more than 50 citations were collected. A bibliometric analysis was performed to collect the top 100 cited articles.

RESULTS

The top-cited articles were published in 27 journals (23%), with a median impact factor of 2.676 (IQR 1.981-5.642). Seventeen of them (63%) belonged to "Urology and Nephrology" category. The median number of citations was 82 (IQR 64-113). The most productive journal, with 23 articles, was "The Journal of Urology." Forty-eight top-cited articles were Guidelines or Reviews of the literature and only four papers were randomized controlled trials. The most relevant topic was "congenital anomalies" with 18 articles. As to minimally invasive surgery, eight studies were identified. All of them dealt with robotic-assisted laparoscopic surgery. Two articles reported the current evidence about transitional care.

CONCLUSIONS

The top-cited articles were dispersed among journals of different areas. Current scientific literature deal with congenital anomalies, more specifically with obstructive uropathies and hypospadias. In the last decade, one of the most relevant innovation in pediatric urology was the introduction of robotic surgery. Transitional care has become a timely topic.

Antibiotic Utilization and Efficacy Associated With Treating Pediatric Urinary Tract Infections in Texas Medicaid Patients in the First Year of Life

BACKGROUND

Historically, amoxicillin (Amoxil) has been used as a first-line agent to treat pediatric urinary tract infections (UTIs). However, emerging antibiotic resistance in urinary pathogens has led to broader treatment options, such as cefdinir (Omnicef). This shift in prescribing practices is predicted to vary among place of service and gender due to differing institutional protocols and antimicrobial stewardship practices.

OBJECTIVE

This study aimed to describe the antibiotic utilization patterns associated with treating pediatric UTIs in Texas Medicaid patients and to assess the real-world efficacy of the antibiotics that were prescribed.

METHODS

Texas Medicaid prescription and medical claims data for patients under 1 year of age were included in the analysis if they presented with a UTI to the healthcare practitioner’s office or the emergency department (ED) and were treated with an outpatient antibiotic. Treatment efficacy was assessed by whether a patient received a second (different) antibiotic within 7 days of their initial antibiotic fill.

RESULTS

A total of 12,795 visits met inclusion criteria; 12,561 visits included prescriptions for the top 4 antibiotics prescribed: cefdinir (50%), amoxicillin (25%), cephalexin (Keflex; 13%), and amoxicillin-clavulanate (Augmentin; 12%). Cefdinir utilization predominated in both places of service [office (50%) and ED (55%)], and gender [males (47%) and females (52%)]. Controlling for gender and place of service, initial treatment with amoxicillin when compared with cefdinir (OR = 2.54; 95% confidence intervals: 1.84–3.54; P < 0.001) was associated with a greater rate of treatment failure.

CONCLUSIONS

In this study of Texas Medicaid patients, the widespread utilization of cefdinir may be appropriate for the empiric treatment of uncomplicated UTIs because of its low rate of treatment failure compared to other commonly used antibiotics.

Challenges of Antibiotic Stewardship in the Pediatric and Neonatal Intensive Care Units

The goals of antimicrobial stewardship programs (ASPs) are to optimize antimicrobial prescribing habits in order to improve patient outcomes, reduce antimicrobial resistance, and reduce hospital costs. Multiple society-endorsed guidelines and government policies reinforce the importance of ASP implementation. Effective antimicrobial stewardship can impact unique patients, hospitals, and societal antibiotic-resistance burden. The role and subsequent success of these programs has largely been reported in the adult population. Pediatric and neonatal intensive care units present unique challenges for traditional antimicrobial stewardship approaches. The purpose of this review article is to explore the challenges of appropriate antibiotic use in the pediatric and neonatal intensive care units and to summarize strategies ASPs can use to overcome these challenges. These problems include non-specific disease presentations, limited evidence for definitive treatment durations in many pediatric infections, fewer pediatric-trained infectious disease physicians, and applicability of intensive laboratory obtainment, collection, and interpretation. Additionally, many ASP implementation studies evaluating the efficacy of ASPs exclude the PICU and NICU. Areas of focus for pediatric ASPs should likely include appropriate antibiotic initiation, appropriate antibiotic duration, and appropriate antibiotic de-escalation.

Resistance Patterns from Urine Cultures in Children Aged 0 to 6 Years: Implications for Empirical Antibiotic Choice

Purpose

Urinary tract infection (UTI) is a frequent disorder of childhood, caused mainly by Gram negative Enterobacterales. The aim of this study is to evaluate etiology and antimicrobial susceptibility patterns of bacterial isolates in urine cultures of children under the age of 6 and to analyze the relationship between previous hospitalization or antibiotic prescriptions and antimicrobial resistance rates.

Patients and Methods

A retrospective study on positive urine cultures from 13 public laboratories in Tuscany, Italy was conducted. Data were obtained by reviewing records of the “Microbiological and Antibiotic-Resistance Surveillance System” (SMART) in Tuscany, Italy. A total of 2944 positive urine cultures were collected from 2445 children.

Results

Escherichia coli represented the majority of isolates (54,2%), followed by Enterococcus faecalis (12,3%), Proteus mirabilis (10,3%) and Klebsiella pneumoniae (6,6%). Isolated uropathogens showed high resistance rates to amoxicillin-clavulanate (>25%), particularly in children under one year of age or hospitalized within the 12 months before the sample collection. High susceptibility rates were reported of aminoglycosides, cephalosporins and quinolones (>90%). Previous antibiotic prescriptions by general pediatricians did not increase resistance rates.

Conclusion

Our results show a rate of amoxicillin-clavulanate resistance of 25%. Higher resistance rates were reported in children under one year of age and with previous hospitalization. Hence, amoxicillin-clavulanate should be used carefully in young children and those with severe symptoms.

Treatment of positive urine cultures in the neonatal intensive care unit: a guideline to reduce antibiotic utilization

BACKGROUND

The pediatric definition of bacterial urinary tract infection (UTI) is >50,000 colony forming units (CFU) of a single organism on catheterized culture or 10,000-50,000 CFU with pyuria on urinalysis.

LOCAL PROBLEM

The diagnosis of UTI in our NICU is clinician-dependent and not based on the accepted pediatric definition.

METHODS

A retrospective review of positive urine cultures between 2015 and 2017 was performed.

INTERVENTION

A treatment guideline for positive urine cultures was adopted and PDSA methodology utilized for incremental improvements.

RESULTS

For 909 pre-intervention neonates, 26 of 38 positive urine cultures were treated for UTI but only 23% (6/26) met the pediatric definition. For 644 post-guideline neonates, only 7 of 25 positive urine cultures were treated and 86% met guideline criteria with no increase in urosepsis.

CONCLUSIONS

A guideline to treat positive urine cultures resulted in a decreased rate of UTI diagnosis and thus prevented unnecessary antibiotic exposure.

Clinical utility of procalcitonin in febrile infants younger than 3 months of age visiting a pediatric emergency room: a retrospective single-center study

BACKGROUND

Fever in infants under 90 days of age is highly likely to be caused by a severe bacterial infection (SBI) and it accounts for a large number of patients visiting the pediatric emergency room. In order to predict the bacterial infection and reduce unnecessary treatment, the classic classification system is based on white blood cell (WBC) count, urinalysis, and x-ray, and it is modified and applied at each center by incorporating recently studied biomarkers such as c-reactive protein (CRP) or procalcitonin (PCT). This study analyzed the usefulness of PCT in predicting SBI when applied along with the existing classification system, including CRP, among infants less than 90 days old who visited with a fever at a single institution pediatric emergency center.

METHODS

We retrospectively reviewed the medical records of patients younger than 3 months of age who presented with fever at the Seoul Asan Medical Center pediatric emergency room between July 2017 and October 2018.

RESULTS

A total of 317 patients were analyzed, and 61 were diagnosed with SBI, among which urinary tract infection (UTI) accounted for the largest proportion (55/61, 90.2%). There were differences in WBC, neutrophil proportion, CRP, and PCT between the SBI group and the non-SBI group, and the AUC values of WBC, CRP, and PCT were 0.651, 0.804, and 0.746, respectively. When using the cut-off values of CRP and PCTs as 2.0 mg/dL and 0.3 ng/mL, respectively, the sensitivity and specificity for SBI were 49.2/89.5, and 54.1/87.5, respectively. WBC, CRP, and PCT were statistically significant for predicting SBI in multivariate analysis (odds ratios 1.066, 1.377, and 1.291, respectively). When the subjects were classified using the existing classification criteria, WBC and CRP, the positive predictive value (PPV) and negative predictive value (NPV) were 29.3 and 88.7%, respectively, and when PCT was added, the PPV and NPV were 30.7 and 92%, respectively, both increased.

CONCLUSION

PCT is useful for predicting SBI in children aged 3 months or less who visit the emergency room with a fever. It is useful as a single biomarker, and when used in conjunction with classic biomarkers, its diagnostic accuracy is further increased.

Prostatic Abscess in a Neonate

Urinary tract infection (UTI) is the most commonly occurring serious bacterial infection in young infants. Uncircumcised male infants have a higher rate of UTI when compared with circumcised male infants and girls. A prostatic abscess is a very rare clinical variety of UTI, especially in neonates.

We present the case of a 15-day-old male neonate who developed a rare variety of urosepsis. The baby was evaluated and found to have a prostatic abscess. Ultrasound of the abdomen showed an enlarged prostate gland with diffuse heterogeneous hypoechogenicity. Magnetic resonance imaging (MRI) of the pelvis showed an enlarged, lobulated prostate with T2 hyperintense signal and T1 hypointense signal and diffusion restriction. The post-contrast images in the pelvis-MRI also showed peripheral rim enhancement suggestive of a prostatic abscess. Urine culture showed growth of methicillin-resistant Staphylococcus aureus (MRSA). The baby was treated with intravenous vancomycin, and pus was drained through a transurethral approach.

Phimosis can cause purulence in the prostate. Prostatic abscess usually has a good prognosis in neonates when diagnosed early and appropriate treatment was instituted.

Infection control and other stewardship strategies in late onset sepsis, necrotizing enterocolitis, and localized infection in the neonatal intensive care unit

Suspected or proven late onset sepsis, necrotizing enterocolitis, urinary tract infections, and ventilator associated pneumonia occurring after the first postnatal days contribute significantly to the total antibiotic exposures in neonatal intensive care units. The variability in definitions and diagnostic criteria in these conditions lead to unnecessary antibiotic use. The length of treatment and choice of antimicrobial agents for presumed and proven episodes also vary among centers due to a lack of supportive evidence and guidelines. Implementation of robust antibiotic stewardship programs can encourage compliance with appropriate dosages and narrow-spectrum regimens.

Association of early life antibiotics and health outcomes: Evidence from clinical studies

Preterm infants are susceptible to infections that can rapidly progress to disastrous outcomes. Antibiotics are lifesaving, but their prolonged and inappropriate use are associated with adverse outcomes. In this review, we discuss the current status of antimicrobial use in the preterm neonatal population, and the challenges in determining the initiation, duration, and choice of antibiotics. Finally, we review the clinical studies on the potential consequences of prolonged antimicrobial exposure in prematurely born infants.

Urinary tract infections in very low birthweight infants: A two-center analysis of microbiology, imaging and heart rate characteristics

BACKGROUND

Increased understanding of characteristics of urinary tract infection (UTI) among very low birthweight infants (VLBW) might lead to improvement in detection and treatment. Continuous monitoring for abnormal heart rate characteristics (HRC) could provide early warning of UTIs.

OBJECTIVE

Describe the characteristics of UTI, including HRC, in VLBW infants.

METHODS

We reviewed records of VLBW infants admitted from 2005-2010 at two academic centers participating in a randomized clinical trial of HRC monitoring. Results of all urine cultures, renal ultrasounds (RUS), and voiding cystourethrograms (VCUG) were assessed. Change in the HRC index was analyzed before and after UTI.

RESULTS

Of 823 VLBW infants (27.7±2.9 weeks GA, 53% male), 378 had > / = 1 urine culture obtained. A UTI (≥10,000 CFU and >five days of antibiotics) was diagnosed in 80 infants, (10% prevalence, mean GA 25.8±2.0 weeks, 76% male). Prophylactic antibiotics were administered to 29 (36%) infants after UTI, of whom four (14%) had another UTI. Recurrent UTI also occurred in 7/51 (14%) of infants not on uroprophylaxis after their first UTI. RUS was performed after UTI in 78%, and hydronephrosis and other major anomalies were found in 19%. A VCUG was performed in 48% of infants and 18% demonstrated vesicoureteral reflux (VUR). The mean HRC rose and fell significantly in the two days before and after diagnosis of UTI.

CONCLUSIONS

UTI was diagnosed in 10% of VLBW infants, and the HRC index increased prior to diagnosis, suggesting that continuous HRC monitoring in the NICU might allow earlier diagnosis and treatment of UTI.

Bacterial profile, antibiotic susceptibility pattern and associated risk factors of urinary tract infection among clinically suspected children attending at Felege-Hiwot comprehensive and specialized hospital, Northwest Ethiopia. A prospective study

Background

Urinary tract infection is one of the most common bacterial infections in children. Understanding the characteristics of uropathogens and their antimicrobial susceptibility pattern in a particular setting can provide evidence for the appropriate management of cases. This study aimed to assess the bacterial profile of urinary tract infection, their antimicrobial susceptibility pattern and associated factors among clinically suspected children attending at Felege-Hiwot Comprehensive Specialized Hospital, Northwest Ethiopia.

Methods

A hospital-based cross-sectional study was conducted from February–April, 2019. A systematic sampling technique was employed. A mid-stream urine sample was inoculated on cystine lactose electrolyte deficient media and incubated for 24–48 h. Sub-culturing was done on Mac-Conkey and blood agar. Antimicrobial susceptibility test was done on Muller-Hinton agar. A binary logistic regression model was used to see the association between dependent and independent factors. A p-value< 0.05 at 95% CI was considered as statistically significant.

Results

The overall prevalence of urinary tract infection was 16.7% (95% CI 12.4–21.1). Both Gram-negative and Gram-positive bacterial isolates were recovered with a rate of 44/50 (88%) and 6/50 (12%) respectively. Among Gram-negative isolates, E. coli 28/44(63.6%) was predominant while S. saprophyticus 2/6(33.3%) was prevalent among Gram-positive bacterial isolates. Overall, a high level of resistance to ampicillin, augmentin, and tetracycline was shown by Gram-negative bacteria with a rate of 44/44(100%), 39/44(88.6%), and36/44 (81.8%) respectively. About 33/50(66%) of overall multidrug resistance was observed (95% CI 52–78). About six Gram-negative bacterial isolates were extended spectrum beta-lactamase (ESBL) producers. Having a history of urinary tract infection (P-0.003, AOR 1.86–22.15) and male uncircumcision (p-0.00, AOR 5.5–65.35) were the independent variables that associate for urinary tract infections.

Conclusion

In the present study, the prevalence of urinary tract infection among children was high and considerably a high proportion of multidrug resistance was observed. This result will have a significant impact on the selection of appropriate antimicrobial agents for the treatment of urinary tract infection.

Relationship Between Clinical Factors and Duration of IV Antibiotic Treatment in Neonatal UTI

OBJECTIVES

To describe practice patterns of intravenous (IV) antibiotic treatment duration in term neonates ≤28 days old with a urinary tract infection (UTI).

METHODS

We performed a retrospective chart review of term neonates ≤28 days old hospitalized for UTI at 2 academic pediatric hospitals from 2012 to 2018. Neonates who were admitted to the PICU or with known preexisting renal and/or urologic anomalies or concomitant bacteremia were excluded. We examined clinical features, complications, and duration of IV antibiotic therapy. Univariate and multivariate analyses of long duration of IV antibiotics (>48 hours) were performed by using logistic regression.

RESULTS

Of 310 neonates identified by diagnostic codes and chart review, 112 met criteria for inclusion. The median IV antibiotic duration was 49 hours (51% received IV antibiotics for >48 hours), and the median total antibiotic duration was 10 days. No demographic features or laboratory values correlated with IV antibiotic duration apart from age <7 days. The odds of long IV antibiotic duration increased if the neonate had a secondary diagnosis extending hospitalization (adjusted odds ratio [aOR] = 3.2; P = .002; 95% confidence interval [CI], 1.2-8.7), subspecialty consult (aOR = 4.79; P < .001; 95% CI, 1.87-12.3), or an abnormal renal ultrasound (aOR = 2.26; P = .02; 95% CI, 1.01-5.08). Only 1 neonate experienced treatment failure.

CONCLUSIONS

Our study revealed the recent trend toward shorter IV antibiotic courses for healthy term neonates with UTI is inclusive of infants ≤28 days at these 2 sites. Few factors associated with neonates' initial clinical presentation appear to influence the length of IV antibiotic treatment.

Prevalence and predictors of urinary tract infection in full-term and preterm neonates

Background

Early and prompt diagnosis of urinary tract infection (UTI) in neonates has important therapeutic implications. The aim of this study was to evaluate the prevalence of UTI in neonates admitted to a referral neonatal intensive care unit (NICU) and to identify predictors associated with an increased risk of UTI in NICU population.

Results

The prevalence of culture-proven UTI in the studied neonates was 6.67%. Moreover, UTI was more frequent (70%) among full-term neonates. Additionally, both fever and pyuria were the only clinical and laboratory findings that showed significant association with UTI (p < 0.05). Binary logistic regression revealed that neonates with pyuria in urine analysis were 5.44 times more liable to have UTI, while the presence of fever constitutes a risk of only 0.166 (odds ratios were 5.44 and 0.166, respectively). Additionally, sensitivity, specificity, positive predictive value, and negative predictive value of the regression model were 50.0, 94.5, 20.05, and 98.57%, respectively.

Conclusions

We conclude that UTI is not uncommon in full-term neonates admitted in NICU. Additionally, pyuria was significantly related to positive urine culture and its detection in urine analysis increases the likelihood of UTI by 5.44 times.

Urinary tract infection in pediatrics: an overview

OBJECTIVE

This review aimed to provide a critical overview on the pathogenesis, clinical findings, diagnosis, imaging investigation, treatment, chemoprophylaxis, and complications of urinary tract infection in pediatric patients.

SOURCE OF DATA

Data were obtained independently by two authors, who carried out a comprehensive and non-systematic search in public databases.

SUMMARY OF FINDINGS

Urinary tract infection is the most common bacterial infection in children. Urinary tract infection in pediatric patients can be the early clinical manifestation of congenital anomalies of the kidney and urinary tract (CAKUT) or be related to bladder dysfunctions. E. coli is responsible for 80-90% of community-acquired acute pyelonephritis episodes, especially in children. Bacterial virulence factors and the innate host immune systems may contribute to the occurrence and severity of urinary tract infection. The clinical presentation of urinary tract infections in children is highly heterogeneous, with symptoms that can be quite obscure. Urine culture is still the gold standard for diagnosing urinary tract infection and methods of urine collection in individual centers should be determined based on the accuracy of voided specimens. The debate on the ideal imaging protocol is still ongoing and there is tendency of less use of prophylaxis. Alternative measures and management of risk factors for recurrent urinary tract infection should be emphasized. However, in selected patients, prophylaxis can protect from recurrent urinary tract infection and long-term consequences. According to population-based studies, hypertension and chronic kidney disease are rarely associated with urinary tract infection.

CONCLUSION

Many aspects regarding urinary tract infection in children are still matters of debate, especially imaging investigation and indication of antibiotic prophylaxis. Further longitudinal studies are needed to establish tailored approach of urinary tract infection in childhood.