Urinary tract infections in hospital pediatrics: Many previous antibiotherapy and antibiotics resistance, including fluoroquinolones

Highly adsorptive protein inorganic nanohybrid of Moringa seeds protein and rice husk nanosilica for effective adsorption of pharmaceutical contaminants

The present study aims to investigate adsorption characteristics and mechanisms of Moringa (MO) seeds protein on nanosilica rice husk and their applications in removal of pharmaceutical residues including the fluoroquinolone antibiotic levofloxacin (LFX) and the nonsteroidal anti-inflammatory drug diclofenac (DCF) in aquatic environment. Molecular weight of MO protein was determined by gel-permeation chromatography (GPC) method while its amino acids were quantified by high performance liquid chromatography (HPLC). The number-(M_n) and weight-average molecular weights (M_w) of MO protein were 1.53 × 10⁴ and 1.61 × 10⁴ g/mol, respectively. Different effective conditions on adsorption protein on nanosilica including contact time, pH, adsorbent dosage, and ionic strength were systematically optimized and found to be 180 min, 10, 10 mg/mL and 1 mM KCl, respectively. The surface charge change by zeta potential, surface modification by Fourier-transform infrared spectroscopy (FT-IR) and adsorption isotherms demonstrated that protein adsorption on nanosilica was governed by both electrostatic and non-electrostatic interactions. Application of protein functionalized nanosilica (ProFNS) in LFX and DCF removal were also thoroughly studied. The selected conditions for LFX and DCF removal using ProFNS were 1 mM KCl for both LFX and DCF; pH 8 and pH 6; contact time 90 and 120 min, and adsorption dosage 10 and 5 mg/ml for LFX and DCF, respectively. Adsorption isotherms of protein on nanosilica as well as LFX and DCF onto ProFNS at different ionic strengths were reasonably fitted by the two-step model while a pseudo-second-order model could fit adsorption kinetic well. The removal of LFX and DCF using ProFNS significantly increased from 51.51% to 87.35%, and 7.97%-50.02%, respectively. High adsorption capacities of 75.75 mg/g for LFX and 59.52 mg/g for DCF, indicate that ProFNS is a great performance for pharmaceutical residues removal in water environment.

Integron detection for prediction of trimethoprim/sulfamethoxazole susceptibility in children with Enterobacterales urinary tract infections

Objectives

In some countries, third-generation cephalosporins (3GCs) serve as first-line therapy in children with urinary tract infections (UTIs). However, their use may contribute to the emergence of antibiotic resistance, notably among Gram-negative bacteria (GNB). Integrons are bacterial genetic elements involved in antibiotic resistance in GNB. Their absence is associated with >97% susceptibility to trimethoprim/sulfamethoxazole in adults infected with GNB. The objective of this study was to examine the value of integron detection directly from urine samples as a predictive marker of resistance to trimethoprim/sulfamethoxazole in children with GNB-related UTIs.

Methods

Children admitted to the Limoges University Hospital’s paediatric emergency department between February 2018 and March 2019 with a suspicion of UTI were eligible for the study. Only confirmed cases presenting a positive urine culture with unique GNB were retained for further study analyses. Integrons were detected directly from urines using real-time PCR.

Results

The data of 72 patients were analysed and integrons were detected in 15 urine samples. The negative predictive value of integron detection for resistance to trimethoprim/sulfamethoxazole was 100% as all of the GNB (all were Enterobacterales) isolated from patients with no integrons detected in their urine samples were susceptible to trimethoprim/sulfamethoxazole.

Conclusions

The detection of integrons in cases of paediatric patients with suspected UTI could help limit 3GC empirical use and empower an empirical first-line strategy better tailored to the needs of each patient.

Antibiotic Prescription Practice for Pediatric Urinary Tract Infection in a Tertiary Center

OBJECTIVES

Prescribing antibiotics for suspected urinary tract infection (UTI) is common practice and may lead to unnecessary antibiotic exposure. We aimed to review UTI diagnosis and management in the emergency department and to identify targets for antimicrobial stewardship.

METHODS

Single-center, retrospective cohort study of children aged 12 weeks to younger than 18 years discharged from the emergency department with a diagnosis of UTI between October and December 2016. Children with genitourinary malformations were excluded. Clinical information, urine collection method, laboratory findings, and urine culture results were gathered. The sensitivity and specificity of nitrite and leukocyte esterase for UTI diagnosis were calculated. The relationship between urinalysis characteristics and confirmed UTI was examined using logistic regression.

RESULTS

A total of 183 children with a median (interquartile range) age of 4.2 (1.1-7.5) years were included; 82.5% were female. Almost all children were discharged home on antibiotics (n = 180, 98%) for a median (interquartile range) duration of 7 (7-10) days. A total of 85 patients (46.4%) received antibiotics despite negative urine cultures leading to 525 unnecessary antibiotic days. The presence of nitrites was the strongest predictor of UTI (odds ratio = 20.22, P < 0.001) and was highly specific.

CONCLUSIONS

Current practice in managing suspected pediatric UTIs in our ED resulted in significant and unnecessary antibiotic exposure. We identified targets to reduce unnecessary antibiotic exposure including improving the diagnostic accuracy of UTIs, a process to discontinue antibiotics for negative cultures and standardizing antimicrobial duration.

Current status of long-term antibiotic prophylaxis for urinary tract infections in children: An antibiotic stewardship challenge

Recurrent urinary tract infections (UTIs) in children are associated with development of pyelonephritis and renal scarring. Traditionally, continuous antibiotic prophylaxis (CAP) has been used to prevent recurrent UTI. Recent studies have challenged the efficacy of CAP for preventing renal scarring and have raised concerns about inducing bacterial resistance. This review focuses on studies published between January 2000 and April 2019 and evaluates the use of CAP in children for avoiding recurrent UTIs and renal scarring. A systematic literature search was carried out using the following search terms and related medical subject headings in the MEDLINE electronic database: ‘urinary tract infection’, ‘antimicrobial/antibiotic prophylaxis’, and ‘children/pediatrics’. Randomized clinical trials (RCTs), original research articles, guidelines, systematic reviews, and meta-analyses describing antibiotic prophylaxis for UTIs were included. A total of 34 RCTs, 9 systematic reviews, and 3 guidelines describing antibiotic prophylaxis were included in this review. The efficacy of CAP for preventing recurrent UTI remains unclear due to non-generalizability of results obtained from suboptimally designed clinical trials. CAP has not been proven as beneficial for preventing new renal scarring in children. Additionally, CAP is associated with increased risk of multidrug resistant infections in children. No conclusive evidence can be drawn from the available clinical data to support routine use of CAP for prevention of renal scarring. Accumulation of evidence from additional well designed studies may result in different conclusions in the future. It is important to identify specific risks for recurrent UTI and ensuing renal injury to ensure more judicious use of CAP.

Ceftriaxone use in a tertiary care hospital in Kilimanjaro, Tanzania: A need for a hospital antibiotic stewardship programme

Excessive use of antibiotics, especially watch group antibiotics such as ceftriaxone leads to emergence and spread of antimicrobial resistance (AMR). In low and middle-income countries (LMICs), antibiotics are overused but data on consumption is scarcely available. We aimed at determining the extent and predictors of ceftriaxone use in a tertiary care university teaching hospital in Kilimanjaro, Tanzania. A hospital-based cross-sectional study was conducted from August 2013 through August 2015. Patients admitted in the medical, surgical wards and their respective intensive care units, receiving antimicrobials and other medications for various ailments were enrolled. Socio-demographic and clinical data were recorded in a structured questionnaire from patients' files and logistic regression was performed to determine the predictors for ceftriaxone use. Out of the 630 patients included in this study, 322 (51.1%) patients were on ceftriaxone during their time of hospitalization. Twenty-two patients out of 320 (6.9%) had been on ceftriaxone treatment without evidence of infection. Ceftriaxone use for surgical prophylaxis was 44 (40.7%), of which 32 (72.7%) and 9 (20.5%) received ceftriaxone prophylaxis before and after surgery, respectively. Three (6.8%) received ceftriaxone prophylaxis during surgery. Predicting factors for that the health facility administered ceftriaxone were identified as history of any medication use before referral to hospital [OR = 3.4, 95% CI (1.0-11.4), p = 0.047], bacterial infection [OR = 18.0, 95% CI (1.4-225.7, p = 0.025)], surgical ward [OR = 2.9, 95% CI (0.9-9.4), p = 0.078] and medical wards [OR = 5.0, 95% CI (0.9-28.3), p = 0.070]. Overall, a high ceftriaxone use at KCMC hospital was observed. Antimicrobial stewardship programs are highly needed to monitor and regulate hospital antimicrobial consumption, which in turn could help in halting the rising crisis of antimicrobial resistance.

Antimicrobial Pharmacotherapy Management of Urinary Tract Infections in Pediatric Patients

Objective: To discuss the risk factors, microbial resistance rates, and pharmacotherapy, including antimicrobial choices and medication dosage regimens, for urinary tract infections (UTIs) in pediatric patients. Data Sources: A MEDLINE literature search (1985 to December 2017) was performed using the following keywords and associated medical subject headings: urinary tract infection, antimicrobial, treatment, and children. Study Selection and Data Extraction: Search was conducted to identify clinical trials, systematic reviews, and guidelines. Search was filtered to include studies with age range between birth and 18 years and published in English. Additional references were identified from selected review articles. Data Synthesis: In total, 27 studies investigating microbial resistance, 31 studies assessing antimicrobial efficacy, 34 studies describing prophylaxis, and 6 systematic reviews were included. The resistance patterns differed across age groups and affected the choice of empirical therapy. If pyelonephritis is suspected, empiric antimicrobials should have high urinary and sufficient parenchymal concentrations. Nitrofurantoin has low microbial resistance rates and can generally be used empirically for treating uncomplicated cystitis in children >1 month of age. Trimethoprim-sulfamethoxazole resistance has increased and should be avoided unless local susceptibility data are available. Certain patients with recurrent UTIs or renal abnormalities may require antimicrobial prophylaxis, which may be associated with adverse effects, such as intolerability or an increased risk of microbial resistance. Conclusion: The resistance pattern of uropathogens should be considered prior to initiating therapy. Controlled trials with large samples are needed to compare the treatment duration of various antimicrobial regimens and the specific role of prophylactic antimicrobials.

Etiological and Resistance Profile of Bacteria Involved in Urinary Tract Infections in Young Children

Background. The objective of this study was to identify the bacteria most frequently responsible for urinary tract infection (UTI) in the population of under-2-year-olds in our geographic area and to evaluate the activity of antibiotics widely used for UTI treatment during a 4-year study period. Materials and Methods. A retrospective analysis was conducted of data on the identification and susceptibility of microorganisms isolated in urine samples from children under 2 years of age. Results. A total of 1,045 uropathogens were isolated. Escherichia coli accounted for the majority (60.3%) of these, followed by Enterococcus faecalis (22.4%) and Klebsiella spp. (6.5%). The highest E. coli susceptibility rates (>90%) were to piperacillin-tazobactam, cefuroxime, cefotaxime, ceftazidime, imipenem, gentamicin, nitrofurantoin, and fosfomycin, and the lowest were to amoxicillin-clavulanic acid and cotrimoxazole. Among all bacteria isolated, we highlight the overall high activity of piperacillin-tazobactam, imipenem, nitrofurantoin, and fosfomycin against both community and hospital isolates and the reduced activity of amoxicillin-clavulanic acid, cephalosporins, gentamicin, and cotrimoxazole. There was no significant change in the total activity of any of the studied antibiotics over the 4-year study period. Conclusion. Empiric treatment with amoxicillin-clavulanic acid, cotrimoxazole, cephalosporins, and gentamicin may be inadequate due to their limited activity against uropathogens in our setting.

[Profile of bacterial resistance in pediatric urinary tract infections in 2014]

In pediatric units, bacteria-producing extended-spectrum-betalactamase (ESBL) have an increasing prevalence among bacteria causing febrile urinary tract infections (UTIs). The purpose of this study was to evaluate the epidemiology of bacteria resistance patterns observed in UTIs, in order to assess the current antibiotic treatment protocols. This study is based upon a single-center retrospective chart review of the cytobacteriological urine cultures performed in UTIs between 1 January and 31 December 2014, in the medical pediatric unit of the Caen University Hospital. Out of the total of 219 cases of UTI, 26.9% were recurrences of UTI, 18.3% were infections in infants less than 3 months old, 21% of the patients suffered from underlying uropathy, and 16.4% of the patients had recently been exposed to antibiotics. In 80.3% of the cases, Escherichia coli was found, while Enterococcus faecalis was found in 5.6%. The antibiograms proved that 33.5% of the bacteria were sensitive. Half of E. coli were resistant to ampicillin, 4.9% to cefixime, 4.9% to ceftriaxone, 1.1% to gentamicin, and 27.8% to trimethoprim-sulfamethoxazole. Nine E. coli and one Enterobacter cloacae produced ESBL, accounting for 4.6% of the UTIs. We did not find any bacteria-producing high-level cephalosporinase. Cefixime resistance was statistically linked to ongoing antibiotic treatment (OR=5.98; 95% CI [1.44; 24.91], P=0.014) and underlying uropathy (OR=6.24; 95% CI [1.47; 26.42], P=0.013). Ceftriaxone resistance was statistically related to ongoing antibiotic treatment (OR=6.93; 95% CI [1.45; 33.13], P=0.015). These results argue in favor of maintaining intravenous ceftriaxone for probabilistic ambulatory treatment. However, in case of hospitalization, cefotaxime can replace ceftriaxone, due to its lower ecological impact. Moreover, it is necessary to continue monitoring bacterial resistance and regularly review our treatment protocols.

Resistance to oral antibiotics in 4569 Gram-negative rods isolated from urinary tract infection in children

To investigate antibiotic resistance among pathogens isolated from urines in a tertiary care children's hospital in Italy. Retrospective analysis of prospectively collected data on antibiotic susceptibility of Gram-negatives isolated from urines at the Istituto Giannina Gaslini, Genoa - Italy from 2007 to 2014. Antibiotic susceptibility was evaluated. By means of CLSI criteria from 2007 to 2010, while from 2011 EUCAST criteria were adopted. Data on susceptibility to amoxicillin-clavulanate, co-trimoxazole, cefuroxime, nitrofurantoin, fosfomycin and ciprofloxacin were evaluated for Escherichia coli, while for other Enterobacteriaceae data were collected for amoxicillin-clavulanate, co-trimoxazole and ciprofloxacin and for ciprofloxacin against Pseudomonas aeruginosa. Univariate and multivariable analyses were performed for risk factors associated with resistance. A total of 4596 Gram-negative strains were observed in 3364 patients. A significant increase in the proportion of resistant strains was observed for E.coli against amoxicillin-clavulanate, cefuroxime and ciprofloxacin and for others Enterobacteriaceae against co-trimoxazole and ciprofloxacin. Resistance to nitrofurantoin and fosfomycin was very infrequent in E.coli. Logistic regression analysis showed that repeated episode of urinary tract infections was a risk factor for E.coli resistance to amoxicillin-clavulanate, co-trimoxazole and cefuroxime, while admission in one of the Units usually managing children with urinary tract malformations was significantly associated to resistance to amoxicillin-clavulanate and cefuroxime.

CONCLUSION

In conclusion the present study shows an increase in antibiotic resistance in pediatric bacteria isolated from urines in children, especially in presence of repeated episodes and/or urinary tract malformations. This resistance is worrisome for beta-lactams and cotrimoxazole, and start to increase also for fluoroquinolones while nitrofurantoin and fosfomycin still could represent useful drugs for oral treatment of these infections.

WHAT IS KNOWN

• Infections are frequent in patients with urinary tract malformations • Antibiotic prophylaxis can select for resistant pathogens What is New: • The increase in the resistance to β-lactams, co-trimoxazole or fluoroquinolones in pathogens causing urinary tract infections cause a reduction of drugs with oral formulations available for therapy • Old drugs like nitrofurantoin and fosfomycin can represent attractive compounds for oral treatment of urinary tract infections in children presence of resistance to other drug classes.

Antimicrobial Susceptibility Patterns in Urinary Tract Infections in Dogs (2010-2013)

Background

Urinary tract infections (UTIs) are common in dogs. The responsible bacterial populations have evolved with increasing resistance to many antimicrobials.

Objective

To characterize the antimicrobial susceptibility patterns of canine urinary tract isolates over a 51‐month period.

Animals

One thousand six hundred and thirty‐six bacterial isolates from 1,028 dogs.

Methods

Aerobic bacterial isolate growth and susceptibility data from urine cultures of dogs were identified, retrospectively. Medical records were reviewed to obtain signalment, comorbidities, and antimicrobial use in the previous 30 days. The UTIs were further categorized as uncomplicated, complicated, or pyelonephritis.

Results

Common bacterial isolates identified were Escherichia coli (52.5%), Staphylococcus spp. (13.6%), and Enterococcus spp. (13.3%). In vitro susceptibility among all isolates varied for commonly prescribed antimicrobials (amoxicillin [59%], amoxicillin/clavulanic acid [76%], cephalexin [66%], enrofloxacin [74%] and trimethoprim‐sulfamethoxazole [86%]). For all antimicrobials tested (except aminoglycosides), in vitro susceptibility was higher in uncomplicated versus complicated infections (P < .05). Uncomplicated infection isolate susceptibility rates remained ≤90% for PO administered antimicrobials. Administration of amoxicillin, doxycycline, and enrofloxacin, but not amoxicillin/clavulanic acid in the previous 30 days was associated with resistance to that antimicrobial. Multidrug resistant isolates of E. coli and Staphylococcus spp. were more common in dogs with complicated than uncomplicated UTIs (36% versus 21%, P < .0001).

Conclusions and Clinical Importance

In vitro susceptibility was highly variable and no PO administered antimicrobial had >90% efficacy among isolates tested. Multidrug resistance was frequent among isolates tested suggesting that routine culture and susceptibility testing is indicated. Previously prescribed antimicrobials may affect empirical choices made pending susceptibility testing.

Comparative analysis of quinolone resistance in clinical isolates of Klebsiella pneumoniae and Escherichia coli from Chinese children and adults

The objective of this study was to compare quinolone resistance and gyrA mutations in clinical isolates of Klebsiella pneumoniae and Escherichia coli from Chinese adults who used quinolone in the preceding month and children without any known history of quinolone administration. The antimicrobial susceptibilities of 61 isolates from children and 79 isolates from adults were determined. The mutations in the quinolone resistance-determining regions in gyrA gene were detected by PCR and DNA sequencing. Fluoroquinolone resistance and types of gyrA mutations in isolates from children and adults were compared and statistically analyzed. No significant differences were detected in the resistance rates of ciprofloxacin and levofloxacin between children and adults among isolates of the two species (all P > 0.05). The double mutation Ser83→Leu + Asp87→Asn in the ciprofloxacin-resistant isolates occurred in 73.7% isolates from the children and 67.9% from the adults, respectively (P = 0.5444). Children with no known history of quinolone administration were found to carry fluoroquinolone-resistant Enterobacteriaceae isolates. The occurrence of ciprofloxacin resistance and the major types of gyrA mutations in the isolates from the children were similar to those from adults. The results indicate that precautions should be taken on environmental issues resulting from widespread transmission of quinolone resistance.