Stratégies thérapeutiques dans les infections urinaires du nourrisson et de l’enfant

Susceptibility and Virulence of Enterobacteriaceae Isolated from Urinary Tract Infections in Benin

Enterobacteriaceae represent one of the main families of Gram-negative bacilli responsible for serious urinary tract infections (UTIs). The present study aimed to define the resistance profile and the virulence of Enterobacteriaceae strains isolated in urinary tract infections in Benin. A total of 390 urine samples were collected from patients with UTIs, and Enterobacteriaceae strains were isolated according to standard microbiology methods. The API 20E gallery was used for biochemical identification. All the isolated strains were subjected to antimicrobial susceptibility testing using the disc diffusion method. Extended-spectrum beta-lactamase (ESBL) production was investigated using a double-disc synergy test (DDST), and biofilm production was quantified using the microplate method. Multiplex PCR was used to detect uro-virulence genes, namely: PapG, IronB, Sfa, iucD, Hly, FocG, Sat, FyuA and Cnf, using commercially designed primers. More than 26% (103/390) of our samples were contaminated by Enterobacteriaceae strains at different levels. Thus, E. coli (31.07%, 32/103), Serratia marcescens (11.65%, 12/103), Klebsiella ornithinolytica (8.74%, 9/103), Serratia fonticola (7.77%, 8/103) and Enterobacter cloacae (6.80%, 7/103) were identified. Among the isolated strains, 39.81% (41/103) were biofilm-forming, while 5.83% (6/103) were ESBL-producing. Isolates were most resistant to erythromycin, cefixime, ceftriaxone and ampicillin (≥90%) followed by ciprofloxacin, gentamycin, doxycycline and levofloxacin (≥50%), and least resistant to imipenem (27.18%). In regard to virulence genes, Sfa was the most detected (28.15%), followed by IronB (22.23%), iucD (21.36%), Cnf (15.53%), PapG (9.71%), FocG (8.74%), Sat (6.79%), FyuA (5.82%) and Hyl (2.91%). These data may help improve the diagnosis of uropathogenic strains of Enterobacteriaceae, but also in designing effective strategies and measures for the prevention and management of severe, recurrent, or complicated urinary tract infections in Benin.

Community-acquired febrile urinary tract infection caused by extended-spectrum beta-lactamase-producing bacteria in hospitalised infants

INTRODUCTION

Extended-spectrum beta-lactamase (ESBL) producing bacteria are infrequent pathogens of urinary tract infections in children. The objective of our study was to investigate the presence, clinically associated characteristics and risk factors for acquisition of urinary tract infection/acute pyelonephritis (UTI/APN) in hospitalised children <2years old caused by community-acquired ESBL.

METHODS

A case-control study in a second level community hospital in Spain, in which 537 episodes of UTI/APN were investigated in a retrospective study between November 2005 and August 2014. Cases were patients with ESBL strains. For each case, four ESBL-negative controls were selected. A questionnaire with the variables of interest was completed for every patient, and the groups were compared.

RESULTS

ESBL-positive strains were found in 19 (3,5%) cultures. Of these 16 (84%) were Escherichia coli. Vesicoureteral reflux (VUR) of any grade was more frequent in the ESBL group (60 vs. 29%), although without statistical significance. Relapses were more frequent in the ESBL group (42% vs. 18%) (P=.029; OR=3.2; 95%CI: 1.09-9.5). The prevalence of UTI/APN due to ESBL-positive strains increased slightly from 2.7% in the period 2005-2009 to 4.4% in the period 2010-2014.

CONCLUSIONS

ESBL UTI/APN were associated with more frequent relapses. VUR of any grade was twice more frequent in the ESBL group. Piperacillin/tazobactam, fosfomycin and meropenem showed an excellent activity. Aminoglycosides may be a therapeutic option, and in our patients gentamicin was the antibiotic most used.

Frequency and characteristics of infectious diseases in internationally adopted children: a retrospective study in Nantes from 2010 to 2012

BACKGROUND AND AIMS

Internationally adopted children are more susceptible to developing and carrying acute or chronic infectious diseases. Specialized consultations exist in the main French cities; however, specialized consultation with a pediatrician is not mandatory. The main objective of this study was to determine the frequency and characteristics of infections (bacterial, viral, and parasitic) among a group of international adoptees in Nantes over a 3-year period.

METHODS

A retrospective chart review was conducted of internationally adopted children who went through the Medical Guidance for Adopted Children Consultation between 2010 and 2012.

RESULTS

A total of 133 children were included in the study. Of these, 55% had an infectious disease; 8% were severe infections. We found a frequency of 38% [confidence interval (CI) 95% 30-46] for parasitic intestinal and 35% (CI 95% 27-43) for dermatologic infections. African children were more likely to have infections that required hospitalization [odds ratio (OR) = 12, p = 0.004, CI 95% 1.3-113.7] and more likely to carry extended-spectrum β-lactamase-producing bacteria.

CONCLUSION

The frequency of infectious diseases, and sometimes severe diseases, found among our cohort of internationally adopted children highlights the need for systematic, specialized medical care.

[Management of urinary tract infections in children. Recommendations of the Pediatric Infectious Diseases Group of the French Pediatrics Society and the French-Language Infectious Diseases Society]

Urine dipsticks have to be used more frequently for the screening of urinary tract infections (UTI) in febrile infants and children (grade A). Confirmation of the UTI by urine culture should prefer other methods of sampling than the urine bag: sampling jet, urethral catheterization, or pubic puncture (grade A). The percentage of Escherichia coli producing extended-spectrum beta-lactamases (ESBL) in children accounts for less than 10 % in France and does not justify revising the 2007 recommendations (grade B). An increase in the use of carbapenems in first-line treatment is a major environmental hazard and exposes the patient to the risk of untreatable infections. For febrile UTI, the expert group recommended: (1) recover the results of susceptibility testing as soon as possible to quickly adapt treatment for possible resistant strains; (2) favor initial treatment with aminoglycosides (particularly amikacin) which remain active in the majority of ESBL strains for patients seen in the pediatric emergency department and/or hospital; (3) ceftriaxone (IV or IM) remains an appropriate treatment for patients seen in the emergency department or outpatient clinic because the percentage of ESBL-producing enterobacteria strains remains low; (4) use oral cefixime (grade B) in nonsevere cases and low-risk patients defined as age>3 months, general condition preserved, disease duration of fever<4 days, no associated comorbidity, and no history of urinary tract infection, uropathy, or prior antibiotic therapy in the last 3 months; (5) oral relay for parenteral treatment is guided by in vitro susceptibility testing, in an attempt to reduce the use of oral cephalosporins to limit the selection of resistant bacterial strains. The total duration of treatment recommended is usually 10 days. Except for special circumstances, there is no need to prescribe retrograde cystography or antibiotic prophylaxis after a first febrile urinary tract infection. For cystitis, the panel recommends systematic urinalysis and initial prescription before the results of the urine culture of one of the three following oral antibiotics: amoxicillin-clavulanate, cotrimoxazole, cefixime. The total duration of antibiotic treatment is 5days to tailor treatment based on clinical progression and antibiotic susceptibility.

Clinical and bacteriological efficacy of amikacin in the treatment of lower urinary tract infection caused by extended-spectrum beta-lactamase-producing Escherichia coli or Klebsiella pneumoniae

Urinary tract infections (UTIs) caused by extended-spectrum beta-lactamase (ESBL)-producing bacteria have become a growing problem limiting therapeutic options. The aim of this study was to investigate the clinical and microbiological efficacy of amikacin treatment in adult patients with lower UTIs due to ESBL-producing Escherichia coli (Ec) or Klebsiella pneumonia (Kp). We conducted a retrospective study of 36 outpatients aged >18 years with dysuria or problems with frequency or urgency in passing urine; pyuria and a positive urine culture (10(5) cfu/ml) for ESBL producing Ec or Kp which is also resistant to nitrofurantoin, fosfomycin, quinolones and trimethoprim/sulfamethoxazole, between January 2013 and February 2014. Patients received intramuscular amikacin 15 mg/kg/day for 10 days. Clinical success was defined as disappearance of symptoms. Bacteriological success was defined as sterile control urine cultures. 58.3% of patients were female. Age range was 18-89 years. All of the patients had at least one complicating factor. 77.8% of the isolates were E. coli. Clinical success rate was 97.2%. Overall bacteriological success rates were 91.7% on the 3 day of treatment, 97.1% at the end of the treatment and 94.1% on the 7-10 days after treatment. After 28-32 days following the treatment, reinfection was found in 12% whereas relapse was not determined. Nephrotoxicity was developed in one patient. The clinicians should keep in mind that amikacin treatment is an efficient and safe alternative treatment option before the carbapenem treatment especially in patients with lower UTIs caused by ESBL-producing Ec or Kp that are resistant to all oral antibiotics.