Diagnosing urinary tract infections in febrile infants and children: when evidence-based medicine and clinical practice collide

Increasing ciprofloxacin resistance of isolates from infected urines of a cross-section of patients in Karachi

BACKGROUND

The objective of the research was to evaluate the current effectiveness of ciprofloxacin on the uropathogens prevalent in infected urines of a cross-section of patients in Karachi, Pakistan.

FINDINGS

An observational study conducted in a private diagnostic laboratory and its branches in key areas of Karachi City from February 2010 to July 2011. A total of 2963 consecutive urine samples were cultured on chocolate agar, CLED medium and selective EMB agar. Growth of possible uropathogens was noted, and compared retrospectively with earlier lab data of suggestive urine cultures (n = 1997) recorded during January 2009 and December 2009. The isolates were identified using routine procedures and the API 20 system and evaluated for their sensitivity to ciprofloxacin by Kirby-Bauer disk diffusion method. Data was subjected to statistical analysis on SPSS version 16. Out of the present-day culture-positive urines, 2409 (80.4%) yielded gram-negative rods, and 554 (18.5%) gram-positive cocci. E.coli (43.1%) was most frequent, followed by Klebsiella pneumoniae (22.4%) and Staphylococcus aureus (15.5%). 57.2% of the Gram-negative bacteria and 48.7% of the Gram-positive isolates were resistant to ciprofloxacin. In the earlier (2009) screening, 39% of Gram-negative rods and 48% of Gram-positive cocci were indifferent to the drug.

CONCLUSIONS

A decrease in bacterial susceptibility of uropathogens to ciprofloxacin, a commonly prescribed drug in our population, is underlined, occurring possibly due to overuse pressure. Empirical initial treatment with ciprofloxacin would be inadequate in more than half of UTI cases, thereby counseling increased C/S testing of urines to provide existing sensitivity data for apt drug prescription.

A head-to-head comparison: "clean-void" bag versus catheter urinalysis in the diagnosis of urinary tract infection in young children

OBJECTIVE

To compare the validity of the urinalysis on clean-voided bag versus catheter urine specimens using the catheter culture as the "gold" standard.

STUDY DESIGN

This is a cross-sectional study of 303 nontoilet-trained children under age 3 years at risk for urinary tract infection (UTI) who presented to a children's hospital emergency department. Paired bag and catheter specimens were obtained from each child and sent for dipstick and microscopic urinalysis. Sensitivity and specificity were compared using McNemar's chi2 test for paired specimens and the ordinary chi2 test for unpaired comparisons.

RESULTS

The bag dipstick was more sensitive than the catheter dipstick for the entire study sample: 0.85 (95% confidence interval [CI]=0.78 to 0.93) versus 0.71 (95% CI=0.61 to 0.81), respectively. Both bag and catheter dipstick sensitivities were lower in infants < or =90 days old (0.69 [95% CI=0.44 to 0.94] and 0.46 [95% CI=0.19 to 0.73], respectively) than in infants >90 days old (0.88 [95% CI=0.81 to 0.96] and 0.75 [95% CI=0.65 to 0.86], respectively). Specificity was consistently lower for the bag specimens than for the catheter specimens: 0.62 (95% CI=0.56 to 0.69) versus 0.97 (95% CI=0.95 to 0.99), respectively.

CONCLUSIONS

Urine collection methods alter the diagnostic validity of urinalysis. These differences have important implications for the diagnostic and therapeutic management of children with suspected UTI.