An update on new antibiotic prophylaxis and treatment for urinary tract infections in children

Risk factors for scabies in hospital: a systematic review

BACKGROUND

Annually, 175.4 million people are infected with scabies worldwide. Although parasitic infections are important nosocomial infections, they are unrecognized compared to bacterial, fungal, and viral infections. In particular, nonspecific cutaneous manifestations of scabies lead to delayed diagnosis and frequent nosocomial transmission. Hospital-based studies on the risk factors for scabies have yet to be systematically reviewed.

METHODS

The study followed the PRISMA guidelines and was prospectively registered in PROSPERO (CRD42023363278). Literature searches were conducted in three international (PubMed, Embase, and CINAHL) and four Korean (DBpia, KISS, RISS, and Science ON) databases. We included hospital-based studies with risk estimates calculated with 95% confidence intervals for risk factors for scabies infection. The quality of the studies was assessed using the Joanna Briggs Institute critical appraisal tools. Two authors independently performed the screening and assessed the quality of the studies.

RESULTS

A total of 12 studies were included. Personal characteristics were categorized into demographic, economic, residential, and behavioral factors. The identified risk factors were low economic status and unhygienic behavioral practices. Being a patient in a long-term care facility or institution was an important factor. Frequent patient contact and lack of personal protective equipment were identified as risk factors. For clinical characteristics, factors were categorized as personal health and hospital environment. People who had contact with itchy others were at higher risk of developing scabies. Patients with higher severity and those with a large number of catheters are also at increased risk for scabies infection.

CONCLUSIONS

Factors contributing to scabies in hospitals range from personal to clinical. We emphasize the importance of performing a full skin examination when patients present with scabies symptoms and are transferred from settings such as nursing homes and assisted-living facilities, to reduce the transmission of scabies. In addition, patient education to prevent scabies and infection control systems for healthcare workers, such as wearing personal protective equipment, are needed.

Bacteriuria in Paediatric Oncology Patients: Clinical Features, Distribution and Antimicrobial Susceptibility of Bacterial Pathogens at University Hospital Centre Zagreb, Croatia over a 4-Year Period

Bacteriuria in paediatric oncology patients have not been well studied. This retrospective study analysed clinical features, distribution and antimicrobial susceptibility of bacterial pathogens cultured from urine in paediatric oncology patients over a 4-year period (2019-2022). A total of 143 episodes of bacteriuria were documented in 74 patients. Neutropenia was present in 17.5% (25/143), symptoms in 25.9% (37/143) and urinary catheter in 7.0% (10/143) episodes. Symptomatic bacteriuria episodes were statistically significantly more frequent in patients with neutropenia (p = 0.0232). The most common bacterial pathogens were Escherichia coli (n = 49; 32.2%), Klebsiella spp. (n = 34; 22.4%), Pseudomonas aeruginosa (n = 22; 14.5%) and Enterococcus spp. (n = 21; 13.8%). Extended-spectrum β-lactamases-producing (ESBL) Enterobacterales were found in 11 episodes (11/143; 7.7%) with the highest proportion among Klebsiella pneumoniae isolates (n = 7/34; 20.6%). No carbapenem-resistant Enterobacterales, multidrug-resistant P. aeruginosa or vancomycin-resistant Enterococcus spp. were found. The most important novelties are demonstrating P. aeruginosa as one of the prominent bacteriuria pathogens in this patient population, presence of ESBL isolates and carbapenem-resistant P. aeruginosa later during hospitalization highlights the need for appropriate antimicrobial treatment. However, because of the small number of symptomatic patients, further studies are needed to clarify the importance of including urine culture in the diagnostic process in patients with febrile neutropenia.

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

BACKGROUND

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

OBJECTIVE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Incidence and Causative Organisms of Bacteriuria in Children With Cancer: A 9-Year Experience in a Tertiary Pediatric Center

Although infection is common in patients with cancer, the distribution of causative agents and the proportion of resistant bacteria in patients with urinary tract infection remain unknown. The aim of this study was to describe the incidence, the causative agents, and the proportion of antimicrobial resistance in bacteria cultured from urine of hospitalized children with cancer. A single-center retrospective chart review of patients with cancer admitted between 2012 and 2020 was performed to identify patients with positive urine culture. Overall, 61 (0.9%) of 7107 patients were identified to have positive urine cultures. Among them, 25 patients (41%) had symptomatic bacteriuria. The most common pathogenic bacterium among all patients was Escherichia coli ( E. coli ) (n=15, 25%), followed by Enterococcus sp. (n=14, 23%), Klebsiella sp. (n=12, 20%), and Pseudomonas aeruginosa ( P. aeruginosa ) (n=12, 20%). Extended spectrum β-lactamases-producing E. coli and Extended spectrum β-lactamases-producing Klebsiella pneumoniae were detected in 1 patient (2%) and 4 patients (7%), respectively. No multidrug-resistant P. aeruginosa and vancomycin-resistant Enterococcus were detected. The incidence of bacteriuria was found to be low in children with cancer. The distribution of causative agents of bacteriuria in children with solid tumors and hematologic diseases may be different from that in previously healthy children.

Epidemiology of Antibiotic Resistant Pathogens in Pediatric Urinary Tract Infections as a Tool to Develop a Prediction Model for Early Detection of Drug-Specific Resistance

Antibiotic resistance is an increasing problem, especially in children with urinary tract infections. Rates of drug-specific resistant pathogens were reported, and an easy prediction model to guide the clinical decision-making process for antibiotic treatment was proposed. Data on microbiological isolation from urinoculture, between January 2007−December 2018 at Istituto Gaslini, Italy, in patients aged <19 years were extracted. Logistic regression-based prediction scores were calculated. Discrimination was determined by the area under the receiver operating characteristic curve; calibration was assessed by the Hosmer and Lemeshow test and the Spiegelhalterz test. A total of 9449 bacterial strains were isolated in 6207 patients; 27.2% were <6 months old at the first episode. Enterobacteriales (Escherichia coli and other Enterobacteriales) accounted for 80.4% of all isolates. Amoxicillin-clavulanate (AMC) and cefixime (CFI) Enterobacteriales resistance was 32.8% and 13.7%, respectively, and remained quite stable among the different age groups. On the contrary, resistance to ciprofloxacin (CIP) (overall 9.6%) and cotrimoxazole (SXT) (overall 28%) increased with age. After multivariable analysis, resistance to AMC/CFI could be predicted by the following: sex; age at sampling; department of admission; previous number of bacterial pathogens isolated. Resistance to CIP/SXT could be predicted by the same factors, excluding sex. The models achieved very good calibration but moderate discrimination performance. Specific antibiotic resistance among Enterobacteriales could be predicted using the proposed scoring system to guide empirical antibiotic choice. Further studies are needed to validate this tool.

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.

Antibiotic Resistance Patterns of Uropathogens Causing Urinary Tract Infections in Children with Congenital Anomalies of Kidney and Urinary Tract

Background: Urinary tract infections (UTI) are common in children worldwide. Congenital anomalies of kidney and urinary tract (CAKUT) increase the risk of UTI and consequently antibiotic resistance. Antibiotic resistance represents an important public health issue worldwide. We aimed to evaluate the local trend in terms of bacterial uropathogen resistance in the western part of Romania in children with CAKUT and UTI. Methods: 252 children with CAKUT were admitted to our hospital over a five-year period. Of them, 91 developed at least one UTI episode, with a total number of 260 positive urine cultures. We collected data about age at diagnosis of CAKUT, sex, origin environment, type and side of CAKUT, number of UTIs, type of uropathogen, and uropathogens antibiotic resistance. Results: Distribution of uropathogens was Escherichia coli (38.84%), Klebsiella spp. (21.15%), Enterococcus spp. (15.76%), Proteus spp. (8.07%), Pseudomonas spp. (8.07%), Enterobacter spp. (2.3%), other Gram-negative bacteria (2.3%), and other Gram-positive bacteria (3.45%). High antibiotic resistance was detected for ampicillin, amoxicillin, and second-generation cephalosporins. Escherichia coli presented high resistance for cefepime and ceftriaxone. Pseudomonas spp. remained susceptible to amikacin, quinolones, and colistin. Vancomycin, teicoplanin, linezolid, and piperacillin/tazobactam remained effective in treating Gram-positive UTI. Conclusions: High antibiotic resistance was identified for frequently used antibiotics. Lower antibiotic resistance was observed for some broad-spectrum antibiotics. Understanding uropathogens’ antibiotic resistance is important in creating treatment recommendations, based on international guidelines, local resistance patterns, and patient particularities.

Multidrug-resistant organisms in urinary tract infections in children

The global spread of multidrug-resistant organisms has led to an increase in urinary tract infections (UTIs) in children that are difficult to treat. This review explores the current literature regarding multidrug-resistant UTIs in childhood and proposes an approach to management. Multidrug-resistant organisms include a wide range of potential urinary tract pathogens and, while most literature on drug resistance in UTIs during childhood has focused on extended-spectrum beta-lactamase producing organisms, in this review, we have included a discussion of multidrug resistance including and beyond beta-lactamase production. We provide definitions for multidrug-resistant organisms in line with current consensus guidelines and summarise clinically relevant mechanisms of resistance. Additionally, in this review, we outline the global epidemiology of multidrug-resistant UTIs in children, summarising published prevalence rates, which range from 5 to 90% in different settings. Finally, we also critically review the evidence on risk factors for colonisation and infection of the urinary tract with multidrug-resistant organisms, including prior antibiotic use, hospitalisation and underlying urological malformations. We also highlight multidrug-resistant UTI occurring in children without any identifiable risk factors, reflecting an increasing prevalence of colonisation with these organisms in the general community. Taken as a whole, this emphasises a need for careful and evidence-based use of antibiotics when treating UTIs in children and, to aide clinicians, we have outlined here potential management strategies for when infection with a multidrug-resistant organism is suspected or confirmed.

Efficacy of Probiotic Prophylaxis After The First Febrile Urinary Tract Infection in Children With Normal Urinary Tracts

BACKGROUND

Growing antibiotic resistance and debates over their efficacy for urinary tract infection (UTI) recurrence warrants studying nonantibiotic prophylaxis for preventing UTI recurrences.

METHODS

We randomly assigned 181 children, aged 4 months to 5 years, with a normal urinary tract after recovery from their first febrile UTI in a 1:1 ratio to receive a probiotic mixture of Lactobacillus acidophilus, Lactobacillus rhamnosus, Bifidobacterium bifidum, and Bifidobacterium lactis (n = 91) or placebo (n = 90) for a total of 18 months of therapy. The primary objective was to show the superiority of probiotic prophylaxis to placebo. The primary end point was composite cure (UTI-free survival) at 18 months, and the secondary end point was the median time to first UTI recurrence.

RESULTS

The probiotics were superior to placebo with respect to the primary efficacy end point. At 18 months, composite cure was observed in 96.7% (3 of 91) of the patients in the probiotic group and 83.3% (15 of 90) of those in the placebo group (P = .02). The median time to the first incidence of UTI recurrence was 3.5 months (range, 1-4 months) and 6.5 months (range, 2-14 months) in the probiotic and placebo groups, respectively (P = .04). The main microorganism that caused recurrent UTI was Escherichia coli, followed by Klebsiella pneumoniae, and these results were not significantly different between the 2 groups. We found no specific adverse events among the participants who received the probiotic mixture during the course of therapy.

CONCLUSIONS

The probiotics were more effective than placebo at reducing the risk of recurrent UTI in children with a normal urinary tract after their first episode of febrile UTI.

Analysis of drug resistance of extended-spectrum beta-lactamases-producing Escherichia coli and Klebsiella pneumoniae in children with urinary tract infection

Objectives:

To investigate the drug resistance of extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli (E. coli) and Klebsiella pneumoniae (K.pneumoniae) in children with urinary tract infection (UTI) and to provide the rationale for clinical use of antibiotics.

Methods:

This is a retrospective analysis of drug susceptibility in children with E. coli or K. pneumoniae-positive urine culture between August 2013 and August 2017, Shenzhen Children’s Hospital, Shenzhen, China. Drug resistance was statistically assessed using Fisher exact test and χ² test.

Results:

A total of 698 cases of E. coli, 426 of which were confirmed ESBL-producing strains, and 217 cases of K. pneumoniae, including 111 ESBL-producing strains, were detected, and the difference in proportion of positive ESBL-producing strains (61.03% versus 51.15%) was statistically significant (p=0.010). The average drug resistance rates of E. coli and K. pneumoniae to piperacillin/tazobactam, meropenem, ertapenem, imipenem, and amikacin were <15%. The average resistance rates of ESBL-producing E. coli and K. pneumoniae to cefpodoxime, cefixime, cefazolin, and ceftriaxone was >98%, while average resistance rates for non-ESBL-producing bacteria to the above 4 drugs was <20%.

Conclusion:

In southern China, the proportion of ESBL-producing strains and the drug resistance rates of E. coli and K. pneumoniae in UTI in children was high, but their resistance rates to carbapenems and β-lactamase inhibitor complexes containing tazobactam were low. Carbapenems are the most effective antibacterial drugs for the treatment of ESBL-producing bacteria.

Urinary Tract Infection in Children

BACKGROUND

Urinary Tract Infection (UTI) is a common infection in children. Prompt diagnosis and appropriate treatment are very important to reduce the morbidity associated with this condition.

OBJECTIVE

To provide an update on the evaluation, diagnosis, and treatment of urinary tract infection in children.

METHODS

A PubMed search was completed in clinical queries using the key terms "urinary tract infection", "pyelonephritis" OR "cystitis". The search strategy included meta-analyses, randomized controlled trials, clinical trials, observational studies, and reviews. The search was restricted to English literature and the pediatric age group. Patents were searched using the key terms "urinary tract infection" "pyelonephritis" OR "cystitis" from www.google.com/patents, http://espacenet.com, and www.freepatentsonline.com.

RESULTS

Escherichia coli accounts for 80 to 90% of UTI in children. The symptoms and signs are nonspecific throughout infancy. Unexplained fever is the most common symptom of UTI during the first two years of life. After the second year of life, symptoms and signs of pyelonephritis include fever, chills, rigor, flank pain, and costovertebral angle tenderness. Lower tract symptoms and signs include suprapubic pain, dysuria, urinary frequency, urgency, cloudy urine, malodorous urine, and suprapubic tenderness. A urinalysis and urine culture should be performed when UTI is suspected. In the work-up of children with UTI, physicians must judiciously utilize imaging studies to minimize exposure of children to radiation. While waiting for the culture results, prompt antibiotic therapy is indicated for symptomatic UTI based on clinical findings and positive urinalysis to eradicate the infection and improve clinical outcome. The choice of antibiotics should take into consideration local data on antibiotic resistance patterns. Recent patents related to the management of UTI are discussed.

CONCLUSION

Currently, a second or third generation cephalosporin and amoxicillin-clavulanate are drugs of choice in the treatment of acute uncomplicated UTI. Parenteral antibiotic therapy is recommended for infants ≤ 2 months and any child who is toxic-looking, hemodynamically unstable, immunocompromised, unable to tolerate oral medication, or not responding to oral medication. A combination of intravenous ampicillin and intravenous/intramuscular gentamycin or a third-generation cephalosporin can be used in those situations. Routine antimicrobial prophylaxis is rarely justified, but continuous antimicrobial prophylaxis should be considered for children with frequent febrile UTI.