Urinary tract infection in outpatient febrile infants younger than 30 days of age: a 10-year evaluation

Pediatric urinary tract infections caused by poultry-associated Escherichia coli

Escherichia coli is the leading cause of urinary tract infections (UTIs) in children and adults. The gastrointestinal tract is the primary reservoir of uropathogenic E. coli, which can be acquired from a variety of environmental exposures, including retail meat. In the current study, we used a novel statistical-genomic approach to estimate the proportion of pediatric UTIs caused by foodborne zoonotic E. coli strains. E. coli urine isolates were collected from DC residents aged 2 months to 17 years from the Children's National Medical Center Laboratory, 2013-2014. During the same period, E. coli isolates were collected from retail poultry products purchased from 15 sites throughout DC. A total of 52 urine and 56 poultry isolates underwent whole-genome sequencing, core genome phylogenetic analysis, and host-origin prediction by a Bayesian latent class model that incorporated data on the presence of mobile genetic elements (MGEs) among E. coli isolates from multiple vertebrate hosts. A total of 56 multilocus sequence types were identified among the isolates. Five sequence types-ST10, ST38, ST69, ST117, and ST131-were observed among both urine and poultry isolates. Using the Bayesian latent class model, we estimated that 19% (10/52) of the clinical E. coli isolates in our population were foodborne zoonotic strains. These data suggest that a substantial portion of pediatric UTIs in the Washington DC region may be caused by E. coli strains originating in food animals and likely transmitted via contaminated poultry meat.IMPORTANCEEscherichia coli UTIs are a heavy public health burden and can have long-term negative health consequences for pediatric patients. E. coli has an extremely broad host range, including humans, chickens, turkeys, pigs, and cattle. E. coli derived from food animals is a frequent contaminant of retail meat products, but little is known about the risk these strains pose to pediatric populations. Quantifying the proportion of pediatric UTIs caused by food-animal-derived E. coli, characterizing the highest-risk strains, and identifying their primary reservoir species could inform novel intervention strategies to reduce UTI burden in this vulnerable population. Our results suggest that retail poultry meat may be an important vehicle for pediatric exposure to zoonotic E. coli strains capable of causing UTIs. Vaccinating poultry against the highest-risk strains could potentially reduce poultry colonization, poultry meat contamination, and downstream pediatric infections.

Increased prevalence of non-E. coli bacteria-caused urinary infection in neonates delivered by cesarian section

OBJECTIVES

to assess the association between delivery mode and causative pathogens of infants with urinary tract infections.

MATERIALS AND METHODS

We conducted a retrospective analysis of the medical records of neonates delivered in a tertiary academic pediatric hospital and diagnosed with urinary tract infections between January 1,2013 and December 31,2017. Excluded were newborns with urinary tract infections post-urological procedures or neurogenic bladders. The retrieved data included demographic characteristics, clinical presentations, laboratory findings, urine cultures, and renal imaging results. Multivariable logistic regressions were employed to identify associations.

RESULTS

95 of the 131 neonates' (72.5%) cultures were positive for Escherichia coli. Neonates born via cesarean section (C/S) had a significantly higher prevalence (12/25, 48%) of non-Escherichia coli infections (p = 0.01). The mode of delivery was the only variable associated with non-Escherichia coli infections (odds ratio = 3.1, p = 0.014). Two of the 12 neonates (17%) with non-Escherichia coli cultures in the C/S group were diagnosed as having dilating vesicoureteral reflux.

DISCUSSION

While the impact of mode of delivery on microbiome composition and UTI risk in the pediatric population is well documented, to the best of our knowledge, our study is the first to evaluate and report on the clinical connection between mode of delivery and neonatal UTIs. Most noteworthy was our finding of an elevated prevalence of non-E. coli cultures in the C/S group (p = 0.014, OR 3.1). This bears important clinical implications, particularly in the setting of congenital anomaly of kidney and urinary tract (CAKUT) screening.

CONCLUSIONS

Our analyses in this study reveal a significant link between delivery by cesarean section and neonatal urinary tract infections with non- Escherichia coli urine cultures. These findings carry implications for vesicoureteral reflux screening in neonates by raising the level of awareness of the association between the 2 factors. Additional prospective studies on larger cohorts are warranted to further elucidate this relationship and refine clinical decision-making in neonatal care.

ACR Appropriateness Criteria® Urinary Tract Infection-Child: 2023 Update

Urinary tract infection (UTI) is a frequent infection in childhood. The diagnosis is usually made by history and physical examination and confirmed by urine analysis. Cystitis is infection or inflammation confined to the bladder, whereas pyelonephritis is infection or inflammation of kidneys. Pyelonephritis can cause renal scarring, which is the most severe long-term sequela of UTI and can lead to accelerated nephrosclerosis, leading to hypertension and chronic renal failure. The role of imaging is to guide treatment by identifying patients who are at high risk to develop recurrent UTIs or renal scarring. This document provides initial imaging guidelines for children presenting with first febrile UTI with appropriate response to medical management, atypical or recurrent febrile UTI, and follow-up imaging for children with established vesicoureteral reflux. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Urinary tract infections in young infants with a normal urine dipstick

AIM

To assess missed urinary tract infections (UTI) in febrile infants ≤2 months when adhering to recent guidelines suggesting not to send a urine culture with a negative dipstick.

METHODS

A retrospective cohort study of 308 infants ≤2 months with a positive urine culture admitted in 2013-2023, divided into subgroups without exposure to urine dipstick results: 'urosepsis' (UTI with bacteraemia), 'UTI' (positive urine culture, elevated inflammatory markers, no other cause of fever) and 'bacteriuria' (positive urine culture, not meeting the above-mentioned criteria). After retrieving the dipstick results, the 'missed UTI' group (UTI+ negative dipstick) was described.

RESULTS

A negative dipstick was found in 2/20 (10%), 32/127 (25%) and 126/161 (78%) of infants with 'urosepsis', 'UTI' and 'bacteriuria', respectively. In the 'missed UTI' group (n = 34), there were more non-Escherichia coli UTI (68% vs. 9% with positive dipstick, p < 0.001), and lower inflammatory markers (leukocytes 15.5 vs. 17.2 k/μL, p = 0.007, C-reactive protein 21 vs. 58 mg/L, p < 0.001). Three infants had high-grade vesicoureteral reflux (VUR) and renal scarring.

CONCLUSIONS

There is a non-negligible rate of infants ≤2 months with UTI and without pyuria, including those with urosepsis, VUR and renal scarring. We suggest obtaining a urine culture regardless of dipstick results.

Urinary Tract Infections in Children

Despite the American Academy of Pediatrics guidelines for the evaluation, treatment, and management of urinary tract infections (UTIs), UTI diagnosis and management remains challenging for clinicians. Challenges with acute UTI management stem from vague presenting signs and symptoms, diagnostic uncertainty, limitations in laboratory testing, and selecting appropriate antibiotic therapy in an era with increasing rates of antibiotic-resistant uropathogens. Recurrent UTI management remains difficult due to an incomplete understanding of the factors contributing to UTI, when to assess a child with repeated infections for kidney and urinary tract anomalies, and limited prevention strategies. To help reduce these uncertainties, this review provides a comprehensive overview of UTI epidemiology, risk factors, diagnosis, treatment, and prevention strategies that may help pediatricians overcome the challenges associated with acute and recurrent UTI management.

NUM-score: A clinical-analytical model for personalised imaging after urinary tract infections

AIM

To identify predictive variables and construct a predictive model along with a decision algorithm to identify nephrourological malformations (NUM) in children with febrile urinary tract infections (fUTI), enhancing the efficiency of imaging diagnostics.

METHODS

We performed a retrospective study of patients aged <16 years with fUTI at the Emergency Department with subsequent microbiological confirmation between 2014 and 2020. The follow-up period was at least 2 years. Patients were categorised into two groups: 'NUM' with previously known nephrourological anomalies or those diagnosed during the follow-up and 'Non-NUM' group.

RESULTS

Out of 836 eligible patients, 26.8% had underlying NUMs. The study identified six key risk factors: recurrent UTIs, non-Escherichia coli infection, moderate acute kidney injury, procalcitonin levels >2 μg/L, age <3 months at the first UTI and fUTIs beyond 24 months. These risk factors were used to develop a predictive model with an 80.7% accuracy rate and elaborate a NUM-score classifying patients into low, moderate and high-risk groups, with a 10%, 35% and 93% prevalence of NUM. We propose an algorithm for approaching imaging tests following a fUTI.

CONCLUSION

Our predictive score may help physicians decide about imaging tests. However, prospective validation of the model will be necessary before its application in daily clinical practice.

Risk factors for urinary tract infection in infants with unexplained hyperbilirubinemia: a single center case-control study

Background

Urinary tract infection (UTI) is a potential cause of neonatal jaundice. Nevertheless, there remains a lack of consensus regarding appropriate screening practices for UTI in infants with hyperbilirubinemia. This study aimed to analyze a group of jaundiced infants to assess the prevalence of UTI, explore potential risk factors, and examine the impact of UTI on the course and severity of neonatal jaundice.

Methods

This retrospective case-control study was conducted on 150 jaundiced infants (aged < 8 weeks) without a known etiology in the hyperbilirubinemia work-up. All subjects underwent phototherapy treatment and UTI screening by catheterization. They were then classified into UTI and non-UTI groups based on urine culture results, with a positive urine culture indicating the growth of ≥10,000 colony-forming units. The clinical characteristics and jaundice-related parameters of both groups were analyzed.

Results

Among the 150 jaundiced patients, the prevalence of UTI was 29%. There was a significantly higher male predominance in the UTI group, and patients with UTI also had a significantly longer duration of hospitalization compared to those without UTI. Significant risk factors associated with UTI in jaundiced infants included male gender and a peak total bilirubin level higher than 18 mg/dl during hospitalization. The most common pathogens identified in urine culture were Escherichia coli (41.9%) and Enterococcus faecalis (30.2%).

Conclusion

In cases of neonatal jaundice where the underlying cause is not evident, screening for UTI should be performed, particularly when associated risk factors or inadequate response to phototherapy is present.

A Comparison of Short Versus Long Course Intravenous Antibiotics When Treating Urinary Tract Infection in Infants <60 Days of Age

Urinary tract infections (UTIs) are a common reason for hospitalization in infants younger than 60 days, and the optimal approach to intravenous (IV) antibiotic therapy upon UTI diagnosis in this cohort is unknown. We determined whether there was an association between IV antibiotic therapy duration (long [>3 days] vs short [≤3 days]) and treatment failure via a retrospective review of infants with confirmed UTIs receiving IV antibiotics at a tertiary referral center. A total of 403 infants were included; 39% were treated with ampicillin and cefotaxime, and 34% with ampicillin and gentamycin or tobramycin. The median IV antibiotic duration was 5 (interquartile range: 3-10) days, and 5% of patients experienced treatment failure. The treatment failure rate was similar in both short- and long-course IV antibiotic groups (P > .05), and there was no significant association between treatment duration and failure. We conclude that treatment failure for infants hospitalized with UTI is uncommon and not associated with IV antibiotic duration.

Prevalence, Pathogenic Bacterial Profile and Antimicrobial Susceptibility Pattern of Urinary Tract Infection Among Children with Congenital Anomalies of the Kidney and Urinary Tract

Purpose

The study was to detect the pathogenic bacterial profile and antibiogram among children with congenital anomalies of the kidney and urinary tract (CAKUT).

Patients and Methods

A retrospective analysis was performed using medical records of urine culture results and antibiotic susceptibility results in patients with UTIs from March 2017 to March 2022. Antimicrobial susceptibility pattern was determined by a standard agar disc diffusion method.

Results

A total of 568 children were included. The proportion of culture-positive UTI was 59.15% (336/568). More than nine types of bacteria were isolated with most pathogens being Gram-negative species. Among Gram-negative isolates, the predominant bacteria were Escherichia coli (30.95%, 104/336) followed by Klebsiella pneumoniae (9.23%). Escherichia coli isolates were highly sensitive to amikacin (95.19%), ertapenem (94.23%), nitrofurantoin (93.27%), imipenem (91.35%), and piperacillin-tazobactam (90.38%) and high rate of resistant were also detected to ampicillin (92.31%), cephazolin (73.08%), ceftriaxone (70.19%), trimethoprim-sulfamethoxazole (61.54%) and ampicillin-sulbactam (57.69%). Klebsiella pneumoniae isolates showed sensitive to ertapenem (96.77%), amikacin (96.77%), imipenem (93.55%), piperacillin-tazobactam (90.32%) and gentamicin (83.87%), while highly resistant were observed to ampicillin (96.77%), cephazolin (74.19%), ceftazidime (61.29%), ceftriaxone (61.29%), and aztreonam (61.29%). The isolated Gram-positive bacteria mainly contained Enterococcus faecalis and Enterococcus faecium (each 15.77%). Enterococcus faecalis were sensitive to vancomycin, penicillin-G, tigecycline, nitrofurantoin and linezolid (100%, 94.34%, 88.68%, 88.68%, 86.79, respectively) and resistant to tetracycline (86.79%), quinupristi (83.02%), erythromycin (73.58%). Enterococcus faecium also showed a similar result. Multiple drug resistance (MDR) was observed in 264 (80.00%) of the 360 bacterial isolates. Only age was significantly associated with a culture-positive UTI.

Conclusion

A higher prevalence of culture-positive UTI was detected. Escherichia coli was the most prevalent uropathogen followed by Enterococcus faecalis and Enterococcus faecium. These uropathogens showed highly resistant to the commonly used antibiotics. Moreover, MDR was commonly observed. Thus, empiric therapy is unsatisfactory as drug sensitivity always varies over time.

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.

Elevated Urinary Hepcidin Level and Hypoferremia in Infants with Febrile Urinary Tract Infection: A Prospective Cohort Study

To evaluate the kinetics of serum and urinary hepcidin levels along with anemia-related parameters during the infection course of infants with febrile urinary tract infection (UTI), we enrolled febrile infants aged one to four months in this prospective study. Febrile patients with UTI were allocated into Escherichia coli (E. coli) or non-E. coli groups according to urine culture results. Septic workup, blood hepcidin, iron profile, urinalysis, and urinary hepcidin-creatinine ratio were collected upon admission and 3 days after antibiotic treatment. In total, 118 infants were included. On admission, the febrile UTI group showed a significant reduction in serum iron level and a significant elevation of urinary hepcidin-creatinine ratio compared to the febrile control counterpart. Moreover, urinary hepcidin-creatinine ratio had the highest odds ratio, 2.01, in logistics regression analysis. After 3 days of antibiotic treatment, hemoglobin and the urinary hepcidin-creatinine ratio were significantly decreased. Patients with an E. coli UTI had a significantly decreased urinary hepcidin-creatinine ratio after 3 days of antibiotics treatment, whereas the non-E. coli group showed insignificant changes. Our study suggested that the urinary hepcidin-creatinine ratio elevated during acute febrile urinary tract infection and significantly decreased after 3 days of antibiotics treatment, especially in E. coli UTI.

Temperature threshold in the screening of bacterial infections in young infants with hypothermia

BACKGROUND

Young infants with hypothermia presenting to the emergency department (ED) are at risk for serious bacterial infections (SBI), however there is no consensus temperature to prompt evaluation for SBI among these children. We sought to statistically derive a temperature threshold to guide detection of SBI in young infants with hypothermia presenting to the ED.

METHODS

We performed a cross-sectional study of infants ≤90 days old presenting to four academic paediatric EDs in the United States of America from January 2015 through December 2019 with a rectal temperature of ≤36.4°C. Our primary outcomes were SBI, defined as urinary tract infection (UTI), bacteraemia and/or bacterial meningitis, and invasive bacterial infections (IBI, limited to bacteraemia and/or bacterial meningitis). We constructed receiver operating characteristic (ROC) curves to evaluate an optimally derived cutpoint for minimum ED temperature and presence of SBI or IBI.

RESULTS

We included 3376 infants, of whom SBI were found in 62 (1.8%) and IBI in 16 (0.5%). The most common infection identified was Escherichia coli UTI. Overall, cohort minimum median temperature was 36.2°C (IQR 36.0°C-36.4°C). Patients with SBI and IBI had lower median temperatures, 35.8°C (IQR 35.8°C-36.3°C) and 35.4°C (IQR 35.7°C-36.3°C), respectively, compared with those without corresponding infections (both p<0.05). Using an outcome of SBI, the area under the ROC curve (AUROC) was 61.0% (95% CI 54.1% to 67.9%). At a cutpoint of 36.2°C, sensitivity was 59.7% and specificity was 59.2%. When using an outcome of IBI, the AUROC was 65.9% (95% CI 51.1% to 80.6%). Using a cutpoint of 36.1°C in this model resulted in a sensitivity of 68.8% and specificity of 60.1%.

CONCLUSION

Young infants with SBI and IBI presented with lower temperatures than infants without infections. However, there was no temperature threshold to reliably identify SBI or IBI. Further research incorporating clinical and laboratory parameters, in addition to temperature, may help to improve risk stratification for these vulnerable patients.

Building nomogram plots for predicting urinary tract infections in children less than three years of age

BACKGROUND AND PURPOSE

Urinary tract infections (UTIs) are the most common bacterial infection in young children. This study aimed to formulate nomogram plots for clinicians to predict UTIs in children aged <3 years by evaluating the risk factors for UTIs in these children.

METHODS

This retrospective study was conducted at a tertiary medical center from December 2017 to November 2020. Children less than three years of age were eligible for the study if they had undergone both urine culture and urinalysis during the study period. Mixed-effects logistic regression models with a stepwise procedure were used to determine the relationship between outcome (positive/negative UTI) and covariates of interest (e.g., weight percentile, laboratory) for each patient. Nomogram plots were constructed on the basis of significant factors. We repeated the analysis thrice to adapt it to three different medical settings: medical centers, regional hospitals, and local clinics.

RESULTS

In the medical center setting, the two most significant factors were urine leukocyte count ≥100 (OR =8.87; 95% CI (Confidence Interval), 4.135-19.027) and urine nitrite level (OR =8.809; 95% CI, 5.009-15.489). The two factors showed similar significance at the regional hospital and local clinic settings. Abnormal renal echo findings were positively correlated with UTI in the medical center setting (OR =2.534; 95% CI 1.757-3.655). Three nomogram plots for the prediction of UTIs were drawn for medical centers, regional hospitals, and local clinics.

CONCLUSION

Using the three nomogram plots, frontline doctors can formulate the probabilities of pediatric UTIs for better decision-making.

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.

Imaging Practices and Implications in Young Infants With Urinary Tract Infection

OBJECTIVES

Management of infants aged ≤60 days with urinary tract infections (UTI) is challenging. We examined renal imaging in infants aged ≤60 days with UTI at a tertiary care children's hospital to identify the impact of standardizing renal ultrasound (RUS) interpretation.

METHODS

We retrospectively studied infants aged ≤60 days hospitalized for UTI or fever with urine culture and renal imaging obtained and final diagnosis of UTI. RUS initially had noncriterion-based (NCB) interpretation by experienced pediatric radiologists. For this study, a single pediatric radiologist used a criterion-based (CB) hydronephrosis grading system to reinterpret films initially classified as "abnormal" on the NCB reading. We compared final renal imaging results between NCB and CB groups.

RESULTS

Of 193 infants, 180 (93%) had inpatient RUS with 114 (63%) abnormal NCB interpretation. Of those with initially abnormal NCB interpretation, 85 OF 114 (75%) had minor and 29 OF 114 (25%) had significant abnormality by CB reinterpretation. In follow-up, the CB "minor abnormality" group showed 25% abnormal renal imaging, whereas the "significant abnormality" group showed 77% abnormal renal imaging with 54% having high-grade reflux on a voiding cystourethrogram (VCUG). Patients with CB inpatient RUS minor abnormality showed 3% abnormal RUS at follow-up, but 13% showed high-grade reflux on VCUG.

CONCLUSIONS

Standardized RUS interpretation in young infants with UTI improved the accuracy of identification of abnormalities on follow-up renal imaging. In patients with CB minor abnormality on inpatient RUS, our results suggest limited utility of follow-up RUS; however, follow-up VCUG remained useful to identify high-grade reflux.

Thiol-Disulfide Homeostasis in Neonatal Patients with Urinary Tract Infection

OBJECTIVE

Urinary tract infection (UTI) is a disease that can cause significant complications in the neonatal period. The thiol-disulfide homeostasis is one of the important antioxidant defense mechanisms. The purpose of this study is to show the relationship between UTI and thiol-disulfide homeostasis in newborns.

STUDY DESIGN

In this prospective study, 40 newborns with UTI and 40 healthy controls were included. Thiol-disulfide tests (disulfide, native thiol, and total thiol levels) and septic screening tests were performed before and after antibiotherapy in UTI group. The control group was selected from healthy newborns who applied to the outpatient clinic.

RESULTS

The C-reactive protein and interleukin-6 levels were higher, while native thiol and native thiol/total thiol ratio were significantly lower in pretreatment group compared with posttreatment and control group. Also, the levels of disulfide, ischemia modified albumin, disulfide/native thiol ratio, and disulfide/total thiol ratio were higher in pretreatment group compared with posttreatment group.

CONCLUSION

The thiol-disulfide homeostasis is an important indicator of oxidative stress during infections. It is valuable to be detected with small amounts of serum in newborns. These molecules can be used to support the diagnosis of UTI in the newborn. Further studies are needed to define the role of thiol-disulfide homeostasis in the UTI of newborn.

KEY POINTS

· The thiol-disulfide homeostasis can be an important indicator of oxidative stress during infections such as UTI.. · The thiol-disulfide homeostasis of newborn is valuable to be detected with small amounts of serum in neonatal period.. · Laboratory tests such as white blood cell count, erythrocyte sedimentation rate, and C-reactive protein are not significantly different in UTIs..

Short-course intravenous antibiotics for young infants with urinary tract infection

OBJECTIVE

Shorter courses of intravenous antibiotics for young infants with urinary tract infection (UTI) have myriad advantages. As practice shifts toward shorter intravenous treatment courses, this study aimed to determine the safety of early intravenous-to-oral antibiotic switch and identify risk factors for bacteraemia with UTI.

METHODS

Retrospective audit of infants aged ≤90 days with a positive urine culture at a quaternary paediatric hospital over 4 years (2016-2020). Data were collected from the hospital electronic medical record and laboratory information system. Short-course intravenous antibiotic duration was defined as <48 hours for non-bacteraemic UTI and <7 days for bacteraemic UTI. Multivariate analysis was used to determine patient factors predicting bacteraemia.

RESULTS

Among 427 infants with non-bacteraemic UTI, 257 (60.2%) were treated for <48 hours. Clinicians prescribed shorter intravenous courses to infants who were female, aged >30 days, afebrile and those without bacteraemia or cerebrospinal fluid pleocytosis. Treatment failure (30-day UTI recurrence) occurred in 6/451 (1.3%) infants. All had non-bacteraemic UTI and one received <48 hours of intravenous antibiotics. None had serious complications (bacteraemia, meningitis, death). Follow-up audiology occurred in 21/31 (68%) infants with cerebrospinal fluid pleocytosis, and one had sensorineural hearing loss. Bacteraemia occurred in 24/451 (5.3%) infants, with 10 receiving <7 days intravenous antibiotics with no treatment failure. Fever and pyelonephritis were independent predictors of bacteraemia.

CONCLUSION

Short-course intravenous antibiotics for <48 hours for young infants with non-bacteraemic UTI should be considered, provided meningitis has been excluded. Treatment failure and serious complications were rare in young infants with UTI.

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.

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.

What are the Optimal Renal Ultrasound Parameters for Detecting Small Kidney in Young Children?

Introduction

Recent guidelines do not recommend routine screening of vesicoureteral reflux after a first febrile urinary tract infection in children without abnormal findings on ultrasound or atypical/recurrent urinary tract infection. Currently, there are no clear ultrasonographic parameters for detecting abnormalities in renal size, especially in young children. The aim of the present study was to determine an optimal cutoff value for detecting small kidney in children without apparent congenital anomalies except vesicoureteral reflux by retrospective chart review.

Patients and Methods

Children aged ≤3 years who had undergone nuclear renal scans and ultrasound were enrolled. Small kidney was defined as split renal function of <40%. Optimal cutoff values of various ultrasonographic parameters for detecting small kidney were calculated.

Results

Of the 69 children included in the present study, small kidney was identified in 20. There was a significant difference in renal size between each kidney in patients with small kidney, whereas there was no significant difference in those without small kidney. With a ratio of estimated renal area of 74.26%, maximum area under the curve with the highest sensitivity, specificity, positive predictive value, negative predictive value, and accuracy rate were obtained. In addition, simple measurement of renal length with a cutoff of 4.97 cm showed high specificity comparable with estimated renal area.

Conclusion

Small kidney may be screened by two-dimensional measurement on ultrasonographic examination, even in young children. With the cutoff described, risk stratification or an individualized approach may be possible.

Factors Affecting Prevalence of Urinary Tract Infection in Neonates with Unexplained Hyperbilirubinemia: A Systematic Review and Meta-Analysis Study in Iran

Background:

The prevalence and risk factors of urinary tract infection (UTI) in neonates with unexplained hyperbilirubinemia are not studied thoroughly. Since the prevalence of UTI is highly variable in different areas and countries, this study aimed to review the existing data of Iranian neonates with UTI presented with unexplained hyperbilirubinemia.

Methods:

This study is a meta-analysis of Iranian newborns with unexplained hyperbilirubinemia. We identified all studies indexed in international (Web of Science, PubMed, Scopus, Google Scholar) and national (Science Information Database, Magiran) databases from 2000–2018. Search terms included: Urinary Tract Infections OR UTI AND urine OR culture OR microbio, jaundice OR icter OR hyperbili, AND Iran.

Results:

Overall, 4210 neonates from 17 studies were included. The pooled prevalence of UTI in neonates with unexplained hyperbilirubinemia was 6.81% (95% CI: 4.86–8.77). Considering the subgroups analyses; the prevalence of UTI was higher in the prolonged vs. not-prolonged state (8.34% vs. 4.00%), low birth weight vs. normal birth weight (7.81% vs. 4.51%), and exclusive vs. non-exclusive breastfeeding (8.84% vs. 4.72%). Male gender and low birth weight increased the risk of UTI about two times compared to the female gender and normal birth weight, respectively. The results of the analyses in neonates with unconjugated hyperbilirubinemia also showed the above-mentioned subgroup differences.

Conclusion:

Due to considerable prevalence of UTI in neonates with unexplained hyperbilirubinemia and risk factors in this age group, investigation for UTI is essential for the workup in this situation.

Evaluation and Management of Well-Appearing Febrile Infants 8 to 60 Days Old

This guideline addresses the evaluation and management of well-appearing, term infants, 8 to 60 days of age, with fever ≥38.0°C. Exclusions are noted. After a commissioned evidence-based review by the Agency for Healthcare Research and Quality, an additional extensive and ongoing review of the literature, and supplemental data from published, peer-reviewed studies provided by active investigators, 21 key action statements were derived. For each key action statement, the quality of evidence and benefit-harm relationship were assessed and graded to determine the strength of recommendations. When appropriate, parents' values and preferences should be incorporated as part of shared decision-making. For diagnostic testing, the committee has attempted to develop numbers needed to test, and for antimicrobial administration, the committee provided numbers needed to treat. Three algorithms summarize the recommendations for infants 8 to 21 days of age, 22 to 28 days of age, and 29 to 60 days of age. The recommendations in this guideline do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

Strengthening the success rate of suprapubic aspiration in infants by integrating point-of-care ultrasonography guidance: A parallel-randomized clinical trial

BACKGROUND

Urinary tract infection (UTI) is a common disease in childhood. A sterile collection of urine samples using suprapubic aspiration (SPA) and bladder catheterization (BC) is helpful for rapid and accurate diagnosis of UTI in infants. With the advent of point-of-care ultrasound (POCUS), the use of ultrasound by non-radiologists at the patient's bedside, great advancement has been noticed in various medical fields. Considering the importance and advantages of using POCUS in the physical examination and guiding procedures, the authors aimed to compare urine sampling's success rate by SPA, BC, and POCUS guided SPA (POCUS-SPA) in infants performed by three pediatricians.

MATERIALS AND METHODS

This study is a randomized clinical trial conducted on 114 neonates and infants with suspected UTI admitted to 17-Shahrivar children's hospital from April 2017 to September 2019. Neonates and infants were randomly assigned to three groups of BC, SPA, and POCUS-SPA. The primary outcome was the success of sampling defined by obtaining 1cc of urine in each method. The secondary outcome was assessing the pain level.

RESULTS

Results showed that the POCUS-SPA had the highest success rate in urine sampling, and a statistically significant relation was noted among the three groups (P = 0.0001). From 38 patients in each group, 37 patients of POCUS-SPA (97.4%), 34 patients of BC (89.5%), and 23 patients of SPA (60.5%) had a successful sampling. Most of the patients in all three groups experienced severe pain.

CONCLUSIONS

In the current study, results showed that the POCUS-SPA significantly increased the success rate of urine sampling and most of the patients in all three groups had severe pain. Based on the shortage of access to radiologists in emergency setups, it seems that the POCUS-SPA by the pediatricians can be one of the most appropriate and applicable diagnostic methods in infants with UTI.

Non-carbapenem antimicrobial therapy in young infant with urinary tract infections caused by community-acquired extended-spectrum β-lactamase-producing Escherichia coli

BACKGROUND

The frequency of urinary tract infections (UTIs) caused by community-acquired extended-spectrum β-lactamase (CA-ESBL)-producing Enterobacteriaceae is increasing worldwide. Increased carbapenem use may lead to selection of carbapenem-resistant organisms, resulting in dire consequences for hospitals. We compared the outcomes of non-carbapenem antimicrobial therapy on UTIs caused by CA-ESBL-producing and non-producing Escherichia coli (E. coli) in infants younger than 6 months of age.

METHODS

We conducted a retrospective chart review, from January 2010 to December 2018, in infants (0-6 months old) with diagnosed UTIs caused by CA-ESBL-producing and non-producing E. coli at the Pusan National University Children's Hospital. Chart reviews were completed for patients whose urine sample had been collected using urinary catheterization. We treated all patients using non-carbapenem antimicrobials. Two weeks after therapy completion, clinical states were evaluated.

RESULTS

There were 105 and 582 patients diagnosed with UTIs caused by CA-ESBL-producing and non-producing E. coli, respectively. The mean age at diagnosis in ESBL and non-ESBL groups was 2.7 ± 1.6 and 2.8 ± 1.1 months (P = 0.711), respectively. There were no significant differences between ESBL and non-ESBL groups in the duration of fever (1.2 ± 0.5 and 1.2 ± 0.4 days, respectively, P = 0.761) or clinical cure states post therapy (101/105 and 567/582, respectively, P = 0.513).

CONCLUSION

This study found no significant differences in treatment outcomes between ESBL and non-ESBL groups treated with non-carbapenem antimicrobials. Therefore, initially administered non-carbapenem antimicrobials can be continued in patients with UTIs caused by CA-ESBL-producing E. coli who show clinical improvement.

López E, Álvarez R, Aung MS, Kobayashi N, Quiñones D. Characterization of Neonatal Infections by Gram-Negative Bacilli and Associated Risk Factors, Havana, Cuba

Infections represent an important problem in neonates because of the high mortality. An increase in neonatal infections has been found in Cuban hospitals in recent years. The aim of this study was to provide evidence on the clinical and microbiological behavior of Gram-negative bacilli that cause neonatal infections in hospitals of Havana, Cuba. It was carried out as a descriptive cross-sectional investigation from September 2017 to July 2018 in The Tropical Medicine Institute "Pedro Kouri" (IPK). Sixty-one Gram-negative bacilli isolated from neonates with infections in six Gyneco-Obstetric and Pediatric Hospitals of Havana were analyzed for their species and antimicrobial susceptibility. Late-onset infections were more common than early-onset ones and included urinary tract infection in the community (87%) and sepsis in hospitals (63.3%). Catheter use (47%) and prolonged stay (38%) were the most frequent risk factors. Species of major pathogens were Escherichia coli (47%) and Klebsiella spp. (26%). The isolated Gram-negative bacilli showed high resistance rates to third-generation cephalosporins, ciprofloxacin and gentamicin, while being more susceptible to carbapenems, fosfomycin, colistin and amikacin. The present study revealed the clinical impact of Gram-negative bacilli in neonatology units in hospitals of Havana. Evaluation of antimicrobial susceptibilities to the isolates from neonates is necessary for selection of appropriate empirical therapy and promotion of the rational antibiotic use.

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.

First UTI episode in life in infants <1 year of age: Epidemiologic, clinical, microbiologic and disease recurrence characteristics

BACKGROUND

To examine the epidemiologic and microbiologic characteristics of first and recurrent UTI in young infants.

METHODS

A retrospective study of all infants <1 year hospitalized during 2014-2017 with their first UTI and followed during their first year of life.

RESULTS

191 infants were enrolled; 69 (36.12%) patients were <2 months and 32 (16.8%) developed R-UTI during the follow-up. The five most common uropathogens were Escherichia coli, Klebsiella spp., Enterococcus spp., Proteus mirabilis and Staphylococcus aureus. High resistance rates were recorded for ampicillin, amoxicillin/clavulanic acid, TMP/SMX, cefuroxime, ceftriaxone, piperacillin/tazobactam and gentamicin among E. coli and Klebsiella spp.; 29.15% E. coli and 42.9% Klebsiella spp. were ESBL-positive. 53.2% of recurrent UTI (R-UTI) episodes were diagnosed within 2 months after the initial UTI episode. E. coli (40.6%) and Klebsiella spp. (37.55) were the most frequent R-UTI pathogens. Twenty-five (78.1%) R-UTIs were caused by recurrent uropathogens representing new infections. Antibiotic resistance rates at recurrence were similar to those at initial UTI, except for a significant increase in E. coli and Klebsiella spp. resistance to piperacillin/tazobactam.

CONCLUSION

We reported high antibiotic resistance rates to major antibiotic classes used in UTI treatment. Most R-UTI episodes were caused by uropathogens different than those isolated at the initial UTI episode and were caused by highly-resistant organisms. Our findings require frequent monitoring and possible modification of the empiric and prophylactic antibiotic therapy protocols in use. As a result of our findings, the protocol for initial empiric treatment of infants with suspicion of UTI was modified by changing gentamicin to amikacin in the treatment of infants <2 months of life and amikacin monotherapy (intravenous or intramuscular) was introduced as first-line therapy for infants >2 months of life.

Neonates With Urinary Tract Infection: Is a Lumbar Puncture Always Indicated?

BACKGROUND

Our objectives were to determine the prevalence of and to identify risk factors for coexisting bacterial meningitis (BM) in neonates with urinary tract infection (UTI).

METHODS

A cross-sectional study was conducted at pediatric emergency department of a tertiary teaching hospital from 2001 to 2017. Infants <29 days of age with UTI (≥10,000 colony-forming units/mL of a single pathogen from a catheterized specimen in association with positive urinalysis) were included. Definite BM was defined as growth of a single bacterial pathogen from a cerebrospinal fluid (CSF) sample and probable BM as (1) positive blood culture with CSF pleocytosis and treatment consistent with BM or (2) antibiotic pretreatment before lumbar puncture, CSF pleocytosis and treatment consistent with BM. Univariate testing was used to identify possible risk factors associated with BM. Receiver operating characteristics curves were constructed for the laboratory markers associated with BM.

RESULTS

Three hundred seventy-one infants were included. Five [1.3%; 95% confidence interval (CI): 0.6%-3.1%] had BM: 4 definite BM and 1 probable BM. Risk factors detected for BM were classified as not being well-appearing and a procalcitonin value ≥0.35 ng/mL [sensitivity of 100% (95% CI: 56.6%-100%) and negative predictive value of 100% (95% CI: 96.1%-100%)].

CONCLUSIONS

Coexisting BM occurs uncommonly in neonates with UTI. Well-appearing neonates with UTI and procalcitonin value <0.35 ng/mL were at very low risk for BM; avoiding routine lumbar puncture in these patients should be considered.

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.

Oral Narrow-Spectrum Antibiotics for the Treatment of Urinary Tract Infection in Infants Younger Than 60 Days

Data on the outcome of infants younger than 60 days treated with a combination of intravenous and oral antibiotics for urinary tract infection are limited. This study examined susceptibility and successful outcomes of treatment with narrow-spectrum oral antibiotics. In addition, we describe the effects of antimicrobial stewardship education intervention on prescribing practices.

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.

Clinical Predictors for Abnormal Renal Bladder Ultrasound in Hospitalized Young Children With a First Febrile Urinary Tract Infection

BACKGROUND

Physicians often obtain a routine renal bladder ultrasound (RBUS) for young children with a first febrile urinary tract infection (UTI). However, few children are diagnosed with serious anatomic anomalies, and opportunity may exist to take a focused approach to ultrasonography. We aimed to identify characteristics of the child, prenatal ultrasound (PNUS), and illness that could be used to predict an abnormal RBUS and measure the impact of RBUS on management.

METHODS

We conducted a single-center prospective cohort study of hospitalized children 0 to 24 months of age with a first febrile UTI from October 1, 2016, to December 23, 2018. Independent variables included characteristics of the child, PNUS, and illness. The primary outcome, abnormal RBUS, was defined through consensus of a multidisciplinary team on the severity of ultrasound findings important to identify during a first UTI.

RESULTS

A total of 211 children were included; the median age was 1.0 month (interquartile range 0-2), and 55% were uncircumcised boys. All mothers had a PNUS with 10% being abnormal. Escherichia coli was the pathogen in 85% of UTIs, 20% (n = 39 of 197) had bacteremia, and 7% required intensive care. Abnormal RBUS was found in 36% (n = 76 of 211) of children; of these, 47% (n = 36 of 76) had moderately severe findings and 53% (n = 40 of 76) had severe findings. No significant difference in clinical characteristics was seen among children with and without an abnormal RBUS. One child had Foley catheter placement, and 33% received voiding cystourethrograms, 15% antibiotic prophylaxis, and 16% subspecialty referrals.

CONCLUSIONS

No clinical predictors were identified to support a focused approach to RBUS examinations. Future studies should investigate the optimal timing for RBUS.

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.

Transition to oral antibiotic therapy for pyelonephritis in children under 60 days of age: An observational retrospective cohort study

Objectives

To describe the use of antibiotics and assess if an early transition from intravenous to oral antibiotic therapy is generally safe in infants less than 60 days of age with a diagnosis of pyelonephritis.

Methods

This retrospective observational cohort study included hospitalized infants less than 60 days with a diagnosis of pyelonephritis based on fever or systemic symptoms and a positive urine culture between January 1, 2015 and July 30, 2017 at a Canadian paediatric tertiary care centre.

Results

A total of 108 infants were included. Forty-eight of them were under 1 month of age. The median intravenous (IV) antibiotic therapy duration was 3.5 days, with a longer duration of 4 days in infants less than 1 month of age. The total antibiotic therapy was almost equally divided between a shorter (10 days) and longer (14 days) duration. The recurrence of pyelonephritis within the 2 months following the initial urinary infection was 9 % in the group with IV antibiotic therapy duration of <4 days, compared to 11% in the group treated ≥4 days IV (P-value 0.75). There was a recurrence of pyelonephritis of 10.2% in the group treated for 10 days, compared to 11.5% of recurrence in the group treated for 14 days (P-value 1.0).

Conclusions

Our study provides limited retrospective data regarding the management of pyelonephritis in infants less than 60 days of age. Prospective research is needed to confirm those findings.

Midstream Clean-Catch Urine Culture Obtained by Stimulation Technique versus Catheter Specimen Urine Culture for Urinary Tract Infections in Newborns: A Paired Comparison of Urine Collection Methods

OBJECTIVE

The group of Herreros Fernández developed a new, safe, quick, and successful technique for collecting midstream clean-catch urine(MS-CCU) in newborns based on bladder stimulation and lumbar paravertebral massage maneuvers. The purpose of this study was to compare the contamination rates of catheter specimen urine (CSU) and MS-CCU by a lumbar/sacral stimulation technique in newborns.

MATERIALS AND METHODS

Full-term newborns ranging in age from 2 to 28 days who needed an investigation for a presumed urinary tract infection (UTI) were included in the study. Two samples, MS-CCU by lumbar/sacral stimulation technique and CSU, were collected consecutively for each patient. Suitable samples were obtained from 90 patients.

RESULTS

The contamination rate in MS-CCU cultures (n = 24/90, 26.66%) was higher than in CSU cultures (n = 9/90, 10%), and the difference was statistically significant (p = 0.039). Thirteen patients had UTI according to both samples (14.14%). In urine analysis, while there was no statistically significant difference in bacteriuria (p = 0.61) and nitrite positivity (p = 0.14) between patients with and without UTI, pyuria (p = 0.01) and leukocyte esterase positivity (p = 0.01) were higher in patients with UTI, and the difference was statistically significant.

CONCLUSION

The contamination rate in MS-CCU cultures was two and a half times greater than in the CSU culture samples. Thus, MS-CCU cannot replace the catheter for the diagnosis of UTI.

Bacterial meningitis in febrile young infants acutely assessed for presumed urinary tract infection: a systematic review

Urinary tract infections, the most common severe bacterial infections in young infants, may be associated with co-existing meningitis. There is no consensus on when to perform a lumbar puncture in these infants. Our aim was to quantify the frequency of co-existing bacterial meningitis in febrile young infants acutely assessed for presumed urinary tract infections. We systematically reviewed PubMed, EMBASE, and the Cochrane Library for studies including infants ≤ 3 months with suspected/confirmed urinary tract infections, who underwent a lumbar puncture. Two investigators independently reviewed articles for inclusion and extracted relevant data. Our outcomes were culture-confirmed meningitis and identification of low-/high-risk criteria of meningitis. Overall 20/2079 studies, including 4191 infants, met inclusion criteria. A total of 11 infants had bacterial meningitis (frequency between 0 and 2.1% across studies) and were mostly neonates. Of 253 infants meeting the low-risk criteria (well-appearing, age > 21 days, procalcitonin ≤ 0.5 ng/ml, and C reactive protein ≤ 20 mg/L) none developed meningitis, but only 15 underwent lumbar puncture.Conclusion: Co-existing bacterial meningitis in febrile young infants with urinary tract infection is rare. In those meeting low-risk criteria, a lumbar puncture may not be indicated. A case by case assessment should be made in infants not meeting low-risk criteria.Trial registration: CRD42018105339 What is known: • When caring for febrile infants ≤ 3 months with urinary tract infections, clinicians may have uncertainty on whether to perform a lumbar puncture (LP) for possible co-existing meningitis What is new: • An up-to-date systematic review of 20 studies found the frequency of co-existing meningitis in this population to be between 0 and 2.1% • Despite limited data, an LP may not be indicated in infants meeting low-risk criteria (being well-appearing, age > 21 days, procalcitonin ≤ 0.5 ng/ml, C reactive protein ≤ 20 mg/L). Ill-appearance and neonatal age appear to be significant risk factors of co-existing meningitis.

Pediatric Genitourinary Infections and Other Considerations

Pediatric patients pose a unique host of challenges to the emergency provider across all complaints and ages, but this is particularly notable in the genitourinary (GU) system. The pediatric GU system is different from that of the adult in its etiology of symptoms, complications, and treatments. Based on age, there are variations in the anatomy. These differences result in symptoms and diagnoses that must be managed differently. Although in many respects management is similar to GU emergency conditions in adults, there are, occasionally subtle, differences between the care of children and adults, which can greatly impact outcomes.

Association of Diagnostic Criteria With Urinary Tract Infection Prevalence in Bronchiolitis: A Systematic Review and Meta-analysis

IMPORTANCE

Concomitant urinary tract infection (UTI) is a frequent concern in febrile infants with bronchiolitis, with a prior meta-analysis suggesting a prevalence of 3.3%. However, the definition of UTI in these studies has generally not incorporated urinalysis (UA) results.

OBJECTIVE

To conduct a systematic review and meta-analysis examining the prevalence of UTI in infants with bronchiolitis when positive UA results are incorporated into the UTI definition.

DATA SOURCES

Medline (1946-2017) and Ovid EMBASE (1976-2017) through August 2017 and bibliographies of retrieved articles.

STUDY SELECTION

Studies reporting UTI prevalence in bronchiolitis.

DATA EXTRACTION

Data were extracted in accordance with meta-analysis of observational studies in epidemiology guidelines via independent abstraction by multiple investigators. Random-effects models generated a weighted pooled event rate with corresponding 95% confidence intervals.

MAIN OUTCOMES AND MEASURES

Prevalence of UTI.

RESULTS

We screened 477 unique articles by abstract, with full-text review of 30 studies. Eighteen bronchiolitis studies reported a UTI prevalence and 7 of these reported UA data for inclusion in the meta-analysis. The overall reported prevalence of UTI in bronchiolitis from these 18 studies was 3.1% (95% CI, 1.8%-4.6%). With the addition of positive UA results (defined as the presence of pyuria or nitrites) as a diagnostic criterion, the prevalence of UTI as reported in the 7 studies in bronchiolitis was 0.8% (95% CI, 0.3%-1.4%). Sensitivity analyses yielded similar results, including for infants younger than 90 days. Heterogeneous definitions of UTI and UA criteria introduced uncertainty into prevalence estimates.

CONCLUSIONS AND RELEVANCE

When a positive UA result is added as a diagnostic criterion, the estimated prevalence of concomitant UTI is less than recommended testing thresholds for bronchiolitis.

Adherence to the 2011 American Academy of Pediatrics Urinary Tract Infection Guidelines for Voiding Cystourethrogram Ordering by Clinician Specialty

OBJECTIVE

To evaluate rates of guideline adherence and associations with voiding cystourethrogram result. The American Academy of Pediatrics guidelines recommend voiding cystourethrogram after abnormal renal ultrasound or 2 febrile urinary tract infections. It is unclear whether guideline adherence increases vesicoureteral reflux detection. Additionally, guidelines targeting children 2-24 months are often applied to other ages.

METHODS

Children undergoing voiding cystourethrogram from January 2012 to December 2013 at 1 institution were retrospectively reviewed. Children with known genitourinary abnormalities were excluded. The primary outcome was guideline adherence. Univariate and multivariate analyses were performed. Subgroup analysis of children 2-24 months was completed.

RESULTS

Voiding cystourethrograms from 365 children were included in the primary analysis, including 187 (51.2%) aged 2-24 months. Overall, 60.3% of voiding cystourethrograms were ordered in accordance with the guidelines. Urologists/nephrologists were more likely to adhere to ordering guidelines than pediatricians/others (76.4% vs 51.7%, odds ratio 3.0 [1.9-4.9], P <.001). Subgroup analysis in children 2-24 months revealed similar findings (76.4% vs 51.5%, odds ratio 3.0 [1.5-6.2], P = .002). Voiding cystourethrograms were abnormal in 31.8% overall and 26.2% aged 2-24 months. Guideline adherence was associated with increased likelihood of abnormal voiding cystourethrogram among all children (P = .02), but not among children 2-24 months (P = .95). Older age, white race, and guideline adherence remained significantly associated with abnormal voiding cystourethrogram in a multiple logistic regression model.

CONCLUSIONS

Guideline adherence was more likely among urologists/nephrologists than pediatricians/others and was not associated with abnormal voiding cystourethrogram among children 2-24 months. Multicenter evaluation is necessary to determine if ordering recommendations should be revised.

The association between continuous antibiotic prophylaxis and UTI from birth until initial postnatal imaging evaluation among newborns with antenatal hydronephrosis

INTRODUCTION

There is a lack of consensus regarding the use of continuous antibiotic prophylaxis (CAP) during the interval between birth and initial postnatal imaging in infants with a history of antenatal urinary tract dilation (AUTD).

OBJECTIVE

To determine the incidence of urinary tract infection (UTI), and the association between CAP use and UTI during the interval between birth and the first postnatal renal ultrasound (RUS) in infants with AUTD.

STUDY DESIGN

A single-institution, retrospective cohort study of newborns with a history of AUTD. Infants undergoing RUS within 3 months of birth for an indication of 'hydronephrosis' between 2012 and 2014 were identified. A random sample of 500 infants was selected; six were excluded for concomitant congenital anomalies. Baseline patient (sex, race, insurance) and clinical characteristics (circumcision status, UTD risk score, receipt of CAP, UTI prior to RUS, age at UTI, and age at RUS) were collected via retrospective chart review. Descriptive statistics were calculated. To adjust for receipt of CAP, propensity score adjusted univariate logistic regression for UTI based on CAP status was performed.

RESULTS

Among the 494 infants with AUTD, 157 (32%) received CAP. Infants with normal/low-risk UTD scores were less likely to receive CAP than those with medium/high-risk UTD (23% vs 77%; P < 0.001). There was no difference in CAP based on sex, insurance, or circumcision status (among 260/365 males with known circumcision status). Overall, seven infants (1.4%) developed UTI prior to imaging: six (1.8%) without CAP vs one (0.64%) with CAP (P = 0.44). The median age at UTI was 59 days (range 2-84); among those with UTI, initial imaging occurred significantly later (66 vs 28 days; P = 0.001). The propensity score adjusted odds of developing UTI with CAP (vs without) was 0.93 (95% CI 0.10-8.32; P = 0.95). The Summary Figure describes the infants with UTI.

CONCLUSION

The incidence of UTI prior to initial neonatal imaging in newborns with AUTD was low. Use of CAP was not associated with UTI incidence after adjusting for UTD severity. Routine use of CAP in newborns with AUTD prior to initial imaging may be of limited benefit in most patients.

Urinary tract infection profile among a hospitalized newborn: a single center study in Iran, 2006-2015

Background: Urinary tract infection in infants is associated with septicemia and genitourinary anomalies. This study was aimed at investigating the frequency, clinical signs, and anomalies in infants hospitalized for urinary tract infection.Methods: This cross-sectional study was conducted on all infants with urinary infection who were hospitalized in the neonatal ward of Be’sat Hospital from 2006 to 2015.Results: Of 79 infants with urinary infection, 62% were male and 87.3% were term infants. The mean age at admission was 16.62±7.17 days, and the mean weight was 3276±478.23 grams. The most frequent clinical sign and the most common pathogen reported were prolonged jaundice (62%) and Escherichia coli (69.6%), respectively. Of the samples, 93.7% were obtained by suprapubic aspiration, 23% had leukocytosis, and 2.5% had urosepsis. In urinalysis examination, 81% had pyuria and 19% had positive nitrate. Among 25.3% infants who had abnormal ultrasound findings, the most abnormal finding was mild bilateral hydronephrosis and 6.3% of the infants had abnormal voiding cystourethrogram (VCUG) in which vesicoureteral reflux was the most frequent finding.Conclusion: It showed that a prolonged jaundice in infants should be considered as a strong factor predicting urinary tract infection.

Androgen exposure potentiates formation of intratubular communities and renal abscesses by Escherichia coli

Females across their lifespan and certain male populations are susceptible to urinary tract infections (UTI). The influence of female vs. male sex on UTI is incompletely understood, in part because preclinical modeling has been performed almost exclusively in female mice. Here, we employed established and new mouse models of UTI with uropathogenic Escherichia coli (UPEC) to investigate androgen influence on UTI pathogenesis. Susceptibility to UPEC UTI in both male and female hosts was potentiated with 5α-dihydrotestosterone, while males with androgen receptor deficiency and androgenized females treated with the androgen receptor antagonist enzalutamide were protected from severe pyelonephritis. In androgenized females and in males, UPEC formed dense intratubular, biofilm-like communities, some of which were sheltered from infiltrating leukocytes by the tubular epithelium and by peritubular fibrosis. Abscesses were nucleated by small intratubular collections of UPEC first visualized at five days postinfection and briskly expanded over the subsequent 24 hours. Male mice deficient in Toll-like receptor 4, which fail to contain UPEC within abscesses, were susceptible to lethal dissemination. Thus, androgen receptor activation imparts susceptibility to severe upper-tract UTI in both female and male murine hosts. Visualization of intratubular UPEC communities illuminates early renal abscess pathogenesis and the role of abscess formation in preventing dissemination of infection. Additionally, our study suggests that androgen modulation may represent a novel therapeutic route to combat recalcitrant or recurrent UTI in a range of patient populations.