Risk factors for community-acquired urinary tract infection caused by ESBL-producing bacteria in children

Impact of inadequate empirical antibiotic treatment on outcome of non-critically ill children with bacterial infections

BACKGROUND

The impact of inadequate empirical antibiotic treatment on patient outcomes and hospitalization duration for non-life-threatening infections in children remains poorly understood. We aimed to assess the effects of inadequate empirical antibiotic treatment on these factors in pediatric patients.

METHODS

The medical records of children admitted for infectious diseases with bacteria isolated from sterile sites between 2018 and 2020 were retrospectively reviewed. Patients who received adequate empirical treatment were compared with those who received inadequate treatment in terms of demographic, clinical, and laboratory variables.

RESULTS

Forty-eight patients who received inadequate empirical antimicrobial treatment were compared to 143 patients who received adequate empirical treatment. Inadequate empirical antimicrobial treatment did not significantly affect the length of hospital stay or the incidence of complications in non-critically ill children with bacterial infections. Younger age and underlying renal abnormalities were identified as risk factors for inadequate antimicrobial treatment, while associated bacteremia was more common in the adequate antimicrobial treatment group.

CONCLUSIONS

inadequate antibiotic treatment did not affect the outcomes of non-critically ill children with bacterial infectious diseases. Therefore, routine empirical broad-spectrum treatment may not be necessary for these cases, as it can lead to additional costs and contribute to antibiotic resistance. Larger prospective studies are needed to confirm these findings.

The risk factors, antimicrobial resistance patterns, and outcomes associated with extended-spectrum β-lactamases-Producing pathogens in pediatric urinary tract infection

BACKGROUND

Extended-spectrum β-lactamases-producing Escherichia coli, Klebsiella pneumoniae, and Proteus mirabilis (ESBL-producing-EKP) are an increasingly common cause of childhood urinary tract infection (UTI) worldwide. Recognizing the risk factors and antimicrobial resistance patterns may guide new management in this population.

METHODS

This is a retrospective cohort study of over 5 years in Taiwan (2017-2021). Inclusion criteria are hospitalized pediatric patients with the discharge diagnosis of UTI caused by E. coli, Klebsiella pneumoniae, or Proteus mirabilis. ESBL-producing-EKP and non-ESBL-producing-EKP UTI cases were reviewed for characteristics, urinary isolate antibiotics resistance, and clinical outcomes.

RESULTS

The incidence rate of ESBL-producing-EKP UTI increased over the study period (Overall incidence rate: 14.1 %, 46/327 patients). Recent antibiotic therapy in ≤6 months (X2 = 11.83, p < 0.01) and a preterm gestational history (X2 = 8.11, p < 0.05) were associated with an increased risk. The proportion of patients with these two risk factors for ESBL acquisition were 37.5 % (X2 = 9.08, p < 0.05). The co-resistance rate of ESBL-producing-EKP to other antimicrobial agents was 63.0 % for gentamicin, 56.5 % for trimethoprim-sulfamethoxazole, 52.2 % for ciprofloxacin, 4.3 % for amikacin, and 2.2 % for imipenem. The generalized linear model analysis identified a significantly longer length of stay (β: 2.85; 95 % confidence interval [CI]: 1.14-4.56; p < 0.01) and intensive care unit duration (β: 5.86; 95 % CI: 1.59-10.12; p < 0.01) among patients with ESBL-producing-EKP UTI.

CONCLUSION

Amikacin should be considered as an alternative antimicrobial choice beyond carbapenems for ESBL-producing-EKP UTI, especially in the context of carbapenem-resistant E. coli/Klebsiella pneumoniae (CRE/CRKP) emergence.

Phenotypic characterization of ESBL-producing urinary isolates of E. coli and Klebsiella spp. in a tertiary care children's hospital in Nepal

BACKGROUND

The production of extended-spectrum beta-lactamases (ESBLs) among uropathogens, particularly E. coli and Klebsiella spp., poses a severe public health concern. This study explored the epidemiology of ESBL-producing E. coli and Klebsiella spp. isolated from urine samples obtained at a tertiary care children's hospital in Nepal.

METHODS

A cross-sectional study was conducted from August 2016 to February 2017. A total of 745 clean catch urine samples were obtained from pediatric patients under the age of 13 and subjected to semiquantitative culture. E. coli and Klebsiella spp. were identified using standard laboratory protocols. Antibiotic susceptibility testing was performed using the Kirby-Bauer disc diffusion method, and ESBL producers were phenotypically identified using the combined disk method.

RESULTS

Among the bacterial isolates, E. coli predominated, accounting for 139 (81.8%) positive cases. Notably, E. coli showed high susceptibility to nitrofurantoin, with 117 (84.2%) isolates being susceptible. Meanwhile, K. pneumoniae showed high susceptibility to gentamicin, with 21 (91.3%) isolates being susceptible. Of the 163 isolates of E. coli and Klebsiella spp., 62 (38.0%) were identified as multidrug-resistant (MDR), with 42 (25.8%) confirmed as phenotypic ESBL producers. Remarkably, all 41 (100%) ESBL-producing E. coli isolates were susceptible to imipenem.

CONCLUSIONS

The prevalence of ESBL producers among E. coli and K. pneumoniae isolates from pediatric patients underscores the importance of antimicrobial stewardship. Nitrofurantoin and gentamicin emerge as effective empirical treatment choices against these pathogens in children. However, the high rates of multidrug resistance and ESBL production highlight the necessity for routine surveillance, and early detection strategies to manage such infections effectively.

Genome profiling of uropathogenic E. coli from strictly defined community-acquired UTI in paediatric patients: a multicentric study

BACKGROUND

Urinary tract infection (UTI) in children is a common bacterial infection. The emergence of extended-spectrum beta-lactamases (ESBLs) poses a major challenge against the treatment of uropathogens. We aimed to characterize the E. coli isolates recovered from children with UTI for their resistance profile and circulating sequence types (ST).

METHODS

Children (> 1.5-18 years of age) from different community health centres of India with symptoms of UTI were enrolled. Isolates causing significant bacteriuria were identified by Matrix-Assisted Laser Desorption Ionization Time of Flight Mass Spectrometry (MALDI-TOF MS) and tested for antimicrobial susceptibility by the automated system, VITEK-2 (Biomeriux, Durhum, US). Nineteen E. coli isolates (15 ESBL positive and 4 ESBL negative) were sequenced in Oxford Nanopore platform followed by core-genome phylogeny, accessory genome cluster analysis, identification of sequence types, mobile genetic elements, genetic antimicrobial resistance markers. The correlation between detection of antimicrobial resistance genes with phenotypic resistance profiles was also investigated.

RESULTS

Eleven percent of children had significant bacteriuria [male:female-1:1, > 50% were 11-18 years of age group]. E. coli was predominant (86%) followed by K. pneumoniae (11%). Susceptibility of E. coli was highest against fosfomycin (100%) followed by carbapenems (90.7%) and nitrofurantoin (88.8%). ST131 (15.8%) and ST167 (10.5%) found as high-risk clones with the presence of plasmid [IncFIB (63.1%), IncFIA (52.6%)], and composite transposon [Tn2680 (46.6%)] in many isolates. Few isolates coharboured multiple beta-lactamases including blaNDM-5 (33.3%), blaOXA-1 (53.3%), blaCTX-M-15 (60%) and blaTEM-4 (60%).

CONCLUSIONS

This study highlights horizontal transmission of resistance genes and plasmids in paediatric patients at community centers across the nation harbouring multidrug-resistant genes such as blaNDM-5 and blaCTX-M-15 associated with high-risk clones ST131 and ST167. The data is alarming and emphasizes the need for rapid identification of resistance markers to reduce the spread in community. To our knowledge, this is the first multicentric study targeting paediatric UTI patients from the community setting of India.

Pediatric community acquired urinary tract infections due to extended-spectrum beta-lactamase versus non-extended-spectrum beta-lactamase producing bacteria

BACKGROUND

This study aimed to evaluate the demographics, clinical characteristics, risk factors, and antibiotic resistance of pediatric community-acquired urinary tract infections (UTIs) caused by extended-spectrum beta-lactamase (ESBL)-producing and non-ESBL-producing uropathogens.

METHODS

This retrospective study was conducted at a tertiary care hospital in Saudi Arabia, among children aged between 0 and 14 years, with a culture-proven diagnosis of community-acquired UTI between February 2019 and September 2021. Patients were divided into two groups based on whether or not their UTI was caused by ESBL-producing bacteria.

RESULTS

A total of 383 patients with community-acquired UTI were evaluated. Escherichia coli was detected in 72.6% of cultures. Extended-spectrum beta-lactamase-producing organisms were responsible for 35.7% of UTI episodes. Of these 69% and 31% were caused by E. coli and Klebsiella pneumoniae, respectively. There were no significant differences between the two groups with regard to clinical presentation or urine analysis. The resistance rates in the ESBL-producing group were 39.4% for amoxicillin/clavulanic acid, 65.7% for ciprofloxacin, 72.3% for co-trimoxazole, 32.8% for nitrofurantoin, 21.2% for gentamicin, and 0.7% for amikacin and carbapenems. In the non-ESBL-producing group, it was 22.4% for amoxicillin/clavulanic acid, 22.4% for ciprofloxacin, 38.2% for co-trimoxazole, 23.6% for nitrofurantoin, 6.1% for gentamicin, and zero for amikacin and carbapenems. The presence of renal abnormalities (p = 0.014) and male gender (p = 0.026) were determined to be independent risk factors for ESBL UTIs.

CONCLUSIONS

Recognizing risk factors and antibiotic resistance for ESBL-producing bacteria may aid in tailoring an antibiotic regimen for pediatric patients at high risk of ESBL-UTIs.

Prevalence of Risk Factors of Urinary Tract Infections in Infants and Children in Arak, Iran: A Cross-sectional Study

Background: Urinary tract infection (UTI) is one of the most common childhood infections. Urinary tract infections are divided into simple and complex types. If the bladder infection is not treated, it can cause secondary kidney infections, such as acute pyelonephritis, which can lead to kidney scar or permanent kidney damage. A significant percentage of patients of any age are re-infected after antimicrobial treatments during the first six months after the first period of UTI. Objectives: This research aimed to investigate the risk factors affecting UTI in infants and children hospitalized in Arak Amir Kabir Hospital in 2017-2018 to prevent UTI and its secondary complications. Methods: In this cross-sectional study, the data collection tool was a validated questionnaire to gather the child's demographic characteristics, including age, sex, type of nutrition, circumcision, age of circumcision, as well as information about fetal birth weight, chronic maternal diseases such as diabetes and stress, and residence place. The content validation method was used to determine the validity of the checklist, and the test-retest was used for reliability. Data were analyzed by SPSS version 22 software. Results: Sixty four percent of children had the normal ultrasound, while 22% had hydronephrosis and nephrolithiasis on ultrasound. The average thickness and size of the right kidney were 71.75 and 9.11, and those of the left kidney were 9.11 and 9.50, respectively. The most common microorganism was Escherichia coli. Conclusions: Given the importance of prevention and timely diagnosis and treatment of UTI to prevent kidney injuries, it is necessary to find UTI risk factors as the first step to preventing children from secondary kidney injuries.

A Case-Control Study Evaluating Risk Factors and Outcomes of Hospitalized Children With ESBL-UTI

Urinary tract infections (UTIs) are among the most common causes of hospitalization in children, with a rising prevalence of extended-spectrum beta-lactamase-producing organisms (ESBL). The purpose of this study was to identify risk factors and treatment outcomes of children with ESBL-UTI. A retrospective case-control study of hospitalized children was performed from July 2014 till December 2017. Medical records from patients with a positive urine culture were reviewed and included in the study if they met criteria for UTI. Cases were defined as ESBL-UTI, while controls were defined as non-ESBL-UTI patients. This study confirmed that there are certain risk factors, such as previous UTI, recent antibiotic use, urinary tract abnormalities, recent hospital admission, and nonrenal comorbidities, that are associated with ESBL-UTI. Most of the patients with ESBL-UTI responded to discordant antibiotics. Other significant outcomes in patients with ESBL-UTI included a longer length of stay and longer intravenous antibiotic therapy.

Investigating Antimicrobial Resistance and ESBL Producing Gene in Klebsiella Isolates among Neonates and Adolescents in Southern Bangladesh

Background

Multidrug-resistant (MDR) clones of Klebsiella pneumoniae (Kpn) have been increasingly documented in community-acquired and nosocomial infections all around the globe. Extended-spectrum β-lactamases (ESBLs) are a rapidly evolving group of β-lactamase enzymes derived from SHV genes by mutations. This research work aimed to investigate and analyze the widespread prevalence of Kpn antibiotic resistance in different areas of the southern part of Bangladesh.

Methods

This particular study was executed and implemented by using 501 clinical samples or isolates from two different hospitals in Chattogram. The disk diffusion method was used to detect Kpn's sensitivity to 16 antibiotics in a drug susceptibility test. By using the PCR technique, the widespread prevalence of antibiotic-resistant gene bla_SHV-11 was studied. Sequencing along with phylogenetic analysis was utilized to verify isolates with the bla_SHV-11 gene.

Results

Almost all of the Kpn isolates were spotted to be antibiotic-resistant. These Kpn isolates were resistant to β-lactams, aminoglycosides, and quinolones at high levels. The spatial analysis displayed that infections involving Kpn were more common in the urban areas (70%) than in the rural areas (30%). Neonates had substantially higher levels (p < 0.001) of resistance to multidrug than other age groups. Cefepime was identified as the most frequent antibiotic-resistant to all age groups (56.68%). The highest numbers of resistant isolates (36.92%) were found in urine samples. The ESBL gene bla_SHV-11 was found in 38% isolates.

Conclusion

The significant frequency of MDR Kpn harboring β-lactamases and AMR genes strongly suggests the requirement to develop effective antimicrobial resistance control and prevention measures in Bangladesh.

Clinical features and treatment strategies of febrile urinary tract infection caused by extended-spectrum beta-lactamase-producing Enterobacteriaceae in children: a multicenter retrospective observational study in Japan

OBJECTIVES

The incidence of infections caused by extended-spectrum beta-lactamase (ESBL)-producing bacteria has increased. This study aimed to clarify the risk factors and treatment strategies for febrile urinary tract infection (fUTI) caused by ESBL-producing bacteria in Japanese children.

METHODS

A retrospective observational study was conducted in 21 hospitals among children aged <16 years diagnosed with an fUTI between 2008 and 2017. Clinical data of children with fUTI caused by ESBL-producing and non-ESBL-producing bacteria were compared.

RESULTS

Of the 2049 cases of fUTI, 147 (7.2%) were caused by ESBL-producing bacteria. Children in the ESBL group were more likely to have a history of recent antibiotic use or prophylactic antibiotic use, and experience recurrent UTIs (P <0.001) compared with those in the non-ESBL group. Of the 124 cases of fUTI due to ESBL-producing bacteria that were reviewed, 20 and 100 had concordant and discordant antibiotic use, respectively, and four had unknown antibiotic susceptibility. The median time from the start of treatment to fever resolution was 24 hours and did not differ significantly by therapy group (P = 0.39).

CONCLUSION

ESBL-producing bacteria should be considered in children with recurrent UTIs and recent antibiotic use. Most children with fUTI experience clinical improvement regardless of the choice of antibiotic.

Molecular Characterization of Extended Spectrum β-Lactamase (ESBL) and Virulence Gene-Factors in Uropathogenic Escherichia coli (UPEC) in Children in Duhok City, Kurdistan Region, Iraq

Background: The presence of extended-spectrum β-lactamase (ESBL)-producing bacteria among uropathogens is significantly increasing in children all over the world. Thus, this research was conducted to investigate the prevalence of E. coli and their antimicrobial susceptibility pattern, and both genes of ESBL-producing E. coli resistant and virulence factor in UTIs patients among children in Duhok Province, Kurdistan, Iraq. Method: a total of 67 E. coli were identified from 260 urine samples of pediatric patients diagnosed with UTIs aged (0−15 years) which were collected from Heevi Pediatric Teaching Hospital, from August 2021 to the end of February 2022. Result: a high proportion of UPEC infections at ages <5 years and the rates among girls (88%) were significantly higher than those among the boys. A wide variety of E. coli are resistant to most antibiotics, such as Amoxicillin, Ampicillin and Tetracycline, and 64% of them were positive for ESBL. Interestingly, the presence of both the ESBL marker genes (blaTEM, and blaCTX-M) as well as both virulence marker genes (pai and hly) were detected in above 90% of E. coli. Conclusion: the data illustrate an alarming increase in UPEC with ESBL production and the emergence of multidrug-resistant drugs in the early age of children. The public health sectors should further monitor the guidelines of using antibiotics in Kurdistan, Iraq.

A study of the 20-year evolution of antimicrobial resistance patterns of pediatric urinary tract infections in a single center

Febrile urinary tract infections (UTIs) are important bacterial infections in children but increasingly difficult to treat due to antimicrobial resistance. We performed a retrospective analysis of the prevalence of uropathogens in hospitalized children with a febrile UTI between 2000 and 2019 in our university hospital to get more insight into trend and determinants of antimicrobial resistance over time. There were 1010 hospitalizations in children with a median age of 1.1 years. Thirty-six percent had an abnormal ultrasound and/or the presence of vesico-ureteral reflux, defined as CAKUT. Escherichia coli was the most prevalent pathogen (76%). However, there was an increasing prevalence towards other gram-negative organisms over time, and these pathogens were more common in children with congenital anomalies of kidney and urinary tract (CAKUT) (OR 4.26 (3.14-5.78), p < 0.001). E. coli strains demonstrated an increase in resistance against amoxicillin clavulanic acid (AMC) over time from 16% (2000-2004) to 36% (2015-2019) with an average increase of 2.0%/year; this was + 1.1%/year for third-generation cephalosporin. Multivariate analysis demonstrated that prior antibiotic use was an additional risk factor for antimicrobial resistance in E. coli. Nevertheless, increasing resistance was also observed in children without reported previous antibiotic treatment (+ 1.9%/year, p = 0.04).    Conclusion: We observed a significant pattern of increasing antimicrobial resistance of E. coli within a relatively short period of time, making it increasingly difficult to treat pediatric UTIs. This pattern was also seen in children without underlying risk factors (recent antibiotic treatment or structural urological disease). This is indicative for a larger problem in the general population and an important threat to our current standard of health care. What is Known: • Escherichia coli is the most frequent pathogen in pediatric urinary tract infections. • There is an increasing antimicrobial resistance against commonly used antibiotics in urinary tract infections. What is New: • The first 20-year retrospective, longitudinal study on characteristics of the microorganisms of pediatric urinary tract infections in a single center. • A 1-2% yearly increase in antimicrobial resistance, not only in children with congenital anomalies of the kidneys or recent antibiotic treatment but also in children without risk factors.

The Influence of Non-E. Coli or Extended-Spectrum β-Lactamase-Producing Bacterial Growth on the Follow-Up Procedure of Infants with the First Febrile Urinary Tract Infection

OBJECTIVE

To evaluate the effects of non-E. coli or extended-spectrum β-lactamase-positive (ESBL-positive) microorganism growth in the first febrile urinary tract infection (UTI) of infants on laboratory findings or renal parenchymal damage presenting the severity of inflammation, anatomic abnormalities defined by imaging studies, and recurrent UTIs in the follow-up period.

METHODS

The data of patients aged between 2 and 24 mo and followed up for at least 6 mo with febrile UTI guideline of the authors' pediatric-nephrology clinic, were retrospectively analyzed. Ultrasonography was performed in all the cases at the time of UTI and dimercaptosuccinic-acid (DMSA) at least 4 mo after the infection. Voiding cystourethrography (VCUG) was performed only if ultrasonography findings were abnormal, the uptake deformity was detected in DMSA scan, or the patients experienced recurrent UTIs. The patients were grouped concerning E. coli or non-E. coli and ESBL-PB or non-ESBL-BP growth in the urine cultures.

RESULTS

There were 277 infants followed up for 28.55 ± 15.24 (6-86) mo. The causative microorganisms were non-E. coli in 73 (26.4%) and ESBL-PB in 58 (20.9%) cases. CRP values, pyuria, and leukocyte-esterase positivity were significantly higher in UTIs caused by E. coli compared to non-E. coli bacteria. All clinical and laboratory findings were similar between the ESBL-PB and non-ESBL groups, but abnormal ultrasonography findings were more common in non-E. coli group.

CONCLUSION

E. coli causes more severe inflammation, but non-E. coli infections are more frequently associated with ultrasound abnormalities. However, ESBL production did not affect either laboratory or radiological findings in the present cohort.

Estimating the impact of cefuroxime versus cefazolin and amoxicillin/clavulanate use on future collateral resistance: a retrospective comparison

Background

Quantitative estimates of collateral resistance induced by antibiotic use are scarce.

Objectives

To estimate the effects of treatment with amoxicillin/clavulanate or cefazolin, compared with cefuroxime, on future resistance to ceftazidime among hospitalized patients.

Methods

A retrospective analysis of patients with positive bacterial cultures hospitalized in an Israeli hospital during 2016–19 was conducted. Patients were restricted to those treated with amoxicillin/clavulanate, cefazolin or cefuroxime and re-hospitalized with a positive bacterial culture during the following year. Matching was performed using exact, Mahalanobis and propensity score matching. Each patient in the amoxicillin/clavulanate and cefazolin groups was matched to a single patient from the cefuroxime group, yielding 185:185 and 298:298 matched patients. Logistic regression and the g-formula (standardization) were used to estimate the OR, risk difference (RD) and number needed to harm (NNH).

Results

Cefuroxime induced significantly higher resistance to ceftazidime than amoxicillin/clavulanate or cefazolin; the marginal OR was 1.76 (95% CI = 1.16–2.83) compared with amoxicillin/clavulanate and 1.98 (95% CI = 1.41–2.8) compared with cefazolin and the RD was 0.118 (95% CI = 0.031–0.215) compared with amoxicillin/clavulanate and 0.131 (95% CI = 0.058–0.197) compared with cefazolin. We also estimated the NNH; replacing amoxicillin/clavulanate or cefazolin with cefuroxime would yield ceftazidime resistance in 1 more patient for every 8.5 (95% CI = 4.66–32.14) or 7.6 (95% CI = 5.1–17.3) patients re-hospitalized in the following year, respectively.

Conclusions

Our results indicate that treatment with amoxicillin/clavulanate or cefazolin is preferable to cefuroxime, in terms of future collateral resistance. The results presented here are a first step towards quantitative estimations of the ecological damage caused by different antibiotics.

Emergence of Extended-Spectrum β-Lactamase-Producing Pathogens in Community-Acquired Urinary Tract Infections Among Infants at a Pediatric Emergency Department

BACKGROUND

Extended-spectrum β-lactamase (ESBL)-producing pathogens are common among adults and are associated with extended and multiple hospitalizations. They cause urinary tract infections (UTIs) among children with known risk factors such as urinary tract abnormalities and antimicrobial prophylaxis. The emergence of UTIs caused by ESBL-producing organisms among infants has not been well characterized.

OBJECTIVE

We sought to describe the incidence and current clinical management of infants who were diagnosed with UTIs caused by ESBL-producing organisms at a pediatric emergency department (ED). In addition, we sought to describe risk factors associated with inpatient hospitalization for UTIs caused by ESBL-producing organisms.

METHODS

We retrospectively identified infants who were treated in the ED from 2013 to 2017 and who had positive urinalyses and urine cultures positive for greater than 50,000 colony-forming unit per milliliter of a single ESBL-producing urinary pathogen. We abstracted details of clinical management and known previous risk factors, including prior neonatal intensive care unit hospitalization stay, prior UTI caused by an ESBL-producing organism, and known urologic abnormalities.

RESULTS

Forty-five UTIs caused by ESBL-producing organisms occurred in 43 patients (mean age of 5.9 months and 59% female)-ESBL Escherichia coli represented the majority (42/45). The incidence of UTIs caused by ESBL-producing organisms ranged from 0.9% to 4.5% during the 5-year study period. The 13 patients (26%) admitted from the ED were significantly younger than discharged patients (1.9 vs 6.7 months, P = 0.016) and more likely to have had prior neonatal intensive care unit hospitalizations (50% vs 15.6%, P = 0.0456). Of the 33 visits (77%) resulting in initial outpatient management, 5 were followed by readmission for parenteral antibiotic treatment. Of those who were readmitted, 40% (n = 2) were afebrile at the time of admission. The remainder (28/33) completed outpatient oral antibiotic courses guided by susceptibilities. Two patients (4%) had negative repeat urine cultures despite in vitro resistance to initial antibiotic coverage.

CONCLUSIONS

Extended spectrum β-lactamase-producing organisms are an increasing cause of UTIs in infants presenting at a pediatric ED, and outpatient management may be reasonable for infants older than 2 months.

Risk factors for cefazolin-resistant febrile urinary tract infection in children

BACKGROUND

Febrile urinary tract infection (fUTI) is a common bacterial infection among children. This study investigated the risk factors for fUTI caused by cefazolin-resistant bacteria in children.

METHODS

The medical records of patients with fUTI hospitalized between April 2014 and March 2020 were retrospectively analyzed. The patients were divided into two groups based on the cefazolin susceptibility of the infection-causing bacteria: cefazolin-resistant and cefazolin-susceptible groups.

RESULTS

The records of 80 patients were evaluated. The median age was 5.0 months (range 0.5-119.4 months). Cefazolin-susceptible bacteria were detected in 60 patients (75.0%). Significant differences were noted between the cefazolin-resistant and cefazolin-susceptible groups regarding UTI-related antimicrobial prophylaxis and recurrence of UTI within 3 months (P = 0.0318 and P = 0.00876, respectively). However, no significant differences were observed between these two groups regarding renal anomalies, or UTI history. Logistic regression analysis revealed that the recurrence of UTI within 3 months was an independent, significant risk factor for cefazolin-resistant fUTI (odds ratio 3.81, 95% confidence interval: 1.07-13.5, P = 0.0388). Six patients who were empirically treated with antibiotics ineffective against the infection-causing bacteria recovered from fever before these antibiotics were switched to those effective against the infection-causing bacteria.

CONCLUSIONS

In children, a recurrence of UTI within 3 months is a risk factor for fUTI caused by cefazolin-resistant bacteria. Recognizing these risk factors before initiating fUTI treatment in children may support treatment with narrower-spectrum antibiotics, such as first-generation cephalosporins (e.g., cefazolin).

Antibiotic Resistance in Paediatric Febrile Urinary Tract Infections

Febrile urinary tract infection (UTI) is currently considered the most frequent cause of serious bacterial illness in children in the first 2 years of life. UTI in paediatrics can irreversibly damage the renal parenchyma and lead to chronic renal insufficiency and related problems. To avoid this risk, an early effective antibiotic treatment is essential. Moreover, prompt treatment is mandatory to improve the clinical condition of the patient, prevent bacteraemia, and avoid the risk of bacterial localization in other body sites. However, antibiotic resistance for UTI-related bacterial pathogens continuously increases, making recommendations rapidly outdated and the definition of the best empiric antibiotic therapy more difficult. Variation in pathogen susceptibility to antibiotics is essential for the choice of an effective therapy. Moreover, proper identification of cases at increased risk of difficult-to-treat UTIs can reduce the risk of ineffective therapy. In this review, the problem of emerging antibiotic resistance among pathogens associated with the development of paediatric febrile UTIs and the best potential solutions to ensure the most effective therapy are discussed. Literature analysis showed that the emergence of antibiotic resistance is an unavoidable phenomenon closely correlated with the use of antibiotics themselves. To limit the emergence of resistance, every effort to reduce and rationalise antibiotic consumption must be made. An increased use of antibiotic stewardship can be greatly effective in this regard.

Sickle cell disease children's gut colonization by extended-spectrum β-lactamase (ESBL)-producing Enterobacterales: an antibiotic prophylaxis effect?

Introduction. Sickle cell disease (SCD) children have a high susceptibility to pneumococcal infection. For this reason, they are routinely immunized with pneumococcal vaccines and use antibiotic prophylaxis (AP).Hypothesis/Gap Statement. Yet, little is known about SCD children's gut microbiota. If antibiotic-resistant Enterobacterales may colonize people on AP, we hypothesized that SCD children on AP are colonized by resistant enterobacteria species.Objective. To evaluate the effect of continuous AP on Enterobacterales gut colonization from children with SCD.Methodology. We analysed 30 faecal swabs from SCD children on AP and 21 swabs from children without the same condition. Enterobacterales was isolated on MacConkey agar plates and identified by matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS) (bioMérieux, Marcy l'Etoile, France). We performed the antibiogram by Vitek 2 system (bioMérieux, Marcy l'Etoile, France), and the resistance genes were identified by multiplex PCR.Results. We found four different species with resistance to one or more different antibiotic types in the AP-SCD children's group: Escherichia coli, Klebsiella pneumoniae, Citrobacter freundii, and Citrobacter farmeri. Colonization by resistant E. coli was associated with AP (prevalence ratio 2.69, 95 % confidence interval [CI], 1.98-3.67, P<0.001). Strains producing extended-spectrum β-lactamases (ESBL) were identified only in SCD children, E. coli, 4/30 (13 %), and K. pneumoniae, 2/30 (7 %). The ESBL-producing Enterobacterales were associated with penicillin G benzathine use (95 % CI, 22.91-86.71, P<0.001). CTX-M-1 was the most prevalent among ESBL-producers (3/6, 50 %), followed by CTX-M-9 (2/6, 33 %), and CTX-M-2 (1/6, 17 %).Conclusion. Resistant enterobacteria colonize SCD children on AP, and this therapy raises the chance of ESBL-producing Enterobacterales colonization. Future studies should focus on prophylactic vaccines as exclusive therapy against pneumococcal infections.

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020)

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020), a Japanese-specific set of clinical practice guidelines for sepsis and septic shock created as revised from J-SSCG 2016 jointly by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine, was first released in September 2020 and published in February 2021. An English-language version of these guidelines was created based on the contents of the original Japanese-language version. The purpose of this guideline is to assist medical staff in making appropriate decisions to improve the prognosis of patients undergoing treatment for sepsis and septic shock. We aimed to provide high-quality guidelines that are easy to use and understand for specialists, general clinicians, and multidisciplinary medical professionals. J-SSCG 2016 took up new subjects that were not present in SSCG 2016 (e.g., ICU-acquired weakness [ICU-AW], post-intensive care syndrome [PICS], and body temperature management). The J-SSCG 2020 covered a total of 22 areas with four additional new areas (patient- and family-centered care, sepsis treatment system, neuro-intensive treatment, and stress ulcers). A total of 118 important clinical issues (clinical questions, CQs) were extracted regardless of the presence or absence of evidence. These CQs also include those that have been given particular focus within Japan. This is a large-scale guideline covering multiple fields; thus, in addition to the 25 committee members, we had the participation and support of a total of 226 members who are professionals (physicians, nurses, physiotherapists, clinical engineers, and pharmacists) and medical workers with a history of sepsis or critical illness. The GRADE method was adopted for making recommendations, and the modified Delphi method was used to determine recommendations by voting from all committee members.As a result, 79 GRADE-based recommendations, 5 Good Practice Statements (GPS), 18 expert consensuses, 27 answers to background questions (BQs), and summaries of definitions and diagnosis of sepsis were created as responses to 118 CQs. We also incorporated visual information for each CQ according to the time course of treatment, and we will also distribute this as an app. The J-SSCG 2020 is expected to be widely used as a useful bedside guideline in the field of sepsis treatment both in Japan and overseas involving multiple disciplines.

Asian guidelines for urinary tract infection in children

The followings are the level of evidence (LE) and grade of recommendation (GR) on pediatric UTI in Asia. Classification according to the sites of infection (lower versus upper tract), the number of episode (first versus recurrent), the severity (simple versus severe), or the existence of complicating factor (uncomplicated versus complicated) is useful to differentiate children with UTI whether they are at risk of renal damage or not (LE: 2, GR: B). Diagnosis of UTI requires both urinalysis that suggests infection and positive urine culture (LE:3, GR B). For pre-toilet trained children, urine specimen for culture should be collected by urethral catheterization or suprapubic aspiration. For toilet trained children, midstream clean catch urine is reliable (LE: 3, GR: A). Urine culture is considered positive if it demonstrates growth of a single bacterium with the following colony counts: (1) any growth by suprapubic aspiration, (2) >5 × 104 CFU/ml by urethral catheterization, or (3) >105 CFU/ml by midstream clean catch (LE:3, GR: B). For children with febrile UTI, renal and bladder ultrasonography (RBUS) should be routinely performed as soon as possible (LE: 3, GR: C). RBUS should be followed up 6 months later in children with acute pyelonephritis and/or VUR (LE: 3, GR: C). Acute DMSA scan can be performed when severe acute pyelonephritis or congenital hypodysplasia is noted on RBUS or when the diagnosis of UTI is in doubt by the clinical presentation (LE: 3, GR: C). Late DMSA scan (>6 months after the febrile UTI) can be performed in children with severe acute pyelonephritis, high-grade VUR, recurrent febrile UTIs, or abnormal renal parenchyma on the follow-up RBUS (LE: 3, GR: C). Top-down or bottom-up approach for febrile UTI is suggested for the diagnosis of VUR. For top-down approach, VCUG should not be performed routinely for children after the first febrile UTI. VCUG is indicated when abnormalities are apparent on either RBUS or DMSA scan or both (LE: 2, GR: B). VCUG is also suggested after a repeat febrile UTI (LE:2, GR: B). Appropriate antibiotic should be given immediately after urine specimen for culture has been obtained (LE:2, GR: A). Initiating therapy with oral or parenteral antibiotics is equally efficacious for children (>3 months) with uncomplicated UTI (LE: 2: GR: A). The choice of empirical antibiotic agents is guided by the expected pathogen and the local resistance patterns (LE: 2, GR: A). For children with febrile UTI, the total course of antibiotic therapy should be 7-14 days (LE: 2, GR: B). Circumcision may, but not definitively, reduce the risk of febrile UTI in males and breakthrough febrile UTI in males with VUR. Circumcision should be offered to uncircumcised boys with febrile UTI and VUR in countries where circumcision is accepted by the general population (LE: 3, GR: B), while in countries where childhood circumcision is rarely performed, other measures for febrile UTI/VUR should be the preferred choice (LE: 4, GR: C). Bladder bowel dysfunction (BBD) is one of the key factors of progression of renal scarring (LE: 2). Early recognition and management of BBD are important in prevention of UTI recurrence (LE:2, GR: A). Antibiotic prophylaxis to prevent recurrent febrile UTI is indicated in children with moderate to high grade (III-V) VUR (LE: 1b, GR: A). Surgical intervention may be used to treat VUR in the setting of recurrent febrile UTI because it has been shown to decrease the incidence of recurrent pyelonephritis (LE: 2, GR: B).

Prevalence of CTX-M β-Lactamases Producing Multidrug Resistant Escherichia coli and Klebsiella pneumoniae among Patients Attending Bir Hospital, Nepal

The emergence of multidrug resistant (MDR) bacteria which is attributable to extended spectrum β-lactamases (ESBLs) production of CTX-M types is an obvious problem worldwide. This study is aimed at determining the prevalence of CTX-M β-lactamases producing multidrug resistant Escherichia coli and Klebsiella pneumoniae among patients attending Bir Hospital. A cross-sectional study was conducted between April and September 2019 at Bir Hospital, Kathmandu, and Department of Microbiology, National College, Kathmandu, Nepal. A total of 5,690 different clinical specimens were subjected to cultural, microscopic, and biochemical analyses for the identification of the isolates. Antimicrobial susceptibility testing of the isolates was done, and MDR isolates were selected and processed for further ESBL confirmation by the combination disks method. All confirmed ESBL isolates were screened for CTX-M type β-lactamases (bla _CTX-M) by PCR. Of the total 345 isolates (227 Escherichia coli and 118 Klebsiella pneumoniae), 232 were MDR. All 232 (67.24%) MDR isolates were suspected as ESBL producers on the screening test. However, on the phenotypic test, 135 (58.18%) of total MDR bacteria were confirmed as ESBL producers with the highest proportion in K. pneumoniae (59.37%). The major source of ESBL producers was urine. ESBL producing isolates were mostly identified from outpatients and patients belonging to age group 41-60. Gentamicin was found to be effective against ESBL producers. The prevalence of bla _CTX-M was (89.62%) with the highest frequency for E. coli (93.81%). High prevalence of ESBL of CTX-M types among MDR E. coli and K. pneumoniae was detected from clinical specimens of patients in Bir Hospital. This study warrants the need for the judicious use of antibiotics as well as emphasize the use of modern diagnostic tools for the early detection of MDR and ESBL producers to curb the emergence and spread of MDR and ESBL producing bacteria in the clinical settings of Nepal.

Evaluation of clinical, etiological and antimicrobial resistance profile of pediatric urinary tract infections in a secondary health care centre

Background

Urinary tract infections are common during childhood. The etiologic agents and empirical antibiotics may vary due to age and geographic area.

Objectives

This study was designed to investigate the urinary tract infection pathogens, their antibiotic resistance profile and risk factors in a sample of well-child population.

Materials and Methods

This retrospective study was conducted in the pediatric clinics of a secondary health-care centre in a one-year period. The source of data was hospital and laboratory records. Toilet trained children and adolescents aged between 5–17 years old with positive urine culture were enrolled into the study. Microbiological studies were conducted according to international guidelines.

Results

During the study 3640 urine samples were analyzed and 342(9.4%) had significant growth. Gram negative enterobacteria were the most common infectious agents. Antibiotic susceptibility tests showed low cephalosporine resistance unless ESBL was positive. Multi drug resistance was remarkable. Extended beta lactamase resistance rate was 17%. Previous history of antibiotic use before the present administration was the only significant risk factor for ESBL positivity.

Conclusion

Treating urinary tract infections may become an emerging problem soon. Unless there are risk factors, cephalosporines are good options, but if so nitrofurantoin or carbapanems should be preferred for treatment in this population.

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020)

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020), a Japanese-specific set of clinical practice guidelines for sepsis and septic shock created as revised from J-SSCG 2016 jointly by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine, was first released in September 2020 and published in February 2021. An English-language version of these guidelines was created based on the contents of the original Japanese-language version. The purpose of this guideline is to assist medical staff in making appropriate decisions to improve the prognosis of patients undergoing treatment for sepsis and septic shock. We aimed to provide high-quality guidelines that are easy to use and understand for specialists, general clinicians, and multidisciplinary medical professionals. J-SSCG 2016 took up new subjects that were not present in SSCG 2016 (e.g., ICU-acquired weakness [ICU-AW], post-intensive care syndrome [PICS], and body temperature management). The J-SSCG 2020 covered a total of 22 areas with four additional new areas (patient- and family-centered care, sepsis treatment system, neuro-intensive treatment, and stress ulcers). A total of 118 important clinical issues (clinical questions, CQs) were extracted regardless of the presence or absence of evidence. These CQs also include those that have been given particular focus within Japan. This is a large-scale guideline covering multiple fields; thus, in addition to the 25 committee members, we had the participation and support of a total of 226 members who are professionals (physicians, nurses, physiotherapists, clinical engineers, and pharmacists) and medical workers with a history of sepsis or critical illness. The GRADE method was adopted for making recommendations, and the modified Delphi method was used to determine recommendations by voting from all committee members. As a result, 79 GRADE-based recommendations, 5 Good Practice Statements (GPS), 18 expert consensuses, 27 answers to background questions (BQs), and summaries of definitions and diagnosis of sepsis were created as responses to 118 CQs. We also incorporated visual information for each CQ according to the time course of treatment, and we will also distribute this as an app. The J-SSCG 2020 is expected to be widely used as a useful bedside guideline in the field of sepsis treatment both in Japan and overseas involving multiple disciplines.

Extended-spectrum beta-lactamase Escherichia coli and Klebsiella pneumoniae urinary tract infections

The prevalence of extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli and Klebsiella pneumoniae urinary tract infections (UTIs) is increasing worldwide. We investigated the prevalence, clinical findings, impact and risk factors of ESBL E. coli/K. pneumoniae UTI through a retrospective review of the medical records of children with UTI aged <15 years admitted to Prince of Songkla University Hospital, Thailand over 10 years (2004–2013). Thirty-seven boys and 46 girls had ESBL-positive isolates in 102 UTI episodes, compared with 85 boys and 103 girls with non-ESBL isolates in 222 UTI episodes. The age of presentation and gender were not significantly different between the two groups. The prevalence of ESBL rose between 2004 and 2008 before plateauing at around 30–40% per year, with a significant difference between first and recurrent UTI episodes of 27.3% and 46.5%, respectively (P = 0.003). Fever prior to UTI diagnosis was found in 78.4% of episodes in the non-ESBL group and 61.8% of episodes in the ESBL group (P = 0.003). Multivariate analysis indicated that children without fever (odds ratio (OR) 2.14, 95% confidence interval (CI) 1.23–3.74) and those with recurrent UTI (OR 2.67, 95% CI 1.37–5.19) were more likely to yield ESBL on culture. Congenital anomalies of the kidney and urinary tract were not linked to the presence of ESBL UTI. In conclusion, ESBL producers represented one-third of E. coli/K. pneumoniae UTI episodes but neither clinical condition nor imaging studies were predictive of ESBL infections. Recurrent UTI was the sole independent risk factor identified.

Trends in Antimicrobial Susceptibility of Escherichia coli Isolates in a Taiwanese Child Cohort with Urinary Tract Infections between 2004 and 2018

The aim of this study was to investigate the annual incidence of Escherichia coli isolates in urinary tract infections (UTIs) and the antimicrobial resistance of the third-generation cephalosporin (3GCs) to E. coli, including the factors associated with the resistance in hospitalized children in Taiwan. A large electronic database of medical records combining hospital admission and microbiological data during 2004–2018 was used to study childhood UTIs in Taiwan. Annual incidence rate ratios (IRR) of E. coli in children with UTIs and its resistant rate to the 3GCs and other antibiotics were estimated by linear Poisson regression. Factors associated with E. coli resistance to 3GCs were assessed through multivariable logistic regression analysis. E. coli UTIs occurred in 10,756 unique individuals among 41,879 hospitalized children, with 92.58% being community associated based on urine culture results reported within four days after the hospitalization. The overall IRR E. coli UTI was 1.01 (95% confidence interval (CI) 0.99–1.02) in community-associated (CA) and 0.96 (0.90–1.02) in healthcare-associated infections. The trend in 3GCs against E. coli increased (IRR 1.18, 95% CI 1.13–1.24) over time in CA-UTIs. Complex chronic disease (adjusted odds ratio (aOR), 2.04; 95% CI, 1.47–2.83) and antibiotics therapy ≤ 3 months prior (aOR, 1.49; 95% CI, 1.15–1.94) were associated with increased risk of 3GCs resistance to E. coli. The study results suggested little or no change in the trend of E. coli UTIs in Taiwanese youths over the past 15 years. Nevertheless, the increase in 3GCs-resistant E. coli was substantial. Interventions for children with complex chronic comorbidities and prior antibiotic treatment could be effective in reducing the incidence of 3GCs-resistant E. coli in CA-UTIs in this region and more generally.

Extended-Spectrum β-Lactamase (ESBL) Genotypes among Multidrug-Resistant Uropathogenic Escherichia coli Clinical Isolates from a Teaching Hospital of Nepal

Urinary tract infections (UTI) represent the most common bacterial infections among patients visiting outpatient clinics of healthcare centers in Nepal. However, treatment of such infections is compounded by emergence and spread of multidrug-resistant uropathogens associated with extended-spectrum β-lactamases (ESBLs). In this study, we aimed to investigate the burden of antimicrobial resistance and occurrence of ESBL genes among clinical isolates of uropathogenic Escherichia coli at a tertiary care teaching hospital of Nepal. During the study period, we processed a total of 1,626 urinary tract specimens, isolated significant bacterial pathogens, and investigated their antimicrobial susceptibilities. Escherichia coli (n = 154), the predominant pathogen associated with UTI, was further investigated for the existence of ESBL enzymes by using conventional phenotypic as well as molecular approaches. Among suspected cases of UTI, we found that 15.2% were having UTI and female patients of the reproductive age group were more affected (p < 0.05). Escherichia coli (154, 62.1%) was the key uropathogen, and majority (∼64.9%) of them were multidrug resistant (MDR). Among MDR E. coli isolates, 40.3% were producing extended-spectrum β-lactamases (ESBLs). bla-TEM (83.8%), bla-CTX-M (66.1%), and bla-SHV (4.8%) were common ESBL genotypes. Nitrofurantoin, gentamycin, and imipenem were the most effective antibiotics for ESBL-producing Escherichia coli isolates. It indicates that the high rates of multidrug-resistant Escherichia coli are frequent causes of UTI in our hospital. Nitrofurantoin and aminoglycosides are the most useful first-line drugs to be used in the cases of UTI. We recommend the regular investigation of drug resistance among all isolates and develop a useful antibiotic prescription policy in our country.

Urinary Tract Infections With Extended-spectrum-β-lactamase-producing Bacteria: Case-control Study

BACKGROUND

Urinary tract infections (UTI) are the most common bacterial infections among infants and young children with fever without a source. Extended-spectrum β-lactamases (ESBLs) have emerged as emerging cause of UTI globally; however, data about risk factors and clinical features of children with ESBL-UTI have been scarce.

OBJECTIVE

To describe the predisposing risk factors, clinical and microbiologic features associated with pediatric UTIs caused by ESBL-producing bacteria (ESBL-PB).

METHODS

Our nested case-control study ran from January 1, 2012 to December 31, 2016. Pediatric patients with ESBL-PB UTI were compared with patients with non-ESBL-PB UTI matched for age and year of diagnosis.

RESULTS

A total of 720 children were enrolled (240 cases and 480 controls). Patients with ESBL-PB UTI were more likely to have a history of prior intensive care unit (ICU) admission (22.5% vs. 12.3%, P < 0.001), at least one underlying comorbidity (19.2% vs. 5.8%, P < 0.001), prior hospitalization (47.1% vs. 32.9%, P < 0.001), exposure to a cephalosporin antibiotic within 30 days before culture (7.5% vs. 4.2%, P = 0.035), and to have cystostomy (7.9% vs. 1.5%, P < 0.001) compared with those with non-ESBL-PB UTI. Patients with ESBL-PB UTI were more likely to present with hypothermia (48.8% vs. 38.5%, P = 0.009); had significantly longer average hospital stays {8.7 days [95% confidence interval (CI): 3.2-14.3] vs. 4.0 days (95% CI: 2.5-5.5)} and were more likely to be admitted to the ICU [odds ratio (OR) 1.8; 95% CI: 1.1-2.9). Multivariate analysis determined that only having cystostomy (OR 3.7; 95% CI: 1.4-9.4] and at least one underlying comorbidity (OR 2.4; 95% CI: 1.3-4.3) were the independent risk factors for ESBL-PB UTI. All ESBL-PB isolates tested against meropenem were susceptible, majority were resistant to multiple non-beta-lactam antibiotics.

CONCLUSIONS

Children with underlying comorbidities and cystostomy are at higher risk for ESBL-PB UTI, but majority of ESBL cases were patients without any known risk factors. Clinical signs/symptoms and commonly used biochemical markers were unreliable to differentiate cases caused by ESBL-PB from those caused by non-ESBL-PB. Further research is needed to elucidate the conditions most associated with ESBL-PB UTIs among children to properly guide empirical therapy in patients at-risk for these infections, to improve the outcomes, and finally, to determine strategies for rational antimicrobial use.

Antimicrobial susceptibility, risk factors and prevalence of bla cefotaximase, temoneira, and sulfhydryl variable genes among Escherichia coli in community-acquired pediatric urinary tract infection

INTRODUCTION

The emergence of extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli has become an important challenge among pediatric patients with community-acquired urinary tract infection (UTI).

OBJECTIVES

The aim of this study was to assess the antimicrobial susceptibility patterns, associated risk factors and to survey the frequency of bla cefotaximase (CTX-M), bla temoneira (TEM), and bla sulfhydryl variable (SHV) genotypes in ESBL-producing E. coli isolated from children with community-acquired UTI.

METHODS

This was a prospective study conducted from November 2012 to March 2016 in a tertiary care center. E. coli isolated in urine cultures from children aged ≤18 years was identified and confirmed for ESBL production. ESBL-positive strains were screened for ESBL encoding genes. Chi-square test and Fisher's exact test were used to compare the difference in antibiotic susceptibility with respect to ESBL positive and negative, and binary logistic regression was used to identify the risk factors associated with ESBL production.

RESULTS

Among 523 E. coli isolates, 196 (37.5%) were ESBL positive, >90% were resistant to cephalosporins, and 56% were resistant to fluoroquinolones. Least resistance was observed for imipenem, netilmicin, and nitrofurantoin (2%, 8.6%, 15.3%). Association between ESBL production and drug resistance was significant for ceftazidime (P < 0.001), cefixime (P < 0.001), cefotaxime (P = 0.010), ceftazidime-clavulanic acid (P < 0.001), levofloxacin (P = 0.037), and gentamicin (P = 0.047) compared to non-ESBL E. coli. CTX-M gene was the most prevalent (87.5%), followed by TEM (68.4%) and SHV (3.1%). Previous history of UTI and intake of antibiotics were the common risk factors.

CONCLUSION

ESBL-producing E. coli from community-acquired pediatric UTI carries more than one type of beta-lactamase coding genes correlating their increased antibiotic resistance. Aggressive infection control policy, routine screening for detecting ESBL isolates in clinical samples, and antimicrobial stewardship are the keys to prevent their dissemination in community settings.

Epidemiology of urological infections: a global burden

INTRODUCTION

Urinary tract infections (UTIs) are among the most frequent infections in clinical practice worldwide. Their frequency and burden must be higher than available data suggest because they are not among mandatory diseases to be notified.

CLASSIFICATION OF URINARY INFECTIONS

Although there are many different proposals for classifying UTIs, classifications based on acquisition settings and complication status are more widely used. These include community- acquired UTIs (CAUTIs) or healthcare-associated UTIs (HAUTIs) and uncomplicated or complicated UTIs.

EPIDEMIOLOGY OF UROLOGICAL INFECTIONS AND GLOBAL BURDEN

As the most frequently seen infectious disease, CAUTIs affect more than 150 million people annually. Complicated UTIs in particular constitute a huge burden on healthcare systems as a frequent reason for hospitalization. The prevalence of HAUTIs ranges between 1.4% and 5.1%, and the majority of them are catheter-related UTIs. Community-onset HAUTIs have gained importance in recent years.

CONCLUSION

As frequent infectious diseases, UTIs create clinical and economic burdens on healthcare systems, and they also affect quality of life determinants.

Risk factors for development of urinary tract infection in children with nephrolithiasis

AIM

Nephrolithiasis is one of the causes of urinary tract infection (UTI). In this study, we investigated risk factors for UTI in children with nephrolithiasis.

METHODS

The data from the patients with nephrolithiasis were evaluated in this retrospective follow-up study. Patients with a history of UTI before admission and congenital anomaly of kidney or urinary tract were excluded. The patients were divided into two groups: patients with UTI (recurrent UTI and single UTI) and patients without UTI.

RESULTS

A total of 599 patients were included in this study. UTI occurred in 181 (30.2%) patients. There was a positive association between the size of stone and UTI (odds ratio (OR): 1.355, P = 0.007). Receiver operating characteristic curve analysis showed that the cut-off value of the size of stone for UTI was 5.3 mm, with a sensitivity of 74.9% and a specificity of 66.1% (area under the curve: 0.572 ± 0.028, P = 0.013). The presence of a metabolic risk factor and age at diagnosis under 2 years were significantly associated with both UTI and recurrence of UTI (OR: 2.272, P = 0.021, OR: 1.809, P = 0.028, respectively, for metabolic risk factor; OR: 1.212, P = 0.041, OR: 1.122, P = 0.046, respectively, for age at diagnosis under 2 years). Hypercalciuria was significantly associated with the recurrence of UTI (OR: 1.854, P = 0.017).

CONCLUSIONS

The age at diagnosis, the presence of a metabolic risk factor and size of stone are significant risk factors for UTI in children with nephrolithiasis. The patients with idiopathic hypercalciuria, metabolic risk factor and age at diagnosis under 2 years have increased risk of recurrence of UTI.

Low relapse rate of urinary tract infections from extended-spectrum beta-lactamase-producing bacteria in young children

BACKGROUND

Extended-spectrum-beta-lactamase (ESBL)-producing bacteria are an increasingly important cause of urinary tract infections (UTIs) worldwide. We evaluated clinical characteristics and associated risk factors of UTIs in young children according to ESBL-producing status and relapse rates.

METHODS

All urinary culture results in patients younger than 2 years old were assessed, and only children with febrile UTIs from gram-negative bacterial infections were reviewed.

RESULTS

Of 845 episodes evaluated, 146 (17.3%) were caused by ESBL-positive bacteria. Significant differences were observed in previous UTIs, use of antibiotics or history of hospitalization within previous 3 months, and underlying urinary abnormalities between the ESBL UTI and non-ESBL UTI groups. After 2 weeks of treatment completion, UTI relapse occurred in 2.7% of children in the ESBL group and 1.1% of children in the non-ESBL group (P = 0.13). In the ESBL UTI group, relapse rate was not significantly different between patients treated with susceptible antibiotics and those treated with non-susceptible but clinically effective antibiotics.

CONCLUSIONS

Previous history of UTI, antibiotic treatment, or hospitalization within previous 3 months and underlying disease are risk factors for ESBL UTI in children under 24 months of age. However, relapse rate was < 3% regardless of in vitro susceptibility of the treating antibiotics, as long as the antibiotics were clinically effective. We cautiously propose that we may continue the use of initial empirical antibiotics when a definite clinical response is observed, although further study is necessary to confirm the findings of this study.

Urinary tract infection caused by extended-spectrum β-lactamase-producing bacteria: Risk factors and antibiotic resistance

BACKGROUND

The aim of this study was to investigate the risk factors for acquisition of extended spectrum β-lactamase (ESBL)-producing bacteria in community-acquired urinary tract infection (UTI) and to evaluate their antimicrobial resistance.

METHODS

The medical records of hospitalized children were retrospectively evaluated. Children with ESBL-producing bacteria UTI were matched with controls with non-ESBL-producing bacteria UTI of the same age and gender.

RESULTS

A total of 243 patients with community-acquired UTI in a 5 year period were evaluated, of whom 46% had UTI caused by ESBL bacteria. Seventy-seven cases were matched with 77 controls. There were no significant differences in the clinical presentation between the two groups apart from a longer hospital stay in the ESBL group (9.1 ± 5.5 days vs 8.0 ± 4.4 days, P = 0.013). Significant potential risk factors for ESBL-UTI were previous use of antibiotics in the last 3 months, previous hospitalization in the last 3 months, history of recurrent UTI, and presence of renal anomalies. On logistic regression analysis, history of previous hospitalization in the last 3 months (OR, 3.83; 95%CI: 1.49-9.84) was identified as an independent significant risk factor for ESBL-UTI. There was a significantly higher resistance to amoxicillin-clavulanate, amikacin, gentamycin and quinolones in the ESBL group compared with the control group.

CONCLUSION

Recognizing the risk factors for ESBL-UTI helps to identify the high-risk cases and enables proper management.

Risk factors for community acquired urinary tract infections caused by extended spectrum β-lactamase (ESBL) producing Escherichia coli in children: a case control study

Background: We noted a recent increase in cases of urinary tract infection due to community-acquired ESBL-producing Escherichia coli in children treated at our institution. Risk factors of urinary tract infection due to ESBL-producing E. coli in children in the USA remain unclear. Methods: A single center retrospective case control study of UTI due to CA-ESBL-producing E. coli during a 5-year period (2012-2016). Control cases with non-ESBL-producing E. coli urinary tract infection were matched by age, gender and year of infection. Results: A total of 111 patients with ESBL-producing E coli urinary tract infection and 103 controls were included. The proportion of ESBL-producing E coli urinary tract infection ranged from 7% to 15% of all UTI cases. The distribution of ESBL cases per year: 27 in 2012; 18 in 2013; 22 in 2014; 15 in 2015 and 29 in 2016. Median age was 4 years with female predominance (84%). The ESBL group was predominantly African American (32%) followed by individuals of Middle Eastern ethnic background (31%). Risk factors by univariate analysis were vesicoureteral reflux: (20.9 ESBL group vs 6% controls; p = .002), prior antibiotic usage in the last 3 months (including β-lactams), prior UTI (last 3 months), recent hospitalization (last 3 months) and Middle Eastern ethnic background. However, multivariate analysis showed that only prior antibiotic usage (p = .001) and Middle Eastern ethnic background (p < .001) were independent risk factors. ESBL-producing strains were more frequently resistant to trimethoprim-sulfamethoxazole (72% vs 25%) and ciprofloxacin (73% vs 5%) than strains not producing ESBL. Conclusion: Risk factors for community-acquired ESBL-producing E coli urinary tract in our pediatric patient population were antibiotic usage within the previous 3 months and Middle Eastern ethnic background. This may be related to increased risk of intestinal colonization with resistant bacterial strains.

The use of nitrofurantoin for children with acute cystitis caused by extended-spectrum Β-lactamase-producing Escherichia coli

BACKGROUND

Acute cystitis in children caused by extended-spectrum β-lactamase (ESBL)-producing Escherichia coli (E. coli) is on the rise. Treatment of these is usually parenteral treatment. The aim of this study was to investigate the clinical and microbiological efficacy of oral nitrofurantoin treatment in children with lower urinary tract infection (UTI) caused by ESBL-producing E. coli.

METHODS

Fifty children with lower UTI due to ESBL-producing E. coli were prospectively studied. Demographic data, clinical condition, laboratory values, treatment regimens, and complications of the patients were recorded. Urine samples were obtained by transurethral catheterization or clean catch; urine bags were not used for specimen collection for culture. Patients with lower UTI due to ESBL-producing E. coli and found to be susceptible to nitrofurantoin were given oral nitrofurantoin. Patients were re-evaluated 3-4 days after the end of treatment. Renal scintigraphy was performed 1-3 months after the end of treatment.

RESULTS

A total of 50 pediatric patients (48 females and 2 males) were enrolled into study. The mean age was 7.5 ± 3.96 years (range, 1-17 years). The duration of nitrofurantoin treatment was 10 days. Bacteriological response was observed in 49 of 50 patients (98%). No patient had symptoms after treatment. No significant side-effect was observed in any of the patients. All patients had normal serum creatinine values. Renal scintigraphic study, which was performed in all patients 1-3 months after completion of treatment, demonstrated the non-scarring in 48 of 50 patients (96%).

CONCLUSIONS

UTIs due to ESBL-producing E. coli are a serious problem because of the bacteria's multidrug antibiotic resistance pattern. This study suggests that oral nitrofurantoin treatment could be a good alternative for lower UTI caused by ESBL-producing E. coli in pediatric patients.

Risk factors for gentamicin-resistant E. coli in children with community-acquired urinary tract infection

According to many guidelines, gentamicin is the empirical parenteral treatment for children with community-acquired urinary tract infection (CA-UTI). However, increasing resistance rates are reported. The purpose of this study is to analyze risk factors for presenting with a UTI caused by a community-acquired gentamicin-resistant Escherichia coli in children in our hospital and to describe their clinical outcome. A retrospective case-control local study was performed in a tertiary care hospital from January 2014 to December 2016. Cases and controls were children below 14 years old diagnosed in the Emergency Department with febrile CA-UTI caused by gentamicin-resistant and gentamicin-susceptible febrile E. coli strains, respectively. During the study period, 54 cases were included and compared with 98 controls. Patients with chronic conditions were more likely to present with a UTI due to gentamicin-resistant E. coli (OR 3.27; 95% CI 1.37-7.8, p < 0.05), as well as children receiving antibiotic prophylaxis (OR 3.5; 95% CI 1.2-10.1, p < 0.05). Cases had longer hospital stays than controls (5.8 ± 5 days vs. 4.4 ± 4 days, p = 0.017). Gentamicin-resistant strains associated higher rates of cefuroxime (29% vs. 3%), cefotaxime (27% vs. 0%), and quinolone resistance (40.7% vs. 6%) (p < 0.01) and produced more frequently extended-spectrum beta-lactamases (ESBL) (20% vs. 0%, p < 0.01) and carbapenemases (7.4% vs. 0%; p = 0.015). All gentamicin-resistant strains were amikacin-sensitive. The presence of chronic conditions and antibiotic prophylaxis could be potential risk factors for gentamicin-resistant E. coli CA-UTI in children. Simultaneous resistance to cephalosporins, quinolones, and ESBL/carbapenemase production is frequent in these strains.

Available evidence of antibiotic resistance from extended-spectrum β-lactamase-producing Enterobacteriaceae in paediatric patients in 20 countries: a systematic review and meta-analysis

OBJECTIVE

To make a systematic review of risk factors, outcomes and prevalence of extended-spectrum β-lactamase-associated infection in children and young adults in South-East Asia and the Western Pacific.

METHODS

Up to June 2018 we searched online databases for published studies of infection with extended-spectrum β-lactamase-producing Enterobacteriaceae in individuals aged 0-21 years. We included case-control, cohort, cross-sectional and observational studies reporting patients positive and negative for these organisms. For the meta-analysis we used random-effects modelling of risk factors and outcomes for infection, and meta-regression for analysis of subgroups. We mapped the prevalence of these infections in 20 countries and areas using available surveillance data.

FINDINGS

Of 6665 articles scanned, we included 40 studies from 11 countries and areas in the meta-analysis. The pooled studies included 2411 samples testing positive and 2874 negative. A higher risk of infection with extended-spectrum β-lactamase-producing bacteria was associated with previous hospital care, notably intensive care unit stays (pooled odds ratio, OR: 6.5; 95% confidence interval, CI: 3.04 to 13.73); antibiotic exposure (OR: 4.8; 95% CI: 2.25 to 10.27); and certain co-existing conditions. Empirical antibiotic therapy was protective against infection (OR: 0.29; 95% CI: 0.11 to 0.79). Infected patients had longer hospital stays (26 days; 95% CI: 12.81 to 38.89) and higher risk of death (OR: 3.2; 95% CI: 1.82 to 5.80). The population prevalence of infection was high in these regions and surveillance data for children were scarce.

CONCLUSION

Antibiotic stewardship policies to prevent infection and encourage appropriate treatment are needed in South-East Asia and the Western Pacific.

Third-generation cephalosporin-resistant urinary tract infections in children presenting to the paediatric emergency department

Background

The incidence of antibiotic-resistant urinary tract infections (UTIs) in children is increasing. The purpose of this study was to describe the incidence, clinical characteristics, and risk factors for third-generation cephalosporin-resistant UTIs presenting to the paediatric emergency department (ED).

Methods

This was a retrospective cohort study conducted at British Columbia Children's Hospital. Children aged 0 to 18 years old presenting to the ED between July 1, 2013 and June 30, 2014 and were found to have UTI due to Enterobacteriaceae and Pseudomonas species were included. Patient demographics, clinical features, laboratory findings, and outcomes were compared using standard statistical analyses. Risk factors for resistant UTIs were analyzed using multiple logistic regression analysis.

Results

There were 294 eligible patients. The median age was 27.4 months. A third-generation cephalosporin-resistant organism was identified in 36 patients (12%). Patients with resistant UTI had lower rates of appropriate empiric antibiotic therapy (25% versus 95.3%, P<0.05), higher rates of hospitalization (38.9% versus 21.3%, P<0.05), higher rates of undergoing a voiding cystourethrogram (19.4% versus 5.0%, P<0.05), and higher rates of UTI recurrence within 30 days (13.9% versus 4.7%, P<0.05). In multivariate analysis, recent hospitalization (odds ratio [OR] 4.3, confidence interval [CI] 1.2 to 16) and antibiotic therapy (OR 3.5, CI 1.5 to 8.5) within the previous 30 days were risk factors for resistant UTI.

Conclusions

Third-generation cephalosporin-resistant organisms account for a significant proportion of community-acquired paediatric UTIs. Recent hospitalization and antibiotic use are associated with increased risk of resistant UTI.

Phenotypic and Genotypic Characterization of Extended-Spectrum β-Lactamase-Producing Enterobacteriaceae in Asymptomatic Bacteriuria in Pregnancy

Asymptomatic bacteriuria (ASB) has been consistently observed in pregnancy. However, there is a paucity of data on the prevalence and characteristics of extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae in ASB in pregnant women. Therefore, we sought to investigate ESBL-producing and multidrug-resistant Enterobacteriaceae in antenatal women with ASB. Urine samples were collected from 310 asymptomatic pregnant women attending primary antenatal clinics and screened for significant bacteriuria. Isolates of Enterobacteriaceae were phenotypically tested for their ESBL production. ESBL genes (CTX-M, TEM, and SHV genes) were then amplified by polymerase chain reaction (PCR). Multiplex PCRs were used to perform phylogenetic typing of ESBL-producing Escherichia coli isolates and to examine the commonality of sequence type 131 (ST131)-O25b and ST131-O16. A total of 103 (33.2%) pregnant women were positive for significant bacteriuria (80 Enterobacteriaceae). Of these isolates, 32.5% (n = 26) were ESBL producers and had a higher rate of multidrug resistance than non-ESBL producers. Genotypic characterization of ESBL-producing isolates showed that 84.6% had the bla_CTX-M gene (bla_CTX-M-15 = 77.3%; bla_CTX-M-9 = 18.2%). None of the isolates were of the TEM or SHV type. Half of the ESBL-producing E. coli isolates were of the phylogroup B2, and 4 (20%) isolates were of the ST131-O16 clonal subgroup. This study is the first in Egypt to provide evidence for the high prevalence of ESBL-producing Enterobacteriaceae in pregnant women with ASB. It also represents an important step toward genotypic characterization of this resistant form of bacteria, which may be useful for future antimicrobial studies.

Extended-spectrum Beta-lactamase-producing Community-acquired Urinary Tract Infections in Children: Chart Review of Risk Factors

Background:

Community acquired urinary tract infections (CA-UTI) caused by extended spectrum beta lactamase (ESBL) producing organisms is on the rise throughout the world. There are known risk factors such as age <1 year, children on uroprophylaxis, recurrent UTI, recent antibiotic usage etc which can predict the occurrence of these ESBL producers.

Objectives:

To correlate known risk factors with occurrence of ESBL UTI and antibiotic susceptibility of uropathogens isolated.

Materials and Methods:

Clinical and microbiological data were collected from 100 children 1month to 12 years with CA-UTI. The risk factors were compared in the ESBL and non-ESBL group and analysed.

Results and Conclusion:

The antimicrobial sensitivity pattern in our study showed increased resistance to cephalosporins, cotrimoxazole, fluoroquinolones and amoxicillin-clavulanic acid which are frequently used in the treatment of UTI, with most isolates being sensitive to aminoglycosides, piperacillin-tazobactam and carbapenems. Statistical analysis did not identify any significant risk factor that predisposes to ESBL UTI.

Antimicrobial Pharmacotherapy Management of Urinary Tract Infections in Pediatric Patients

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

A comparison of blood stream infections with extended spectrum beta-lactamase-producing and non-producing Klebsiella pneumoniae in pediatric patients

Background

Rapid development and global spread of multidrug resistant Klebsiella pneumonia (K. pneumoniae) as a major cause of nosocomial infections is really remarkable. The aim of this study was to explore risk factors for health care associated blood stream infections (BSI) caused by ESBL-producing K. pneumoniae in children and analyze clinical outcomes.

Methods

A retrospective review of patients younger than 18 years-old with blood stream infection caused by K. pneumoniae was performed. Patients with ESBL-producing K. pneumoniae isolates were compared with ESBL-non-producing isolates in terms of risk factors, outcome and mortality.

Results

Among 111 K. pneumoniae isolates 62% (n = 69) were ESBL –producing K. pneumoniae. The median total length of hospitalization and median length of stay in hospital before infection was significantly higher in patients with ESBL-producing isolates than ESBL-non-producing. Use of combined antimicrobial treatment was significantly different between ESBL-producing and ESBL-non-producing groups, 75.4% and 24.6%, respectively (p = 0.001). Previous aminoglycoside use was higher in cases with ESBL –producing isolates (p = 0.001). Logistic regression analysis showed a significant correlation between mortality and use of combined antibiotics (OR 4.22; p = 0.01).

Conclusion

ESBL production in K. pneumoniae isolates has a significant impact on clinical course of BSIs. Total length of hospitalization, length of hospital stay before infection, prior combined antibiotic use and use of aminoglycosides were significant risk factors for development of ESBL-producing K. pneumoniae related BSI.

Extended-spectrum β-lactamase-producing Escherichia coli bacteremia: Comparison of pediatric and adult populations

BACKGROUND/PURPOSE

The prevalence of extended-spectrum β-lactamase (ESBL)-producing Escherichia coli is increasing worldwide. This study investigated the clinical features and bacteriology of pediatric patients with ESBL-producing E. coli bacteremia and compared their characteristics with those of adult patients.

METHODS

Clinical and laboratory data from all of the 41 patients aged ≤18 years diagnosed with E. coli bacteremia were collected over 5 years. Patients aged >18 years diagnosed with E. coli bacteremia, matched 1:1 for calendar time, were enrolled as the adult group. All E. coli isolates were tested for their blaCTX-M group and sequence type 131 (ST131). A novel seven-single nucleotide polymorphism-based clonotyping test was applied to detect the septatypes of each isolate.

RESULTS

In the adult group, patients with ESBL-producing E. coli bacteremia had more previous hospitalizations and antimicrobial agent use than did those with non-ESBL-producing E. coli bacteremia, but these differences were not found in pediatric group. In the pediatric group, the proportion of isolates producing CTX-M group 9 was higher than that in the adult group (85.7% vs. 42.9%; p < 0.05). Among both groups, there were more E. coli ST131 in ESBL isolates in than there were non-ESBL isolates. The distribution of septatypes was more homogenous in ESBL-producing E. coli among the pediatric patients than among the adult patients.

CONCLUSION

ST131 was the major clone causing E. coli bacteremia in both pediatric and adult populations. The pediatric population demonstrated a higher number of isolates producing CTX-M group 9 with more homogenous septatypes compared with the adult population.

Uropathogenic Escherichia coli ST131 in urinary tract infections in children

PURPOSE

Escherichia coli sequence type (ST) 131, a multidrug-resistant clone causing extraintestinal infections, has rapidly become prevalent worldwide. However, the epidemiological and clinical features of pediatric infections are poorly understood. We aimed to explore the characteristics of ST131 Escherichia coli isolated from Korean children with urinary tract infections.

METHODS

We examined 114 uropathogenic E. coli (UPEC) isolates from children hospitalized at Chung-Ang University Hospital between 2011 and 2014. Bacterial strains were classified into STs by partial sequencing of seven housekeeping genes (adk, fumC, gyrB, icd, mdh, purA, and recA). Clinical characteristics and antimicrobial susceptibility were compared between ST131 and non-ST131 UPEC isolates.

RESULTS

Sixteen UPEC isolates (14.0%) were extended-spectrum β-lactamase (ESBL)-producers; 50.0% of ESBL-producers were ST131 isolates. Of all the isolates tested, 13.2% (15 of 114) were classified as ST131. There were no statistically significant associations between ST131 and age, sex, or clinical characteristics, including fever, white blood cell counts in urine and serum, C-reactive protein, radiologic abnormalities, and clinical outcome. However, ST131 isolates showed significantly lower rates of susceptibility to cefazolin (26.7%), cefotaxime (40.0%), cefepime (40.0%), and ciprofloxacin (53.3%) than non-ST131 isolates (65.7%, 91.9%, 92.9%, and 87.9%, respectively; P<0.001 for all). ESBL was more frequently produced in ST131 (53.3%) than in non-ST131 (8.1%) isolates (P<0.01).

CONCLUSION

ST131 E. coli isolates were prevalent uropathogens in children at a single medical center in Korea between 2011 and 2014. Although ST131 isolates showed higher rates of antimicrobial resistance, clinical presentation and outcomes of patients were similar to those of patients infected with non-ST131 isolates.

Urinary tract infection caused by community-acquired extended-spectrum β-lactamase-producing bacteria in infants

OBJECTIVE

Urinary tract infection (UTI) caused by resistant strains of bacteria is increasingly prevalent in children. The aim of this study was to investigate the clinical characteristics and risk factors for UTI caused by community-acquired extended-spectrum β-lactamase (CA-ESBL)-producing bacteria in infants.

METHODS

This was a retrospective study performed over 5 years in a single Korean center. Hospitalized infants with febrile UTI were enrolled and divided into two groups (CA-ESBL vs. CA non-ESBL UTI). The yearly prevalence was calculated. Baseline characteristics and clinical course such as fever duration, laboratory and radiological findings were compared between the two groups. Risk factors associated with the CA-ESBL UTI were investigated.

RESULTS

Among the enrolled infants (n=185), 31 (17%) had CA-ESBL UTI. The yearly prevalence of ESBL of CA-ESBL UTI increased during the study (0% in 2010, 22.2% in 2015). Infants with CA-ESBL UTI had a longer duration of fever after initiating antibiotics (2.0±1.1 vs. 1.5±0.6 days, p=0.020). Cortical defects on renal scan and early treatment failure were more frequent in CA-ESBL (64.5 vs. 42.2%, p=0.023; 22.6 vs. 4.5%, p=0.001). A logistic regression analysis revealed that urinary tract abnormalities and previous UTI were independent risk factors for CA-EBSL UTI (odds ratio, 2.7; p=0.025; 10.3; p=0.022).

CONCLUSION

The incidence of UTI caused by ESBL-producing bacteria has increased in Korean infants. Recognition of the clinical course and risk factors for ESLB-producing UTI may help to determine appropriate guidelines for its management.