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Markham JL, Burns A, Hall M, Molloy MJ, Stephens JR, McCoy E, Ugalde IT, Steiner MJ, Cotter JM, House SA, Collins ME, Yu AG, Tchou MJ, Shah SS. Outcomes associated with initial narrow-spectrum versus broad-spectrum antibiotics in children hospitalized with urinary tract infections. J Hosp Med 2024. [PMID: 38734985 DOI: 10.1002/jhm.13390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 04/16/2024] [Accepted: 04/23/2024] [Indexed: 05/13/2024]
Abstract
OBJECTIVE The aim of this study is to describe the proportion of children hospitalized with urinary tract infections (UTIs) who receive initial narrow- versus broad-spectrum antibiotics across children's hospitals and explore whether the use of initial narrow-spectrum antibiotics is associated with different outcomes. DESIGN, SETTING AND PARTICIPANTS We performed a retrospective cohort analysis of children aged 2 months to 17 years hospitalized with UTI (inclusive of pyelonephritis) using the Pediatric Health Information System (PHIS) database. MAIN OUTCOME AND MEASURES We analyzed the proportions of children initially receiving narrow- versus broad-spectrum antibiotics; additionally, we compiled antibiogram data for common uropathogenic organisms from participating hospitals to compare with the observed antibiotic susceptibility patterns. We examined the association of antibiotic type with adjusted outcomes including length of stay (LOS), costs, and 7- and 30-day emergency department (ED) revisits and hospital readmissions. RESULTS We identified 10,740 hospitalizations for UTI across 39 hospitals. Approximately 5% of encounters demonstrated initial narrow-spectrum antibiotics, with hospital-level narrow-spectrum use ranging from <1% to 25%. Approximately 80% of hospital antibiograms demonstrated >80% Escherichia coli susceptibility to cefazolin. In adjusted models, those who received initial narrow-spectrum antibiotics had shorter LOS (narrow-spectrum: 33.1 (95% confidence interval [CI]: 30.8-35.4) h versus broad-spectrum: 46.1 (95% CI: 44.1-48.2) h) and reduced costs [narrow-spectrum: $4570 ($3751-5568) versus broad-spectrum: $5699 ($5005-$6491)]. There were no differences in ED revisits or hospital readmissions. In summary, children's hospitals have low rates of narrow-spectrum antibiotic use for UTIs despite many reporting high rates of cefazolin-susceptible E. coli. These findings, coupled with the observed decreased LOS and costs among those receiving narrow-spectrum antibiotics, highlight potential antibiotic stewardship opportunities.
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Affiliation(s)
- Jessica L Markham
- Department of Pediatrics, Children's Mercy Kansas City, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
- Department of Pediatrics, University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Alaina Burns
- Department of Pharmacy, Children's Mercy Kansas City, University of Missouri-Kansas City School of Pharmacy, Kansas City, Missouri, USA
| | - Matthew Hall
- Department of Pediatrics, Children's Mercy Kansas City, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
- Children's Hospital Association, Lenexa, Kansas, USA
| | - Matthew J Molloy
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - John R Stephens
- Departments of Medicine and Pediatrics, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Elisha McCoy
- Department of Pediatrics, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Irma T Ugalde
- Department of Emergency Medicine, McGovern Medical School, Houston, Texas, USA
| | - Michael J Steiner
- Departments of Medicine and Pediatrics, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Jillian M Cotter
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Samantha A House
- Department of Pediatrics, Dartmouth Health Children's, Lebanon, New Hampshire, USA
| | - Megan E Collins
- Department of Pediatrics, Children's Mercy Kansas City, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
| | - Andrew G Yu
- Department of Pediatrics, University of Texas Southwestern Medical Center and Children's Health, Dallas, Texas, USA
| | - Michael J Tchou
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Samir S Shah
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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He XT, Chang CN, Yu CH, Wang CC. The risk factors, antimicrobial resistance patterns, and outcomes associated with extended-spectrum β-lactamases-Producing pathogens in pediatric urinary tract infection. Pediatr Neonatol 2024; 65:242-248. [PMID: 37951832 DOI: 10.1016/j.pedneo.2023.04.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 03/14/2023] [Accepted: 04/20/2023] [Indexed: 11/14/2023] Open
Abstract
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.
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Affiliation(s)
- Xin-Tian He
- Department of General Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chia-Ning Chang
- Department of Pediatrics, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chia-Hsiang Yu
- Department of Pediatrics, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chih-Chien Wang
- Department of Pediatrics, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan.
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Alsubaie MA, Alsuheili AZ, Aljehani MN, Alothman AA, Alzahrani AS, Mohammedfadel HA, Alnajjar AA. Pediatric community acquired urinary tract infections due to extended-spectrum beta-lactamase versus non-extended-spectrum beta-lactamase producing bacteria. Pediatr Int 2023; 65:e15620. [PMID: 37735838 DOI: 10.1111/ped.15620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 06/29/2023] [Accepted: 07/09/2023] [Indexed: 09/23/2023]
Abstract
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.
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Affiliation(s)
| | | | | | | | | | | | - Abeer A Alnajjar
- Infectious Diseases Unit, Department of Pediatrics, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
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Hassor S, Etinger V, Villacis DS, Houssay M, Bukhari A, Gruber J, Iskowitz S, Marin BF, Chinga ML, Sedor A, Rockwell M, Berrios L, Calderon R, Laufer PM, Gupta A, Salyakina D, Clemente M. A Case-Control Study Evaluating Risk Factors and Outcomes of Hospitalized Children With ESBL-UTI. Clin Pediatr (Phila) 2022; 61:759-767. [PMID: 35883255 DOI: 10.1177/00099228221100064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Mohammed D, Isa HM, Ali MF. Microbial Etiology and Antibiotic Resistance Patterns of Urinary Tract Pathogens in Hospitalized Infants in Bahrain: A Tertiary Care Center Experience. Cureus 2022; 14:e29236. [PMID: 36277545 PMCID: PMC9578659 DOI: 10.7759/cureus.29236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/16/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction: Urinary tract infections (UTIs) are fairly common in infants. Early diagnosis and prompt treatment are crucial to avoid complications. However, providing appropriate antibiotic treatment is a challenge to any clinician considering the rise in the urinary pathogens that are resistant to the commonly used antibiotics especially with the emergence of extended-spectrum beta-lactamase (ESBL)-producing organisms. Consequently, this leaves the physician with limited options of antibiotic choices. This study aims to investigate the local resistance patterns of uropathogens causing UTIs in hospitalized infants in Bahrain and to provide guidance for the preferred choice of empirical antibiotic treatment. Methods: A retrospective cross-sectional study with an analysis of the medical records of infants from birth to one year of age admitted with UTIs at Salmaniya Medical Complex between June 2015 and June 2017 was conducted. Results: Data were obtained from 117 term infants (no preterm infants were included), with 80 (68.4%) being male. A total of 106 (90.6%) patients were less than six months of age. The most frequently isolated organisms were Escherichia coli found in 66 (49.6%) patients, followed by Klebsiella in 43 (32.3%). Forty-eight (36%) were ESBL-producing organisms (31 and 17 of E. coli and Klebsiella, respectively). The highest antibiotic resistance of E. coli was found against cephalosporin (55.5%), while penicillin resistance was only 19.4% and co-trimoxazole was 14.4%. Resistance rates of non-E. coli organisms were highest against cephalosporin (44.6%), followed by nitrofurantoin (19.1%) and penicillin (18.5%). The overall resistance to cephalosporin antibiotics was highest against cephalothin (a first-generation cephalosporin) (54.9%). The second highest resistance rate was demonstrated against cefuroxime (a second-generation cephalosporin) (50.5%), followed by ceftriaxone (a third-generation cephalosporin) (45.1%). Lower resistance rates were found against cefotaxime (22.3%), followed by ceftazidime (33.3%). A resistance rate of zero was found against cefepime (a fourth-generation cephalosporin). Aminoglycosides and nitrofurantoin demonstrated the lowest resistance rates among all cultured uropathogens. Among all cultures, 3.9% of the E. coli were resistant to aminoglycosides, while non-E. coli organisms showed zero resistance to aminoglycosides. Regarding the nitrofurantoin antibiotic, 19% of non-E. coli bacteria showed resistance, while only 1.7% of E. coli were resistant to this antibiotic. Zero resistance to carbapenem was found in E. coli organisms (both ESBL and non-ESBL), compared to 1.9% resistance by non-E. coli organisms (both ESBL and non-ESBL combined). Conclusion: E. coli is the predominant uropathogen causing UTI in infants with high rates of ESBL organisms in our community. Since the highest resistance was found against cephalosporins, aminoglycosides and nitrofurantoin are the preferred empirical antibiotic options for the treatment of UTIs. For infants with ESBL organisms, carbapenem antibiotics represent a good treatment option.
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Tamas V, Shah S, Hollenbach KA, Kanegaye JT. Emergence of Extended-Spectrum β-Lactamase-Producing Pathogens in Community-Acquired Urinary Tract Infections Among Infants at a Pediatric Emergency Department. Pediatr Emerg Care 2022; 38:e1053-e1057. [PMID: 35226630 DOI: 10.1097/pec.0000000000002653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Vanessa Tamas
- From the Department of Pediatrics, University of California San Diego School of Medicine, La Jolla; and Rady Children's Hospital San Diego, San Diego, CA
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Nakanishi K, Okutani T, Kotani S, Kamoi Y, Kim S, Yamane M. Risk factors for cefazolin-resistant febrile urinary tract infection in children. Pediatr Int 2022; 64:e15046. [PMID: 34738685 DOI: 10.1111/ped.15046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 10/13/2021] [Accepted: 11/01/2021] [Indexed: 12/01/2022]
Abstract
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).
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Affiliation(s)
- Keita Nakanishi
- Department of Pediatrics, Saiseikai Hyogoken Hospital, Kobe, Japan
| | - Takahiro Okutani
- Department of Pediatrics, Saiseikai Hyogoken Hospital, Kobe, Japan
| | - Shinpei Kotani
- Department of Pediatrics, Saiseikai Hyogoken Hospital, Kobe, Japan
| | - Yoshiaki Kamoi
- Department of Pediatrics, Saiseikai Hyogoken Hospital, Kobe, Japan
| | - Sooyun Kim
- Department of Pediatrics, Saiseikai Hyogoken Hospital, Kobe, Japan
| | - Masayuki Yamane
- Department of Pediatrics, Saiseikai Hyogoken Hospital, Kobe, Japan
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Montagnani C, Tersigni C, D'Arienzo S, Miftode A, Venturini E, Bortone B, Bianchi L, Chiappini E, Forni S, Gemmi F, Galli L. Resistance Patterns from Urine Cultures in Children Aged 0 to 6 Years: Implications for Empirical Antibiotic Choice. Infect Drug Resist 2021; 14:2341-2348. [PMID: 34188500 PMCID: PMC8236245 DOI: 10.2147/idr.s293279] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 03/03/2021] [Indexed: 11/30/2022] Open
Abstract
Purpose Urinary tract infection (UTI) is a frequent disorder of childhood, caused mainly by Gram negative Enterobacterales. The aim of this study is to evaluate etiology and antimicrobial susceptibility patterns of bacterial isolates in urine cultures of children under the age of 6 and to analyze the relationship between previous hospitalization or antibiotic prescriptions and antimicrobial resistance rates. Patients and Methods A retrospective study on positive urine cultures from 13 public laboratories in Tuscany, Italy was conducted. Data were obtained by reviewing records of the “Microbiological and Antibiotic-Resistance Surveillance System” (SMART) in Tuscany, Italy. A total of 2944 positive urine cultures were collected from 2445 children. Results Escherichia coli represented the majority of isolates (54,2%), followed by Enterococcus faecalis (12,3%), Proteus mirabilis (10,3%) and Klebsiella pneumoniae (6,6%). Isolated uropathogens showed high resistance rates to amoxicillin-clavulanate (>25%), particularly in children under one year of age or hospitalized within the 12 months before the sample collection. High susceptibility rates were reported of aminoglycosides, cephalosporins and quinolones (>90%). Previous antibiotic prescriptions by general pediatricians did not increase resistance rates. Conclusion Our results show a rate of amoxicillin-clavulanate resistance of 25%. Higher resistance rates were reported in children under one year of age and with previous hospitalization. Hence, amoxicillin-clavulanate should be used carefully in young children and those with severe symptoms.
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Affiliation(s)
- Carlotta Montagnani
- Infectious Disease Unit, Meyer Children's University Hospital, Florence, Italy
| | - Chiara Tersigni
- Postgraduate School of Paediatrics, University of Florence, Florence, Italy
| | | | | | | | - Barbara Bortone
- Infectious Disease Unit, Meyer Children's University Hospital, Florence, Italy
| | - Leila Bianchi
- Infectious Disease Unit, Meyer Children's University Hospital, Florence, Italy
| | - Elena Chiappini
- Infectious Disease Unit, Meyer Children's University Hospital, Florence, Italy.,Department of Health Sciences, University of Florence, Florence, Italy
| | - Silvia Forni
- Regional Health Agency of Tuscany, Florence, Italy
| | | | - Luisa Galli
- Infectious Disease Unit, Meyer Children's University Hospital, Florence, Italy.,Department of Health Sciences, University of Florence, Florence, Italy
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Wang ME, Greenhow TL, Lee V, Beck J, Bendel-Stenzel M, Hames N, McDaniel CE, King EE, Sherry W, Parmar D, Patrizi ST, Srinivas N, Schroeder AR. Management and Outcomes in Children with Third-Generation Cephalosporin-Resistant Urinary Tract Infections. J Pediatric Infect Dis Soc 2021; 10:650-658. [PMID: 33595081 DOI: 10.1093/jpids/piab003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Accepted: 01/06/2021] [Indexed: 11/14/2022]
Abstract
BACKGROUND Third-generation cephalosporin-resistant urinary tract infections (UTIs) often have limited oral antibiotic options with some children receiving prolonged parenteral courses. Our objectives were to determine predictors of long parenteral therapy and the association between parenteral therapy duration and UTI relapse in children with third-generation cephalosporin-resistant UTIs. METHODS We conducted a multisite retrospective cohort study of children <18 years presenting to acute care at 5 children's hospitals and a large managed care organization from 2012 to 2017 with a third-generation cephalosporin-resistant UTI from Escherichia coli or Klebsiella spp. Long parenteral therapy was ≥3 days and short/no parenteral therapy was 0-2 days of concordant parenteral antibiotics. Discordant therapy was antibiotics to which the pathogen was non-susceptible. Relapse was a UTI from the same organism within 30 days. RESULTS Of the 482 children included, 81% were female and the median age was 3.3 years (interquartile range: 0.8-8). Fifty-four children (11.2%) received long parenteral therapy (median duration: 7 days). Predictors of long parenteral therapy included age <2 months (adjusted odds ratio [aOR] 67.3; 95% confidence interval [CI]: 16.4-275.7), limited oral antibiotic options (aOR 5.9; 95% CI: 2.8-12.3), and genitourinary abnormalities (aOR 5.4; 95% CI: 1.8-15.9). UTI relapse occurred in 1 of the 54 (1.9%) children treated with long parenteral therapy and in 6 of the 428 (1.5%) children treated with short/no parenteral therapy (P = .57). Of the 105 children treated exclusively with discordant antibiotics, 3 (2.9%, 95% CI: 0.6%-8.1%) experienced UTI relapse. CONCLUSIONS Long parenteral therapy was associated with age <2 months, limited oral antibiotic options, and genitourinary abnormalities. UTI relapse was rare and not associated with duration of parenteral therapy. For UTIs with limited oral options, further research is needed on the effectiveness of continued discordant therapy.
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Affiliation(s)
- Marie E Wang
- Division of Pediatric Hospital Medicine, Stanford University School of Medicine and Lucile Packard Children's Hospital Stanford, Stanford, California, USA
| | - Tara L Greenhow
- Division of Infectious Diseases, Kaiser Northern California, San Francisco, California, USA
| | - Vivian Lee
- Division of Hospital Medicine, Children's Hospital Los Angeles and Department of Pediatrics, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Jimmy Beck
- Department of Pediatrics, University of Washington School of Medicine and Seattle Children's Hospital, Seattle, Washington, USA
| | | | - Nicole Hames
- Division of Pediatric Hospital Medicine, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Corrie E McDaniel
- Department of Pediatrics, University of Washington School of Medicine and Seattle Children's Hospital, Seattle, Washington, USA
| | - Erin E King
- Division of Hospital Medicine, Children's Minnesota, Minneapolis, Minnesota, USA
| | - Whitney Sherry
- Division of Pediatric Hospital Medicine, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Deepika Parmar
- Department of Pediatrics, Kaiser Northern California, Oakland, California, USA
| | - Sara T Patrizi
- Department of Pediatrics, Kaiser Northern California, Oakland, California, USA
| | - Nivedita Srinivas
- Division of Pediatric Hospital Medicine, Stanford University School of Medicine and Lucile Packard Children's Hospital Stanford, Stanford, California, USA.,Division of Pediatric Infectious Diseases, Stanford University School of Medicine, Stanford, California, USA
| | - Alan R Schroeder
- Division of Pediatric Hospital Medicine, Stanford University School of Medicine and Lucile Packard Children's Hospital Stanford, Stanford, California, USA.,Division of Pediatric Critical Care Medicine, Stanford University School of Medicine, Stanford, California, USA
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't Hoen LA, Bogaert G, Radmayr C, Dogan HS, Nijman RJM, Quaedackers J, Rawashdeh YF, Silay MS, Tekgul S, Bhatt NR, Stein R. Update of the EAU/ESPU guidelines on urinary tract infections in children. J Pediatr Urol 2021; 17:200-207. [PMID: 33589366 DOI: 10.1016/j.jpurol.2021.01.037] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 01/22/2021] [Accepted: 01/25/2021] [Indexed: 12/27/2022]
Abstract
INTRODUCTION/BACKGROUND Urinary tract infections (UTIs) are common in children and require appropriate diagnostic evaluation, management and follow-up. OBJECTIVE To provide a summary of the updated European Association of Urology (EAU) guidelines on Pediatric Urology, which were first published in 2015 in European Urology. STUDY DESIGN A structured literature review was performed of new publications between 2015 and 2020 for UTIs in children. The guideline was updated accordingly with relevant new literature. RESULTS The occurrence of a UTI can be the first indication of anatomical abnormalities in the urinary tract, especially in patients with a febrile UTI. The basic diagnostic evaluation should include sufficient investigations to exclude urinary tract abnormalities, but should also be as minimally invasive as possible. In recent years, more risk factors have been identified to predict the presence of these anatomical anomalies, such as a non-E. Coli infection, high grade fever and ultrasound abnormalities. When these risk factors are factored into the diagnostic work-up, some invasive investigations can be omitted in a larger group of children. In addition to the treatment of active UTIs, it is also essential to prevent recurrent UTIs and consequent renal scarring. With the increase of antimicrobial resistance good antibiotic stewardship is needed. In addition, alternative preventative measures such as dietary supplements, bladder and bowel management and antibiotic prophylaxis could decrease the incidence of recurrent UTI. CONCLUSION This paper is a summary of the updated 2021 EAU guidelines on Pediatric Urology. It provides practical considerations and flowcharts for the management and diagnostic evaluation of UTIs in children.
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Affiliation(s)
- Lisette A 't Hoen
- Department of Pediatric Urology, Erasmus Medical Center, Rotterdam, the Netherlands.
| | - Guy Bogaert
- Department of Urology, University of Leuven, Leuven, Belgium
| | - Christian Radmayr
- Department of Urology, Medical University of Innsbruck, Innsbruck, Austria
| | - Hasan S Dogan
- Division of Pediatric Urology, Hacettepe University, Ankara, Turkey
| | - Rien J M Nijman
- Department of Urology and Pediatric Urology, University Medical Center Groningen, Rijks University Groningen, Groningen, the Netherlands
| | - Josine Quaedackers
- Department of Urology and Pediatric Urology, University Medical Center Groningen, Rijks University Groningen, Groningen, the Netherlands
| | | | - Mesrur S Silay
- Division of Pediatric Urology, Department of Urology, Istanbul Biruni University, Istanbul, Turkey
| | - Serdar Tekgul
- Division of Pediatric Urology, Hacettepe University, Ankara, Turkey
| | - Nikita R Bhatt
- Department of Urology, East of England Deanery, Urology, Cambridge, United Kingdom
| | - Raimund Stein
- Center for Pediatric, Adolescent and Reconstructive Urology, Medical Faculty Mannheim, University of Medical Center Mannheim, Heidelberg University, Mannheim, Germany
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11
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Ziegler J, Chapman H, Rueth M, Hays A, Schriever C, Tsaras G. Potential Perinatally Acquired Extended Spectrum β-Lactamase Escherichia coli Urinary Tract Infection in an Infant. J Pediatr Pharmacol Ther 2020; 25:266-269. [DOI: 10.5863/1551-6776-25.3.266] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Extended-spectrum β-lactamases (ESBL) are produced mainly by members of the Enterobacteriaceae family and confer resistance to most β-lactam antibiotics. Because of limited treatment options, ESBL infections are typically more challenging to treat resulting in poor outcomes, increased complications, and mortality. Because ESBL-producing organisms are primarily seen in critically ill patients, along with those patients having prolonged hospital stays, extensive courses of antimicrobials, and/or use of invasive medical devices (i.e., urinary catheters, central venous lines, or endotracheal tubes), guidelines regarding the management of ESBL-producing organisms in the pediatric population are scant. A review of current recommended treatment options for infections caused by ESBL-producing organisms centers on the use of carbapenems, with some supportive literature regarding the utility/effectiveness of other non-β-lactam therapy. We present a case report of an 8-month-old female diagnosed with a urinary tract infection due to ESBL-producing Escherichia coli successfully treated with sulfamethoxazole/trimethoprim. Multidrug resistant infections in pediatric patients without risk factors remains an important field of study because these unique infections may pose a problem when choosing an effective empiric antimicrobial therapy.
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13
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Wang ME, Lee V, Greenhow TL, Beck J, Bendel-Stenzel M, Hames N, McDaniel CE, King EE, Sherry W, Parmar D, Patrizi ST, Srinivas N, Schroeder AR. Clinical Response to Discordant Therapy in Third-Generation Cephalosporin-Resistant UTIs. Pediatrics 2020; 145:peds.2019-1608. [PMID: 31953316 DOI: 10.1542/peds.2019-1608] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/19/2019] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To describe the initial clinical response and care escalation needs for children with urinary tract infections (UTIs) resistant to third-generation cephalosporins while on discordant antibiotics. METHODS We performed a retrospective study of children <18 years old presenting to an acute care setting of 5 children's hospitals and a large managed care organization from 2012 to 2017 with third-generation cephalosporin-resistant UTIs (defined as the growth of ≥50 000 colony-forming units per mL of Escherichia coli or Klebsiella spp. nonsusceptible to ceftriaxone with a positive urinalysis). We included children started on discordant antibiotics who had follow-up when culture susceptibilities resulted. Outcomes were escalation of care (emergency department visit, hospital admission, or ICU transfer while on discordant therapy) and clinical response at follow-up (classified as improved or not improved). RESULTS Of the 316 children included, 78% were girls and the median age was 2.4 years (interquartile range 0.6-6.5). Children were evaluated in the emergency department (56%) or clinic (43%), and 90% were started on a cephalosporin. A total of 7 of 316 children (2.2%; 95% confidence interval 0.8%-4.5%) experienced escalation of care. For the 230 children (73%) with clinical response recorded, 192 of 230 (83.5%; 95% confidence interval 78.0%-88.0%) experienced clinical improvement. In children with repeat urine testing while on discordant therapy, pyuria improved or resolved in 16 of 19 (84%) and urine cultures sterilized in 11 of 17 (65%). CONCLUSIONS Most children with third-generation cephalosporin-resistant UTIs started on discordant antibiotics experienced initial clinical improvement, and few required escalation of care. Our findings suggest that narrow-spectrum empiric therapy is appropriate while awaiting final urine culture results.
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Affiliation(s)
| | - Vivian Lee
- Division of Hospital Medicine, Children's Hospital Los Angeles and Keck School of Medicine of University of Southern California, Los Angeles, California
| | | | - Jimmy Beck
- Department of Pediatrics, School of Medicine, University of Washington and Seattle Children's Hospital, Seattle, Washington
| | | | - Nicole Hames
- Division of Pediatric Hospital Medicine, School of Medicine, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia; and
| | - Corrie E McDaniel
- Department of Pediatrics, School of Medicine, University of Washington and Seattle Children's Hospital, Seattle, Washington
| | - Erin E King
- Children's Minnesota, Minneapolis, Minnesota
| | - Whitney Sherry
- Division of Pediatric Hospital Medicine, School of Medicine, Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia; and
| | - Deepika Parmar
- Department of Pediatrics, Kaiser Permanente Northern California, San Francisco, California
| | - Sara T Patrizi
- Department of Pediatrics, Kaiser Permanente Northern California, San Francisco, California
| | - Nivedita Srinivas
- Divisions of Pediatric Hospital Medicine.,Pediatric Infectious Diseases, and
| | - Alan R Schroeder
- Divisions of Pediatric Hospital Medicine.,Pediatric Critical Care Medicine, School of Medicine, Stanford University and Lucile Packard Children's Hospital at Stanford, Stanford, California
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14
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Hyun HS, Kim JH, Cho MH, Park E, Ha IS, Cheong HI, Kang HG. Low relapse rate of urinary tract infections from extended-spectrum beta-lactamase-producing bacteria in young children. Pediatr Nephrol 2019; 34:2399-2407. [PMID: 31270617 DOI: 10.1007/s00467-019-04298-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 05/30/2019] [Accepted: 06/20/2019] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Hye Sun Hyun
- Department of Pediatrics, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.,Department of Pediatrics, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ji Hye Kim
- Department of Pediatrics, Seoul National University Children's Hospital, 101 Daehak-ro, Jongno-gu, Seoul, Republic of Korea
| | - Myung Hyun Cho
- Department of Pediatrics, Seoul National University Children's Hospital, 101 Daehak-ro, Jongno-gu, Seoul, Republic of Korea
| | - Eujin Park
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Republic of Korea.,Department of Pediatrics, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Republic of Korea
| | - Il-Soo Ha
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Republic of Korea.,Department of Pediatrics, Seoul National University Children's Hospital, 101 Daehak-ro, Jongno-gu, Seoul, Republic of Korea
| | - Hae Il Cheong
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Republic of Korea.,Department of Pediatrics, Seoul National University Children's Hospital, 101 Daehak-ro, Jongno-gu, Seoul, Republic of Korea
| | - Hee Gyung Kang
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Republic of Korea. .,Department of Pediatrics, Seoul National University Children's Hospital, 101 Daehak-ro, Jongno-gu, Seoul, Republic of Korea.
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15
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Albaramki JH, Abdelghani T, Dalaeen A, Khdair Ahmad F, Alassaf A, Odeh R, Akl K. Urinary tract infection caused by extended-spectrum β-lactamase-producing bacteria: Risk factors and antibiotic resistance. Pediatr Int 2019; 61:1127-1132. [PMID: 31206219 DOI: 10.1111/ped.13911] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Revised: 05/20/2019] [Accepted: 06/11/2019] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Jumana H Albaramki
- Department of Pediatrics, School of Medicine, University of Jordan, Amman, Jordan.,Department of Pediatrics, Jordan University Hospital, University of Jordan, Amman, Jordan
| | - Tariq Abdelghani
- Department of Pediatrics, School of Medicine, University of Jordan, Amman, Jordan.,Department of Pediatrics, Jordan University Hospital, University of Jordan, Amman, Jordan
| | - Alaa Dalaeen
- Department of Pediatrics, School of Medicine, University of Jordan, Amman, Jordan.,Department of Pediatrics, Jordan University Hospital, University of Jordan, Amman, Jordan
| | - Fareed Khdair Ahmad
- Department of Pediatrics, School of Medicine, University of Jordan, Amman, Jordan.,Department of Pediatrics, Jordan University Hospital, University of Jordan, Amman, Jordan
| | - Abeer Alassaf
- Department of Pediatrics, School of Medicine, University of Jordan, Amman, Jordan.,Department of Pediatrics, Jordan University Hospital, University of Jordan, Amman, Jordan
| | - Rasha Odeh
- Department of Pediatrics, School of Medicine, University of Jordan, Amman, Jordan.,Department of Pediatrics, Jordan University Hospital, University of Jordan, Amman, Jordan
| | - Kamal Akl
- Department of Pediatrics, School of Medicine, University of Jordan, Amman, Jordan.,Department of Pediatrics, Jordan University Hospital, University of Jordan, Amman, Jordan
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16
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Zhu FH, Rodado MP, Asmar BI, Salimnia H, Thomas R, Abdel-Haq N. Risk factors for community acquired urinary tract infections caused by extended spectrum β-lactamase (ESBL) producing Escherichia coli in children: a case control study. Infect Dis (Lond) 2019; 51:802-809. [PMID: 31429616 DOI: 10.1080/23744235.2019.1654127] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
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.
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Affiliation(s)
- Frank H Zhu
- Division of Infectious Diseases, Children's Hospital of Michigan , Detroit , MI , USA
| | - Maria P Rodado
- Division of Infectious Diseases, Children's Hospital of Michigan , Detroit , MI , USA
| | - Basim I Asmar
- Division of Infectious Diseases, Children's Hospital of Michigan , Detroit , MI , USA.,Carman and Ann Adams Department of Pediatrics, Wayne State University , Detroit , MI , USA
| | - Hossein Salimnia
- Department of Pathology, Wayne State University , Detroit , MI , USA.,Detroit Medical Center University Laboratories , Detroit , MI , USA
| | - Ronald Thomas
- Carman and Ann Adams Department of Pediatrics, Wayne State University , Detroit , MI , USA
| | - Nahed Abdel-Haq
- Division of Infectious Diseases, Children's Hospital of Michigan , Detroit , MI , USA.,Carman and Ann Adams Department of Pediatrics, Wayne State University , Detroit , MI , USA
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17
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Kara A, Gurgoze MK. The use of nitrofurantoin for children with acute cystitis caused by extended-spectrum Β-lactamase-producing Escherichia coli. J Pediatr Urol 2019; 15:378.e1-378.e5. [PMID: 31014984 DOI: 10.1016/j.jpurol.2019.03.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 03/07/2019] [Accepted: 03/26/2019] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- A Kara
- Department of Pediatric Nephrology, Firat University School of Medicine, 23119, Elazig, Turkey.
| | - M K Gurgoze
- Department of Pediatric Nephrology, Firat University School of Medicine, 23119, Elazig, Turkey.
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18
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Roldan-Masedo E, Sainz T, Gutierrez-Arroyo A, Gomez-Gil RM, Ballesteros E, Escosa L, Baquero-Artigao F, Méndez-Echevarría A. Risk factors for gentamicin-resistant E. coli in children with community-acquired urinary tract infection. Eur J Clin Microbiol Infect Dis 2019; 38:2097-2102. [PMID: 31359255 DOI: 10.1007/s10096-019-03643-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 07/15/2019] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
| | - Talia Sainz
- Pediatric Infectious and Tropical Diseases Department, Hospital La Paz Institute for Health Research (IdiPAZ), Paseo de la Castellana 261, 28046, Madrid, Spain
- Translational Research Network in Pediatric Infectious Diseases (RITIP), Paseo de la Castellana 261, 28046, Madrid, Spain
| | | | - Rosa Maria Gomez-Gil
- Microbiology Department, Hospital La Paz, Paseo de la Castellana 261, 28046, Madrid, Spain
| | - Estefania Ballesteros
- Pediatric Nephrology Department, Hospital La Paz, Paseo de la Castellana 261, 28046, Madrid, Spain
| | - Luis Escosa
- Pediatric Infectious and Tropical Diseases Department, Hospital La Paz Institute for Health Research (IdiPAZ), Paseo de la Castellana 261, 28046, Madrid, Spain
| | - Fernando Baquero-Artigao
- Pediatric Infectious and Tropical Diseases Department, Hospital La Paz Institute for Health Research (IdiPAZ), Paseo de la Castellana 261, 28046, Madrid, Spain
- Translational Research Network in Pediatric Infectious Diseases (RITIP), Paseo de la Castellana 261, 28046, Madrid, Spain
| | - Ana Méndez-Echevarría
- Pediatric Infectious and Tropical Diseases Department, Hospital La Paz Institute for Health Research (IdiPAZ), Paseo de la Castellana 261, 28046, Madrid, Spain.
- Translational Research Network in Pediatric Infectious Diseases (RITIP), Paseo de la Castellana 261, 28046, Madrid, Spain.
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Antibiotic treatment and antimicrobial resistance in children with urinary tract infections. J Glob Antimicrob Resist 2019; 20:4-10. [PMID: 31252156 DOI: 10.1016/j.jgar.2019.06.016] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 03/04/2019] [Accepted: 06/19/2019] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVES The aim of this study was to describe antibiotic prescribing patterns and antimicrobial resistance rates in hospitalised children with febrile and afebrile urinary tract infections (UTIs). METHODS Antibiotic prescriptions and antibiograms for neonates, infants and older children with UTI admitted to a general district hospital in Central Greece were evaluated. Data covering a 5-year period were collected retrospectively from the Paediatric Department's Electronic Clinical Archive. Patients were included based on clinical and microbiological criteria. Antimicrobial susceptibility was determined by the Kirby-Bauer disk diffusion method. RESULTS A total of 230 patients were included in the study. Among 459 prescriptions identified, amikacin (31.2%) was the most common antibiotic prescribed in this population, followed by amoxicillin/clavulanic acid (17.4%) and ampicillin (13.5%). Children received prolonged intravenous (i.v.) treatments for febrile (mean ± S.D., 5.4 ± 1.45 days) and afebrile UTIs (mean ± S.D., 4.4 ± 1.64 days). A total of 236 pathogens were isolated. The main causative organism was Escherichia coli (79.2%) with high reported resistance rates to ampicillin (42.0%), trimethoprim/sulfamethoxazole (26.5%) and amoxicillin/clavulanic acid (12.2%); lower resistance rates were identified for third-generation cephalosporins (1.7%), nitrofurantoin (2.3%), ciprofloxacin (1.4%) and amikacin (0.9%). Klebsiella spp. isolates were highly resistant to cefaclor (27.3%). CONCLUSION High prescribing rates for amikacin and penicillins (± β-lactamase inhibitors) and prolonged i.v. treatments were observed. Escherichia coli was highly resistant to ampicillin, whilst third-generation cephalosporins exhibited greater in vitro efficacy. Establishment of antimicrobial stewardship programmes and regular monitoring of antimicrobial resistance could help to minimise inappropriate prescribing for UTIs.
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20
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Extended-spectrum β-lactamase producing E. coli in urinary tract infections: A two-center, cross-sectional study of prevalence, genotypes and risk factors in Amman, Jordan. J Infect Public Health 2018; 12:21-25. [PMID: 30145152 DOI: 10.1016/j.jiph.2018.07.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 07/26/2018] [Accepted: 07/31/2018] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND To determine the prevalence, phenotypes, and genotypes of extended spectrum β-lactamase (ESBL)-producing Escherichia coli (E. coli) among patients with urinary tract infection along with identifying the associated risk factors. METHODS A cross-sectional study was conducted at two tertiary hospitals in Amman, Jordan between June and October, 2016. One hundred twenty one E. coli isolates from hospitalized patients with urinary tract infection were phenotypically assessed for ESBL production using the double disc diffusion test. Positive isolates to ESBL production were further genotyped using multiplex PCR. A nested case-control study was used to determine the independent risk factors. RESULTS ESBL-producing E. coli were found in 75/121 (62%) isolates. Molecular genotyping demonstrated that CTX-M group1 (42.7%) predominated followed by combination of SHV and CTX-M group1 (20%). In the regression model, previous hospitalization and use of urinary catheter were identified as independent risk factors for ESBL-producing E. coli infections. CONCLUSION We report a high prevalence of ESBL-producing E. coli which is in concordance with other studies from developing countries. Additionally, CTX-M group1 has emerged as the predominant ESBL produced by E. coli, which is consistent with reported results throughout the world. Independent risk factors to UTI infections due to ESBL-producing E. coli include previous hospitalization and use of urinary catheter.
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21
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Lashkar MO, Nahata MC. Antimicrobial Pharmacotherapy Management of Urinary Tract Infections in Pediatric Patients. J Pharm Technol 2018; 34:62-81. [DOI: 10.1177/8755122518755402] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
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.
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22
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Madhi F, Jung C, Timsit S, Levy C, Biscardi S, Lorrot M, Grimprel E, Hees L, Craiu I, Galerne A, Dubos F, Cixous E, Hentgen V, Béchet S, Bonacorsi S, Cohen R. Febrile urinary-tract infection due to extended-spectrum beta-lactamase-producing Enterobacteriaceae in children: A French prospective multicenter study. PLoS One 2018; 13:e0190910. [PMID: 29370234 PMCID: PMC5784917 DOI: 10.1371/journal.pone.0190910] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 12/21/2017] [Indexed: 01/12/2023] Open
Abstract
Objectives To assess the management of febrile urinary-tract infection (FUTIs) due to extended-spectrum β-lactamase–producing Enterobacteriaceae (ESBL-E) in children, the Pediatric Infectious Diseases Group of the French Pediatric Society set up an active surveillance network in pediatric centers across France in 2014. Materials and methods We prospectively analysed data from 2014 to 2016 for all children < 18 years old who received antibiotic treatment for FUTI due to ESBL-E in 24 pediatric centers. Baseline demographic, clinical features, microbiological data and antimicrobials prescribed were collected. Results 301 children were enrolled in this study. The median age was 1 year (IQR 0.02–17.9) and 44.5% were male. These infections occurred in children with history of UTIs (27.3%) and urinary malformations (32.6%). Recent antibiotic use was the main associated factor for FUTIs due to ESBL-E, followed by a previous hospitalization and travel history. Before drug susceptibility testing (DST), third-generation cephalosporins (3GC) PO/IV were the most-prescribed antibiotics (75.5%). Only 13% and 24% of children received amikacine alone for empirical or definitive therapy, respectively, whereas 88.7% of children had isolates susceptible to amikacin. In all, 23.2% of children received carbapenems in empirical and/or definitive therapy. Cotrimoxazole (24.5%), ciprofloxacin (15.6%) and non-orthodox clavulanate–cefixime combination (31.3%) were the most frequently prescribed oral options after obtaining the DST. The time to apyrexia and length of hospital stay did not differ with or without effective empirical therapy. Conclusions We believe that amikacin should increasingly take on a key role in the choice of definitive therapy of FUTI due to ESBL-E in children by avoiding the use of carbapenems.
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Affiliation(s)
- Fouad Madhi
- Service de Pédiatrie Générale, Centre Hospitalier Intercommunal de Créteil, Créteil, France
- GPIP (Groupe de Pathologie Infectieuse Pédiatrique) de la SFP (Société Française de Pédiatrie), Paris, France
- Université Paris Est, IMRB-GRC GEMINI, Créteil, France
- * E-mail:
| | - Camille Jung
- Service de Pédiatrie Générale, Centre Hospitalier Intercommunal de Créteil, Créteil, France
- Centre de Recherche Clinique (CRC), Centre Hospitalier Intercommunal de Créteil, Créteil, France
| | - Sandra Timsit
- Service des Urgences Pédiatriques, CHU Necker, Paris, France
| | - Corinne Levy
- GPIP (Groupe de Pathologie Infectieuse Pédiatrique) de la SFP (Société Française de Pédiatrie), Paris, France
- Université Paris Est, IMRB-GRC GEMINI, Créteil, France
- Centre de Recherche Clinique (CRC), Centre Hospitalier Intercommunal de Créteil, Créteil, France
- ACTIV, Association Clinique et Thérapeutique Infantile du Val de Marne, Saint-Maur des Fossés, France
| | - Sandra Biscardi
- GPIP (Groupe de Pathologie Infectieuse Pédiatrique) de la SFP (Société Française de Pédiatrie), Paris, France
- Université Paris Est, IMRB-GRC GEMINI, Créteil, France
- Service des Urgences Pédiatriques, Centre Hospitalier Intercommunal de Créteil, Créteil, France
| | - Mathie Lorrot
- GPIP (Groupe de Pathologie Infectieuse Pédiatrique) de la SFP (Société Française de Pédiatrie), Paris, France
- Service de Pédiatrie Générale, CHU Robert Debré, Paris, France
| | - Emmanuel Grimprel
- GPIP (Groupe de Pathologie Infectieuse Pédiatrique) de la SFP (Société Française de Pédiatrie), Paris, France
- Service de Pédiatrie Générale, CHU Trousseau, Paris, France
| | - Laure Hees
- GPIP (Groupe de Pathologie Infectieuse Pédiatrique) de la SFP (Société Française de Pédiatrie), Paris, France
- Service des Urgences Pédiatriques, CHU Lyon, Lyon, France
| | - Irina Craiu
- GPIP (Groupe de Pathologie Infectieuse Pédiatrique) de la SFP (Société Française de Pédiatrie), Paris, France
- Service des Urgences Pédiatriques, CHU Bicêtre, Bicêtre, France
| | - Aurelien Galerne
- GPIP (Groupe de Pathologie Infectieuse Pédiatrique) de la SFP (Société Française de Pédiatrie), Paris, France
- Service des Urgences Pédiatriques, CHU Jean Verdier, Bondy, France
| | - François Dubos
- GPIP (Groupe de Pathologie Infectieuse Pédiatrique) de la SFP (Société Française de Pédiatrie), Paris, France
- Service des Urgences Pédiatriques, CHU Lille, Lille, France
| | - Emmanuel Cixous
- GPIP (Groupe de Pathologie Infectieuse Pédiatrique) de la SFP (Société Française de Pédiatrie), Paris, France
- Service des Urgences Pédiatriques, Centre Hospitalier de Roubaix, Roubaix, France
| | - Véronique Hentgen
- GPIP (Groupe de Pathologie Infectieuse Pédiatrique) de la SFP (Société Française de Pédiatrie), Paris, France
- Service de Pédiatrie Générale, Centre Hospitalier de Versailles, Versailles, France
| | - Stéphane Béchet
- Service des Urgences Pédiatriques, CHU Necker, Paris, France
| | | | - Stéphane Bonacorsi
- Service de Microbiologie, Hopital Robert-Debré, AP-HP, Centre National de Référence associé Escherichia coli, Paris, France
| | - Robert Cohen
- GPIP (Groupe de Pathologie Infectieuse Pédiatrique) de la SFP (Société Française de Pédiatrie), Paris, France
- Université Paris Est, IMRB-GRC GEMINI, Créteil, France
- Centre de Recherche Clinique (CRC), Centre Hospitalier Intercommunal de Créteil, Créteil, France
- ACTIV, Association Clinique et Thérapeutique Infantile du Val de Marne, Saint-Maur des Fossés, France
- Unité Court Séjour, Petits Nourrissons, Service de Néonatologie, Centre Hospitalier Intercommunal de Créteil, Créteil, France
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The urinary and serum levels of IL-32 in children with febrile urinary tract infections. Future Sci OA 2017; 3:FSO242. [PMID: 29134126 PMCID: PMC5674269 DOI: 10.4155/fsoa-2017-0076] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Accepted: 08/10/2017] [Indexed: 12/18/2022] Open
Abstract
Aim We assessed the urinary and serum levels of IL-32 in pediatric patients with acute pyelonephritis (APN) with and without renal scarring. Results We enrolled children aged 2 months to 16 years with APN. Dimercaptosuccinic acid scans and ultrasonography studies were ordered for all patients, and a voiding. A total of 86 children (aged 57 ± 39 months, 74 [86%] female) were enrolled in this study. Group 1 was composed of 19 (16 female) patients, group 2 of 38 (35 female) patients and group 3 of 29 (23 female) patients. There were no significant differences in the serum and absolute urinary levels of IL-32 (UIL-32) between groups, but the urinary IL-32/creatinine ratio (UIL-32/Cr) was significantly higher in children with pyelonephritis than controls.
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Parajuli NP, Maharjan P, Parajuli H, Joshi G, Paudel D, Sayami S, Khanal PR. High rates of multidrug resistance among uropathogenic Escherichia coli in children and analyses of ESBL producers from Nepal. Antimicrob Resist Infect Control 2017; 6:9. [PMID: 28096977 PMCID: PMC5225645 DOI: 10.1186/s13756-016-0168-6] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Accepted: 12/29/2016] [Indexed: 01/06/2023] Open
Abstract
Background Emergence of Extended-spectrum beta-lactamase producing Escherichia coli causing urinary tract infections (UTI) among pediatric patients is an increasing problem worldwide. However, very little is known about pediatric urinary tract infections and antimicrobial resistance trend from Nepal. This study was conducted to assess the current antibiotic resistance rate and ESBL production among uropathogenic Escherichia coli in pediatric patients of a tertiary care teaching hospital of Nepal. Methods A total of 5,484 urinary tract specimens from children suspected with UTI attending a teaching hospital of Nepal over a period of one year were processed for the isolation of bacterial pathogens and their antimicrobial susceptibility testing. Escherichia coli (n = 739), the predominant isolate in pediatric UTI, was further selected for the detection of ESBL-production by phenotypic combination disk diffusion test. Results Incidence of urinary tract infection among pediatric patients was found to be 19.68% and E coli (68.4%) was leading pathogen involved. Out of 739 E coli isolates, 64.9% were multidrug resistant (MDR) and 5% were extensively drug resistant (XDR). Extended spectrum beta lactamase (ESBL) was detected in 288 (38.9%) of the E coli isolates. Conclusion Alarming rate of drug resistance among pediatric uropathogens and high rate of ESBL-producing E. coli was observed. It is extremely necessary to routinely investigate the drug resistance among all isolates and formulate strict antibiotics prescription policy in our country.
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Affiliation(s)
- Narayan Prasad Parajuli
- Department of Clinical Laboratory Services, Manmohan Memorial Medical College and Teaching Hospital, P.O.B.: 15201, Swayambhu, Kathmandu, Nepal ; Department of Laboratory Medicine, Manmohan Memorial Institute of Health Sciences, Kathmandu, Nepal
| | - Pooja Maharjan
- Department of Clinical Laboratory Services, Manmohan Memorial Medical College and Teaching Hospital, P.O.B.: 15201, Swayambhu, Kathmandu, Nepal
| | - Hridaya Parajuli
- Department of Clinical Laboratory Services, Manmohan Memorial Medical College and Teaching Hospital, P.O.B.: 15201, Swayambhu, Kathmandu, Nepal
| | - Govardhan Joshi
- Department of Clinical Laboratory Services, Manmohan Memorial Medical College and Teaching Hospital, P.O.B.: 15201, Swayambhu, Kathmandu, Nepal
| | - Deliya Paudel
- Department of Clinical Laboratory Services, Manmohan Memorial Medical College and Teaching Hospital, P.O.B.: 15201, Swayambhu, Kathmandu, Nepal
| | - Sujan Sayami
- Department of Pediatrics, Manmohan Memorial Medical College and Teaching Hospital, Kathmandu, Nepal
| | - Puspa Raj Khanal
- Department of Laboratory Medicine, Manmohan Memorial Institute of Health Sciences, Kathmandu, Nepal
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