Urinary Tract Infections in Infants and Children

Roseola Infantum: An Updated Review

BACKGROUND

Roseola infantum is a common viral disease that occurs during childhood worldwide.

OBJECTIVE

The purpose of this article is to familiarize pediatricians with the clinical manifestations, evaluation, diagnosis, and management of roseola infantum.

METHODS

A search was conducted in April, 2022, in PubMed Clinical Queries using the key terms "roseola infantum" OR "exanthem subitum" OR "sixth disease". The search strategy included all clinical trials, observational studies, and reviews published within the past 10 years. Only papers published in the English literature were included in this review. The information retrieved from the above search was used in the compilation of the present article.

RESULTS

Roseola infantum is a viral illness characterized by high fever that lasts 3 to 4 days, followed by the sudden appearance of rash at defervescence. The disease occurs most frequently in children between 6 months and 2 years of age. Human herpesvirus-6 (HHV-6) is the major cause of roseola infantum, followed by HHV-7. Transmission of the infection most likely results from the asymptomatic shedding of the virus in the saliva of the caregivers or other close contacts. Characteristically, the rash is discrete, rose-pink in color, circular or elliptical, macular or maculopapular, measuring 2 to 3 mm in diameter. The eruption is first seen on the trunk. It then spreads to the neck and proximal extremities. Typically, the rash blanches on pressure and subsides in 2 to 4 days without sequelae. Most children look well otherwise and appear to be happy, active, alert, and playful. The diagnosis is mainly clinical. Febrile seizures occur in 10 to 15 % of children with roseola infantum during the febrile period. In general, serious complications are rare and occur more often in individuals who are immunocompromised. There is no specific treatment. An antipyretic may be used to reduce fever and discomfort.

CONCLUSION

Roseola infantum is generally a benign and self-limited disease. Failure to recognize this condition may result in undue parental fear, unnecessary investigations, delay in treatment for conditions that mimic roseola infantum and complications from roseola infantum, unnecessary treatment of roseola infantum per se, and misuse of healthcare expenditure.

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

BACKGROUND

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

OBJECTIVE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

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

Purpose

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

Patients and Methods

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

Results

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

Conclusion

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

The Association between Serum Vitamin D Levels and Urinary Tract Infection Risk in Children: A Systematic Review and Meta-Analysis

The association between serum vitamin D levels and urinary tract infection (UTI) in children is unclear. We undertook a systematic review and meta-analysis to evaluate the relationships between different vitamin D levels and the likelihood of UTI in children. Online databases, including Web of Science, PubMed, Embase, and Cochrane Library, were searched up to 6 February 2023 for studies based on the inclusion criteria. Weighted mean difference (WMD) and Odds Ratios (ORs), along with their 95% confidence intervals (CI), were calculated, and the random-effects model was used for analysis. Twelve case-control studies and one cross-sectional study (839 children with UTI and 929 controls) were included. We found that children with UTI had lower levels of serum vitamin D than healthy controls (WMD: -7.730, 95% CI: -11.57, -3.89; p < 0.001). Low vitamin D levels were significantly associated with UTI in children (OR: 2.80; 95% CI: 1.55, 5.05; p = 0.001). The likelihood of children having a UTI significantly increased when their serum vitamin D level was less than 20 ng/mL (OR: 5.49, 95% CI: 1.12, 27.04; p = 0.036). Therefore, vitamin D level, especially when less than 20 ng/mL, is a risk factor in UTI.

Trends in hospitalization for urinary tract infection in the paediatric age group in the 2000-2015 period in Spain

OBJECTIVE

To analyse the trends in hospital admissions related to urinary tract infection among children aged 0-14 years in Spain in the 2000-2015 period.

METHODS

We conducted a retrospective observational study using the minimum basic hospital discharge dataset system of Spain, which applies the International Classification of Diseases, version 9 (ICD-9) coding system. We included every hospitalisation due to cystitis, pyelonephritis and unspecified UTI among children aged less than 15 years. We collected data on patient sex and age, type of discharge, main diagnosis, comorbidities, length of stay and overall cost. We calculated crude hospitalization rates per 1000 inhabitants aged less than 15 years and performed a joinpoint regression analysis to identify temporal trends.

RESULTS

In the 2000-2015 period, there were 124 696 hospitalizations in children under 15 years. Of these patients, 72.97% were aged 0-1 year and 60.12% had a diagnosis of unspecified UTI, 39.27% of pyelonephritis, and 0.52% of cystitis. The crude rate of hospitalization due to UTI ranged from 1.24 in year 2000 to 0.98 in 2015. The rate of hospitalization was higher in female versus male patients. The joinpoint analysis found a decreasing trend in the rate of hospitalization due to UTI, with an average annual percent change (AAPC) of -1.5% (95% confidence interval [CI], -2.4 a -0.6). The largest decreases occurred in female patients (AAPC, -1.8; 95% CI, -2.5 a -1.0) and children aged 7-10 years (AAPC - 5.9; 95% CI, -6.7 a -5.2).

CONCLUSIONS

The rate of hospitalization related to UTI in Spain in patients aged up to 14 years decreased during the 2000-2015 period. The highest hospitalization rates occurred in female patients and in the 0-to-1 year age group.

Risk factors for community acquired pediatric urinary tract infection with extended-spectrum-β-lactamase Escherichia coli - A case-control study

INTRODUCTION

Community-acquired (CA) infections caused by extended-spectrum β-lactamase (ESBL) producing Escherichia coli urinary tract infections (UTI) have become increasingly prevalent, posing a serious threat to public health. Risk factors for ESBL UTI have not been extensively studied in the pediatric population. We report findings from a case control study to identify risk factors for CA ESBL-producing E. coli UTI in children.

MATERIALS AND METHOD

A cohort of children with CA ESBL Escherichia coli UTI evaluated at a tertiary referral hospital from January 2014 through April 2021, were matched 1:3 with control group of non-ESBL CA E. coli UTI based on age at first episode of non-ESBL UTI. To identify potential risk factors for ESBL E. coli UTI, conditional logistic regression model was utilized accounting for age matching. Univariate models were fitted for each clinical risk factor. Factors found to be significantly associated with ESBL UTI were simultaneously included in a single model to check for associations adjusted for all other factors.

RESULTS

On conditional multivariate analyses for univariate testing, male sex (P = 0.021), history of Urology care (P = 0.001), and antibiotic treatment within 30 days prior to positive culture (P = 0.004) were identified as independent risk factors for CA ESBL E. coli UTI. Comorbidity scores were assigned to each patient according to pediatric comorbidity index (PCI); children with ESBL UTI were more likely to have higher morbidity risk than non-ESBL UTI children (P < 0.001). From the logistic model, the higher the morbidity scores, the more likely children will have CA ESBL UTI (P < 0.001).

DISCUSSION

Identifying risk factors for ESBL-producing E. coli UTI in children is important because of limited therapeutic options. This knowledge is essential for clinical decision making and to develop intervention strategies to reduce disease burden. Our study found that although females have an increased predisposition to UTIs, we observed that the male sex is an independent risk factor for ESBL E. coli UTI. This finding warrants further investigation to determine underlying cause. Because of the retrospective design of the study, collection of data from a single center, and differences in characteristics between patient populations, treatments, and prescribing patterns in the community, this study may not be generalizable.

CONCLUSIONS

Findings from our case-control study suggest that the male sex, history of Urology care, and previous antibiotic exposure are independent risk factors for CA ESBL-GNB UTI. Children with ESBL E. coli UTI are more likely to have longer admission duration and higher comorbidity index.

Epidemiology and Risk Factors of UTIs in Children-A Single-Center Observation

Urinary tract infections (UTIs) are one of childhood’s most common bacterial infections. The study aimed to determine the clinical symptoms, laboratory tests, risk factors, and etiology of different UTIs in children admitted to pediatric hospitals for three years. Methods: Patients with positive urine cultures diagnosed with acute pyelonephritis (APN) or cystitis (CYS) were analyzed for clinical symptoms, laboratory tests, risk factors, and etiology, depending on their age and sex. Results: We studied 948 children with UTIs (531 girls and 417 boys), with a median age of 12 (IQR 5−48 months). A total of 789 children had clinical symptoms; the main symptom was fever (63.4% of patients). Specific symptoms of UTIs were presented only in 16.3% of patients. Children with APN had shown significantly more frequent loss of appetite, vomiting, lethargy, seizures, and less frequent dysuria and haematuria than children with CYS. We found significantly higher median WBC, CRP, and leukocyturia in children with APN than with CYS. The risk factors of UTIs were presented in 46.6% of patients, of which 35.6% were children with APN and 61.7% with CYS. The main risk factor was CAKUT, more frequently diagnosed in children with CYS than APN, mainly in children <2 years. The most commonly isolated bacteria were Escherichia coli (74%). There was a higher percentage of urine samples with E. coli in girls than in boys. Other bacteria found were Klebsiella species, Pseudomonas aeruginosa, Proteus mirabilis, and Enterococcus species. Conclusions: Patients with APN were younger and had higher inflammatory markers. Often, fever is the only symptom of UTI in children, and other clinical signs are usually non-specific. The most common UTI etiology is E. coli, regardless of the clinical presentation and risk factors.

Parental Knowledge and Awareness of Childhood Urinary Tract Infections: A Cross Sectional Survey

Background

Parent's misconceptions or lack of knowledge about childhood urinary tract infections (UTIs) can negatively impact their children's health. Therefore, the present study aimed to determine the childhood urinary tract infections awareness and understanding among parents in Saudi Arabia.

Patients and Methods

An online validated cross-sectional survey of parents in Saudi Arabia was conducted from August to September 2021. Study participants who met the inclusion criteria were selected using a convenience sampling technique. A questionnaire with two domains was used to assess parental awareness of childhood urinary tract infection symptoms, complications, treatment, prevention, epidemiology, and diagnosis. The total childhood urinary tract infections awareness scores were classified into three categories: low awareness, moderate awareness, and high awareness. Descriptive statistics were used to determine the data distribution. A chi-square test was used to evaluate the relationship between parental awareness about urinary tract infections in children and other variables. Statistical significance was established at 0.05.

Results

Of the 1688 parents who completed the survey, 1289 (76.4%) were female, 1581 (93.7%) were married, and 1161 (68.8) had a university degree. Parent's total awareness scores were high; however, individual domain scores indicate a moderate level of knowledge. Statistically significant relationship were observed between total awareness and gender, occupation, and level of educational level ((P=0.004, P=0.001, P=0.007, respectively). Another statistically significant relationship was noted between the history of urinary tract infections and awareness of disease prevention (P=0.009).

Conclusion

In Saudi Arabia, parental knowledge about childhood urinary tract infections is moderate to high. However, future studies are needed to investigate gender, educational, and occupational variations in childhood UTI knowledge among parents in Saudi Arabia.

Epidemiologic, microbiologic and imaging characteristics of urinary tract infections in hospitalized children < 2 years of age diagnosed with anatomic abnormalities of the urinary tract

BACKGROUND

To compare the epidemiologic, microbiologic and imaging characteristics of urinary tract infections (UTI) in children <2 years of age with and without anatomic urinary tract abnormalities (AA).

METHODS

All children hospitalized with UTI during 1.1.2005-31.12.2018 were included. The study group (patients with AA) included 76 patients. The control group (99 patients) included patients without AA.

RESULTS

1163 children were hospitalized. Age at diagnosis was younger in the study group vs. controls (5.2 ± 6.0 vs. 7.9 ± 7.5 months, P = 0.038). Uropathogens distribution was different (P = 0.007), with lower Escherichia coli (Ec) and Proteus mirabilis (Pm) percentages in the study group and higher percentages of Enterococcus spp. (Ent) in controls. In the study group, Ec nonsusceptibility rates to ampicillin, amoxicillin/clavulanic acid, cefazolin, cefuroxime, TMP/SMX and ceftriaxone were 58%, 40%, 14%, 14%, 12% and 10%, respectively, with no differences vs. controls. Ultrasound (US) was performed in 69/76 (98%) patients with AA (84.1%, abnormal); bilateral (39.7%) and unilateral (32.7%) ureteral dilatation were the most frequent findings. Voiding cystourethrography was performed in 46 patients (pathologic in 35, 76%); 31 (81.6%) patients had vesicoureteral reflux (VUR) (bilateral in 11, 35.5%; grade 4/5 in 7 patients). Uropathogens distribution in VUR patients differed between study and control groups, with lower Ec and Pm in the first group and higher Pseudomonas aeruginosa and Ent percentages in the control group.

CONCLUSION

Age at diagnosis was lower and pathogen distribution was different in patients with AA. Antibiotic susceptibility patterns of the main uropathogens were similar between patients with or without AA.

Serum Calprotectin Is a Valid Biomarker in Distinction of Bacterial Urinary Tract Infection From Viral Respiratory Illness in Children Under 3 Years of Age

BACKGROUND

Febrile illnesses in young children can be a major diagnostic challenge, despite the routine use of various laboratory markers. Recent advancements in the understanding of inflammatory processes have highlighted the role of calprotectin, a heterodimer consisting of S100A8 and S100A9 proteins, with many studies suggesting its clinical value as a biomarker of inflammation. This research aimed to evaluate the usefulness of serum calprotectin (sCal) as a biomarker of urinary tract infection (UTI), which was due to its high pooled prevalence and feasibility of urine culture as a diagnostic reference standard selected for a model of bacterial infection in children.

METHODS

Febrile children aged 0-36 months with suspected UTI based on positive urinalysis or viral respiratory tract infection were included. Children with significant bacteriuria in urine culture were labeled as cases (n = 58), while those with confirmed viral infection (n = 51), as well as those with suspected UTI but sterile urine culture who went on to develop symptoms consistent with viral respiratory infection (n = 7), were labeled as controls. sCal levels were determined by a commercial immunoassay. Conventional inflammation markers (C-reactive protein, procalcitonin, white blood cell count, absolute neutrophil count, and neutrophil percentage) were measured on the day of the clinical examination. Differences in measured inflammatory markers between cases and controls were analyzed with Mann-Whitney U-test. ROC analysis reported cut-off values with the best sensitivity and specificity to distinguish bacterial UTI from viral respiratory infection.

RESULTS

All analyzed inflammatory biomarkers, including sCal, were significantly higher in cases than in controls. Median concentration of sCal was 4.97 μg/mL (IQR 3.43-6.42) and 2.45 μg/mL (IQR 1.63-3.85) for cases and controls, respectively (p < 0.001). For identifying bacterial UTI, sensitivity and specificity of sCal were 77.6 and 69.0%, respectively, at an adjusted cut-off point of >3.24 μg/mL (AUC 80.2%).

CONCLUSION

sCal could have substantial added value in the management of a child with fever and positive urinalysis and is a promising biomarker in distinction between bacterial UTI and viral respiratory causes of febrile illness in children under the age of 3 years.

Molecular Study of Escherichia albertii in Pediatric Urinary Tract Infections

Background:

There are insufficient data about the presence of E. albertii as a causative organism in urinary tract infection in pediatric patients. Objective: The present study aimed to detect E. albertii by polymerase chain reaction (PCR) for detection of uidA, mdh, and lysP genes among isolated E.coli from children with urinary tract infection.

Methods:

The present study was a cross-sectional retrograde study which was carried out on 100 isolates of phenotypically confirmed E.coli detected in urine samples of children suffering from urinary tract infection. The isolates were subjected to molecular identification by PCR for uidA, mdh, and lysP genes.

Results:

E. albertii was identified by PCR in 7% of the isolates and E.coli was identified in 93% of the isolates. Two mdh and lysP genes were detected for E. albertii and the uidA gene for E. coli. E. albertii isolates had marked resistance to gentamicin (71.4%), followed by resistance to ciprofloxacin (57.1%), meropenem and imipenem (42.9% each) and ESBL activity by double discs method was reported in 57.1% of the isolates. However, none of the isolates had shown resistance to nalidixic acid and only one isolate had resistance to norfloxacin. There was a statistically insignificant difference between resistance to the used antibiotics such as aztreonam (P=0.083), ampicillin/clavulanate (P=0.5), ciprofloxacin (P=0.69), gentamicin (P=0.3) and ceftazidime (P=1.00).

Conclusion:

The present study highlights the emergence of E. albertii as a pathogen associated with urinary tract infections in children. There is marked antibiotic resistance of this pathogen, especially toward extended spectrum beta-lactams antibiotics. The identification method depends mainly on genetic studies. Further longitudinal studies with large number of patients are required to verify the accurate prevalence of this bacterium.

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.

Exploring Inflammatory Status in Febrile Seizures Associated with Urinary Tract Infections: A Two-Step Cluster Approach

BACKGROUND

Urinary tract infections (UTIs) are considered common facilitating factors, along with other infections, in triggering febrile seizures (FS). The main purpose of our study was to identify specific inflammatory patterns of UTI cases from other infections in a specific cluster, using a combination of inflammatory biomarkers to differentiate UTIs from other bacterial diseases triggering FS.

METHOD

This prospective study included a number of 136 patients with 197 distinct FS events, from patients hospitalized in the Pediatric Clinical Hospital Sibiu, among which 10.2% were diagnosed with UTIs.

RESULTS

In one-third of the patients with UTIs (20 cases), the symptoms were limited to fever and FS. Using two-step cluster analysis, a distinct UTI inflammatory pattern has emerged: highest platelet values (PLT), median value 331 × 103/mm3 and intermediate C-reactive protein (CRP), median value 15 mg/dL, platelet distribution width (PDW), median value 9.65%, platelet-large cell ratio (P-LCR), median value 14.45%, mean platelet volume (MPV), median value 8.60 fL and neutrophil-to-lymphocyte values (NLR), median value 3.64. Furthermore, higher PDW (median value 12.25%), P-LCR (median value 28.55%), MPV (median value 10.40 fL), CRP (median value 74.00 mg/dL) and NLR values (median value 4.11) were associated mainly (85.7%) with bacterial lower respiratory infections. UTIs were highly unlikely in these patients with significantly increased CRP values and normal values of platelet indices.

CONCLUSIONS

Considering the nonspecific clinical picture of UTIs at an early age, to optimize the management of FS, a fast diagnosis of UTI is mandatory. The analysis of the inflammatory biomarker clusters (rather than individual parameters) correlated with urine leukocyte and nitrite stick evaluation for specific age groups could help in identifying even oligosymptomatic UTIs patients. The study limitation (20 UTI cases) recommends future multicentric trials on larger datasets to validate the model.

Prevalence of urinary tract infections and antibiogram of uropathogens isolated from children under five attending Bagamoyo District Hospital in Tanzania: A cross-sectional study

Background: Urinary tract infection (UTI) is a common condition in children that recurs frequently. This study aimed to determine the prevalence of UTIs among children under five attending Bagamoyo District Hospital and determine its association with nutritional status. Methods: This was a cross-sectional study that enrolled 214 children under five years old attending Bagamoyo District Hospital in Tanzania. Midstream urine was collected in sterile conditions and bottles. Samples were transported to the laboratory to isolate bacteria using cysteine lactose electrolyte deficient (CLED) agar.  Identification was undertaken using Gram staining, single iron agar test, sulfide-indole motility (SIM) test, and catalase and oxidase tests. A susceptibility test was done using the disc diffusion method. Anthropometric measurements were employed to assess malnutrition status and body mass index was determined using each child's weight and height. Results: Of the 214 children under five enrolled in the study, 123 (57.4%) were girls and 91 (42.6%) were boys. A total of 35 children were confirmed UTI-positive, making the prevalence 16.4%. Of positive children, 17 (7.9%) were girls and 18 (8.4%) were boys. The UTI prevalence was higher in boys than in girls but not statistically significant (p=0.244). Among the isolated uropathogens, Escherichia coli were common bacteria accounting for 65.7% of all isolates. The rate of other uropathogens isolated was Klebsiella spp. (17.1%), Pseudomonas spp. Proteus spp (11.4%) and (2.9%) and Staphylococci spp. (2.9%). The antibiogram of the isolated bacterial uropathogens showed high in-vitro resistance ranging from 90-95% to erythromycin, trimethoprim-sulfamethoxazole and ampicillin. Conclusion: The prevalence of UTI for children under five was 16.4%. The most common causative agent of UTI was Escherichia coli. There was no association between UTI status and malnutrition status of the children. High resistance to antibiotics calls for antimicrobial stewardship and surveillance to preserve antibiotics' effectiveness in treating uropathogens.

Transient Pseudohypoaldosteronism Secondary to Group B Streptococcus Pyelonephritis

Secondary pseudohypoaldosteronism is a condition characterized by aldosterone resistance in renal tubules. It is highly associated with urinary tract infection and urinary tract malformations. Only a few cases of pseudohypoaldosteronism secondary to group B Streptococcus pyelonephritis have been reported to date. A four-month-old boy developed poor sucking and weight loss, and his laboratory test results revealed hyponatremia, hyperkalemia, renal dysfunction, high anion gap metabolic acidosis, pyuria, and hydronephrosis. Laboratory tests including urinalysis confirmed the diagnosis of pseudohypoaldosteronism secondary to group B Streptococcus. He was treated with intravenous normal saline and antimicrobial therapy. Electrolyte disorders were addressed and he was discharged on the 10th day of hospitalization without any sequelae. Voiding cystourethrography performed after discharge showed bilateral grade 5 vesicoureteral reflux and intrarenal reflux in the right kidney. Transient pseudohypoaldosteronism is an important consideration in the differential diagnosis in infants with hyponatremia and hyperkalemia. A thorough evaluation for urinary tract malformations should be performed, including early abdominal ultrasonography and systemic management.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Urinary Tract Infections with Non-Escherichia coli Pathogens in Children: An Observational Study

Background: Urinary tract infections (UTIs) with non-Escherichia coli (E. coli) species are associate with urological abnormalities. Objectives: To compare the prevalence of non-E. coli infections in patients with urological anomalies, neurogenic bladder dysfunction, and those with apparently normal urinary systems. Methods: Pediatric nephrology clinic at a tertiary-care center in east of Iran. Children affected by UTI enrolled from 2003 to 2016. The results of urine culture were noted at enrolment. Cases with nephrolithiasis who had normal voiding cystourethrogram were excluded. After the implementation of imaging and urodynamic examinations, 832 patients enrolled according to the following inclusion criteria: cases with vesicoureteral reflux, urinary obstruction, neurogenic bladder, and patients with apparently normal urinary tract. The prevalence of infections with E. coli vs. non-E. coli pathogens were compared between different groups of enrolled cases. Results: In this study, 62.26% of the subjects had a normal urinary system, while 33.77%, 3.97%, and 2.4% of whom had vesicoureteral reflux, neurogenic bladder, and obstruction, respectively. Non-E. coli pathogens were responsible for infections in 17.29%, 19.39%, 33.74%, and 17.15% of these cases, respectively. Infections with non-E. coli pathogens were significantly more prevalent in cases with neurogenic bladder (P = 0.003). Pseudomonas species were responsible for 4/125, 5/118, 5/28, and 0/6 episodes of non-E. coli infections in cases with apparently normal urinary system, patients with vesicoureteral reflux, cases with neurogenic bladder, and those with urinary obstruction, respectively (P = 0.004). Conclusions: Infections with non-E. coli and also Pseudomonas species are significantly more prevalent in patients with neurogenic bladder dysfunction rather than those with urological abnormalities and/or cases with apparently normal urinary system.

The effect of educational intervention program on promoting preventive behaviors of urinary tract infection in girls: a randomized controlled trial

Background

Urinary tract infection is one of the most common infectious diseases in children, which can lead to serious complications for a child. The purpose of this study was to investigate the impact of Theory Planned Behavior (TPB) -based education on the promotion of preventive behaviors of urinary tract infection in mothers with a daughter under age two.

Methods

The present study is an educational randomized controlled trial that its sample consisted of 100 mothers who had a daughter under age two. They were selected through convenience sampling and then were randomly assigned to the intervention and control groups (each group included 50 participants). The data collection tool was a reliable and valid questionnaire based on TPB constructs. First, in both groups, the pre-test was administrated and then the educational intervention in the intervention group was conducted in the form of four educational sessions in 1 month (based on the pre-test need assessment) and then 3 months after the intervention (according to the ideas of Panel of Experts), post-test in both groups was administrated and then the data were analyzed through SPSS version 23 software with inferential statistics (independent t-test, paired t-test, and chi-square). The significance level was considered 0.05.

Results

Three months after the intervention, the mean score of the constructs of TPB in the intervention group was significantly higher than the control group. The performance of prevention of urinary tract infection in the intervention group before the education increased from 2.85 ± 0.51 to 3.74 ± 0.29 (out of 4) (p = 0.001).

Conclusions

TPB-based education with active and interventional follow-up was effective in promoting the preventive behaviors of urinary tract infection. Therefore, due to the side effects of UTI, especially in vulnerable periods such as childhood, it is recommended that trainings based on this model be carried out in other health care centers in order to maintain children health.

Trial registration

This trial has been registered at IRCT, IRCT2017031533090N1. Registered on 9 July 2017, https://en.irct.ir/trial/25621

Urinary Tract Infection in Children

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Features of urinary Escherichia coli isolated from children with complicated and uncomplicated urinary tract infections in Mexico

The Hospital Infantil de México Federico Gómez (HIMFG) is a tertiary care hospital in Mexico City where Escherichia coli is frequently isolated from the urine samples of pediatric patients with urinary tract infections. A collection of 178 urinary Escherichia coli (UEc) isolates associated with complicated and uncomplicated urinary tract infections were evaluated in this study. The patterns of resistance to 9 antibiotic classes showed that 60.7% of the UEc isolates had a highly multidrug-resistant (MDR) profile. Genetic diversity analyses of the UEc isolates showed a high variability and revealed 16 clusters associated with four phylogenetic groups, namely, groups A, B1, B2, and D. Phylogenetic group B2 was widely associated with the 16 clusters as well as with virulence and fitness genes. The virulence and fitness genes in the UEc isolates, which included fimbriae-, siderophore-, toxin-, and mobility-associated genes, were grouped as occurring at a low, variable, or high frequency. Interestingly, only the papF gene could be amplified from some UEc isolates, and the sequence analysis of the pap operon identified an insertion sequence (IS) element and gene loss. These data suggested pathoadaptability and the development of immune system evasion, which was confirmed by the loss of P fimbriae-associated agglutination in the UEc isolates. E. coli clone O25-ST131 had a prevalence of 20.2% among the UEc isolates; these isolates displayed both a highly MDR profile and the presence of the papGII, fimH, papGIII, iutD, sat, hlyA, and motA genes. In conclusion, the UEc isolates from complicated urinary tract infection (cUTI) were characterized as being MDR, highly genetically diverse, and associated with phylogenetic group B2 and many virulence and fitness genes. Additionally, gene loss and IS elements were identified in some UEc isolates identified as clone O25-ST131.