Antibiotic prophylaxis in children with relapsing urinary tract infections: review

A retrospective study of uropathogen and its antibiotic resistance among children with urinary tract infection from a single center in China

Urinary tract infection (UTI) is a well-known bacterial infection posing serious health problem in children. A retrospective study was conducted to explore the uropathogen and its antibiotic resistance in children with UTI. Data of urine culture and antimicrobial susceptibility test was collected. Consequently, 840 children were included. The overall culture-positive UTI was 458 (54.52 %) with Escherichia coli 166 (36.24 %), followed by Enterococcus faecalis 59 (12.88 %), Enterococcus faecium 70 (15.28 %) and others. They were highly resistant to the most commonly used antibiotics. In 694 children with complicated UTI, there were 8 children with fungal infection. Multiple drug resistance (MDR) was recorded in 315 (80.98 %). The overall proportion of Extended Spectrum β-Lactamase (ESβL) production was 25 (6.43 %). In 146 children with simple UTI, MDR were also detected in 47 (77.05 %). There were 6 (9.84 %) positive for ESβL production. Our study found that complicated UTI was relatively common. Escherichia coli was the most prevalent isolate, followed by Enterococcus faecium and Enterococcus faecalis. These organisms were highly resistant to the most commonly used antibiotics. Relatively high prevalence of MDR and low ESβL-producing organisms were observed.

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.

Effective antimicrobial therapies of urinary tract infection among children in low-income and middle-income countries: protocol for a systematic review and meta-analysis

INTRODUCTION

Urinary tract infection (UTI) is a frequently diagnosed infection in women and children. Treatments are often initiated with broad-spectrum antibiotics without performing any culture and sensitivity test. Inappropriate and empirical antimicrobial regimens and poor adherence to the drugs lead to the recurrence of the disease. Moreover, resistance against antibiotics in the urinary tract bacteria due to inadequate therapies is a more significant cause of concern. This systematic review will explore the different antimicrobial options for treating UTIs in children and compare their effectiveness.

METHODS AND ANALYSIS

Four electronic databases MEDLINE, Cochrane Central Register of Controlled Trials, Scopus and Web of Science will be searched in February 2022 to find relevant studies. After the initial screening by two independent review authors, the selected articles will go through the full-text evaluation to filter the inclusion criteria. Using an appropriate tool, the risk of bias will also be assessed by two independent review authors. The review results showing the treatment effects of different antimicrobials will be presented as a narrative synthesis, and a meta-analysis will be conducted if applicable. Assessment of heterogeneity between studies, assessment of publication bias, and sensitivity analysis will also be performed.

ETHICS AND DISSEMINATION

The study protocol of this systematic review has been approved by the institutional review board of North South University. The dissemination of the results will be conducted in the form of scientific publication in a peer-reviewed journal and presentations in different regional and international conferences.

PROSPERO REGISTRATION NUMBER

CRD42021260415.

Bacterial and Fungal Profile, Antibiotic Susceptibility Patterns of Bacterial Pathogens and Associated Risk Factors of Urinary Tract Infection Among Symptomatic Pediatrics Patients Attending St. Paul’s Hospital Millennium Medical College: A Cross-Sectional Study

Background

Urinary tract infection is a common infection in pediatrics. Understanding the common etiology of urinary tract infections, their antimicrobial susceptibility pattern, and associated risk factors in a particular setting can provide evidence for the appropriate treatment of the cases.

Purpose

The current study is aimed to determine the common etiology and prevalence of uropathogens associated with urinary tract infection, as well as the antibiotic susceptibility profile of bacterial isolates, and to identify risk factors associated with urinary tract infection among pediatric patients.

Materials and Methods

The study was conducted at St. Paul Hospital Millennium Medical College between October 2019 and July 2020. Urine was collected aseptically from patients, inoculated onto culture media, and incubated at 37 °C for 18–48 hours. Bacteria and yeast were identified following standard procedures. Antibiotic susceptibility testing of bacterial pathogens was carried out by the Kirby Bauer disc diffusion method. Descriptive statistics and logistical regressions were used to estimate the crude ratio with a 95% confidence interval. P-value < 0.05 was considered significant.

Results

Significant bacterial/fungal growth was observed in 65 samples giving a prevalence of 28.6% of which 75.4% (49/65) and 24.6% (16/65) were bacterial and fungal pathogens, respectively. About 79.6% of bacterial etiology were Escherichia coli and Klebsiella pneumoniae. The highest resistance was observed against ampicillin (100%), cefazolin (92.1%), and trimethoprim-sulfamethoxazole (84.1%), both of which are commonly used for empirical treatment in Ethiopia. Length of hospital stay (P=0.01) and catheterization (P=0.04) were statistically associated with urinary tract infection.

Conclusion

The high prevalence of urinary tract infection was observed in our study. Enterobacteriaceae were the major cause of urinary tract infection. Length of hospital stay and catheterization were significantly associated with urinary tract infection. Both Gram-negative and Gram-positive bacteria were extremely resistant to ampicillin and trimethoprim-sulfamethoxazole.

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.

Etiological Agents of Urinary Tract Infection and 7 Years Trend of Antibiotic Resistance of Bacterial Uropathogens in Sudan

Introduction:

Bacterial infections of the urinary tract represent a major cause of outpatient visits as well as hospital-acquired infections. As the prevalence of multidrug-resistant uropathogens is increasing, updated knowledge of the commonest bacterial causes and their susceptibility patterns is crucial for the proper selection and use of antimicrobial drugs and the development of effective local prescribing guidelines.

Methods:

Handling of urine samples, identification of organisms and antimicrobial susceptibility testing were made according to guidelines in Monica Cheesbrough 2000, 2006. The prevalence of resistance of the pathogens against each antibiotic was calculated as the proportion of resistant isolates over the entire tested isolates. Data were analyzed using Epi info; the chi-square test and Fisher exact test were used to assess the statistical significance of results.

Results:

In this study, 774 samples were cultured from patients with suspected urinary tract infection (UTI), 705 (91%) urinary isolates showed significant growth (>105 CFU /L) while the other 69 samples showed no significant growth. 431 (61%) of the patients were female, while the other 274 (39%) were males. 13 types of pathogens were identified in 705 urinary isolates. E.Coli was the main bacterial uropathogen identified. Microbiological susceptibility of a total of 28 antibiotics was tested; for each urinary isolate, different sets of these antibiotics were used. 601(96%) of the bacteria were resistant to at least one antibiotic. 17 antibiotics were found to have a bacterial resistance rate of more than 50%, including all B lactams (except cefuroxime), Nalidixic acid, Ciprofloxacin, Norfloxacin, Clindamycin, Co-Trimoxazole and Tetracyclines(Tetracycline and Doxycycline). Other antibiotics were found to have resistance rates of less than 50%. Amikacin & Imipenem had the highest susceptibility rates. Throughout the 7 years, resistance to most of the antibiotics showed an incremental pattern.

Conclusion:

Current empirical antibiotic therapy for UTI should be modified, and new guidelines should be established based on local resistance rates. This study comes up with precious regional data for evidence-based empirical antibiotic treatment, but a national sentinel surveillance system and regional antibiograms should be established to track the bacterial susceptibility profiles in Sudan.

Management of antenatal hydronephrosis

Antenatal hydronephrosis (AHN) is the most frequently detected abnormality by prenatal ultrasonography. Differential diagnosis of AHN includes a wide variety of congenital abnormalities of the kidney and urinary tract ranging from mild abnormalities such as transient or isolated AHN to more important ones as high-grade congenital vesicoureteral reflux or ureteropelvic junction obstruction. It is well known that the outcome depends on the underlying etiology. Various grading systems have been proposed for the classification of AHN on prenatal and postnatal ultrasonography. Mild isolated AHN represents up to 80% of cases, is considered to be benign, and majority of them resolve, stabilize, or improve during follow-up. Controversies exist regarding the diagnosis and management of some important and severe causes of AHN such as high-grade vesicoureteral reflux and ureteropelvic junction obstruction. Current approach is becoming increasingly conservative during diagnosis and follow-up of these patients with less imaging and close follow-up. However, there is still no consensus regarding the clinical significance, postnatal evaluation, and management of infants with AHN. The aim of this review is to discuss the controversies and provide an overview on the management of AHN.

Urinary tract infection in pediatrics: an overview

OBJECTIVE

This review aimed to provide a critical overview on the pathogenesis, clinical findings, diagnosis, imaging investigation, treatment, chemoprophylaxis, and complications of urinary tract infection in pediatric patients.

SOURCE OF DATA

Data were obtained independently by two authors, who carried out a comprehensive and non-systematic search in public databases.

SUMMARY OF FINDINGS

Urinary tract infection is the most common bacterial infection in children. Urinary tract infection in pediatric patients can be the early clinical manifestation of congenital anomalies of the kidney and urinary tract (CAKUT) or be related to bladder dysfunctions. E. coli is responsible for 80-90% of community-acquired acute pyelonephritis episodes, especially in children. Bacterial virulence factors and the innate host immune systems may contribute to the occurrence and severity of urinary tract infection. The clinical presentation of urinary tract infections in children is highly heterogeneous, with symptoms that can be quite obscure. Urine culture is still the gold standard for diagnosing urinary tract infection and methods of urine collection in individual centers should be determined based on the accuracy of voided specimens. The debate on the ideal imaging protocol is still ongoing and there is tendency of less use of prophylaxis. Alternative measures and management of risk factors for recurrent urinary tract infection should be emphasized. However, in selected patients, prophylaxis can protect from recurrent urinary tract infection and long-term consequences. According to population-based studies, hypertension and chronic kidney disease are rarely associated with urinary tract infection.

CONCLUSION

Many aspects regarding urinary tract infection in children are still matters of debate, especially imaging investigation and indication of antibiotic prophylaxis. Further longitudinal studies are needed to establish tailored approach of urinary tract infection in childhood.

Urinary tract infection in children with nephrotic syndrome: A systematic review and meta-analysis

OBJECTIVE

Urinary tract infection (UTI) is among the most common infection diseases in children with nephrotic syndrome (NS), resulting in treatment failure and relapse. No systematic reviews have estimated the prevalence of UTI in children with NS on a global scale, therefore, did the first systematic review and meta-analysis study to estimate the prevalence of UTI in children with NS in different geographical regions and different countries.

METHODS

PubMed, EMBASE, Scopus, Web of Science and Google Scholar databases were systematically searched up to 20 February 2019, for studies assessing the prevalence of UTI in children with NS. Pooled prevalence of UTI was calculated using the random effects model. Data were stratified based on WHO geographical regions and individual countries. Subgroup analysis regarding the gender and socio-demographic variables were also performed.

RESULTS

Thirty studies involving 6314 children with NS were included. The pooled prevalence of UTI was 21.6% (95%CI, 17.1-26.5%), with the highest prevalence in the African region (34.8%, 95%CI: 4.7-73.9%), and lowest prevalence in the region of the Americas (7.4%, 95% CI: 1.7-16.2%). With respect to countries, the lowest and highest prevalence rates were reported from USA (3.3%) and Indonesia (45.9%). In subgroup analyses, a higher prevalence was observed in females, and in countries with lower levels of income and human development index. The most common isolated bacteria were Escherichia coli (28%), and Klebsiella spp. (22.4%).

CONCLUSIONS

The high prevalence of UTI in children with NS reported in this study is a significant health threat for these patients. These results call for intervention strategies and preventive measures for children with NS to reduce the burden of UTI.

Safety and Efficacy of Ceftazidime-Avibactam in the Treatment of Children ≥3 Months to <18 Years With Complicated Urinary Tract Infection: Results from a Phase 2 Randomized, Controlled Trial

BACKGROUND

Ceftazidime-avibactam is effective and well tolerated in adults with complicated urinary tract infection (cUTI), but has not been evaluated in children with cUTI.

METHODS

This single-blind, multicenter, active-controlled, phase 2 study (NCT02497781) randomized children ≥3 months to <18 years with cUTI (3:1) to receive intravenous (IV) ceftazidime-avibactam or cefepime for ≥72 hours, with subsequent optional oral switch. Total treatment duration was 7-14 days. Primary objective was assessment of safety. Secondary objectives included descriptive efficacy and pharmacokinetics. A blinded observer determined adverse event (AE) causality and clinical outcomes up to the late follow-up visit (20-36 days after the last dose of IV/oral therapy).

RESULTS

In total, 95 children received ≥1 dose of IV study drug (ceftazidime-avibactam, n = 67; cefepime, n = 28). The predominant baseline Gram-negative uropathogen was Escherichia coli (92.2%). AEs occurred in 53.7% and 53.6% patients in the ceftazidime-avibactam and cefepime groups, respectively. Serious AEs occurred in 11.9% (ceftazidime-avibactam) and 7.1% (cefepime) patients. One serious AE (ceftazidime-avibactam group) was considered drug related. In the microbiologic intent-to-treat analysis set, favorable clinical response rates >95% were observed for both groups at end-of-IV and remained 88.9% (ceftazidime-avibactam) and 82.6% (cefepime) at test-of-cure. Favorable per-patient microbiologic response at test-of-cure was 79.6% (ceftazidime-avibactam) and 60.9% (cefepime).

CONCLUSIONS

Ceftazidime-avibactam was well tolerated in children with cUTI, with a safety profile consistent with that of adults with cUTI and of ceftazidime alone, and appeared effective in children with cUTI due to Gram-negative pathogens.

The efficacy of probiotics in prevention of urinary tract infection in children: A systematic review and meta-analysis

BACKGROUND

A consensus has not been reached yet about the efficacy of probiotics in reducing the incidence of urinary tract infections (UTIs) in children. This systematic review and meta-analysis was designed to assess the efficacy of probiotics in prevention UTI in children.

METHODS

The present study was designed based on guidelines for systematic reviews of clinical trials. Two independent reviewers performed an extensive search in the Medline, Embase, Web of Science and Scopus electronic databases up to the end of 2016. The summery of eligible studies was assessed independently by two reviewers and recorded in the data extraction form. Finally, a pooled relative risk (RR) was reported with a 95% confidence interval (95% CI).

RESULTS

Data from 10 studies were entered in the present meta-analysis. Probiotic therapy did not have any beneficial effect on the incidence of UTI (RR = 0.94; 95% CI 0.85-1.03; p = 0.19) and its recurrence (RR = 0.93; 95% CI 0.85-1.02; p = 0.14). Subgroup analyses showed that probiotics as monotherapy do not have any beneficial effects on prevention of UTI (RR = 0.96; 95% CI 0.89-1.04; p = 0.31). However, the incidence of UTI is reduced if probiotics are used as adjuvant therapy to antibiotics (RR = 0.92; 95% CI 0.85-0.99; p = 0.02).

CONCLUSION

The present meta-analysis showed that probiotics did not have a beneficial effect in reducing the incidence or recurrence of UTI. Only a moderate efficacy was seen when a probiotic was used as adjuvant therapy to antibiotics.

Antibiotic Resistance and Virulence Phenotypes of Recent Bacterial Strains Isolated from Urinary Tract Infections in Elderly Patients with Prostatic Disease

Acute bacterial prostatitis is one of the frequent complications of urinary tract infection (UTI). From the approximately 10% of men having prostatitis, 7% experience a bacterial prostatitis. The purpose of this study was to investigate the prevalence of uropathogens associated with UTIs in older patients with benign prostatic hyperplasia and to assess their susceptibility to commonly prescribed antibiotics as well as the relationships between microbial virulence and resistance features. Uropathogenic Escherichia coli was found to be the most frequent bacterial strain isolated from patients with benign prostatic hyperplasia, followed by Enterococcus spp., Enterobacter spp., Klebsiella spp., Proteus spp., Pseudomonas aeruginosa, and Serratia marcescens. Increased resistance rates to tetracyclines, quinolones, and sulfonamides were registered. Besides their resistance profiles, the uropathogenic isolates produced various virulence factors with possible implications in the pathogenesis process. The great majority of the uropathogenic isolates revealed a high capacity to adhere to HEp-2 cell monolayer in vitro, mostly exhibiting a localized adherence pattern. Differences in the repertoire of soluble virulence factors that can affect bacterial growth and persistence within the urinary tract were detected. The Gram-negative strains produced pore-forming toxins-such as hemolysins, lecithinases, and lipases-proteases, siderophore-like molecules resulted from the esculin hydrolysis and amylases, while Enterococcus sp. strains were positive only for caseinase and esculin hydrolase. Our study demonstrates that necessity of investigating the etiology and local resistance patterns of uropathogenic organisms, which is crucial for determining appropriate empirical antibiotic treatment in elderly patients with UTI, while establishing correlations between resistance and virulence profiles could provide valuable input about the clinical evolution and recurrence rates of UTI.

Prevalence of ESBL-producing Enterobacteriaceae in paediatric urinary tract infections: A systematic review and meta-analysis

OBJECTIVES

We aimed to evaluate the prevalence of paediatric urinary tract infections (UTIs) caused by extended spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-PE), identify predisposing factors and examine their effect on the length of hospital stay (LOS).

METHODS

For this systematic review and meta-analysis, we searched the PubMed and EMBASE databases for studies that provide data on the rate of ESBL-PE among paediatric UTIs.

RESULTS

Out of 1828 non-duplicate citations, 16 studies reporting a total of 7374 cases of UTI were included. The prevalence of ESBL-PE was 14% [(95%CI 8, 21)]. Vesicoureteral reflux (VUR) [OR = 2.79, (95%CI 1.39, 5.58)], history of UTI [OR = 2.89 (95%CI 1.78, 4.68)] and recent antibiotic use [OR = 3.92, (95%CI 1.76, 8.7)] were identified as risk factors. The LOS was significantly longer among children infected with ESBL-PE, compared to those infected with other uropathogens. [SMD = 0.88, (95%CI 0.40, 1.35)].

CONCLUSIONS

In the paediatric population, 1 out of 7 UTIs are caused by ESBL-PE. Patients with VUR, previous UTI or recent antibiotic use constitute a high risk group and these pathogens are associated with increased LOS. The significant incidence of ESBL-PE in this population should be taken into consideration in the development of empiric treatment protocols and antibiotic stewardship programmes, especially in high-prevalence areas.

Update on the approach of urinary tract infection in childhood

OBJECTIVE

Urinary tract infection (UTI) is the most common bacterial infection in childhood. UTI may be the sentinel event for underlying renal abnormality. There are still many controversies regarding proper management of UTI. In this review article, the authors discuss recent recommendations for the diagnosis, treatment, prophylaxis, and imaging of UTI in childhood based on evidence, and when this is lacking, based on expert consensus.

SOURCES

Data were obtained after a review of the literature and a search of Pubmed, Embase, Scopus, and Scielo.

SUMMARY OF THE FINDINGS

In the first year of life, UTIs are more common in boys (3.7%) than in girls (2%). Signs and symptoms of UTI are very nonspecific, especially in neonates and during childhood; in many cases, fever is the only symptom.

CONCLUSIONS

Clinical history and physical examination may suggest UTI, but confirmation should be made by urine culture, which must be performed before any antimicrobial agent is given. During childhood, the proper collection of urine is essential to avoid false-positive results. Prompt diagnosis and initiation of treatment is important to prevent long-term renal scarring. Febrile infants with UTIs should undergo renal and bladder ultrasonography. Intravenous antibacterial agents are recommended for neonates and young infants. The authors also advise exclusion of obstructive uropathies as soon as possible and later vesicoureteral reflux, if indicated. Prophylaxis should be considered for cases of high susceptibility to UTI and high risk of renal damage.

Urinary tract infections in children: EAU/ESPU guidelines

CONTEXT

In 30% of children with urinary tract anomalies, urinary tract infection (UTI) can be the first sign. Failure to identify patients at risk can result in damage to the upper urinary tract.

OBJECTIVE

To provide recommendations for the diagnosis, treatment, and imaging of children presenting with UTI.

EVIDENCE ACQUISITION

The recommendations were developed after a review of the literature and a search of PubMed and Embase. A consensus decision was adopted when evidence was low.

EVIDENCE SYNTHESIS

UTIs are classified according to site, episode, symptoms, and complicating factors. For acute treatment, site and severity are the most important. Urine sampling by suprapubic aspiration or catheterisation has a low contamination rate and confirms UTI. Using a plastic bag to collect urine, a UTI can only be excluded if the dipstick is negative for both leukocyte esterase and nitrite or microscopic analysis is negative for both pyuria and bacteriuria. A clean voided midstream urine sample after cleaning the external genitalia has good diagnostic accuracy in toilet-trained children. In children with febrile UTI, antibiotic treatment should be initiated as soon as possible to eradicate infection, prevent bacteraemia, improve outcome, and reduce the likelihood of renal involvement. Ultrasound of the urinary tract is advised to exclude obstructive uropathy. Depending on sex, age, and clinical presentation, vesicoureteral reflux should be excluded. Antibacterial prophylaxis is beneficial. In toilet-trained children, bladder and bowel dysfunction needs to be excluded.

CONCLUSIONS

The level of evidence is high for the diagnosis of UTI and treatment in children but not for imaging to identify patients at risk for upper urinary tract damage.

PATIENT SUMMARY

In these guidelines, we looked at the diagnosis, treatment, and imaging of children with urinary tract infection. There are strong recommendations on diagnosis and treatment; we also advise exclusion of obstructive uropathy within 24h and later vesicoureteral reflux, if indicated.

Ultrasound bladder wall thickness measurement in diagnosis of recurrent urinary tract infections and cystitis cystica in prepubertal girls

OBJECTIVE

To evaluate urinary bladder wall thickness (BWT) assessed by ultrasound as a diagnostic tool for cystitis cystica.

PATIENTS AND METHODS

This was a 9-year prospective study comprising 120 prepubertal girls. Sixty subjects of whom half underwent cystoscopy represented cases while the other 60 (those with a single urinary tract infection and healthy subjects) represented controls.

RESULTS

Based on receiver operating characteristics (ROC) analysis, BWT discriminated very well between cases and controls with area under the ROC curve close to 1.0. At the optimum cut-off defined at 3.9 mm, negative predictive value (NPV) was 100% leaving no probability of cystic cystitis with BWT <3.9 mm. Positive predictive value (PPV) was also very high (95.2%), indicating only around 4.82% probability of no cystic cystitis in patients with BWT values ≥3.9 mm. BWT could also distinguish between healthy subjects and those with a cured single urinary tract infection, although discriminatory properties were moderate (area under ROC 86.7%, PPV 78.8%, NPV 85.2%).

CONCLUSION

Ultrasound mucosal bladder wall measurement is a non-invasive, simple and quite reliable method in diagnosis of cystitis cystica in prepubertal girls with recurrent urinary tract infections.

Antibiotics and Antifungals in Neonatal Intensive Care Units: A Review

The incidence of infections is higher in the neonatal period than at any time of life. The basic treatment of infants with infection has not changed substantially over the last years. Antibiotics (with or without supportive care) are one of the most valuable resources in managing sick newborn babies. Early-onset (ascending or transplacental) or late-onset (hospital acquired) infections present different chronology, epidemiology, physiology and outcome. Some classes of antibiotics are frequently used in the neonatal period: penicillins, cephalosporins, aminoglycosides, glycopeptides, monobactams, carbapenems. Other classes of antibiotics (chloramphenicol, cotrimoxazole, macrolides, clindamycin, rifampicin and metronidazole) are rarely used. Due to emergence of resistant bacterial strains in Neonatal Intensive Care Units (NICU), other classes of antibiotics such as quinolones and linezolid will probably increase their therapeutic role in the future. Although new formulations have been developed for treatment of fungal infections in infants, amphotericin B remains first-line treatment for systemic Candida infection. Prophylactic antibiotic therapy is almost always undesirable. Challenges from pathogens and antibiotic resistance in the NICU may warrant modification of traditional antibiotic regimens. Knowledge of local flora and practical application of different antibiotic characteristics are key to an effective and safe utilization of antibiotics and antifungals in critical newborns admitted to the NICU, and especially in very low birth weight infants.

Uropathogenic Escherichia coli infection: potential importance of epigenetics

Patients suffering from recurrent urinary tract infections (UTIs) may be maintained on antibiotic prophylaxis, or even treated by surgery. However, there are no biological data on which to base such treatment selection for the individual patient. This highlights the need for a biological marker that might predict UTI recurrence risk. Infection of mammalian tissues with bacteria, viruses and other pathogens results in the modification of the host cell epigenome, particularly DNA methylation. We recently demonstrated that in vitro infection of bladder uroepithelial cells with uropathogenic Escherichia coli results in hypermethylation of the tumor suppressor gene CDKN2A, providing proof-of-concept that uropathogenic E. coli infection modulates the host cell epigenome. If postinfection persistence of UTI-induced uroepithelial DNA hypermethylation were to be associated with subsequent UTI propensity, these epigenetic marks could act as a potential biomarker for UTI recurrence risk and could be used to rationalize and improve treatment of patients with infection-associated uropathies.

Community-acquired enterococcal urinary tract infections in hospitalized children

The objectives of this study were to characterize community-acquired (CA) enterococcal urinary tract infections (UTIs) in a tertiary pediatric center and to determine risk factors for their occurrence, their association with renal abnormalities, their antibiotic susceptibility profile, and the appropriateness of the empiric antibiotic treatment, in comparison to those of Gram-negative UTIs. In a 5-year prospective clinical and laboratory study, we found that enterococcal UTIs caused 6.2% (22/355) of culture-proven CA UTIs. Compared with Gram-negative UTI, enterococcal UTI was associated with male predominance, higher rates of underlying urinary abnormalities (70 vs. 43.7%; p = 0.03) and inappropriate empiric antibiotic therapy (22 vs. 5.6%; p = 0.02), and mainly vesicoureteral reflux (53% of cases). This study highlights the importance of early detection of CA enterococcal UTIs because of their association with underlying urinary abnormalities and a high rate of inappropriate empiric antibiotic therapy. Renal imaging is recommended for children with enterococcal UTIs; Gram stain is suggested in selected cases to detect Gram-positive cocci for early diagnosis of enterococcal UTIs and initiation of appropriate antibiotics.

Cranberry juice for the prevention of recurrences of urinary tract infections in children: a randomized placebo-controlled trial

BACKGROUND

Cranberry juice prevents recurrences of urinary tract infections (UTIs) in adult women. The objective of this study was to evaluate whether cranberry juice is effective in preventing UTI recurrences in children.

METHODS

A double-blind randomized placebo-controlled trial was performed in 7 hospitals in Finland. A total of 263 children treated for UTI were randomized to receive either cranberry juice (n = 129) or placebo (n = 134) for 6 months. Eight children were omitted because of protocol violations, leaving 255 children for the final analyses. The children were monitored for 1 year, and their recurrent UTIs were recorded.

RESULTS

Twenty children (16%) in the cranberry group and 28 (22%) in the placebo group had at least 1 recurrent UTI (difference, -6%; 95% confidence interval [CI], -16 to 4%; P = .21). There were no differences in timing between these first recurrences (P = .32). Episodes of UTI totaled 27 and 47 in the cranberry and placebo groups, respectively, and the UTI incidence density per person-year at risk was 0.16 episodes lower in the cranberry group (95% CI, -.31 to -.01; P = .035). The children in the cranberry group had significantly fewer days on antimicrobials (-6 days per patient-year; 95% CI, -7 to -5; P < .001).

CONCLUSIONS

The intervention did not significantly reduce the number of children who experienced a recurrence of UTI, but it was effective in reducing the actual number of recurrences and related antimicrobial use.

Community-acquired Pseudomonas aeruginosa urinary tract infections in children hospitalized in a tertiary center: relative frequency, risk factors, antimicrobial resistance and treatment

BACKGROUND

The practice of antibiotic prophylaxis against recurrent urinary tract infection (UTI), with hospitalization reserved for severe or complicated cases, has led to changes in the nature and culprit uropathogens of community-acquired (CA), hospital-treated UTI. Characterization of subgroups that need special considerations is crucial.

OBJECTIVES

To elucidate the trends and characteristics of CA Pseudomonas UTI in hospitalized children; define the antibiotic susceptibility; determine the appropriateness of the empiric antibiotics used; compare to other causes of UTI in this population; and thereby define predictors for Pseudomonas UTI.

METHODS

A prospective clinical and laboratory study from 2001 through 2005. Children with P. aeruginosa UTI were characterized and compared with non-Pseudomonas UTI.

RESULTS

Of 351 episodes of culture-proven CA UTI, 28 (8%) were caused by Pseudomonas, representing a 2.8-fold increase from our previous study. Pseudomonas UTI was more common in children > 5 years (p < 0.01), with urinary abnormalities (p < 0.01) and with previous antibiotic use in the previous month (p < 0.001). Pseudomonas UTI was often resistant to antibiotics usually recommended for empiric therapy; 25% was initially treated with inappropriate IV antibiotics (4.6% in the non-Pseudomonas group, p < 0.001) with 1.3 days longer IV antibiotics. On multivariate analysis, risk factors for Pseudomonas UTI were previous antibiotic therapy and underlying urinary pathology.

CONCLUSIONS

Pseudomonas UTI seems to increase in CA, hospital-treated children and is often treated inappropriately according to current treatment protocols. Awareness of this trend and knowledge of the defined risk factors of Pseudomonas UTI might improve the empiric antibiotic therapy.

Is antibiotic prophylaxis necessary in infants with obstructive hydronephrosis?

PURPOSE

We investigated the relationship between the level of obstruction of the upper urinary tract and the risk and onset of urinary tract infection in infants with severe obstructive hydronephrosis to determine the need for antibiotic prophylaxis.

MATERIALS AND METHODS

A total of 105 patients were prenatally diagnosed with severe hydronephrosis (Society for Fetal Urology grade III or IV) due to upper urinary tract obstruction between 1994 and 2004. Of these patients 75 had ureteropelvic junction obstruction and 30 had lower ureteral obstruction. We retrospectively evaluated the clinical course and incidence of urinary tract infection during the first 12 months postnatally without antibiotic prophylaxis.

RESULTS

The incidence of overall urinary tract infection during followup was 36.2% (38 of 105 patients), and it demonstrated a higher trend with lower ureteral obstruction than with ureteropelvic junction obstruction (50% vs 30.7%, p=0.063). Most cases of urinary tract infection (92.8%) occurred before age 6 months, with a mean age at onset of 2.6 months. Of 105 patients 77 (73.3%) underwent corrective surgery at a mean age of 3.8 months. The incidence of urinary tract infection before surgical correction was 33.8% at a mean age of 2.1 months. The incidence of urinary tract infection in surgical cases was significantly higher with lower ureteral obstruction than with ureteropelvic junction obstruction (54.2% vs 24.5%, p=0.011).

CONCLUSIONS

Urinary tract infection in infants with severe obstructive hydronephrosis has a high incidence, occurs before age 6 months and is more common with lower ureteral obstruction than with ureteropelvic junction obstruction. These findings indicate that infants with severe hydronephrosis due to obstruction of the upper urinary tract should receive antibiotic prophylaxis.

Fatores associados à recorrência da infecção do trato urinário em crianças

OBJETIVOS: verificar a freqüência de infecção urinária recorrente (ITU) e avaliar os fatores associados à recorrência da ITU em crianças. MÉTODOS: estudo retrospectivo de 95 pacientes com seguimento de um ano (68 meninas e 27 meninos, mediana de idade três anos). As variáveis estudadas foram: sexo, idade, febre, constipação, tipo de bactéria, refluxo vésico-ureteral (RVU), anormalidades na cintilografia renal com ácido dimercaptosuccínico (DMSA). RESULTADOS: infecção urinária recorrente ocorreu em 49,5% crianças (19 com trato urinário normal, 19 com RVU e 9 com estenose da junção pielocalicial). Comparando o grupo com ITU recorrente com o grupo sem ITU recorrente não se encontrou diferença significativa entre sexos, presença de febre, constipação e anormalidades na cintilografia renal com DMSA. A ITU recorrente foi significativamente maior nas crianças com um ano ou menos, naquelas menores de dois anos com RVU, nas com bactéria diferente da Escherichia coli e sem profilaxia antibacteriana. Os fatores de risco significativos para a recorrência ITU foram idade < 2 anos (OR = 3,83) e refluxo vésico-ureteral (OR = 4,95). CONCLUSÕES: por causa da elevada freqüência de ITU recorrente é importante o seguimento regular de grupo de crianças com fatores de risco para ITU recorrente.

Pediatric urinary tract infections

Pediatric urinary tract infections are common. These infections have been recognized as a source of acute morbidity and long-term medical consequences in adulthood. There are various risk factors and clinical presentations in children with urinary tract infections. The main objectives in management include prompt diagnosis, appropriate antimicrobial therapy, identification of anatomic anomalies, and, in select patients, long-term follow-up.

May we go on with antibacterial prophylaxis for urinary tract infections?

Recurrent urinary tract infections (UTIs), with or without vesicoureteric reflux (VUR), are by far the most frequent reason for long-term antibacterial prophylaxis in infants and children today. However, the strategies of antibacterial prophylaxis for the prevention of recurrent urinary tract infection are no longer universally accepted. In infants and children at risk, the benefits of antibacterial prophylaxis definitively are not yet proven by evident data. To put antibacterial prophylaxis in its place, risk groups for recurrent symptomatic infections, ascending UTI and permanent renal damage have to be defined and the efficacy of prophylaxis in these groups has to be proved by prospective randomised studies. Nevertheless, until the results of these studies are available, antibacterial prophylaxis will remain one of the most frequently practised methods to protect risk patients from pyelonephritic damage and UTI recurrences.

Timing of follow-up voiding cystourethrogram in children with primary vesicoureteral reflux: development and application of a clinical algorithm

BACKGROUND AND OBJECTIVES

Of children diagnosed with urinary tract infection, 30% to 40% have primary vesicoureteral reflux (VUR). For the majority of these children, treatment involves long-term prophylactic antibiotics (ABX) and a periodic voiding cystourethrogram (VCUG) until resolution of VUR as detected by VCUG. Radiation exposure and considerable discomfort have been associated with VCUG. To date, no clear guidelines exist regarding the timing of follow-up VCUGs. The objective of this study was to develop a clinically applicable algorithm for the optimal timing of repeat VCUGs and validate this algorithm in a retrospective cohort of children with VUR.

METHODS

Based on previously published data regarding the probability of resolution of VUR over time, a decision-tree model (DTM) was developed. The DTM compared the differential impact of 3 timing schedules of VCUGs (yearly, every 2 years, and every 3 years) on the average numbers of VCUGs performed, years of ABX exposure, and overall costs. Based on the DTM, an algorithm optimizing the timing of VCUG was developed. The algorithm then was validated in a retrospective cohort of patients at an urban pediatric referral center. Data were extracted from the medical records regarding number of VCUGs, time of ABX prophylaxis, and complications associated with either. VUR in patients in the cohort was grouped into mild VUR (grades I and II and unilateral grade III for those < or =2 years old), and moderate/severe VUR (other grade III and grade IV). Kaplan-Meier survival curves were created from the cohort data. From the survival curves, the median times to resolution of VUR were determined for the cohort, and these times were compared with the median times to VUR resolution of the data used for the DTM. The numbers of VCUGs performed, time of ABX exposure, and costs in the cohort were compared with those that would have occurred if the algorithm had been applied to both mild and moderate/severe VUR groups.

RESULTS

Using an algorithm that results in a recommendation of VCUGs every 2 years in mild VUR would reduce the average number of VCUGs by 42% and costs by 33%, with an increase in ABX exposure of 16%, compared with a schedule of yearly VCUGs. For moderate/severe VUR, a VCUG performed every 3 years would reduce the average number of VCUGs by 63% and costs by 51%, with an increase in ABX exposure of 10%. Applying this algorithm to the retrospective cohort consisting of 76 patients (between 1 month and 10 years old) with primary VUR would have reduced overall VCUGs by 19% and costs by 6%, with an increase in ABX exposure of 26%. The patterns of VUR resolution, age distribution, and prevalence of severity of VUR were comparable between previously published results and the retrospective cohort.

CONCLUSIONS

Delaying the schedule of VCUG from yearly to every 2 years in children with mild VUR and every 3 years in children with moderate/severe VUR yields substantial reductions in the average numbers of VCUGs and costs, with a modest subsequent increase in ABX exposure.

Dietary factors affecting susceptibility to urinary tract infection

Urinary tract infection (UTI) is usually an ascending infection caused by bacteria derived from stools. Since the bacterial composition of stools is dependent on the diet, it is likely that the risk of UTI will change with changes in the diet. Most data describing diet as a risk factor for UTI come from epidemiological and interventional trials. It has been shown in a case-control setting that frequent consumption of fresh berry or fruit juices and fermented milk products containing probiotic bacteria decreases the risk for UTI recurrence in women. Several interventional trials have found Vaccinium berry products to provide protection from UTI recurrence. Probiotics have not been able to prevent UTI in interventional trials. However, the lack of an effect may be related to too low a dose or to the use of non-optimal products in these trials. Limited data are available on the effects of nutrition on UTI in children. However, there is no reason to expect that children would be different from adults in this respect. In this review, we discuss the dietary factors affecting the susceptibility to UTI.

Antibiotic prophylaxis by low-dose cefaclor in children with vesicoureteral reflux

Sulfamethoxazole/trimethoprim (SMX/TMP) and nitrofurantoin are the most frequently used agents for prophylaxis to reduce the risk of recurrent urinary tract infections (UTIs) in children with vesicoureteral reflux (VUR). Nitrofurantoin, however, is not available in Japan and increasing resistance of organisms to SMX/TMP has recently raised doubts about its effectiveness as a prophylactic agent. This study was conducted to investigate whether antibiotic prophylaxis using low-dose cefaclor can effectively reduce the risk of recurrent UTIs. Thirty-nine children (31 male, 8 female) with primary VUR were enrolled. Ages varied from 0.5 to 111 months (mean 10.6 months). A prophylactic dose of 5-10 mg cefaclor per kg per day was given 1-3 times daily depending on the patient's age. Mean duration of prophylactic treatment was 15.5 months. Eleven children (ten male, one female) developed breakthrough UTIs during a total of 606 months treatment (or about one further infection in 55 months). Resistance to cefaclor was noted in three organisms: Enterococcus spp., Morganella spp., and Pseudomonas spp. Evidence of antibacterial activity was present in the morning urine samples from all of seven children tested. Cefaclor was well accepted and tolerated by all subjects. None withdrew from the study because of side effects. These results suggest that cefaclor can be an alternative choice for prophylactic treatment because of its safety, good compliance and low rates of resistant Escherichia coli.

Vesicoureteric reflux and reflux nephropathy

Reflux nephropathy i.e. renal scarring associated with vesico-ureteric reflux (VUR) and urinary tract infection (UTI) was originally considered an acquired disease. The renal scarring seems to get worse with recurrent urine infections especially in the young. Therefore, in the past much effort was undertaken to correct the VUR surgically and minimize the number of recurrent urinary tract infections by antibiotic prophylaxis with the hope of reducing if not arresting the onset of complications that follow i.e. hypertension and renal failure. However, it is now becoming clear that reflux nephropathy encompass at least two major categories of disease; "acquired" renal scarring secondary to UTI and VUR predominantly affecting females and "congenital" scarring with dysplastic features associated with prenatal VUR but with no infection and predominantly affecting boys. The latter is much less common but is disproportionately represented in the group of patients with reflux nephropathy that go on to develop renal failure. Unfortunately, the susceptibility to renal scarring, the onset of hypertension and progression to renal failure seems to be significantly influenced by genetic factors and hence measures undertaken to prevent recurrence of UTI may not change the ultimate outcome although it will certainly improve the comfort of the individual. Therefore, the extensive investigation and management routines adopted today in these children may not be cost-effective in preventing end stage renal disease in VUR. The progression to renal failure, however, can be delayed but not halted with adequate control of high blood pressure and hence the need for life long follow-up.

Community acquired urinary tract infection: etiology and bacterial susceptibility

PURPOSE: Urinary tract infections (UTI) are one of the most common infectious diseases diagnosed. UTI account for a large proportion of antibacterial drug consumption and have large socio-economic impacts. Since the majority of the treatments begins or is done completely empirically, the knowledge of the organisms, their epidemiological characteristics and their antibacterial susceptibility that may vary with time is mandatory. OBJECTIVE: The aim of this study was to report the prevalence of uropathogens and their antibiotic susceptibility of the community acquired UTI diagnosed in our institution and to provide a national data. METHODS: We analyzed retrospectively the results of urine cultures of 402 patients that had community acquired urinary tract infection in the year of 2003. RESULTS: The mean age of the patients in this study was 45.34 ± 23.56 (SD) years. There were 242 (60.2%) females and 160 (39.8%) males. The most commonly isolated organism was Escherichia coli (58%). Klebsiella sp. (8.4%) and Enterococcus sp.(7.9%) were reported as the next most common organisms. Of all bacteria isolated from community acquired UTI, only 37% were sensitive to ampicillin, 51% to cefalothin and 52% to trimethoprim/sulfamethoxazole. The highest levels of susceptibility were to imipenem (96%), ceftriaxone (90%), amikacin (90%), gentamicin (88%), levofloxacin (86%), ciprofloxacin (73%), nitrofurantoin (77%) and norfloxacin (75%). CONCLUSION: Gram-negative agents are the most common cause of UTI. Fluoroquinolones remains the choice among the orally administered antibiotics, followed by nitrofurantoin, second and third generation cephalosporins. For severe disease that require parenteral antibiotics the choice should be aminoglycosides, third generation cephalosporins, fluoroquinolones or imipenem, which were the most effective.

Urinary tract infection at the age extremes: pediatrics and geriatrics

Urinary tract infections (UTIs) are common and generally benign conditions among healthy, sexually active young women without long-term medical sequelae. In contrast, UTIs are more complicated among those individuals at either end of the age spectrum: infants/young children and geriatrics. UTI in children younger than 2 years has been associated with significant morbidity and long-term medical consequences, necessitating an extensive and somewhat invasive imaging evaluation to identify possible underlying functional or anatomic abnormalities. Pediatric UTI should be considered complicated until proved otherwise, and treatment should reflect the severity of signs and symptoms. Management in the acutely ill child frequently involves parenteral broad-spectrum antimicrobial agents, and less ill children can be treated with trimethoprim- sulfamethoxazole (TMP-SMX), beta-lactams, and cephalosporins.UTI among older patients (>65 years) may be complicated by comorbidities, the baseline presence of asymptomatic bacteriuria, and benign urinary symptoms that can complicate diagnosis. The etiology of UTI encompasses a broader spectrum of infecting organisms than is seen among younger patients and includes more gram-positive organisms. Symptomatic UTI is generally more difficult to treat than among younger populations. Management should be conservative, of longer treatment durations, and cover a broad spectrum of possible uropathogens. Oral or parenteral treatment with a fluoroquinolone for 7 days is the preferred empiric approach. TMP-SMX can also be considered a first-line agent in women only, but only if the pathogen is known to be TMP-SMX sensitive.

Renal transport of antibiotics and nephrotoxicity: a review

The renal excretion of a drug can essentially be divided schematically into three functional processes: glomerular filtration, tubular reabsorption and tubular secretion. When assessing nephrotoxicity, the tubular secretion system, which allows transport of the drug from the blood to the urine via the tubular cells, is particularly important. Historically, two distinct tubular secretion mechanisms have been described for drugs: one via organic cations and the other via organic anions. More recently, a third tubular secretion mechanism has been identified, mediated by P-glycoprotein. In the present review, a number of examples will be given relating to antibiotic-induced kidney damage determined via the tubular reabsorption mechanism (aminoglycosides, amphotericin B) and via the tubular secretion mechanism (cephalosporins, vancomycin), respectively. Drug transport within the tubular cells is the first fundamental stage in the onset of the nephrotoxic process. Knowledge of these concepts is important for the prevention of iatrogenic kidney damage, particularly in patients with underlying disease receiving concomitant treatment with several potentially nephrotoxic molecules.

Urinary PGE(2) concentrations measured by a new EIA method in infants with urinary tract infections or renal malformations

In this work PGE(2)concentrations were measured by a new EIA method in the urine of infants (mean age: 9.35+/-4.24 months) with recurrent urinary tract infections or renal malformations. Compared to healthy subjects, PGE(2)excretion rates resulted significantly higher in both pathological groups, in particular in subjects with obstructive uropathies (29.55+/-8.12 vs 18.37+/-4.64 pg/ml). We did not find any age- or pH-dependent difference in urinary excretion of PGE(2); none of the examined indices of renal function showed any significant relationship to PGE(2). These results suggest that this parameter, measured non-invasively in the urine, could help in the differential diagnosis between obstructive vs non-obstructive dilatation and in monitoring renal function in presence of recurrent UTI episodes.

Cefixime in urinary tract infections with special reference to pediatrics: overview

Cefixime is a third-generation oral cephalosporin that is highly active against a broad range of gram-negative and some gram-positive aerobic bacteria. In non-complicated urinary tract infections it is at least as effective as other usual treatments, and has a low rate of side effects. Several clinical studies have been performed on cefixime in urinary tract infections both in adults and children. On the basis of the literature data, cefixime could be indicated in the treatment of non-complicated urinary tract infections in children either as monotherapy or as switch therapy.

Amphotericin B-induced nephrotoxicity: a review

Amphotericin B is the gold standard for antifungal treatment for the most severe mycoses. However, adverse effects are common, with nephrotoxicity being the most serious, occurring early in the course of treatment, and usually being reversible in most patients. Tubular damage is a well known problem associated with amphotericin B therapy but acute renal failure is the most serious complication. Recent studies have examined ways to ameliorate the well-known toxicities of amphotericin B. A new approach has been to complex the drug with lipids or entrap it in liposomes. This review will concern amphotericin B-induced nephrotoxicity, whose mechanisms are not completely clear. Nephrotoxicity seems related to direct amphotericin B action on the renal tubules as well as to drug-induced renal vasoconstriction. The main mechanisms of nephrotoxicity suggested in the literature are presented. The clinical picture at different ages (adults, children, newborns), interactions of clinical significance, strategies for prevention of amphotericin B-induced nephrotoxicity are summarized. To provide optimal patient care, it is imperative that the clinician understand the etiology of and the signs and symptoms associated with nephrotoxicity, as well as interventions to prevent nephrotoxicity in patients receiving amphotericin B.

Fluoroquinolones in pediatrics and their nephrotoxicity in adults: minireview

In recent years there is increasing pressure to use fluoroquinolones in pediatric patients but relatively few data have been published in the literature. Therefore this paper reviews the available information about the pharmacokinetics of fluoroquinolones in children and their use in pediatric urinary tract infections, taking into account their potential as nephrotoxic agents. From the available data it seems reasonable to suggest that there is no risk of quinolone-induced nephrotoxicity and that this class of antibiotics may therefore be considered as potential candidates in urinary tract infections in children. Nevertheless adequate pharmacokinetic investigations and further studies on long-term monitoring for potential toxicity need to be conducted in pediatric populations.

Antibiotics in neonatal infections: a review

The bacteria most commonly responsible for early-onset (materno-fetal) infections in neonates are group B streptococci, enterococci, Enterobacteriaceae and Listeria monocytogenes. Coagulase-negative staphylococci, particularly Staphylococcus epidermidis, are the main pathogens in late-onset (nosocomial) infections, especially in high-risk patients such as those with very low birthweight, umbilical or central venous catheters or undergoing prolonged ventilation. The primary objective of the paediatrician is to identity all potential cases of bacterial disease quickly and begin antibacterial treatment immediately after the appropriate cultures have been obtained. Combination therapy is recommended for initial empirical treatment in the neonate. In early-onset infections, an effective first-line empirical therapy is ampicillin plus an aminoglycoside (duration of treatment 10 days). An alternative is ampicillin plus a third-generation cephalosporin such as cefotaxime, a combination particularly useful in neonatal meningitis (mean duration of treatment 14 to 21 days), in patients at risk of nephrotoxicity and/or when therapeutic monitoring of aminoglycosides is not possible. Another potential substitute for the aminoglycoside is aztreonam. Triple combination therapy (such as amoxicillin plus cefotaxime and an aminoglycoside) could also be used for the first 2 to 3 days of life, followed by dual therapy after the microbiological results. In late-onset infections the combination oxacillin plus an aminoglycoside is widely recommended. However, vancomycin plus ceftazidime (+/- an aminoglycoside for the first 2 to 3 days) may be a better choice. Teicoplanin may be a substitute for vancomycin. However, the initial approach should always be modified by knowledge of the local bacterial epidemiology. After the microbiological results, treatment should be switched to narrower spectrum agents if a specific organism has been identified, and should be discontinued if cultures are negative and the neonate is in good clinical condition. Penicillins and third-generation cephalosporins are generally well tolerated in neonates. There is controversy regarding whether therapeutic drug monitoring of aminoglycosides will decrease toxicity (particularly renal damage) in neonates, and on the efficacy and safety of a single daily dose versus multiple daily doses of these drugs. Toxic effects caused by vancomycin are uncommon, but debate still exists over the need for therapeutic drug monitoring of this agent. When antibacterials are used in neonates, accurate determination of dosage is required, particularly for compounds with a low therapeutic index and in patients with renal failure. Very low birthweight infants are also particularly prone to antibacterial-induced toxicity.