Urinary tract infections in children younger than 5 years of age: epidemiology, diagnosis, treatment, outcomes and prevention

Risk factors for hospitalization at the pediatric intensive care unit among infants and children younger than 5 years of age diagnosed with infectious diseases

BACKGROUND

Children hospitalized with infectious diseases may develop severe, life-threatening conditions, often requiring admission to pediatric intensive care unit (PICU). The objectives of this study were to identify independent risk factors for PICU hospitalization with an infectious disease in children <5 years of age.

METHODS

In southern Israel, two populations live side by side: the middle-high income Jewish population and the low-income Bedouin population, both receiving equal and free medical care at the only tertiary medical center in the area. The study population included all children born in southern Israel and hospitalized at PICU with an infectious disease during 1991-2012. Risk factors for PICU hospitalizations were retrospectively studied by Kaplan-Meier and Cox proportional hazard survival analyses.

RESULTS

9951 Jewish children and 18,002 Bedouin children were enrolled; overall, 1135 episodes of PICU hospitalizations with an infectious disease were recorded (879, 77.4% Bedouin and 256, 22.6% Jewish patients). Bedouin children had a higher risk for PICU hospitalization with an infectious disease compared with Jewish children (adjusted Hazard Ratio [adj. HR] 1.7, 95% CI 1.5-2.0); maternal multiparity and low-birth weight (<2500 g) were additional risk factors for PICU hospitalization with an infectious disease compared to firstborns (adj. HR = 1.2, 95% CI 1.0-1.5) or to children with a birth weight ≥2500 g (adj. HR = 1.5, 95% 1.2-1.9). Older age was a protective factor for PICU hospitalization (adj. HR = 0.98, 95% CI 0.97-0.99). Children hospitalized with a central nervous system infection had the highest risk of PICU hospitalization (adj. HR 6.8, 95% CI 5.5-8.4), followed by those with urinary tract infections (UTI, adj. HR 3.1, 95% CI 2.5-3.8) and those with lower respiratory tract infections (LRTI, adj. HR 2.9, 95% CI 2.4-3.4).

CONCLUSION

Bedouin ethnicity, low birth weight, maternal multiparity and younger age were significant risk factors for PICU hospitalizations with an infectious disease. Among the infectious diseases analyzed, CNS infection had the highest risk for PICU hospitalization, followed by UTI and LRTI.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Enhanced quantitative urine culture technique, a slight modification, in detecting under-diagnosed pediatric urinary tract infection

Objectives

The pediatric urinary tract infection (UTI) often remains under-diagnosed or neglected owing to non-specific clinical presentations, patients failing to describe the actual situation and of clinical practice in diagnosis. The study was aimed to determine the etiologies of UTI in children with enhanced quantitative urine culture (EQUC) technique.

Results

Of enrolled 570 pediatric urine samples, the significant growth positivity was higher in EQUC 92 (16.15%) compared to standard urine culture (SUC) 73 (12.80%) technique. 20.6% of the significant isolates as detected with EQUC were missed on the SUC technique. The age group, in range 1–4 years, was more prone to the infection, where E. coli was the commonest pathogen. EQUC detected, probably all isolates, contributing UTI i.e. multidrug-resistant (MDR), extensive drug-resistant (XDR), and extended-spectrum β-lactamase (ESBL) producers, as some of them skipped on the SUC technique. Of total organisms isolated from EQUC, 46% were ESBL producer, 56.5% were MDR, and 1.4% were XDR. However, 40.5% ESBL, 44% MDR but no XDR detected on SUC. Hence a simple modification on conventional culture protocol could be a crucial modification for the detection of etiologies, contributing UTI, and hence to reduce inapt antimicrobial burden.

Incidence and risk factors for positive urine culture at the time of pediatric urologic surgery

PURPOSE

Urinary tract infections are relatively common in pediatric patients. Unrecognized bacteriuria at the time of urologic surgery puts patients at increased risk for perioperative complications. Many pediatric urologists obtain preoperative or intraoperative urine cultures prior to surgery, but data are lacking regarding rates and risk factors for positive intraoperative urine cultures. We conducted a retrospective cohort study of patients undergoing pediatric urologic surgery to examine factors associated with positive intraoperative urine cultures.

MATERIALS AND METHODS

Charts of patients of age 0-18 years from a single pediatric urologist with associated intraoperative urine culture results between 2008 and 2013 were retrospectively reviewed. Demographics, prior culture results, and information regarding possible risk factors of interest-history of constipation, hydronephrosis, neurogenic bladder, posterior urethral valves, ureterocele, UPJ obstruction, urolithiasis, vesicoureteral reflux, and circumcision status-were collected and analyzed.

RESULTS

Seven hundred and fifty procedure encounters with associated intraoperative urine culture results were reviewed. Overall positive urine culture rate was 13.5%. Factors associated with increased odds of positive intraoperative urine culture included neurogenic bladder (odds ratio 26.3, p < 0.001), prior positive culture (OR 5.4, p < 0.001), female sex (OR 2.1, p 0.007), constipation (OR 2.9, p < 0.001), and urolithiasis (OR 1.58, p = 0.04). Patients without any of these risk factors had no positive intraoperative cultures (p = 0.03).

CONCLUSIONS

Patients with neurogenic bladder, prior positive urine culture, constipation, female gender, and urolithiasis were at increased risk for positive intraoperative urine culture. This may aid in decision-making regarding obtaining preoperative or intraoperative urine cultures in pediatric urology patients.

Predictive value of clinical and laboratory features for the main febrile diseases in children living in Tanzania: A prospective observational study

BACKGROUND

To construct evidence-based guidelines for management of febrile illness, it is essential to identify clinical predictors for the main causes of fever, either to diagnose the disease when no laboratory test is available or to better target testing when a test is available. The objective was to investigate clinical predictors of several diseases in a cohort of febrile children attending outpatient clinics in Tanzania, whose diagnoses have been established after extensive clinical and laboratory workup.

METHOD

From April to December 2008, 1005 consecutive children aged 2 months to 10 years with temperature ≥38°C attending two outpatient clinics in Dar es Salaam were included. Demographic characteristics, symptoms and signs, comorbidities, full blood count and liver enzyme level were investigated by bi- and multi-variate analyses (Chan, et al., 2008). To evaluate accuracy of combined predictors to construct algorithms, classification and regression tree (CART) analyses were also performed.

RESULTS

62 variables were studied. Between 4 and 15 significant predictors to rule in (aLR+>1) or rule out (aLR+<1) the disease were found in the multivariate analysis for the 7 more frequent outcomes. For malaria, the strongest predictor was temperature ≥40°C (aLR+8.4, 95%CI 4.7-15), for typhoid abdominal tenderness (5.9,2.5-11), for urinary tract infection (UTI) age ≥3 years (0.20,0-0.50), for radiological pneumonia abnormal chest auscultation (4.3,2.8-6.1), for acute HHV6 infection dehydration (0.18,0-0.75), for bacterial disease (any type) chest indrawing (19,8.2-60) and for viral disease (any type) jaundice (0.28,0.16-0.41). Other clinically relevant and easy to assess predictors were also found: malaria could be ruled in by recent travel, typhoid by jaundice, radiological pneumonia by very fast breathing and UTI by fever duration of ≥4 days. The CART model for malaria included temperature, travel, jaundice and hepatomegaly (sensitivity 80%, specificity 64%); typhoid: age ≥2 years, jaundice, abdominal tenderness and adenopathy (46%,93%); UTI: age <2 years, temperature ≥40°C, low weight and pale nails (20%,96%); radiological pneumonia: very fast breathing, chest indrawing and leukocytosis (38%,97%); acute HHV6 infection: less than 2 years old, (no) dehydration, (no) jaundice and (no) rash (86%,51%); bacterial disease: chest indrawing, chronic condition, temperature ≥39.7°c and fever duration >3 days (45%,83%); viral disease: runny nose, cough and age <2 years (68%,76%).

CONCLUSION

A better understanding of the relative performance of these predictors might be of great help for clinicians to be able to better decide when to test, treat, refer or simply observe a sick child, in order to decrease morbidity and mortality, but also to avoid unnecessary antimicrobial prescription. These predictors have been used to construct a new algorithm for the management of childhood illnesses called ALMANACH.

Personal History and Physical Examination in Judgment of Urinary Tract Infection in Children Aged 3 Months to 2 Years

BACKGROUND

Pediatricians ubiquitously rely on urine analysis for diagnosing urinary tract infection (UTI) in young febrile children due to discrepancies in symptom presentation. This study aimed to identify the determinants of physical examination and personal history for diagnosing UTI.

METHODS

Four hundred and ten patients aged between 3 months and 2 years presenting with a tympanic temperature of >38°C for >24 hours were requested to undergo urinary tests. Pediatricians completed patient record charts before the test results were generated, examined the final results of the tests, and compared the results with those reported in the medical records. Multivariate logistic regression analysis was performed to detect potential confounding factors.

RESULTS

An age of <1 year [odds ratio (OR): 5.05; p < 0.01], female sex (OR: 2.117; p < 0.05), and the absence of throat redness (OR: 1.907; p < 0.05) were risk factors for UTI. Patients defecating ≤3 times/day (OR: 8.80; p < 0.05) were more likely to have pyuria than those who defecated >3 times/day.

CONCLUSION

For febrile patients in the age group examined, the absence of throat redness and female sex were independent predictors of UTI. Moreover, the risk of UTI was higher in younger patients.

Bacterial Uropathogens Causing Urinary Tract Infection and Their Resistance Patterns Among Children in Turkey

Background

Urinary tract infection (UTI) is a common problem in infants and children, as well as adults.

Objectives

The aim of this study was to assess the most common bacterial uropathogens, their susceptibility, and resistance to antibiotics in children with UTI.

Materials and Methods

This study included 7,365 urine samples sent from various departments to the Kars state hospital microbiology laboratory between January 2012 and May 2014. Bacterial isolation from clinical samples was made using standard microbiological methods. Antibiotic susceptibilities were determined by disk diffusion, according to CLSI recommendations.

Results

Bacterial growth was obtained in 1,373 samples (18.5%). The percentage distributions of the isolates were as follows: Escherichia coli, 940 (68.5%); Proteus spp, 183 (13.3%); Staphylococcus spp, 85 (6.2%); Enterococcus spp, 65 (4.7%); Klebsiella, 62 (4.5%); Pseudomonas aeruginosa, 21 (1.5%); and other Gram-negative bacteria and Gram-positive bacteria, 17 (1.2%). UTIs were more prevalent, after two years of age, among females than males (P < 0.001).

Conclusions

The identification of the most common microorganisms causing infectious diseases and regional resistance patterns is important in order to determine the antimicrobial policies and infection control guidelines of hospitals.

Evaluation of the Bladder Stimulation Technique to Collect Midstream Urine in Infants in a Pediatric Emergency Department

OBJECTIVE

Midstream clean-catch urine is an accepted method to diagnose urinary tract infection but is impracticable in infants before potty training. We tested the bladder stimulation technique to obtain a clean-catch urine sample in infants.

MATERIALS AND METHODS

We included 142 infants under walking age who required a urine sample in a cross-sectional study carried out during a 3-months period, from September to November 2014, in the emergency department of the University Children's Hospital of Nice (France). A technique based on bladder stimulation and lumbar stimulation maneuvers, with at least two attempts, was tested by four trained physicians. The success rate and time to obtain urine sample within 3 minutes were evaluated. Discomfort (EVENDOL score ≥4/15) was measured. We estimated the risk factors in the failure of the technique. Chi-square test or Fisher's exact test were used to compare frequencies. T-test and Wilcoxon test were used to compare quantitative data according to the normality of the distribution. Risk factors for failure of the technique were evaluated using a multivariate logistic regression model.

RESULTS

We obtained midstream clean-catch urine in 55.6% of infants with a median time of 52.0 s (10.0; 110.0). The success rate decreased with age from 88.9% (newborn) to 28.6% (>1 y) (p = 0.0001) and with weight, from 85.7% (<4 kg) to 28.6% (>10 kg) (p = 0.0004). The success rate was 60.8% for infants without discomfort (p<0.0001). Heavy weight and discomfort were associated with failure, with adjusted ORs of 1.47 [1.04-2.31] and 6.65 [2.85-15.54], respectively.

CONCLUSION

Bladder stimulation seems to be efficient in obtaining midstream urine with a moderate success rate in our study sample. This could be an alternative technique for infants before potty training but further randomized multicenter studies are needed to validate this procedure.

Causes of non-malarial febrile illness in outpatients in Tanzania

Objective

In sub‐Saharan Africa, the use of malaria rapid diagnostic tests (mRDT) has raised awareness of alternative fever causes in children but few studies have included adults. To address this gap, we conducted a study of mRDT‐negative fever aetiologies among children and adults in Tanzania.

Methods

A total of 1028 patients aged 3 months to 50 years with a febrile illness and negative mRDT were enrolled from a Tanzanian hospital outpatient department. All had a physical examination and cultures from blood, nasopharynx/throat and urine. Patients were followed on Days 7 and 14 and children meeting WHO criteria for pneumonia were followed on Day 2 with chest radiology.

Results

Respiratory symptoms were the most frequent presenting complaint, reported by 20.3% of adults and 64.0% (339/530) of children. Of 38 X‐rayed children meeting WHO pneumonia criteria, 47.4% had a normal X‐ray. Overall, only 1.3% of 1028 blood cultures were positive. Salmonella typhi was the most prevalent pathogen isolated (7/13, 53.8%) and S. typhi patients reported fever for a median of 7 days (range 2–14). Children with bacteraemia did not present with WHO symptoms requiring antibiotic treatment. Young children and adults had similar prevalences of positive urine cultures (24/428 and 29/498, respectively).

Conclusion

Few outpatient fevers are caused by blood stream bacterial infection, and most adult bacteraemia would be identified by current clinical guidelines although paediatric bacteraemia may be more difficult to diagnose. While pneumonia may be overdiagnosed, urinary tract infection was relatively common. Our results emphasise the difficulty in identifying African children in need of antibiotics among the majority who do not.

Association between UTI and urinary tract abnormalities: a case-control study in Erbil City/Iraq

OBJECTIVE

To determine the proportion of ultrasound abnormalities of the urinary system between two groups of children: affected with urinary tract infection (UTI) and unaffected (control). Further, to determine the most common microorganisms causing UTI in those children with urinary tract abnormalities.

METHODS

A case-control study was carried out in Erbil, Iraq between September and December 2012. Ultrasound examinations were carried out on 64 children affected with UTI and on 64 unaffected with UTI (control) in order to detect differences, in the presence of abnormalities, in the urinary tract between the two groups.

RESULTS

A majority (59.4%) of children affected with UTI had ultrasound abnormalities, compared with 26.6% of the control group (P<0.001). Escherichia coli was the most common microorganism in both groups, although the difference was not statistically significant. More than one half (75%) of patients with UTI were female, compared with 25% who were male (P<0.001).

CONCLUSION

More than one half of the children in the present study who presented with UTI were found to have ultrasound abnormalities. E. coli was the most common causative pathogen for children with or without ultrasound abnormalities.

A one-year prospective study on the antibiotic resistance of E. coli strains isolated in urinary specimens of children hospitalized at the University Pediatric Medical Center in Novi Sad, Serbia

PURPOSE

Urinary tract infections (UTIs), the most common serious bacterial infections in children, are frequently caused by Escherichia coli. The purpose of this study was to investigate E. coli resistance/multidrug resistance to antibiotics most frequently used for UTIs.

METHODS

Children 0-18 years of age, hospitalized at the University Pediatric Hospital in Novi Sad, Serbia, were included in a 1-year observational prospective study. The microbiological analysis was performed using the standard Kirby-Bauer disk diffusion method. The results were analyzed using WHONET 5.4 software.

RESULTS

E. coli was isolated from 61.7 % of positive urine specimens. In general, higher average E. coli antibiotic resistance was found in infants and toddlers compared to children and adolescents (33.4 vs. 25.0 %) (p < 0.0001). Furthermore, it was observed that the average resistance to all the tested antibiotics was higher in boys than in girls (37.0 vs. 25.1 %) (p < 0.0001). E. coli was highly susceptible to piperacillin/tazobactam (>93.1 %), amikacin (86.3 %), quinolones (>75.0 %), and penems (>96.6 %). The prevalence of multiresistant E. coli strains was significantly higher in infants and toddlers (72.3 vs. 36.8 %) (p < 0.0001).

CONCLUSIONS

E. coli, a common cause of UTIs in children admitted to pediatric hospitals, is highly resistant/multidrug-resistant to commonly used antibiotics. Higher average resistance is found in infants and toddlers than in children and adolescents, as well as in boys compared to girls. These findings are important for the regional empiric therapy of UTIs and call for actions to decrease E. coli antibiotic resistance.

Urinary tract infection in the newborn and the infant: state of the art

Urinary tract infection is one of the most common causes of infection in newborns. Obtaining a urinary tract infections (UTIs) diagnosis just on the basis of the clinical findings is frequently difficult, however, being the pediatrician's goal to reduce the risk of renal scarring, a prompt diagnosis and treatment is of extreme importance. The key instrument for the diagnosis of UTIs is represented today by urine culture. However, in reality, the caregivers and investigators are increasingly demanding fast and cheap methods for a rapid and effective diagnosis.

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.

Early treatment of acute pyelonephritis in children fails to reduce renal scarring: data from the Italian Renal Infection Study Trials

OBJECTIVES

The American Academy of Pediatrics recommendation for febrile infants and young children suspected of having a urinary tract infection is early antibiotic treatment, given parenterally if necessary. In support of this recommendation, data suggesting that delay in treatment of acute pyelonephritis increases the risk of kidney damage are cited. Because the risk was not well defined, we investigated renal scarring associated with delayed versus early treatment of acute pyelonephritis in children.

METHODS

The research findings are derived from 2 multicenter, prospective, randomized, controlled studies, Italian Renal Infection Study 1 and 2, whose primary outcomes dealt with initial antibiotic treatment and subsequent prophylaxis, respectively. From the 2 studies, we selected the 287 children with confirmed pyelonephritis on acute technetium-99m-dimercaptosuccinic acid scans who underwent repeat scanning to detect scarring 12 months later. The children were 1 month to <7 years of age when they presented with their first recognized episode of acute pyelonephritis in northeast Italy.

RESULTS

Progressive delay in antibiotic treatment of acute pyelonephritis from <1 to >/=5 days after the onset of fever was not associated with any significant increase in the risk of scarring on technetium-99m-dimercaptosuccinic acid scans obtained 1 year later. The risk of scarring remained relatively constant at 30.7 +/- 7%. Clinical and laboratory indices of inflammation were comparable in all groups, as was the incidence of vesicoureteric reflux.

CONCLUSIONS

Early treatment of acute pyelonephritis in infants and young children had no significant effect on the incidence of subsequent renal scarring. Furthermore, there was no significant difference in the rate of scarring after acute pyelonephritis when infants and young children were compared with older children.

Part 1: Vesicoureteral reflux treatment: the past, present, and future

The purpose of this manuscript is to provide clinicians with highlights of key findings pertaining to our current understanding and treatment of the condition of vesicoureteral reflux (VUR). This includes a review of the disease, patient characteristics, current treatment options, challenges for managed care and patients, and opportunities for improvements in care. This is not intended as a comprehensive review of VUR. This manuscript does, however, serve to introduce three additional manuscripts contained within this supplement. The first article in this series is designed to provide the clinician with real-world data pertaining to treatment patterns and outcomes in patients with VUR (Examining pediatric vesicoureteral reflux: a real-world evaluation of treatment patterns and outcomes: Hensle TW, Hyun G, Grogg AL, Eaddy M). The second article considers the efficacy of prophylactic antibiotics in reducing the likelihood of urinary tract infections (UTIs) when compared with endoscopic injection with dextranomer/hyaluronic acid (Endoscopic injection versus antibiotic prophylaxis in the reduction of urinary tract infection in patients with vesicoureteral reflux: Elder JS, Shah MB, Batiste LR, et al.). The third article explores the role medication noncompliance plays in contributing to antibiotic resistance, the consequences associated with resistance (longer lasting illness and costs), and the difficulties with resistance specific to UTI pathogens in children (Considerations regarding the medical management of VUR: what have we really learned?: Koyle MA, Caldamone A). This supplement is intended to provide the clinician with valuable information regarding the treatment patterns, the role of compliance, and the efficacy of treatments for pediatric patients with VUR.

Non-Escherichia coli versus Escherichia coli community-acquired urinary tract infections in children hospitalized in a tertiary center: relative frequency, risk factors, antimicrobial resistance and outcome

BACKGROUND

Currently hospitalization for children with urinary tract infections (UTIs) is reserved for severe or complicated cases. Changes may have taken place in the characteristics and causative uropathogens of hospital-treated community-acquired UTI.

OBJECTIVES

To study children hospitalized in a tertiary center with community-acquired UTI, compare Escherichia coli and non-E. coli UTI, define predictors for non-E. coli UTI and elucidate the appropriate therapeutic approach.

PATIENTS AND METHODS

A prospective clinical and laboratory study from 2001 through 2002 in a tertiary pediatric medical center. Patients were divided by results of the urine culture into E. coli and non-E. coli UTI groups, which were compared.

RESULTS

Of 175 episodes of culture-proved UTI, 70 (40%) were caused by non-E. coli pathogens. Non-E. coli UTI was more commonly found in children who were male (P = 0.005), who had underlying renal abnormalities (P = 0.0085) and who had received antibiotic therapy in the prior month (P = 0.0009). Non-E. coli uropathogens were often resistant to antibiotics usually recommended for initial therapy for UTI, including cephalosporins and aminoglycosides; 19% were initially treated with inappropriate empiric intravenous antibiotics (compared with 2% for E. coli UTI, P = 0.0001), with a longer hospitalization.

CONCLUSIONS

Current treatment routines are often inappropriate for hospitalized children with non-E. coli UTI, which is relatively common in this population. The defined risk factors associated with non-E. coli UTIs and its antimicrobial resistance patterns should be considered to improve empiric antibiotic therapy for these infections.

Preputial Bacterial Colonisation in Preschool and Primary School Children

OBJECTIVES

Preputial bacterial colonisation was investigated in preschool and primary school children with and without phimosis before the circumcision procedure.

METHOD

The study group consisted of 32 boys admitted to our clinic consecutively between June 2003 and September 2003 for circumcision. The indication for surgery was religious belief in all patients. Immediately before the procedure, a swab was swept circumferentially once around the surface of the glans starting just proximal to the urethral meatus. In case of phimosis the same procedure was performed after complete retraction of the foreskin avoiding external contamination. The cultures were repeated in all patients after cleansing the glans and nearby preputium with polyvidon-iodine solution.

RESULTS

The mean age of the patients' was 6 (4-12) years. All 5 (100%) patients with phimosis had clinically significant (> or =100,000 cfu/ml) uropathogenic bacterial colonisation. In 27 (84.3%) patients without phimosis culture reports revealed the absence of growth in 8 (29.6%) patients while 3 (11.1%) had Diphteroids and 1 (3.7%) had alpha-haemolytic Streptococci isolated from their preputial swabs which were accepted as harmless skin commensals. The rest of the boys (55.5%) had uropathogenic species in their preputium and all except 2 (7.4%) cases had counts exceeding 100,000 cfu/ml. The overall rates for individual species including any count were found as E. coli 3.1%, Klebsiella 18.8%, coagulase-negative Staphylococci12.5% and Enterococcus 43.8%. Cleansing of perimeatal and periurethral region with 10% polyvidon-iodine solution markedly decreased the bacterial count in 80% of the patients with phimosis. Including eight patients with no growth before cleansing 88.9% of the patients in the non-phimosis group were free of preputial bacteria after cleansing with iodine solution.

CONCLUSION

Significant preputial colonisation with uropathogens might still be present in preschool and primary school children.

Modern Management of Nonneurologic Pediatric Incontinence

Incontinence affects 20%-30% of children. Historically, evaluation of voiding problems in children has involved complete urodynamic studies and treatment based primarily on bladder findings and anticholinergic medications. Unfortunately, success with this approach has been poor. This article describes new advances in our understanding of the causes of nonneurologic pediatric incontinence and its associated problems and provides new treatment strategies to manage these patients. A strategy incorporating an escalating approach to evaluation and treatment is the cornerstone of this approach. Minimizing the routine use of invasive studies and medication is the result.

The role of imaging in urinary tract infections

The aim of imaging in urinary tract infections (UTI) is to detect conditions that must be corrected to avoid imminent deterioration of kidney function, or to prevent recurrent infections and long-term kidney damage. The most threatening conditions are obstruction of an infected upper tract and abscesses of the genitourinary system. An image-guided percutaneous drainage can be lifesaving. The role of imaging in small children with UTI is controversial in terms of the importance of anatomical and functional disorders in relation to the preventive measures to be taken. In newborns identified with hydronephrosis during pregnancy or by neonatal screening, vesicoureteral reflux (VUR) and renal scarring are congenital and not caused by infection. Most of these patients are males and the VUR is of a higher grade than VUR detected in girls after the first UTI. Imaging in children with UTI should only be ordered after a thorough evaluation of the risk of renal damage and the benefits of preventive measures. In adult females, no imaging is necessary in cystitis, while ultrasonography and plain films are recommended in acute pyelonephritis. Since uncomplicated UTI in men is rare, diagnostic imaging should be started early to rule out complicating factors in the urinary tract. In prostatitis, vesiculitis, epididymitis and orchitis the role of imaging is to rule out abscess formation and testicular malignancies.

Managing complicated urinary tract infections: the urologic view

Patients with complicated UTIs are a diverse group. These patients have upper UTIs and structural or functional abnormalities that reduce the efficacy of antimicrobial therapy. They are at increased risk for morbidity such as bacteremia and sepsis, perinephric abscess, renal deterioration, and emphysematous pyelonephritis. Appropriate urinary tract imaging, antimicrobials, medical and surgical therapies, and follow-up are required to avoid potentially devastating outcomes.

The etiology of urinary tract infection: traditional and emerging pathogens

The microbial etiology of urinary infections has been regarded as well established and reasonably consistent. Escherichia coli remains the predominant uropathogen (80%) isolated in acute community-acquired uncomplicated infections, followed by Staphylococcus saprophyticus (10% to 15%). Klebsiella, Enterobacter, and Proteus species, and enterococci infrequently cause uncomplicated cystitis and pyelonephritis. The pathogens traditionally associated with UTI are changing many of their features, particularly because of antimicrobial resistance. The etiology of UTI is also affected by underlying host factors that complicate UTI, such as age, diabetes, spinal cord injury, or catheterization. Consequently, complicated UTI has a more diverse etiology than uncomplicated UTI, and organisms that rarely cause disease in healthy patients can cause significant disease in hosts with anatomic, metabolic, or immunologic underlying disease. The majority of community-acquired symptomatic UTIs in elderly women are caused by E coli. However, gram-positive organisms are common, and polymicrobial infections account for up to 1 in 3 infections in the elderly. In comparison, the most common organisms isolated in children with uncomplicated UTI are Enterobacteriaceae. Etiologic pathogens associated with UTI among patients with diabetes include Klebsiella spp., Group B streptococci, and Enterococcus spp., as well as E coli. Patients with spinal cord injuries commonly have E coli infections. Other common uropathogens include Pseudomonas and Proteus mirabilis.Recent advances in molecular biology may facilitate the identification of new etiologic agents for UTI. The need for accurate and updated population surveillance data is apparent, particularly in light of concerns regarding antimicrobial resistance. This information will directly affect selection of empiric therapy for UTI.

The etiology of urinary tract infection: traditional and emerging pathogens

The microbial etiology of urinary infections has been regarded as well established and reasonably consistent. Escherichia coli remains the predominant uropathogen (80%) isolated in acute community-acquired uncomplicated infections, followed by Staphylococcus saprophyticus (10% to 15%). Klebsiella, Enterobacter, and Proteus species, and enterococci infrequently cause uncomplicated cystitis and pyelonephritis. The pathogens traditionally associated with UTI are changing many of their features, particularly because of antimicrobial resistance. The etiology of UTI is also affected by underlying host factors that complicate UTI, such as age, diabetes, spinal cord injury, or catheterization. Consequently, complicated UTI has a more diverse etiology than uncomplicated UTI, and organisms that rarely cause disease in healthy patients can cause significant disease in hosts with anatomic, metabolic, or immunologic underlying disease. The majority of community-acquired symptomatic UTIs in elderly women are caused by E coli. However, gram-positive organisms are common, and polymicrobial infections account for up to 1 in 3 infections in the elderly. In comparison, the most common organisms isolated in children with uncomplicated UTI are Enterobacteriaceae. Etiologic pathogens associated with UTI among patients with diabetes include Klebsiella spp., Group B streptococci, and Enterococcus spp., as well as E coli. Patients with spinal cord injuries commonly have E coli infections. Other common uropathogens include Pseudomonas and Proteus mirabilis.Recent advances in molecular biology may facilitate the identification of new etiologic agents for UTI. The need for accurate and updated population surveillance data is apparent, particularly in light of concerns regarding antimicrobial resistance. This information will directly affect selection of empiric therapy for UTI.

Diagnosis and imaging in urinary tract infections

The aim of imaging in urinary tract infection is to detect conditions that must be treated in order to avoid immediate deterioration or recurrences, and probable long-term kidney damage. In newborns identified with hydronephrosis during pregnancy or by neonatal screening, vesicoureteral reflux and renal scarring are congenital and not caused by infection. Most of these patients are male and the vesicoureteral reflux is of a higher grade than that detected in girls having had urinary tract infection. In children with urinary tract infection, several authors advocate a more selective policy and recommend imaging only in those children who are at risk for developing renal damage. In adult females no imaging is necessary in cystitis, whereas ultrasonography and plain films are recommended in acute pyelonephritis. Because uncomplicated urinary tract infection in men is rare, diagnostic evaluation including imaging should be started early in order to rule out complicating factors within the urinary tract. The role of imaging in prostatitis, vesiculitis, epididymitis and orchitis is primarily to rule out abscess formation, but also to exclude testicular malignancies.