European Journal of Cardiovascular Medicine

Urinary tract infections (UTIs) are among the most prevalent bacterial infections affecting children, accounting for a significant proportion of both outpatient and inpatient pediatric visits worldwide. If left untreated or inadequately managed, UTIs in children can lead to serious complications such as renal scarring, hypertension, and impaired renal function [1]. The primary etiological agents of pediatric UTIs are typically Gram-negative organisms, with Escherichia coli being the most common uropathogen [2, 3]. Empirical antibiotic therapy is frequently initiated based on the clinical diagnosis of a UTI, often before the results of urine cultures are available. However, the increasing prevalence of antimicrobial resistance among uropathogens presents a major challenge to effective management. The misuse and overuse of antibiotics have led to the emergence of multidrug-resistant (MDR) organisms, reducing the effectiveness of first-line antibiotics such as ampicillin and cotrimoxazole [4, 5]. This situation emphasizes the need for continuous local and regional surveillance to guide evidence-based empirical therapy and reduce treatment failures [6]. While numerous studies have explored microbial profiles and resistance patterns in adult populations, data on pediatric populations, especially in longitudinal studies, are still limited. Additionally, resistance patterns can vary significantly based on geographical location and over time, underscoring the need for regular, localized surveillance to identify emerging resistance trends [7].

Such data are essential to optimize treatment protocols and guide more precise, personalized management of UTIs in pediatric patients. This study aims to evaluate the distribution of causative organisms and their antibiotic resistance profiles in pediatric urinary tract infections over a 12-month period. By identifying prevalent pathogens and their resistance trends, this study seeks to provide crucial insights that can guide clinicians in selecting the most appropriate empirical therapies for pediatric UTIs.

Study Design and Duration: This was a longitudinal observational study conducted over a period of eight months, from June 2020 to January 2021.

Study Setting: The study was carried out in the Department of Pediatrics at Saraswathi Institute of Medical Sciences Hapur, India.

Study Population: A total of 100 pediatric patients, aged between 1 month and 12 years, presenting with clinical symptoms suggestive of urinary tract infection (UTI), were enrolled in the study. Patients were included irrespective of gender, and both outpatient and inpatient cases were considered.

Inclusion Criteria: Children aged 1 month to 12 years Clinically suspected UTI with symptoms such as fever, dysuria, abdominal pain, frequency, or urgency Positive urine culture (≥10⁵ CFU/mL of a single uropathogen)

Exclusion Criteria: Patients who had received antibiotics in the preceding 48 hours Recurrent UTI cases

Patients with known congenital renal anomalies

Sample Collection and Processing:

Midstream clean-catch urine samples were collected in sterile containers. In infants, urine samples were collected using appropriate sterile adhesive collection bags. Samples were transported promptly to the microbiology laboratory and processed within one hour of collection.

Microbiological Analysis:

Urine cultures were performed using cysteine lactose electrolyte-deficient (CLED) agar. Identification of bacterial isolates was done based on colony morphology, Gram staining, and standard biochemical tests. Only samples yielding significant bacteriuria (≥10⁵ CFU/mL) were considered positive.

Antibiotic Susceptibility Testing:

Antimicrobial susceptibility testing was performed using the modified Kirby-Bauer disk diffusion method on Mueller-Hinton agar. The interpretation of results was done according to Clinical and Laboratory Standards Institute (CLSI) guidelines (2020 update). The antibiotics tested included ampicillin, cotrimoxazole, ciprofloxacin, nitrofurantoin, and imipenem, among others.

Definition of Multidrug Resistance (MDR):

MDR was defined as resistance to at least three different classes of antibiotics.

Data Analysis:

Data were entered into Microsoft Excel and analyzed using SPSS version 25. Descriptive statistics were used to calculate frequencies and percentages. Trends in resistance patterns over time were also evaluated.

Ethical Consideration:

The study protocol was approved by the Institutional Ethics Committee of Saraswathi Institute of Medical Sciences ,Hapur Informed consent was obtained from the parents or guardians of all participants prior to enrollment.

A total of 100 pediatric patients diagnosed with urinary tract infections (UTIs) were included in this longitudinal observational study. The participants' ages ranged from 1 month to 12 years, with a mean age of 5.4 ± 3.1 years. The majority of the patients were female (62%), while males constituted 38% of the sample.

Uropathogen Distribution

The predominant causative organism isolated was Escherichia coli, accounting for 66% of the isolates, followed by Klebsiella pneumoniae (14%), Proteus mirabilis (8%), Enterococcus faecalis (6%), and Pseudomonas aeruginosa (4%) (Table 1). This distribution highlights the dominance of Gram-negative bacilli in pediatric UTIs.

Table 1: UTI Causative Organisms (n=100)

Antibiotic Resistance Patterns

The antibiotic resistance profile of the top five uropathogens revealed high levels of resistance to commonly used agents such as ampicillin and cotrimoxazole. Among E. coli isolates, 84.8% were resistant to ampicillin, 71.2% to cotrimoxazole, and 60.6% to ciprofloxacin. Resistance to nitrofurantoin was relatively low at 21.2%, and only 1.5% of E. coli showed resistance to imipenem. Similar trends were observed in Klebsiella pneumoniae, where 92.9% were resistant to ampicillin and 64.3% to cotrimoxazole. Notably, Pseudomonas aeruginosa showed 100% resistance to ampicillin and 75% resistance to both cotrimoxazole and ciprofloxacin (Table 2).

Table 2: Antibiotic Resistance Patterns in Top 5 Pathogens (% Resistance)

Note: Resistance values represent the percentage of isolates resistant to each antibiotic.

Multidrug Resistance

Multidrug resistance (MDR), defined as resistance to three or more antibiotic classes, was observed in 42% of E. coli isolates and 28.6% of Klebsiella spp. isolates. Overall, 38% of all uropathogens demonstrated MDR patterns (Table 3). These findings underscore the growing concern regarding antibiotic resistance in pediatric urinary tract infections.

Table 3:  Multidrug Resistance (MDR) Prevalence Organism MDR Prevalence (%)

Temporal Trends in Resistance

Throughout the 12-month observation period, a slight upward trend in resistance to ampicillin and cotrimoxazole was observed, whereas resistance to nitrofurantoin remained consistently low. These trends suggest evolving resistance dynamics and reinforce the importance of continuous surveillance and tailored empirical therapy.

This study highlights the microbial profile and antibiotic resistance patterns among pediatric patients with urinary tract infections (UTIs) at a tertiary care Centre  Hapur, Uttar Pradesh . Escherichia coli was identified as the predominant uropathogen, accounting for 66% of the isolates, followed by Klebsiella pneumoniae (14%). These findings align with previous literature, where E. coli is reported as the causative agent in 60–80% of pediatric UTI cases globally and in India [8, 9]. A major concern identified in this study was the high resistance rates against commonly used first-line antibiotics. Resistance to ampicillin was observed in 84.8% of E. coli and 92.9% of Klebsiella isolates, while cotrimoxazole resistance exceeded 70% in E. coli. This trend reflects the global rise in antimicrobial resistance among uropathogens, often attributed to inappropriate antibiotic use in pediatric populations [8, 10]. Our findings are comparable to resistance rates observed in Central Romania and Australian pediatric cohorts, where similar resistance patterns have emerged over recent years [9, 10]. Although ciprofloxacin showed moderately lower resistance rates, with 60.6% of E. coli isolates being resistant, its empirical use in children remains limited due to safety concerns. On the other hand, nitrofurantoin retained good sensitivity against E. coli and Enterococcus, consistent with reports from Australian and European studies supporting its continued role in treating uncomplicated lower UTIs [10, 11]. Imipenem demonstrated high efficacy across all isolates, though its use is reserved for severe or resistant cases to prevent further resistance development [11]. Multidrug resistance (MDR), defined as resistance to three or more antibiotic classes, was observed in 42% of E. coli and 28.6% of Klebsiella isolates. This is in agreement with findings from recent Indian and international studies, which report MDR prevalence between 30% and 50% among pediatric UTI pathogens [9, 11]. The emergence of MDR organisms presents a significant clinical challenge, necessitating the use of broader-spectrum antibiotics, increased healthcare costs, and potential treatment failures. A noteworthy observation in our study was the temporal increase in resistance to ampicillin and cotrimoxazole over the eight-month study period. Similar time-series analyses from other tertiary care hospitals have documented rising trends in antibiotic resistance, underscoring the urgent need for surveillance and stewardship [10]. Overall, these findings reinforce the importance of establishing local antibiograms and updating empirical treatment guidelines based on resistance trends. Continuous microbiological monitoring, rational antibiotic prescribing, and strict antimicrobial stewardship are essential to mitigate the spread of resistant uropathogens. Inadequate treatment of pediatric UTIs due to resistance can lead to recurrent infections, renal scarring, and long-term renal complications, as emphasized in recent global expert reviews [8].

This study highlights the alarming prevalence of antibiotic resistance among uropathogens causing pediatric urinary tract infections in a tertiary care setting. Escherichia coli remained the most common isolate, with high resistance rates noted for ampicillin, cotrimoxazole, and ciprofloxacin. Nitrofurantoin and imipenem were found to be the most effective antibiotics. The presence of multidrug resistance in over one-third of isolates is a serious concern, limiting empirical treatment options. The findings underscore the urgent need for local antibiotic stewardship programs, regular surveillance of resistance trends, and rational prescribing practices to combat the rising threat of antimicrobial resistance in the pediatric population and ensure effective UTI management.

1. Kot B. Antibiotic Resistance Among Uropathogenic Escherichia coli. Pol J Microbiol. 2019 Dec;68(4):403-415. doi: 10.33073/pjm-2019-048. Epub 2019 Dec 5. PMID: 31880885; PMCID: PMC7260639.
2. Copp HL, Shapiro DJ, Hersh AL. National ambulatory antibiotic prescribing patterns for pediatric urinary tract infection, 1998-2007. Pediatrics. 2011 Jun;127(6):1027-33. doi: 10.1542/peds.2010-3465. Epub 2011 May 9. PMID: 21555502; PMCID: PMC3103269.
3. Saperston KN, Shapiro DJ, Hersh AL, Copp HL. A comparison of inpatient versus outpatient resistance patterns of pediatric urinary tract infection. J Urol. 2014 May;191(5 Suppl):1608-13. doi: 10.1016/j.juro.2013.10.064. Epub 2014 Mar 26. PMID: 24679887; PMCID: PMC4165638.
4. Erol B, Culpan M, Caskurlu H, Sari U, Cag Y, Vahaboglu H, Özumut SH, Karaman MI, Caskurlu T. Changes in antimicrobial resistance and demographics of UTIs in pediatric patients in a single institution over a 6-year period. J Pediatr Urol. 2018 Apr;14(2):176.e1-176.e5. doi: 10.1016/j.jpurol.2017.12.002. Epub 2018 Jan 9. PMID: 29428362
5. Edlin RS, Shapiro DJ, Hersh AL, Copp HL. Antibiotic resistance patterns of outpatient pediatric urinary tract infections. J Urol. 2013 Jul;190(1):222-7. doi: 10.1016/j.juro.2013.01.069. Epub 2013 Jan 28. PMID: 23369720; PMCID: PMC4165642.
6. Ghorashi Z, Ghorashi S, Soltani-Ahari H, Nezami N. Demographic features and antibiotic resistance among children hospitalized for urinary tract infection in northwest Iran. Infect Drug Resist. 2011;4:171-6. doi: 10.2147/IDR.S24171. Epub 2011 Oct 11. PMID: 22114509; PMCID: PMC3215345.
7. Yelin I, Snitser O, Novich G, Katz R, Tal O, Parizade M, et al. Personal clinical history predicts antibiotic resistance of urinary tract infections. Nat Med. 2019 Jul;25(7):1143-1152. doi: 10.1038/s41591-019-0503-6. Epub 2017 Jul 4. PMID: 31273328; PMCID: PMC6962525.
8. Becknell B, Schober M, Korbel L, Spencer JD. The diagnosis, evaluation and treatment of acute and recurrent pediatric urinary tract infections. Expert Rev Anti Infect Ther. 2015 Jan;13(1):81-90. doi: 10.1586/14787210.2015.986097. Epub 2014 Nov 25. PMID: 25421102; PMCID: PMC4652790.
9. Duicu C, Cozea I, Delean D, Aldea AA, Aldea C. Antibiotic resistance patterns of urinary tract pathogens in children from Central Romania. Exp Ther Med. 2016 Jul;22(1):748. doi: 10.3892/etm.2016.10180. Epub 2018 May 12. PMID: 34055063; PMCID: PMC8138273.
10. Fasugba O, Mitchell BG, Mnatzaganian G, Das A, Collignon P, Gardner A. Five-Year Antimicrobial Resistance Patterns of Urinary Escherichia coli at an Australian Tertiary Hospital: Time Series Analyses of Prevalence Data. PLoS One. 2016 Oct 6;11(10):e0164306. doi:10.1371/journal.pone.0164306. PMID: 27711250; PMCID: PMC5053592.
11. Gaspari RJ, Dickson E, Karlowsky J, et al. Antibiotic resistance trends in paediatric uropathogens. Int J Antimicrob Agents. 2005;26:267. -