Background: Urinary tract infections (UTIs) rank among the most prevalent bacterial infections in pediatric populations.1 It is estimated that around 1% of boys and 3% of girls will experience UTIs in their first decade of life. The primary cause of this condition is typically due to an ascending infection from the urethra.
Objectives:
Material & Methods: Study Design: Hospital-based descriptive study. Study area: The study was conducted in the Department of Paediatrics of a tertiary care hospital. Study Period: 1 year. Study population: Hospitalized Children aged between 0-18 years and diagnosed with urinary tract infection. Sample size: The study consisted of a total of 189 subjects.
Results: Among the Escherichia coli isolates, high resistance was observed for Ampicillin (87.9%) and Nalidixic acid (88.6%) followed by Cotrimoxazole (67.5%), Cefotaxime (66.9%), Ceftriaxone (66.9%), Cefixime (64.4%), Aztreonam (64.4%) Norfloxacin (64.2%), Cefipime (57.2%), Gentamicin (53.9%), Amoxicillin-Clavulunate (47.8%).
Conclusion: This study highlights the significant burden of urinary tract infections (UTIs) in children, particularly those under 5 years of age. The emergence of antibiotic-resistant bacteria, such as ESBL and carbapenemase-producing Enterobacteriaceae, poses a major challenge in treating these infections.
Urinary tract infections (UTIs) rank among the most prevalent bacterial infections in pediatric populations.1 It is estimated that around 1% of boys and 3% of girls will experience UTIs in their first decade of life. The primary cause of this condition is typically due to an ascending infection from the urethra. Identifying UTIs in young children is crucial, as it can indicate potential urinary tract abnormalities. Early detection is vital for safeguarding the renal function of developing kidneys.2 E. coli, a gram-negative bacterium from the Enterobacteriaceae family, is the leading cause of UTIs; however, other Enterobacteriaceae such as Klebsiella pneumoniae and Proteus mirabilis, as well as Staphylococcus saprophyticus, are also frequently implicated.3,4 Although the advent of antimicrobial treatment has enhanced the management of UTIs, the rise of antimicrobial resistance poses a significant challenge and concern in numerous countries.5-7
Most routinely used UTI medicines, including ampicillin, co-trimoxazole, nitrofurantoin, and fluoroquinolones, have developed resistance during the last several decades.8 UTI is a major risk factor for developing renal insufficiency or end-stage renal disease.9
Global figures show that 8.3 million outpatient clinic visits are attributed to UTIs.
Annually, the emergency department deals with one million.
Approximately 100,000 people were admitted to hospitals for complicated UTIs (10).
Urinary tract infections have significant medical and budgetary ramifications. Acute uncomplicated UTI in non-obstructed, non-pregnant female adults is considered a harmless infection with no long-term medical implications. UTI increases the risk of pyelonephritis, early birth, and fetal mortality in pregnant women. It also reduces kidney function and end-stage renal disease in juvenile patients. The estimated annual cost of community-acquired UTI is around $1.6 billion (11).
The treatment of urinary tract infections (UTIs) is primarily based on empirical methods rather than relying on urine cultures or susceptibility tests for therapeutic guidance. This approach poses a risk for the development of antimicrobial resistance in uropathogens. The widespread and inappropriate application of empirical antimicrobial treatments has led to the emergence of antimicrobial resistance, which has recently become a significant global concern. The rising occurrence and swift spread of multi-drug resistance among uropathogens have now turned into a worldwide issue, particularly in countries such as Japan, China, the United States, India, Brazil, Nepal, and Saudi Arabia.12
It is essential to have an understanding of the causative organism and its antibiotic resistance profile before initiating appropriate empirical antibiotic treatment, to curb the increasing prevalence of antibiotic resistance in uropathogens. Furthermore, the information regarding the causative organisms and their susceptibility to antibiotics varies consistently between hospitals and across different regions; thus, diligent monitoring, collection, and regular updates of such information are strongly advised. Hence, the objective of this study was to determine the clinical and microbiological characteristics of urinary tract infections, as well as to offer insights into their causes, antibiotic resistance, and suitable antibiotic therapies.
OBJECTIVES:
Study Design: Hospital-based descriptivestudy.
Study area: The study was conducted in the Department of Paediatrics of a tertiary care hospital.
Study Period: 1 year.
Study population:Hospitalized Children aged between 0-18 years and diagnosed with urinary tract infection.
Sample size: The study consisted of a total of 189 subjects.
The proportion of those patients with Recurrent UTI in the previous study- 36.4% Sample size has been calculated using open Epi software Two Sided significant level (1-alpha) - 95% Power (1-beta, % chance of detecting) - 80%
Sample size required- 184 (We documented 189 cases during the study period).
Sampling Technique: Simple Random technique.
Inclusion Criteria:
Exclusion Criteria:
Ethical consideration: Institutional Ethical committee permission was taken before the commencement of the study.
Study tools and Data collection procedure:
This study was conducted in a tertiary care pediatric hospital over a period of 12 months. Written informed consent was taken from the parents of the children included in the study. Hospitalized children diagnosed with culture-proven urinary tract infections were taken into the study after satisfying the inclusion and exclusion criteria. Demographic data, clinical presentation, history of previous UTI and associated risk factors were recorded by direct questionnaire to the parents as per proforma. Anthropometric measurements such as weight, and length/height were noted. A spine examination was done for the identification of anomalies. Genitals were examined for Circumcision status, Phimosis in boys and labial adhesions in the case of girls. It was ensured that the urine sample was collected by appropriate technique and under aseptic precautions. Samples were sent to the lab immediately for processing. Urine microscopy reporting of >5WBC/High Power Field was considered as pyuria and >5RBC/HPF as hematuria from the centrifuged sample. Leukocyte esterase and Nitrite positivity were tested using dipsticks.
As per the Indian Society of Pediatric Nephrology consensus statement(13), the criteria for diagnosis of UTI (if culture shows the growth of a single bacterial species) are as follows-
Antibiotic susceptibility testing, screening for resistance mechanisms such as ESBL and Carbapenemase production among uropathogens was done as per Clinical and Laboratory Standards Institute 2014 protocol(14).
Method of processing urine sample for culture-
Screening for resistance mechanisms (CLSI 2014 protocol)(14)-
Antimicrobial susceptibility testing-
ESBL Detection using phenotypic confirmatory test-
Amp C Detection-
CRE detection using Modified Hodge Test-
Vancomycin Resistance and High Level Aminoglycoside Resistance (HLAR) in Enterococci-
MRSA detection by Cefoxitin disc diffusion method-
Treatment details-
Data regarding empiric antibiotics initiated and treatment response were followed up. No response to empirical antibiotics was considered when there was no deference within 72 hours of initiation of drug (or) change of antibiotic as per sensitivity reported (or) persistence of uropathogen in repeat urine cultures (if done) during the hospital stay.
STATISTICAL ANALYSIS-
Comparisons between categorical variables were done using the statistical program SPSS 16. Continuous data were expressed as mean ± standard deviation (SD) or median with ranges. Frequencies were expressed as percentages. Statistical evaluation of differences in proportions was performed by Fisher’s exact test. A two-sided p value of <0.05 indicated significance. Odds ratios (OR) with 95% confidence intervals (95% CI) were calculated for each variable.
Table 1: AGE WISE DISTRIBUTION
Age |
Number of children |
Percentage |
<1 month |
16 |
8.5 |
1month to 1 year |
66 |
35 |
1 to 5 years |
72 |
38 |
5 to 10 years |
24 |
12.7 |
>10 years |
11 |
5.8 |
The majority (73%) of the children who presented with UTI were between 1 month to 5 years of age. The median age of the study group was 18 months (age range 0 to 17 years).
Table 1: SEX DISTRIBUTION
Age |
Male |
Percentage |
Female |
Percentage |
<1month |
11 |
69% |
5 |
31% |
1mo – 1yr |
38 |
57.5% |
28 |
42.5% |
1 – 5yrs |
28 |
38.9% |
44 |
61.1% |
5 – 10yrs |
10 |
41.6% |
14 |
58.3% |
>10yrs |
4 |
36.3% |
7 |
63.6% |
TOTAL |
91 |
48% |
98 |
52% |
Out of 189 children males were 91(48%) and females were 98(52%) with male to female ratio of 0.9:1. Male predominance was found in neonates and 1-month to 1-year infants. Beyond infancy, females were predominant.
Out of 189 children, 153 were 1st Episode UTI and 36 were Recurrent UTI.Males were predominant among children with recurrent UTI, whereas female predominance was found in 1st episode UTI group.
Table 3: PRESENTING SYMPTOMS
AGE GROUP
|
Fever n (%) |
Vomiting n (%)
|
Dysuria n (%)
|
Abdomen pain n (%)
|
Frequency n (%)
|
Diarrhea n (%)
|
Poor feeding n (%) |
Failure to thrive n (%)
|
Jaundice n (%)
|
<1month |
8 (50) |
3 (18.75) |
- |
- |
- |
0 |
7 (43.75) |
3 (18.75) |
8 (50) |
1month - 1yr |
64 (96.9) |
37 (56) |
23 (34.8) |
- |
7 (10.6) |
16 (24.2) |
29 (43.9) |
4 (6) |
- |
1yr – 5yrs |
67 (93) |
28 (39.4) |
39 (54.9) |
6 (8.4) |
10 (14) |
13 (18) |
29 (40.8) |
2 (2.8) |
- |
5yrs – 10yrs |
18 (75) |
11 (45.8) |
16 (66.6) |
12 (50) |
6 (25) |
0 |
1 (4.1) |
1 (4.1) |
- |
>10yrs |
9 (81.8) |
3 (27.2) |
9 (81.8) |
7 (63.6) |
2 (18) |
0 |
- |
2 (18) |
- |
Fever (87.8%) was the predominant symptom in our study among all age groups. Among neonates, fever (50%) and jaundice (50%) were the common presenting symptoms followed by poor feeding, vomiting, and failure to thrive. In infants 1 month to 1 year, fever (96.9%) and vomiting (56%) followed by poor feeding (43.9%) were the common symptoms. Among 1 to 5-year-old children, fever, dysuria, vomiting, and poor feeding were common. Whereas among children beyond 5 years old, fever, dysuria and pain abdomen were found to be predominant.
Table 4: Comparison of risk factors between 1st episode and recurrent UTI group
Risk Factor |
1st Episode UTI (n=153) |
(%) |
Recurrent UTI (n=36) |
(%) |
P –VALUE (Odds Ratio) |
Age <1year |
69 |
(45.3) |
13 |
(36.1) |
0.313 |
Voiding dysfunction |
12 |
(7.8) |
9 |
(25) |
0.003 (0.257) |
Constipation |
29 |
(19) |
7 |
(19.4) |
0.960 |
Congenital anomalies of the kidney and urinary tract |
19 |
(12.5) |
11 |
(30.5) |
0.008 (0.325) |
Spinal anomalies |
4 |
(2.6) |
3 |
(8.3) |
0.104 |
Among the risk factors, voiding dysfunction (P-0.003) and congenital anomalies of the kidney and urinary tract (P-0.008) were observed to be significantly associated with recurrent UTIs.
Table 5: MICROBIOLOGICAL PROFILE
Uropathogen |
Number of isolates |
GRAM NEGATIVE BACILLI (n=180)
|
|
Enterobacteriaceae (n=168) Escherichia coli Klebsiella pneumonia Klebsiellaoxytoca Proteus vulgaris Proteus mirabilis Enterobacteraerogenes Enterobacter cloacae Citrobacter species Morganellamorganii |
121 26 2 4 2 2 3 7 1 |
Pseudomonas species |
10 |
Acinetobacter species |
2 |
GRAM POSITIVE COCCI (n=9) |
|
Enterococcus faecalis |
7 |
Staphylococcus aureus |
2 |
Total |
189 |
Among the uropathogens isolated, GNB (Gram Negative Bacilli) was 180 and GPC (Gram Positive Cocci) were 9. Escherichia coli-121 (64%) was the predominant uropathogen isolated, followed by Klebsiella-28 (14.8%), Pseudomonas-10(5.3%), Citrobacter-7 (3.7%), Enterococcus faecalis-7 (3.7%), Proteus species-6(3.2%), Enterobacter- 5 (2.6%), Staphylococcus aureus-2(1%), Morganella morganii-1 (0.5%). Enterobacteriaceae group (n=168) constitute 88% of the total gram-negative isolates, of which ESBL producers were 77 (45.8%), Amp C Beta-lactamase producers were 15(8.9%), Carbapenemase producers were 15 (8.9%).
Table 6: Antibiotic resistance patterns among the Gram-negative bacilli
GRAM-NEGATIVE BACILLI |
Escherichia coli (n=121) |
Klebsiella species (n=28) |
Pseudomonas species(n=10) |
Proteus species (n=6) |
Enterobacter species (n=5) |
Citrobacter species (n=7) |
Acinetobacter species (n=2) |
|||||||
Antibiotic Tested |
T |
R (%) |
T |
R (%) |
T |
R (%) |
T |
R (%) |
T |
R (%) |
T |
R (%) |
T |
R (%) |
Ampicillin |
83 |
73(87.9) |
NT |
NT |
NT |
NT |
5 |
3(60) |
NT |
NT |
NT |
NT |
NT |
NT |
Amoxicillin/ Clavulanate |
115 |
55(47.8) |
26 |
10(38.4) |
NT |
NT |
4 |
3(75) |
1 |
1(100) |
4 |
0 |
NT |
NT |
Piperacillin/ Tazobactum |
121 |
25(20.6) |
28 |
4(14.2) |
10 |
0 |
6 |
0 |
5 |
2(40) |
7 |
1(14.3) |
2 |
0 |
Ceftriaxone |
121 |
81(66.9) |
28 |
18(64.2) |
NT |
NT |
6 |
0 |
5 |
4(80) |
7 |
5(71.4) |
2 |
0 |
Cefotaxime |
121 |
81(66.9) |
28 |
18(64.2) |
NT |
NT |
6 |
0 |
5 |
4(80) |
7 |
5(71.4) |
2 |
0 |
Cefoperazone/ Sulbactam |
121 |
24(19.8) |
28 |
3(10.7) |
10 |
0 |
6 |
0 |
4 |
2(50) |
7 |
1(14.3) |
2 |
0 |
Cefixime |
90 |
58(64.4) |
23 |
13(56.5) |
1 |
0 |
6 |
0 |
3 |
2(66.6) |
5 |
4(80) |
NT |
NT |
Cefipime |
110 |
62(57.2) |
25 |
11(44) |
9 |
1(11.1) |
6 |
0 |
5 |
4(80) |
7 |
3(42.8) |
2 |
0 |
Amikacin |
121 |
20(16.5) |
28 |
3(10.7) |
10 |
0 |
6 |
0 |
5 |
1(20) |
7 |
1(14.3) |
2 |
0 |
Gentamicin |
113 |
61(53.9) |
28 |
5(17.8) |
9 |
1(11.1) |
5 |
0 |
5 |
3(60) |
6 |
2(33.3) |
2 |
0 |
Ceftazidime |
NT |
NT |
NT |
NT |
9 |
3(33.3) |
6 |
0 |
1 |
1(100) |
NT |
NT |
2 |
1(50) |
Meropenem |
121 |
9(7.5) |
28 |
3(10.7) |
10 |
1(10) |
6 |
0 |
5 |
2(40) |
7 |
1(14.3) |
2 |
0 |
Aztreonam |
45 |
29(64.4) |
12 |
4(33.3) |
8 |
3(37.5) |
3 |
0 |
2 |
2(100) |
NT |
NT |
NT |
NT |
Colistin |
24 |
0 |
9 |
0 |
5 |
0 |
NT |
NT |
2 |
0 |
1 |
0 |
2 |
0 |
Tigecycline |
9 |
0 |
3 |
0 |
NT |
NT |
NT |
NT |
2 |
0 |
1 |
0 |
NT |
NT |
Cotrimoxazole |
114 |
77(67.5) |
27 |
12(44.4) |
1 |
1(100) |
6 |
3(50) |
4 |
2(50) |
5 |
1(20) |
2 |
1(50) |
Nitrofurantoin |
113 |
27(23.8) |
21 |
17(80.9) |
3 |
3(100) |
3 |
0 |
5 |
4(80) |
7 |
1(14.3) |
NT |
NT |
Nalidixic acid |
106 |
94(88.6) |
22 |
8(36.3) |
1 |
1(100) |
6 |
2(33.3) |
5 |
3(60) |
7 |
5(71.4) |
NT |
NT |
Norfloxacin |
109 |
70(64.2) |
26 |
10(38.4) |
5 |
1(20) |
6 |
0 |
5 |
3(60) |
6 |
2(33.3) |
NT |
NT |
Ciprofloxacin |
NT |
NT |
NT |
NT |
3 |
0 |
NT |
NT |
2 |
2(100) |
1 |
1(100) |
2 |
0 |
(T-Tested, NT-Not Tested, R-Resistant)
Among the Escherichia coli isolates, high resistance was observed for Ampicillin (87.9%) and Nalidixic acid (88.6%) followed by Cotrimoxazole (67.5%), Cefotaxime (66.9%), Ceftriaxone (66.9%), Cefixime (64.4%), Aztreonam (64.4%) Norfloxacin (64.2%), Cefepime (57.2%), Gentamicin (53.9%), Amoxicillin-Clavulunate (47.8%).Klebsiella isolates showed the highest resistance to Nitrofurantoin (80.9%) followed by Cefotaxime (64.2%), Ceftriaxone (64.2%), Cefixime (56.5%). E. coli and Klebsiella species showed 100% sensitivity to colistin and tigecycline. Among E.coli and Klebsiella species, high sensitivity was observed to meropenem (92.5%, 89.5%), Amikacin (83.5%, 89.3%), Cefoperazone-Sulbactum (80.5%, 89.3%) and Piperacillin-Tazobactum (79.4%, 85.8%) respectively. Out of 10 Pseudomonas isolates, resistance to ceftazidime was observed in 33%. All the isolates tested for Piperacillin-Tazobactum and ciprofloxacin were 100%sensitive. 50% of Proteus isolates tested for Cotrimoxazole showed resistance.
Table 7: Antibiotic resistance pattern among the Gram-positive cocci
GPC |
Enterococcus faecalis(n=7) |
MSSA(n=2) |
||
Antibiotics tested |
T |
R (%) |
T |
R (%) |
Ampicillin |
7 |
2(28.6) |
2 |
0 |
Gentamicin |
7 |
3(42.8) |
2 |
0 |
Cotrimoxazole |
NT |
NT |
2 |
0 |
Nitrofurantoin |
7 |
1(14.3) |
2 |
0 |
Norfloxacin |
7 |
4(57) |
2 |
0 |
Ciprofloxacin |
2 |
2(100) |
NT |
NT |
Vancomycin |
5 |
0 |
2 |
0 |
Linezolid |
5 |
0 |
2 |
0 |
Teicoplanin |
5 |
0 |
2 |
0 |
Out of 9 gram-positive isolates, 7(77.8%) were Enterococcus faecalis and 2(22.2%) were staphylococcus aureus (methicillin sensitive). 3 of 7 Enterococcus isolates were HLAR (High Level Aminoglycoside Resistance) strains. Enterococcus faecalis showed low resistance to nitrofurantoin (14.3%). MSSA was sensitive to all the antibiotics tested. All the gram-positive isolates were 100% sensitive to Vancomycin, Linezolid and Teicoplanin.
The majority of the children had pyuria (93%) and leukocyte esterase positivity (84%), followed by bacterial presence (65.5%). Nitrites were positive in only 55% of children.
Serum creatinine was done in all the children. The average Serum creatinine value of the study population was 0.55. 19 children were found to have reduced estimated GFR. Of the 12 had underlying urological anomalies (Posterior urethral valves-4, Hydroureteronephrosis-1, Hydronephrosis with dysplastic kidney-2, Dysplastic kidney with thinned out parenchyma-3, Bilateral high-gradevesicoureteric reflux with scarring-2), 1 with Obstructive uropathy secondary to calculi, 1 was a Nephrotic syndrome child, 2 were CKD patients whereas no obvious reason was found in 3 children.
All 7 children whose blood cultures showed growth of pathogen were in the age range of 1 month to 5 years. 6 out of 7 children were in the age group of 1 month to 1 year. One was a 36-month-old young boy. All 7 children had corresponding urine cultures showing growth of the same pathogen.
Even though 28 children inthe beta-lactamase-producing group responded to 3rd generation cephalosporins, there was a significant difference in treatment response when compared to the ESBL group. A significant number of children (20 patients) infected with ESBL &And producing organisms failed to respond to third-generationcephalosporins when compared with the non-ESBL group. (P value <0.001).
Table 8: Comparison of mean duration of hospital stay
Group |
Mean duration of hospital stay in days |
Non-ESBL |
5.55 |
ESBL & Amp C |
6.13 |
CRE |
7.53 |
Blood culture Positive |
11 |
The mean duration of hospital stay appears to be more in the blood culture positive, CRE, ESBL & Amp C group of patients compared to that of the non-ESBL group. But statistically, there was no significant difference (P value- 0.158).
Urinary tract infections rank among the most prevalent bacterial infections in children.15 In recent years, Gram-negative bacteria from the Enterobacteriaceae family have become significant contributors to both healthcare-associated and community-acquired infections, experiencing a notable increase in their resistance to antimicrobial drugs. The rise in antimicrobial resistance poses a serious challenge, restricting available treatment options.16 The appearance of urinary pathogens that produce extended-spectrum β-lactamase and carbapenemase has been observed in the community, resulting in the utilisation of broad-spectrum antimicrobials for relatively simple febrile UTIs. This research offers insights into the clinical and microbiological characteristics of UTIs within a pediatric tertiary care facility. Monitoring the causes of UTIs, along with the patterns of antimicrobial susceptibility, is essential for informing empirical treatment choices.17
In our study, the majority of the children (73%) were in the age range of 1 month to 5 years. Our observation was similar to studies by Patel et al. (18)& Gupta et al. (19), where they reported that the majority (60.5% & 83%, respectively) of children were less than 5 years of age. The median age of the study cohort was 18 months. Mantadakiset al. (20), reported a median age of 16 months.
Fever was the main presenting symptom in this study cohort. Serna et al (21) reported fever as the most frequent symptom among all the age groups. A similar finding was reported by Sharma et al(22)., as well. Fever without focus is the main presenting symptom of UTI in very young children. Among neonates, fever and jaundice were the common presenting symptoms followed by poor feeding, vomiting, and failure to thrive which was by the study by Lin et al(23) The presenting symptoms among the infants and older children observed in this study were similar to that described in NICE guidelines (UK) and ISPN guidelines. Beyond 2 years of age vomiting, abdominal pain and from were predominant presenting symptoms, reported by Serna et al (21) which was by our observations.
Among the uropathogens isolated, the majority of the isolates were Gram-negative bacteria (95.2%) and a small percentage were Gram-positive bacteria (4.8%). The study by Serna et al (21) showed 95% of GNB 4.3% of GPC and 0.7% Candida. Jithendran et al(24) from Kerala reported similar observations.
Escherichia coli have been reported to be the most frequently isolated uropathogen in numerous studies and a similar observation was found in our study. E. coli (64%) was the predominant uropathogen isolated followed by Klebsiella (14.8%), Pseudomonas, Citrobacter, Enterococcus faecalis, Proteus, Enterobacter species, Staphylococcus aureus and Morganellamorganii. Similar findings were observed in various studies.(22), (25), (21).
Among Enterobacteriaceae, 49.6% of E. coli isolates and 39.3% of Klebsiella pneumoniae isolates were ESBL producers in our current study. In contrast to this, a study by Serna et al (21) from South America reported that 6.3% of the E. coli isolates and 15.4% of Klebsiella were ESBL producers. In a study by Ahmed et al(26) from Pakistan, 53.4 % of isolates of E. coli and 24.5 % of isolates of K. pneumoniae were ESBL producers. The percentage of ESBL producers appears to be less in the Western world compared to developing countries.
The reported overall prevalence of Carbapenemase Producing Enterobacteriaceae was 2.73% in a study by Eshetie et al(27) from Ethiopia and 10.8% by Amit Shah et al (28) from India. In our study prevalence of CRE was 8.9%. The percentage of CRE urinary isolates among children during 1999-2012fromthe USA database was 0.03%. (16) Based on the observations from our study and literature, the prevalence of resistant urinary isolates was dramatically high when compared with the developed countries.
Relatively high resistance to third-generationcephalosporins (66.9% of E. coli isolates) was observed in our study. Flavia Brad et al. (29), in their study, observed a high percentage of resistance to Ampicillin (86%), Cotrimoxazole (74%) and Cephalosporins (42-72%). Pourakbari, B. et al. (30), from Iran (2012), reported high resistance rates for E. coli against Cotrimoxazole (84%), Cefixime (50%) and Ceftriaxone (45%). In contrast to this, Mantadakis et al (20) from Greece reported a low resistance to third-generation cephalosporins (4%) and Cotrimoxazole (20.5%). From the above observations, we infer that a wide range of variability in antimicrobial resistance patterns exists among the isolates from different parts of the world.
In the present study urine analysis showed Pyuria in 93%, Leukocyte esterase positivity in 84%, Bacteriuria in 65.5% and Nitrite positivity in 55% of cases respectively. Serna et al. (21), reported that Pyuria was present in the majority of cases and Nitrite positivity the least. The sensitivity of the urine analysis results was in agreement with AAP clinical practice guidelines.
In the present study, the treatment response to empirical antibiotics was observed among the resistant uropathogens of the Enterobacteriaceae group. 168 children belong to Enterobacteriaceae. Of them, 92 children belong to the ESBL & Amp C producing organism group and 61 belong to the Non-ESBL producing organism group. In the comparison of treatment response to 3rd generation cephalosporins among the non-beta-lactamase and beta-lactamase producing groups, we observed that there is a difference in treatment response. Even though 58.4% of children infected with ESBL & Amp C producing organisms responded to 3rd generation cephalosporins, asignificant number of them failed to respond as well. Our observation correlates with the study conducted by Lee et al.(31), (2014) which showed that the mean time taken for defervescence and hospital stay was higher among the ESBL group. Microbiological clearance after 5 days of adequate treatment was only 77% among the ESBL group.
In the present study, 9 out of 15 children in the CRE group were started on Ceftriaxone and 5 of them showed clinical response and were continued with the same antibiotic. 3 were escalated to colistin and 1 to amikacin as per sensitivity reported. The 5 children who responded clinically showed microbiological persistence of the same uropathogen in the repeat urine culture without any symptoms of infection.
This study shows that resistant uropathogens were on the rise. Resistance to commonly prescribed empirical antibiotics like Cephalosporins and Cotrimoxazole was high. Sensitivity to Amikacin, Piperacillin-Tazobactum&Carbapenams was good which may be used in empiric treatment, especially in suspected high-risk cases.
This study highlights the significant burden of urinary tract infections (UTIs) in children, particularly those under 5 years of age. The emergence of antibiotic-resistant bacteria, such as ESBL and carbapenemase-producing Enterobacteriaceae, poses a major challenge in treating these infections. Early diagnosis, appropriate antibiotic therapy, and addressing underlying risk factors like voiding dysfunction and congenital anomalies are crucial for preventing complications and improving outcomes in children with UTIs.