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Research Article | Volume 13 Issue:1 (, 2023) | Pages 1525 - 1532
Clinical Characteristics of Urinary Tract Infections and Antibiotic Resistance Patterns in A Tertiary Care Facility
 ,
1
Assistant Professor, Department of Paediatrics, Alluri Sitaramaraju Academy of Medical Sciences and Research Center, Eluru, Andhra Pradesh. India
2
Assistant Professor, Department of Paediatrics, Bhaskar Medical College, Yenkepally, Moinabad, Telangana. India
Under a Creative Commons license
Open Access
DOI : 10.5083/ejcm
Received
Jan. 29, 2023
Revised
Feb. 8, 2023
Accepted
Feb. 25, 2023
Published
March 20, 2023
Abstract

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:

  • To describe the clinical profile of infants and children hospitalized with urinary tract infections.
  • To study the current antibiotic susceptibility patterns of the prevailing urinary pathogens.
  • To study the treatment outcome of urinary tract infections in children.

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.

Keywords
INTRODUCTION

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:

  • To describe the clinical profile of infants and children hospitalized with urinary tract infections.
  • To study the current antibiotic susceptibility patterns of the prevailing urinary pathogens.
  • To study the treatment outcome of urinary tract infections in children.
MATERIALS AND METHODS

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:

  • Children between 0-18yrs of age
  • Hospitalized children diagnosed with urinary tract infection (Culture proven)

 

Exclusion Criteria:

  • Children visiting the outpatient department with urinary tract infection
  • Children with Hospital Acquired Urinary Tract Infection
  • Children, whose urine culture showed insignificant (or) mixed growth of urinary pathogens
  • Children, whose urine culture showed fungal growth

 

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-

  1. Any number of colony forming units in supra-pubic sample.
  2. >5 x 104 CFU in the catheterized sample.
  3. >105 CFU in mid-stream clean catch sample.

 

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.

RESULTS

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)

(25)

0.003 (0.257)

Constipation

29 

(19)

(19.4)

0.960

Congenital anomalies of the kidney and urinary tract

19 

(12.5)

11 

(30.5)

0.008 (0.325)

Spinal anomalies

(2.6)

(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).

DISCUSSION

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.

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. 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.

REFERENCES
  1. Watson AR, Taylor CM, McGraw M. Disorders of the urinary system. Forfar and Arneil’s Textbook of Pediatrics, 6th eds. Neil McIntosh, Peter Helms, Rosalind Smyth. Churchill Livingstone, Spain 2003: 613-20.
  2. Schlager TA. Urinary tract infections in children younger than 5 years of age: epidemiology,
  3. diagnosis, treatment, outcome and prevention. Paediatr Drugs. 2001; 3:219-27.
  4. Czaja CA, Scholes D, Hooton TM, Stamm WE. Population-based epidemiologic analysis of acute pyelonephritis. Clin Infect Dis. 2007;45(3):273-80.
  5. Echols RM, Tosiello RL, Haverstock DC, Tice AD. Demographic, clinical, and treatment parameters influencing the outcome of acute cystitis. Clin Infect Dis. 1999;29(1):113-9.
  6. Habte TM, Dube S, Ismail N, Hoosen AA. Hospital and community isolates of uropathogens at a tertiary hospital in South Africa. S Afr Med J. 2009;99(8):584.
  7. Kahlmeter G. An international survey of the antimicrobial susceptibility of pathogens from uncomplicated urinary tract infections: the ECO.SENS Project. J AnAntimicrobChemother. 2003;51(1):69-76.
  8. Gupta K, Hooton TM, Naber KG, Wullt B, Colgan R, Miller LG et al. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: A 20 10 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis. 2011;52(5): e103-20.
  9. World Health Organization. Urinary Tract Infections in Infants and Children in Developing Countries in the Context of IMCI. 2005. Available at: https://apps.who.int/iris/handle/10665/69160.
  10. Elder JS. Urinary disorders in infants and children. In: Kliegman RM, Geme III JWS, Behrman RE. Editors. Nelson Textbook of Pediatrics, 21st Edition. New Delhi: Elsevier. 2020.
  11. Naber KG, Schito G, Botto, H, Palou J. and Mazzei T. Surveillance study in Europe and Brazil on clinicalaspects and Antimicrobial Resistance Epidemiology in Females with Cystitis (ARESC): implications for empiric therapy. EurUrol 2008;54(5):1164-75.
  12. Foxman B. Epidemiology of urinary tract infections:incidence, morbidity, and economic costs.Am J Med 2002;113:5-13.
  13. Dehbanipour R, Rastaghi S, Sedighi M, Maleki N, FaghriJ. High prevalence of multidrug-resistance uropathogenicEscherichia coli strains, Isfahan, Iran. J Nat SciBiol Med 2016;7:226.
  14. Indian Society of Pediatric Nephrology, Vijayakumar M, Kanitkar M, Nammalwar BR, Bagga A. Revised statement on management of urinary tract infections. Indian Pediatr. 2011 Sep; 48(9):709–17.
  15. Williams G, Craig JC. Long-term antibiotics for preventing recurrent urinary tract infections in children. Cochrane Database Syst Rev. 2011 ;( 3):CD001534.
  16. Baumer JH, Jones RW. Urinary tract infection in children, National Institute for Health and Clinical Excellence. Archives of disease in childhood-Education & practice edition. 2007 Dec 1; 92(6):189-92.
  17. Ducel G, Fabry J, Nicolle L. Prevention of hospital-acquired infections: a practical guide. Prevention of hospital-acquired infections: a practical guide. 2002(Ed. 2).
  18. Logan LK, Renschler JP, Gandra S, Weinstein RA, Laxminarayan R, for the Centers for Disease Control and Prevention Epicenters Program. Carbapenem-Resistant Enterobacteriaceae in Children, United States, 1999–2012. Emerg Infect Dis. 2015 Nov; 21(11):2014–21.
  19. Patel P, RN GaralaRng. Bacteriological profile and antibiotic susceptibility pattern (antibiogram) of urinary tract infections in paediatric patients. J Res Med Dent Sci. 2014; 2(1):20.
  20. Magliano E, Grazioli V, Deflorio L, Leuci AI, Mattina R, Romano P, et al. Gender and Age-Dependent Etiology of Community-Acquired Urinary Tract Infections, Gender and Age-Dependent Etiology of Community-Acquired Urinary Tract Infections. Sci World J Sci World J. 2012 Apr 26; 2012, 2012:e349597.
  21. Gupta P, Mandal J, Krishnamurthy S, Barathi D, Pandit N. Profile of urinary tract infections in paediatric patients. Indian J Med Res. 2015 Apr; 141(4):473–7.
  22. Mantadakis E, Tsalkidis A, Panopoulou M, Pagkalis S, Tripsianis G, Falagas ME, et al. Antimicrobial susceptibility of pediatric uropathogens in Thrace, Greece. IntUrolNephrol. 2011 Jun; 43(2):549–55.
  23. Sharma A, Shrestha S, Upadhyay S, Rijal P. Clinical and bacteriological profile of urinary tract infection in children at Nepal Medical College Teaching Hospital. Nepal Med Coll J NMCJ. 2011 Mar; 13(1):24–6.
  24. Zorc JJ, Kiddoo DA, Shaw KN. Diagnosis and Management of Pediatric Urinary Tract Infections. ClinMicrobiol Rev. 2005 Apr; 18(2):417–22.
  25. Levy Hara G, Gould I, Endimiani A, Pardo PR, Daikos G, Hsueh P-R, et al. Detection, treatment, and prevention of carbapenemase-producing Enterobacteriaceae: recommendations from an International Working Group. J Chemother Florence Italy. 2013 Jun; 25(3):129–40.
  26. Jitendranath A, Radhika R, Bhargavi L, Bhai G, Beevi R. Microbiological Profile of Urinary Tract Infection in Pediatric Population from a Tertiary Care Hospital in South Kerala. J Bacteriol Mycol. 2015 Jun. Vol 1, Issue 1. Open Access 1(1): 00002. DOI: 10.15406/jbmoa.2015.01.00002
  27. Nisha K. V, Rathika D. Shenoy, A. Veena Shetty, Vijaya M. Shenoy, Avinash K. Shetty. “Trends in Antimicrobial Resistance among Uropathogens with Special Reference to Escherichia coli in Community-Acquired Pediatric Urinary Tract Infections from Kerala”. Journal of Evolution of Medical and Dental Sciences 2015; Vol. 4, Issue 54, July 06; Page: 9313-9320.
  28. Eshetie S, Unakal C, Gelaw A, Ayelign B, Endris M, Moges F. Multidrug-resistant and carbapenemase-producing Enterobacteriaceae among patients with urinary tract infection at Referral Hospital, Northwest Ethiopia. Antimicrob Resist Infect Control. 2015; 4:12.
  29. Shah A, Vinzuda M, Prajapati B, Rajput A, Kadam M. Clinico-Microbiological Profile of Urinary Tract Infection in Tertiary Care Hospital in Ahmedabad, Gujarat, India. Int. J. Curr. Microbiol. App. Sci. 2015; 4(9):288-95.
  30. Giorgiana-Flavia Brad I, Marcovici T, Mariş I, Dăescu C, Belei O, Vetesi T, Nilima K, Hoduţ A, Popoiu CM. Antibiotic Resistance In Urinary Tract Infections In Children. JurnalulPediatrului. 2010. Vol.13: p51-52.
  31. Yolbaş I, Tekin R, Kelekci S, Tekin A, Okur MH, Ece A, et al. Community-acquired urinary tract infections in children: pathogens, antibiotic susceptibility and seasonal changes. Eur Rev Med Pharmacol Sci. 2013 Apr; 17(7):971–6.
  32. Lee B, Kang SY, Kang HM, Yang NR, Kang HG, Ha IS, et al. Outcome of Antimicrobial Therapy of Pediatric Urinary Tract Infections Caused by Extended-Spectrum β-Lactamase-Producing Enterobacteriaceae. Infect Chemother. 2013 Dec; 45(4):415–21.
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