Clinical Profile and Antibiotic Sensitivity Pattern of Community Acquired Urinary Tract Infections in Children Attending a Tertiary Care Hospital in Assam, India

1. Associate Professor, Department of Paediatrics, Gauhati Medical College and Hospital, Guwahati, Assam, India. 2. Postgraduate Trainee, Department of Paediatrics, Gauhati Medical College and Hospital, Guwahati, Assam, India. 3. Assistant Professor, Department of Paediatrics, Gauhati Medical College and Hospital, Guwahati, Assam, India.

Abstract

Introduction: Urinary Tract Infection (UTI) is a common problem in children. It is a very common cause of fever in children after gastrointestinal and respiratory diseases. Uropathogens causing community acquired UTI is increasing due to changing antibiotic sensitivity pattern over time. Appropriate choice of antibiotic is crucial to prevent complications related to UTI.

Aim: To study the clinical profile, risk factors, associated pathogen spectrum and their antibiotic sensitivity pattern in community acquired UTI.

Materials and Methods: A cross-sectional observational study with 150 sample size was conducted in the Department of Paediatrics, Gauhati Medical College and Hospital, Guwahati, Assam, India and was carried out among children (1 month to 12 years of age) with community acquired UTI, over a period of one year in the state of Assam. Fresh urine samples were collected by clean catch mid-stream method for toilet trained children and by transurethral catheterisation for infants and young children. It was followed by routine urine examination and culture and sensitivity testing to diagnose UTI. Descriptive statistics was used to describe the results Proportion test was used for statistical evaluation.

Results: Majority of UTI cases were in the age group 1-5 years (57.3%) and there was female preponderance (59.3%). Fever was the most common presentation (55.3% cases) in the present study. This was followed by poor feeding (12.6%), lower abdominal pain (10.6%), failure to gain weight (10.6%). In urinalysis, 87 cases (58%) showed pyuria, 6 cases (4%) showed significant haematuria. Most prevalent uropathogens in the present study was Escherichia coli (E.coli) (66%cases), followed by Enterococcus sp. (16.7%), Klebsiella sp. (14%). E.coli had maximum sensitivity for nitrofurantoin (90.9%). It was followed by amikacin (80%), co-trimoxazole in 64.6% and gentamycin in 62.6% cases.

Conclusion: All fever cases in children should be screened to rule out UTI. All UTI cases should undergo culture and sensitivity testing to determine the sensitivity pattern.

Antimicrobial agents, Paediatric infection, Renal scarring, Uropathogen

Infection of the urinary tract system is a common problem in the community. The overall prevalence of UTI in the population is 11% (1). UTI is common in children consisting 3% of all paediatric infections (2). The prevalence of UTI among children visiting medical emergency is 5-14% (3),(4). Mostly children present with fever. Any children presenting with unexplained fever more than 38°C should be evaluated for UTI (5). However, other clinical features for older children can be dysuria, pain abdomen, increase frequency of urine, but younger children most of the time present with non specific symptoms like vomiting, failure to thrive, jaundice etc. It is more common in male than female in neonatal and early infancy period, after that female preponderance is evident (5). It is associated with several risk factors such as recent catheterisation, cleaning perineum from back to front, constipation, usage of tight underclothing, diaper usage, worm infestation, neurological abnormality, voluntary withholding of urine etc., (6). Also, UTI can be associated with long-term complications like hypertension, impaired renal function, end-stage renal disease etc., especially when timely proper antibiotic has not been administered (7). Hence, early diagnosis and early initiation of appropriate antibiotic therapy is necessary to prevent these complications. Again, the prevalence of the uropathogens causing UTI i.e., E.coli, Klebsiella, Proteus, Enterococcus etc., and their sensitivity pattern to antibiotics vary among different geographic areas around the world. Moreover, emergence of antibiotic resistance among these uropathogens is a concern now-a-days (2). Therefore, reviewing the sensitivity profile of the bacteria through scientific research from time to time is important to guide the treatment so that, authors can start empirical antibiotic therapy while waiting for urine culture and sensitivity report.

Till now, no data is available regarding clinical profile and antibiotic sensitivity pattern in community acquired UTI among children in Assam, however a few studies done on adult population are available for review (8),(9). Hence, considering all these facts, the present study was conducted with the objective to study the clinical profile, risk factors, associated pathogen spectrum and their antibiotic sensitivity pattern in community acquired UTI.

Material and Methods

This was a cross-sectional observational study which was conducted in the Department of Paediatrics, Gauhati Medical College and Hospital, Guwahati, Assam, India, from 1st May 2020 to 30th April 2021. The proposed format was passed by the ethics committee of Gauhati Medical College and Hospital. Ethical approval number given was 190/2007/pt-11/Dec- 2019/03. Informed written consent was taken from the parents of the children enrolled in the study in their native language.

Sample size calculation: Considering the prevalence of UTI among children visiting healthcare facility to be 10%, the present study was conducted with sample size of 150 patients (7),(10),(11). Sample size was calculated using Danial’s formula: Sample size, n=Z²p(1-p)/d².

Inclusion criteria: Patient in the age group of one month to 12 years attending Paediatric Emergency and Outpatient service with suspicion for urinary infection were worked up and only the urine culture positive cases were enrolled in the study.

Exclusion criteria: Patients were excluded if: (a) they had history of antibiotic usage in last one week; (b) acquired infection in the hospital after 48 hours of hospitalisation for other reason (12); (c) with known congenital genitourinary anomalies; and (d) recurrent UTI. A total of 150 patients were included in the study and 60 patients were excluded.

Study Procedure

History was taken enquiring age of the patient, presenting complaint with duration, past illness with urinary complaints and fever, any surgical intervention done for urinary tract abnormality, whether there is history of constipation, pin worm infestation etc. Physical examination was performed to check the vitals of the child and for preliminary systemic survey. Data was collected in pretested proforma.

Fresh urine samples were collected by clean catch mid-stream method for toilet trained children and by transurethral catheterisation for infants and young children. It was followed by routine urine examination and culture and sensitivity testing to diagnose UTI. Total leucocyte count was done in all cases. Additional tests like Ultrasonography of kidney-urinary bladder and Micturating Cystourethrogram (MCU) were done as per the need of the patient. In routine examination of urine >5 pus cells/HPF in centrifuged sample were considered for pyuria (13) and >5 red blood cells/HPF for haematuria (14). Urine culture was done using CLED agar plate and sensitivity was checked using Vitek 2 Compact, Identification and Antibiotic Sensitivity Testing System. In the present study, for Midstream clean catch urine sample, more than or equal to 105 CFU/mL was considered significant for infection and for urethral catheterisation sample, more than or equal to 5×104 CFU/mL was considered significant to have infection (14).

Statistical Analysis

The data collected from the patients were formatted into Microsoft excel sheets to generate master chart, tables, and graphs. Diagrammatic representations were used to depict significant clinical data from patients with culture proven UTI. Descriptive statistics was used to describe the results. Proportion test was used for statistical evaluation. A p-value less than 0.05 was considered as statistically significant at 5% level of significance and p-values calculated using Chi-square test. SPSS software version 28 was used to analyse the data.

Results

The study was conducted with sample size of 150 from age one month to 12 years. Out of that 67 were male and 83 female. Majority of the cases were in the 1-5 year age group (57.3%). In infancy, 20.7% cases were seen (Table/Fig 1).

Regarding gender distribution, it was found that female 89 cases (59.3%) and male 61 cases (40.6%) in the present study. Fever was the most common presentation (55.3% cases) in the present study. This was followed by poor feeding (12.6%), lower abdominal pain (10.6%), failure to gain weight (10.6%), increase frequency of micturition (10.7%), vomiting (10%), burning micturition (6.7%). The present study found maximum number of fever cases presented in the age group of 1-5 years (60 cases, 40%) and this was statistically significant (p<0.001). Lower abdominal pain was the presenting symptom of UTI, mostly in the age group of 5-10 years (13 cases, 8.6%) (p-value=0.12). Failure to gain weight was most common presenting feature in infancy (12 cases, 8%). Burning micturition was the clinical presentation in children with UTI in more than five years age group in the present study. Total of 6.7% cases presented with this symptom in the present study. Total of 10.6% cases in the study had increase frequency of micturition as a clinical feature. Maximum children with increased frequency of micturition (10 out of 16 cases, 6.7%) were found in the age group 1-5 years (Table/Fig 2).

Out of 150, 4.7% cases with UTI were associated with diaper rash, 2% were associated with constipation and 2% with pin worm infection (Table/Fig 3).

In the present study, most prevalent uropathogen was E.coli (66%), followed by Enterococcus sp. (16.7%), Klebsiella sp. (14%). Least commonly found organisms were Candida 2 (1.3%) and Morganella 3 (2%) as revealed from the urine culture studies (Table/Fig 4). E.coli was the most common organism in all age group and most children with E.coli infection were presented with fever (51.5%), followed by poor feeding (15.2%), failure to gain weight (11.1%), pain abdomen (10.1%), increased frequency of micturition (8.1%), burning micturition (7%).

It was seen that, E.coli had maximum sensitivity for nitrofurantoin (90.9%). It was followed by amikacin (80%). It was sensitive to co-trimoxazole in 64.6% cases, gentamycin in 62.6% cases, tigecycline in 56.6% cases, to meropenem 54.4% cases, piperacillin in 53.5% cases. It shows Enterococcus had highest sensitivity for linezolid (92%) and vancomycin (92%). It is followed by its sensitivity for teicoplanin (88%), tetracycline (84%), tigecycline (76%). Klebsiella was sensitive to amikacin (76.2%), aztreonam (76.2%) and colistin (76.2%) in maximum number cases (Table/Fig 5).

Further, in the present study total 83 out of 150 (55.3%) cases presented with leucocytosis and maximum number was in the age group of 1-5 years (51 cases) (Table/Fig 6).

In urinalysis, 87 cases (58%) showed pyuria, 6 cases (4%) showed significant haematuria and significant urine albumin present in 24% cases. Again, in ultrasonographic evaluation of kidney-urinary bladder in the present study, 4 out of 150 (2.7%) cases were found to have posterior urethra valve, 13 out of 150 (8.6%) cases had cystitis.

Discussion

The present study determined the distribution and antibiotic susceptibility pattern of microbial species isolated from paediatric patients with community acquired UTI from a tertiary care centre along with clinical profile. In the present study, maximum prevalence of UTI was found in the age group of 1-5 years. Other workers like Patel AH et al., Sharma A et al., from different parts of the country found similar picture (15),(16). Patel AH et al., had 41.07% cases and Sharma A et al., had 50% cases in this age group of 1-5 years (15),(16). On the other hand, in the study by Gupta P et al., maximum cases found to be in infants (56.4%) (17).

The present study showed there was female preponderance among the cases (55.3%) and this was concordant with the findings in the studies reviewed. Patel AH et al., found 57.1% female in their study, Bhonsle K et al., found 54% female, Singh SD and Madhup SK found 67.4% female cases among the cases positive for UTI (15),(18),(19). This is because of shorter urethra, close approximation of urethral opening and anal canal in female, which makes them susceptible to contamination with faecal flora and ascent of faecal flora into the urinary tract.

Among clinical features, fever was most common in the present study (55%), and others are pain abdomen, vomiting, failure to gain weight, burning micturition, increase frequency of micturition, poor feeding. Different researchers from different parts of the country also found fever as the most common clinical presentation of UTI in children. Patel AH et al., had 69.6% patients presenting with fever, Singh SD and Madhup SK had 74.8% cases, Badhan R et al., had 41.7% (15),(19),(20).

In the present study, 4.7% cases with UTI were associated with diaper rash, 2% were associated with constipation and 2% with pin worm infection. Malla KK et al., found constipation in 7.1% cases with UTI (21). Patel AH et al., found constipation in 5.4% cases with UTI (15). Regarding routine urine examination this study showed 58% cases of pyuria. This was comparable with findings of Hanna-Wakim RH et al., who showed in their study 60.1% cases had pyuria (22). However, in the study done by Sriram G et al., found that 13.5% cases had pyuria (23).

Again, in the present study E.coli was the most common uropathogen associated with UTI (66%), followed by Enterococcus and Klebsiella. This finding was supported by finding from other studies reviewed. Bhonsle et al., had 60.3% cases and Badhan R et al., had 42.3% infections with E.coli (18),(20). Patel AH et al., had 58.9% cases, Gupta P et al., had 68.3% cases, Sriram G et al., had 54.5% cases and Kaur N et al., had 45.4% cases (15),(17),(23),(24). Among the gram-positive organism Enterococcus was found to a causative agent in the present study (16.7%) cases.

Also, the present study observed that sensitivity of E.coli to nitrofurantoin is 90.9%. This comparable to the findings in Patel AH et al., (100%), Gupta P et al., (100%), Badhan R et al., (94%), Kaur N et al., (95%) (15),(17),(20),(24). It was found in this study that sensitivity of E.coli to amikacin was in 80.8% cases. This finding is comparable to the studies done by, Patel AH et al., (90.9%), Gupta P et al., (90.7%) and Patwardhan V et al., (89.8%). Sensitivity of E.coli to amoxiclav was 46.5% in this study. This value is near to the values found in the studies done by Patel AH et al., (48.5%) and Patwardhan V et al., (51.8%) (15),(25); whereas Kaur N et al., recorded only 29% cases to be sensitive to amoxiclav (24). Also, found in this study that E.coli was sensitive to Trimethoprim sulfamethoxazole in 64.6% cases, gentamycin in 62.6% cases, tigecycline in 56.6% cases, meropenem in 54.4% cases, piperacillin in 53.5% cases. The (Table/Fig 7) shows comparative sensitivity of most common organism causing UTI in children i.e., E.coli, from different studies reviewed (15),(17),(20),(24),(25).

The present study showed Klebsiella were most sensitive to amikacin (76.2%). Patel AH et al., Badhan R et al., were also reported comparable values, 77.8% and 71%, respectively (15),(20).

However, Gupta P et al., had 53.3% cases and Kaur N et al., had 59% cases of Klebsiella with sensitive to amikacin (17),(24).

It was also found from the present study that Enterococcus had maximum sensitivity for Linezolid (92%) and vancomycin (92%). However, Gupta P et al., found in their study that Enterococcus was 96.8% sensitive to meropenem (17). Kaur N et al., from their study found that Enterococcus was most sensitive to Nitrofurantoin (24). From the present study, the authors have seen that most of the uropathogens are not sensitive to commonly used oral antibiotics like co-amoxiclav, co-trimoxazole. Klebsiella is sensitive to no oral antibiotics and Enterococcus is sensitive to linezolid only, among oral antibiotics.

Limitation(s)

One of the limitations of the present study was that, it was an observational study. Moreover, it was a small study and sample size was small. Further, the study was conducted in a short period.

Conclusion

All fever cases in children should be screened to rule out UTI. High suspicion should be kept in case of infants, to detect UTI with the aim to prevent urosepsis and renal scarring. Improper and overzealous use of antibiotic should be stopped to prevent emergence of new resistant strains of bacteria. Also, over the counter selling of antibiotics should be stopped. Regional surveillance program can be conducted periodically in each region to know the prevalent uropathogens pattern and their change in antibiotic susceptibility pattern in the community level.

DOI and Others

DOI: 10.7860/JCDR/2023/62444.17654

Date of Submission: Dec 22, 2022
Date of Peer Review: Jan 06, 2023
Date of Acceptance: Feb 09, 2023
Date of Publishing: Mar 01, 2023

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

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ETYMOLOGY: Author Origin