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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 9  |  Issue : 2  |  Page : 137-141

Microbiologic spectrum and susceptibility pattern of urinary isolates from pediatric patients in a superspecialty Hospital: A 3-year experience


1 Department of Microbiology, Dr. BSA Medical College and Hospital, New Delhi, India
2 Department of Microbiology, G. B. Pant Hospital, New Delhi, India

Date of Web Publication29-Sep-2016

Correspondence Address:
Abha Sharma
Department of Microbiology, Dr. BSA Medical College and Hospital, Rohini, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2349-5006.191249

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  Abstract 

Introduction: UTI causes significant child morbidity and mortality. Enterobacteriaecae are most common uropathogens. Recently Enterococcus spp, yeast and Staphylococcus aureus have emerged as paediatric uropathogens. Understanding of local susceptibility pattern guides antibiotic therapy in UTI. This study describes demographic and susceptibility profile of uropathogens in children.
Method: The urinary isolates were analysed retrospectively and data on age, sex, result of urine culture, etiological agent and susceptibility pattern were obtained from laboratory record books.
Result: 315 urine samples analysed showed 34% significant bacteruria. Prevalence of UTI among male and female children was 62% and 37.9% respectively, statistically significant (P= .0329). Predominant uropathogens were Klebsiella spp. (66.6%), Escherichia coli (25.9%), Candida albicans (20.3%) and Enterococcus spp (15.7%). Bacteruria with pyuria was 26.03%. Sterile pyuria present in 9.52% of cases. A statistically significant correlation between Pseudomonas and pyuria was noted. Both Klebsiella spp and E coli were least susceptible to augmentin and cephalosporins (25%) and most susceptible to carbapenems. Proteus spp was most susceptible to aminoglycosides (75%) and Acinetobacter spp to Piperacillin-tazobactam (83.3%) while Pseudomonas to carbapenem (75%). Acinetobacter was most resistant with 100% resistance to augmentin, cephalosporins, aminoglycosides, fluoroquinolones and nitrofurantoin. All GNRs were 100% resistant to nitrofurantoin except E coli (39.2%) and Klebsiella spp (41.6% ) susceptible. Enterococcus were 100% sensitive while 87.5% of Staphylococcus aureus were sensitive to teicoplanin and linezolid.
Conclusion: Ongoing monitoring should note any changes in paediatric uropathogens and their antibiotic resistance pattern to guide the clinicians for proper empirical management of UTI in children.

Keywords: Children, urinary tract infection, uropathogens


How to cite this article:
Sharma A, Mishra B, Dogra V. Microbiologic spectrum and susceptibility pattern of urinary isolates from pediatric patients in a superspecialty Hospital: A 3-year experience. Indian J Health Sci Biomed Res 2016;9:137-41

How to cite this URL:
Sharma A, Mishra B, Dogra V. Microbiologic spectrum and susceptibility pattern of urinary isolates from pediatric patients in a superspecialty Hospital: A 3-year experience. Indian J Health Sci Biomed Res [serial online] 2016 [cited 2020 Jul 5];9:137-41. Available from: http://www.ijournalhs.org/text.asp?2016/9/2/137/191249


  Introduction Top


One of the important causes of morbidity and mortality during childhood, especially in the first 2 years of life, is urinary tract infection (UTI). [1],[2] The incidence of UTI has been reported as 7% in girls and 2% in boys during the first 6 years of life. [3] Escherichia coli and Klebsiella spp. are the most common causes of UTI in children similar to adults, [4] however recently, Enterococcus spp., yeast and Staphylococcus aureus are emerging as prominent UTI agents. [5],[6] Urine culture and antimicrobial sensitivity testing will guide proper management of children with UTI. Limited studies are available [5],[6],[7] on pediatric UTI in India. After a single episode of UTI, 15-41% of the children are thought to develop renal scarring which can cause long-term complications such as chronic kidney disease, proteinuria, and hypertension. [8],[9],[10] And so, prompt diagnosis and treatment of UTI is desirable. Empirical antibiotic therapy is often initiated even before culture results are available. In addition, there is a problem of increased antibiotic resistance among uropathogens worldwide, and this is likely to have clinical implications for the empirical use of antibiotics. [11] This study has been conducted to know the bacterial profile of pediatric uropathogens and their antimicrobial resistance pattern to guide the clinicians in deciding appropriate empirical treatment for pediatric UTI.


  Methods Top


This retrospective study analyzed the urinary isolates of children admitted in a super specialty hospital. Urine samples were obtained from children with suspected UTI who were admitted in the Intensive Care Unit (ICU). The period of study was from 2012 to 2014. Patients were children aged from 1 week to 14 years without a history of genitourinary abnormalities, antibiotic usage, or recent hospitalization. Data on age, sex, result of urine culture, etiological agent, and susceptibility pattern were obtained from laboratory record books. Midstream urine samples were collected from toilet-trained children and bladder catheter in young children and infants. Direct microscopic examination was done, and samples were inoculated on 5% sheep Blood agar and MacConkey's agar and were read after overnight incubation at 37°C. The urine cultures were classified as negative/positive/contaminated. The antibiotic sensitivity testing was performed when the result of urine culture was between 10 4 and 10 5 colony-forming unit [CFU]/ml in midstream samples and 10 2 CFU/ml in suprapubic samples/catheter samples in infants and young children. Identification of bacteria was done by Gram reaction, morphology, and biochemical tests. The antibiotic sensitivity testing was performed by Kirby-Bauer disc diffusion method. The commercial antibiotic discs used were augmentin (AMC), ceftriaxone, cefotaxime, cefoperazone, amikacin, gentamicin, norfloxacin, ofloxacin, piperacillin-tazobactam (PT), nitrofurantoin, imipenem, meropenem, and ertapenem for Gram-negative bacilli. For Gram-positive cocci (GPC), AMC, amikacin, cefepime, ofloxacin, norfloxacin, nitrofurantoin (NF), PT, linezolid (LZ), and teicoplanin (TEICO) were used. The statistical analysis of data was performed using the GraphPad software by Fisher's exact test for P value.


  Results Top


From 2012 to 2014, a total of 315 urine samples from children were submitted for analysis and culture. Out of these, 108 (34%) showed bacterial growth higher than 10 5 CFU/ml (95% confidence interval [CI] = 0.2905-0.3982). The prevalence of UTI among male and female children suspected to have UTI was 62% (95% CI = 0.5219-0.7120) and 37.9% (95% CI = 0.2880-0.4781), respectively, with a statistically significant association (P = 0.0329). Of these patients [Table 1], 4.6% (95% CI = 0.0152-0.1047) were infants and 54.6% (95% CI = 0.4476-0.6424) were more than 11 years old, statistically not significant (P = 0.7700). The predominant uropathogens were Klebsiella spp. (66.6%), followed by E. coli (25.9%), Candida albicans (20.3%), and Enterococcus spp. (15.7%).
Table 1: Uropathgenic profile of pediatric cases along with age and sex wise distribution

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[Table 2] shows the relation between bacteriuria and pyuria. The findings of this study showed that the presence of bacteriuria with pyuria was 26.03%. However, bacteriuria without pyuria was 1.9%. Sterile pyuria was seen in 9.52% of the urine specimens. The distribution of uropathogens according to the number of pus cells [Table 3] showed that there was a statistically significant correlation between Pseudomonas infection and presence of pyuria (>5 pus cells/high-power field [HPF]). Other urinary isolates had no statistical significance with pyuria.
Table 2: Distribution of bacteriuria and pyuria of all 315 cases

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Table 3: The relation between uropathogens and pus cells

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In vitro sensitivity testing of Gram-negative rods (GNRs) [Table 4] showed that both Klebsiella spp. and E. coli were least susceptible to AMC and cephalosporins (25%) and most susceptible to carbapenems. Proteus spp. was most susceptible to aminoglycosides (AMG) (75%) and Acinetobacter spp. to PT (83.3%) while Pseudomonas to carbapenem (75%). The most resistant uropathogen was Acinetobacter with 100% resistance to AMC, cephalosporins, AMG, fluoroquinolones (FQ), and NF. Almost all GNRs were 100% resistant to NF except E. coli (39.2% susceptible) and Klebsiella spp. (41.6% susceptible).
Table 4: Percentage susceptibility for Gram‑negative bacilli

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Among GPC [Table 5], almost 100% strains of Enterococcus were sensitive to TEICO and LZ while 87.5% of S. aureus were sensitive to TEICO and LZ.
Table 5: Percentage susceptibility of Gram‑positive cocci

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  Discussion Top


Many studies have been done on pediatric UTI s in the past. However, the significance of similar studies is that ongoing monitoring should be there to note any changes in the uropathogens and their antibiotic resistance pattern. Therefore, this retrospective study was conducted to describe the demographic and susceptibility profile of uropathogens in children suspected with UTI in a super specialty hospital. The understanding of the local susceptibility pattern of uropathogens is very essential for the proper management of UTI.

In our study, 315 urine samples from children suspected of having UTI were analyzed and 34% had a UTI. Another study in North India [7] reported 28.3% pediatric samples with a positive urine culture. Our tertiary care center is a super specialty hospital and 34% culture positivity indicates a high risk of UTI because usually the children are admitted for prolonged duration in the hospital in ICUs due to the underlying clinical condition. Most probably, the UTI is due to nosocomial transmission, as long-term indwelling catheterization and surgical interventions are major risk factors in these children. The majority of the urinary isolates were Gram-negative bacilli (GNR), with Klebsiella spp. being the most common uropathogen (66.6%), which is different in comparison to other studies, where authors have reported E. coli as the most common uropathogen. [7],[11],[12] However, one study has reported Klebsiella spp. as the most common pathogen with significance higher in males. [11] The prevalence of UTI was higher in males in our study (62%) as compared to females (37.9%), which was found to be statistically significant indicating that male gender was a risk factor in acquiring UTI in pediatric age group. Similar findings have been reported by Taneja et al. [7] Probably that is why Klebsiella spp. was the most common isolate in our study because of the male preponderance. However, many other studies have reported female preponderance in pediatric patients with UTI aged beyond 2 years. [13],[14] This implies the role of gender in the etiology of UTI and should be considered before the management of UTI. After Enterobacteriaceae, Candida spp. was the next common uropathogen with C. albicans being the common species as compared to adults where non-C. albicans is emerging as a major uropathogen in hospitalized patients. In our study, 15.7% of the uropathogens were Enterococcus spp., which is emerging as an important cause of UTI in children over the years.

The findings in our study showed that the presence of bacteriuria with pyuria (>5 pus cells/HPF) was 26.03%. Bacteriuria without pyuria was 1.9%, and sterile pyuria was seen in 9.52% samples. Other studies have reported bacteriuria with pyuria as high as 50% and bacteriuria without pyuria between 15% and 44%, which is much higher in comparison to our study (1.9%). [15],[16],[17] Sterile pyuria in our study was similar to 9% in the study done in Libya, [15] however it was much lower than that reported by Pead and Maskell (45%). [16] A statistically significant association of Pseudomonas infection was seen with pyuria (P = 0.0234). Other uropathogens showed no association with pyuria. One study [15] has reported E. coli having a significant association with pyuria (40%). Not much studies have been done on the association with the type of uropathogen with pyuria.

Ever since the problem of antibiotic resistance has been uniformly recognized, there has been an upsurge in literature addressing this issue. In relation to UTI in children, the resistance pattern of uropathogens has been evolving. Since UTI in children at our center was thought to be nosocomial mostly in origin as the children were hospitalized and catheterized in most of the cases, a high drug resistance was anticipated among uropathogens. For E. coli, Klebsiella spp., and Pseudomonas spp., carbapenems were the most sensitive, Proteus spp. was most susceptible to AMG and Enterococcus spp. was 100% susceptible to TEICO and LZ. All the Gram-negative bacilli except E. coli and Klebsiella were 100% resistant to NF. Resistance to FQ was also very high among the uropathogens. Rapidly increasing rates of highly fluoroquinolone-resistant E. coli isolates from urine have been reported from 1998-2001. [18]


  Conclusion Top


Our study was a small regional retrospective study showing a high antibiotic resistance level among uropathogens in children of a super specialty hospital. Gender plays an important role in the etiology of UTI. NF and FQ are the most resistant to uropathogens and therefore, not recommended for empirical therapy of UTI in children. Empirical therapy of UTI in children should be based on the local prevalence of the type of uropathogen and its antibiotic resistance pattern along with the age and gender of the children. We recommend a larger nationwide research to determine the true prevalence, demographic characteristics, etiology, and resistance pattern of pediatric uropathgoens.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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Jadresic LP. Diagnosis and management of urinary tract infections in children. Paediatr Child Health 2010;20:274-8.  Back to cited text no. 1
    
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Edlin RS, Shapiro DJ, Hersh AL, Copp HL. Antibiotic resistance patterns of outpatient pediatric urinary tract infections. J Urol 2013;190:222-7.  Back to cited text no. 3
    
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Narasimhan KL, Chowdhary SK, Kaur B, Mittal BR, Bhattacharya A. Factors affecting renal scarring in posterior urethral valves. J Pediatr Urol 2006;2:569-74.  Back to cited text no. 5
    
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Taneja N, Chatterjee SS, Singh M, Singh S, Sharma M. Pediatric urinary tract infections in a tertiary care center from North India. Indian J Med Res 2010;131:101-5.  Back to cited text no. 7
[PUBMED]  Medknow Journal  
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Chang SL, Shortliffe LD. Pediatric urinary tract infections. Pediatr Clin North Am 2006;53:379-400, vi.  Back to cited text no. 8
    
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Faust WC, Diaz M, Pohl HG. Incidence of post-pyelonephritic renal scarring: A meta-analysis of the dimercapto-succinic acid literature. J Urol 2009;181:290-7.  Back to cited text no. 9
    
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Berg UB, Johansson SB. Age as a main determinant of renal functional damage in urinary tract infection. Arch Dis Child 1983;58:963-9.  Back to cited text no. 10
    
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Mirsoleymani SR, Salimi M, Shareghi Brojeni M, Ranjbar M, Mehtarpoor M. Bacterial pathogens and antimicrobial resistance patterns in pediatric urinary tract infections: A four-year surveillance study (2009-2012). Int J Pediatr 2014;2014:126142.  Back to cited text no. 11
    
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Ilic T, Gracan S, Arapovic A, Capkun V, Subat-Dežulovic M, Saraga M. Changes in bacterial resistance patterns in children with urinary tract infections on antimicrobial prophylaxis at University Hospital in Split. Med Sci Monit 2011;17:CR355-61.  Back to cited text no. 12
    
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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.  Back to cited text no. 13
    
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Elder JS. Urinary tract infections. In: Kleigman RM, Behrman RE, Jenson HB, Stanton B, editors. Nelson Textbook of Pediatrics. 18 th ed. Philadelphia: Saunders Elsevier; 2007. p. 2223-7.  Back to cited text no. 14
    
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Khamees SS. Urinary tract infection: Causative agents, the relation between bacteriuria and pyuria. World Appl Sci J 2012;20:683-6.  Back to cited text no. 15
    
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Pead L, Maskell R. Study of urinary tract infection in children in one health district. BMJ 1994;309:631-4.  Back to cited text no. 16
    
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Ginsburg CM, McCracken GH Jr. Urinary tract infections in young infants. Pediatrics 1982;69:409-12.  Back to cited text no. 17
    
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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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