Download Frequency and causative agents of urinary tract infection and their

Frequency and causative agents of urinary tract infection and their antimicrobial
susceptibilities among children in Sana'a city Yemen.
Abstract
Objective: To determine the frequency and causative agents of UTI and their
antimicrobial susceptibilities among children in Sana'a city.
Methods: A cross sectional study was carried out from January to October 2015 in
Specialized Sam Pediatric Center and Al-Mamoon Diagnostic Medical Center. Out of
740 urine samples from patients suspected of having a UTI were analyzed, 282 were
culture-positive and included in this study. Isolated bacteria were identified by
standard tests, the bacterial strains were identified using biochemical testes and
antibiotic susceptibility was determined by disk diffusion method. Data about the
age, gender and the duration of symptoms were collected.
Results: A total of 282 children were having a UTI, their age ranged from <1-15 years
with a frequency of 38.11% (36 males and 246 females). Bacterial isolates included
Escherichia coli 231 (81.91%), Pseudomonas aeruginosa 18 (6.38%), Staphylococcus
aureus 15 (5.31%), Klebsiella spp and Enterococcus 6 (2.1%). Bacterial culture
revealed that, Escherichia coli is susceptible to nitrofurantoin (88.06%), azithromycin
(76.79%), cefotaxime (67.19%), cefuroxime (54.84%), cefixim (54.67%), amoxicillinclavulanic acid (44.16%) and trimethoprim–sulfamethoxazole (41.33%)
Conclusion: Escherichia coli was the predominant pathogens isolated followed by
Pseudomonas aeruginosa, Staphylococcus aureus, Klebsiella spp and Enterococcus.
The most effective antibiotics were nitrofurantoin, azithromycin, cefotaxime,
cefuroxime, cefixim and amoxicillin-clavulanic. Therefore, urine culture is essential
for a UTI diagnosis as well as for proper antimicrobial empirical therapy selection.
Keywords: Urinary tract infection, Bacterial agents, Antibiotics.
Introduction. Urinary tract infection (UTI) is one of the most common infectious
diseases and is an important cause of morbidity and mortality in children. The
reported incidence of UTI is 7% among girls and 2% among boys during the first 6
years of life.1 Most Urinary tract infections in children result from ascending
infections, although hematogenous spread may be more common in the first 12
weeks of life. Infected urine motivates an immunological and inflammatory reaction,
which may lead to renal injury and permanent kidney damage.2,3,4 Therefore, early
diagnosis of UTI and prompt therapy are important in the avoidance of long-term UTI
sequelae.5 The symptoms and signs of UTI vary markedly with age and are not a
dependable indicator of infection in infants and children, where no specific symptoms
can be used to identify UTI.3,6 They may present with fever, colic, irritability, jaundice,
vomiting, or failure to thrive.7 While the classic signs such as dysuria, frequency,
urgency, hesitancy, small-volume voids, or lower abdominal pain begin to appear in
the older children with UTI. Urinalysis alone is not sufficient for diagnosing UTI but it
can help in ruling out urinary tract infections in cases with low clinical suspicion.
While urine culture is essential for a definitive diagnosis of UTI in children if there is
high clinical suspicion, cloudy urine, or if urine dipstick testing shows positive
leukocyte esterase or nitrite activity.3,8 The most common bacteria isolated from
urine samples from children with UTI is Escherichia coli, which constitute 80%. While,
Klebsiel1a, Proteus and Enterobacter constitute smaller proportions of UTI cases. 9
Empirical antibiotic treatment is frequently recommended even before the culture
results are available which is dependent on a number of factors, the predominant
bacteria in the patient's age group, the sensitivity pattern of bacteria to antibiotics in
the practice area, the clinical status of the patient, the opportunity for close followup, and cost of treatment.10,6 However, regular monitoring of resistance patterns is
essential to improve plans for empirical antibiotic therapy.11,12
The aim of the study is to determine the bacterial etiologic agents of urinary tract
infections and their antibiotic sensitivity patterns among children in Specialized Sam
Pediatric Center and Al-Mamoon Diagnostic Medical Center.
Patients and methods
A cross sectional study was carried out in Specialized Sam Pediatric Center and AlMamoon Diagnostic Medical Center during ten months from January to October
2015. Both centers offers services to the community by outpatient clinics and
laboratory departments and receives patients from Sana'a city, adjacent areas and
occasionally from other governorates, along with referred cases from private clinics.
Sample size and collection: The sample comprised 740 children of both gender their
age ranged from below 1-15 years with clinical suspicion of UTI. Information
regarding age, gender, male circumcision and the duration of symptoms were
collected.
Inclusion criteria: All patients who were diagnosed as UTI, which based on clinical findings
and laboratory investigations, were included in the study. Almost all patients who
suspected of having a UTI that had clinical findings (one or more symptoms and/or
signs) of the UTI were recorded and underwent laboratory investigations. Clinical
findings of UTI included urgency, frequency, dysuria or abdominal pain usually
present in older children, other features commonly present in younger children
failure to thrive, irritability, jaundice, vomiting, colic, unexplained fever…..etc.
Laboratory investigations. Mid-stream, voided urine samples from toilet-trained
patients were collected in sterile wide-mouthed containers and non-toilet-trained
children urine samples were collected in sterile urine bags with instruction on how
perineal/genital cleaning in any age of child to reduce the risk of contamination. The
urine samples were examined macroscopically for color and turbidity and looking for
pH, glucose, protein and nitrite using dipstick. The centrifuged sediment samples
were examined microscopically for the presence of red blood cells, white blood cells
(pus cells), protozoa, yeasts and crystals.
Isolation and identification of organisms using HI media. All fresh samples were
labelled and transported to the laboratory for analysis within one hour of collection.
Inoculated onto blood agar and MacConkey agar (HIMEDIA) and incubated at 37 °C
for 24 hours, and for 48 hours in negative cases. All positive cultures were recognized
by their specific appearance on their own media and gram-staining reaction and
confirmed by the pattern of biochemical reactions using the standard method.
Growing bacterial colonies were recognized by standard bacteriological techniques
and susceptibility was determined by disk diffusion method. National Committee on
Clinical Laboratory Standards (NCCLS) recommendations, using Mueller–Hinton
medium.13 Antimicrobial agents tested were nitrofurantoin, azithromycin,
cefotaxime, cefuroxime, cefixim, amoxicillin-clavulanic, ceftriaxone and
trimethoprim–sulfamethoxazole.
Exclusion criteria: patients who had no symptoms suggestive of UTI at the time of
presentation or patients on corticosteroid or antibiotic therapy or patients with
history of hospitalization a week before their attendance to outpatient clinic to rule
out hospital-acquired infections.
Urinary Tract Infection: UTI diagnosis requires both the presence of symptoms and
growth of a significant number of organisms that grows more than 100,000
colonies/ml of a single organism on an appropriately collected urine specimen.
Ethical approval and consent. Medical Corporation of Specialized Sam Pediatric
Center and Al-Mamoon Diagnostic Center approved the study. Consent approvals
were taken from the parents and caregivers of children involved in the study.
Results: Out of 740 urine samples from patients suspected to have a UTI were
analyzed and 282 of them were positive for bacterial infection, providing a frequency
of 38.11%. Males were 36 (13%) and all were circumcised, females were 246 (87%),
male to female ratio of 0.15:1 and their age ranged from below 1-15 years. The
frequency of bacterial isolates showed that Escherichia coli strains were 231 (81.91%),
Pseudomonas aeruginosa 18 (6.38%), Staphylococcus aureus 15 (5.31%), Klebsiella
spp and Enterococcus 6 (2.1%). Escherichia coli in children younger than 5 years of
age was 147 (64%) and was more frequently in females (94.37%) compared to
(5.63%) in male (p = < .00001.) as well as Pseudomonas aeruginosa was more in
females (55.55%). Whereas Staphylococcus aureus in children older than 5 years of
age was more in males (60%) than in females (40%) as shown in table 1. Bacterial
culture revealed that, E. coli strains were susceptible to nitrofurantoin (88.06%),
azithromycin (76.79%), cefotaxime (67.19%), cefuroxime (54.84%), cefixim (54.67%),
amoxicillin-clavulanic acid (44.16%) and trimethoprim–sulfamethoxazole (41.33%)
table 2. Pseudomonas aeruginosa was susceptible to azithromycin (83.33%),
cefotaxime (80%), nitrofurantoin and cefuroxime (40%), co-trimoxazol (33.33%) and
cefixim (16.67%). Staphylococcus aureus was susceptible to amoxicillin-clavulanic acid
and trimethoprim–sulfamethoxazole (100%), cefotaxime and cefuroxime (80%) and
azithromycin (60%) table 3.
Discussion
Urinary tract infection (UTI) is the most common bacterial infections disease among
children.14,6 In the present study, the overall growth positive rate of samples from
patients suspected of having a UTI (38.11%) was nearly in agreement with previous
study15 which revealed the frequency of urinary tract infections was 36.8% but it was
in disagreement with many studies. In Muoneke V et al study,6 the prevalence rate of
UTI was 3.0%, in Rabasa AI, Gofama MM study,16 the prevalence of UTI was 13.7%, in
Musa-Aisien AS et al study,17 the prevalence was 9% and studies carried out in
Tabrizand and Qazvin, the prevalence of UTI was 13.2% and 7.2% respectively. 13
These differences of the prevalence rate of UTI can be attributed to the symptoms
and signs of UTI vary markedly with age, infants and children younger than 2 years
with UTI present with nonurinary tract manifestations such as feeding problem,
diarrhea, unexplained fever, colic pain, irritability or failure to thrive. Older children
may present with dysuria, urgency frequency or abdominal pain. The high prevalence
rate may be noted when the urine culture carried out in highly suspected patients
where there is cloudy urine, or urine dipstick testing shows positive leukocyte
esterase or nitrite activity.
In this study, the prevalence of UTI in females (87%) and in males (13%) was nearly
similar to a study15 that revealed females were 272 (90.1%) and males were 30
(9.9%). However, it was varied partially with a study 12 that revealed male to female
ratio was 1:1.8 (34.9% males, 65.1% female) as well as a study of Shaikh N et al. 18 But
it was in contrast with Mirsoleymani SR et al study19 that showed UTI was more
frequent in males (54.9%). This may be explained by the short urethra in girls
predisposing them to UTI and uncircumcised male infants are at risk of UTI during the
first year of life where they had a 4.27 -fold increase in incidence of UTI compared
with circumcised infant males.20
In the current study, bacterial isolates were Escherichia coli strains 231 (81.91%),
Pseudomonas aeruginosa 18 (6.38%), Staphylococcus aureus 15 (5.31%), Klebsiella
spp and Enterococcus 6 (2.1%). This study agrees partially with a study that revealed
bacterial isolates were Escherichia coli (74.6%), Klebsiella spp (11.7%), Staphylococcus
saprophyticus (6.4%), and Pseudomonas aeruginosa (2.2%).13 In a study 15, the
isolated bacteria was Escherichia coli 201 (66.3%), Staphylococcus suprofyticus 45
(14.9%), Proteus spp 15 (4.9%), Klebsiella 12 (3.9%) and Enterococcus spp 12 (3.9%).
In Gul Z et al study12, the most common isolated organism was Escherichia coli
(65.1%) followed by E. fecalis (20.8%). In a study by Adedoyin OT et al14, the
commonest organisms isolated were Escherichia coli 12(36, 4%) and Klebsiella
12(36.4%. In studies by Rai GK et al,21 Escherichia coli (93.3%) was the most common
organism isolated. other study 19, Escherichia coli was the most common etiological
agent of UTI (65.2%), and followed by Klebsiella spp. (26%), Pseudomonas aeruginosa
(3.6%), and Staphylococcus coagulase positive (3.7%). While in a study 6, the
commonest organisms isolated in urine were Klebsiella (27, 24.5%), and
Staphylococcus aureus (24, 21.8%). In Musa-Aisien AS et al study,17 the most
commonly organisms isolated were Klebsiella spp (24.5%), S. aureus (21.8%),
Pseudomonas aeruginosa (14.5%), Streptococcal spp (14.5%), and E. coli (13.6%). In
our study Escherichia coli was the most common isolated pathogen from both sexes,
more frequently in females (94.37%) compared to (5.63%) in males and 147 (64%) of
infected patients were younger than 5 years of age. In a study15, more than half 154
(51%) of infected patients were less than three years old. In Musa-Aisien AS1 study,
67% of infected patients younger than 5 years of age and 53.6% were in fact less than
2 years old. This vulnerability has been attributed to an incompletely developed
immune system in younger children.22 In addition, an uncircumcised male infant has
a higher incidence of UTI during the first year of life when compared with a
circumcised infant male.20
In the present study, Escherichia coli strains were susceptible to nitrofurantoin
(88.06%), azithromycin (76.79%), cefotaxime (67.19%), cefuroxime (54.84%), cefixim
(54.67%), amoxicillin-clavulanic acid (44.16%) and trimethoprim–sulfamethoxazole
(co-trimoxazol) (41.33%) In a study15, sensitivity of Escherichia coli to Nalidexic acid
was 70%, to Amoxicillin/Clavulanic acid was 29.9%, to Co-trimoxasole was 16.4%, and
to Nitrofurantoin was 15.9%. In a study 6, the drugs that were most sensitive to these
organisms were Gentamicin (50, 45.5%), Ceftriaxone (49, 44.5%), and Ciprofloxacin
(36, 32.7%). In a study 19, antimicrobial susceptibility analysis for Escherichia coli to
commonly used antibiotics are as follows: Amikacin (79.7%), Ofloxacin (78.3%),
Gentamicin (71.6%), Ceftriaxone (41.8), Cefotaxime (41.4%), and Cefixime (27.8%).
In a study 13, sensitivity of Escherichia coli to commonly used antibiotics are as
follows: amikacin (97.8%), gentamicin (97%), ciprofloxacin (94%), nitrofurantoin
(87.1%), nalidixic acid (93.7%), trimethoprim-sulfamethoxazole (48.2%), cephalexin
(76%), and ampicillin (6.9%). In a study 12, the most common isolated organism was
Escherichia coli (65.1%) followed by E. fecalis (20.8%).Vancomycin, Amikacin,
Nitrofurantoin and Impinime showed good sensitivity while Ampicillin and Ceftriaxone
showed highest resistance. In a study14, there was increased sensitivity of these
organisms Escherichia coli and Klebsiella to both ceftazidime and the quinolones.
However, the urine of all suspected cases of UTI should be cultured and sensitivity
pattern determined for appropriate treatment.6 Selection of empirical antibiotic
therapy should be depend on the local frequency of bacterial organisms and their
sensitivities to antibiotics rather than on universal or even national guidelines.
Limitation of this Study. Although this research was carefully prepared, there were
some unavoidable limitation. The main limitations we did not use the invasive
methods, suprapubic bladder puncture and urethral catheterization for urine samples
collection. However, these methods have benefits and limitations, they have lower
rate of contamination but they are very painful and for successful sterile urine
sampling, skill and expertise are important factors. February 1, 200823 reported that
the Invasive methods should be considered in infant who is unwell and a sample of
urine is needed immediately for diagnostic purposes. If the chance exists to delay for
a clean catch, this method continues to be touchstone and seems to have a
consistent level of reliability comparable to the more invasive methods of urine
sampling.
In
conclusion: Escherichia coli was the predominant pathogens isolated followed by
Pseudomonas aeruginosa, Staphylococcus aureus, Klebsiella spp and Enterococcus.
The most effective antibiotics were nitrofurantoin, azithromycin, cefotaxime,
cefuroxime, cefixim, amoxicillin-clavulanic acid and trimethoprim–sulfamethoxazole.
Therefor urine culture should be done for all suspected patients of UTI to determine
the sensitivity pattern for appropriate treatments as well as for selection of
antimicrobial empirical therapy, which must be, depend on the local bacterial
prevalence and sensitivities to antibiotics.
Acknowledgment. The authors want to acknowledge the patients, caregivers, the
data collectors and the staff of microbiology department who helped in the study.
The authors thank Dr. Afrah Al Gadri, for her valuable participation in this study.
5. References
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Table 1. Patterns of organisms isolated from urine samples and their distribution by
sex among symptomatic children in Sana'a city. (n=282).
Organisms isolated
No and %
Males
(n=36)
Females
(n=246)
P valve
chi-square
Escherichia coli
13
(5.63%)
8
(44.44%)
9 (60%)
218
(94.37%)
10 (55.55%)
< .00001.
363.8528.
.504985.
0.4444.
6 (40%)
.273322.
1.2.
Klebsiella pneumonia
231
(81.91%)
18
(6.38%)
15 (5.31
%)
6 (2.1%)
3 (50%)
3 (50%)
1.
0.
Enterococcus
6 (2.1%)
0 (0%)
6 (100%)
.000532.
12.
Enterococcus + Pseudomonas
aeruginosa
3 (1.06%)
1
(33.33%)
2 (66.67%)
Enterococcus + Staphylococcus
aureus
3 (1.06)
2
(66.67%)
1 (33.33%)
282
36 (13%)
246 (87%)
< .00001.
312.766.
Pseudomonas aeruginosa
Staphylococcus aureus
Total
Table 2. The sensitivity of E coli to antibiotics among symptomatic children in Sana'a
city (n=231)
Antibiotics
No
Sensitivity
High
Moderate
Total
sensitivity
Resistance
Nitrofurantoin
201
126
(62.69%)
51
(25.37%)
177
(88.06%)
24 (11.94%)
Azithromycin
168
36
(21.43%)
93
(55.36%)
129
(76.79%)
39 (23.21%)
Cefotaxime
192
117
(60.94&)
12
(6.25%)
129
(67.19%)
63 (32.81%)
Cefuroxime
186
63
(33.87%)
39
(20.97%)
102
(54.84%)
84 (45.16%)
cefixim
225
108 (48%)
15
(6.67%)
123
(54.67%)
102
(45.33%)
Ceftriaxone
45
15
(33.33%)
6
(13.33%)
21
(46.67%)
24 (53.33%)
Amoxicillin-clavulanic acid
231
Trimethoprim–
sulfamethoxazole
225
66
(28.57%)
78
(34.67%)
36
(15.58%)
15
(6.67%)
102
(44.16%)
93
(41.33%)
129
(55.84%)
132
(58.67%)
Table 3. The sensitivity of Pseudomonas aeruginosa and Staphylococcus aureus to
antibiotics among symptomatic children in Sana'a city.
Antibiotics
No
Sensitivity
High
Moderate
Total
sensitivity
Resistance
Pseudomonas aeruginosa (n=18)
Azithromycin
18
15
(83.33%)
0 (0%)
15
(83.33%)
3 (16.67%)
Cefotaxime
15
6 (40%)
6 (40%)
12 (80%)
3 (20%)
Nitrofurantoin
15
3
(20%)
3 (20%)
6 (40%)
9 (60%)
Cefuroxime
15
3
(20%)
3 (20%)
6
Trimethoprim–
sulfamethoxazole
Cefixim
18
6 (33.33%)
0 (0%)
6 (33.33%)
12 (66.67%)
18
0
3 (16.67%)
3
(16.67%)
15 (83.33%)
3
(16.67%)
15 (83.33%)
Amoxicillin18
clavulanic acid
Staphylococcus aureus (n=15)
(0%)
3 (16.67%) 0
(0%)
(40%)
9 (60%)
Amoxicillinclavulanic acid
trimethoprim–
sulfamethoxazole
Cefuroxime
15
9 (60%)
6 (40%)
15 (100%)
0 (0%)
15
6 (40%)
9 (60%)
15 (100%)
0 (0%)
15
9 (60%)
3 (20%)
12 (80%)
3 (20%)
Cefotaxime
15
9 (60%)
3 (20%)
12 (80%)
3 (20%)
Azithromycin
15
3 (20%)
6 (40%)
9 (60%)
6 (40%)