Microbiological profile of urinary tract infection in pediatric population from a tertiary care hospital in South Kerala

This was a prospective study done in Sree Gokulam medical college, Trivandrum from June (2013), to May (2014). Children aged 2months to (12)years attending pediatric outpatient department with symptoms like fever, abdominal pain, dysuria, smelly urine were subjected for urine routine and microscopic examination. Those with Pus cells more than 5 per high power field were then sent for urine culture and sensitivity.


Introduction
The problem of UTI spans all age groups beginning with Neonates. The frequency of UTI in infants is 1 to 2% much more common in boys during the first 3months and thereafter in girls. Pyelonephritis is common in infants .1 UTI is mainly due to the ascending infection from the urethra. The diagnosis of UTI in young children is important as it may be the marker of urinary tract abnormalities. Diagnosis based on clinical features is difficult because of the varied non specific clinical features. Early diagnosis is important to preserve renal function of the growing kidney. 2 catheter and greater than or equal to 100,000 UFC, if it was collected by spontaneous voiding, according to criteria established by the American Pediatric Academy14.
Antibiotic discs were bought from Hi-Media diagnostic laboratory, Mumbai.

Extended spectrum beta lactamase (ESBL) detection
Suspected ESBL isolates were tested and confirmed using Combined disc diffusion test with Ceftazidime and Ceftazidime clavulunic acid. Multiple drug resistant isolates were those which were shown to be resistant to 2 or more group of antibiotics. An isolate was considered Multi drug resistant if it was found to be resistant to 2 or more family of drugs.

Results
932 cases of suspected cases were screened 170 were culture positive. Among them girls were 100 (58%) and boys were 70 (42%).
Majority of the isolates were Gram negative bacilli (85%), followed by gram positive cocci (11.5%) and the rest were yeast ( Figure 1).
All the gram negative organisms showed a high degree of sensitivity to Imipenem, Cefaperazone sulbactum, and Piperacillin tazobactum. Amoxycillin clavulunic acid showed a high level of drug resistance ( Table 3).
The gram positive cocci were found to be of the sensitive variety with high degree of sensitivity to Nitrofurantoin followed by Amoxycillin clavulunic acid (Table 4).
Maximum percentages of ESBL were seen in Klebsiella with 20%. Klebsiella also had a high percentage of Multi drug resistant strain of organism with resistant pathways different to ESBL (Table 5).    Congenital disorder of Urinary tract 5 Neurogenic bladder 2 Figure 1 Distribution of organism isolated.

Recurrence
Out of the 170 culture positive 38 patients experienced recurrence. This was associated with underlying pathological conditions. The remaining cases didn't have any underlying pathological conditions ( Table 6).
Out of the 38 cases who were followed up for recurrence of UTI, 36 (94%) cases were resolved completely with intensive and longer duration treatment. 2 cases of neurogenic bladder had repeat infection with different microbe with different organism (Table 6).

Discussion
The appropriate choice of antibiotic for UTI requires an adequate understanding of epidemiology and profiles of local antimicrobial resistance of associated uropathogen. Antibiotic sensitivity change over a period of time. 4 Therefore pediatrician awareness of rising resistance of urinary pathogen needs to be done on a periodic basis. 5 There is variation regarding age group of children with higher prevalence in this study of girls to boys. This is in accordance with various studies. 6 The age group 0-6years is the most affected in the study conducted. This can be attributed to the fact majority of children of this age group are not toilet trained 7 (Table 1). Gram positive cocci were few in comparison to gram negative bacilli. Staph saprophyticus was the predominant gram positive cocci isolated. This is similar to most studies conducted 9 (Table 1) ( Figure  1).

E. coli and
At present it is not clear what is the most effective therapy and appropriate antibiotic treatment time for a UTI, but a review of the Cochrane collaboration of (2012) found that 10days of antibiotic treatment was effective in eliminating bacteriuria. 15 In our study it was found that treatment was for a period of 7days which was found to be effective in almost all cases of UTI except for 2 cases of recurrent UTI which didn't resolve and had infection with a different microbe with a different sensitivity pattern.
Sulfamethoxazole trimethoprim and amoxicillin-clavulanate are the most utilized oral antibiotics which was similarly practiced in our hospital too where there was escalation of treatment after culture reports were sent 9,13 (Table 3) (Table 4).
Empirically for severe UTI in pediatric patients here are given Cefotaxim was given intravenous. According to sensitivity pattern if it comes resistant there will be escalation of treatment to Cefaperazone sulbactum.
Adult antibiotic profile in UTI cases in this institute has a higher resistance pattern to antibiotics. It shows sensitivity to Imipenem (90%), followed by Piperacillin tazobactum (82%) ( Table 3).
In this present study there was total sensitivity ( 100%) to Imipenem, followed by Cefaperazone sulbactum and Piperacillintazobactum (93%) for E.coli and Klebsiella. This finding correlates with the study done by Catalina et al in (2014) and Marzouk et al in 2015. 13,15 Rajabhandri et al. earlier reported nitrofurantoin as a most sensitive drug. Nitrofurantoin showed 90% sensitivity in this study. Nitrofurantoin is a bactericidal agent for Gram positive cocci and bacteriostatic agent for gram negative.
Some studies indicate that Nitrofurantoin has adequate renal excretion and can be used for complicated renal infections. However, there may be non compliant for Nitrofurantoin due to its bitter taste. 10,15 Amoxicillin clavulunic acid and Cotrimoxazole resistance were found to be at 74 % and 52%.
Resistance of Enterobacteriaceae to beta-lactam antibiotics has increased in the past 30years.
This was first detected in Germany in (1980) and was quickly reported in the United States. This resistance is principally observed in E. Coli and Klebsiella, but can also be identified in other Enterobacteria 11 (Table 3) ( Table 4).
The results obtained from this study showed a high resistance of Enterobacteria to Amoxycillin clavulunic acid and Cotrimoxazole. This is similar to recent articles in which Several authors report resistances that fluctuate between 24 and 58% for Amoxycillin clavulunic acid and are up to 36% for Cotrimoxazole 12 (Table 3).
Multi drug resistance along with ESBL production was seen in 67 (37%) of the isolates. They were seen only in Klebsiella and E.coli. ESBL production was seen 24(14.1%) cases of the total isolates. This was in accordance with the study done by Ismail et al (2011) and Catalina et al (2014) 12,13 (Table 6).

Conclusion
This was a prospective study done in SreGokulam medical college, Trivandrum from June 2013 to May 2014. E.coli was found to be the most common organism with Imipenem, Piperacillin tazobactum and Cefaperozone sulbactum found to be the most effective antibiotics. Important facts emanating from the present study include: i. Girls and infants in age group 0-6years were more commonly affected (Table 1).
ii. Underlying surgical and indwelling catheter were the most important causes of recurrent UTI (Table 6).
iii. Empirical treatment with cotrimoxazole and amoxicillin clavulunic acid for UTIs were the drugs of choice initially and they may be insufficient due to the elevated rate of resistance of E. coli and other isolated uropathogens (Table 3) (Table 4).
iv. Conversely, amikacin, and nitrofurantoin would be therapeutic alternatives in pediatric patients with uncomplicated UTI and Piperacilin tazobactum and cefeoperazone sulbactum in those with more severity, as in the case of urosepsis (Table 3) (Table  4).
Present study along with previous studies indicate the need for periodic monitoring of organisms with antibiotic sensitivity of the same.