Clinical Presentation and Aetiological Agents of Urinary Tract Infection in Children

1. Muhammad Azam Khan 2. Fareeha Fatima 3. Asim Khurshid

1. Asstt. Prof. of Paeds, NMC, Multan 2. Medical Officer of Peads, NMC, Multan
3. Asstt. Prof. of Peads, Institute of Child Health, Multan

ABSTRACT

Objective: To describe the clinical presentation and to identify the aetiological agents causing urinary tract  infection.

Study Design: Descriptive study

Place and Duration of Study: This study was carried out in the Department of Paediatric Medicine, Nishtar Medical College/Hospital, Multan from January 2013 to December 2013.

Materials and Methods: A total of 50 children were included in the study conducted at Nishtar Medical College/Hospital, Multan.

Results: Out of 50 children, 38 were female and 12 were male. 28 children were from 1-3 years age group and 22 were of more than 3 years. Most common clinical presentations were fever, urinary symptoms, vomiting and pain abdomen. Aetiological agents in study were  Escherichia coli, klebsiella, proteus, staphylococcus saprophyticus, streptococcus fecalis or pseudomonas.four cases of UTI (3 females, 1 male) were associated with nephritic syndrome. Four cases were associated with malnutrition.

Conclusion: It is concluded from study that UTI is more common in females between the age of 2-4 years mostly due to problems in their toilet training.

Key Words:Urinary tract infection, Fever, Dysuria


INTRODUCTION

Urinary tract infection (UTI) is defined as the presence of a single bacterial growth of >10  colony  forming units/ml1 in a clean catch, mid stream urine sample or > 10 organisms/ml in a catheter or suprapubic aspirated of urine2. 

Urinary tract infections are a common clinical problem in childhood and may lead to renal scarring, hypertension or end stage renal dysfunction3. Urinary tract infections occur in 3-5% of girls or 1% of boys. In girls, the first UTI usually occurs by the age  of 5 years, with peaks during infancy or toilet training. In boys, most UTIs occur during the first year of life; UTIs are much more common in uncircumcised boys4. Several studies shown that infants and young children can  present with fever as a sole manifestation of a UTI5.

Symptoms of UTI in older children may include fever, urinary symptoms and abdominal pain6. Occasionally, older children may present with failure to thrive, nephropathy or hypertension secondary to unrecognized UTIs earlier in childhood7.

MATERIALS AND METHODS

This descriptive study was carried out in the Department of Paediatric Medicine, Nishtar Medical College/Hospital, Multan from January 2013 to December 2013. A total of 50 children were included in the study.

 

RESULTS

Out of 50 children, 38 were female and 12 were male. 28 children were from 1-3 years age group and 22 were of more than 3 years. Mean age of the children was 2.75 + 1.05. Mean weight was12.41 + 2.3 kg and mean height was 91.1 + 7.97 cm.

The most common symptoms noted in present study were fever 84%, urinary frequency 32% and vomiting 30% as shown in table-1.

Clinical findings noted were generalized abdominal tenderness 24%, lumber tenderness 18% and suprapubic tenderness 14% as shown in Figure-1.

Regarding the aetiology, E. coli was responsible for UTI in 78% children (Table-2).

Table No.1: Symptoms  of UTI (n=50)

Symptoms

Patients age

Total

1-3   Years (28)

>3 years (22)

Fever

25(89.3%)

17 (77%)

42(84%)

Urine frequency

07   (25%)

09 (41%)

16(32%)

Vomiting

08   (28%)

07 (32%)

15(30%)

Table No.2: Aetiology of the UTI (n=50)

Aetiology

No. of children

%age

E. coli

39

78.0

Klebsiellae

04

04.0

S. saprophyticus

02

04.0

P. aeruginosa

02

04.0

S. facalis

02

04.0

Proteus

01

02.0

 

DISCUSSION

The common symptoms noted in present study were fever 84%, urinary frequency 32% and vomiting 30%. In a study it has been reported that fever 92%, dysuria 68% and failure to thrive 31%5.  Fever in 73.3%, failure to thrive 46.6%, vomiting and pallor (40% each were the most common presentations in another study8.  Ahmad et al have found fever the most common presentation (78%) followed by pain abdomen 54% and dysuria 40% in patients of UTI9, while to thrive was observed 1in 12% of patients. Ahmadzaden et al have reported fever 83% and dysuria 48% in patients of UTI in the study10

In a study it is reported that 48% of the patients did not have any pain5. Others presented with generalized abdominal pain 21, lumber tenderness 18% and hypogastric pain 13% in descending order of frequency. Similar findings were observed in other study11.

S. saprophyticus was found 4% in present study. It was 14.9%, 10-15% in other studies12.  P. aeruginosa was found 4% in [resent study. In present study of 50 children the ratio of female to male was 3.2:1. In a study, female to male ratio in the patients of UTI up to the age of 7 years was found 4.9:113. It was found 16.7%  and 9% respectively in other studies14.

It was found that single and multidrug resistance to ampicillin, amoxicillin, cefazolin, ciprofloxacin, nitrofurantoin and co-trioxazole were found on all specimens of UTI patients. The E. coli resistance to ampicillin peaked in toddlers (52.8%) but was high in infants 50.4%. the most common co-resistance in all age groups was ampicillin/co-trimoxazole15. In another study E.coli had a resistance rate of more than 50% to ampicillin, amoxicillin, co-trimoxazole, cephradine andfosfomycin, but a very  low resistance rate (<4%) to 3rd generation cephalosporin, nitrofurantoin, azactum and amikacin16. I a study conducted, trimethoprim resistance was found 15.2% overall, with a resistance rate for E. coli to trimethoprim was 17.7%. Rates of antibiotic resistance for all organisms to nitrofurantoin (2.9%) and norfloxacin 0.9%) remain low17

CONCLUSION

It is concluded from study that UTI is more common in females between the age of 204 years mostly due to problems in their toilet training.

REFERENCES

1.       Khan PA, Kundi MZ, editors. Basic of paediatrics. Multan. Carvan Book Centre; 2002.p.378-409.

2.       Asharam K, Bhimma R, Adhikari M, Human immunodeficiency virus and UTI in children. Ann Trop Paediatr 2003; 23: 273-7.

3.       Qureshi AM. Organisms cauring UTI in pediatric patients. J Auyb Med Coll 2005; 17: 72-4.

4.       Huicho L, Campos SM, Alamo C. Meta analysis of urine screening tests for determining the risk of UTI in children. Paediatr Infect Dis J 2002;21:1-11

5.       Qureshi AM. Clinical presentation of UTI among children. J Auyb Med Coll 2005; 17: 79-81.

6.       Elder JS, Urologic disorders in infants andchildren. In: Behraman RE, Kleigman RM, Jenson HD editors. Nelson’s textbook of pediatrics. 17th ed. Philadelphia: WB Saunders; 2004.p.1783-1826.

7.       Lizama CM, Luco IM, Reichard TC, Hirsch BT. UTI in a pediatrics emergency department. Rev Chilena Infectol 2005; 22:235-41.

8.       Hafeez F, Anwar S, Ahmad TM. UTIin children. Pak Paed Med J 2005; 29: 35-40.

9.       Ahmad A, Hussain W, Waqar S, Khan A. Presenting features of UTI in children. Pak Paed J 2006; 30: 91-4.

10.    Ahmadzedeh A, Askarpour S. Asociation of urinary tract abnormalities in children. Pak J Med Sci 2007; 23: 89-91.

11.    Gallager SA, Hemphill RR. UTI,epidemiology, detection and evaluation. [online]. 2003 [cited 2008 March 21.

12.    Ronald A. The etiology of UTI. Dis Mon 2003; 49:71-82.

13.    Williams GJ, Wei L, Lee A, Craig JC. Long term antibiotics for preventing recurrent UTI in children. Cochrane Database Syst Rev 2001;(4): CDOO 1534.

14.    Sobczyk D, Krynicki T, Blumczynski A, Zaniew M, Kroll P, Siwinska A, et al. New, successful treatment of UTI. Przegl Lek 2006; 63: 140-1.

15.    Gaspari RJ, Dickson E, Karlowsky J, Doern G. Multidrug resistance in pediatric UTI. Microb Drug Eesist 2006; 12: 126-9.

16.    Fan SY, Zhang BL, Wang WH, Zhang X. Bacterial pathogens and resistance patterns in community acquired pediatric UTI. Zhongguo Dang Dai Er Ke Za Zhi 2006;8: 115-7.

17.    Mangin D, Toop L, Chambers S, Ikram R, Harris B. Increased rates of trimethoprim resistance in uncomplicated UTI. N Z Med J 2005; 118: 1726-9

 

DISCUSSION

The aim of this study was to compare the two surgical procedures i.e. intraoral approach and extraoral approach, used for reduction of mandibular angle fractures in terms of various post operative complications i.e. infection, nerve damage, malocclusion, Facial Cosmetic dissatisfaction, keloid scar and limited mouth opening to determine which of the two procedures show better post operative results.6-8 In this study, Road traffic accident  with motor-cycle riding was the common cause of mandibular fractures which is different than the study of Zaki MA9 and Muzzafar K10 who have reported falls as the second most commonest factor of mandibular fractures13-15. The results confirm that post operative complication rates in terms of nerve damage (20%) and Facial Cosmetic dissatisfaction (60%) were much higher in patients where extra oral approach was used. This finding is similar to other studies which have reported the advantages of the intraoralroute over the extraoral route. The results of the study show that infection occurred in13.3% of the patients treated through intra oral approach whereas it was 20% with extra-oral approach. These results are comparable with the study conducted by Lawoyin DO11, in which the infection rate in patients treated with open reduction and internal fixation for mandibular fractures was 12.5%.Malocclusion was assessedin this study solely through patientcomplaints as in other studies. It was observed in 6.6% of the cases operated by intra-oral approach and 13.3% in the cases operated by extra-oral approach. Nerve damage in terms of both sensory and motor neuropathies was noted according to the patient’s complaint. Motor disturbances were seen in the patient’s treated by extra oral approach, which is similar to study by Renton TF12. Hypertrophic(keloid) scars were seen in 6.6% of the patients in extraoral approach which is comparable with study which reported 2.56 % hypertrophic scar through extra oral approach.

The possible limitation of the study is duration. However since this study followed an experimental study design, the sample size was sufficient enough to fulfill the aims and objectives of the study. Based on the findings of this study it is recommended that the motor-cycle persons must used helmet while driving.

CONCLUSION

Based on this single study, at a single institution, we can conclude that the intra oral approach with rigid fixation is our effective and superior technique as compare to the extra oral approach but distal to last molar difficulty in placement of mini-plate via a intraoral approach.

REFERENCES

1.       Ajmal S,  Khan MA, Jadoon H, et al. Management protocol of Mandibular fractures at Pakistan Institute Of Medical Science, Islamabad, Pakistan. J Ayub Med Coll Abottabad 2007;19(3):51-5.

2.       Fridrich KL, Pena-Velasco G, Olson RA. Changing trends with mandibular fractures. J Oral Maxillofac Surg 1992;50:586-589.

3.       Haug RH, Barber E, Reifeis R. A comparison of mandibular angle fracture plating techniques Oral Surg Oral Med Oral Pathol 1996;82:257-263.

4.       Singh V, Gupta M, Bhagol A. Is a Single Miniplate at the inferior Border Adequate in the Management of an Angle Fracture of the Mandible. American Academy of Otalaryngology – Head and Neck Surgery Foundation 2011;145:213.

5.       Ali S, Ahmed R, Dastagir MU, Comparison of two surgical procedures in reduction of mandibular angle fractures. Pakistan Oral & Dental J 2010;30:2.

6.       Mehra P, Murad H, Internal fixation of mandibular angle fractures. A comparison TWO techniques. J Oral Maxillofacial Surg 2008;66(11):2254-60.

7.       Chritah A, Lazow S, Berger J. Transoral 2.0-mm miniplate fixation of mandibular fractures plus 1 week maxillomandibular fixation: A prospective study, J Oral Maxillofacial Surg 2005; 63:1737.

8.       Andrew J, Gear L, Apasova E, John P. Schmitz et al. Treatment modalities for mandibular angle fractures. J Oral Maxillfac Surg 2005; 63: 655-663.

9.       Zaki MA, Islam T, Memon S, Aleem A. Pattern of maxillofacial injuries received at Abbasi Shaheed Hospital, KMDC, Karachi. Annual Abbasi Shaheed Hosp 2002;7:291-93.

10.    Muzzafar K. Management of maxillofacial Trauma. AFID Dent J 1998; 10: 18-21.

11.    Lawoyin DO, Lawoyin JO, Lawoyin TO. Fractures of facial skeleton in Tabuk North West Armed Forces Hospital. A five-year review. African J Med & Med Sci 1996; 25: 385-87.

12.    Renton TF, Wiesnfeld D. Mandibular fractures osteosynthesis: a comparison of three techniques. Br J Oral Maxillofac Surg 1996; 34: 166-73.

13.    J.E barrera, MD; Arlen, D Meyer, MD. Mandibular Angle Fractures. Medscape  2010.

14.    Alkan A, Celebi N, Ozden B, Bas B, Inal S. Biomechanical comparision of different plating techniques in repair of mandibular angle fractures. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;104:752-6.

15.    Maloney PL, Lincoln RE, Coyne CP. A protocol for the management of compound mandibular fractures based on the time from injury to treatment. J Oral Maxillofac Surg 2001;59:
879–884.

 

 

 

Address for Corresponding Author:

Dr.Zaib un Nisa,
Assistant Professor of Periodontology

LUMHS, Jamshoro