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LETTER TO EDITOR
Year : 2015  |  Volume : 4  |  Issue : 1  |  Page : 61-64

Microbiological profile and antibiogram of uropathogens in pediatric age group


Department of Microbiology, Employees' State Insurance Corporation Medical College, PGIMSR, Bengaluru, Karnataka, India

Date of Web Publication13-Jan-2015

Correspondence Address:
Kirtilaxmi Benachinmardi
Department of Microbiology, Employees' State Insurance Corporation Medical College, PGIMSR, Bengaluru, Karnataka - 560 010
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-344X.149280

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How to cite this article:
Benachinmardi K, Padmavathy M, Malini J, Navaneeth B V. Microbiological profile and antibiogram of uropathogens in pediatric age group. Int J Health Allied Sci 2015;4:61-4

How to cite this URL:
Benachinmardi K, Padmavathy M, Malini J, Navaneeth B V. Microbiological profile and antibiogram of uropathogens in pediatric age group. Int J Health Allied Sci [serial online] 2015 [cited 2020 Apr 10];4:61-4. Available from: http://www.ijhas.in/text.asp?2015/4/1/61/149280

Sir,

Urinary tract infection (UTI) involves invasion, lodgment, and multiplication of organisms in urinary tract which leads to an inflammatory response. [1] UTI is one of the most frequent infection in children. At least 8% of girls and 2% of boys will have a UTI in childhood. [2] UTI in pediatric age group differs in all the way from adults mainly by following congenital abnormalities of urinary tract namely posturethral valves, pelvi-ureteric junction obstruction, neurogenic bladder, stricture urethra, vesicoureteral reflux which is very true in infants (<1 year age group). [3]

Pediatric UTI often remains undiagnosed with nonspecific signs and symptoms. [4] It is very much essential to diagnose and treat the condition as it could be the first presentation of an underlying urological anomalies as already mentioned above or it may in itself lead to significant morbidity from renal scarring, hypertension, and eventually renal failure. [5]

Incidence, prevalence, and antibiogram of pediatric UTI differ from country to country and within the same country between different geographical areas and also in different age groups. [6],[7] On extensive literature search, it was observed that microbiological profile and antibiogram of pediatric UTI has not been reported from this part of our country, that is, Southern Karnataka. Hence, this study was undertaken to determine the microbial profile and antibiogram of pediatric UTI.

This cross-sectional study was undertaken in the Department of Microbiology at a tertiary care teaching hospital over a period of 6 months from June 1, to November 30, 2013. All the children <18 years were involved in the study. Midstream urine samples were collected unless otherwise mentioned as suprapubic aspiration or from catheterized patients. Samples were processed immediately in the following manner. Wet mount microscopy was performed to detect pyuria, bacteriuria, hematuria, or candiduria. Standard loopful of urine was inoculated on blood agar and MacConkey agar and incubated overnight at 37°C. Significant growth was determined as ≥10 5 colony forming units (CFU)/ml of midstream urine, ≥10 2 CFU/ml of a catheter specimen and any number of colonies from a suprapubic sample. [8] Isolates were identified by standard biochemical tests as described by Mackie and McCartney. [9] Antibiotic susceptibility testing was done by Kirby-Bauer disc diffusion method using commercially available antibiotic discs (Hi-media). All Enterobacteriaceae and nonfermentative Gram-negative bacilli (NFGNB) were tested against amikacin (30 μg), gentamicin (10 μg), nitrofurantoin (300 μg), nalidixic acid (30 μg), trimethoprim-sulfamethoxazole (1.25-23.75 μg), ciprofloxacin (5 μg), norfloxacin (10 μg), amoxyclav (20/10 μg), cefoperazone (75 μg), cefotaxime (30 μg) ceftazidime (30 μg), cefuroxime (30 μg), piperacillin (100 μg), piperacillin-tazobactam (100/10 μg), and imipenem (10 μg). The results were interpreted as per Clinical and Laboratory Standard Institute guidelines. [10] Controls used were  Escherichia More Details coli ATCC 25922 and Pseudomonas aeruginosa ATCC 27853. Extended spectrum beta-lactamase (ESBL) production was detected by double-disc synergy test and results were interpreted as per CLSI guidelines. [10]

A total of 1132 urine samples was obtained from pediatric patients suspected of having UTI during 6 months study period. Males and females were equally affected with male to female ratio of 1:1, however, males were more commonly affected before the age of five (62.7%). Age and sex distribution is shown in [Figure 1]. Of the 220 culture positive children, 225 isolates (60.9% inpatients, 29.1% outpatients and 10% from pediatric intensive care unit) were obtained. In five samples, growth of two organisms (polymicrobial infection) was obtained which is shown in [Table 1]. Gram-negative isolates were 185 (82.22%), E. coli 119 (52.9%) being the predominant one followed by Klebsiella pneumoniae 17 (7.6%), NFGNB 06 (2.7%), Citrobacter koseri 06 (2.7%), Proteus mirabilis 06 (2.7%), Proteus vulgaris 05 (2.2%), P. aeruginosa 05 (2.2%), Citrobacter freundii 05 (2.2%), Enterobacter 04 (1.8%), Atypical E. coli 04 (1.8%), Morganella morganii 03 (1.3%), Providencia 02 (0.9%), Klebsiella oxytoca 02 (0.9%), and Klebsiella ozaenae 01 (0.4%). Gram-positive isolates were 36 (16%), coagulase-negative Staphylococcus (CONS) 22 (9.8%), Enterococcus species 13 (5.7%), and Staphylococcus aureus 01 (0.8%). Candida species were 04 (1.8%). Distribution of isolates is shown in [Table 2].
Figure 1: Bar diagram showing age and sex distribution

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Table 1: Combination of organisms in a polymicrobial growth

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Table 2: Isolated organisms

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The antibiotic resistance pattern of GNB and Gram-positive cocci is shown in [Table 3] and [Table 4], respectively. Majority of the GNB isolates showed resistance to nalidixic acid, norfloxacin, nitrofurantoin, amoxyclav, and co-trimoxazole as shown in [Table 3]. ESBL producers were 46 accounting for 20.4% of the total isolates [Table 5].
Table 4: Antibiotic resistance pattern of Gram-positive cocci

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{Table 4}
Table 5: ESBL producing GNB

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Urinary tract infection is one of the most frequent infections in children and important cause of morbidity. Intensive investigations and continuous urinary surveillance are required to eliminate the pathogen, to prevent urosepsis and to minimize complications due to these infections such as renal scarring. [2] All individuals may be susceptible to UTIs however; the prevalence of infection differs with age, sex, and certain predisposing factors like underlying systemic illness, structural and functional abnormality of urinary tract, interventions like instrumentation including catheterization. [11] The occurrence of UTI is more common in girls (5%) as compared to boys (1-2%), but this frequency is more in boys before the age of one. [12],[13] This finding was true in our study where male to female ratio was 1:1, however, male children 69 (62.7%) outnumbered female children 41 (37.2%) before the age of five. Although there are studies showing variation in sex distribution of cases in different geographical regions. [2],[3],[4],[14],[15] Females are said to be more susceptible to UTI after the age of 6 months due to their shorter urethra which provides easy access of bacteria to the bladder. [16]

The age group most commonly affected by UTI in our study was 1-5 years (39.1%) and least affected was 0-1 years (10.9%) which is similar to other studies. [3],[15] In contrast, Chander and Singla [4] and Kalantar et al. [2] found more cases in the age group of <1 year, that is, 86% and 40.9%, respectively.

Escherichia coli was the most common isolate (52.9%) identified in our study as observed in other studies from other parts of India and also from different countries across the world such as Israel, Iran, Kuwait, Nigeria, Britain and USA. [2],[3],[4],[14],[15],[17],[18],[19],[20],[21],[22],[23],[24] In our study isolation of Gram-positive cocci was 16% among which CONS was the most common isolate followed by Enterococcus spp. Gram-positive organisms have received more attention nowadays as a cause of bacteriuria and UTI. Even though CONS, Streptococci and Enterococcus spp. are seen in small numbers, they are recognized as an important cause of UTI. [25],[26] Candida species were isolated in 1.8% which is comparatively low compared to other studies by Chander and Singla [4] (7.80%) and Rekha et al. [14] (4%). In pediatric patients isolation of Candida species mostly indicates urinary tract abnormalities and prematurity. Candiduria needs immediate and serious attention as it could be the first manifestation of disseminated candidiasis in this age group. [27]

Drug resistance among uropathogens has increased over the past few decades because of their widespread indiscriminate use, easy availability, and over the counter sale. This is heading us toward the use of higher spectrum antibiotics. Therefore, the magnitude of the problem should be accessed properly and in an accurate way. [2] In the present study, the antimicrobial resistance profile of E. coli to nalidixic acid was 84.9% followed by amoxyclav 81.5% and third generation cephalosporins 74-79%, least resistance was observed for imipenem (1.7%), amikacin (5.9%), and nitrofurantoin (13.5%) respectively.

The second most common isolate in our study was K. pneumoniae (7.6%). More than 50% of resistance was observed for piperacillin (70%), amoxyclav (75%), ceftazidime (60%), cefuroxime (60%), cefaperazone (50%), and least resistance was observed for gentamicin (20%), piperacillin-tazobactam (20%), norfloxacin (25%), ciprofloxacin (25%), cefaperazone-sulbactam (20%), and 100% sensitivity was observed for amikacin and imipenem. Nalidixic acid, nitrofurantoin, amoxicillin + clavulanic acid once the mainstay in the treatment of UTI were no longer useful in our center as 50-80% resistance was observed to these drugs.

Among the Enterobacteriaceae, majority of the isolates have shown resistance to third-generation cephalosporins ranging from 60% to 80%. Nonfermenters showed more resistance to almost all the antibiotics than the Enterobacteriaceae family. Ciprofloxacin has shown good activity (60%) against most of the Gram-negative isolates in our study which is in concordance with other studies. [2],[14],[15] This is in contrast to the study by Taneja et al. [3] who found 79.6% resistance. However, it is not recommended for use in the paediatric population because of its arthropathic effects in immature animals. But the international society of chemotherapy suggests that fluoroquinolones can be used in pediatric patients with UTI when alternate and effective therapy is not available. [28]

Among the Gram-positive organisms isolated in our study Enterococcus species had a very high level of resistance (53-93%) to most of the drugs used in our study but showed 100% sensitivity to vancomycin, linezolid, and teicoplanin. This is in consistence with other studies. [1],[4],[14] Among the CONS isolated most of the isolates showed 30-70% resistance for the antibiotics used and 100% sensitivity was seen for teicoplanin, vancomycin, and linezolid.

In our study, 20.4% of uropathogens were ESBL producers, which is in contrast with studies of Rekha et al. [14] (30%) and Taneja et al. [3] (36.5%). ESBL production, AmpC production, reflux mechanism and porin deficiency are the different mechanisms of drug resistance in GNB among which ESBL production is the most common. The detection of ESBL and their antibiogram guides empirical therapy for various infections. [29]

To conclude, E. coli was the most common isolate among GNB followed by K. pneumoniae. Among GPC, CONS was the most common isolate followed by Enterococcus spp. The highest and lowest mean resistance among Gram-negative bacteria to common antibiotics was 70.5% to amoxyclav and to 7.7% imipenem, respectively. Although the prevalent pathogens of UTI remain same over the years, the resistance pattern of these pathogens is definitely increasing. Continuous monitoring of the changing pattern of resistance is required as regional and demographic differences in the susceptibilities pattern of uropathogens mandates local population-specific surveillance to choose appropriate empiric pharmacotherapy for UTI in children. Infection control practices also play a major role in the prevention of UTIs.

 
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    Figures

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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