SUMMARY Journal of Rawalpindi Medical College (JRMC); 2017;21(3): 290-292 290 Original Article Bacteriological Spectrum and Sensitivity Pattern in Culture Proven Urinary Tract Infection in Children Mulazim Hussain 1, Bilal Ahmad 2, Nasira Bhatti 1, Shagufta Husain 1 1.The Children Hospital, Pakistan Institute of Medical Sciences (PIMS),Islamabad;2.Department of Paediatrics , Railway Hospital and Islamic International Medical College, Rawalpindi Abstract Background: To determine the different types of organisms causing urinary tract infections in children and their sensitivity to antibiotics. Methods: This cross sectional study was conducted at Children Hospital, PIMS Islamabad and consisted of 117 patients of either gender between age of 03 months to 12 years. Results: Mean age of children enrolled in our study was 4.4 (± 2.6) years. Out of 117 patients, 63 (54 %) were girls. The most common isolate was E. coli (57.3%) percent, followed by Klebsiella (18.8 %), Staphylococcus aureus (13.7 %), Pseudomonas (5.1 %) and Proteus (3.4 %) children. All isolates were sensitive to ciprofloxacin, of loxacin, amikacin, cefixime and imepenem. Only 38.5% E coli and 37.5% Klebsiella were sensitive to Ampicillin, and 14.3% E coli and 9.1% Klebsiella were sensitive to Trimethoprim-sulphamethoxazole. Conclusion: The most common isolate was E. coli, followed by Klebsiella, Staphylococcus aureus, Pseudomonas and Proteus. Most antibiotics tested for the E. coli, Klebsiella, Staphylococcus, Pseudomonas and Proteus are effective except Cotrimoxazole, Ampicillin, and Gentamicin which show high resistance. Key Words: Urinary Tract infections, Bacteriological Spectrum, Sensitivity Pattern. Introduction Urinary tract infections (UTIs) are responsible for considerable morbidity and when associated with urinary obstruction or renal papillary damage. Early treatment of UTI with an effective antibiotic is essential for prevention from long-term consequences. Selection of appropriate antibiotic needs knowledge of possible pathogens and their sensitivity pattern .Girls are more susceptible because their urethra is shorter and closer to the anus. This makes it easier for the bacteria to get access to urethra and then to bladder. 1,2 Up to 11.3% of girls and 3.6% of boys will have had a UTI by the age of 16 years, and recurrence of infection is also common.3 The incidence of UTI varies in early infancy and childhood, being more common in boys in first three months of life with reported male to female incidence of 5:1.In later childhood the reported male to female ratio was 1:10.4 Imaging studies to detect anatomic abnormalities of the urinary tract should be obtained in infants and young children following a first-time diagnosis of acute pyelonephritis. The purpose of these studies is to identify those at increased risk for kidney damage and recurrent infections, namely those with obstructive malformations, renal abnormalities, or severe VUR. The risk of UTI is increased by incomplete bladder emptying secondary to anatomic obstruction or a neurogenic bladder and by voiding dysfunction.5 Untreated and recurrent UTIs can cause serious complications in children including renal scarring, hypertension and end-stage renal disease.1 Early and effective treatment with carefully selected antibacterial agent can prevent most of these complications. Success of the treatment is based on and guided by results of urine culture.6 The choice of empiric antibiotic therapy depends on the knowledge of the expected causative organisms and their susceptibility pattern. Growing resistance to multiple antibiotics has been reported world over which poses an important challenge for clinicians.7,8 Patients and Methods This cross sectional study was carried out over a period of six months from April 1, 2009 to September 30, 2009, at inpatient department of Children Hospital, Pakistan Institute of Medical Sciences, Islamabad.In children who were admitted with clinical suspicion of urinary tract infection (fever, dysurea, pain abdomen, vomiting, unusual crying, poor weight gain, mal odorous urine etc.), a urine sample was carefully collected. In case of infants a sterile, adhesive urine collection bag was applied after disinfecting the skin of genitals, whereas in toilet trained children a mid stream sample was obtained. When it was not possible Journal of Rawalpindi Medical College (JRMC); 2017;21(3): 290-292 291 to collect the urine by non-invasive methods a catheterized sample was collected. A routine urinalysis including microscopy and culture and sensitivity were done on all specimens. A colony count of >100,000 per cmm of a single organism or >10,000 per cmm in symptomatic children was considered as a positive culture. Antibiotic sensitivity was tested to different antibiotics. Results Out of 117 children 54% were girls. Age of children ranged between 3 months and 12 years with a mean of 4.4 (± 2.6) years. Table 1 .Patient characteristics Number Percentage Age categories (years) < 1 5 4.3% 1 to 5 77 65.8% > 5 35 29.9% Gender Male 54 46.1% Female 63 53.9% Table 2.Microorganisms isolated on urine culture Number Percentage E-coli 67 57.2% Klebsiella 22 18.8% Staph. Aureus 16 13.6% Pseudomonas 6 5.1% Proteus 4 3.4% Others 2 1.7% (Table 1). E. coli (57.2%) was the commonest isolate(Table 2).All organisms (100%) were sensitive to amikacin, norfloxacin , ofloxacin , ciprofloxacin and imepenem. Only 38.5 % E coli and 37.5 % Klebsiella were sensitive to ampicillin where as 14.3% Esch. coli and 9.1 % Klebsiella were sensitive to trimethoprim- sulphamethaxazole.100% Esch coli and 75% Klebsiella were sensitive to cefixime.94.7% Esch coli and 83.3% Klebsiella were sensitive to ceftriaxone. However sensitivity of ceftriaxone to staphylococcus and pseudomonas was 100%(Table 3). Discussion Urinary tract infections (UTIs) are one of the most frequent infections in children and a significant cause of morbidity, occurring in about 5 percent of febrile infants and 2 percent of febrile children of less than 5 years of age particularly when associated with structural abnormalities of urinary tract. 9 The most common organism isolated in our study was Esch. Coli (57.3%) .This finding is similar to most of the studies conducted around the world where E coli was isolated from 42.3 % to 81.7 %. 10-14 Information obtained through these studies indicates that irrespective of hospital setting, community or country E Coli remains the most common uropathogen. Klebsiella (18.8%) was the second most common organism isolated in our study. This finding is similar to the observations in other studies where Klebsiella was isolated in 16.7 % to 25 %, although, rare isolation of Klebsiella (5.5%) has also been reported in Bangladesh.15-17 Interestingly Staphylococcus aureus was a common isolate in our study(13.7%).This is in contrast to most of the early findings where staph aureus was an uncommon isolate although occasionally it has been reported in many studies.11,17 Pseudomonas auroginosa and Proteus mirabilus were rare isolates like all other studies we could access.18,19 The results of sensitivity to different antibiotics show that all organisms isolated in our study had low to poor sensitivity to the common antibiotics used in community i,e, ampicillin and Trimethoprim Sulphamethaoxazole. Increasing antibiotic resistance among urinary tract isolates to Ampicillin, Trimethoprim Sulphamethoxazole, and first- generation Cephalosporins has earlier been reported by many observers.20 On the other hand sensitivity to flouroquinolones and aminoglycosides is almost 100 %. Gupta and co- investigators reported in their study that resistance to Table 3: Sensitivity Pattern Amp CTX Cef Norfl Amk Gen Ofl Pip Imi Ceft Cip Ecoli 38.5% 14.3% 100% 100% 100% 86.7% 100% 89.5% 100% 94.7% 100% Kleb 37.5% 9.1% 75% 100% 100% 88.9% 100% 90.9% 100% 83.3% 100% Staph 66.7% -- -- -- 100% 100% 100% 100% -- 100% 100% Pseud -- -- -- 100% 100% 66.7% -- 66.7% 100% 100% 100% Amp: Ampicillin, Cef: Cefixime, CTX: Trimethoprim sulphamethoxazole, Norfl: Norfloxacin, Amk: Amikacin, Gen: Gentamicin, Ofl: Ofloxacin,: Pipemidic acid, Imi:Imipenem, Ceft: Ceftriaxone, Cip: Ciprofloxacin, Kleb: Klebsiella, Staph: Staphlococcus aureus, Pseud: Pseudomonas Journal of Rawalpindi Medical College (JRMC); 2017;21(3): 290-292 290 Fluoroquinolones was absent among gram-negative pathogens and Christiaen et al reported that only one percent of the pathogens were resistant to Fluoroquinolones.21,22 This low resistance of pathogens might be attributed to the fact that quinolones are relatively new antibiotics and have not been extensively used in children. Although sensitivity to gentamycin is around 90 % it is 100 % to amikacin. This is possibly due to less frequent use of amikacin in community and widespread use of gentamycin. Sensitivity to imepenem is also 100 % which is comparable to the findings of M.I.Majumder et al. from Bangladesh who have reported 98% sensitivity of uropathogens to meropenem. 23 Cefixime is a 3rd generation oral cephalosporin which has good palatability and tolerance in children due to its taste and convenient dosage regimen. This was effective against all E coli isolates though it was only 75 % effective against Klebsiella. These findings are comparable with study of Dreshaj Sh,which showed 88% effectiveness of cefixime in uncomplicated UTIs.24) Conclusion E coli and Klebsiella are common bacterial urinary pathogens in children. Cefixime, quinolones and aminoglycosides maintain good sensitivity to common pathogens. Resistance to antibiotics frequently used in community is increasing. References 1. 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