Proven Urinary Tract Infection Research Articles

Efficacy of a Novel Prophylactic Scheme of Fosfomycin Trometamol in Patients Undergoing Endoscopic Surgery for Benign Prostatic Hyperplasia: Findings from a Prospective Monocentric Single-Arm Study.

This study aimed to assess the efficacy of a novel prophylactic scheme of fosfomycin trometamol in patients undergoing elective HoLEP (holmium laser enucleation of the prostate) or TURP (transurethral resection of the prostate) procedures for treating benign prostatic hyperplasia. Patients affected by benign prostatic hyperplasia and undergoing elective HoLEP or TURP procedures during the period February 2022-June 2023 were prospectively enrolled. Two 3 g oral fosfomycin trometamol doses 12 h apart were administered at 8.00 p.m. on day -1 (i.e., the day before HoLEP or TURP procedure) and at 8.00 a.m. on day 0 (i.e., the day of the surgical procedure). The following outcomes were assessed: prevalence of fever occurring in the first 48 h after surgical procedure; prevalence of urological complications occurring after the surgical procedure; prevalence of proven urinary tract infections (UTIs) and/or bloodstream infections (BSIs) at 14 days post-procedure; and prevalence of emergency department admission for UTI-related sepsis at 14 days post-procedure. Univariate analysis comparing patients with and without proven UTI, BSI, or emergency department admission at 14 days post-procedure was carried out. Overall, 96 patients (median age 70 years) undergoing HoLEP (82.3%) or TURP (17.7%) were prospectively included. Median (IQR) time of surgical procedure after the morning fosfomycin dose was 226.5 min (range 88.5-393.75 min). Fever in the post-surgical 48 h occurred in 3/96 patients (3.1%). Prevalence of proven UTI at 14 days was as low as 1.0% (1/96), whereas no patient had proven BSI or UTI-related sepsis requiring emergency department admission at 14 days. Our findings support the contention that a prophylactic scheme based on two doses of fosfomycin trometamol 12 h apart before surgical intervention may represent a valuable strategy for preventing infectious complications in urologic patients undergoing HoLEP or TURP. Larger definitive confirmatory studies are warranted.

MP52-04 PATIENT'S EXPERIENCE AND SATISFACTION WITH INTRAVESICAL GENTAMICIN IRRIGATIONS

You have accessJournal of UrologyCME1 Apr 2023MP52-04 PATIENT'S EXPERIENCE AND SATISFACTION WITH INTRAVESICAL GENTAMICIN IRRIGATIONS Patricia Maymi-Castrodad, Connie Pines, Martin Forchhmeimer, Denise Tate, and Anne Cameron Patricia Maymi-CastrodadPatricia Maymi-Castrodad More articles by this author , Connie PinesConnie Pines More articles by this author , Martin ForchhmeimerMartin Forchhmeimer More articles by this author , Denise TateDenise Tate More articles by this author , and Anne CameronAnne Cameron More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003300.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Gentamicin bladder instillations have been shown to decrease urinary tract infections (UTI) in patients with neurogenic lower urinary tract dysfunction (NLUTD) on intermittent self-catheterization (ISC). Even with proven clinical efficacy of gentamicin irrigation, patient’s experience has not been studied. We aim to assess patient’s experience and satisfaction with intravesical gentamicin irrigations in patient with NGLUTD with refractory recurrent urinary tract infections. METHODS: An interview study of patients who tried gentamicin bladder instillations either presently or in the past. Eligibility was patients with NGLUTD performing CIC and recurrent UTIs (3 culture proven UTI in a year requiring antibiotics). We conducted interviews focusing on patient’s UTI history, bladder health, use of gentamycin, and validated questionnaire Neurogenic Bladder Symptom Scale (NBSS), Spinal Cord Injury Quality of Life (SCI-QOL) Bladder complications, management difficulties, and Patient- Reported Outcome Measurement (PROMIS) Global Health Scale. RESULTS: 36 patients met the inclusion criteria; 56.4% were male and 92.3% White, median age of 61 years (range 33-77). Etiology of NGLUTD were Spinal Cord Injury (71.8%), Spina Bifida (5.1%), Multiple Sclerosis (10.3%), and Transverse Myelitis (2.6%). Only 5.6% had undergone bladder surgery. 77.8% reported still doing gentamicin flushes, with 78.6% very satisfied with the experience. The median number of documented UTI prior to starting irrigations was 3 (range 2-6.5) and the number of documented UTI during the 12 months after was 0 (range 0-1). Reasons for stopping irrigations included difficulty conducting the flushes (12.5%), insurance or other financial reasons (25.0%) or recurrent UTIs (62.5%). The NBSS showed 63.9% of participants when experiencing UTIs can be treated at home with antibiotics and 22.2% required hospital admission. The SCI-QOL showed 83.3% of patient are not limited in their daily activities as a result of their UTIs. The PROMIS showed 44.4 % would rate their QOL as good, 25.0% as very good, and 11.1% as Excellent. CONCLUSIONS: Gentamycin instillations reduce the incidence of UTI in NGLUTD patients performing CIC. Participants reported satisfaction and good QoL when not having UTIs with the use of intravesical gentamicin instillations. Education on technique for the installations and insurance or financial coverage in this population may improve patient’s compliance to maintain reduce risk of UTI. Source of Funding: National Institute of Independent Living and Disability Research © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e703 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Patricia Maymi-Castrodad More articles by this author Connie Pines More articles by this author Martin Forchhmeimer More articles by this author Denise Tate More articles by this author Anne Cameron More articles by this author Expand All Advertisement PDF downloadLoading ...

Frequency of Urinary Tract Infection (UTI) in Neonates Admitted with Indirect Hyperbilirubinemia

Objective: To determine the frequency of urinary tract infection (UTI) in neonates admitted with indirect hyperbilirubinemia. Study Design: A cross-sectional study. Place and Duration of the Study: Inpatient department of Pediatric Medicine, Bolan Medical College/Hospital Quetta from Jan 2019 to Dec 2020. Methodology: A total of 130 neonates of either gender (delivered at ≥ 32 weeks) admitted with primarily complaints of jaundice (with evidence of indirect hyperbilirubinemia) were included. Sex, age, weight and height of all neonates were noted. Serum bilirubin levels were asses and urine samples were also evaluated for the existence of urinary tract infection (UTI). Results: In a total of 130 neonates, 58 (44.6%) were males and 72 (55.4%) females. The UTI was found to be present in 41 (31.5%) neonates admitted with indirect hyperbilirubinemia. Among these 41 culture proven UTI cases, most common organism was E. coli found in 15 (36.6%) cases while Klebsiella was the 2nd most commonly found microorganism noted in 11 (26.8%) cases. Conclusion: Frequency of UTI was high (31.5%) among asymptomatic jaundiced newborns. Children presenting with jaundice needs to be evaluated for UTI. Keywords: E.Coli, indirect hyperbilirubinemia, Klebsiella , Urinary tract infection (UTI).

764 Operative vaginal delivery as an independent risk factor for maternal postpartum infection

Recent studies suggest prophylactic antibiotics are effective in reducing maternal postpartum (PP) infection following operative vaginal delivery (OVD). There is limited data in the US, where episiotomy and laceration repair practices may differ, affecting the risk of PP infection after OVD. We sought to evaluate whether OVD is an independent risk factor for maternal PP infection. Retrospective cohort study of all singleton vaginal deliveries >34 weeks’ gestation at a single perinatal center (2013-2018). Women were categorized by mode of delivery: spontaneous vaginal delivery (SVD) or OVD (forceps/vacuum assisted). The primary outcome was a composite of confirmed or suspected maternal infection up to 6 weeks after delivery defined as: (1) endometritis (CDC definition), (2) perineal wound morbidity (infection or breakdown) or (3) culture proven urinary tract infection. Outcomes were compared between groups; multivariable generalized estimating equations were used to estimate the adjusted odds ratios (95% CI) with SVD as the reference group. Of 14,646 deliveries meeting inclusion criteria, 732 (5%) were OVDs. The overall composite rate was 1.4%. Women undergoing an OVD were more likely to be nulliparous, undergo labor induction, develop chorioamnionitis, have an episiotomy, and sustain a 3rd/4th degree laceration (Table 1). After controlling for these known confounders, there was no difference in composite infection following OVD compared to SVD (aOR 1.28 [0.73-2.23]) or any of its individual components (Table 2). There were no differences in receipt of PP antibiotics or PP fever. We considered the individual contribution of forceps (p=0.20) vs vacuum (p=0.95) on the adjusted odds of the composite outcome, which indicated no differences by instrument. Accounting for risk factors associated with PP infection and the need for OVD, OVD itself does not appear to be an independent risk factor for maternal PP infection in our population. Routine use of prophylactic antibiotics with OVD may not be warranted based on contemporary 2nd stage labor management patterns in the US.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Diagnosing and treating occult vesicoureteric reflux using PIC cystography: Is it influenced by abnormalities on DMSA?

Positioning the Instillation of Contrast cystography (PICc) is used to identify occult vesicoureteric reflux (VUR) in patients with recurrent urinary tract infections (UTI) despite optimized bladder and bowel function and without VUR demonstrated on conventional imaging. To determine the incidence of finding occult VUR in such patients usingPICc and the benefit, if any, of treating it. We also assessed if this was influenced by abnormalities on the pre-operative DMSA. This was a retrospective review of PICc in our hospital between 2016 and 2018 and involved three paediatric urologists. The primary indication for PICc was two or more culture proven UTIs despite optimized bladder and bowel function and no reflux on voiding cystourethrography (VCUG) or indirect radionuclide cystography (I-RNC). All children had a preoperative DMSA scan to document any abnormalities. PICc was performed in a standardized way to each ureteric orifice. If occult reflux was found, it was treated concomitantly by cystoscopic injection of Deflux®. To assess the influence of the pre-operative DMSA status, the cohort was subdivided into two groups based on the DMSA scan: Group 1-abnormal DMSA, Group 2-normal DMSA. The median follow-up was 26 months (range 3-39 months). PICc was performed in 25 patients [23 females and 2 males; median age: 7 years (range 2-16 years; IQR=4)]; 17 from Group 1 and 8 from Group 2. Occult VUR was identified in 22 patients (88%); 15/17 (88.2%) in Group 1 and 7/8 (87.5%) in Group 2 (p=0.9). After cystoscopic treatment, 21/25 (84%) became infection free and this was not influenced by the preoperative DMSA status (p=0.6). Fig 1. In this challenging group of patients, looking for and treating occult reflux appears to be clinically useful and beneficial. The ability to test and treat at the same sitting is an added advantage of PICc. The DMSA results did not influence the diagnostic or therapeutic aspect of the process. Our results concur with other published literature. There is a high incidence of finding occult reflux using PICc in this cohort of patients. Concomitant cystoscopic treatment led to 84% of children becoming infection free on follow up. Abnormalities on DMSA did not influence either the likelihood of finding occult reflux or the likelihood of successful treatment.

16: Bundled interventions and an institutional focus on infection prevention significantly reduces post-hysterectomy infectious morbidity

To determine the impact of bundled interventions to prevent infectious morbidity after hysterectomy. An Infection prevention bundle was developed utilizing elements of previously published checklists as well as several data-driven measures developed from the Michigan Surgical Quality Collaborative (MSQC) to reduce post-hysterectomy infectious morbidity. These Michigan specific interventions included: addition of Metronidazole to first-generation cephalosporins for antibiotic prophylaxis, administration of beta-lactam antibiotics (unless the patient had documented anaphylactic reaction to penicillin), subcuticular closure of open incisions, early removal of Foley catheter. Moreover, an institutional focus on reducing infections consisted of a dedicated multi-disciplinary surgical site infection prevention committee consisting of infection prevention specialists, operating room nursing, surgeons and departmental leadership. Simultaneously, institution-wide efforts to increase handwashing and implement enhanced recovery were launched. All patients undergoing hysterectomy between 10/08/2015 - 10/07/2018 were divided into 3 equal yearly time frames for the analysis. Clinicopathologic data, operative details, and 30-day outcomes were obtained from three sources: electronic medical record, MSQC outcome dataset, and departmental infection prevention committee database. The primary outcome of interest was overall infection rate. This included superficial surgical site infection, deep and organ space infections, Clostridium difficile infection, culture proven urinary tract infections and others. A total of 1,867 hysterectomies were included in the analysis. Baseline demographic and operative details were similar between the patients in the three timeframes. Overall, 30-day infection rate fell from 4.5% (29/644) during year-1 to 2.6% (16/607) during year-2 to 2.1% (13/616) in year-3 (p = 0.036). Details of each category of infection included are presented in Table 1. On multivariate analysis, after adjusting for age, race, body mass index, malignancy and surgical approach, year of surgery remained an independent predictor with lower odds of infection (year-2 vs. year-1: OR 0.364 [95% CI 0.14 – 0.95]; year-3 vs. year-1: OR 0.281[95% CI 0.095 – 0.84]). A systemwide approach of implementing bundled interventions with an emphasis on infection prevention can significantly reduce infectious morbidity after hysterectomy.

Does the Trace Element Deficiency (Vit A, D & Zinc) Have Any Role in Vulnerability to Urinary Tract Infection in Children: A Case-Control Study: Tehran, Iran

Background and Objective: Urinary Tract Infection (UTI) is one of the most common causes of hospital admission in our young population. This prospective cohort study was carried out to assess the relation of serum levels of zinc, vitamins A and D with UTI in children with proven UTI. Methods: The serum levels of Zinc, vitamins A and D were compared between 25 proven UTI cases (admitted in 2 educational hospitals in Tehran) and 40 controls without infection (children who had undergone for elective surgery). The average age of children was 2.17 years. Atomic absorption Spectrophotometry, Radioimmunoassay, and HPLC methods were used for measuring the Zinc, Vit D and A, respectively. Results: Although the serum levels of zinc were significantly lower in UTI cases (P=0.05), no significant differences had observed between cases and controls for vitamins A and D in sera (P=0.4 and P=0.9). Conclusion: Due to established lower zinc level in UTI cases (p-value = 0.05), zinc deficiency might have a role in susceptibility to UTI in studied children. Administration of zinc could be helpful in preventing UTI. To establish the role of Vitamins A and D in vulnerability to UTI, further extensive research with larger samples is needed. Conclusion: Due to established lower zinc level in UTI cases (p-value = 0.05), zinc deficiency might have a role in susceptibility to UTI in studied children. Administration of zinc could be helpful in preventing UTI. To establish the role of Vitamins A and D in vulnerability to UTI, further extensive research with larger samples is needed.

A 9-year audit of the efficacy of diathermy for cystitis cystica

The aim of this study was to assess whether cystoscopy with diathermy for cystitis cystica in patients with recurrent urinary tract infection (UTI) is associated with decreased incidence of UTI. A retrospective 9-year audit was performed in a single urogynaecology centre. Patients with proven recurrent UTI and failed conservative therapy underwent cystoscopy with diathermy to cystitis cystica. The number of UTI’s 12- months pre and post cystoscopy was evaluated using women as their own controls with multivariant analysis of cofounding factors. Of 82 patients with recurrent UTI, 47 patients underwent cystoscopy with diathermy to cystitis cystica (median follow up 2 months [interquartile range, IQR6-31, one patient lost to follow up]). Pre-cystoscopy median UTI per annum was 3 per patient (IQR1-4). Post cystoscopy, median UTI for each woman was significantly reduced (median reduction -2[IQR-5-1], mean -2.14[95%CI -2.94, -1.34], P=<0.001). In the subgroup of patients who had previous vaginal mesh repair for prolapse (n=8) there was no significant benefit from diathermy (median reduction - 1.5[95%CI -0.988, 3.988], P=0.197). In conclusion, cystoscopy and diathermy of cystitis cystica was generally associated with significant reductions in UTI’s in the 12 months following diathermy.

Correlation of Sacral Ratio and Urinary Tract Infection in Children

Introduction:The sacral bone anomalies have an important effect on urinary and gastrointestinal tract and sacral ratio was defined as an indicator for estimating the anorectal abnormalities in children. This study was carried out for determining the association between sacral ratio and Urinary Tract Infections (UTI) among children.Material and Methods:In a cross sectional study, 100 children under 15 years with proven febrile UTI were referred to a referral children center considering the presence and grading of VUR according to VCUG enrolled in this study.Sacral ratio was measured for all cases and the data were compared by student T test, Chi 2 and Mann Whitney tests. SPSS 16.0 software was used for data analysis. P values less than 0.05 were considered significant.Results:41 boys and 59 girls with mean age 4.8 years were enrolled in this study. The average range of sacral ratio was 0.82. There was no staistical difference between two different genders and ages (p> 0.05).The values of SR in patients with VUR were lower than patients without VUR(P˂0.05) but there was no statistically significant difference between both bilateral and unilateral VUR and SR (p> 0.05).Conclusion:The risk of sacral bone abnormality in patients with VUR is more than patients without VUR. Therefore, in patients with UTI and low SR simultaneously, tighter evaluation for VUR and treatment should be considered.

Community Acquired Urinary Tract Infections’ Etiological Organisms and Antibiotics Susceptibility Patterns

Objectives: This study aimed at estimating the prevalence of bacterial strains isolated from patients with community acquired urinary tract infections (UTIs) and comparing the antibiotic susceptibility patterns among different genders. Methods: This prospective study was conducted between June 2011 and August 2012 in Iran, Tehran, on patients referred with symptomatic UTI. Midstream samples were taken and sent to the laboratory. The bacterial resistance was determined in patients with proven UTI by the Kirby Bauer’s disc diffusion method. Data were stratified by age and gender. Results: A total of 762 individuals were included in this prospective study, from which 573 (75.1%) were female and 189 (24.9%) were male patients. The most prevalent pathogen in different age, gender, inpatient and outpatient groups was Escherichia coli. The E. coli isolates were significantly higher in females compared to males (P = 0.03). High prevalence of resistance was observed against nalidixic acid (77.9%) in male patients, while amoxicillin (74%) was the most resistant antibiotic in females. However, the highest sensitivity was observed against imipenem in both male and female groups (97.9% and 97.2%, respectively) with no significant difference among them (P > 0.05). Conclusions: To date, this is the first study to determine the distribution and antibiotic susceptibility patterns in patients with UTI in Iran. This study showed that E. coli was the leading bacterial pathogen of community acquired UTIs in Iran, Tehran. An increasing resistance to first line antibiotics for UTI pathogens was also indicated, which emphases the need to improve empiric treatment.

Terminology and Pathophysiology of Overactive Bladder (OAB)

In 2002, the International Continence Society defined the term overactive bladder (OAB) as a symptom syndrome that is accompanied by urgency with or without urge incontinence, frequency and nocturia. A proven urinary tract infection or other obvious pathologies must be excluded.The pathophysiology of OAB has not been clarified in detail and is the subject of ongoing research, so partially overlapping hypotheses exist. The urothelium-based hypothesis suggests functional changes of urothelial receptors as well as functional changes regarding the sensitivity and coupling of the suburothelial myofibroblasts, which ultimately lead to increasing activity of afferent signals and urgency. The myogenic hypothesis is based on the assumption that unstable detrusor contractions may be triggered by changes in their excitability and coupling with other myocytes or myofibroblasts. Unstable detrusor contractions generate increased afferent activity followed by symptoms of overactive bladder. The hypothesis of abnormal processing of afferent signals assumes that damage to central inhibitory pathways and/or sensitisation of afferent nerves lead to the activation of the micturition reflex, which, in turn, induces unstable detrusor contractions. In addition, hormonal and psychological influences are discussed.

Predictors of fever-related admissions to a paediatric assessment unit, ward and reattendances in a South London emergency department: the CABIN 2 study

ObjectiveTo explore the risk factors for ward and paediatric assessment unit (PAU) admissions from the emergency department (ED).DesignProspective observational study.Setting and patientsFebrile children attending a large tertiary care ED during...

Profile of urinary tract infections in paediatric patients.

Background & objectives:This cross-sectional study was conducted at a tertiary care centre in Puducherry, south India, with the aim of finding the profile of the paediatric urinary tract infection (UTI), bacterial pathogens involved, and also to observe vesicoureteric reflux (VUR) and renal scarring in these patients.Methods:A total of 524 paediatric patients ≤13 yr, suspected to have UTI, were included in the study. Urine samples were collected, processed for uropathogen isolation and antibiotic susceptibility test was performed as per the Clinical and Laboratory Standards Institute (CLSI) guidelines. Thirty two culture proven children with UTI underwent micturating cysto-urethrography (MCU) and dimercaptosuccinic acid (DMSA) scanning was done for 69 children.Results:of the 524 children, 186 (35.4%) had culture proven UTI with 105 (56.4%) being infants, 50 (27.4%) between 1-5 yr, 30 (16.12%) between 5-13 yr and 129 (69.35%) males. Posterior urethral valve (PUV) was noted in three, hydronephrosis in one, VUR in 18 and renal scarring in 33. VUR as well as renal scarring were more in males >1 yr of age. A significant association (P=0.0054) was noted with a combined sensitivity and specificity of these investigations being 83 and 90 per cent, respectively of the MCU and DMSA scans for detecting VUR. Escherichia coli was the most common pathogen isolated, sensitive to nitrofurantoin, followed by cefoperazone-sulbactam, aminoglycosides and meropenem.Interpretation & conclusions:Our results indicate that UTI varies with age and gender and extensive evaluation is required in boys under one year of age with UTI. This study also highlights the better efficacy of aminoglycosides, cefoperazone-sulbactam and nitrofurantoin in vitro compared with meropenem in Gram–negative uropathogens.

PS-368 12 Years Data On Resistance Pattern Of Uropathogens: Abstract PS-368 Table 1

Background Urinary tract infection (UTI) is a common bacterial infection in infants and children. Traditionally, Trimethoprim has been the first line antibiotic of choice for the treatment of Coliform UTI. Empirical antibiotic treatment in UTI in children should be based on local surveillance data on the epidemiology and resistance patterns of common uropathogens. This has been endorsed in the guideline on UTI in children by National Institute for Health and Care Excellence in the UK. Aim To evaluate the resistance pattern to commonly used antibiotics in children with culture proven UTI. Methods We retrospectively analysed all cases with proven UTI from 2002–2013. Cases were identified by the clinical coding system and data obtained from the Hospital Information Support System. Results 1151 cases were identified; 95% (1090/1151) had pure growth of E.coli. Microbiology results were analysed to evaluate the sensitivities to commonly used antibiotics. Increasing resistance to Trimethoprim (TMP) and Co-Amoxiclav was observed during 2002–2008. Change in antibiotic policy has resulted in some decline in TMP resistance (Table below) over the recent years. Conclusion This comprehensive data on children with culture proved UTI supports the use of cefalexin as empirical treatment of choice for all presumed UTIs (pending culture results) in our region. Alternatively, TMP can be used (provided that urine sensitivity is known before commencing antibiotic treatment) if it is sensitive to coliform. It is vital to continue to monitor the resistance pattern to ensure early identification of emergence of drug resistance.

Antibiotics for acute pyelonephritis in children.

Urinary tract infection (UTI) is one of the most common bacterial infections in infants. The most severe form of UTI is acute pyelonephritis, which results in significant acute morbidity and may cause permanent kidney damage. There remains uncertainty regarding the optimum antibiotic regimen, route of administration and duration of treatment. This is an update of a review that was first published in 2003 and updated in 2005 and 2007. To evaluate the benefits and harms of antibiotics used to treat children with acute pyelonephritis. The aspects of therapy considered were 1) different antibiotics, 2) different dosing regimens of the same antibiotic, 3) different duration of treatment, and 4) different routes of administration. We searched the Cochrane Renal Group's Specialised Register, CENTRAL, MEDLINE, EMBASE, reference lists of articles and conference proceedings without language restriction to 10 April 2014. Randomised and quasi-randomised controlled trials comparing different antibiotic agents, routes, frequencies or durations of therapy in children aged 0 to 18 years with proven UTI and acute pyelonephritis were selected. Four authors independently assessed study quality and extracted data. Statistical analyses were performed using the random-effects model and the results expressed as risk ratio (RR) for dichotomous outcomes or mean difference (MD) for continuous data with 95% confidence intervals (CI). This updated review included 27 studies (4452 children). This update included evidence from three new studies, and following re-evaluation, a previously excluded study was included because it now met our inclusion criteria.Risk of bias was assessed as low for sequence generation (12 studies), allocation concealment (six studies), blinding of outcome assessors (17 studies), incomplete outcome reporting (19 studies) and selective outcome reporting (13 studies). No study was blinded for participants or investigators. The 27 included studies evaluated 12 different comparisons. No significant differences were found in duration of fever (2 studies, 808 children: MD 2.05 hours, 95% CI -0.84 to 4.94), persistent UTI at 72 hours after commencing therapy (2 studies, 542 children: RR 1.10, 95% CI 0.07 to 17.41) or persistent kidney damage at six to 12 months (4 studies, 943 children: RR 0.82, 95% CI 0.59 to 1.12) between oral antibiotic therapy (10 to 14 days) and intravenous (IV) therapy (3 days) followed by oral therapy (10 days). Similarly, no significant differences in persistent bacteriuria at the end of treatment (4 studies, 305 children: RR 0.78, 95% CI 0.24 to 2.55) or persistent kidney damage (4 studies, 726 children: RR 1.01, 95% CI 0.80 to 1.29) were found between IV therapy (three to four days) followed by oral therapy and IV therapy (seven to 14 days). No significant differences in efficacy were found between daily and thrice daily administration of aminoglycosides (1 study, 179 children, persistent clinical symptoms at three days: RR 1.98, 95% CI 0.37 to 10.53). Adverse events were mild and uncommon and rarely resulted in discontinuation of treatment. This updated review increases the body of evidence that oral antibiotics alone are as effective as a short course (three to four days) of IV antibiotics followed by oral therapy for a total treatment duration of 10 to 14 days for the treatment of acute pyelonephritis in children. When IV antibiotics are given, a short course (two to four days) of IV therapy followed by oral therapy is as effective as a longer course (seven to 10 days) of IV therapy. If IV therapy with aminoglycosides is chosen, single daily dosing is safe and effective. Insufficient data are available to extrapolate these findings to children aged less than one month of age or to children with dilating vesicoureteric reflux (grades III-V). Further studies are required to determine the optimal total duration of antibiotic therapy required for acute pyelonephritis.

Escherichia coli biofilm formation and recurrences of urinary tract infections in children

It has been suggested that biofilm formation by uropathogenic Escherichia coli (UPEC) isolates is associated with recurrence and persistence of urinary tract infection (UTI). We compared the in vitro biofilm formation of UPEC isolates from children with acute or recurrent UTI. Employing 206 consecutive clinical UPEC isolates from children with proven UTI, i.e., pyelonephritis (n = 78), recurrent pyelonephritis (n = 10), cystitis (n = 84) or recurrent cystitis (n = 34), we applied 1 % crystal violet staining to polystyrene microtitre plates at 72 h and measured the optical density (OD) values. The method had been validated to measure biofilm formation against confocal laser scanning microscopy and scanning electron microscopy. The OD values were lower in the recurrent cystitis group than in the other groups (mean OD 0.36, SD 0.21 vs mean 0.47, SD 0.36, P = 0.04) and higher in the recurrent pyelonephritis group than in the other groups (mean OD 0.69, SD 0.33 vs mean OD 0.44, SD 0.34, P = 0.006) indicating biofilm formation of strains causing recurrent pyelonephritis. It appears that the properties of UPEC isolates required for effective biofilm growth on an abiotic surface are important for recurrent pyelonephritis, but not for recurrent cystitis. It would be valuable in the future to analyze whether the biofilm properties of E. coli observed in vitro predict a slower clinical response to antimicrobial treatment and increased renal scar formation after UTI.

Etiology of Recurrent Abdominal Pain in Children

Introduction: Recurrent abdominal pain (RAP) is one of the most common gastrointestinal complaints during childhood and most frequent presentation in paediatric clinics. RAP has been classified etiologically into two broad groups: organic and functional. Functional causes of RAP were reported to be present in 90% of cases in the past. Because of the new diagnostic tools and an improved knowledge, the prevalence of RAP has been now increasing. The current study was done to find out the etiology of RAP in Nepalese children. Materials and Methods: This was a prospective study conducted in Civil Services Hospital, Paediatric department from April 2010 to March 2011 in children aged between 4 and 15 years, attending the outpatient department. All the children with RAP, who fulfilled the Apley’s criteria were included in this study. Results: Out of 47 children with RAP, organic causes were found in 41 children while non-organic causes, in 6 children. Parasitic infestation was the commonest organic cause of RAP, followed by idiopathic chronic constipation. Other causes were culture proven urinary tract infection, antral gastritis and H. pylori infection. Conclusion: Organic disorder is still the commoner cause of RAP in our part of the world. The key step in the management of RAP is to first investigate for the organic cause based on the symptoms. DOI: http://dx.doi.org/10.3126/jnps.v33i1.7413 J Nepal Paediatr Soc. 2013;33(1):31-33

An evaluation of leukocyte esterase activity as a rapid screening test for significant bacteriuria in children

The diagnosis of UTI is usually confirmed by microscopy and culture of properly collected urine specimens; however, due to scarce resources and other limitations, this is often not practicable in many resource poor nations. Since UTI if not identified early and treated could lead to serious complications, this study was therefore carried out to ascertain the clinical importance of Leukocyte esterase (LE) enzyme as a diagnostic tool for screening of Urinary Tract Infections (UTIs) in resource poor countries. The study was cross-sectional in nature comprising 250 asymptomatic pupils (120 males and 130 females) drawn from five nursery schools in Ikot Ansa in Calabar municipal area council in Nigeria. Subjects were selected using computer assisted random sampling methods. Urine specimens were collected, stored, transported, cultured and processed using standard laboratory procedures, while leukocyte esterase (LE) dipsticks were used as a screening tool for UTl and results compared with culture positive results. Significant bacteriuria through culture was recorded in 14 (5.6%) pupils and the commonest bacteria recovered were Escherichia coli 42.9% (6),Proteus mirabilis 21.5% (3) and Klebsiella pneumoniae 14.5% (2). Leukocyte esterase dipstick test correctly identified positive urine culture in 10 of 14 proven UTI (71.4%). The positive and negative predictive values were 25 and 98.1%, respectively. Leukocyte esterase test, though it has limitations in diagnosing UTI when compared to the culture methods, still proves useful in communities without facilities and requisite personnel for urine culture. The test is recommended for use in result limited communities, but where feasible, urine culture should be done. Key words: Children, leukocyte esterase, screening, urinary tract infection.

Vesicoureteral reflux in children with suspected and proven urinary tract infection

The aim of this study was to estimate the prevalence of vesicoureteral reflux (VUR) and clinically significant ultrasonography (US) abnormalities in a large group of children with proven and suspected urinary tract infection (UTI). The medical reports on renal US and voiding cystouretrographies (VCUG) of 2,036 children were reviewed. Renal US was performed on all children and VCUG on 1,185 children (58%). Based on the urine culture data, the UTI diagnoses were classified into five reliability classes (proven, likely, unlikely, false and no microbial data). The UTI diagnose was considered proven in 583/2036 (28.6%) and false in 145 (7.1%) cases. The prevalence of VUR was similar among those with proven and false UTI [37.4 vs. 34.8%; relative risk (RR) 1.08, 95% confidence intervals (95% CI) 0.7-1.7, P = 0.75] and decreased with increasing age (P = 0.001). Clinically significant US abnormalities occurred in 87/583 (14.9%) cases with proven UTI and significantly less often (11/145, 7.6%) in the false UTI class (RR 1.96, 95% CI 1.1-3.6, P = 0.02). Our finding supports the claim that VUR is not significantly associated to UTI and that its occurrence among children even without UTI is significantly higher than traditional estimates. This challenges the recommendations of routine VCUG after UTI.

Letters to the Editor

17 August 2009 Dear Editor, STERILE CEREBROSPINAL FLUID PLEOCYTOSIS IN INFANTS WITH URINARY TRACT INFECTION I read the paper entitled ‘Incidence of sterile cerebrospinal fluid pleocytosis in infants with urinary tract infection’1 with interest. The study is a useful addition to existing evidence (including our own2) that urinary tract infection (UTI) during early infancy may be associated with sterile cerebrospinal fluid (CSF) pleocytosis, but is rarely associated with CSF sepsis. As Yam et al. note, their study extends existing knowledge as they were able to exclude previous antibiotic therapy by measuring antimicrobial activity in the urine. However, I was surprised that the discussion regarding the clinical relevance of their findings was limited to ‘The importance of reporting CSF pleocytosis in UTI is educational so clinicians do not treat such infants for an unnecessary duration for possible bacterial meningitis’. In my view, this statement is not terribly helpful. The decision to cease intravenous antibiotic therapy in an infant with a proven UTI that has responded to therapy, and in whom the CSF cultures are sterile, is relatively straight forward. This was demonstrated by Yam et al.'s findings, as only one of the 12 infants with UTI and sterile CSF pleocytosis received a prolonged course of intravenous antibiotics. The more common and difficult clinical conundrum is: in an infant with working diagnosis of UTI (established on the basis of the full ward of an adequately collected sample), should one perform a lumbar puncture (LP) in the first place? Among the 106 infants with UTI who also had LP performed in the study by Yam et al.,1 there were no cases of bacterial meningitis identified. Similarly, among the 75 infants with UTI who also had an LP performed in our study,2 only one case of ‘probable’ bacterial meningitis was identified. There were no infants who relapsed with bacterial meningitis identified in either. Surely then, the relevant conclusion is, that in a well-looking infant with a working diagnosis of UTI, LP may not be necessary. Of course caution is required as the existing evidence is retrospective, and meningitis is a subtle and significant diagnosis in young infants. We suggested that a reasonable approach might be to limit the LP to infants at higher risk of coexisting CSF sepsis: neonates, infants with signs of septicaemia (pallor, tachycardia, inadequate perfusion), and infants with specific signs of meningitis (paradoxical irritability, a bulging fontanel, neck stiffness).