Prevalence of Urinary Tract Pathogens and Antimicrobial Resistance Patterns in Children Aged 1 to 12 Years

Research Article

J Bacteriol Mycol. 2018; 5(2): 1066.

Prevalence of Urinary Tract Pathogens and Antimicrobial Resistance Patterns in Children Aged 1 to 12 Years

Batabyal B1* and Himanshu2

¹Research Scholar, OPJS University, Churu, Rajasthan, India

²Department of Microbiology, Associate Professor, OPJS University, Churu, Rajasthan, India

*Corresponding author: Batabyal B, Research Scholar, OPJS University, Churu, Rajasthan, India

Received: March 26, 2018; Accepted: April 19, 2018; Published: April 26, 2018


Background: Urinary tract infections (UTIs) are counted among the most common infections in children. Most commonly, members of Enterobactericeae, particularly urinary pathogenic strains of Esch. coli and Enterobacter aerogenes are the primary causative organisms of UTIs in different parts of the world. In spite of the availability and use of the antimicrobial drugs, UTIs caused by bacteria have been showing increasing trends. Antibiotics are a mainstay in the treatment of bacterial infections, though their use is a primary risk factor for the development of antibiotic resistance. Antibiotic resistance is a growing problem in pediatric urology as demonstrated by increased urinary pathogen resistance. The extensive and inappropriate use of antimicrobial agents has invariably resulted in the development of antibiotic resistance which, in recent years, has become a major problem worldwide. Increasing antibiotic resistance among urinary pathogens to commonly prescribed drugs has become a global reality today. Complex pediatric patients with histories of hospitalizations, prior antibiotic exposure, and recurrent UTIs are also at high risk for acquiring UTIs due to extended spectrum beta-lactamase [ESBL] producing organisms. Data regarding the impact of in vitro antibiotic susceptibility testing interpretation on UTI treatment outcomes is lacking. The resistance of bacteria causing urinary tract infection (UTI) to commonly prescribed antibiotics is increasing both in developing as well as in developed countries. Resistance has emerged even to more potent antimicrobial agents.

Objective: To determine the prevalence and to find out the causative agents of UTI and their antibiotic resistance pattern among suspected UTI patients in children.

Methodology & Results: A total of 512 urine samples were collected from out patients of age between 1 to 12 years of both sex of children at Serum Analysis Center Pvt. Ltd. [Referral Laboratory]; Howrah; West Bengal; India between December 2016 to November 2017. The urine samples were cultured on HiCrome UTI Agra media and Eosin Methylene Blue Agar media [EMB] and the bacterial isolates were identified by gram staining and conventional biochemical methods. Antimicrobial susceptibility testing was performed by Kirby Bauer disk diffusion method according to the current National Committee for Clinical Laboratory Standards (NCCLS) guidelines.

Among the 512 urine samples examined [1 to 12 years of children], included 276 (54.0%) in Male child & 236 (46.0%) in Female child and 220 (42.9%) of urinary pathogens are isolated. The bacteria were isolates 104 (37.7%) of male child and 116 (49.2%) of female child. In patient of male child, 50% of Esch. coli, 34.6% of Klebsiella pneumoniae, 15.4% of others gram negative bacilli and 52.0% Extended- spectrum Beta lactamase [ESBL] stains were isolates. In patient of female child, 72.4% of Esch. coli, 20.7% of Klebsiella pneumoniae, 6.9% of others gram negative bacilli and 58.7% Extended- Spectrum Beta lactamase [ESBL] stains were isolates.

Resistance rates of Esch. coli [1 to 12 years of children] isolates were 83.8% to Amoxicillin/clavulanic acid, 70.5% to Cefixime, 23.5% to Fosfomycin, 26.5% to Nitrofurantoin, 63.2% to Ofloxacin, 66.1% to Ceftriaxone, 67.6% to Cefotaxime, 22.0% to Gentamicin, 89.7% to Cefpodoxime, 63.2% to Ciprofloxacin, 19.2% to Tobramycin, 80.8% to Cefprozil, 63.2% to Co-trimoxazole, 92.6% to Cefaclor, 70.5% to Doxycycline, 4.5% to Amikacin, 57.4% to Levofloxacin, 58.9% to Tetracycline and 89.8% to Cefalexin.

Resistance rates of Klebsiella pneumoniae [1 to 12 years of children] isolates were 66.7% to Amoxicillin/clavulanic acid, 43.3% to Cefixime, 23.3% to Fosfomycin, 63.3% to Nitrofurantoin, 20.0% to Ofloxacin, 43.3% to Ceftriaxone, 43.3% to Cefotaxime, 13.3% to Gentamicin, 90.0% to Cefpodoxime, 23.3% to Ciprofloxacin, 13.3% to Tobramycin, 76.6% to Cefprozil, 50.0% to Cotrimoxazole, 73.3% to Cefaclor, 33.3% to Doxycycline, 6.6% to Amikacin, 20.0% to Levofloxacin, 36.7% to Tetracycline and 80.0% to Cefalexin.

Resistance rates of Others Gram negative Bacilli [1 to 12 years of children] isolates were 75.0% to Amoxicillin/clavulanic acid, 33.4% to Cefixime, 33.4% to Fosfomycin, 41.7% to Nitrofurantoin, 16.7% to Ofloxacin, 66.7% to Ceftriaxone, 16.7% to Cefotaxime, 8.3% to Gentamicin, 91.6% to Cefpodoxime, 25.0% to Ciprofloxacin, 8.3% to Tobramycin, 91.6% to Cefprozil, 41.7% to Cotrimoxazole, 91.6% to Cefaclor, 41.7% to Doxycycline, 8.3% to Amikacin, 8.3% to Levofloxacin, 41.7% to Tetracycline and 91.6% to Cefalexin.

Conclusion: High prevalence of drug-resistant urinary tract pathogens, particularly to commonly use of oral antibiotics in UTI like Amoxicillin/ clavulanate, Cefixime, Cefpodoxime, Cefprozil, Cephalexin and Co-trimoxazole (Trimethoprim/sulfamethoxazole) among children suggests cautious use of antibiotic therapy for the treatment. Finally, we suggest that empirical antibiotic selection should be based on knowledge of the local prevalence of bacterial organisms and antibiotic sensitivities rather than on universal guidelines.

Keywords: Urinary Tract Infections; Antibiotic Resistance; Pediatrics; Antibiogram


Urinary Tract Infections (UTIs) are a common problem in pediatric patients. Resistance to common antibiotic agents appears to be increasing over time, although resistance rates may vary based on geographic region or country. Prior antibiotic exposure is a pertinent risk factor for acquiring resistant organisms during a first UTI and recurrent UTI. Judicious prescribing of antibiotics for common pediatric conditions is needed to prevent additional resistance from occurring. Complex pediatric patients with histories of hospitalizations, prior antibiotic exposure, and recurrent UTIs are also at high risk for acquiring UTIs due to extended spectrum betalactamase- producing organisms. Data regarding the impact of in vitro antibiotic susceptibility testing interpretation on UTI treatment outcomes is lacking.

A urinary tract infection (UTI) is one of the most important causes of morbidity and mortality in the developing countries like India. Acute urinary tract infections are relatively common in children, with 8 percent of girls and 2 percent of boys having at least one episode by seven years of age, and between 30% and 40% will have another episode within two years [1-2]. Several studies has demonstrated that the geographical variability of pathogen occurrence in case of UTI among inpatients and outpatients populations is limited by the predominance of gram-negative species usually Enterobactericeae and particularly Esch. coli and Enterobacter aerogenes in various regions of the world [3-4]. The most common pathogen is Escherichia coli, accounting for approximately 85 percent of urinary tract infections in children. Renal parenchyma defects are present in 3 to 15 percent of children within one to two years of their first diagnosed urinary tract infection. Clinical signs and symptoms of a urinary tract infection depend on the age of the child, but all febrile children two to 24 months of age with no obvious cause of infection should be evaluated for urinary tract infection (with the exception of circumcised boys older than 12 months). Evaluation of older children may depend on the clinical presentation and symptoms that point toward a urinary source (e.g., leukocyte esterase or nitrite present on dipstick testing; pyuria of at least 10 white blood cells per high-power field and bacteriuria on microscopy).

The worldwide increase of urinary pathogens resistant to former first line antibiotics, such as cotrimoxazole, fluoroquinolones and cephalosporins, has had detrimental consequences not only for treatment but also for prophylaxis of infectious complications after urological interventions. A paradigm shift concerning asymptomatic bacteriuria has had a great impact on the definition and management of UTIs today [5-8].

However, for complicated, nosocomial and severe UTI including pyelonephritis, antibiotic therapy will still be a corner stone in combination with treatment of the underlying complicating conditions. Unfortunately, there are few new antimicrobial drugs in the pipelines of pharmaceutical companies with prospects to overcome the problem of multi and extended drug resistant urinary pathogens [9].

Urinary tract infections (UTIs) are the most common serious bacterial infections in infants and young children. Infection of the urinary tract may be limited to the bladder, one or both kidneys, or both sites. In general, infections of the bladder (cystitis), although they cause substantial morbidity, are not regarded as serious bacterial infections. By contrast, infections that involve the kidney (pyelonephritis) may cause both acute morbidity and lead to scarring with the consequences of hypertension, preeclampsia, and chronic renal disease. Accordingly, differentiation of the site of infection has received considerable attention.

Antibiotics are medicines used to prevent and treat bacterial infections. Antibiotic resistance occurs when bacteria change in response to the use of these medicines. Bacteria, not humans or animals, become antibiotic-resistant. These bacteria may infect humans and animals, and the infections they cause are harder to treat than those caused by non-resistant bacteria. Antibiotic resistance leads to higher medical costs, prolonged hospital stays, and increased mortality.

Antimicrobial resistance among urinary tract isolates has recently been reported with an increased frequency all over the world [10-13]. The world urgently needs to change the way it prescribes and uses antibiotics. Even if new medicines are developed, without behavior change, antibiotic resistance will remain a major threat. Behavior changes must also include actions to reduce the spread of infections through vaccination, hand washing, practicing safer sex, and good food hygiene.

For more than half a century, antibiotic drugs have ensured that potentially life-threatening bacterial infections are treatable. Today, however, more and more bacterial infections fail to respond to antibiotic treatment. A federal task force recently warned that antibiotic resistance is “a growing menace to all people” and concluded that if nothing is done, treatments for common infections will become “increasingly limited and expensive- and, in some cases, nonexistent” (Table 1).