Ramakrishna Paramahamsa Rongala

Frequency of urinary tract infection in febrile children of one to five years of age

Rongala R.P ¹, Konkay K.P ², Naik R ³, Jaddu S.R⁴, Kakara R.K⁵

¹Dr. Ramakrishna Paramahamsa Rongala, Associate Professor, ²Dr. Keerthi Priya Konkay, Post Graduate, ³Dr. Raveendra Naik Dumavath, Post Graduate, ⁴Dr. Sankara Rao Jaddu, Post Graduate, ⁵Dr. Ravindra Kanna Kakara, Post Graduate; all authors are affiliated with Department of Pediatrics, GSL Medical College, Rajahmundry, Andhra Pradesh, India

Address for correspondence: Dr. Ramakrishna Paramahamsa Rongala, Email: drramakrishnapr@gmail.com

Abstract

Introduction: Fever is the most common reason for children 1-5 years of age to visit Emergency / out patient departments. Little attention has been focused on the identification of urinary tract infections in febrile children, despite recent information that suggests a high prevalence of urinary tract infections and significant associated morbidity in these patients. This study is undertaken to determine the prevalence of urinary tract infection in febrile children one year to five years of age and to evaluate various diagnostic methods for a case of Urinary tract infection. Method: Febrile children (rectal ≥38.3˚C or auxiliary temperature ≥37.8˚C) of 1 to 5 years of age were studied over a period of 12 months February 2015 to January 2016 at our tertiary care centre. History and relevant investigations were done. Result: The study included 200 children. The overall prevalence rate of urinary tract infection in the present study was 5.5% with prevalence in children 1-2 years of age 2%. 13.5% of cases showed significant pyuria. Among pyuric patients 40.74% were culture positive with a M:F of 1.2:6. USG done in significant pyuric cases revealed renal involvement /anomaly in 6 cases. Conclusion: Clinicians should consider obtaining a urine specimen as part of their diagnostic evaluation as urinary tract infection is a possibility in febrile children. Pyuria of ≥ 5 pus cells /HPF in centrifuged sample should be considered as significant pyuria and further evaluation should be done promptly to initiate treatment and to prevent morbidity and long term sequalae.

Key words: Children, Culture and sensitivity, Fever, Pyuria, Urinary tract infection

Manuscript received: 04th July 2016, Reviewed: 15th July 2016
Author Corrected; 26th July 2016, Accepted for Publication: 10th August 2016

Introduction

Fever is the most common reason for children between one to five years of age to visit Emergency / outpatient departments. Unlike occult bacteremia or severe bacterial illness, little attention has been focused on the identification of urinary tract infections in febrile children in the emergency department, despite recent information suggests a high prevalence of urinary tract infections and significant associated morbidity in these patients. Urinary Tract Infections (UTI) affects approximately 7% to 8% of girls and 2% of boys during the first 8 years of life. Fever and significant bacteriuria and pyuria in children with undocumented sources of infections must be presumed to be symptoms of Acute Pyelonephritis (APN), an invasive infection of the renal parenchyma requiring prompt treatment [1, 2]. High fever with temperature of 39.5oC or more is the single best predictive parameter [3,4] . The risk of APN increases when bladder infection occurs in patients Vesicoureteral reflux ( VUR), because colonized lower tract urine then has direct retrograde access to the upper tract [5]. Pyelonephritis leads to renal scarring in 27% to 64% of children with urinary tract infections in this age group, even in the absence of underlying urinary tract abnormalities [6,7]. A study from Sweden showed that focal renal scarring caused by Pyelonephritis in children carried a risk of 23% for hypertension, 10% for end - stage renal disease, and a risk of 15% for toxemia during pregnancy as an adult [8]. The present study was undertaken to estimate the frequency of urinary tract infection in febrile children of 1-5 years of age and to assess the validity of routine microscopic urine analysis and urine culture in the diagnosis of Urinary Tract infection.

Aims and objectives

The study was undertaken to determine the frequency of urinary tract infection in febrile children between one to five years of age and to assess the validity of routine microscopic urine analysis and urine culture in the diagnosis of urinary tract infection.

Materials and Method

The study was conducted in the department of pediatrics, GSL Medical College, Rajahmundry, for duration of 12 months from February 2015 to January 2016. Febrile (rectal ≥38.3˚C or axiliary temperature ≥37.8˚C) children between one to five years attending the outpatient department or admitted in the hospital were included in the study. Children who have received antibiotics 48 hours prior or those with known congenital genitourinary anomalies were excluded from the study. About 200 children were included in the study. The data related to age, gender, nutritional status, socioeconomic status and predisposing risk factors like urethral instrumentation, bowel and bladder habits were noted. A complete history related to the onset, duration of fever and associated symptoms such as nausea, vomiting, diarrhea, pain abdomen, urinary disturbances, other systems involvement was obtained. A thorough physical examination followed by blood counts, urine analysis was done. In children between one to two years of age, urine was collected by a bag, and midstream sample was collected in toilet trained children. The urine specimens were centrifuged in a standard manner, 10ml of urine was spun at the rate of 2500 rpm for 20-30mintes, supernatant discarded off and wet mount was prepared with the sediment which was examined under microscope for hematuria, and leukocyturia. In the present study ≥5 pus cells/HPF in a centrifuged urine sample was taken as significant pyuria and urine culture and sensitivity was performed in those cases by inoculating into blood and Mac conkey agar plates with a 0.01ml calibrated loop. All plates were incubated at 35-370C for 24hrs under aerobic condition to obtain accurate colony count. A positive urine culture was defined as growth of >105 colonies of a single urinary tract pathogen/ml of specimen in a mid-stream of urine. Samples showing insignificant growth, mixed growth of two or more pathogens or growth of non-pathogens were not considered as culture positive. Ultrasonograghy (USG) of abdomen was done in culture positive cases, one Dimercaptosuccinic acid (DMSA) scan and one Voiding Cystourethrogram (VCUG) was done.

Results

The study included 200 children during the study period after excluding the children mentioned above. There was slight female predominance with male female ratio of 1:1.15; 93 (46.50%) were males, 107 (53.50%) were females (table1). Children less than two years of age were 89 (44.5%). Most of the children in the study were below three years of age, 150(75%). Youngest child in the study group was 1 year old and eldest child in the study group was 5 years old.

Table-1: Age and gender Wise Distribution of Study Subjects

Age (In months)	Gender
	Male		Female		Total
	Number	%	Number	%	Number	%
12 – 24	32	36.0%	57	64.0%	89	100.0%
25 – 36	42	68.9%	19	31.1%	61	100.0%
37 – 48	10	38.5%	16	61.5%	26	100.0%
49 – 60	9	37.5%	15	62.5%	24	100.0%
Total	93	46.5%	107	53.5%	200	100.0%

In this study 27 children (13.5%) showed pyuria in centrifuged urine sample of which 11 (40.7%) were males and 16(59.3%) were females. Age and gender wise distribution of these are shown in table 2. Majority (40.74%) were between 1- 2 years of age.

Table- 2: Age and gender wise distribution of patients with urine ≥ 5 pus cells/hpf

Age (in months)	Gender
	Male		Female		Total
	Number	Percentage	Number	Percentage	Number	Percentage
12 – 24	4	36.4%	7	63.6%	11	100.0%
25 – 36	3	42.9%	4	57.1%	7	100.0%
37 – 48	3	50.0%	3	50.0%	6	100.0%
49 – 60	1	33.3%	2	66.7%	3	100.0%
Total	11	40.7%	16	59.3%	27	100.0%
Chi square calculated value is 0.382 for 3 d.f and P-Value 0.944 (Not Significant)

Chi square calculated value is 0.382 for 3 d.f and P-Value 0.944
(Not Significant)

Majority of children belong to lower middle class (female - 53.8%; male 46.2%) according to modified Kuppu Swamy Scale of Socio Economic Status. The details are shown in table 3.

Table-3: Socio economic status and sex wise distribution with urine showing ≥5 pus cells/hpf

Socio Economic Status	Sex
	Male		Female		Total
	Number	Percentage	Number	Percentage	Number	Percentage
Upper Class	0	0.0%	0	0.0%	0	0.0%
Upper Middle	2	50.0%	2	50.0%	4	100.0%
Lower Middle	6	46.2%	7	53.8%	13	100.0%
Upper Lower	1	16.7%	5	83.3%	6	100.0%
Lower	2	50.0%	2	50.0%	4	100.0%
Total	11	40.7%	16	59.3%	27	100.0%
Chi square calculated value is 1.882 for 3 d.f and P-Value 0.597 (Not Significant)

Chi square calculated value is 1.882 for 3 d.f and P-Value 0.597
(Not Significant)

In this study, among 200 children, 27 (13.5%) showed significant pus cells in urine, 81.4% of children with pyuria showed 5 -10pus cells / HPF and 18.5% showed more than 10 pus cells/ HPF.

In the study, growth ( > 105 CFU/ml) of single organism was considered significant growth. In children with pyuria, 16 (59.25%) showed no significant growth and 11 (40.7%) showed positive growth on urine culture. Gender distribution of urine culture is shown in table 4. Among positive cultures, E.coli was the bacteria most frequently isolated; the other organisms isolated were Klebsiella , Pseudomonas aeruginosa, and Serratia species as shown in table 5.

Table- 4: Urine analysis of subjects

Pyuria	Sex
	Male		Female		Total
	Number	percentage	Number	percentage	Number	Percentage
< 5	82	47.4%	91	52.6%	173	100.0%
5-10	9	40.9%	13	59.1%	22	100.0%
>10	2	40.0%	3	60.0%	5	100.0%
Total	93	46.5%	107	53.5%	200	100.0%
Chi square calculated value is 0.418 for 2 d.f and P-Value 0.812 (Not Significant)

Chi square calculated value is 0.418 for 2 d.f and P-Value 0.812
(Not Significant)

Table-5: Distribution of urine culture

ORGANISM ISOLATED	Sex
	Male		Female		Total
	Number	%	Number	N %	Number	%
No growth/ Contaminated	8	50.0%	8	50.0%	16	100.0%
E.COLI	0	.0%	6	100.0%	6	100.0%
KLEBSIELLA	1	50.0%	1	50.0%	2	100.0%
Pseudomonas aeruginosa	1	50.0%	1	50.0%	2	100.0%
SERRATIA sp	1	100.0%	0	.0%	1	100.0%
Total	11	40.7%	16	59.3%	27	100.0%

Though children with known congenital genitourinary anomalies were excluded in the study, USG was done in all significant pyuric cases (table 6); renal involvement / anomaly was seen in six children (54.54%) of which two were males, four were females. Twenty one children showed no significant radiological abnormality. One case showed DMSA &VCUG abnormality.

Table-6: Abdominal USG findings in culture positive children

Abdominal ultra sound	Sex			Total
	Male	Female
Bilateral hydronephrosis with thickened bladder wall with cystitis		1		1
Crossed fused ectopic left kidney/mild hepatosplenomegaly	1			1
Evidence of large bladder calculi		1		1
Features suggestive of bilateral moderate hydronephrosis nephroureterosis/cystitis		1		1
Massive hydronephrosis (lt side)		1		1
Rt sided hydronephrosis with PUJ obstruction with dysplastic kidney on Rt side with s/o VUR	1			1
Suggestive of hepatosplenomegaly		1		1
No significant radiological abnormality	1	4		1
Total	3		8	11

Table 7: Symptoms and signs in culture positive cases (N=11)

	Symptoms and Signs	culture positive cases		PERCENT(%) Approx
1	Fever	11		100
2	Dysuria	6		55
3	Vomiting	3		63
4	Chills & rigors	7		27
5	Passing high colored urine	5		64
6	Burning micturition	6		55
7	Refusal of feeds	5		45
8	Foul smelling urine	1		1
9	Abdominal pain	4		36
10	Temperature≥37.8˚ C	11	100
11	Ill toxic appearance	6	55
12	Supra pubic tenderness	4	36
13	Phimosis	3	27
14	Puffiness of face	1	1
15	Hypertension	1	1

Among the culture positive cases, fever (temperature of ≥37.8˚C) is most common symptom (100%), followed by passing of high colored urine (64%) and vomiting (63%). Ill toxic look (55%) and suprapubic tenderness (36%) were also found (table 7).

Discussion

Urinary tract infections are common, potentially serious infections of childhood. It may lead to renal scarring, hypertension, and end stage renal disease. Although children with pyelonephritis tend to present with fever, it can be difficult on clinical grounds to distinguish cystitis from pyelonephritis, particularly in young children (those younger than two years) [9]. Its diagnosis in young children is important as it may be the marker of urinary tract abnormalities. Early diagnosis is important to preserve renal function of the growing kidney.

UTI is one of the most important risk factor for development of renal insufficiency or end stage renal disease. A high index of suspicion is required for the diagnosis as signs and symptoms in younger age group are not localized. Therefore, early detection and therapy are needed to prevent scarring and further renal damage [10]. Accurate diagnosis of UTI is important to facilitate appropriate management of acute illness and to ensure appropriate evaluation and follow up. Equally important is accurately ruling out a urinary tract infection to avoid unnecessary cost and potentially harmful treatment and evaluation.

A total of 200 febrile children were included in the study, among them, 93(46.50%) were males and 107(53.50%) were females with Male: Female ratio 1:1.1 and majority of them i.e.75 % were between one to three years of age. Out of 200 children, 27 children showed significant pyuria (11 cases male and 16 female.); amongst these, 11 cases showed bacterial growth. The overall prevalence is 5.5%, which is comparable to many studies. Roberts k.et al [11] have coated prevalence of 4.1% and Fallahzadeh M.H et al [12] have reported a similar prevalence of 4.4%. Shaikh N et al [13] and Bauchner et al [14] have reported a prevalence rate of 7.8% and 8% respectively. In this study prevalence of UTI in 1-2 years age group was 2% which was similar to that reported by P.R Srivasths et al[15] which is 2.48% in children<2years. Shaikh N, et al[13] have reported a prevalence of 4.5% in this age group (table 8).

Table- 8: Comparative analysis of prevalence and gender distrubution

S.no	Study	Prevalence		Male: female ratio
1	Shaikh N, et al [13]	12-24 mon	4.5%
		1-5yrs	7.8%
2	Bauchner et al [14]	12-24 mon	5.4%
		1-5yrs	8%
3	Roberts k.et al [11]	4.1%
4	Fallahzadeh M.H et al[12]	4.4%		1:10
5	Jack S Elder et al [16]			1:10
6	Present study	12-24 mon	2%	1:2.6
		1-5yrs	5.5%

In this study, significant pyuria was more prevalent in females [11(40.7%) were males and 16(59.3%) were females],and was more common in one to three years age group [18(66.7%)] than in three to five years age [9(33.3%)].

Amongst 27 significant pyuric cases sent for urine culture 11cases showed growth, of which 3 were males and 8 were female giving overall incidence of 3.32% in males and 7.47% in females with male: female ratio of 1:2.6 which is similar to Jack S Elder et al [16] (table 8). This can be easily attributed to short urethra in female. Male: female ratio of culture positive cases in the age group of 12-24 months was 1:1.5 and above 24 months it was 1:2.5. As the age advances prevalence is more in female children.

There was no consistent symptom common to all patient with UTI other than fever. However chills and rigors, burning micturition, dysuria are were the predominant symptoms, with other nonspecific refusal of feeds, vomiting,. Hypertension was noted in one case with UTI which is similar to the observation made by Jaya et al [17]. Fever appears to be consistently present in children with urinary tract infection; no other signs or symptoms accurately predict the presence of urinary tract infection. Most of the children had no other signs other than fever indicating the importance of recognition of UTI in such patients.

In the present study 45% of children who showed pus cells >10 /HPF were culture positive and 27.27% of children showing ≥ 5pus cells were culture positive. Hence the presence of ≥5 leukocytes/HPF in a centrifuged sample is a significant indicator of UTI but pus cells in urine does not always indicate UTI. They can be noted in any inflammatory condition of the renal system such as Glomerulonephritis, Systemic lupus erythematosus, Henoch Schonlein Purpura vasculitis etc.

Gram -negative bacilli were isolated from all culture positive cases. The organisms isolated were Escherichia coli 54.54% and 18.18% each of Pseudomonas aeruginosa and Klebsiella, Serratia species 9%, which correlates with other studies. Bryan C.S et al [18] reported E. coli as the common urinary pathogen in 85%of cases, this result is nearly similar to Arvind Bagga et al [19] who reported about 90% of first symptomatic urinary tract infection and 70% of recurrent infections are due to E. coli. According to Srivaths P.R et al [15] , E. coli was the most common bacteriological agent isolated from UTI cases, similar to the studies by Bell LE, et al [20] and Bensman A et al [21] in which , it accounted for 80% of UTI. Other organisms Klebsiella, Proteus, Enterobacter and Enterococcus species can also cause UTI.

According Mohammed et al [22] ,of the 920 tested sample, 100 samples showed growth of pathogens among which the most prevalent were E. coli (61%) followed by Klebsiella spp (22%). The majority (66.66%) of the isolates were from female while the remaining was from male ( table 9).

Table-9: Analysis of culture report

Organism isolated	Mohammed et al [22]	Present study
E. coli	61%	54.54%
Pseudomonas aeruginosa	4.0%	18.18%
Klebsiella	22%	18.18%
Serratia spp	-	9.10%
S.aureus	7.0%	-
A. baumannii.	3.0%	-
Citrobacter spp.	2.0%	-
E. faecalis	1.0%	-

This is consistent with the findings of previous studies in which E. coli was the predominant pathogen isolated from patients with UTIs. In the present study the majority (72.72%) of the isolates were from female while the remaining was from male.

Studies by Copp et al [23] and Dahle et al [24] reported E. coli as most commonly isolated organism in pediatric UTI with prevalence ranging from 80 to 90 percent, followed by others such as Enterococcus species, Enterobacter species, Pseudomonas aeruginosa, Klebisiella pneumonia, Proteus mirabilis and Staphylococcus species.

Because of economic constraints urine cultures were done only in children who showed significant pyuria which revealed positive culture in 40.74%. Hence validity of urine examination could not be accurately ascertained. Though children with known congenital genitourinary anomalies were excluded in the study, USG done in all significant pyuric cases revealed renal involvement / anomaly in 6 cases (54.54%) among 11 cases, 2 were males 4 were females. Five cases showed no significant radiological abnormality. One case showed DMSA &VCUG abnormality.

Among the 11 children with culture proven UTI, one child who underwent VCUG scan had Vesicouretral reflux (VUR). Renal scarring was noted in the child who underwent DMSA scan. DMSA scan is a useful investigation for the diagnosis of renal scarring and it is indicated in febrile children with recurrent UTI after the febrile period is over. An abnormal DMSA is a strong indication for work up for VUR.

Conclusions

Clinicians should be aware of the possibility that febrile children may have urinary tract infection and should consider obtaining a urine culture specimen as part of their diagnostic evaluation. The presence of another potential source of fever such as upper respiratory tract infection or otitis media is not reliable in excluding urinary tract infection. Present study reveals overall prevalence of UTI (5.5%) in febrile children 1 year to 5 years and 2% in children 1-2 years of age. Radiological evaluation plays an important role in culture positive cases of UTI.

In the study urine culture was done in only those children showing significant pyuria of ≥ 5 pus cells/ HPF of centrifuged urine sample and found that 40.74% of febrile pyuric children were culture positive. Hence we conclude that pyuria of ≥ 5 pus cells /HPF in centrifuged sample should be considered as significant pyuria and further evaluation should be done promptly to initiate treatment and to prevent morbidity and long term sequalae.

Funding: Nil, Conflict of interest: Nil
Permission from IRB: Yes

References

1. Hellström A, Hansson E, Hansson S, Hjälmås K, Jodal U. Association between urinary symptoms at 7 years old and previous urinary tract infection. Arch Dis Child. 1991 Feb;66(2):232-4. [PubMed]

2. Mårild S, Jodal U. Incidence rate of first-time symptomatic urinary tract infection in children under 6 years of age. Acta Paediatr. 1998 May;87(5):549-52. [PubMed]

3. Pecile P, Miorin E, Romanello C,Vidal E, Contardo M, Valent F et al.Age-related renal parenchymal lesions in children with first febrile urinary tract infections. Pediatrics 2009 Jul;124(1):23-9. doi: 10.1542/peds.2008-1192.

4. Shaikh N, Ewing AL, Bhatnagar S, Hoberman A. Risk of renal scarring in children with a first urinary tract infection: a systematic review. Pediatrics. 2010 Dec;126(6):1084-91. doi: 10.1542/peds.2010-0685. Epub 2010 Nov 8.

5. Hudson RG. Lessons from the guidelines: understanding evidence-based vesicoureteral reflux treatment in 2010. Dialogues in Pediatric Urology 2011;32:5-6.

6. Rushton HG, Majd M, Jantausch B, Wiedermann BL, Belman AB. Renal scarring following reflux and non reflux pyelonephritis in children: evaluation with 99m technetium-dimercaptosuccinic acid scintigraphy. J Urol. 1992 May;147(5):1327-32. [PubMed]

7. Berg UB. Long-term follow up of renal morphology and function in children with recurrent pyelonephritis. J Urol. 1992 Nov;148(5 Pt 2):1715-20. [PubMed]

8. Jacobson SH, Eklöf O, Eriksson CG, Lins LE, Tidgren B, Winberg J. Development of hypertension and uraemia after pyelonephritis in childhood: 27 year follow up. BMJ. 1989 Sep 16;299(6701):703-6. [PubMed]

9. Saadeh SA, Mattoo TK, Managing urinary tract infections. Pediatr Nephrol. 2011 Nov;26(11):1967-76. doi: 10.1007/s00467-011-1801-5. Epub 2011 Mar 16. [PubMed]

10.Hoberman A, Charron M, Hickey RW, Baskin M, Kearney DH, Wald ER. Imaging studies after a first febrile urinary tract infection in young children. N Engl J Med. 2003 Jan 16;348(3):195-202. [PubMed]

11. Roberts KB, Charney E, Sweren RJ, Ahonkhai VI, Bergman DA, Coulter MP, Fendrick GM, Lachman BS, Lawless MR, Pantell RH, et al. Urinary tract infection in infants with unexplained fever: a collaborative study. J Pediatr. 1983 Dec;103(6):864-7. [PubMed]

12. Fallahzadeh MH, Alamdarlu HM. Prevalence of urinary tract infection in pre-school febrile children. Iranian J of Med Sci 1999; 24: 35-9.

13. Shaikh N, Morone NE, Bost JE, Farrell MH. Prevalence of urinary tract infection in childhood: a meta-analysis. Pediatr Infect Dis J. 2008 Apr;27(4):302-8. doi: 10.1097/INF.0b013e31815e4122. [PubMed]

14.Bauchner H, Philipp B, Dashefsky B, Klein JO. Prevalence of bacteriuria in febrile children. Pediatr Infect Dis J. 1987 Mar;6(3):239-42. [PubMed]

15.Srivaths PR, Rath B, Prakash SK, Talukdar B. Usefulness of screening febrile infants for urinary tract infection. Indian Pediatr. 1996 Mar;33(3):218-20. [PubMed]

16. Jack S. Elder: Urologic disorders in infants and children. Richard E Behrman, Kliegman RM, Stanton BF,(19th eds): Nelson textbook of Pediatrics, Elsevier and Saunders 2011 p p. 1827-1864. [PubMed]

17. Jaya G, Bal CS, Padhy AK, Bandopadhyaya GP, Pattnayak SK, Malathi KE. Radionuclide studies in the evaluation of urinary tract infections. Indian Pediatr. 1996 Aug;33(8):635-40. [PubMed]

18. Bryan CS, Reynolds KL. Hospital acquired Bacteremic urinary tract infection: Epidemiology and Outcome. J Urol. 1984 Sep;132(3):494-8.

19. BaggaA, Sharma J. Urinary tract infections clinical features, evaluation and treatment. Pediatr today 2000; 3: 395-401.

20. Bell LE, Mattoo TK. Update on childhood urinary tract infection and vesicoureteral reflux. Semin Nephrol. 2009 Jul;29(4):349-59. doi: 10.1016/j.semnephrol.2009.03.011. [PubMed]

21. Bensman A, Dunand O, Ulinski T. Urinary Tract Infection. In : Avner ED, Harmon WE, Niaudet P, Yoshikawa N, eds, pediatric nephrology Berlin; Springer – Verlag; 2009.pp 1299-310. [PubMed]

22. Akram M, Shahid M, Khan AU. Etiology and antibiotic resistance patterns of community-acquired urinary tract infections in J N M C Hospital Aligarh, India.Annals of Clinical Microbiology and Antimicrobials 2007;6:4. doi:10.1186/1476-0711-6-4. [PubMed]

23. Copp HL, Shapiro DJ, Hersh AL. National ambulatory antibiotic prescribing patterns for pediatric urinary tract infection, 1998-2007. Pediatrics. 2011 Jun;127(6):1027-33. doi: 10.1542/peds.2010-3465. Epub 2011 May 9. [PubMed]

24. Dahle KW, Korgenski EK, Hersh AL, Srivastava R, Gesteland PH. Clinical Value of an Ambulatory-Based Antibiogram for Uropathogens in Children. J Pediatric Infect Dis Soc. 2012 Dec;1(4):333-6. doi: 10.1093/jpids/pis055. Epub 2012 Jun 29. [PubMed]

How to cite this article?

Rongala R. P, Konkay K. P, Naik R, Jaddu S. R, Kakara R. K. Frequency of urinary tract infection in febrile children of one to five years of age. Int J Pediatr Res.2016;3(8):610-617.doi:10.17511/ijpr.2016.8.10.