Organisms causing urinary tract infections in children and their sensitivity pattern in a level 2 pediatric hospital at a district place in South India

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Introduction
Urinary Tract Infection (UTI) is a bacterial infection routinely encountered by clinicians in developing countries [1] and is one of the most common bacterial infections in infants and young children  In routine urine analysis, urine microscopy was done using un-centrifuged urine.Observation of more than 5 pus cells/HPF was taken as a positive diagnosis of UTI [16].Then the urine specimen was inoculated in culture media using standard loop technique usually within 30 min.UTI was diagnosed only when a single uropathogen with CFU ≥ 105/mL, designated as significant growth was present [17].

Results
Out of 446 CCU samples of urine collected from children with the clinical suspect of UTI, 139 (31%) samples yielded growth and were positive for pathogenic organisms.more female preponderance in their study [21,22].
The current study did not find any gram positive organisms.The reason could be that these organisms account for very small numbers in the above studies and the current study excluded the growth of staphylocci, pseudomonas and multiple organisms from the present study group.
After analyzing the antibiogram of the isolates, it was observed that Amikacin was the most active antibiotic against all the gram-negative isolates followed by gentamicin and ofloxacin [9,11,27,34,35].All the organisms showed more than 50% sensitivity to these three drugs.The efficacy of third generation cephalosporins was reduced because of the high rate of production of ESBL resulting in drug resistance [9,26,[35][36][37].
Nalidixic acid showed high resistance to all isolates similar to other studies from different parts of the world [26,38].These results are mainly because of the irrational use of antibiotics even in rural areas and provide the physician with an idea of selecting appropriate antibiotics so that high antimicrobial resistance is not developed at the community level.

Limitations of this study
Infants with very illnesses excluded from the as they required immediate intensive care rather than wasting time in the collection of urine by midstream method.What does the study add to the existing knowledge?
Prospective regional studies should be carried out [2].UTI accounts for 2.1-7.5% of febrile children attending to hospital based on age and sex [3].It is often missed because of its non specific presentations especially in infants [4,5].Prompt and appropriate antimicrobial therapy should lead to rapid recovery and the avoidance of complications.Delayed or incorrect antibiotic treatment may result in recurrence, particularly in children with renal abnormalities who are at risk of developing progressive renal damage with renal scar, hypertension and chronic renal failure [6,7].Various studies carried out in infants and children to determine the type of organisms causing UTI have shown that (E.coli) is the most commonly cultured organism followed by other organisms including Klebsiella spp, Pseudomonas, Staphylococci ,Proteus Mb and Enterobacter etc [8-10].Increasing levels of infection with extended-spectrum β-lactamase (ESBL)-producing E. coli strains have been described in many countries [11,12] requiring monitoring of antimicrobial susceptibility.In children with suspected UTI, antibiotic treatment is usually started empirically especially in rural and suburban areas.Empirical antibiotic selection should be based on knowledge of the local prevalence of bacterial organisms and antibiotic sensitivities, because resistance patterns may vary in different regions and over a period of time [8, 13-15] Aim The objective of this study is to know the uropathogens causing UTI in children and their susceptibility pattern to commonly used antimicrobials for deriving options to empirical antibiotic therapy in children with community acquired UTI.

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A retrospective observational study of all positive urine cultures in children Setting: A 25 bedded level-2 exclusive pediatric hospital catering mainly rural and low socioeconomic status population at a district place in southern India.Materials: Retrospective information of all the urine culture positive cases done between the age group of 0-13 years who attended OPD as well as IPD over a period of 2 years from 01 Jan 2018 to 31 Dec 2019was collected from laboratory and medical records stored in computers.Methods: In all cases, urine was collected before starting antibiotics on the first day itself through the midstream clean-catch urine method (CCU).Even in most of the infants, urine was collected through the CCU method by specially training the mothers [5].Children requiring intensive care management with the immediate necessity of antibiotic therapy and hospital-acquired infections were excluded from the study group.According to US Centers for Disease Control and Prevention (CDC) guidelines, any infection48 hours after admission and before discharge should be categorized as hospitalacquired and those taken before or within 48 hours of admission should be categorized as communityacquired.
Growth of uncommon organisms, such as staphylococcus, pseudomonas, Citrobacter etc and the growth of multiple organisms was considered as a sign of contamination [18].The culture positive cases were tested for sensitivity by using combined gram negative microbial sensitivity discs consisting of 12 antibiotics i,e amikacin, gentamicin, ofloxacin, and nalidixic acid.Statistical Analysis: All the data were entered into MS-Excel and later exported to SPSS Version 23.Results were presented in terms of frequencies and percentages.The study was conducted as per the recommendations of the local ethical committee and in confirmation with the declaration of Helsinki.

FigDiscussions
Fig-3: Uropathogens isolated periodically at different regions to determine the local prevalence of organisms and antimicrobial susceptibilities in order to guide the proper use of antibiotics empirically in managing children with UTI in the absence of facilities for urine culture especially in rural and suburban areas. 18

Table - 2: Antibiotic sensitivity of uropathogens
. Tosif S, Baker A, Oakley E, Donath S, Babl FE.Contamination rates of different urine collection methods for the diagnosis of urinary tract [Crossref]