Prevalence of Urinary Tract Infection among Children attending Khartoum State Hospitals

1 M.Sc, Microbiology Department, Faculty of Medical Laboratory Sciences, University of Medical Sciences and Technology (UMST),


INTRODUCTION
UTI among children it accounted for 10% of all febrile illnesses in children, which is a major public health problems and second to infection of the respiratory tract among children. Bacterial infections are serious problems to the successful treatment of the UTI resulting in complications sometimes as the sequelae of untreated UTI in children lead to chronic atrophic pyelonephritis and renal failure to fatal sepsis occur in low-income and middle-income countries (Mohamed et al., 2014). Most UTIs in children result from ascending infections, although hematogenous spread may be more common in the first 12 weeks of life (Alper and Curry, 2005). Both anatomic and physiologic factors put children at risk of developing UTI; which is occur more often in girls, because of their urethras are shorter and closer to the anus. This make it easier for bacteria to enter the urethra, urinary obstruction, Vesicoureteral reflux (VUR), neurogenic bladder which is the improper storage of urine in bladder and improper emptying of urine from bladder, and uncircumcised boys (Alper and Curry, 2005).
The common bacterial pathogens responsible for urinary tract infections are gram-negative bacteria (90%) like Escherichia coli, Klebsiella species, Proteus mirabilis, Pseudomonas aeruginosa, Acinetobacter, and Serratia. while only 10% of the cases are triggered gram positive bacteria which include Enterococcus, Staphylococcus Species mainly S.aurues, and Streptococcus agalactiae. Furthermost UTIs in children are mono-microbic, frequently due to y Escherichia coli (60 to 80 % of cases), Proteus (more common in boys and in children with renal stones), Klebsiella, Enterococcus, and coagulase negative Staphylococci (Alper and Curry, 2005) . In virtually all cases, there is a need to start empirical treatment before the final microbiological results are available since the emergence of antimicrobialresistant clinical isolates, there have been reports of increasing rate of infection by multi-drug resistant bacteria has established itself as the common cause UTI of nosocomial as well as community acquired infection. So, in this study, we determined the bacteriological profile of UTI infections among children and their antimicrobial susceptibility patterns across the demographic data. Further, we also studied the incidence of UTI among Uncircumcised boys.

MATERIALS AND METHODS
A descriptive cross-sectional study which had been conducted during period from February to June 2018.Three hospitals in Khartoum (Gafar Ibn Auf Specialized Children Hospital, Yastabshiron Hospital, and Soba University Hospital). A total of 200 clean catch midstream urine samples were collected from children who had symptoms and/or signs suggestive of UTI in sterile universal containers and questionnaires were filled. Children taking antibiotics at the time of taking samples were excluded from our calculations for the prevalence.
The samples collected were examined microscopically for pus cells and casts. The samples were also processed using standard microbiological procedures. All the urine samples were cultured immediately on Cystine lactose electrolytes deficient (CLED) media by 0.01 ml standard loop method and incubated at 37°C overnight. The culture plate's results were interpreted as being significant, insignificant and no growth. A growth of ≥10 4 colony forming units/mL was considered as significant bacteriuria. The isolated organism was identified by routine microbiology methods from the samples showing significant bacteriuria. The Kirby-Bauer technique was carried out for antimicrobial susceptibility testing and interpretations of bacterial isolates to common antibiotics used for UTI in children irrespective to the hospital antibiotic policy (MacKie and McCartney's).

Data analysis
Statistical analysis data was tabulated and analyzed using the version 21-Statistical Package for Social Sciences (SPSS) software was presented as frequencies. Chi-square analysis (χ 2 ) was used in findings on comparison of positively UTI cases according to individual characteristics. Evaluations were carried out at 95% confidence level and P < 0.05 was considered statistically significant.   aeruginosa (3/58; 5.2%), and Proteus mirabilis (1/58; 1.7%). Antimicrobial sensitivity: in vitro susceptibility testing showed high sensitivity to impenem, amikacin, gentamycin, nitrofurontoin and ciprofloxacin (Table 2). However, resistance to several antibiotics was also observed; only a small portion of isolates were sensitive to norfloxacin, amoxicillin clavulinate, co-trimoxazole , amoxicillin, ceftazidime and none were sensitive to ampicillin and amoxicillin (0%). Whereas Individual isolate susceptibility testing of isolated uropathogens from 58 patients and gram-positive uropathogens represent (5/16; 31.2%) resistant to vancomycin (table 3).

DISCUSSION
The overall prevalence of UTI in our study population was 29%. In accordance with ranging of UTI among children age (<2-16 years)  reported in East Africa. This might be due to considerable regional variation in the prevalence of UTI in the developing countries depending on location and populations setting. Since the UTI is the 3rd most common infection experienced by children after respiratory and gastro-intestinal infections. However, the UTI symptoms include abdominal pain, back pain, dysuria, frequency, new-onset incontinence, but none of these symptoms alone is sufficient to establish UTI diagnosis in verbal children.
The prevalence of UTI is higher in females 38 (33.6%) than males20 (23%), this might be clarified by the anatomical structure differences between the two sexes as the female had a shorter urethra than male. These results come to an agreement with study conducted by Kirtilaxmi et al. (2015) and Pouladfar et al. (2017), in that is female has incidence of UTI higher than male. Prevalence of UTI corresponding to age groups has been also observed; this difference suggests that age is one of the risk factor associated with UTI as the high incidence of UTI amongst the preschooler's children age group (2-5 years) might be due to poor toilet and hygiene habits mainly at child daycare. An observation from Sudan showed that 74% of affected children with UTI were less than 5 years. 74% of them were below 5-years of age (Ali and Osman, 2009).
The high incidence of UTI amongst the uncircumcised boy 75%in the current study is comparable with that reported by Nader sheikh (Nader et al., 2008). Since the circumcision tends to decrease the frequency of UTI by 10-20 fold; which prevalence of UTI varied by circumcision status of boys, uncircumcised boy have highest baseline prevalence of UTI than circumcised boy because moisture can trapped between penis and foreskin, which create and ideal environment for bacteria of male how are uncircumcised.
Among the uropathogens isolated 72.4% gramnegative bacteria while only 27.6% of the cases are caused by gram-positive bacteria which principally significant bacteriuria. The highest prevalence of gramnegative bacteria in this study is in accordance with that reported by (Merga et al., 2018;Samuel, 2016;Mirzarazi et al., 2013). Despite study differs from findings reported by previous author (Nwokocha et al., 2014).
Furthermore, we assessed the relationship between UTI and various demographic variables like age, gender, Resident social class mother's education and employment status there was no significant difference (p value >0.05). Throughout childhood the risk of UTI was 8% for girls and 2% for boys according to department of urology/university of Wisconsin education module number 7 of Pediatric Urinary Tract Infection (www.urology.wisc.edu/education/module_7_pediatric_uti .pdf (2016). The Incidence of UTI is bimodal; highest during the first year of life and peaking again during adolescence, in our study there is no statistically significant difference between age group and UTI, this results agree with Nader et al. (2008).
Since antibiotics are given empirically, it is necessary to assess the distribution and susceptibility of the microorganisms in each case. In addition, there should be a periodic re-evaluation for UTI treatment policies in children. The results also revealed that among seventeen antibiotics used for susceptibility test; impenem was the most effective antibiotics (96.6%) followed by amikacin (94.8%) and gentamycin (75.9%). This might be due to the fact that impenem, amikacin and gentamicin are not offered astablets form and its unavailability by selfprescription in the community, that may minimized the chance to abuse. Also P.aeruginosa had highest resistant to norfloxacin (66.7%), and highest susceptibility to impenem (98.2%), and gentamycin (73.7%), amikacin (94.9%) , The drug susceptibility profile of uropathogens obtained in the present study was similar with the findings by Kirtilaxmi et al. (2015), and Pouladfar et al. (2017). Gram positive isolates with highest resistant to antibiotics ampicillin (100%), amoxicillin(100%), and susceptibility to impenem (98.2%), and gentamycin (73.7%), amikacin (94.9%), nitrofurontoin (91.7%) ,this result strongly contradicts with the findings reportedby (Kirtilaxmi et al., 2015), (Pouladfar et al., 2017), and (Madhi et al., 2018).
Klebsiella spp isolates in this study showed more resistance than E. coli isolates. The major difference was observed for gentamicin and amikacin; E. coli isolates showed low resistance to ciprofloxacin and tetracycline, while Klebsiella isolates showed high resistance to these agents despite being sensitive for many years (Kiffer et al., 2007).
On the other hand, a high degree of resistance was observed in Enterococcus faecalis, were resistant to ampicillin, amoxicillin, amoxyclave, erythromycin and cotrimoxazoleby 100% and by 66.7% to cephalosporin's antimicrobials. While the emergence of vancomycin resistant among gram-positive isolates was 31.2% (50% E. faecalis and 30% S. aureus), that due to overprescription, inadequate dosage of these antibiotics used during self-medication in our community is likely to be a factor contributing to the development of resistant strains.

CONCLUSION
The overall prevalence of UTI is 29% in the study area among children attending refer clinic with age range from 2-15 years, and more prevalent among in female than male. Circumcision tend to decrease the incidence of UTI, the rate of UTI in uncircumcised boys are more prone to UTI. The most frequently isolated uropathogen were Gram-negative organisms.
E. coli was the commonest organisms isolated followed by Klebsiella spp and S. aureus which are the principal urinary pathogen. Data presented in this study indicate that antibiotics commonly used for the treatment of UTIs in children are less effective. Since this was a cross-sectional study and time limited. Further regular studies is need to reliable information about prevalence of UTI among children and the resistance pattern of urinary pathogens for optimal empirical therapy.

Ethical consideration
Approval to carry out research was obtained from the Sudan Ministry of Health-research and Ethics Committee, University Medical sciences and technology-faculty of graduate studies-department of medical microbiology. Written informed consent was obtained from parents of the children who fit for inclusion in the study.