Urinary tract infection in febrile under-five children admitted in paediatric wards at Muhimbili national hospital Dar es Salaam, Tanzania 2010

Abstract

Background: Urinary tract infection (UTI) is a common and significant cause of morbidity and long-term complications in paediatric population. These infections are caused mainly by gram negative bacteria, which constitute the normal flora of gastrointestinal tract colonizing the perineum and ascending into the genital urinary system through the urethra. Children present with non specific symptoms and signs making the diagnosis of UTI in children challenging, furthermore obtaining urine specimen for confirming the diagnosis of UTI is difficult resulting in presumptive treatment of these patients. Effective and appropriate treatment depends on clinician's high index of suspicion which is influenced by knowledge of the prevalent bacteriological uropathogens and antimicrobial susceptibility pattern in the specific area of practice. There is limited information on clinical epidemiology of UTI in children in Dar es Salaam, and the few studies that are available were conducted several years ago. Therefore findings of those studies may not be applicable in the current circumstances bearing in mind the dynamic nature of antimicrobial susceptibility pattern of uropathogens. Objective: To determine the prevalence of UTI, aetiological uropathogens and antimicrobial susceptibility pattern in febrile children under-five years of age admitted in general paediatric wards ofMuhimbili National Hospital, Dar es Salaam, Tanzania. Methodology: This was a cross-sectional hospital based study which was conducted among febrile children less than five years of age. The children were consecutively recruited at admission in the general paediatric wards and the study was carried out for six months, from September, 2009 to February, 2010. Standardized questionnaires were used to collect socio- demographic characteristics and clinical presentation of study participants. The diagnosis of UTI was confirmed by urinalysis and bacteriological culture of urine specimens, which were obtained by supra-pubic aspiration or catheterization. The laboratory investigations were performed in accordance with the standard operating laboratory procedures. After isolation of bacterial uropathogens on a urine specimen antimicrobial susceptibility testing was performed using discs for the following antimicrobials ampicillin, co-trimoxazole, clavulanate- potentiated amoxillin, ceftriaxone, gentamycin and amikacin.

VII Results: A total of 382 children fulfilled the eligibility criteria and were enrolled into the study; out of which 212 (55.5%) were males and 170 (44.5%) were females. Among the 382 children sixty four children were confirmed to have UTI by urine culture, giving an overall prevalence of UTI of 16.8%. Females were noted to have higher prevalence of UTI than males, however, the difference was not statistically significant (p=0.332). Escherichia coli was the most commonly isolated organism accounting for 35.7%, followed by Klebsiella spp. Gram positive organisms were also isolated and these included Staphylococcus epiderm idis , Staphylococcus aureus and Streptococcus faecalis. Resistance rates of the isolated uropathogens to ampicillin, co-trimoxazole and clavulanate-potentiated amoxillin were 79.7%, 89.1 % and 70.3% respectively, while gentamycin and ceftriaxone had slightly lower resistance rates of 54.7% and 50% respectively. Amikacin had least resistance rate of 12.5%. Nitrite test had sensitivity and specificity of 68.8% and 92.4%, while leukocyte esterase test had sensitivity and specificity of 76.65 and 85.9%. When used in combination the nitrite and leukocyte esterase tests had a sensitivity and specificity of 85.9% and 79.6% respectively. Patients with fever for seven days or more were noted to have higher prevalence of UTI as compared to those with fever for less than seven days (OR 3.42; 95%CI 1.91-6.12, p<O.OI) while patients with history of convulsion had lower prevalence of UTI than those without (OR 2.37; 95%CI 1.16-4.85, p=0.016). Conclusion: Urinary tract infection was prevalent in children less than five years of age admitted with fever, particularly those with fever of longer than seven days duration. The isolated bacterial uropathogens have shown a relatively high resistance to ampicillin, eo- trimoxazole and clavulanate-potentiated amoxillin. Recommendations: Children admitted with fever should be evaluated for UTI and urine culture and sensitivity should guide the choice of antimicrobials in their treatment.