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UTIs not caused by E. coli more likely in certain children

Publish date: August 2, 2016
By
Deepak Chitnis

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Study’s findings unsurprising, but not to be taken lightly

In this study of almost 800 children in the Pittsburgh area, the investigators sought to identify children at risk for urinary tract infections that more likely would have a bacterial organism not susceptible to standard first-line empiric antibiotic treatment.

They found that circumcised males, children with grade 3-4 vesicoureteral reflux, Hispanic children, and children without fever were more likely to have a UTI caused by organisms other than Escherichia coli and, therefore, less likely to respond to standard first-line antibiotic therapy. These investigators are the preeminent authorities in UTI management for children, so their findings should be viewed in that light.

Dr. Michael E. Pichichero

The advance from the study is not a major one because all children with a suspected UTI should have a suitable culture specimen obtained before starting antibiotics, and the treatment choice continued or changed based on culture results. So really, the findings apply only to a decision about initial empiric treatment while awaiting culture results.

As a guide, if a clinician were to consider the diagnosis of UTI based on history, examination, and urinalysis, and the child was a circumcised male, a child with known grade 3 or 4 vesicoureteral reflux, Hispanic, or without fever, then the empiric antibiotic selected should be broader spectrum while awaiting urine culture results.

Michael E. Pichichero, MD, a specialist in pediatric infectious diseases, is director of the Research Institute, Rochester (N.Y.) General Hospital. He is also a pediatrician at Legacy Pediatrics in Rochester. Dr. Pichichero said he had no relevant financial disclosures.


 

FROM THE PEDIATRIC INFECTIOUS DISEASE JOURNAL

References

Certain children are more highly predisposed to contracting a urinary tract infection caused by a pathogen other than Escherichia coli, which is typically the most common cause of UTIs, a study showed.

“It may be clinically important to predict which children have UTIs caused by organisms other than E. coli because these organisms differ in their patterns of antimicrobial susceptibility,” wrote the study authors led by Nader Shaikh, MD, of the University of Pittsburgh. “Furthermore, some guidelines have suggested that screening for vesicoureteral reflux (VUR) with a voiding cystourethrogram (VCUG) should, at least in part, be based on whether an organism other than E. coli is recovered,” they wrote.

Dr. Nader Shaikh

Dr. Nader Shaikh

Dr. Shaikh and his coinvestigators examined the medical records of children in the Randomized Intervention for Children With Vesicoureteral Reflux (RIVUR) trial and the Careful Urinary Tract Infection Evaluation (CUTIE), both of which were prospective multicenter studies. Children included in both studies were 2-71 months of age; RIVUR subjects had VUR grades 1-4 and presented with either a first or second febrile or symptomatic UTI, while CUTIE subjects presented with either their first or second UTI but not VUR (Ped Inf Dis J. 2016. doi:10.1097/INF.0000000000001301).

In total, 769 children from 19 centers were included from both studies, of which 703 (91%) were female and 596 (78%) were white. Nine percent of all the children had UTIs that were not caused by E. coli. Circumcised males had the highest odds ratio associated with non–E. coli UTIs, with an OR of 5.5 (95% CI, 1.18-17.1; P = .003). significantly higher than the 1.6 odds ratio for uncircumcised males (95% CI, 0.6-4.6; P = .35).

Hispanic children also had a higher risk (OR = 2.3; 95% CI, 1.1-4.6; P = .02) than either non-Hispanic children or females, which were reference cohorts. Other groups found to be at higher-than-normal risk for non–E. coli UTIs were children without fever (OR = 2.8; 95% CI, 1.2-6.6; P = .02) and children with VUR grade 3 or 4 (OR = 2.2; 95% CI, 1.2-4.1; P = .01).

While more than 90% of children’s UTIs were caused by E. coli, the most common pathogens causing UTIs, causative organisms in the other 70 children were Proteus species (21 children, 30%), Klebsiella species (16, 23%), Enterococcus species (14, 20%), Enterobacter species (8, 11%), and “other species” (11, 16%).

“Children with UTIs caused by organisms other than E. coli were twice as likely to have high-grade VUR (grade 3 and 4), which is consistent with prior studies,” Dr. Shaikh and his coauthors noted, adding, “the association between Hispanic ethnicity and non-E. coli pathogens is novel and may be due to differences in genes involved with susceptibility to UTIs.”

There were no disclosures or sources of funding provided.

dchitnis@frontlinemedcom.com

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