Childhood Kidney Diseases

Korean Society of Pediatric Nephrology (대한소아신장학회)
권호 표지
DOI QR코드

DOI QR Code

Clinical Significance and Incidence of Gram-positive Uropathogens in Pediatric Patients Younger than 1 Year of Age with Febrile Urinary Tract Infection

1세 이하의 발열성 소아 요로감염에서 Gram-Positive Uropathogens의 발생 빈도 및 임상적 의의

  • Yang, Tae Hwan (Department of Pediatrics, College of Medicine, Korea University) ;
  • Yim, Hyung Eun (Department of Pediatrics, College of Medicine, Korea University) ;
  • Yoo, Kee Hwan (Department of Pediatrics, College of Medicine, Korea University)
  • 양태환 (고려대학교 의과대학 소아과학교실) ;
  • 임형은 (고려대학교 의과대학 소아과학교실) ;
  • 유기환 (고려대학교 의과대학 소아과학교실)
  • Received : 2013.08.08
  • Accepted : 2013.08.27
  • Published : 2013.10.31
Download PDF
⟨ Previous Next ⟩

Abstract

Purpose: Urinary tract infection (UTI) caused by gram-positive uropathogens is usually hospital-acquired and associated with predisposing conditions. However, the incidence of gram-positive bacteria in community-acquired UTIs has recently increased worldwide. We aimed to investigate the clinical significance of UTI and associated genitourinary malformations in young children with febrile UTIs caused by gram-positive bacteria. Methods: We retrospectively reviewed the medical records of 566 patients (age, <1 year) who visited the Korea University Medical Center for febrile UTIs between January 2008 and May 2013. We classified the patients into the following two groups: gram-positive (P group) and gram-negative (N group), according to the results of urine culture. The fever duration; white blood cell (WBC) counts and C-reactive protein (CRP) levels in peripheral blood; and the presence of hydronephrosis, cortical defects, vesicoureteral reflux (VUR), and renal scarring were compared between the two groups. Results: The number of patients with gram-positive bacteria was 23 (4.1%) and with gram-negative bacteria was 543 (95.9%). The most common pathogen was Escherichia coli, and Enterococcus faecalis showed the highest incidence among gram-positive uropathogens. Patients with gram-positive bacteria showed longer fever duration compared to that in patients with gram-negative bacteria (P vs. N, $3.4{\pm}1.2$ vs. $2.9{\pm}1.6$ days, P <0.05). The incidence of VUR was increased in the gram-positive group compared to that in the gram-negative group (P vs. N, 55.6 vs. 17.8%, P<0.05). However, there were no significant differences in other laboratory and radiologic findings. Conclusion: The findings of our study show that community-acquired UTIs in patients younger than 1 year of age, caused by gram-positive uropathogens, can be associated with prolonged fever duration and the presence of VUR.

목적: 요로감염은 대부분 그람 음성 균에 의해 발생한다고 알려져 있으나 최근 연구들에 의하면 병원내 감염의 주요원인으로 알려졌던 그람 양성균에 의한 요로감염이 증가하고 있고 일반적인 경험적 항생제에 내성이 증가하고 있어 균혈증 등으로 진행이 가능하지만 지역사회 획득 소아 요로감염에 미치는 연구들은 아직 미흡한 실정이다. 본 연구에서는 1세 이하의 지역사회 획득 발열성 소아 요로감염에서 그람 양성균이 요로감염의 중증도 및 동반 비뇨기계 기형과 연관이 있는지 알아보고자 하였다. 방법: 2008년 1월부터 2013년 5월까지 고려대학교 의료원에 입원 치료한 1세 이하의 발열성 요로감염 소아 566명을 대상으로 하였다. 치골 상부 방광 천자 및 도뇨관 으로 채취한 요 배양 검사에 따라 그람 양성균 군과 그람 음성균 군으로 나누어 입원 전후 발열 기간, 말초 혈액 내 백혈구 수와 혈청 C-반응성 단백, 수신증의 유무, 초기 신결손 및 신반흔의 유무, 방광요관역류의 유무 등의 항목들을 후향적으로 비교분석 하였다. 결과: 대상 환아 566명 중 그람 양성균 군은 23명, 그람 음성균 군은 543명 이었으며 그람 양성균 중 E. faecalis가 20주(71.4%)로 가장 많았고, 그람 음성균에서는 E. coli가 493주(86.8%)로 가장 높은 빈도를 보였다. 그람 양성균 군의 평균 입원 전후 발열 기간은 $3.4{\pm}1.2$일 이었으며 그람 음성균 군은 $2.9{\pm}1.6$일로 그람 양성균 군에서 유의하게 길었다. 또한, 배뇨 중 방광요도조영술상 방광요관역류는 그람 양성균 군에서 55.6%, 그람 음성균 군에서 17.8%로 그람 양성균 군에서 유의하게 높은 빈도로 나타났다. 그러나, 그 외 혈액 및 영상 검사 소견에서는 유의한 차이를 보이지 않았다. 결론: 저자들은 그람 양성균에 의한 1세 이하의 발열성 소아 요로감염에서 발열 기간 및 방광요관역류가 증가 할 수 있으므로 요로감염의 치료에 있어 경험적 항생제 선택에 신중을 기해야 하며 동반 기형을 찾기 위한 요로계 영상 검사와 추적 관찰이 꼭 필요함을 제시하는 바이다.

Keywords

References

  1. Brohard B, Travis L. Infections of the urinary tract. Rudolph AM, Hoffman JIEPediatrics. 18th ed. East Normark, Appleton & Lange 1987:1197-202.
  2. Williams G, Craig JC. Prevention of recurrent urinary tract infection in children. Current opinion in infectious diseases 2009;22:72-6. https://doi.org/10.1097/QCO.0b013e328320a885
  3. Winberg J, Andersen H, Bergström T, Jacobsson B, Larson H, Lincoln K. Epidemiology of symptomatic urinary tract infection in childhood. Acta Paediatrica 1974;63:1-20.
  4. Shaikh N, Morone NE, Bost JE, Farrell MH. Prevalence of urinary tract infection in childhood: a meta-analysis. The Pediatric infectious disease journal 2008;27:302-8. https://doi.org/10.1097/INF.0b013e31815e4122
  5. Kwon YD, Kim MJ, Kim HU, Oh SH, Song JY, Ko JT, et al. Antibiotic sensitivity pattern of pathogens from children with UTI. Journal of the Korean Society of Pediatric Nephrology 2006;10:182-91.
  6. Jodal U. The natural history of bacteriuria in childhood. Infectious disease clinics of North America 1987;1:713-29.
  7. Hoberman A, Charron M, Hickey RW, Baskin M, Kearney DH, Wald ER. Imaging studies after a first febrile urinary tract infection in young children. New England Journal of Medicine 2003;348:195-202. https://doi.org/10.1056/NEJMoa021698
  8. Jacobson SH, Eklöf O, Eriksson CG, Lins L-E, Tidgren B, Winberg J. Development of hypertension and uraemia after pyelonephritis in childhood: 27 year follow up. BMJ: British Medical Journal 1989;299:703. https://doi.org/10.1136/bmj.299.6701.703
  9. Merrick MV, Notghi A, Chalmers N, Wilkinson AG, Uttley WS. Long-term follow up to determine the prognostic value of imaging after urinary tract infections. Part 2: Scarring. Archives of disease in childhood 1995;72:393-6. https://doi.org/10.1136/adc.72.5.393
  10. Bitsori M, Maraki S, Raissaki M, Bakantaki A, Galanakis E. Community-acquired enterococcal urinary tract infections. Pediatric Nephrology 2005;20:1583-6. https://doi.org/10.1007/s00467-005-1976-8
  11. Ko YH, Oh JS, Cho DY, Bea JH, Koh SK. Changes of causative organisms and antimicrobial sensitivity of urinary tract infection between 1979 and 2001. Korean Journal of Urology 2003;44:342-50.
  12. Wagenlehner F, Naber K. Emergence of antibiotic resistance and prudent use of antibiotic therapy in nosocomially acquired urinary tract infections. International journal of antimicrobial agents 2004;23:24-9. https://doi.org/10.1016/j.ijantimicag.2003.09.004
  13. Yiee J, Wilcox D. Management of fetal hydronephrosis. Pediatric Nephrology 2008;23:347-53. https://doi.org/10.1007/s00467-007-0542-y
  14. Jaksic E, Bogdanovic R, Artiko V, Saranovic DS, Petrasinovic Z, Petrovic M, et al. Diagnostic role of initial renal cortical scintigraphy in children with the first episode of acute pyelonephritis. Annals of nuclear medicine 2011;25:37-43. https://doi.org/10.1007/s12149-010-0431-5
  15. Jakobsson B, Svensson L. Transient pyelonephritic changes on 99mTechnetium-dimercaptosuccinic acid scan for at least five months after infection. Acta Paediatrica 1997;86:803-7.
  16. Goldraich NP, Manfroi A. Febrile urinary tract infection: Escherichia coli susceptibility to oral antimicrobials. Pediatric Nephrology 2002;17:173-6. https://doi.org/10.1007/s00467-001-0808-8
  17. Lee S, Cho S, Kim S, Jeong D, Chung S, Lee K. Urinary tract infection in febrile infants with pyuria. Korean J Pediatr Infect Dis 2004;11:90-100.
  18. Flegal KM, Carroll MD, Kuczmarski RJ, Johnson CL. Overweight and obesity in the United States: prevalence and trends, 1960-1994. International journal of obesity and related metabolic disorders: journal of the International Association for the Study of Obesity 1998;22:39-47. https://doi.org/10.1038/sj.ijo.0800541
  19. Celebi S, Hacimustafaoglu M, Ozdemir O, Ozakin C. Nosocomial Gram-positive bacterial infections in children: Results of a 7 year study. Pediatrics International 2007;49:875-82. https://doi.org/10.1111/j.1442-200X.2007.02485.x
  20. Ma JF, Shortliffe LMD. Urinary tract infection in children: etiology and epidemiology. Urologic Clinics of North America 2004;31:517-26. https://doi.org/10.1016/j.ucl.2004.04.016
  21. Cho TH, Kim BJ, Ma JS. Clinical and bacteriological studies of urinary tract infection in children. Chonnam Medical Journal 1999;35:69-78.
  22. Ryu KH, Kim MK, Jeong YB. A recent study on the antimicrobial sensitivity of the organisms that cause urinary tract infection. Korean Journal of Urology 2007;48:638-45. https://doi.org/10.4111/kju.2007.48.6.638
  23. Oh E, Lee H, Lim HS, Park Y. Epidemiology and Resistance Patterns of Bacterial Pathogens in Urinary Tract Infections in the Northern Gyeonggi-do Area during 2007-2011. Laboratory Medicine Online 2013;3:34-9. https://doi.org/10.3343/lmo.2013.3.1.34
  24. Schlager TA. Urinary tract infections in children younger than 5 years of age. Paediatric drugs 2001;3:219-27. https://doi.org/10.2165/00128072-200103030-00004
  25. Wu C-S, Wang S-M, Ko W-C, Wu J-J, Yang Y-J, Liu C-C. Group B streptococcal infections in children in a tertiary care hospital in southern Taiwan. Journal of Microbiology, Immunology and Infection 2004;37:169-75.
  26. Choi WS, Seo YB, Jo YM, Kim JY, Kee SY, Jeong HW, et al. Epidemiology and clinical significance of bacteriuria caused by vancomycin-resistant enterococci. Infection and Chemotherapy 2006;38:242-9.
  27. Schouten M, Voss A, Hoogkamp-Korstanje J. Antimicrobial susceptibility patterns of enterococci causing infections in Europe. Antimicrobial agents and chemotherapy 1999;43: 2542-6.
  28. Muratani T, Matsumoto T. Bacterial resistance to antimicrobials in urinary isolates. International journal of antimicrobial agents 2004;24:28-31. https://doi.org/10.1016/j.ijantimicag.2004.02.001
  29. Noble W, Virani Z, Cree RG. Co-transfer of vancomycin and other resistance genes from< i> Enterococcus faecalisNCTC 12201 to< i> Staphylococcus aureus. FEMS Microbiology Letters 1992;93:195-8. https://doi.org/10.1111/j.1574-6968.1992.tb05089.x
  30. Kim SH, Lim TJ, Kim HY, Park SE, Kim SY. Clinical Characteristics of Community Acquired Enterococcal Urinary Tract Infections In Children. Journal of the Korean Society of Pediatric Nephrology 2013;17:19-24. https://doi.org/10.3339/jkspn.2013.17.1.19
  31. Berger C, Uehlinger J, Ghelfi D, Blau N, Fanconi S. Comparison of C-reactive protein and white blood cell count with differential in neonates at risk for septicaemia. European journal of pediatrics 1995;154:138-44. https://doi.org/10.1007/BF01991918
  32. Choi L, Cho SE, Yim HE, Yoo KH, Hong YS, Lee JW. Clinical Significance of Pyuria in Pediatric Patients with Febrile Urinary Tract Infection. Journal of the Korean Society of Pediatric Nephrology 2011;15:66-75. https://doi.org/10.3339/jkspn.2011.15.1.66
  33. Jung JI, Lim DH, Yim HE, Park MS, Yoo KH, Hong YS, et al. Fever duration and renal scar in pediatric urinary tract infection. Journal of the Korean Society of Pediatric Nephrology 2008; 12:70-7. https://doi.org/10.3339/jkspn.2008.12.1.70
  34. Michael Zerin J. Hydronephrosis in the neonate and young infant: current concepts. Seminars in Ultrasound, CT and MRI; 1994: Elsevier, 1994: 306-16.
  35. REPRESENTATIVES L. Practice Parameter: The Diagnosis, Treatment, and Evaluation of the Initial Urinary Tract Infection in Febrile Infants and Young Children. American Academy of Pediatrics. Committee on Quality Improvement. Subcommittee on Urinary Tract Infection. Pediatrics 1999;103.
  36. Newman TB. The new American Academy of Pediatrics urinary tract infection guideline. Pediatrics 2011;128:572-5. https://doi.org/10.1542/peds.2011-1818
  37. Peru H, Bakkaloglu SA, Soylemezoglu O, Buyan N, Hasanoglu E. The relationship between urinary tract infections and vesicoureteral reflux in Turkish children. International urology and nephrology 2009;41:947-51. https://doi.org/10.1007/s11255-008-9420-1
  38. Honkinen O, Lehtonen O-P, Ruuskanen O, Huovinen P, Mertsola J. Cohort study of bacterial species causing urinary tract infection and urinary tract abnormalities in children. BMJ: British Medical Journal 1999;318:770. https://doi.org/10.1136/bmj.318.7186.770
  39. Davis NF, Flood HD. The Pathogenesis of Urinary Tract Infections.
  40. Montini G, Zucchetta P, Tomasi L, Talenti E, Rigamonti W, Picco G, et al. Value of imaging studies after a first febrile urinary tract infection in young children: data from Italian renal infection study 1. Pediatrics 2009;123:e239-e46. https://doi.org/10.1542/peds.2008-1003