Pediatric Infection and Vaccine

The Korean Society of Pediatric Infectious Diseases (대한소아감염학회)
권호 표지
DOI QR코드

DOI QR Code

Clinical Features of and Antibiotic Resistance in Recurrent Urinary Tract Infection in Children with Vesicoureteral Reflux

  • Eun, So Hyun (Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine) ;
  • Kang, Ji-Man (Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine) ;
  • Kim, Ji Hong (Department of Pediatrics, Gangnam Severance Hospital, Yonsei University College of Medicine) ;
  • Kim, Sang Woon (Department of Urology and Urological Science Institute, Yonsei University College of Medicine) ;
  • Lee, Yong Seung (Department of Urology and Urological Science Institute, Yonsei University College of Medicine) ;
  • Han, Sang Won (Department of Urology and Urological Science Institute, Yonsei University College of Medicine) ;
  • Ahn, Jong Gyun (Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine)
  • Received : 2019.10.29
  • Accepted : 2019.11.28
  • Published : 2020.04.25
Download PDF
⟨ Previous Next ⟩

Abstract

Purpose: This study aimed to investigate the clinical features of recurrent urinary tract infection (UTI) in children with vesicoureteral reflux (VUR) and to compare the causative uropathogen and antibiotic susceptibility between the first and recurrent UTI episodes. Methods: We retrospectively reviewed the medical records of children with VUR who had recurrent UTI. Group 1 included patients in whom the same pathogen caused the first and recurrent UTI episodes. Group 2 included patients in whom different pathogens caused the first and recurrent UTI episodes. Results: During a 13-year study period (2005-2018), 77 children with VUR experienced at least one episode of UTI. Among these, 47 patients (61.0%) had recurrent UTI. Of the children with recurrent UTI, 19 (40.4%) were in group 1 and 28 (59.6%) were in group 2. Escherichia coli was the most commonly isolated uropathogen (n=37; 39.4%) in both episodes of recurrent UTIs, followed by Klebsiella pneumoniae (n=18; 19.1%), Enterococcus faecalis (n=14; 14.9%), and Enterobacter aerogenes (n=7; 7.4%). Although the difference was not significant, the rate of resistance to the antibiotics ceftazidime, piperacillin/tazobactam, and trimethoprim-sulfamethoxazole increased in patients with the second episode of E. coli recurrence in group 1, and that to cefotaxime, ceftazidime, piperacillin/tazobactam, and meropenem increased in children with the second episode of E. aerogenes recurrence in group 1. Conclusions: When selecting empirical antibiotics for recurrent UTI in children with VUR, it is important to consider that the pathogen and antimicrobial susceptibility of the previous UTI are not always the same in recurrent UTIs.

목적: 본 연구의 목적은 방광 요관 역류(vesicoureteral reflux) 환아에서 재발성 요로감염의 임상양상을 조사하고, 첫 번째 및 재발성 요로감염 간의 원인균과 항생제 감수성 결과를 비교하는 것이다. 방법: 방관 요관 역류로 진단된 소아 환자 중에서 요로감염이 발생한 환자의 의무기록을 후향적으로 검토하였다. 첫 번째와 두 번째 요로감염 건에서 같은 균종이 동정된 경우를 1군으로, 다른 균종이 동정된 경우를 2군으로 분류하여 분석하였다. 결과: 2005년 4월부터 2018년 2월까지 총 13년 간의 연구 기간 동안, 총 77명의 방관 요관 역류 환아가 적어도 한 번 이상의 요로감염을 경험하였다. 이중 47명의 환자(61.0%)가 재발성 요로감염소견을 보였다. 재발성 요로감염 환자중에서 1군은 19명(40.4%)이었고, 2군은 28명(59.6%)이었다. Escherichia coli (n=37, 39.4%)는 재발성 요로감염환자의 첫번째 및 두번째 요로감염 건에서 가장 흔하게 분리된 원인균이었고, 그 다음으로는 Klebsiella pneumoniae (n=18, 19.1%), Enterococcus faecalis (n=14, 14.9%), Enterobacter aerogenes (n=7, 7.4%), 및 Pseudomonas aeruginosa (n=4, 4.3%) 순이었다. 비록 통계적 차이는 없었지만, E. coli에 의한 재발 시, 같은 균에 의한 재발 임에도 ceftazidime, piperacillin/tazobactam과 trimethoprim-sulfamethoxazole에 대한 항생제 내성의 비율이 첫 번째보다 두 번째 감염에서 증가하였고, E. aerogenes에의한재발에서도 cefotaxime, ceftazidime, piperacillin/tazobactam 및 meropenem에 대한 항생제 내성의 비율이 첫 번째보다 두 번째 감염에서 증가하였다. 결론: 방관 요관 역류 환아의 재발성 요로감염에서 경험적 항생제를 선택할 때, 이전 감염의 병원균 및 항균제 감수성 결과가 재발 시에 항상 동일하지는 않다는 점을 염두에 두어야 한다.

Keywords

References

  1. Skoog SJ, Peters CA, Arant BS Jr, Copp HL, Elder JS, Hudson RG, et al. Pediatric vesicoureteral reflux guidelines panel summary report: clinical practice guidelines for screening siblings of children with vesicoureteral reflux and neonates/infants with prenatal hydronephrosis. J Urol 2010;184:1145-51. https://doi.org/10.1016/j.juro.2010.05.066
  2. Younis N, Quol K, Al-Momani T, Al-Awaisheh F, Al-Kayed D. Antibiotic resistance in children with recurrent or complicated urinary tract infection. JNMA J Nepal Med Assoc 2009;48:14-9.
  3. Lu KC, Chen PY, Huang FL, Yu HW, Kao CH, Fu LS, et al. Is combination antimicrobial therapy required for urinary tract infection in children? J Microbiol Immunol Infect 2003;36:56-60.
  4. Zorc JJ, Kiddoo DA, Shaw KN. Diagnosis and management of pediatric urinary tract infections. Clin Microbiol Rev 2005;18:417-22. https://doi.org/10.1128/CMR.18.2.417-422.2005
  5. Downs SM. Technical report: urinary tract infections in febrile infants and young children. The Urinary Tract Subcommittee of the American Academy of Pediatrics Committee on Quality Improvement. Pediatrics 1999;103:e54. https://doi.org/10.1542/peds.103.4.e54
  6. Hoberman A, Charron M, Hickey RW, Baskin M, Kearney DH, Wald ER. Imaging studies after a first febrile urinary tract infection in young children. N Engl J Med 2003;348:195-202. https://doi.org/10.1056/NEJMoa021698
  7. Jerardi KE, Jackson EC. Urinary tract infections. In: Kliegman RM, St. Geme JW III, Blum NJ, Shah SS, Tasker RC, Wilson KM, editors. Nelson textbook of pediatrics. 21st ed. Philadephia: Elsevier Inc., 2020:2789-95.
  8. RIVUR Trial Investigators, Hoberman A, Greenfield SP, Mattoo TK, Keren R, Mathews R, et al. Antimicrobial prophylaxis for children with vesicoureteral reflux. N Engl J Med 2014;370:2367-76. https://doi.org/10.1056/NEJMoa1401811
  9. Lebowitz RL, Olbing H, Parkkulainen KV, Smellie JM, Tamminen-Mobius TE. International system of radiographic grading of vesicoureteric reflux. International reflux study in children. Pediatr Radiol 1985;15:105-9. https://doi.org/10.1007/BF02388714
  10. Aydin A, Ahmed K, Zaman I, Khan MS, Dasgupta P. Recurrent urinary tract infections in women. Int Urogynecol J 2015;26:795-804. https://doi.org/10.1007/s00192-014-2569-5
  11. Clinical and Laboratory Standards Institute. Methods for dilution antimicrobial susceptibility tests for bacteria that grow aerobically; approved standard-eighth edition. CLSI document M07-A10. Wayne: Clinical and Laboratory Standards Institute, 2009:1-65.
  12. Chand DH, Rhoades T, Poe SA, Kraus S, Strife CF. Incidence and severity of vesicoureteral reflux in children related to age, gender, race and diagnosis. J Urol 2003;170:1548-50. https://doi.org/10.1097/01.ju.0000084299.55552.6c
  13. Jang HC, Lee KH, Park JS. Primary vesico-ureteral reflux: comparison of factors between infants and children. Korean J Urol 2011;52:206-9. https://doi.org/10.4111/kju.2011.52.3.206
  14. Montini G, Rigon L, Zucchetta P, Fregonese F, Toffolo A, Gobber D, et al. Prophylaxis after first febrile urinary tract infection in children? A multicenter, randomized, controlled, noninferiority trial. Pediatrics 2008;122:1064-71. https://doi.org/10.1542/peds.2007-3770
  15. Roussey-Kesler G, Gadjos V, Idres N, Horen B, Ichay L, Leclair MD, et al. Antibiotic prophylaxis for the prevention of recurrent urinary tract infection in children with low grade vesicoureteral reflux: results from a prospective randomized study. J Urol 2008;179:674-9.
  16. Dias CS, Silva JM, Diniz JS, Lima EM, Marciano RC, Lana LG, et al. Risk factors for recurrent urinary tract infections in a cohort of patients with primary vesicoureteral reflux. Pediatr Infect Dis J 2010;29:139-44. https://doi.org/10.1097/INF.0b013e3181b8e85f
  17. Park S, Song SH, Lee C, Kim JW, Kim KS. Bacterial pathogens in first febrile urinary tract infection affect breakthrough infections in infants with vesicoureteral reflux treated with prophylactic antibiotics. Urology 2013;81:1342-5. https://doi.org/10.1016/j.urology.2012.11.014
  18. Shim YH, Lee JW, Lee SJ. The risk factors of recurrent urinary tract infection in infants with normal urinary systems. Pediatr Nephrol 2009;24:309-12. https://doi.org/10.1007/s00467-008-1001-0
  19. Wu TH, Huang FL, Fu LS, Chou CM, Chien YL, Huang CM, et al. Treatment of recurrent complicated urinary tract infections in children with vesicoureteral reflux. J Microbiol Immunol Infect 2016;49:717-22. https://doi.org/10.1016/j.jmii.2014.08.024
  20. Lange K, Buerger M, Stallmach A, Bruns T. Effects of antibiotics on gut microbiota. Dig Dis 2016;34:260-8. https://doi.org/10.1159/000443360
  21. Becattini S, Taur Y, Pamer EG. Antibiotic-induced changes in the intestinal microbiota and disease. Trends Mol Med 2016;22:458-78. https://doi.org/10.1016/j.molmed.2016.04.003
  22. Soto SM. Importance of biofilms in urinary tract infections: new therapeutic approaches. Adv Biol 2014;2014:543974.
  23. Sanchez CJ Jr, Mende K, Beckius ML, Akers KS, Romano DR, Wenke JC, et al. Biofilm formation by clinical isolates and the implications in chronic infections. BMC Infect Dis 2013;13:47. https://doi.org/10.1186/1471-2334-13-47
  24. Hooton TM. Pathogenesis of urinary tract infections: an update. J Antimicrob Chemother 2000;46 Suppl A:1-7. https://doi.org/10.1093/jac/46.suppl_1.1
  25. Jantunen ME, Saxen H, Salo E, Siitonen A. Recurrent urinary tract infections in infancy: relapses or reinfections? J Infect Dis 2002;185:375-9. https://doi.org/10.1086/338771
  26. Russo TA, Stapleton A, Wenderoth S, Hooton TM, Stamm WE. Chromosomal restriction fragment length polymorphism analysis of Escherichia coli strains causing recurrent urinary tract infections in young women. J Infect Dis 1995;172:440-5. https://doi.org/10.1093/infdis/172.2.440
  27. Foxman B, Zhang L, Tallman P, Palin K, Rode C, Bloch C, et al. Virulence characteristics of Escherichia coli causing first urinary tract infection predict risk of second infection. J Infect Dis 1995;172:1536-41. https://doi.org/10.1093/infdis/172.6.1536
  28. Craig JC, Simpson JM, Williams GJ, Lowe A, Reynolds GJ, McTaggart SJ, et al. Antibiotic prophylaxis and recurrent urinary tract infection in children. N Engl J Med 2009;361:1748-59. https://doi.org/10.1056/NEJMoa0902295