URINARY TRACT INFECTION IN CHILDREN WITH NEPHROTIC SYNDROME.

Background: Urinary Tract Infection (UTI) is an important cause of relapses Objective: Study the prevalence of UTI and clinical presentation among group of children NS. Study urinalysis and culture results, the causative microorganism and their sensitivity pattern to 15 types of Antibiotics Methods: A prospective study including children with steroid sensitive NS was carried out in the Pediatric Nephrology Clinic of Al Imamain Kadhimien Medical city and Microbiology Department in Collage of medicine / AL- Nahrain University for the period from 1 st Dec. 2016 –

Relapse was regarded as proteinuria >40 mg/h/m2 or >50 mg/kg/day or Albustix +++ for 3 consecutive days after having been in remission (1) During relapse, all patients were sent for the following laboratory investigations; urinalysis, urine culture and sensitivity.
Urine samples from all patients were collected by clean catch method in sterile containers and promptly transported to the laboratory in the Department of Microbiology in Collage of Medicine in AL-Nahrain University .
Oral approval was taken from parents of children for taking the urine samples.All patients with no previous history of antibiotic intake. Loopful of the sample were inoculated on a blood agar and MacConkey agar aerobically for 18 -24 hours at 37°c.
The identification of Enterobacteriaceae family was performed according to the biochemical tests indicated in the scheme of Farmer and his co-workers (8) Other bacterial species were identified by gram stain. Resistance patterns of bacterial isolated to 15 various antibiotics were determined by Kirby-Bauer's disk diffusion test (DDT).
Significant pyuria was indicated as the presence of > 5 white blood cells (pus cells)/high power field (HPF) in centrifuged urine sample (3).
The case was regarded as UTI with the detection of the pathogen by the urine culture ± presence of clinical signs and symptoms.

Results:-
Total number of patients in the present study was 50 patients; there were 30 (60%) males and females 20 (40%), with male to female ratio 1.5: 1.

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Age of patients at time of presentation was ranging from 1 -12 year (mean of 5.2 + 3.1 year), most common age group of patients was 7 -12 year (60%).
Nearly all positive cultures were detected among age groups below 12 years, only 1 (5.88%) was more than 12 years. P value was significant 0.5957.
Clinical presentation had no correlation with culture result. P value 0.9403 Regarding pyuria, 11 (64.71) with > 5 Pus cells/ High power Field (PC/ HPF) had positive culture, while only 6 (35.29) patients with < 5 PC / HPF had positive culture .P value was significant 0.0124.
We notice a lower rate of sensitivity to commonly used antibiotics as 3 patients only (17.6%) were sensitive to trimethoprim , both gentamycin and cephalex show sensitivity in 1 patients (5.8%) , ampicillin show no sensitivity at all and 100% resistant .
Distribution of age groups in this study was similar to the finding of an Indonesian study, in which the most common age group of patients with NS was from 9-12 year 20 patients (27%) ( 14). While several studies recorded younger age group below 6 year as the commonest (9, 11, 13, 16, 17) . This study was conducted in tertiary center where most of the cases were referred from other centers, which explain higher age group.
This study show that UTI was present in 17 patients (10 males and 7 females) 34%, UTI was recorded in percentages ranging from 25 % -60.7% from different studies (7, 9, 10, 11, 13, 14, 15, 16, 17 All these studies proved that UTI is a common infection associated with NS. Significant pyuria with > 5 PC/ HPF was found in (38%) of cases in this study. Study from India reported slightly less figure of 26.32% (15) Another 2 studies , regarded pyuria as presence of > 10 PC /HPF in non centrifuged urine sample, reported higher figures of 64% and 57.89% respectively (13, 16)

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The presence of >5 PC/ HPF in a centrifuged sample and 10 PC /HPF in an uncentrifuged sample of urine is seen in the majority of patients with UTI (3) Although pain was the commonest symptom among our study population , 2 studies reported lower rates of pain with 6% and 10% respectively (11, 13) Two studies from Pakistan reported fever as high as 86.6% and 86% respectively (10 , 11), while another study from India reported low rate of 18% for fever. (13) Differences in clinical presentation varies between population and different age groups and is often nonspecific Different studies show that the commonest organism isolated was Escherichia coli, which was agreed upon in this study (9, 10, 13, 14, 15, 16 , 18) Enterococcus faecalis ranked second in this study with 29.4% . Compared with 2 other studies, lower rates of 5% and 21.1% was found respectively ( 15,18) Striking finding came from Adeleke study with Staphylococcus aureus as the commonest organism with 67.9% (17) The differences in the types of NS in different regions compared to those seen in Caucasians of this study may account for the varying causative microorganisms for UTI in patients with NS As seen in Table 2;data revealed significantly more females (58.82%) than males (41.18%) with proven positive urine culture among children with NS . This is similar to Indonesia study who found that UTI was more common in Females (67.6% ) compared to males (32.4%) (14). It is well established that overall prevalence of UTI occurred more frequently in females (2) Two studies found no significant correlation between sex and UTI in children with NS ( 6, 15), while another 2 studies found male predominance ( 13, 16)  Similarly ,2 recent studies from Indonesia and China found the most common antibiotics to which bacteria were sensitive were imipenem and amikacin (14,18) 343 Dillip; found all E.coli species were 100 % sensitive to amikacin and ceftriaxone. Also much better sensitivity patterns to other antibiotics. (16) Sawai found 50% sensitivity to amikacin, while 90% for gentamycin , 100% for Cefixime , which much higher than us. (15) Also Adeleke from Nigeria reported invitro sensitivity to commonly used antibiotics including trimethoprim sulphamethoxazole ampicillin, and nitrofurantoin was 35 percent or less (17) These observations pointing that there is an increasing resistance of bacteria mainly to common antibiotics. The malpractice and drug abuse could explain this unfortunate trend.

Conclusion:-
As UTI found in a considerable rate among children with NS, routine urine cultures should be carried out on patients with NS, especially during relapse.