|Year : 2021 | Volume
| Issue : 1 | Page : 19-21
Urinary tract infections in children presenting with acute gastroenteritis
Fatemeh Saeedi1, Iran Malekzadeh2, Mastaneh Moghtaderi3
1 Department of Pediatrics, Clinical Research Development Unit, Bahar Hospital, Shahroud University of Medical Sciences, Shahroud, Iran
2 Children Medical Center Hospital, Tehran University of Medical Sciences, Tehran, Iran
3 Department of Pediatric Nephrology, Pediatric Chronic Kidney Disease Research Center, Children Medical Center Hospital, Tehran University of Medical Sciences, Tehran, Iran
|Date of Submission||17-Nov-2020|
|Date of Decision||30-Mar-2021|
|Date of Acceptance||15-Apr-2021|
|Date of Web Publication||30-Jun-2021|
Department of Pediatric Nephrology, Chronic Kidney Disease Research Center, Children Medical Center Hospital, Tehran University of Medical Sciences, Tehran
Source of Support: None, Conflict of Interest: None
Management of acute gastroenteritis (AGE) includes treatment of underlying infections as well, since AGE may be an atypical presentation of urinary tract infection (UTI). The present study was planned to study the prevalence of UTI in children presenting with AGE. Two hundred consecutive patients presenting with AGE at 2 months to 4 years of age to one center's emergency department over 1 year were evaluated for UTI. Of 200 patients, 103 were male and 97 were female. One patient had infectious diarrhea. One hundred and forty-one (70.5%) patients were febrile, 63 (31.5%) patients had mild dehydration, 107 (53.5%) patients had moderate dehydration and 30 (15%) patients had severe dehydration. Twenty-five (12.5%) patients had pyuria. Fifteen (7.5%) patients had positive urine cultures. One of these (6.7%) patients had a history of UTI in the mother and 5 (33.3%) patients reported a history of UTI in their siblings. Of 15 patients with UTI, 13 (86.6%) were girls; 5 (38.4%) had labial adhesions. Escherichia coli and Klebsiella were isolated in 4 and one cases in urine culture, respectively. UTI underlies 7.5% of children presenting with AGE.
Keywords: Acute gastroenteritis, children, urinary tract infection
|How to cite this article:|
Saeedi F, Malekzadeh I, Moghtaderi M. Urinary tract infections in children presenting with acute gastroenteritis. Asian J Pediatr Nephrol 2021;4:19-21
|How to cite this URL:|
Saeedi F, Malekzadeh I, Moghtaderi M. Urinary tract infections in children presenting with acute gastroenteritis. Asian J Pediatr Nephrol [serial online] 2021 [cited 2022 Jan 17];4:19-21. Available from: https://www.ajpn-online.org/text.asp?2021/4/1/19/320190
| Introduction|| |
Urinary tract infection (UTI) is the second-most common bacterial infection in infants younger than 2 years and has a prevalence of 1%–3% in girls and 1% in boys. It is difficult to diagnose UTI in young children, especially if presenting with non-specific symptoms such as acute gastroenteritis (AGE) This study aimed to find the prevalence of UTI in patients presenting with AGE.
| Methods|| |
This cross-sectional prospective descriptive study enrolled all children with AGE referred for admission to our emergency department during the year 2018. AGE was defined as increased stool frequency with altered consistency with or without accompanying symptoms or signs, such as nausea, vomiting, fever or abdominal pain. Laboratory tests, including complete blood counts, electrolytes, urinalysis and stool examination, were performed in all patients. In children without bladder control, a urine bag was applied to collect urine sample after cleaning and sterilizing the genital area. If the first urinalysis showed leukocyturia, i.e., more than 5 white blood cells per high power field (HPF), a second urinalysis with urine culture was promptly performed with cautious sample collection using sterile precautions. The second urine samples was collected using catheter or suprapubic aspiration.
All urine samples were analyzed within an hour of collection. According to convention, blood agar (non-selective medium) and MacConkey agar (for Gram negative rods) were used for urine culture. UTI was defined as leukocyturia associated with positive urine culture, with growth of a single species of bacteria of over 105 colony forming units per mL. As bacteriuria is operator dependent, we did not consider it in our results.
| Results|| |
Two hundred patients with AGE were studied. Only one patient had presumably infectious diarrhea with high fever, toxic appearance and ≥5 leukocytes and red cells each per HPF of the stool sample. Bacterial cultures of all stool sample were negative. The duration of diarrhea and vomiting was <2 weeks in all patients. Fever (≥38.3°C) was present in 141 patients. Fifteen (7.5%) patients had positive urine cultures. [Table 1] demonstrates the findings in all patients enrolled, while [Table 2] represents the findings of those with UTI.
|Table 2: Findings in 15 patients with acute gastroenteritis and concomitant urinary tract infection (UTI)|
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All patients with UTI with AGE had normal spine, without any lumbosacral hemangioma or hairy patch. Most (86.6%) patients with UTI were girls. While vomiting was more frequent in patients with UTI than in those without UTI, fever was not more frequent and diarrhea not more severe in patients with UTI (P = 0.41). Patients with UTI more often had family history of UTI than those without UTI (P < 0.0001). Labial adhesions were more common in girls with UTI than those without UTI (P < 0.0001). UTI was associated with elevated C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) (respective P = 0.009 and 0.002). Patients with UTI had leukocytosis insignificantly more often than those without UTI (P = 0.15). Seven patients had thrombocytosis (platelet count >450,000/μL). Fourteen patients had bacteriuria. Hematuria was more common in patients with than without UTI (P = 0.01). Positive leukocyte esterase and nitrite tests were seen in 5 and 3 patients, respectively.
| Discussion|| |
This study reports AGE as an atypical presentation of UTI in 7.5% of patients with AGE. There are several studies regarding AGE and UTI in children. Yousefichaijan, et al., reported UTI in 7.5% of patients with diarrhea, predominantly (86.7%) in girls, chiefly in association with moderate to severe dehydration; pyuria was present in 12.5% of all patients. Thakar et al., reported UTI in 8 patients, chiefly girls aged 6–12 months, caused by Escherichia coli and Klebsiella sp., similar to our study. Narayanappa, et al., reported UTI in 5% of patients with AGE, while Fallahzadeh, et al., found UTI in 12.5% of 120 patients, again, chiefly (87.5%) in girls, and predominantly by E. coli and Klebsiella. Afridi, et al., found 27 patients with UTI, chiefly caused by E. coli, and Citrobacter or Pseudomonas sp.
All these studies showed that pyuria, hematuria and leukocyte esterase and nitrite positivity are significantly associated with UTI.,,,, UTI was not associated with the severity of dehydration and elevated urea or creatinine. We failed to find any association of UTI with fever, age, and severity of diarrhea; however, UTI appeared to be associated with female gender, vomiting, family history of UTI, labial adhesions, elevated ESR and CRP, leukocytosis, thrombocytosis, and UTI. The presence of pyuria, hematuria, leukocyte esterase positivity and nitrite positivity suggested a UTI. There was no relationship of UTI with severe dehydration or high creatinine.
| Conclusion|| |
To conclude, UTI underlies approximately 7.5% of acute diarrhea among children aged <4 years. Vomiting and positive family history might be useful pointers to UTI. Our and previous studies suggest the utility of bedside urinalysis in young children with AGE, especially girls younger than 3 years old. Leukocytosis, high levels of ESR and CRP, and positive family history of UTI in patients with AGE may indicate an atypical presentations of UTI. More precise criteria should be defined to help evaluate patients with AGE for an underlying UTI.
We express our gratitude to Seyed Abolhassan Alemohammad M.D. (Chief dermatologist of NIOC hospital, Tehran, Iran) for advising us during the course of this research. We are also immensely grateful to him for his comments on an earlier version of the manuscript.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Okarska-Napierała M, Wasilewska A, Kuchar E. Urinary tract infection in children: Diagnosis, treatment, imaging – Comparison of current guidelines. J Pediatr Urol 2017;13:567-73.
Stein R, Dogan HS, Hoebeke P, Kočvara R, Nijman RJ, Radmayr C, et al
. Urinary tract infections in children: EAU/ESPU guidelines. Eur Urol 2015;67:546-58.
Yousefichaijan P, Dorreh F, Ziaei E, Pakniyat A. Distribution of abnormal laboratory tests in patients with dehydration due to gastroenteritis: A medical audit study. J Compr Pediatr 2016;7:e38387.
Thakar R, Rath B, Prakash SK, Mittal SK, Talukdar B. Urinary tract infection in infants and young children with diarrhea. Indian Pediatr 2000;37:886-9.
Narayanappa D, Rajani HS, Sangameshwaran A Jr. Study of urinary tract infection in infants and young children with acute diarrhea. Indian J Public Health Res Dev 2015;6:226.
Fallahzadeh MH, Ghane F. Urinary tract infection in infants and children with diarrhoea. East Mediterr Health J 2006;12:690-4.
Afridi JM, Amir S, Rehman Y, Rahim F. Urinary tract infection as a cause of parenteral diarrhea in children. Med Forum Mon 2018;29:11-4.
[Table 1], [Table 2]