INTRODUCTION:

UTIs are inflammations that can affect any part of the urinary system and are caused by a range of pathogen. In children, UTIs are considered one of the most common type of infection with prevalence variations according to both age and gender^1-6. During the first year of their life, 0.7% of girls and 2.7% of boys will suffer from UTIs ^{7, 8}, whereas after the age of one, girls will develop UTI more than boys ^(9,
10). By the age of seven, about 7.8% of girls and 1.7% of boys will have at least one episode^{11, 12, 13}, and by the age of sixteen 11.3% of girls and 3.6% of boys will have at least one episode ^{11, 12, 13}.

Escherichia coli is the most frequent uropathogen, since it is responsible for approximately 80% of children UTIs ³. Other pathogens have been reported to cause severe UTIs such as Enterobacter aerogenes, Klebsiella pneumoniae, Proteus mirabilis, Citrobacter, Pseudomonas aeruginosa, Enterococcus spp., and Serratia spp.^1-6.

Importantly, the appropriate treatment for UTIs must preserve the renal function. Oral antibiotics have been recommended to treat UTIs, such as amoxicillin-clavulanate, nitrofurantoin, first or second generation cephalosporins, trimethoprim-sulfamethoxazole or fluoroquinolones. In more complicated UTIs cases, parenteral antibiotic have been administrated, including second generation cephalosporins, third generation cephalosporins (cefotaxime, ceftriaxone), aminoglycosides (gentamycin, amikacin).

Currently, finding the appropriate and effective antibiotic for UITs treatment has become challenging due to the increasing resistance of uropathogens to common prescribed antibiotics ^(14-30). Several studies have demonstrated multi-antibiotics resistance of uropathogens making the treatment of UTIs more difficult ^{1-6, 31}.

Unfortunately, in Syria as for many countries, antibiotics are unnecessarily and inappropriately prescribed in most cases of UTIs. The results of an in-vitro study for antibiotic resistance of bacteria causing urinary tract infection from Syrian adults showed the high resistance rates and multi-antibiotic resistance as well ³². In order to highlight these concerns for children with UTIs, the aim of this work was to study the prevalence of antibiotic resistance of bacteria causing UTIs in Syrian patients under the age of eighteen.

MATERIALS AND METHODS:

In the laboratory, urine samples were collected in sterile urine containers. To detect and identify microrganisms causing UTIs, blood and MacConkey agar plates were used in the culture study of urine samples. 24 hours after the incubation of urine samples at 37°C, colony forming units (CFU) were counted. In case of CFU greater than 100,000/ml, antibiotic sensitivity tests were then carried out using Mueller Hinton Agar (MHA). The level of antibiotics susceptibility of bacteria was determined by measuring the zone of inhibition.

The studied antibiotics discs include; amikacin 30μg, gentamycin 10μg, nitrofurantoin 300μg ceftriaxone 30µg, ciprofloxacin 30μg, imipenem 10μg, nalidixic acid 30 μg, norofloxacin 10μg, cefpodoxime 30μg, cefuroxime 30μg, cefotaxime 30μg, cephalexin 30μg, cefixime 5μg, Amoxicillin-clavulanic acid 30μg and trimethoprim-sulfamethoxazole 75μg.

RESULTS:

This study was conducted on 48 urine samples from pediatric UTI patients aged from day zero to eighteen years collected in the laboratory between August 2020 and June 2021. 77 % of collected urine samples were obtained from female UTI patients (37 patients) while 23% of samples were obtained from male UTI patients (11 patients). The ratio female/male UTI patients was 4:1, which is in accordance with previous results obtained for Syrian adult UTI patients. The percent of adult female UTI patients were higher than that of adult male UTI patient and the ratio female/male was approximately 4:1. In fact, many studied observed the higher prevalence of UTI in both children and adult females in comparison to males due to both anatomical and physiological considerations ³³. For instance in Turkey, a study found similar results where the female/male ratio was 4:1 ³⁴.

It is very important to notice that 21% of studied urine samples was from children under one year old, 31% from children between one and six years old and 48% from children between six and eighteen years old (figure 1).

Figure 1: Prevalence of studied children UTIs patient by age.

E. coli was the first cause of UTIs in childhood (63%), followed by Klebsiella pneumonia (25%) and by others bacteria like Enterobacter and beta-hemolytic streptococcus (12%). Similar results was observed in other studies conducted for Syrian adult UTI patients ³² and for children patients with UTI from Turkey ³⁴, Greece ³⁵, and other countries ^36-39.

Cephalosporins, aminoglycosides, fluoroquinolones, trimethoprim-sulfamethoxazole and other antibiotics are prescribed to manage the infections of urinary tract both in adult and children patients. In this study, the susceptibility of isolated urine bacteria to fifteen antibacterial drugs was tested including amikacin, gentamycin, nitrofurantoin, ceftriaxone, ciprofloxacin, imipenim, nalidixic acid, norofloxacin, cefpodoxime, cefuroxime, cephalexin, cefexime, amoxicillin-clavulanic acid, trimethoprim-sulfamethoxazole and cefotaxime.

The study of susceptibility of bacteria isolates from pediatric UTI patient highlighted a serious problem concerning the resistance of uropathogens. Only one bacteria isolate was resistant to one antibiotic (2%) while 47 bacteria isolates were resistant to at least 2 antibiotics (98%).

A high rate of resistance (≥ 20%) was observed among isolated urine bacteria to twelve antibiotics. While only three antibiotics showed a rate of resistance below 20% (figure 2). These results are consistent with previous reports regarding the resistance of uropathogens in children which demonstrated both high rates of resistance and multiple-antibiotic resistance as well ^34-38.

Figure 2: Percent of studied antibiotic according to the resistance rate among isolated urine bacteria from UTI young patients.

Susceptibility of 48 bacteria isolates tested against 15 antibiotics is presented in the Figure 3. Amikacin, showed the highest activity for bacterial urine isolates whatever the pathogen causing the infection (0% resistance). Gentamaycin and Imipenem both displayed a lower resistance rate (10%). Moderate overall resistance rate was found for Nitrofurantoin (20%), Ciprofloxacin (29%), Norofloxacin (27%), and Amoxicillin - Clavulanic acid (36%). The highest overall resistance rate was observed for Cefetriaxone (64%), Cefotaxime (74%), Trimethoprim - Sulfamethoxazole (76%), Cefuroxime (79%), Nalidixic acid (80%), Cefexime (90%), Cephalexin (93%) and Cefpodoxime (100%).

Figure 3: Susceptibility results of 48 urine samples from IUT patients. S: susceptible, I: intermediate, R: resistant.

Surprisingly, in most cases of resistance, the susceptibility of uropathogenic bacteria to studied antibiotic was null (as shown in the Figure 4). These results highlighted the difficulties to find effective antibiotics against uropathogens in Syrian pediatric patients. As in many other countries, antibiotics are available over the counter in Syria, and can be purchased without medical prescription, which eventually lead to inappropriate use by UTIs patients. For instance, Trimethoprim-Sulfamethoxazole, which is the most common used oral antibiotic to treat UTIs in children, exhibited a high resistance rate (76%). Furthermore, as shown figure 4, Trimethoprim-Sulfamethoxazole had no effect on the resistant uropathogens (inhibition zone equal to zero, 74%).

Figure 4: a comparison between the rate of resistance (R%) and the zero inhibition zone (0%) of bacteria urine isolates to antibiotics

In order to gain further insight into the factors affecting the UTI bacteria resistance, the effect of isolated urinary bacteria type on resistance rates to antibiotics was investigated.

As mentioned before, UTIs in child patients are mainly caused by E. Coli and Klebsiella. A comparison of resistance rates between E. Coli and Klebsiella to 15 antibiotics for pediatric UTI patients is presented in Figure 5. Amikacine showed the highest activity against all urinary pathogens with 0% resistance. The resistance rates to Cefepodoxime, Cephelxin, Naldixic acid, Trimethoprim-Sulfamethoxazole, Cefexime, Cefetriaxone was approximately similar for E. Coli and Klebsiella. Klebsiella urine isolates were more resistant to Ciprofloxacin, Amoxicillin-Clavulanic acid, Gentamycin and Nitrofurantoin than E. Coli. On the other hand, E. Coli urine isolates were more resistant to Cefatotoxime, Cefuroxime, Norfloxacin and Imipenem than Klebsiella.

Figure 5: resistance rate of E. Coli and Klebsiella urine isolates to studied antibiotics.

DISCUSSION:

UTI is one of the most common types of inflammatory diseases in Syria and across the world, it can affect any part of the urinary system. The most UTIs cases are observed in the lower urinary tract: the urinary bladder and the urethra, which are painful and often accompanied with bleedings. On the other hand, upper urinary tract infections affect profoundly kidney’s functions such as filtration and thus clearance could be severely altered ¹⁸. The most recurrent symptoms of UTIs involve frequent but small volume urination accompanied with burning sensations as well as colored urine due to bleedings. Women are more likely to develop UTIs than males due to anatomical considerations especially because they have a shorter urethra, The average females urethra is 1-2 inches long, will in males it is 6 inches long, this difference is important during bacterial infections as it means that germs can easily infect the urinary bladder ^{17, 20}. In addition, in female, the placement of urethra is closer to the rectum compared to males, which increases in prevalence of UITs in female ³³. On the other hand, hormonal changes happening during female life cycle including estrogen levels changes make the urethral epithelium thinner and thus more vulnerable to infection ²⁰. UTIs are also common in children especially young aged ones, in the first year of their life, boys can develop UTIs more often than girls ^{7, 8}. After the first year, girls will have frequently inflammatory episodes as compared to boys ^9-13.

Antibiotic resistance of UTIs bacteria isolates was reported by many studies, in a previous report (29), we have demonstrated the presence of high resistance rates and multi-antibiotic resistance for bacteria causing urinary tract infection in Syrian adults. The results obtained in the present study conducted on urine samples from Syrian children are in accordance with the previous one ⁽³²⁾. The high resistance rate observed in the present study highlighted a serious health problem caused by the inappropriate use of antibiotics, especially that the highest resistance levels was obtained for antibiotics “commonly” used by patients without medical prescription, and unfortunately sometimes in absence of medical consultation. Our results emphasize on the necessity to perform urine culture on samples from UTIs patients as a routine procedure (which is at the mean time not always the case) since resistance for some antibiotics was considerably different between Escherichia coli and Klebsiella pneumonia. Performing the susceptibility study enabled to obtain specific susceptibility patterns of uropathogens which is critical for choosing the adequate antibiotic for UTIs treatment.

CONCLUSION:

The aim of this research was to study the antibiotics susceptibility of bacteria causing UTIs in patients under 18 years of age in Syria. The obtained results revealed high overall resistance rates of urinary bacteria isolates for 13 antibiotics (resistance rates ≥20%). Amikacin proved high activity with resistance rate 0%. Gentamycin and imipenem were efficient with overall resistance rate below 10%. The resistant bacteria may result from the incorrectly prescribed antibiotics including choice of agent, or duration of antibiotic. The best example is the first choice antibiotic to treat UTIs is rimethoprim & sulfamethoxazol. Due to these finding antibiotics sales in Syria should be regulated and restricted to medical prescription.

REFERENCE:

1. Korbel L, Howell M, Spencer JD. The clinical diagnosis and management of urinary tract infections in children and adolescents. Paediatr Int Child Health. 2017 Nov;37(4):273-279. doi: 10.1080/20469047.2017.1382046. Epub 2017 Oct 5. PMID: 28978286.

2. Leung AKC, Wong AHC, Leung AAM, Hon KL. Urinary Tract Infection in Children. Recent Pat Inflamm Allergy Drug Discov. 2019;13(1):2-18. doi: 10.2174/1872213X13666181228154940. PMID: 30592257; PMCID: PMC6751349.

3. Kaufman J, Temple-Smith M, Sanci L. Urinary tract infections in children: an overview of diagnosis and management. BMJ Paediatr Open. 2019;3(1):e000487. Published 2019 Sep 24. doi:10.1136/bmjpo-2019-000487.

4. Robinson JL, Finlay JC, Lang ME, Bortolussi R; Canadian Paediatric Society, Infectious Diseases and Immunization Committee, Community Paediatrics Committee. Urinary tract infections in infants and children: Diagnosis and management. Paediatr Child Health. 2014;19(6):315-325. doi:10.1093/pch/19.6.315.

5. O'Brien K, Edwards A, Hood K, Butler CC. Prevalence of urinary tract infection in acutely unwell children in general practice: a prospective study with systematic urine sampling. Br J Gen Pract. 2013 Feb;63(607):e156-64. doi: 10.3399/bjgp13X663127. PMID: 23561695; PMCID: PMC3553642.

6. Shaikh N, Morone NE, Bost JE, Farrell MH. Prevalence of urinary tract infection in childhood: a meta-analysis. Pediatr Infect Dis J. 2008 Apr;27(4):302-8. doi: 10.1097/INF.0b013e31815e4122. PMID: 18316994.

7. Chang SL, Shortliffe LD. Pediatric urinary tract infections. Pediatr Clin North Am. 2006 Jun;53(3):379-400, vi. doi: 10.1016/j.pcl.2006.02.011. PMID: 16716786.

8. Simões e Silva AC, Oliveira EA. Update on the approach of urinary tract infection in childhood. J Pediatr (Rio J). 2015 Nov-Dec;91(6 Suppl 1):S2-10. doi: 10.1016/j.jped.2015.05.003. Epub 2015 Sep 7. PMID: 26361319.

9. Schlager TA. Urinary Tract Infections in Infants and Children. Microbiol Spectr. 2016 Oct;4(5). doi: 10.1128/microbiolspec.UTI-0022-2016. PMID: 28087926.

10. Zorc JJ, Kiddoo DA, Shaw KN. Diagnosis and management of pediatric urinary tract infections. Clin Microbiol Rev. 2005;18(2):417-422. doi:10.1128/CMR.18.2.417-422.2005.

11. Stephens GM, Akers S, Nguyen H, Woxland H. Evaluation and management of urinary tract infections in the school-aged child. Prim Care. 2015 Mar;42(1):33-41. doi: 10.1016/j.pop.2014.09.007. Epub 2014 Nov 18. PMID: 25634703.

12. Larcombe J. Urinary tract infection in children. Am Fam Physician. 2010 Nov 15;82(10):1252-6. PMID: 21121537.

13. Expert Panel on Pediatric Imaging:, Karmazyn BK, Alazraki AL, Anupindi SA, Dempsey ME, Dillman JR, Dorfman SR, Garber MD, Moore SG, Peters CA, Rice HE, Rigsby CK, Safdar NM, Simoneaux SF, Trout AT, Westra SJ, Wootton-Gorges SL, Coley BD. ACR Appropriateness Criteria® Urinary Tract Infection-Child. J Am Coll Radiol. 2017 May;14(5S):S362-S371. doi: 10.1016/j.jacr.2017.02.028. PMID: 28473093.

14. Critchley IA, Cotroneo N, Pucci MJ, Mendes R. The burden of antimicrobial resistance among urinary tract isolates of Escherichia coli in the United States in 2017. PLoS One. 2019 Dec 10;14(12):e0220265. doi: 10.1371/journal.pone.0220265. PMID: 31821338; PMCID: PMC6903708.

15. Schwaber MJ, Navon-Venezia S, Schwartz D, Carmeli Y. High levels of antimicrobial coresistance among extended-spectrum-beta-lactamase-producing Enterobacteriaceae. Antimicrob Agents Chemother. 2005;49(5):2137-2139. doi:10.1128/AAC.49.5.2137-2139.2005

16. Morosini MI, García-Castillo M, Coque TM, et al. Antibiotic coresistance in extended-spectrum-beta-lactamase-producing Enterobacteriaceae and in vitro activity of tigecycline. Antimicrob Agents Chemother. 2006;50(8):2695-2699. doi:10.1128/AAC.00155-06

17. Astal Z, Sharif FA, Abdallah SA, Fahd MI. Multiresistant Escherichia coli isolated from women with community-acquired urinary tract infections in the Gaza Strip. J Chemother. 2002;14(6):637-8. doi: 10.1179/joc.2002.14.6.637. PMID: 12583559.

18. lores-Mireles AL, Walker JN, Caparon M, Hultgren SJ. Urinary tract infections: epidemiology, mechanisms of infection and treatment options. Nat Rev Microbiol. 2015;13(5):269-84. doi: 10.1038/nrmicro3432. Epub 2015 Apr 8. PMID: 25853778; PMCID: PMC4457377.

19. Can F, Kurt-Azap Ö, İspir P, Nurtop E, Seref C, Loçlar İ, Aktaş ON, Orhan YC, Ergonul O. The clinical impact of ST131 H30-Rx subclone in urinary tract infections due to multidrug-resistant Escherichia coli. J Glob Antimicrob Resist. 2016;4:49-52. doi: 10.1016/j.jgar.2015.10.006. Epub 2015 Nov 14. PMID: 27436393.

20. Samir Issa Bloukh, Nageeb A. Hassan, Rand S. AlAni, Sabrina Ait Gacem, Urinary Tract Infection and Antibiotic Resistance among Pregnant and Non-pregnant females in UAE, Research J. Pharm. and Tech. 2021; 14(1):461-465. doi: 10.5958/0974-360X.2021.00084.6.

21. Nanda Anima, Dhamodharan S, Nayak BK, Antibiotic Resistance Pattern Exhibited by Esbl (Extended Spectrum β-Lactamases) in Multidrug Resistant Strains, Escherichia coli, Research J. Pharm. and Tech 2017; 10(11): 3705-3708. doi: 10.5958/0974-360X.2017.00672.2

22. Sreeja MK, Gowrishankar NL, Adisha. S, Divya. KC, Antibiotic Resistance-Reasons and the Most Common Resistant Pathogens – A Review, Research J. Pharm. and Tech., 2017; 10(6): 1886-1890. doi: 10.5958/0974-360X.2017.00331.6.

23. Sangeetha N, Guidelines for Antibiotic Therapy of Urinary Tract Infection in Acute Pyelonephritis, Bacteriuria in Adolescents. Asian J. Pharm. Res., 2018; 8(2): 83-86. doi: 10.5958/2231-5691.2018.00014.X.

24. Joshi Y, Gurung P, Jain S, Evaluation and Assessment of Drug Utilization in Patients of Urinary Tract Infections, Asian J. Pharm. Res., 2018; 8(3): 167-169. doi: 10.5958/2231-5691.2018.00029.1.

25. Rajesh KS, Honey VS, Ullas Prakash D’souza, Ragava Sharma, Bharath Raj KC, Study of Antibiotic resistance pattern in uropathogens at a Tertiary Care Hospital. Research J. Pharm. and Tech., 2020; 13(3): 1253-1256. doi: 10.5958/0974-360X.2020.00231.0.

26. Ahmed Abduljabbar Jaloob Aljanaby, Israa Abduljabbar Jaloob Aljanaby, Profile of Antimicrobial Resistance of Aerobic Pathogenic Bacteria isolated from Different Clinical Infections in Al-Kufa Central Hospital –Iraq During period from 2015 to 2017, Research J. Pharm. and Tech., 2017; 10(10):3264-3270. doi: 10.5958/0974-360X.2017.00579.0.

27. Shireen Rana, Siddesh Basawaraj Sirwar, Vijayaraghavan. Prevalence and Antibiogram of Extended Spectrum beta- Lactamase Producing Klebsiella pneumoniae and Proteus mirabilis in UTI, Research J. Pharm. and Tech. 2015: 8(11): 1465-1468. doi: 10.5958/0974-360X.2015.00262.0.

28. Isbera M, Abbood A, Ibrahim W. Weight and Content Uniformity of Warfarin Sodium Half Tablets. Research J. Pharm. and Tech. 9(3): Mar., 2016; Page 215-218. doi: 10.5958/0974-360X.2016.00039.1

29. Abbood A, Layka R. Weight and content uniformity Study of captopril half-tablets. Research J. Pharm. and Tech. 2017; 10(6): 1621-1626. doi: 10.5958/0974-360X.2017.00285.2.

30. Chbani D, Abbood A, Alkhayer M, Determination of Nitrite and Nitrate Ions levels in some types of processed meats marketed locally. Research J. Pharm. and Tech 2018; 11(4): 1442-1447. doi: 10.5958/0974-360X.2018.00269.X

31. Rachel L. Medernach, Latania K. Logan, The Growing Threat of Antibiotic Resistance in Children, Infectious Disease Clinics of North America, Volume 32, Issue 1, 2018, Pages 1-17, ISSN 0891-5520, ISBN 9780323581561, https://doi.org/10.1016/j.idc.2017.11.001.

32. Abbood A, Al-Homsh Y, Thallaj N, In vitro study for antibiotic resistance of bacteria causing urinary tract infection from Syrian adults, Research J. Pharm. and Tech. 2020.

33. White B, Diagnosis and Treatment of Urinary Tract Infections in Children, Oregon Health and Science University, Portland, Oregon, Am Fam Physician. 2011 Feb 15;83(4):409-415.

34. Samancı S, Çelik M, Köşker M. Antibiotic resistance in childhood urinary tract infections: A single-center experience. Turk Pediatri Ars. 2020 Dec 16;55(4):386-392. doi: 10.14744/TurkPediatriArs.2020.22309.

35. K. Vazouras, K. Velali, I. Tassiou, A. Anastasiou-Katsiardani, K. Athanasopoulou, A. Barbouni, C. Jackson, L. Folgori, T. Zaoutis, R. Basmaci, Y. Hsia, Antibiotic treatment and antimicrobial resistance in children with urinary tract infections, Journal of Global Antimicrobial Resistance, Volume 20, 2020, Pages 4-10, ISSN 2213-7165, https://doi.org/10.1016/j.jgar.2019.06.016.

36. Islam MA, Begum S, Parul SS,. Tajuddin Bhuyian AKM, Islam MT, Islam MK, Antibiotic Resistance Pattern in Children with UTI: A Study in a Tertiary Care Hospital, Dhaka, Bangladesh, American Journal of Pediatrics. 2019, 5, (4): 191-195. doi: 10.11648/j.ajp.20190504.14.

37. Duicu, C., Cozea, I., Delean, D., Aldea, A. A., Aldea, C. Antibiotic resistance patterns of urinary tract pathogens in children from Central Romania. Experimental and Therapeutic Medicine 22, no. 1 (2021): 748. https://doi.org/10.3892/etm.2021.10180

38. Iqbal Z., Mumtaz MZ., Malik A., Extensive drug-resistance in strains of Escherichia coli and Klebsiella pneumoniae isolated from paediatric urinary tract infections, Journal of Taibah University Medical Sciences, Volume 16, Issue 4, 2021, Pages 565-574, ISSN 1658-3612, https://doi.org/10.1016/j.jtumed.2021.03.004.

39. Sangeetha N., Guidelines for Antibiotic Therapy of Urinary Tract Infection in Acute Pyelonephritis, Bacteriuria in Adolescents. Asian J. Pharm. Res. 2018; 8(2): 83-86. doi: 10.5958/2231-5691.2018.00014.X.

Received on 02.01.2022 Modified on 05.03.2022

Research J. Pharm. and Tech 2022; 15(11):4935-4939.

DOI: 10.52711/0974-360X.2022.00829