Trop Doct 2008;38:247-249
doi:10.1258/td.2008.070356
© 2008 Royal Society of Medicine Press
The incidence of urinary tract infections in febrile children during a two-year period in Tehran, Iran
Yunes Panahi *
Fatemeh Beiraghdar 
Yashar Moharamzad 
Zahra Khalili Matinzadeh
Behzad Einollahi
* Research Center of Chemical Injuries;
Trauma Research Center;
Nephrology and Urology Research Center, Baqiyatallah Medical Sciences University, Tehran, P.O. Box 199 45/581, Islamic Republic of Iran
Correspondence to: Yunes Panahi, Baqiyatallah Medical Sciences University - Research Center of Chemical Injuries, Tehran, PO Box 199 45/581, Islamic Republic of Iran Email: yunespanahi{at}bmsu.ac.ir
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SUMMARY
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Of 433 febrile children examined in the paediatric clinics of
two university hospitals in Tehran, Iran, 39 (9%) children (27
girls and 12 boys) were diagnosed as having urinary tract infection
in which
Escherichia coli was the most frequently detected pathogen
(84.6%). According to the voiding cystourethrogram, nine (75%)
boys and 17 (63%) girls had urinary tract abnormalities. This
result is slightly higher than seen in other reports from developing
countries.
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Introduction
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Urinary tract infection (UTI), one of the most common clinical
problems in children, can lead to pyelonephritis, renal scarring,
hypertension and end-stage renal dysfunction.
1 It is imperative
that physicians identify these children in order to institute
early treatment, evaluate the urinary tract and monitor for
recurrent UTI.
2 Most UTIs in children are monomicrobic, often
caused by
Escherichia coli, Proteus, Klebsiella, Enterococcus
and coagulase-negative staphylococci.
3
Although children with pyelonephritis tend to present with fever, it is often difficult to distinguish pyelonephritis from other infections in childhood.4 The overall prevalence of UTI is approximately 5% in febrile infants, although it varies widely by race and sex.5,6 In addition, UTI prevalence has been reported to be higher among uncircumcised than circumcised males.7 The purpose of this study was to determine the incidence of UTI and identify demographic and clinical factors among young febrile children seen in the paediatric clinics of two general university hospitals in Tehran.
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Patients and methods
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This prospective cross-sectional study was performed in two
general university hospitals in Tehran from 2004 to 2006. All
children aged 60 months or younger, with rectal temperatures
38°C for those younger than 24-month old and axillary temperatures
equal to or more than 38°C for children older than 24 months,
were eligible for the study. Children who had received antibiotics
within 48 hours of presentation were excluded from the study.
During the study period, 433 febrile children were enrolled. In 257 cases (59.3%), the cause of the fever was diagnosed at the clinic; the other 176 patients (40.7%) needed laboratory tests to confirm the diagnoses. These tests included urine analysis (UA) and culture (UC) and stool examination, as appropriate.
In infants less than or equal to one-year-old, cultures were performed on urine samples collected from supra pubic puncture, and any growth was considered positive. In those between one to two-year-old, urine was collected by sterile urine bags after disinfecting the perineum. In these, a urine culture of >103 colony-forming units (cfu)/mL was considered positive. If UC was negative, the patient assumed to not have UTI. In children older than two-year-old, a midstream specimen, with a long bladder time, was collected after uncovering the urethral orifice – a colony count >105 cfu/mL was considered to be positive.
An ultrasound of kidneys was performed for all patients in order to reveal dilatation of the upper urinary tract, severe loss of renal parenchyma or urinary system anomalies. For documented UTI patients, further investigations consisted of an ultrasound of kidneys and urinary tracts, Technetium-99 m-DMSA (dimercaptosuccinic acid) and voiding cystourethrogram (VCUG). Using the Technetium-99 m-DMSA results, three types of renal scar were determined: type 1 (no more than two scarred areas), type 2 (more than two scars with some areas of renal parenchyma between them) and type 3 (generalized damage to the whole kidney similar to obstructive nephropathy.)
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Results
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We entered 433 febrile children into the study. The mot common
diagnosis was upper respiratory tract infections including rhinitis,
otitis media, common cold and pharyngitis (217 cases, 50%).
Table
1 shows the final diagnoses of the febrile children
studied.
Thirty-nine (9%; 27 girls and 12 boys) had UTI (Table
2).
In 15 (38.4%) ultrasound showed positive findings such as small
kidneys and dilatation of calyces. In addition, Technetium-99
m-DMSA was performed on 31 patients: 19 patients (61.2%) had
type 1 renal scar and five (16.3%) had a normal DMSA scan.
After sensitivity tests and treatment by antimicrobial regimens
all patients were evaluated for vesicoureteral reflux (VUR)
by fluoroscopic contrast VCUG. Among the boys: one (8.3%) had
posterior urethral valve plus bilateral grade III VUR; one (8.3%)
had hydronephrosis and uretropelvic junction obstruction in
his left kidney; five (41.6%) had mild to moderate VUR (grades
I–III); and two (16.6%) had severe VUR (grades IV and
V). Twenty-five percent of the UTI boys were uncircumcised and
had no urinary tract abnormalities. In girls' group: 11 (40.7%)
had mild to moderate VUR; five (18.5%) had severe VUR; and one
(3.7%) had a neurogenic bladder without VUR. Ten patients (37%)
had a normal VCUG.
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Discussion
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Studies from developing countries show that the around 10% of
children with febrile illnesses have UTI.
8 In our study there
was a slightly increased rate of UTI among girls. The high rate
of fever >39°C in children diagnosed with UTI highlights
the importance of considering taking urine cultures for all
febrile infants without a definite source of fever. Similarly,
although the prevalence of UTI was higher among children with
a temperature >39°C, the rate of UTI in children with
lower temperatures fever was significant.
The most common pathogen was E. coli, which is in accordance to other reports from developing countries.9,10 Jeena et al.8 reported that Gram-negative pathogens accounted for 87.5% of all cases of UTI. E. coli (56%) and Klebsiella pneumoniae (19%) had been the most common detected pathogens in their report.
Nine boys (75%) had a urinary tract abnormality in their VCUG, which is higher in comparison with other studies. For example, according to Weinberg et al.2 the rate of urinary tract abnormalities was only 20%.
Although older children with UTI may have urinary symptoms, fever may be the only sign in infants and young children. All young children with persistent fever without a definite source should undergo a UA and further appropriate laboratory tests should be evaluated. We suggest routine VCUGs for children younger than five with a febrile UTI, boys of any age with a first UTI and children with recurrent UTI. We suggest that a renal scan (DMSA) should be performed in children younger than five who have a febrile UTI and those with recurrent UTI because of the frequency of UTI attacks.
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References
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SUMMARY
Introduction
