Pattern of infection in children presented with obstructive uropathy-a hospital based study

Background: Obstructive uropathy refers to the structural impedance to the flow of urine anywhere along the urinary tract which may result from congenital (anatomic) lesions or can be caused by trauma, neoplasia, calculi, inflammatory process or surgical procedure. It is responsible for about 40lo ofend-stage renal disease. Obstructive uropathy is invariably associated with some co-morbid conditions specially infection. Objecctive: This study was conducted in the deparhnent of pediatric nephrology, Bangabandhu Sheil*r Mujib Medical University (BSMM[I), Shahbag, Dhaka, Bangladesh with an objective to identiff different pattern of infections in children with obstructive uropathy. Methods: A total of 55 patients of obstructive uropathy were enrolled. Thorough clinical and laboratory evaluation including hematological , biochemical, radiological and radio nucleotide imaging were done along with blood and urine culture. Result: Out of 55 cases, 42.27o/o of obstructive uropathy was detected between I to 5 years and 89.27%o was infected. Among obstructive uropathy cases, majority had posterior urethral valve @UV) (42.27%). Urinary tact infection was the commonest (60%) type of infections followed by septicemia and respiratory tract infection. Conclusion: Age between 1 to 5 years was the commonest age of children for hospital admission due to obstructive uropathy. Among various manifestations of obstructive uropathy, infections, mostly urinary tract infection was the commonest one.


Introduction:
Obstructive uropathy is an important cause of chronic renal failure in children.lObstruction is defined as arr impediment to the urinary outflow which if not treated promptly, can cause progressive renal damage.'Urinarytract obstruction can result from congenital (anatomic) lesions or can be caused by trauma) neoplasia, calculi, inflammatory process or surgical procedure.2Each year about 211000 people in the United States of Ameica ( USA) are hospita hzed for obstructive uropathy.3 The condition has a bimodal distribution.In childhood, it is mainly due to congenital anomalies of the urinary tract.3Overall, obstructive uropathy is responsible for abo ut 4o/o of end-stage renal disease.3Children generally present Address for Correspondence: Habibur Rahman, Professor, Department of Pediatric Nephrology, BSMMU, E mail: adiba@dhaka.netwith dribbling of urine, pain during micturition, fever, urinary tract infection , poor stream and palpable bladder and kidney.lInfection compli cating obstruction may cause dysuria, pprua, urinary urgency and frequency, referred kidney and ureteral pain, costovertebral angle tenderness, fever, and, occasionally, septicemia.3Most obstruction can be corrected, but a delay in therapy can lead to irreversible renal damage.How long it takes for nephropathy to develop is variable depending on the underlying pathology, the presence or absence of Urinary Tract Infection (UTI), and the degree and duration of the obstruction.Prognosis is worse if UTI remains untreated.3From March 1993 to December 1994, a study was conducted among a totalof 304 children less than 5 years of age with their first documented symptomatic urinary tract infection who presented consecutively to the emer- gency department of a paedi atrrc hospital in Australia.Of those patients bacteraemia occulred in 60 , all of whom were under 6 months of age.E. coli was the causal organism tn 84o/o.oUsing the US He althcare Cost and TJtrhza- tion Project Kids Inpatient Database, a sample size of 2832 children were studied.They identified that comorbid UTIs complicated 6.7% of congenital obstructive uropathy (COU), which increased mean hospital charges by $7910 ($4770-$ 1 1,040) and length of hospital stay ( LOS) by 2.66 days as compared to COU discharged without associated UTI.These children deserve special attention, not only to reduce hospital costs, but more importantly because these complicated UTIs may compli cate other comorbid conditions such as chronic kidney disease that may accomp any the CUO.5 Bangabandhu Sheikh Mujib Medical University (BSMMU), Sh ahfiag, Dhaka is a tertiary level hospital in Bangladesh which deals with referral cases from the whole country.Every yeff a number of obstructive uropa- thy cases presenting with features of different types of infections along with symptoms of urinary tract obstruction get admitted into this hospital .The objective of this After obtaining informed written consent, data were collected using standard questionnaires.The characteristics examination included age and sex of patients, present- ing complaints.like urinary incontinence, dribbling, strainin g, fiaffow stre am) hemafurLa, presence of abdomi- nal mass, abdominal pain, dysuria , respiratory distress, fever or not growing well.Patients were thoroughly examined.During examination, degree of pallor, resp :r:a' tory rate and pattern, temperature , heart rate, blood pressure, edem a, arfihropometry and bed side urine test for albumin were looked for.Regarding systemic e"a*irution, urogenital system, cardiovascular system, respira- tory system and vertebral spine were examined thoroughly.Complete blood count included hemoglobin percent d1a, total and differential counts of white blood corpuscles , peripheral blood film , urine for routine and microscopic examination were also done.Urine for culfure and sensitivity with c-olony count, 24 hours urine for total protein, blood urea, serum creatinine, serum electrolyte were sent a part of detailed evaluation.
Glomerular filtration rate was estimated by Schwartz formula considering 0 45 in Infant and 0.55 in children as the constant( K).Chest way was done for patients with respiratory complains and suspected pneumonia cases.
Blood culfure was done in bloo d agar, chocol ate agar and Mac-conkeys agar media.Collection of urine specimen varied with age like midstream clean catch specimen .frombag applied to the perenium and temporary transurethral catheri zation Eafly morning urine sample was preferred.Urine culture was done in chromogenic media' .' 'In' positive ' cases sensitivity pattern was also identified.Digital chest X-Ray andrelevant renal imag- ing'were' 'performed.Ultrasonogta{n of KUB region waS done by expert sortologists of the Institute of' Nucleat medicine,,and Ultrasound of BSMMU,by using Toshiba 2D machine.DTPA renogram was done to see.to{al and hospital admission were excluded.
split renal function and here Tc99 isotope.For anatomical details , DMSA Scintigraphy by using commertially avail- able kit with Tc99 isotope was used.For Micturating Cystourethrogram (MCU) and lrttra Venous Urography (IVU) the dye Lopamiro was used.Radioneucleotide imaging was considered according to requirement on the basis of presenting complaints and physical findings of patients.Patients need for radio-imaging of renal tract were individuahzed and all modalities of imaging were not done for each and every patient.The charucteristics were tabulated.Data were analyzed as percentage of the total and inference was drawn. Result: In this cross sectional study, a total of 55 patients of obstructive uropathy were enrolled.Out of 55 patients 47.27% were between 1 to 5 years age group.In our study 89.09% patients were male and only 10.9l% patients were female and male female ratio was 8: 1.There was avariety of obstructions like Posterior urethral valve(PUV), Pelvi- ureteric junction(PUJ) obstruction, Vesico Ureteric Reflux(VUR), Bladder neck hypertrophy (BNH) etc.

Table-Il
Presenting features of the patients according to type of obstructive uropathy (n:5 (7s%) (2s%) \lt ut (o%) (1oo%) NB: PIIV-Posterior urethral vhlve, VUR-Vesico Ureteric Reflux, PUJ-Pelvi-Ureteric Junction'Obstruction obstruction, BNH-Bladder heck hypertrophy, UB.Urinary bladder.NB:S-Sensitive, R -Resistant Discussion: Obstructive uropathy is one of the commonest cause of hospitaltzation of children.It refers to the structural impedance to the flow of urine anywhere along the urinary tract leading to 'hydronephrosis', which is the dilation of the renal pelvis and calyces.6,Dilatation of the renal pelvis can occur even in the absence of urinary obstruction; therefore, hydronephrosis and obstructive uropathy are not interchangeable or synonymous terms.
The damage to renal parenchyma caused by these conditions often leads to'obstructive nephropathy' contributing to a decrease in renal function.'LJnlike many other renal diseases, obstructive uropathy, if treated early, is a poten- tially curable form of kidney disease.8 Obstructive uropathy accounts for 16.5%of all preven- tive strategies need to be devised in the United States.e'l0 Prenatal ultrasound in the antenatal period is the corner stone of early detectionll'12 Very often, children with various forms of obstruction in urinary tractpresent with infection.But there are very few studies in this regard.This study tried to highlight differentpatterns of infections ina child with obstructive uropa- thy.
In this study, 55 children of both sexes from 8 months to 13 years with different types of obstructive uropathy were clinically, biochemic ally, hematologically and microbio- logically evaluated.Radio-nucleotide analysis was also done to find out different types of obstruction, infection and extent of renal impairment.It was observed from this study that, most of the patients (41 .27%)were between 1-5 years of age range (mean age 33 months), most of whom were male (89.09%).This result has similarity to another study conducted in department of pediatrics, Osaka Medical Colle ge, Japan which shows 21 reported patients of obstructive uropathy ranging from 0.4 to 3 years.The sex distribution showed a strong male predominance.llIn BSMMU, the most common pattern was posterior urethral valve (27.27%), but, in a study conducted in department of pediatrics, South Valley University, Egypt to screen for obstructive uropathy in rural Egyptian children showed the highest prevalence for mild pyelocaliectasis ( antero posterior renal pelvic diam- eter 10-15 mm) followed by presence of urinary tract stones.lOHere the common presenting features of urinary tract obstruction was incontinence, dribbling, straining, naffow stream, abdominal mass, hematuria, abdominal pain, respiratory distress ,fever and not growing well.
Obstruction anywhere in the urifiary tract causes stasis of urine.This provides a favorable environment for bacterial proliferation, multiplication and development of symptomatic or asymptomatic UTI.In this study , UTI was considered to be present when the centrifuged urine contained more than 5 pus cells.perhigh power field along with a positive urine culture for organism whether symp- tomatic or not.In a similar study regarding epidemiology of symptomatic UTI in children, VUR (19.9%) and PUV (27.6%) were found to be the common risk factors in children suffering from UTI.12 E. coli (84.37%) was isolated from most of the patients suffering from UTI where other patients had growth of streptococcus and klebsiella .Most of the infectious cases were sensitive to ceftriaxone, cefradine and cefixime followed by levofloxacin, amikacin and nitrofurantoin, probably due to haphazard and irrational use of antibiotics in the community.
As obstructive uropathy of any type is a cause of chronic sufferings, children become immune compromised.So risk of other types of infections increase as well.Besides UTI, some children were found to have sepsis as another co-morbidity.There are some case reports in this regard.l3 Sepsis is a potentially fatal whole body inflammation caused by severe infection.Patients having clinical features of sepsis and a positive blood culture were included in this category.
Respiratory tract infection (RTI) included both upper and lower respiratory tract infections.Upper respiratory tract infections included tonsillitis, pharyngitis , laryngitis, sinusitis, otitis media, influenza and common cold.Lower respiratory tract infection (pneumonia) was considered as more serious than the upper resp tatory tractinfections.In this sfudy, patients were considered to have upper respiratory tract infection if symptoms and signs were sugges- tive, and lower respiratory tract infection if there was radiolo grcal finding.There is a review of acute bilateral obstructive uropathy among 3258 children who have various forms of upper respiratory tract infections and also pneumonia.la It was observed from this cross sectional study that obstructive uropathy with their variable presentation commonly seek medical advice between 1 to 5 years.
Among the various presentations infection is the commonest one which may lead to chronic kidney disease if not detected and treated.

Conclusion:
It is concluded from this study that age between 1 to 5 years is the commonest age of children for hospital admission due to obstructive uropathy.Posterior urethral valve in male child is the leading cause of obstructive uropathy.
Among various manifestations of obstructive uropathy, infections, mostly urinary tractinfection is the commonest one.

Table - fV
Micro organisms isolated in UTI cases in patients with obskuctive uropathy(n=55)

Table - V
A Microbial agents and their sensitivity pattern to antimicrobials(n-55)