NEP/01(P).PREVALENCE OF URINARY TRACT INFECTION IN FEBRILE CHILDREN
AND FACTORS AFFECTING IT
Lt Col Amarendra N Prasad, Col P L Prasad
Deptt. of Pediatrics, Military Hospital, MHOW, Indore - 453441
Objective: Establish prevalence rates of urinary tract infection (UTI) in febrile infants and young
children in a pediatric outpatient department by demographics, risk factor exposure and clinical
parameters. Methods: Cross-sectional prevalence survey of 1840(64%) of all infants and children
younger than 2 years of age presenting to the pediatric outpatient department with a fever ( 38.5°C)
who did not have a definite source for their fever and who were not on antibiotics or
immunosuppressed. Otitis media, gastroenteritis, and upper respiratory infection were considered
potential but not definite sources of fever. Risk factors in females included various causes of
perineal contamination and external irritation; and circumcision in males.
Results: Overall
prevalence of UTI (growth of 104 CFU/mL of a urinary tract pathogen) was 3.6% (95% confidence
interval [CI]: 2.8,4.4). Higher prevalence occurred in girls (4.8%; 95% CI: 3.6,6), girls with one or
more risk factor exposure (10.7%; 95% CI: 7.1,14.3), uncircumcised boys (8.0%; 95% CI:
1.9,14.1), and those who did not have another potential source for their fever (5.9%; 95% CI:
3.8,8.0), had a history of UTI (9.3%; 95% CI: 3.0,20.3), had abdominal or suprapubic tenderness on
examination (13.2%; 95% CI: 3.7,30.7), or had fever 39°C (4.4%; 95% CI: 3.3,5.5). Girls had a
16.1% (95% CI: 10.6,21.6) prevalence of UTI. Isolated organisms included Escherichia coli,
Enterococcus, Klebsiella pneumoniae, group B Streptococcus, Streptococcus viridans, and
Staphylococcus aureus. Conclusions: UTI is prevalent in young children, particularly girls, without
a definite source of fever. Specific clinical signs and symptoms of UTI are uncommon, and the
presence of another potential source of fever such as upper respiratory infection or otitis media is
not reliable in excluding UTI. These results suggest that a urine examination is necessary part of the
evaluation of all febrile infants and children younger than 2 years of age regardless of another focus
of presumed bacterial infection. Also, UTI is an important cause of childhood morbidity.
NEP/02(O).THE IMPACT OF RENIN-ANGIOTENSIN SYSTEM BLOCKADE IN
EXPERIMENTAL ACUTE PYELONEPHRITIS
A.K.Singal, M.Bajpai, A.K.Dinda
Consultant Pediatric Urologist, MGM’s New Bombay Hospital, Vashi, Navi Mumbai, Maharashtra
Background: Acute Pyelonephritis can lead to renal scarring if not treated in time. Renal scarring is
a known risk factor for hypertension and renal insufficiency. We studied whether ReninAngiotensin system blockade in experimental settings blunts the fibrotic response. Methods:
Experimental Pyelonephritis model was created in 45 Adult female WISTAR rats aged 8-12 weeks,
by direct inoculation of 0.1 ml of E.coli suspension into the parenchyma of the kidney exposed by
lumbotomy incision. These were subdivided into 3 treatment groups: Group A – treated with
antibiotics only; Group B- Captopril and antibiotics and Group C- Losartan and antibiotics.
Changes of acute inflammation, parenchymal destruction and scarring were compared between the
groups on histopathological sections. Kruskal-Wallis test was used for statistical analysis. Results:
Changes consistent with acute pyelonephritis and subsequent scar formation were seen in all the
kidneys. Mean % scar area in Group A, Group B and Group C was 37.08±1.79, 24.40±1.88 and
24.68±1.32 % respectively at end of six weeks. Mean tubular density in Group A, B and C was
17.26±1.92, 47.18±3.00 and 47.00±5.08-tubules/lac μm2 respectively. The differences between the
control and the treated animals were significant, though the results did not differ between the
losartan and captopril treated rats. Conclusions: Induction of acute pyelonephritis by direct
inoculation of bacteria into renal cortex produced a consistent scar at 6 weeks. Blockade of renin
angiotensin system by either captopril or losartan decreased the renal scar area by almost 1/3 at 6
weeks.
NEP/03(P).FACTORS INFLUENCING OUTCOME OF VESICOURETERAL RFLUX
MANAGED BY ENDOSCOPIC INJECTION THERAPY
Arbinder K Singal, Stephen J Canon, Venkata R Jayanthi, Stephen A Koff, Seth A Alpert
Consultant Pediatric Urologist, MGM’s New Bombay Hospital, Vashi, Navi Mumbai, Maharashtra
Background: Injection therapy using Dextranomer/hyaluronic acid (Dx/HA or Deflux) is a highly
successful method of treating children with primary reflux (VUR). Little is known about factors that
may
lead
to
unsuccessful
injection.
Methods: We retrospectively analyzed the clinical and radiographic features of 160 sequential
patients (236 systems) treated with Dx/HA injection for symptomatic VUR to try to determine
factors associated with failure, defined as persistence of any grade of reflux after injection. All
patients had been assessed and treated for dysfunctional elimination syndromes (DES) prior to
injection. Urodynamic studies were performed as needed. Follow-up ultrasonography and voiding
cystography were obtained at least 3 months after injection. Parameters evaluated included
laterality, grade of reflux, volume injected, presence of DES, and the presence of visible mounds
on
postoperative
ultrasonography.
Results: 143 patients had simple systems (212 ureters) while 17 pts had duplex VUR. Mean grade
of reflux was 2.4. Dysfunctional elimination syndrome occurred in 45%. Mean follow-up was 20
months. In 74% of simple system refluxing ureters, VUR was eliminated after one injection and in
79% after 2 injections. Treated DES, implant volume (mean 0.56 cc), bladder wall thickness and
bilateralism did not predict outcome. The success rate in duplex VUR was only 41% (p<0.05).
Preoperative grade of VUR and presence of mounds on USG post-injection did correlate with
outcome. Seven patients with apparent resolution of reflux after injection developed recurrence and
57%
of
these
had
DES
at
presentation.
Conclusion: Injection therapy is reasonably successful in patients with primary non-duplex reflux.
Implant volume, bladder wall thickness and treated DES do not appear to affect success rates. DES
however may predict long-term recurrence of reflux after apparently successful injection. A late
recurrence rate of 5% in children recognized clinically may significantly underestimate the rate of
recurrent reflux in asymptomatic children.
NEP/04(P).GLOMERULAR FILTRATION RATE IN CHILDREN
KK Locham, Manpreet Sodhi, Kamaljeet Kaur, Rahul Gandhi
Deptt. Of Pediatrics, Govt. Medical College / Rajindra Hospital. Patiala.147001
Objective : To evaluate glomerular filtration rate (GFR) in children with different systemic diseases.
Setting and Methods : 70 children admitted with different diseases to Department of Pediatrics,
Govt. Medical College, Patiala were the subjects of the study. Age, sex, chief complaints, place of
residence, general physical and systemic examination were recorded on a pretested proforma.
Investigations whenever required were done. GFR was evaluated by Schwartz formula after
estimating serum creatinine. GFR = K x L (length in cms) P.creatinine (mg/dl) K = 0.45 for children
and adolescent girls K = 0.70 for adolescent boys The data so obtained was analysed statistically.
Results : The study included 12 infants. There were 30 children in 1-4 year age group, 20 in 5-8
year age group. 8 children were above the age of 8 years. 49 males and 21 females were included in
the study. Maximum number of children (18) were of acute gastroentritis followed by 16 of
meningitis, 14 of urinary tract infection (UTI), 12 of pneumonia, 6 of nephrotic syndrome and 4 of
diabetic ketoacidosis. Acute renal failure was observed in 27 children. Mean GFR (ml/min./1.73m2)
was 62.80  22.93, 60.62  17.97, 77.30  23.58 in children with acute gastroentritis, pneumonia
and meningitis respectively. It was 75.25  29.98, 74.17  19.19 and 71.61  13.48 in children with
nephrotic syndrome, UTI and diabetic ketoacidosis respectively. The statistical comparison of GFR
between various groups was non significant (P>0.05). Conclusion: Glomerular filtration rate in
children is altered in systemic diseases not necessarily involving the kidneys. Modification of drugs
is required in cases.
NEP/05(P).GLOMERULAR FILTRATION RATE IN NEWBORN
KK Locham, Manpreet Sodhi, Kamaljeet Kaur, Rahul Gandhi
Deptt. Of Pediatrics, Govt. Medical College / Rajindra Hospital. Patiala.147001
Renal involvement in the newborn increases the risk of morbidity and mortality. Drug doses need
modification in such cases. Objective : To study glomerular filtration rate (GFR) in normal and sick
newborns. Setting and Methods : 51 newborns admitted to Neonatology section of Department of
Pediatrics, Govt. Medical College, Patiala were the subjects of study. Antenatal risk factors, sex,
age, gestation, mode of delivery, Apgar score were recorded on a pretested proforma. Investigations
were done whenever required. GFR was calculated by Schwartz formula after estimating serum
creatinine. GFR = K x L (length in cms) P.creatinine (mg/dl) K = 0.34 for preterm babies K = 0.45
for term babies The data so obtained was analysed statistically. Results : Out of 51 babies, 23 babies
were sick and 28 were normal. 20 babies were preterm and 31 were term. Antenatal risk factors
were present in 14 newborns. In sick group, 9 babies each had birth asphyxia and septicemia. One
had urinary tract infection. 4 babies had multisystem involvement. In sick group, preterm babies
(12) outnumber term babies (11) whereas in normal group term babies (20) outnumber the preterm
ones (8). Birth asphyxia was observed in sick babies. Acute renal failure was present in 6 sick
babies. Average GFR (ml/min./1.73m2) was 27, 23.22, 21.2 and 30 in birth asphyxia, septicemia,
urinary tract infection and multisystem involvement respectively. Mean GFR (ml/min./1.73m 2) was
24.92  6.37 and 27.73  10.19 in healthy and sick babies respectively. The difference in mean GFR
between healthy and sick babies was statististically non significant (p>0.05). Conclusion : Mean
GFR (ml/min.1.73m2) was 24.92  6.37 and 27.73  10.19 in healthy and sick babies respectively.
NEP/06(P).NECROTISING INFECTIONS IN NEPHROTIC SYNDROME IN CHILDREN
Harmeet Singh Arora, Madhuri Kanitkar, Rakesh Gupta
Dept of Paediatrics, Armed Forces Medical College, Pune
Nephrotic syndrome is a common disease of childhood & may be complicated by various types of
infections. Necrotising fasciitis & acute necrotizing periodontitis & gingivitis are uncommon
infections associated with the disease & have rarely been reported in nephrotic children . We report
two children with nephrotic syndrome who developed necrotizing fasciitis of the abdominal wall &
acute necrotizing periodontal disease respectively & were treated successfully with intensive
medical & surgical treatment. Objective: To report two cases of rare necrotising infections
associated with nephrotic syndrome in children. Case report 1: A 5year old male child, a known
case of nephrotic syndrome on treatment for a relapse for four months with steroids & other
immunosuppressants developed a furuncle over the abdominal wall which progressively worsened
to cause extensive necrotizing fasciitis with both Staphylococcus aureus and Pseudomonas
aeruginosa on culture. He also had features of steroid toxicity & neuroimaging revealed central
pontine myelinolysis. Patient was managed with intensive local & systemic care including skin
grafting and judiciously reducing immunosuppresion. Case report 2 : 3 year old male child a
known case of steroid resistant nephrotic syndrome on daily oral steroids & oral cyclophosphamide
presented with septicemic shock. On resucitation he had dysphagia, bleeding from gums, malodor,
looseness of teeth, and redness of lips, cheeks & gingiva with firm induration of right cheek,
brownish- black discoloration of gingival & labial mucosa,yellowish brown slough over palate &
submandibular lymphadenopathy. Cultures from oral lesions revealed growth of fusobacterium and
spirochetes. Managed as a case of septicemia with acute necrotizing periodontal disease.
Discussion:Nephrotic syndrome is often associated with an increased predisposition to infections.
Therapy may aggravate this situation resulting at times in life threatening infections. Judicious use
of immunosuppresants & antibiotics along with intensive care may improve the outcome.
NEP/07(P).URINARY TRACT INFECTIONS (UTI) IN FEBRILE CHILDREN:
PREVALENCE, DIAGNOSIS AND BACTERIAL AETIOLOGIC AGENTS.
Pushpa Chaturvedi, Punit Malhotra, Akash Bang
Department of Pediatrics, Mahatma Gandhi Institute of Medical Sciences and Kasturba Hospital,
Sevagram. 442102. Dst. Wardha
Aims: To determine the prevalence of UTI in febrile children, to compare the urine cultures of
midstream-urine (MSU) and suprapubic-bladder-aspiration (SBA) and to find out the responsible
organisms and their sensitivity. Method: 253 febrile children aged 1-14 yrs had 2 MSU samples
collected 6 hrs apart. 59 patients had SBA done. Any growth in SBA or growth of >105/ml of
single, similar organism in both the MSU cultures was taken as UTI. Result: Prevalence of UTI was
8.3% with female dominance (M:F=1:1.3). Febrile under 5 children, male infants and females above
1 yr were more commonly affected. Below 5 yrs, nonspecific symptoms (urinary tract unrelated)
were more common and UTI more commonly missed. Urinary pus cell count >5 per HPF had
maximum likelihood ratio (LR=35.9) to detect UTI but still missed 38% cases. MSU cultures
significantly under diagnosed UTI than SBA culture. SBA success rate at first attempt was
significantly more in infants. The only complication- transient hematuria- was in no case requiring
only one attempt. E.coli was the commonest isolate, followed by Klebsiella, Group A Streptococci
& Staphylococci. Gram -ve bacilli were mostly sensitive to Amikacin and Gram +ve cocci to
Gentamicin, Cipofloxacin and Ampicillin. Conclusion: UTI must be considered in febrile children
especially below 5 yrs age, male infants and females above 1 yr age. Due to nonspecific symptoms,
it must be keenly sought by urine culture- the gold standard of diagnosis. MSU is atraumatic urine
collection method but under diagnoses UTI and is difficult in infants. SBA is the most aseptic,
accurate collection method and is more preferred in infants as it is easy to perform with minimum
complications due to intra-abdominal urinary bladder. Gram -ve bacilli cause most UTI and most
are sensitive to Amikacin. Combination of IV Ampicillin and Amikacin is the best therapy in sick
febrile UTI cases needing admission. Though we could not study sensitivity to TMP-SMZ as it
requires special medium, we still recommend it for first line use in children who can be sent with
oral therapy.
NEP/08(R).MULTICYSTIC DYSPLASTIC KIDNEY A RARE CAUSE OF RAP
D.N.Virmani; S. Mehta1; M. S. Akhtar
Department of Pediatrics, Kasturba Hospital, Delhi 110002.
CASE REPORT: A 12-year female presented with right-sided flank pain, for 3 days. She also noted
fever with chills and rigors and vomiting. Birth & developmental history was normal. She had
similar episodes of pain in the past. Nobody in the family had similar complains. General physical
examination and systemic examination revealed no abnormality. The investigation showed CBC in
normal limits, kidney and liver functions were normal. Her Urine microscopy revealed 40-45 pus
cells/HPF & 5-6 RBC/HPF and white cell casts. Urine culture grew Klebsiella species-sensitive to
ceftriaxone. The x-ray KUB was normal, the ultrasonography of abdomen revealed a multicystic right
kidney with unremarkable pelvis. The left kidney, urinary bladder and was normal. Colour doppler of
both the kidneys was normal. MCU was normal. The DMSA scan of the right kidney showed moderately
decreased function of the right kidney. A diagnosis of unilateral right Multicystic Dysplastic kidney
with UTI was established. The patient is on conservative management for three years now. She
has pain in the right flank off and on, responding to NSAIDS. She never had any urinary
complains during this period. Her blood pressure remains in normotensive range.
Ultrasonography shows no change in the cysts. Kidney profile is normal. The contralateral kidney
is normal with no obstructive uropathy. No other systemic anomalies.