Niger J Paed 2013; 40 (3) : 278 –283  
Elo-Ilo JC  
Iroezindu MO  
Egbuonu I  
Ezechukwu CC  
Chukwuka JO  
Prevalence of asymptomatic  
bacteriuria among pre-school  
children in Nnewi, South-East  
Accepted : 8th January 2013  
Abstract Background: Early di-  
agnosis and management of uri-  
nary tract infection (UTI) in  
young children reduces the risk of  
renal scarring and chronic renal  
insufficiency. We determined the  
prevalence of asymptomatic bac-  
teriuria (ASB) among pre-school  
children in Nnewi, South-East  
Methodology: This was a cross-  
sectional survey involving appar-  
ently healthy nursery school chil-  
dren aged 3-5 years. A pre-tested,  
care-giver administered question-  
naire was used to obtain informa-  
tion about the participants includ-  
ing age, sex, history of fever and  
antibiotic administration in the  
two weeks preceding the study.  
Following a clinical examination,  
a sample of mid-stream urine was  
collected from each participant for  
dipstick urinalysis, and urine mi-  
croscopy and culture. ASB was  
Results: Out of 792 children, 417  
(52.3%) were females and 375  
(47.4%) were males. The mean  
age of the children was 4.0 ± 0.7  
years. ASB was found in 31 chil-  
dren (4%). The prevalence of ASB  
in females (7.2%) was signifi-  
cantly higher than in males (0.5%),  
p<0.001. The highest prevalence  
of ASB of 5.6% occurred in the 4-  
year-olds and the lowest of 2.0 %  
occurred in 5 year olds, p=0.09.  
The commonest bacterial isolates  
among the ASB cases were  
Staphlococcus aureus, 13 (40.6%);  
Streptococcus faecalis, 9 (28.1%)  
and Escherichia coli, 5 (15.6%).  
Conclusion: Asymptomatic bacte-  
riuria is commoner in female pre-  
school children and S. aureus is  
the commonest bacterial isolate.  
Routine evaluation of female pre-  
school children for bacteriuria is  
Elo-Ilo JC  
Department of Paediatrics,  
Federal Medical Centre,  
Owerri, Imo state.  
Email: elochinyere@yahoo.com  
Iroezindu MO  
Department of Medicine,  
University of Nigeria Teaching  
Ituku/Ozalla, Enugu  
Egbuonu I, Ezechukwu CC  
Chukwuka JO  
Department of Paediatrics,  
Nnamdi Azikiwe University Teaching  
Hospital, Nnewi, Anambra State.  
defined as the presence of  
Key words: Asymptomatic bacte-  
riuria, Pre-school children, Preva-  
10 CFU/ml of urine in a partici-  
pant who had no symptoms of  
especially if it occurs before five years of age. About  
0-35% of children with ASB have vesico-ureteric  
Infection of the urinary tract is among the commonest  
reflux and other renal abnormalities. It has also been  
shown that there is an association between renal scarring  
during childhood and increased risk of hypertension and  
causes of diseases in childhood. It affects the entire  
paediatric age group, and has been shown to be a signifi-  
cant cause of morbidity and long-term complications  
chronic renal insufficiency in later life. However, early  
especially in the tropics and subtropics. In children,  
diagnosis of UTI and prompt treatment reduces the risk  
of renal impairment and 3prevents deterioration of renal  
function in such children.  
especially the pre-school age group, urinary tract infec-  
tion (UTI) could be symptomless otherwise known as  
asymptomatic bacteriuria (ASB). When symptoms are  
present, they are usually vague and non-specific, and  
may not be referable to the urinary tract. It may there-  
fore escape diagnosis by the primary care physician.  
Urine microscopy/culture is not routinely carried out in  
the evaluation of apparently healthy children especially  
in resource-limited settings. This poses a challenge to  
the identification of children with ASB and further com-  
promises the benefits of timely intervention to prevent  
possible renal damage. We carried out a cross-sectional  
survey to determine the prevalence of ASB in a large  
Asymptomatic bacteriuria may be followed by sympto-  
matic UTI. Whether symptoms are present or not, renal  
damage and scarring occur in a number of patients  
population of pre-school children in Nnewi, South-East  
Where N = minimum sample size, Z= constant at 95%  
confidence interval= 1.96, P= Prevalence of ASB from a  
previous study in South-East Nigeria= 2.1% , Q = (1 –  
P) = 1- 0.103 = 0.897, δ=precision allowed=0.05. In  
consideration of a 10% attrition rate in the pilot study,  
the sample size was increased to 825. The schools in  
each quarter of the town were listed and two schools  
were randomly selected by balloting. In each school  
selected, the school register was used to stratify the  
nursery school population into 3, 4 and 5 years age  
strata, and each age stratum was further divided into  
male and female sub-groups.  
Materials and Methods  
Study design and population  
This was a cross-sectional study conducted in Nnewi  
town, Anambra State in South-East Nigeria. The popula-  
tion of the town at the time of the study was about  
21,065. The inhabitants of Nnewi are predominantly  
Ibos and their occupation is mainly trading and subsis-  
tence farming, with few public servants. As at the time  
of this study, the town had four geographical quarters  
with 49 local government-approved nursery schools all  
of which were privately owned. The study duration was  
between February and April, 2004. Eight nursery  
schools, two from each quarter of the town were  
randomly selected.  
The study population comprised apparently healthy  
nursery school children aged 3-5 years as at their last  
birthday, who met the inclusion criteria. Only children  
who were toilet trained and off nappies were enrolled.  
Children with fever, body swelling or symptoms sugges-  
tive of genitourinary abnormalities were excluded from  
the study. In addition, malnourished children and those  
with history of antibiotic use in the preceding two weeks  
of the study were also excluded.  
Data Collection  
Information obtained with the questionnaires included  
date of birth/age, sex, history of fever and antibiotic  
administration in the preceding two weeks. Data collec-  
tion lasted for an average of 10 days in each school. This  
period was used for the selection of the subjects, distri-  
bution and retrieval of the questionnaires, and collection  
of urine samples. The pre-tested questionnaire was ad-  
ministered to the parents/guardians of the pupils as they  
brought or collected their wards from school. For the  
few of them that could not be directly reached by the  
researchers, the questionnaires were administered  
through the child’s teacher. The parents/guardians were  
encouraged to complete the questionnaires at home and  
to return them the subsequent day. Those who were not  
literate were assisted with translation by the class teach-  
ers before the questionnaires were completed.  
Permission for the study was obtained from the Ethical  
Committee of the Nnamdi Azikiwe University Teaching  
Hospital (NAUTH), Nnewi as well as Nnewi North Lo-  
cal Government School Board. The headmaster/  
headmistress of each selected school also approved of  
the study and the project was appropriately explained to  
the teachers and parents. Informed consent was obtained  
from the parents/guardians of the children.  
A clinical examination was performed on each of the  
participants with emphasis on anthropometry (height  
and weight), axillary temperature, general physical ex-  
amination, and features of renal disease such as facial  
puffiness, oedema, renal angle tenderness and ballotable  
kidneys. 8Axillary temperature of37.5 C was regarded  
as fever. Weight was measured using a scale with a  
sensitivity of ± 50 g. The scale was checked for zero  
error and standardization was done with standard weight  
before using it. The values of the weight and height were  
compared with standards according to the National Cen-  
tre for Health Statistics charts in order to exclude those  
who were malnourished.  
Pilot Study  
A pilot study was conducted in December, 2003 on 30  
pupils randomly selected from a nursery school in one  
of the quarters of the town. Questionnaires were admin-  
istered to the parents/guardians of the 30 pupils and  
were self-completed at home. Another 30 randomly se-  
lected pupils had their parents/guardians interviewed  
using researcher-administered questionnaires. The re-  
sponses were compared and there was no significant  
difference between the self-completed responses and the  
responses from the researcher-administered question-  
naires. Based on this, it was concluded that the question-  
naire was understood and could easily be completed at  
home by the care-givers. Data obtained from the pilot  
study were not included in the main study.  
A sample of mid-stream urine was collected from each  
participant with the help of the class teacher into previ-  
ously labeled sterile universal bottle containing boric  
acid crystals. In females, the class teachers parted the  
labia during micturition and in all subjects it was en-  
sured that the specimen bottle did not come in contact  
with the perineum, external genitalia or adjacent skin to  
avoid contamination. The urine samples were trans-  
ported to the microbiology laboratory within two hours  
of collection for immediate analysis. The urine speci-  
mens were divided into two aliquots. One aliquot was  
used for dipstick urinalysis while the second aliquot was  
used for microscopy and culture.  
Sample size and Sampling  
A minimum sample size of 750 subjects was calculated  
using the formula for cross-sectional surveys:  
N =  
Laboratory investigations  
Statistical analysis  
Dipstick urinalysis  
Data analysis was carried out using the Statistical Prod-  
uct and Service Solutions (SPSS) version 15. Means (±  
SD) and proportions were used to describe continuous  
and categorical variables respectively. Differences be-  
tween proportions were tested using Yates’s corrected  
chi square test or Fisher’s exact test. Statistical signifi-  
cance was set at p <0.05.  
Dipstick urinalysis was done on one aliquot of uncentri-  
fuged urine using multistix 10SG (Bayer incorporations,  
USA) which is capable of testing for ten different  
parameters including protein, pH, glucose, specific  
gravity, leucocytes, urobilinogen, bilirubin, ketones,  
nitrites and blood.  
Urine microscopy  
Ten milliliters of urine specimen from each participant  
was centrifuged in a test tube at 3,000 revolutions per  
minute (rpm) for five minutes. The supernatant fluid  
was decanted and the remaining contents were shaken to  
mix and a wet preparation made with one or two drops  
of the sediment. The slide was examined under high  
power objective of a microscope for white blood cells,  
red blood cells, bacteria debris and casts. The leucocyte  
count per high power field was taken as the average  
value from at least four high power fields.  
Age and sex distribution of the children  
Table 1 shows the age and sex distribution of the study  
participants. Out of 825 children enrolled, 33 had inade-  
quate data for analysis leaving a total of 792 children.  
Out of 792 children, 417 (52.3%) were females and 375  
(47.4%) were males. The ages of the children ranged  
from 3 to 5 years, with a mean age of 4.0 ± 0.7 years.  
Across all ages, there were more females than males but  
the difference was not statistically significant, p=0.62.  
Urine culture, colony count and bacterial identification  
Urine culture was carried out by simultaneous plating of  
blood agar and MacConkey agar plates. Before inocula-  
tion of the urine, there was prior incubation of the plates  
Table1: Age and Sex distribution of all the children studied  
Age (years) Male n (%) Female n (%)  
Total n (%)  
at 37 C for 30 minutes to dry the surface and eliminate  
108 (28.8)  
155 (41.3)  
114 (27.3)  
contamination. The inoculated plates were incubated  
aerobically at 37 C for 18-24 hours, after which the  
colonies were counted using the Kass criteria. Bacterial  
identification was done using various methods including  
the appearance of the colonies, gram staining and stan-  
dard biochemical methods. The Biochemical methods  
included triple sugar iron, oxidase, coagulase, urease  
and indole tests. Gram staining was used to classify the  
bacteria into gram positives and gram negatives.  
χ =0.96, p=0.62  
Prevalence of asymptomatic bacteriuria and colony  
The prevalence of ASB and colony counts is shown in  
Table 2. Thirty two of the 792 urine samples had colony  
counts 10 CFU/ml and all qualified as ASB giving a  
Case definitions  
The following case definitions were applicable:  
prevalence of 4.0%. Fourteen urine samples had bacte-  
rial growth between 10 and 10 CFU/ml while 62 urine  
Significant pyuria was defined as the presence of  
five or more leucocytes per high power field  
samples had colony count of <10 CFU/ml. Six hundred  
and eighty four urine samples (86.4%) were sterile.  
5 WBC/hpf).  
Significant bacteriuria was regarded as bacteria  
counts of 10 colony forming units per ml  
Table 2: Urine colony counts in the study population  
Colony count (CFU/ml)  
N=792 n (%)  
Negative culture was defined as bacteria counts of  
Asymptomatic bacteriuria was said to be present  
10 CFU/ml.  
>10 (ASB)  
0 -410  
when a urine sample contained10 CFU/ml of  
urine in a participant who had no symptoms of UTI.  
684 (86.4)  
ASB= Asymptomatic bacteriuria, CFU= Colony forming units  
Contaminated sample: culture plates with colony  
counts of > 10 but <10 CFU/ml growing two or  
more organisms. For contaminated samples, the  
urine culture was repeated with a fresh specimen  
collected from the pupil concerned within 48 hours.  
Table 3 shows the sex and age distribution of  
participants with ASB. Of the 32 children with ASB; 30  
93.7%) were females and 2 (6.3%) were males. The  
prevalence of ASB in females (7.2%) was significantly  
higher than in males (0.5%), p<0.001. The highest  
prevalence of ASB of 5.6% occurred in the 4-year-olds  
and the lowest of 2.0 % occurred in 5 year olds but the  
difference in the prevalence of ASB across the ages was  
not statistically significant as p=0.09.  
Escherichia coli, 5(16.7%), Klebsiella species, 3(10%),  
and Pseudomonas aeruginosa, 2 (6.7%).  
Fig 2: Frequency of the bacterial isolates from the 32 children  
Table 3: Distribution of asymptomatic bacteriuria by age and  
with ASB  
Asymptomatic bacteriuria  
n (%)  
n (%)  
Age (years)  
30 (7.2)  
2 (0.5)  
387 (92.8)  
373 (99.5)  
9 (0.04)  
18 (0.06) 302 (0.94)  
5 (0.02)  
213 (0.96)  
245 (0.98)  
Bacterial isolates from children with ASB  
Gram positive organisms were the predominant bacterial  
isolates, responsible for 22 (68.8%) of the cases of ASB  
while gram negatives were responsible for 10 (31.2%) of  
the cases. The two (100%) males with ASB had  
gram-positive organisms while 20 (62.5%) out of the 30  
females with ASB had gram positive organisms.  
The remaining 10 (31.3%) females had gram negative  
Urinalysis and microscopy result of children with ASB  
The dipstick urinalysis showed that 26 (81.3%) of the  
children with ASB had an acidic urine; 4 (12.5%) had  
alkaline urine while 2 (6.2%) had neutral urine. Tests for  
nitrites and leucocytes esterase were negative in all the  
subjects with ASB. There was neither blood nor glucose  
in their urine. Two (6.2%) of the bacteriuric children had  
Figure1 shows the Gram staining distribution of the  
organisms according to age. Gram positive organisms  
were predominant across all ages, 80% in children aged  
+ of protein while 3 (9.4%) had trace of protein. Only  
years, 66.7% in the 4 year olds and 66.7% in the 3  
one child (3.1%) had protein of 2++. Pyuria (5 WBC/  
hpf) was seen in only one female subject (3.1%) who  
had 7 WBC/hpf. The majority of the children with ASB  
had between 1-3 WBC/hpf while the remaining subjects  
had no white cells at all. There was no cast in all the  
cases but uric acid crystal was demonstrated in 2  
year olds. The difference in the rate of gram positive  
organisms was not statistically significant across the  
ages, χ =4.76, p=0.09.  
Fig 1: Gram staining distribution of the organisms according  
to age  
6.25%) subjects and calcium oxalate crystal in another  
subject (6.25%).  
In this cross-sectional survey, we determined the preva-  
lence of ASB in pre-school children in Nnewi, South-  
East Nigeria. The prevalence of ASB was found to be  
%. The prevalence of ASB in this study agrees with  
previous reports of about 3-6% in studies carrie10d-12out  
both outside Nigeria and within the country. In  
Europe, Nebigel et al documented a prevalence of  
.8% amongst pre-school children while Oner et al  
reported a prevalence of 3.3%. Eyong et al studied pre  
-school children in Calabar, Nigeria and found a preva-  
lence of 5.6%. Similarly, an 1A3 SB prevalence of 7.3%  
was reported by Jombo et al in a study of pre-school  
children in Calabar, Nigeria.  
The bacterial isolates in the children with ASB is shown  
in Fig. 2. The commonest organisms were Staphlococ-  
cus aureus, 13 (40.6%); Streptococcus faecalis,  
Contrarily, some authors have reported ASB prevalence  
rat1e4s much higher than what we found. Kondapaneni et  
al reported ASB prevalence of 16.5% among 200  
(28.1%) and Escherichia coli, 5(15.6%). The two  
males with ASB had either of Streptococcus faecalis and  
Staphylococcus aureus isolated from their samples. The  
organisms isolated in the females were Staphlococcus  
aureus 12 (40%), Streptococcus faecalis, 8 (26.7%),  
school children in India while Salem et al documented  
a rate of 30% in Egyptian children. In Nigeria, reports of  
higher ASB rates include 10.3% by Iduoriyekemwen et  
al and 15% by Wogu et al both in Benin City, and 48  
matter. Conversely, some studies in Nigeria involving  
pre-school children reported no gender difference in the  
prevalence of ASB despite the13,s1l8ight female preponder-  
ance in their study population.  
by Alo et al in rural primary school children in  
Ebonyi State.  
The higher ASB prevalence in the above studies can be  
explained by a number of reasons. Some of the studies  
In this study, Staphylococcus aureus (40.6%) was found  
to be the most predominant bacterial isolate, followed  
by Streptococcus faecalis (28.1%), Escherichia coli  
(15.6%), and Klebsiella spp (9.4%). Staphylococcus  
aureus has been reported as the predominant organism  
among children with ASB by some authors inclu1d8ing  
involved relatively lower sample siz15es of 100-200.  
In addition; Iduoriyekemwen et al included a large  
number of infants who are known to have a hig5her pre-  
disposition to UTI. The fact that Salem et al studied  
children with typ6e 1 diabetes and the subjects of Iduori-  
yekemwen et al were all HIV-infected children could  
Frank-Peterside in Port Harcourt and Alo et al in  
have also contributed to the high values they found.  
While our study was carried out in the community, those  
Ebonyi State, Nigeria where it was isolated in 30% and  
43.6% of cases respectively. The Predominance of S.  
aureus among the bacterial isolates in this study is in  
contrast with most reports from outside and within Nige-  
ria where gram negative organisms dominated with Es-  
of Salem et al and Iduoriyekemwen et al were hospi-  
tal-based studies and as such the children are considered  
to have a higher risk of UTI or sample contamination.  
Th8e very high ASB rate of 48% documented by Alo et  
1, 12,  
c16h, e22richia coli being the most prevalent organisms.  
al could be attributed to the fact that the study was  
carried out among children in a rural area who are  
known to have a low level of hygiene and poor health  
consciousness. Although most of the authors did not  
indicate the time between urine collection and its analy-  
sis, time lag between the two processes may also ac-  
count for higher ASB rates in some of the studies due to  
higher false positive results. On the other hand, some  
other authors documented ASB prevalence rates much  
lowe1r9 than what we found; 0.1220% and 0.37% by Joseph  
et al in India and Yayli et al in Turkey respectively.  
Decline in the predominance of Escherichia coli as the  
causative agent of UTI has been attributed to improve-  
ment in the use of culture media such as MacConkey.  
This culture medium acts as a selective and differential  
medium for gram negative bacilli. This greatly enhances  
the separation of groups of organisms into their respec-  
tive genera and their appropriate species. MacConkey  
and nutrient agar media were employed in this study and  
they would have enhanced better differentiation and  
identification of the organisms isolated. Furthermore,  
decline in E. coli predominance with a shift to S. aureus  
has been attributed to the indiscriminate use and mi2s5use  
of antibiotics and emergence of resistant organisms.  
Compared to our study, Yayli et al screened a much  
larger population of 10,289. In addition, the participants  
in both studies were older children of 5-14 years who  
are known to be less predisposed to UTI. While it can be  
argued that the better level of hygiene in developed  
countries such as Turkey may be contributory to the low  
Significant pyuria defined as the presence of at least 5  
WBC/hpf of centrifuged urine in this studywas found in  
one bacteriuric female child. This suggests the unreli-  
ability of pyuria alone as an indicator of ASB, 26. In agree-  
ASB rates among the participants of Yayli et al , the  
same cannot be said for India which is a developing  
country. A number of studies in Nigeria including those  
involving older children have also 7r,e2p1orted lower  
prevalence of ASB of about 1-2%.  
ment with our observation, some authors share the  
same opinion that pyuria is a poor indicator of bacteri-  
uria, and that the absence of pus cells does not rule out  
There was no statistically significant difference in the  
prevalence of ASB across various ages in this study.  
However, the highest rate of ASB occurred amongst the  
significant bacteriuria. Dogunro in Port Harcourt noted  
that only 1.7% of school children aged 4-15 years had  
both significant bacteriuria and significant pyuria.  
The clinical importance of ASB in children goes beyond  
its prevalence. It is its predisposition to renal scarring  
that makes it a critical issue. In one of the studies where  
ASB prevalence was found to be low, detailed investiga-  
tions showed that a reasonable propor1t9ion of affected  
children had evidence of renal damage. In developing  
countries with poor hygienic conditions, ASB remains a  
big challenge amongst pre-school children. Incidentally,  
diagnostic facilities are inadequate in these settings and  
children with ASB who later develop renal damage may  
not be identified early enough for appropriate interven-  
tions aimed at halting or reversing renal damage. This  
means that health education on improved hygiene and  
screening for ASB in young children remains the eco-  
nomically viable option.  
year olds (5.6%), followed by the 3 year olds (4.1%).  
The 5 year olds recorded the lowest rate of 2.0%. This is  
similar to the findings of Nebigil el al who recorded  
the highest prevalence of ASB in the pre-school age  
group among the 2,591 children aged 1 day to 16 years.  
The relatively higher prevalence of ASB in younger  
children can be explained by the fact that this age coin-  
cides with the period of toilet training when the child is  
more predisposed to urinary tract infection from faecal  
In this study, the prevalence of ASB was significantly  
higher in females (7.2%) than in males (0.5%) giving a  
male to female ratio of 1:15. The female predominance  
was consistent across all ages. Similarly, other authors  
have recor1d6e, 1d7, 2f2e. male predominance among children  
with ASB.  
This observation is attributed to the  
short female urethra, which is in close proximity to the  
anus from which it can be easily contaminated by faecal  
Our study had some limitations. We were unable to  
carry out radiological investigations for children with  
significant bacteriuria. This would have helped in deter-  
mining the presence and extent of renal pathology as  
well as the co-existence of congenital or structural  
urogenital abnormalities in these children.  
unwanted consequences of bacteriuria and its higher  
prevalence in females, all female pre-school children  
should be routinely evaluated for bacteriuria as part of  
the school health programme.  
Conflict of Interest: None.  
Funding: None.  
In conclusion, ASB remains an important problem in pre  
-school children. The prevalence of ASB was signifi-  
cantly higher in females, being 15 times that of their  
male counterparts. Gram positive organisms were the  
predominant isolates among children with ASB with S.  
aureus and S. faecalis accounting for over 68% of the  
cases. Escherichia coli which has been widely reported  
to be the predominant isolate in many studies was  
We are grateful to the pupils and their parents/guardians  
for participating in this study. The headmasters/  
headmistresses and the teachers of the eight Nursery  
schools where the study was carried out are deeply  
appreciated for their contributions.  
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