Niger J Paed 2014; 41 (4):350 - 353

ORIGINAL

Yauba MS

Significant bacteriuria in children

Aikhionbare HA

Ogunrinde GO

with sickle cell anaemia in a

Bugaje MA

Nigerian tertiary hospital

DOI:http://dx.doi.org/10.4314/njp.v41i4,12

Accepted: 18th June 2014

Abstract Background: Urinary

was detected in 22 (8.1%) of the

tract infections (UTI) in children

272 subjects, 156 boys (57.4%)

Yauba MS

(

)

with sickle cell anemia (SCA)

and 116 (42.6%) girls. The preva-

Aikhionbare HA, Ogunrinde GO

may result in long term morbidity

lence of significant bacteriuria was

Bugaje MA

and mortality due to chronic renal

higher among those in crisis, 18

Department of Paediatrics,

dysfunction.

(20.7%) than among those in

Ahmadu Bello University Teaching

steady than, 4 (2.2%) state: χ² =

Hospital,

Objectives : To evaluate the preva-

PMB 06, Shika-Zaria,

lence of significant bacteriuria

27.323, p = 0.001. The most com-

Kaduna state, Nigeria.

among children with SCA and to

mon organism isolated was Es-

Email:saadyko@yahoo.co.uk

determine their antimicrobial sen-

cherichia coli , 11 (50.0%). The

sitivity patterns of isolates.

antibiotic with the best sensitivity

Methods : Two hundred and sev-

was ceftriaxone. Most organisms

enty two children with SCA in

were resistant to the commonly

steady state (n = 185) and in cri-

used

antibiotics

like

co-

ses (n = 87) aged 6 months to 15

trimoxazole, amoxicillin and am-

years had their urine samples

picillin.

screened for significant bacteri-

Conclusion: The prevalence of

uria. The urine samples were col-

significant bacteriuria was found

lected aseptically and incubated

to be higher in SCA subjects in

aerobically at 37°C for 24 hours.

crisis (20.7%) than among those in

Children whose urine samples

steady state (2.2%). The most

yielded ≥ 10 cfu/ ml of bacteria on

5

prevalent urinary pathogens were

two consecutive cultures were

sensitive to ceftriaxone but resis-

regarded as having significant

tant to commonly used antibiotics.

bacteriuria.

The

antimicrobial

sensitivity pattern of isolates was

Keywords: Sickle Cell Anaemia,

determined.

Children, Prevalence, Significant

Results:

Significant

bacteriuria

Bacteriuria

Introduction

would contribute to reviewing treatment policies. Also,

early treatment of identified cases would limit develop-

Urinary tract infection (UTI) is a major cause of morbid-

ment of chronic kidney disease in this high-risk group of

ity in children with sickle cell anemia (SCA). These

children. This study was undertaken to determine the

children have impaired immunological state and are

prevalence of significant bacteriuriain children with

susceptible to recurrent infections including UTI . Uri-

1

SCA in a tertiary hospital. Early detection and manage-

nary tract infections in children with SCA, whether

ment of ASB in SCA children may retard this progres-

symptomatic or asymptomatic, may ultimately lead to

sion and reduce the morbidity and mortality from CKD.

chronic kidney disease due to repeated infarctions of the

kidney, papillary necrosis, and inability of the kidneys to

concentrate urine . Significant bacteriuriais defined as

2

the presence of 10 or more organisms per milliliter of

5

Subjects and methods

midstream urine . Asymptomatic bacteriuria can also be

3

defined as quantitative growth of bacteria ≥ 10 colony

5

The study was conducted at the Department of Paediat-

forming units per milliliter of urine of the same organ-

rics, Ahmadu Bello University Teaching Hospital

ism, from aseptically collected midstream urine speci-

(ABUTH), Zaria, over a period of six months. The study

men, in the absence of symptoms of UTI, usually in re-

was prospective, descriptive and cross-sectional. The

peated urine samples . periodic study of the pattern of

4

sample population consisted of consecutively selected

the organisms implicated in childhood UTI, and their

children with SCA (in steady state and in crisis) aged 6

antibiotic sensitivity of isolates is very important as this

months to 15 years. Children with SCA who had been

351

onantibiotics one week preceding enrolment into the

Prevalence of children with significant bacteriuria

study, those with confirmed (or suspected) congenital

urogenital anomalies and those who had recent (<1

Significant bacteriuria was detected in 22(8.1%) of the

week) manipulative urogenital procedure (like catheteri-

272 subjects with SCA (Table 2). There were

zation and cystoscopy) were excluded from the study.

12(54.5%) males and 10(45.5%) females with signifi-

Those whose parents or guardians did not consent and

cant bacteriuria (p = 0.96). Among the 22 SCA subjects

those with HbSC and other forms of sickle cell disease

with significant bacteriuria, 13(59.1%) were less than 5

other than SCA were also excluded. Ethical approval

years, 6(27.3%) were between 5 and 9 years and

was obtained from the ABUTH Research Committee

3(13.6%) were between 10 and 15 years old. The appar-

and a written consent obtained from guardians of sub-

ent decrease in significant bacteriuria with increasing

jects. Age, sex and other socio-demographic characteris-

age is not significant between the age groups (p = 0.13).

tics were recorded.

The prevalence of significant bacteriuria was higher

The urine samples were collected aseptically using stan-

among those in crisis, 18(20.7%), than among those in

steady state,4(2.2%) - χ = 27.323, p = 0.001. Fifteen

2

dard techniques as described by Anochie et al , as fol-

5

lows: the subject’s external genitalia was cleaned, mid-

(68.2%) of the 22 subjects with SCA with bacteriuria,

stream urine was collected, stored in a refrigerator and

were drawn from low social class, 3(13.6%) from the

then submitted to the laboratory within an hour of col-

middle class, and 4(18.2%) from the upper class fami-

lection. The urine samples were then incubated aerobi-

lies. Family social class was not associated with preva-

cally at 37°C for 24 hours within one hour of collection.

lence of significant bacteriuria - Fisher exact, p = 0.19.

Children whose urine samples yielded ≥ 10 cfu/ ml of

5

bacteria on two consecutive cultures were regarded as

Table 2: Distribution of children with significant bacteriuria

having significant bacteriuria. Mixed growths of more

by age and clinical status

than two speciesin a single urine sample were regarded

Children with SB, n (%)

Children without SB, n

(%)

as contaminants and therefore disregarded. Organisms

In steady

In

In steady state

In

were identified using standard identification techniques .

6

state

crisis

crisis

Antibiotic sensitivity test was also determined using

Age

Yes

No

Total

(years)

standard methods .

7

<5

4 (100.0)

9 (50.0)

58 (32.1)

35 (50.7)

106 (39.0)

5-9

0 (0.0)

6 (33.3)

75 (41.4)

21 (30.5)

102 (37.5)

Data analysis

10-15

0 (0.0)

3 (16.7)

48 (26.5)

13 (18.8)

64 (23.5)

Total

4 (100.0)

18 (100.0)

181 (100.0)

69 (100.0)

272 (100.0)

Data was analyzed using Epi Info version 3.5.3 statisti-

Χ = 4.150, df = 2, p = 0.13

2

cal software. Values for continuous variables were ex-

pressed as frequency, mean and standard deviation. Chi-

Bacterial isolates

square test was used to compare subgroups. P-values

less than 0.05 were considered significant.

A total of 22 organisms were isolated from the 22 chil-

dren with SCA (Table 3). The most frequently isolated

organism was Escherichia coli (11; 50.0%) followed by

Klebsiellapneumonia (5; 22.7%) and Proteus species (3;

Results

13.6. The least common isolates were Staphylococcus

Socio-demographic characteristics

aureus (2; 9.1%) and Salmonella typhi (1;4.6%) Table 3.

Antimicrobial sensitivity test revealed that Escherichia

The ages of the 272 subjects with SCA analyzed ranged

coli, Klebsiella pneumonia and Proteus species were

from six (6) months to 15 years with a mean age (± 1

sensitive to gentamycin (95.5%), ciprofloxacin (100%)

SD) of 6.4 ±3.8 years. Of these 185 (68.0%) were in

and ceftriaxone (100%).The organisms were also sensi-

steady state and 87 (32.0%) were in crisis (Table 1). The

tive to nitrofurantoin (68.2%), cephalexine (61.9%),

mean age of SCA subjects in steady state was 6.8 ±3.9

nalidixic acid (54.5%) and clavulonic acid potentiated

years while that of those in crisis was 5.6 ±3.7 years (p =

amoxycillin (45.5%). The isolates were least sensitive to

0.00). There were 156 (57.4%) males and 116 (42.6%)

ampicillin (9.1%), cotrimoxazole (13.6%) and amoxicil-

females in the ratio of 1.3: 1 with no gender difference

lin (18.2%).

(p = 0.96). The sex distribution in children in steady

state was also not different from that of children present-

Table 3: Urinary bacterial isolates among patients with SCA

ing in crises ( χ = 0.084, p = 0.39).

2

Organisms

Frequency (%)

Table 1: Age and gender distribution of SCA subjects in crisis

Escherichiacoli

11 (50.0)

and in steady state

Klebsiellaspecies

5 (22.7)

In steady state, n (%)

In crisis, n (%)

Proteus species

3 (13.6)

Ages

Male

Female

Male

Female

Total

Staphylococcusaureus

2 (9.1)

(Years)

Salmonella typhi

1 (4.6)

< 5

35 (33.3)

27 (33.8)

26 (51.0)

18 (50.0)

106 (84.1)

Total

22 (100.0)

5-9

40 (38.1)

35 (43.8)

16 (31.4)

11 (30.6)

102 (71.5)

10-15

30 (28.6)

18 (22.5)

9 (17.6)

7 (19.4)

64 (44.3)

Total

105

80 (100.0)

51 (100.0)

36 (100.0)

272 (100.0)

(100.0)

352

Discussion

The current study also showed that the percentage of

patients with significant bacteriuria was significantly

The overall prevalence of significant bacteriuria in chil-

higher in children with SCA crisis than in those in

dren with SCA in this study was found to be 8.1%.

steady state. The 20.7% prevalence of significant bacte-

Higher prevalence of significant bacteriuria of 26.7%

riuria in children with sickle cell crises obtained in this

was reported amongst HbSS patients in Zaria , 26.0% in

8

study is in agreement with the 21.6% prevalence re-

ported earlier by Asinobi et al . On the other hand, the

12

Maiduguri all in Nigeria and 10.9% in Jamaica . The

9

10

prevalence observed in this study was also lower than

20.7% prevalence of significant bacteriuria observed in

12.85% reported by Akinbami et al

11

in Lagos and

this study in those with SCA crisis was higher than that

(10.0%) observed by Tarry et al in USA and 25.6%

16

21.6% reported by Asinobi et al

12

in Ibadan. The lower

reported by Elbashier and Badu

17

prevalence of significant bacteriuria obtained in our

in Saudi Arabia. Dif-

study could be due to the fact that most of our study

ferences in the study design and age distribution of

population were SCA subjects in steady state, while

study population used might have contributed to the

difference in the prevalence. The study by Tarry et al

16

Zaria , Maiduguri and Ibadan

8

9

12

studies were febrile

children with SCA. Differences in the methodology may

was retrospective and included children above 15 years

have contributed to the lower prevalence observed in our

of age while this study included children less than 15

study as compared to studies by Akinbami et al and

11

years. This study included only children with SCA while

Elbashier and Badu included other haemoglobin phe-

17

Cumming et al . Whilst our study used clean-catch, mid

10

-stream and supra pubic aspiration urine specimen,

notypes and their study was retrospective in design,

Cumming and Akinbami et al used only clean catch,

11

which may explain the difference observed in their study

midstream urine sample for their study. Supra pubic

as compared to the present study. Racial variations may

aspiration is more aseptic technique with reduced con-

also contribute to the differences in the prevalence.

tamination rate.

However, the prevalence observed in this study was

The 2.2% prevalence of significant bacteriuria in steady

higher than the 6.0% reported by Chuckwu et al in

13

state SCA subjects obtained in our study was lower than

the 6.0% prevalence obtained by Chukwu et al

13

Enugu. The higher prevalence observed in our study as

in

may be

Enugu and the 5.8% reported by Ajasin and Adegbola

15

compared to that reported by Chuckwu et al

13

contributed by those children with SCA crisis. This

in Lagos in children with SCA in steady state. The lower

study included children with SCA both in crisis and in

prevalence observed in this study as compared to those

of Chukwu et al and Ajasin and Adegbola may be

13

18

steady state while Chuckwu et al included only chil-

13

dren in steady state.

due to the difference in methods of urine collection.

Whilst this study used clean-catch, mid-stream and su-

pra pubic aspiration specimen, Chukwu et al and

13

This study revealed that prevalence of significant bacte-

Ajasin and Adegbola used only clean catch, midstream

18

riuria did not decreased with increasing age a finding

different from that reported by Akuse and Mava et al

8

9

urine sample for their study.

where their prevalence decreases with increasing age.

The differences in the genetic constitutions among the

The most frequently isolated organism from the urine

study populations may explain the difference in the

specimens was Escherichia coli , followed by Klebsiel-

laspp, a finding similar to that of other studies

9,14

prevalence. Regarding those in crisis, significant bacteri-

. The

virulent factors associated with E . coli may have con-

18

uria was also found to be commoner among the age

group less than 5 years than in the older children, a find-

tributed to the organisms being the most frequently iso-

ing similar to that of Akuse and Mava et al . Preponder-

7

9

lated. Salmonella typhi and Staphylococcus aureus were

ance of significant bacteriuria in this age group could be

the organisms least isolated in our study, a findingsimi-

lar to that reported byothers . The rarity of Salmonella

9

explained by the fact of incompletely developed immu-

nity .

8,9

UTI in our study as well as these other studies was be-

cause Salmonella typhi is not a common cause of UTI in

Our study revealed that significant bacteriuria was not

children.

associated with gender even though it had been shown

that bactriuria is commoner in females than males in

This study revealed that most of the pathogens isolated

children older than one year

9,12,14

. This could be attrib-

were resistant to cotrimoxazole, ampicillin, cephalexin

uted to the small number of children with confirmed

and amoxicillin but highly sensitive to ceftriaxone,

significant bacteriuria in the present study and the vary-

ciprofloxacin, gentamycin, cefuroxime and nitrofuran-

ing cultural/ religious practices in these environments. In

toin. These findings were similar to those reported by

other workers

12,19

the environment where the current study was conducted

. This may be partly attributed to the

male children are not often circumcised before the age

high cost of these drugs.

of seven years. Early circumcision is the norm in South-

ern parts of Nigeria and the Western world where Aki-

nola et al conducted their study. Lack of circumcision

14

has been associated with increased risk of UTI in boys .

15

Conclusion

Significant bacteriuria being not associated with child’s

socio-economic status contrasted with the finding by

The prevalence of significant bacteriuria was found to

Chukwu et al .

13

be higher in SCA subjects in crisis than in those in

353

steady state. Escherichia coli still remained the com-

Acknowledgements

monest pathogen isolated. There was a high degree of

resistance of isolated urinary organisms to commonly

We wish to acknowledge Dr. Adamu Ali Zainab of the

used antibiotics. It is recommended that routine urine

General Out-patient Department, ABUTH, Dr. Suleiman

screening for UTI be carried out in children, particularly

Saidu Bashir of the Department of Community Medi-

under-fives, presenting to our hospitals with SCA crisis.

cine, ABUTH for their immense technical assistance as

Ceftriaxone, cefuroxime or gentamycin should be a drug

well as Dr. Ibrahim Adulrasul of the Department of

of choice for empiric treatment of UTI in children with

Microbiology, ABUTH for assisting in the laboratory

SCA.

aspect of this study.

Authors’ contributions

MS conceived the study, participated in the design and

coordination of the study, collected the samples, contrib-

uted in the laboratory work, analyzed the data and wrote

the final manuscript. HA,GO and MA participated in the

design, writing, analyzing and supervision of the study.

All contributors approved the final version of the manu-

script.

Conflict of interest: None

Funding: None

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