Niger J Paed 2016; 43 (1):30 – 33
ORIGINAL
Ocheke OI
The febrile child: how frequent
John CC,
Ogbe P,
should we investigate for urinary
Donli A,
tract infection
Oguche S
DOI:http://dx.doi.org/10.4314/njp.v43i1.6
Accepted: 3rd August 2015
Abstract : Background: Febrile
where necessary: blood film for
illness in children remains the
malarial parasite identification and
Ocheke OI (
)
most common cause of emer-
count, cerebrospinal fluid (CSF)
John CC, Ogbe P, Donli A, Oguche S
gency room visit. In many tropical
analysis and chest X-ray.
Department of Paediatrics,
Jos University Teaching Hospital
countries where malaria is en-
Results: Of the 303 children 180
P. M. B 2076, Jos, Nigeria
demic, children presenting with
(59.4%) were males and 123 were
Email: ieocheke@yahoo.com
fever are treated for malaria pre-
females (40.6%). The mean age
sumptuously. Current evidence
was 21.7±14.0months, 54.5% were
suggests however that malarial
less than 24months.
parasitaemia in febrile children is
ARI accounted for 44.6% (mainly
declining and the prevalence of
tonsillitis, 61%, pneumonia, 27%
other causes of fever apparently
and otitis media, 12%), while ma-
on the increase. Therefore, high-
laria and UTI were observed in
lighting such causes of fever as
38.3% and 4.6% respectively.
urinary tract infection (UTI) is
Five (35.7%) patients with UTI
indispensable. This is much so as
were males while 9 (64.3%) were
UTI not only is common in
females. Their combined mean age
younger children and often ne-
was 25.4±18.6months, 57% of
glected but also associated with
these children were less than 24
long term complications
months old. In 3(21.4%), UTI co-
Methods:
Children
aged
6-
existed with malaria.
59months with fever of less than
Conclusions: Acute respiratory
2weeks were consecutively re-
infection, malaria and UTI are the
cruited. Each child had both clini-
three leading causes of fever in
cal evaluation and preliminary
children under 5 years.
laboratory assessment such as
dipstick urinalysis. Further micro-
Keywords: Fever, Children, Acute
biological
and
radiological
respiratory infection, Malaria,
evaluations
were
performed
UTI.
Introduction
malaria parasitaemia accounted for only 35 % of 5,217
children presenting with fever.
8
Febrile illness represents the most common cause of
The pre-treatment identification of malaria parasites in a
hospital visits and admission in children globally.
1,2
The
suspected case is beneficial in many ways much as only
underlying causes are predominantly infectious and UTI
individuals with the infection are treated. A new prob-
is increasingly recognised as an important cause. Ap-
3
lem as a result of this step however is, what appropriate
proximately two decades ago, it was noted that 30% of
treatment would those who test negative for Plasmo-
outpatient and 50% of inpatient children under the age
dium falciparum parasites receive, particularly at the
of five years living in Sub-Saharan Africa had malaria.
4
first and secondary-level health facilities. Available evi-
Without a reliable case definition, children presenting
dence suggests that with the decrease in the use of anti-
with febrile illness in most cases were treated presump-
malarials, there has been a corresponding increase in the
tively for malaria.
1,5-6
Current evidence suggests how-
indiscriminate use of antibiotics in febrile children.
9,10
ever that there is declining malarial transmission in
Many times, the choice of antibiotics and their dosages
many of the malarious countries in Africa. This necessi-
are inappropriate, inadequate and unnecessary. This
tated the World Health Organisation (WHO), point-of-
practice can lead to increase in the development of sev-
care rapid diagnostic test which ensures that all children
eral resistant microbial strains. It could also lead to poor
presenting with fever are tested for malaria before em-
care and missed diagnosis of bacterial infections that
barking on antimalarial treatment. In Nigeria a recent
7
may result in long term complications particularly in
younger children.
11
multicentre study conducted in 2009/2010 showed that
31
It has been shown that urinary tract infection (UTI) is
Laboratory assessment
common in children presenting with febrile illness par-
ticularly in younger age groups, and could be associated
A dipstick urinalysis was done on a portion of urine
12,13,14
with long-term complications.
These complications
specimen (catheter urine and clean catch for children 2
could be prevented by early diagnosis and prompt treat-
years and below, while mid-stream urine for older ones),
ment.
for each subject who did not have any obvious focus of
infection. This was to identify the presence of nitrite and
Considering these, a systematic approach to case man-
or leukocyte esterase (LE). Only the urine of children
agement of febrile children, particularly those under-five
whose dipstick urinalysis was positive for both nitrite
years is imperative. Such a measure would include care-
and LE or for either of the two were subjected to further
ful clinical evaluation and laboratory assessment to iden-
microbiological analysis according to National Institute
for Health and Care Excellence (NICE) guidelines.
16
tify the underlying cause of fever in each child. This
study was therefore, undertaken to highlight the underly-
The remaining portion of such urine sample was sent to
ing causes of fever in children six months to 59 months
the JUTH microbiology laboratory for microscopy, cul-
with specific emphasis on UTI identification in our hos-
ture and sensitivity within one hour of collection accord-
pital.
ing to standard protocol. The confirmation of UTI was
made only in children with a single bacterial isolate of
≥10 colony forming units (CFU) per ml of mid-stream
5
17
urine and 10 CFU/ml of catheter urine.
3
Materials and methods
Venous blood was obtained for peripheral smear and
subjected to Giemsa stain for Plasmodium falciparum
This was prospective, cross-sectional and descriptive
identification and counting. Similarly, all children with
study, carried out in the paediatric emergency and outpa-
features suggestive of acute central nervous system in-
tient units of the Jos University Teaching Hospital, Ni-
fections (fever with seizures, nuchal rigidity or uncon-
geria. Study participants were children aged 6 to 59
sciousness) had lumbar punctures for cerebrospinal fluid
months seen in these units from the first of April to the
(CSF) analysis.
end of October 2012. Ethical approval was obtained
Data obtained were entered into EPI info version
from the Institution's Health Research and Ethics Com-
3.4.3software for analysis. The student‘t’ test was used
mittee. All children who presented with fever (axillary
to compare group means and the Chi-squared test to
temperature ≥ 37.5 C), that had lasted less than two
o
compare proportions. Fisher exact was used when cells
weeks and whose parental/caregiver consent had been
contained observations less than 5. P value less than
obtained were consecutively recruited. Children with
0.05 was considered significant.
moderate to severe malnutrition according to world
health organization (WHO)
15
reference charts, those
with sickle cell anaemia or any underlying chronic ill-
nesses (renal, cardiac and chronic infection such as tu-
Results
berculosis or human immunosuppressive virus) were
excluded. Similarly, children who had used antibiotics
A total of 303 children were recruited for the study. One
within one week prior to hospital visit were not in-
hundred and eighty (59.4%) were males while 123
cluded. All the children seen during the study, including
(40.6%) were females. Table 1 show the clinical charac-
those who participated and those who did not were
teristics of the subjects. The combined mean age for
given appropriate medical care following careful evalua-
both males and females was 21.67±14.02 while the me-
tion.
dian age was 17 months. One hundred and ninety nine
(65.7%) were aged less than 24 months.
Clinical assessment
Fig 1 shows the causes of fever in the study population.
The history of illness was obtained from the patient’s
Acute respiratory infection, comprising tonsillitis, pneu-
parent/caregiver. Each child had physical examination to
monia and otitis media in that order, was the leading
identify possible focus of infection or any other feature
cause of fever in the children, constituting 44.6%. Ma-
that could assist in making diagnosis. Those who have
laria was the second common cause of fever followed by
clinical features suggestive of acute lower respiratory
urinary tract infection at 38.3% and 4.6% respectively.
infections had chest radiography. All participating sub-
Of the children with ARI, 93 (69%) were aged 24
jects had their weight taken using a Seca® standing or
months and below with majority, 54 (58.1%) in this
bassinet weighing scales (infants), while height/length
group aged 12 months and less. Similarly, 86 (62.4%) of
was measured in recumbent or standing positions based
the children who had malaria were aged 24 months and
on the age of the child respectively.
below. There were 14 children with UTI, 5(35.7%) in
The mid upper arm circumference (MUAC), was meas-
males and 9(64.3%) in females. Their mean age was
ured in all the children using an inelastic tape and meas-
25.4 ± 18.6 months. Eight children (57%) were 24
urement recorded to the nearest 0.1cm.
months or less while the remaining 6 (43%) patients
were older.
Three of the children with UTI also had parasitological
evidence of malaria. The commonest organism
32
responsible for UTI was Escherichia coli in 8(57.1%).
graphical location may also have contributed as the find-
The other organisms included Klebsiella species in 3
ing from Tanzania showed; the pattern of infection in
(21.4%), Staphylococcus aureus 2(14.3%) and Proteus
febrile children was different between the mainland and
species in 1(7.1%). A significantly high proportion
Zanzibar Island.
(86.4%) of the organisms isolated were sensitive to
flouroquinolones, sensitivity to gentamicin was 56.8%,
The prevalence of UTI in our study of 4.6% is much
while to the third generation cephalosporin (ceftriaxone)
lower than two previous and similar studies from other
parts of Nigeria.
22,23
Ibeneme et al
22
was 46.2%.
reported a UTI
prevalence of 11% in febrile children aged 1 to 59
Fig 1: Underlying diagnosis of fever in the children
months in South East Nigeria. Their study included chil-
(Others- cellulitis, chicken pox, measles and mumps)
dren of much younger age than ours. It is known that the
prevalence of UTI is higher in younger infants, particu-
larly in the first few months of life.
12,14
Furthermore,
urine culture for microbiological confirmation of UTI
was done for all their study population without initial
screening for nitrite and LE, while we relied on positive
urine nitrite and/or LE for further urine culture. Conver-
sion of nitrate to nitrite does not occur with all bacteria
and it takes about 4 hours or more for conversion of
urine nitrate to nitrite in the bladder.
24
Therefore, if a
child had not retained urine for such period, it was pos-
Table 1: Characteristics of the study subjects
sible the screening will be falsely negative even where
Variable
Total
Male
Female
P value
UTI was present. In their study from north western Ni-
Study population
303
180
123
-
geria, Wammanda et al
23
reported a UTI prevalence of
Age(months)
21.7 ±14.02
21.1 ±13.9
22.6 ±14.3
0.72
(Mean±SD)
24.3% in 185 febrile children who had symptoms refer-
Axillary Temp ( C)
o
38.2 ±0.78
38.2 ±0.76
38.2 ±0.81
0.73
able to the urogenital system. This figure is equally
(Mean±SD)
much higher than our finding. The higher rate they re-
Duration of fever
5.6±4.3
5.3±3.6
5.4±3.5
0.82
before presentation
ported is likely attributable to the fact that only those
(days) (Mean±SD)
children who had urinary signs and symptoms were re-
cruited. In that study, they also compared the ability of
positive urine nitrite to detect UTI with urine culture and
noted that nitrite was less sensitive but had an excellent
specificity. In other words, there is likelihood for this
23
Discussion
test not to detect UTI even where infection is present.
From our study, acute respiratory infection was identi-
fied as the leading infection in children presenting with
Our study evaluated children for UTI only if they had no
fever, followed by malaria. Urinary tract infection was
focus of infection and where preliminary screening for
the third common cause of fever in these children. This
nitrite and LE was positive. It has been shown that nei-
general pattern is similar to findings from other studies
ther absence nor presence of a focus of infection neces-
sarily affects the existence of UTI in children. This may
14
in Africa and elsewhere in the world.
18,19,20,21
In a study
of 418 children with fever in Gabon, Bouyou-Akotet et
have contributed to the lower prevalence rate observed
al reported UTI prevalence of 4.1%, while D’Acre-
18
in this study.
mont et al , in his review of the causes of fever in 1005
19
The prevalence of UTI in febrile children in our study
Tanzanian (Zanzibar) children 2 months to 10 years re-
may have come in a distant third position, but it empha-
ported a prevalence of 5.9%. These studies also showed
sise a significant point that this condition is to be looked
that acute respiratory infection was the commonest
for in children presenting with fever when there is no
cause of fever in the children as our study demonstrated.
focus of infection. This is more so that managing the
We found that malaria was the second most common
long term complications associated with renal scarring
cause of fever similar to the report from Gabon,
18
but
from pyelonephritis is much more challenging and diffi-
this contrasts with the observation from Zanzibar
19
cult in our environment.
where malaria was the fourth common cause of fever.
Our study has some limitations: urine culture was car-
This variation may be related to capacities for further
ried out only in children whose dipstick urinalysis was
laboratory investigations, environmental and weather
positive for nitrite and/or LE. There may have been
conditions. For instance, in mainland Tanzania, the com-
some of these children whose dipstick urinalysis was
monest cause of fever among 870 paediatric and adult
negative for nitrite and LE but who may actually have
patients was bacterial zoonoses while malaria was re-
UTI. However, this study has shown that, for children
sponsible in only 1.6%. Similarly, among 1180 hospi-
20
presenting with fever in our environment, acute respira-
talized Cambodian children under 8 years with 1225
tory infection is the commonest condition, followed by
febrile episodes, Chheng et al reported that acute respi-
21
malaria and then UTI, stressing the need to evaluate
ratory infection was the foremost cause of fever fol-
such children with this order in mind.
lowed by different kinds of viral infections. The geo-
33
Acknowledgments
Mrs Carol Okorie for carefully analysing the entire
blood specimen for malaria parasites for the children.
We are grateful to all the children and their parents that
participated in this study. We also acknowledge
Conflict of interest: None
Funding: None
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