Some etiological and clinical aspects of pyelonephritis and antibiotic resistance of pathogens causing children’s pyelonephritis in Mongolia / Монголын Анагаах Ухаан

IntroductionPyelonephritis is generally the result of an ascending infection of the urinary tract (reflux is seen in 30- 50% of affected children) most common organism is Escherichia coli (Heiberger R.E., 2006). The bacteria that are most likely to cause pyelonephritis are those that normally occur in the feces. Pathogens isolated from patients with pyelonephritis include both gram positive and gram negative bacteria. R.E.Neiberger reported that of gram negative bacteria E.coli, Klebsielle, Enterobacter, Proteus, Pseudomonas and of gram positive bacteria Enterococcus, Staphylococcus saphrophiticus, group B.Streptococcus were prevalent in children with pyelonephritis. In another study conducted at the Pennsylvania University, USA, 70-95% of causes were related with E.coli, Proteus, Klebsiella, Pseudomonas, Staphylococcus saphrophiticus and Еnterobacter (Sammuel Baron, 2004). In the Indian study E.coli accounted for 88.1%, Pseudomonas aeruginosa for 7.1% and Klebsiella was in 4.8% of cases (Namalwar B.R., Vijayakumar M., Janani Sankar., Ramnath B and Prahlad N., 2004). Serotypes 01; 02; 04; 06; 07 were considered as most prevalent among E.coli causes of UTI (Sammuel Baron, 2004). Escherichia coli causes about 85% of acute bladder and kidney infections in patient with no obstruction or history of surgical procedures. Proteus, Klebsiella, Enterobacter or Pseudomonas are other common causes of infection(Namalwar B.R., Vijayakumar M., Janani Sankar., Ramnath B and Prahlad N., 2004). Once these organisms enter the urinary tract, they cling to the tissues that line the tract and multiply in them (Parveen J Kumar Michael L Clark Clinical medicine. London, 2003). Pyelonephritis is characterized by tubulo-interstitial inflammation, hyperaemia and oedema. Affected patients present with the abrupt onset of fever and chills, constant dull flank pain, and symptoms of cystitis (dysuria, frequency, urgency). Urinalysis usually procedures microabscess. Urine cultures will frequency be negative in the setting of haematogenousinfection (Namalwar B.R., Vijayakumar M., Janani Sankar., Ramnath B and Prahlad N., 2004). Asymptomatic infections of the urinary tract or Asymptomatic bactreuria are common. In childgood, about 1 percent of girls have asymptomatic bacteruria (Namalwar B.R., Vijayakumar M., Janani Sankar., Ramnath B and Prahlad N., 2004). In Mongolia females aged between 20-40 years old accounted for 60.3% of all patients with chronic pyelonephritis. In cases of bacteriuria E.Coli was 74.05%, with highest sensitivity to claforan (91.25%) and ciprofloxacin (90.65%) (B.Selengee, 2003). Last 5 years (2004-2008) 3709 children were treated in Nephrological department of Mathernal and Children’s Scientific Center, but between them 741(19.97%) children were illned by pyelonephritis. However no study was conducted on bacterial causes of pyelonephritis in children in Mongolia. Purpose:The main goal of study was to indicate the etiological and clinical specialaty of children’s pyelonephritis. Especially, to indicate the prevalently occurred type and the etiological bacterial groups also the clinical specialaty of children’s pyelonephritis. To study microbiological spectrum of pathogens causing pyelonephritis in Mongolian children, sensitivity of them to antimicrobial agent, mechanisms of their resistance and to identify genes related with microbial pathogenity.Materials and Мethods:My study covered 254 children wich illned by pyelonephritis, these were treated in Nephrological department of Mathernal and Children’s Scientific Center in last 5 years (2004-2008). From patient’s history we also used the clinical laboratorial analysis results such as biochemical, blood count and urine analysis. We used retrospective and prospective statistical methods for study on pathient’s history of children wich sickned by pyelonephritis and bacteriological method for indicating groups of bacteria. We collected information about patients by questionary chart. During study we also used electro-sonography(echo), Xray, radio-isotope, computer-tomography and reno-vascular angiography methods. Antibiotic susceptibility testing covered total 212 bacterial species to 19 kind of antibiotics by disk diffusion(DD) and minimium inhibitory concentration(MIC) methods. Strains were identified by API tests strip (BioMerieux, France) and antibiotic susceptibility was determined by disk diffusion method according to the ELSI recommendations. Types of the beta lactamase were determined by PCR using the blaTEM, blaSHV and blaCTX-M specific primer. 1080 bp, 400 bp and 570 bp PCR product were interpreted as positive for blaTEM, blaSHV and blaCTX-M genes. WHONET5.1 programm was used for the analysis of susceptibility testing according to the WHO recommendation. Pathogens from 1 month consequent urine culture of patients treated at the pediatric nephrology, urology units and outpatient clinic at the MCHRC and patients from nephrology and urology departments at the CCH were isolated using disk diffusion test and minimum inhibitory concentration. Bacterial resistance and pathogenity related genes were identified using PCR method.Results:There were the girls prevalently sicked by pyelonephritis (n=181 or 71.25%) than boys (n=73 or 28.74%) and the primary (n=155 or 61.02%) and secondary chronic pyelonephritis (n=99 or 38.97%) also was prevalently occurred. During pyelonephritis are occurring following clinical symptoms these are high temperature, edema eyelid, loss of appetite, sludged urinate, skin dryness, womiting and nicthuria. By our study the main clinical symptoms of children’s pyelonephritis are high temperature (58.55%), back pain (51.0%), edema of eyelid (34.42%) and polyuria (25.79%). Also the main influencing factors for inducing children’s pyelonephritis are hyphoplasia (33.3%), hydronephrosis (19.23%), single kidney (15.38%) and vesico-uretheral reflux (6.41%). Study was conducted on 110 positive cultures (E.coli-52, Citrobacter spp.-8, E.cloacae-10, Proteus spp.-7, K.pneumoniae-7, P.aeruginosae-22 ба A.baumennii-2, S.aureus-1, Enterococci-1). The bacterial sensitivity and resistance to antimicrobial agents differed between various pathogens. From Gram negative oxydase negative Enterobacteriaceae by PCR testing, 19 isolates contained blaTEM types, 11 strains contained blaSHV types and 16 strains contained blaCTX-M type genes. On the study of PCR the virulence gene “aer” were determined 50% of E.coli strains. blaTEM type resistance can divided to 5 groups, from them 2 groups had the resistance to single beta-lactamic antibiotics, but 3 groups had to both beta-lactamic and aminoglycoside antibiotics.blaSHV type resistance had 2 groups antibiotics, these were beta-lactamic and aminoglycoside antibiotics. blaCTX-M type resistance had 2 groups, these were beta-lactamic and aminoglycoside antibiotics. Both the blaTEM and blaSHV type co-resistance had 2 groups, these were CEP and CXA antibiotics. blaTEM and CTX-M type resistance can divided to 4 groups, from them 1 group had the resistance to single beta-lactamic antibiotics, other 3 groups had to aminoglycoside antibiotics. Both the blaSHV and CTX-M type co-resistance had 2 groups, these were lactamic and aminoglycoside antibiotics. blaTEM, SHV and CTX-M type co-resistance can divided to 3 groups, these were also beta-lactamic and aminoglycoside antibiotics. On the study of PCR the virulence “aer (aerobacterin) gene” expression was identified in 50% of E.coli strains.Conclusion:There were the girls (181 cases or 71.25%) prevalently sick by pyelonephritis than boys(73 cases or 28.74%) was prevalently occurred.In Mongllia the primary pyelonephritis(155 cases or 61.02%) was occurred prevalently than secondary chronic pyelonephritis( 99 cases or 38.97%). The gasteroenterological and toxic symptoms prevalently occurred in clinical symptoms, but later kidney and urinary tract symptoms noticed.In Mongolia the main influencing factors for inducing children’s pyelonephritis are hyphoplasia (33.3%), hydronephrosis (19.23%), single kidney (15.38%) and vesico-uretheral reflux (6.41%).The prevalent pathogen causing pyelonephritis in Mongolia is E.coli. Other causes include Enterobacter spp., Klebsilla spp., Proteus spp., P.aeruginosa, Aceinobacter baumenii and S.aureus. The virulence gene “aer” were determined 50% of E.coli strains. The most prevalent resistance was resistance to beta-lactam, aminoglycoside, tetracycline and trimethoprim sulfometohoxazole. Resistance to beta-lactamic antibiotics was related with blaSHV, blaTEM, blaCTX-M gene experessions in 25-40% of cases. blaTEM, blaSHV and bla CTX-M type of the beta-lactamase were determined 25-40% of Gram negative oxidase negativebacilli. Pathogenic “aer” gene was identified in 50% of E.coli in Mongolia.

Efficacy of Cyclic Voiding Cystourethrography in Detection of Vesicoureteral Reflux in Young Children

PURPOSE: To evaluate the efficacy of cyclic voiding cystourethrography (VCUG) for the detection of vesicoureteral reflux (VUR) in young children. MATERIALS AND METHODS: Two cycles of cyclic VCUG were performed in 119 kidney-ureter units (KUUs) of 60 children (mean age; 9 months, range; 5 days-2 years). Spot radiographs and fluoroscopic-image captures were obtained. We analyzed the presence of VUR and the grade of VUR according to the standards of the international grading system. We recorded the amount of total contrast material on each cycle and the total fluoroscopic time. RESULTS: VUR was present in 21 (17.6%) KUUs of 13 (21.7%) children. On the first and second cycle, the reflux occurred in 9 (15.0%) children and 13 (12.6%) KUUs. In one hundred-four KUUs of 51 children whose VCUG results were negative on the first cycle, the reflux occurred in 4 (7.8%) children and 6 (5.8%) KUUs during the second cycle. The grading of the reflux was upgraded during a second cycle in one case. A new detection and upgrade of VUR by the second cycle was observed in 5 (9.8%) children and 7 (6.7%) KUUs. In 4 KUUs (53%) of these 7 KUUs, the VUR was higher than grade II. The mean amounts of contrast solution were 28 cc (range; 5-100 cc) on the first cycle and 39 cc (range; 10-100 cc) on the second cycle. The mean of the total fluoroscopic time was 147 seconds (range; 59-338 seconds). CONCLUSION: Cyclic VCUG can enhance the ability of the method to detect and grade VUR in children under 2 years of age.

Vesicoureteral Reflux in Children: Comparison of Contrast - Enhanced Voiding Ultrasonography with Radiographic Voiding Cystourethrography: Preliminary Report

PURPOSE: To compare the usefulness of contrast-enhanced voiding ultrasonography(US) with that of radiographic voiding cystourethrography(VCUG) for the diagnosis of vesicoureteral reflux(VUR) in children. MATERIALS AND METHODS: Ninety-five kidney-ureter units of 47 patients referred for investigation of VUR underwent contrast-enhanced voiding US followed by radiographic VCUG. After baseline US examination of the urinary tract, residual urine in the bladder was drained through an inserted Foley catheter and the bladder was gravity filled at a height of 1 m with normal saline. A galactose-based, microbubble-containing echo-enhancing agent (Levovist; Schering, Berlin, Germany) was then administered. The amount of this was approximately 10% of bladder capacity, and VUR was diagnosed when microbubbles appeared in the ureter or pelvo-calyceal system. Using radiographic VCUG as a reference point, the accuracy with which contrast-enhanced voiding US detected VUR was calculated. RESULTS: In 87 of 95 kidney-ureter units (91.6%), the two methods showed similar results regarding the diagnosis or exclusion of VUR, which was detected by both in 12 units, but by neither in 75. VUR was shown to occur in a total of 20 units, but in eight of these by one method only. In two units, VUR detected by contrast-enhanced voiding US was not demonstrated by radiographic VCUG; in six units, the reverse was true. In the detection of VUR, contrast-enhanced voiding US showed a sensitivity of 66.7%, a specificity of 97.4%, a positive predictive value of 85.7%, and a negative predictive value of 92.6%. CONCLUSION: Contrast-enhanced voiding US is highly specific and has high positive and negative predictive values; its sensitivity, however, is not sufficiently high. The modality appears to be a useful diagnostic tool for the detection of VUR without exposure to ionizing radiation, though to be certain of its value, more experience of its use is first required.

Radiological Findings after Endoscopic Incision of Ureterocele

PURPOSE: Endoscopic incision of ureterocele is considered a simple and safe method for decompression of urinary tract obstruction above ureterocele. The purpose of this study was to evaluate the radiological findings after endoscopic incision of ureterocele. MATERIALS AND METHODS: We retrospectively reviewed the radiological findings ultrasonography (US), intravenous urography, and voiding cystourethrography(VCU)] in 16 patients with ureterocele who underwent endoscopic incision (mean age at surgery, 15 months; M: F=3:13; 18 ureteroceles). According to the postoperative results, treatment was classified as successful when urinary tract obstruction improved without additional treatment, partially successful when medical treatment was still required, and second operation when additional surgical treatment was required. RESULTS: Postoperative US (n=10) showed that in all patients, urinary tract obstruction was relieved: the kidney parenchyma was thicker and the ureterocele was smaller. Intravenous urography (n=8), demonstrated that in all patients, urinary tract obstruction and the excretory function of the kidney had improved. Postoperative VCU indicated that in 92% of patients (12 of 13), endoscopic incision of the ureterocele led to vesicoureteral reflux(VUR). Of these twelve, seven (58%) showed VUR of more than grade 3, while newly developed VUR was seen in five of eight patients (63%) who had preoperative VCU. Surgery was successful in four patients (25%), partially successful in three (19%), and a second operation-on account of recurrent urinary tract infection and VUR of more than grade 3 during the follow-up period was required by nine (56%). CONCLUSION: Although endoscopic incision of a ureterocele is a useful way of relieving urinary tract obstruction, an ensuing complication may be VUR. Postoperative US and intravenous urography should be used to evaluate parenchymal change in the kidney and improvement of urinary tract obstruction, while to assess the extent of VUR during the follow-up period, postoperative VCU is required.

The Grade of Vesicoureteral Reflux in Voiding cystourethrography: Comparison with Ultrasonography and Tc99m-DMSA renal Scintigraphy

PURPOSE: To evaluate the prevalence of abnormalities seen on sonography and renal scintigraphy, according tothe grade of vesicoureteral reflux (VUR) on in voiding cystourethrography (VCUG). MATERIALS AND METHODS: Onehundred and forty-nine patients (age range : 1 months - 10 years) with urinary tract infection underwentsonography, VCUG, and renal scans, and 32 showed VUR on VCUG. We retrospectively evaluated the frequency andcharacteristic findings of sonographic abnormalities according to the grade of VUR, and also the frequency ofcortical defects seen on renal scans of 32 patients with VUR. The remaining 117 patients without VUR were alsoevaluated for the frequency of abnormal findings seen on sonography and renal scans. RESULTS: Among 32 patients(49 kidneys) with VUR, abnormal findings were not detected in 17 (29 kidneys) on sonography ; thus, findings wereabnormal in 15(20 kidneys, 41%). Among these 20 kidneys, renal calyceal and/or pelvic dilatation and dilatation ofdistal ureter were seen in 11, all of which were grade 4-5 VUR. Renal pelvic dilatation only was noted in eightkidneys ; two were grade 1-3 and six were grade 4-5 VUR. Nineteen patients (24 kidneys, 49%) showed focal corticaldefects on renal scintigraphy. Six kidneys were grade 1-3, and 18 kidneys were grade 4-5 VUR. Of 117 patientswithout VUR, 34 patients (29%) showed renal pelvic dilatation on sonography and in 14 patients (12%), corticaldefects were seen on renal scintigraphy. CONCLUSION: Among 32 patients with VUR, 41% showed abnormal sonographicfindings and in 49%, cortical defects were seen on renal scintigraphy. With a higher grade of VUR, the prevalenceof abnormalities increased on both sonography and renal scintigraphy. Sonographic demonstration of renal calicealand/or pelvic dilatation associated with ipsilateral distal ureteric dilatation was the characteristic finding inhigh grade VUR.