Rajiv Gandhi University of Health Sciences, Bangalore, Karnataka s26

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE, KARNATAKA

PROFORMA FOR REGISTRATION OF DISSERTATION

“PREVALENCE OF URINARY TRACT INFECTION IN FEBRILE CHILDREN LESS THAN FIVE YEARS OF AGE”

Dr. SIDDU CHARKI POSTGRADUATE DEPARTMENT OF PEDIATRICS K.V.G. MEDICAL COLLEGE, SULLIA. RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE, KARNATAKA

ANNEXURE- II

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1 NAME OF THE CANDIDATE DR. SIDDU CHARKI AND ADDRESS POSTGRADUATE (IN BLOCK LETTERS) DEPARTMENT OF PEDIATRICS K.V.G. MEDICAL COLLEGE, SULLIA.

2 NAME OF THE INSTITUTION KVG MEDICAL COLLEGE, KURUNJIBAG, SULLIA DK-574327 KARNATAKA.

3 COURSE OF STUDY AND M.D. PEDIATRICS SUBJECT

4 DATE OF ADMISSION TO 28/05/2010 COURSE

5 TITLE OF THE TOPIC PREVALENCE OF URINARY TRACT INFECTION IN FEBRILE CHILDREN LESS THAN FIVE YEARS OF AGE 6. BRIEF RESUME OF THE INTENDED WORK: 6.1 Need for the study: Children with fever comprise a substantial proportion of the practice in outpatient department and Emergency Medicine. Fever is the most common reason for children under 5 years of age to visit emergency / outpatient departments. Unlike occult bacteraemia or severe bacterial illness (in infants and children) little attention has been focused on the identification of urinary tract infections in febrile children in the emergency department, despite recent information that suggests a high prevalence of urinary tract infections and significant associated morbidity in these patients. Quite often, child receives antibiotics empirically, without adequate evaluation for urinary tract infection. Fever, however, is often the only symptom in children with urinary tract infections.

Fever with significant bacteriuria and pyuria in children with undocumented sources of infections must be presumed to be symptoms of pyelonephritis, an invasive infection of the renal parenchyma requiring prompt treatment. Recent studies using renal parenchyma - avid nuclear scans to determine the presence of urinary tract infection have revealed that more than 75% of children under 5 years of age with febrile urinary tract infection have pyelonephritis.1, 2, 3

Pyelonephritis leads to renal scarring in 27% to 64% of children with urinary tract infections in this age group, even in the absence of underlying urinary tract abnormalities.4, 5

Most urinary tract infections that lead to scarring or diminished kidney growth occur in children younger than 4 years of age especially among infants in the first year of life.2, 5

Among children under 3 years of age with recurrent urinary infections, putting them at higher risk for renal scarring, as many as one-third being asymptomatic.6

It is essential to identify urinary tract infections in febrile children and institute prompt treatment to reduce the potential for lifelong morbidity.

The present study is undertaken to estimate the prevalence of urinary tract infection in febrile children less than 5 years of age and to determine the validity of urine routine microscopy in febrile children visiting KVG Medical College Hospital, Sullia. 6.2 Review of literature : Infection of the urinary tract is identified by growth of a significant number of organisms of a single species in the urine, in the presence of symptoms. Certain terms commonly used in the evaluation and management of children with UTI as per IAP recommendations are mentioned in table 1. 7 TABLE- 1

Colony count of >105/ml of a single species in a Significant bacteriuria midstream clean catch sample Asymptomatic Presence of significant bacteriuria on two or more bacteriuria specimens in a child with no symptoms. Recurrent UTI Second attack of UTI Presence of fever >38.5ºC, toxicity, persistent Complicated UTI vomiting, dehydration and renal angle tenderness. UTI with low grade fever, dysuria, frequency, urgency Simple UTI but none of the above symptoms.

The detection of significant numbers of pathogenic bacteria from culture of the urine has remained the gold standard for the diagnosis of urinary tract infection since Kass defined >105 CFU /ml of a single pathogenic bacterium isolated from urine culture as being significant in children with pyelonephritis or asymptomatic bacteriuria.8

A cross sectional study done by Shaw and Gorelick in 1999 reported , the prevalence rates of urinary tract infection in febrile infants in the emergency department as approximately 3-5% with higher rates for white girls, uncircumcised boys, and those without another potential source of fever.1 Fallahzadeh et al (1999) estimated prevalence of urinary tract infections in preschool children and reported a prevalence of 4.4%.9 Roberts K et al (1983) studied 193 febrile children less than 2 years and reported a prevalence of urinary tract infection as 4.1%. The prevalence of urinary tract infection in febrile girls was 7.4%.10 Bauchner et al in 1987 evaluated the frequency of urinary tract infection in 664 febrile children younger than 5 years of age and reported the prevalence as 1.7%.11 According to Hoberman et al (1993) the prevalence of urinary tract infection in febrile infants was 5.3% and the prevalence in infants less than 2 months was 4.6% and in infants with no suspected urinary tract infection, with associated other illnesses the prevalence was 5.1%.12

Dharnidharka et al (1993) reported the overall prevalence rate of Urinary Tract Infection to be 5.4% in febrile infants.13 According to P.R. Srivaths et al (1996) the prevalence rate of Urinary Tract Infection in children less than 2 years was 2.48% which is the lowest reported from a developing country and is similar to the prevalence rates reported from developed countries.14

The prevalence of urinary tract infection varies with age. During the 1st year of life, the male: female ratio is 2.8: 5.4: 1. Beyond 1-2 years, there is a striking female preponderance, with a male: female ratio of 1:10.15

In boys most urinary tract infections occur in the first year of life. Approximately 3-5% of girls and 1% of boys acquire a urinary tract infection. In girls, the average age at the first diagnosis is 3 years, which coincides with the onset of toilet training. 15

A careful urinalysis, on a fresh midstream urine sample, can identify children with a high likelihood of a urinary tract infection. Several rapid screening tests are commonly used. Urinalysis may show leukocyturia, bacteria on gram stain, mild proteinuria, positive leukocyte esterase and nitrite test by dipstick. The presence of >5 leucocytes/ high power field in a centrifuged sample or >10 leukocytes / mm3 in an uncentrifuged sample is suggestive of urinary tract infection. The most accurate method of measuring pyuria is to measure urinary leucocyte excretion. An excretion rate of 4,00,000 leukocytes / hour or greater correlates with symptomatic urinary tract infection.16

Jenkins et al determined that uncentrifuged gram-stained urine that revealed atleast one organism per oil immersion field correlated with >105 CFU / ml urine with sensitivity and specificity of almost 90%.17 Both Gram stain and dipstick analysis for nitrite and leucocyte esterase perform similarly in detecting UTI in children and are superior to microscopic analysis for pyuria.18 The analysis of urine samples obtained by catheter for the presence of significant pyuria (≥10 white blood cells/mm3) can be used to guide decisions regarding the need for urine culture in young febrile children.19

6.3 Objectives of the study:

1. To determine the prevalence of urinary tract infection in febrile children less than 5 years of age.

2. To determine the validity of routine urine microscopy in febrile children visiting KVG Medical College Hospital, Sullia.

MATERIALS AND METHODS 7.1 Source of data- Febrile children less than 5years attending the outpatient department or admitted in K.V.G. Medical College and Hospital, Sullia over a period of 12 months will be included in the study. 7.2 Method of collection of data Definition: 1. Febrile Child: Children with history of fever (Temperature; rectal ≥38.3°C or axillary temperature ≥37.8°C). 2. Urinary Tract Infection: Urinary tract infection is defined as growth of a significant number of organisms of a single species in the urine, in the presence of symptoms. Significant bacteriuria is growth with a colony count of >105/ml of a single species in a mid - stream clean catch urine sample.

Febrile children less than 5 years attending outpatient department or admitted in KVG Medical College Hospital Sullia will be submitted to preliminary screening interview to suspect urinary tract infection. Children with symptoms suggestive of urinary tract infections will be enrolled and interviewed using structured questionnaire for urinary tract infection. All symptomatic children will be referred for urine routine microscopy and culture tests.

7.3 COLLECTION OF URINE SAMPLE

From all 200 cases a sample of urine will be collected. In children less than 2 years of age urine will be collected by a bag and in others midstream sample will be collected.

Inclusion criteria : 1. All febrile children between1month to 5years. 2. Fever {rectal ≥38.3°C or axillary temperature ≥37.8°C}. Exclusion criteria :

1. Children below 1month and above 5 years. 2. Any child who has received antibiotics 48 hours prior to evaluation will not be included in the study.

3. Children with known congenital genitourinary anomalies.

4. Parents/guardians not willing to enrol the child in the study.

Study design : Cross sectional study Sample Size : Sample size of 200 estimated with population prevalence 4.4% and absolute precision 3%. Hence the 200 febrile children attending outpatient department or admitted in Department of Pediatrics KVG MCH Sullia constitute the study population.

Analysis Of Data: The data will be analyzed on SPSS version 15 software. Data will be analyzed with appropriate statistical tests at 5% level of significance.

Follow up : Nil

Follow up period : Nil

7.3 Does the study require any investigations or interventions to be conducted on patients or other humans or animals? If so please describe briefly. Yes Urine analysis with urine routine microscopy and urine culture is required to diagnose Urinary tract infection.

7.4 Has ethical clearance been obtained from your institution in case of 7.3?

Yes 8. BIBLIOGRAPHY

1. Shaw KN, Gorelick MH. Urinary tract infection in the pediatric patient. Pediatric clinics of North America 1999; 46: 6.

2. Benador D, Benador N, Siosman DO, Nussle D, Mermillod B, Girardin E.Cortical scintigraphy inthe evaluation of renal parenchymal changes in children with pyelonephritis. J pediatr 1994; 124:17-20.

3. Majd M, Rushton HG, Jantausch B, Wiedermann BL. Relationship among Vesicoureteral reflux, P-fibrinated Escherichia coli and, acute pyelonephritis in children with febrile urinary tract infection. J Pediatr 1991; 119: 578-85.

4. Rushton HG, Majd M, Jantausch B, Wiedermann BL, Belman AB. Renal scarring following reflux and non reflux pyelonephritis in children: Evaluation with 99m technetium- dimercaptosuccinic acid scintigraphy. J Urol 1992; 147: 1327-32.

5. Berg UB. Long term follow-up of renal morphology and function in children with recurrent pyelonephritis. J Urol 1720; 148: 1715-20.

6. Cohen M. Urinary tract infections in children: Females aged 2 Through 14, first two infections. Pediatrics 1972; 50:271-78.

7. Recommendations on management of urinary tract infections. Indian Pediatr J 2001;38:1106-15

8. Kass EH. Bacteriuria and the Diagnosis of infections of the urinary tract. Arch Intern Med 1957; 10: 709.

9. Fallahzadeh MH, Alamdarlu HM. Prevalence of urinary tract infection in preschool febrile children. Irn J Med Sci 1999; 24: 35-39

10. Roberts KB, Charney E, Sweren RJ, Ahonkhai VI, Bergman DA, coulter MP . Urinary tract infection in infants with unexplained fever: A collaborative study. J Pediatr 1983; 103: 864- 67.

11. Bauchner H, Philipp B, Dahefsky B, Klein JO. Prevalence of bacteriuria, in febrile children. Pediatr Infect Dis 1987; 6:239-42.

12. Hoberman A, Chao HP, Keller DM, Hickey R, Davis HW, Ellis D. Prevalence of urinary tract infection in febrile infants. J Pediatr 1993; 123: 17-2 13. Dharnidharka VR. Prevalence of bacteriuria in febrile infants. Indian Pediatr 1993; 30: 981- 86.

14. Srivaths PR, Rath B, Krishan prakash S, Talukdar B . Usefulness of screening febrile infants for urinary tract infection. Indian Pediatr 1990; 33: 218-20.

15. Jack Elder S: Urologic disorders in infants and children. Richard EBehrman, Kleigman RM, Jenson HB, (eds): Nelson textbook of Pediatrics, Harcourt and Saunders 2000; 1621-22.

16. Little PJ. A comparison of urinary white cell count with the white cell excretion vale. Br J Urol 1964; 36: 360.

17. Jenkins RD, Fenn JP, Matsen JM. Review of urine microscopy for bacteriuria. JAMA 1986; 255:3397.

18. Marc Gorelick H , Kathy Shaw N. Screening Tests for Urinary Tract Infection in children: A Meta-analysis .Pediatrics 1999; 104(5):54.

19. Hoberman, Alejandro, Wald, Ellen R, Reynolds, Ellen A. RN et al. Pediatr Infect Dis J 1996; 15(4): 304-9 SIGNATURE OF THE CANDIDATE:

REMARKS OF THE GUIDE : Recommended

Dr. EDWIN DIAS NAME AND DESIGNATION OF THE DCH, MD, DNB. GUIDE: Professor and HOD ETHICAL COMMITTEE CLEARANCE Department of Pediatrics, K.V.G. Medical college, Sullia 1.TITLE OF DISSERTATION PREVALENCE OF URINARY TRACT INFECTION IN FEBRILE CHILDREN LESS SIGNATURE OF THE THAN FIVE YEARS OF AGE GUIDE:

2.NAME OF THE Dr. EDWIN DIAS CANDIDATE Dr SIDDU. CHARKI HEAD OF THE DEPARTMENT: DCH, MD, DNB. Professor and HOD 3. NAME OF THE GUIDE Dr EDWIN DIAS Department of Pediatrics, K.V.G. Medical college, Sullia 4. APPROVED / NOT

APPROVED SIGNATURE OF THE HEAD OF THE DEPARTMENT:

REMARKS OF PRINCIPAL:

SIGNATURE Sri KRISHNAMURTHY, Chairperson.

Dr. SUBBANNAYYA KOTIGADDE, Secretary.

Dr. S. GOPALRAO , Member

Dr. C.S.MOHANRAJ , Member

Dr. H.R.SHIVAKUMAR , Basic scientist

LAW EXPERT : Sri KRISHNAMURTHY , Advocate

PRINCIPAL

K.V.G. Medical College and Hospital, Sullia.