Table 2
The frequency of BMI classesof children with AP within different gender and age groupsa
BMI group
|
Gender
|
Total
|
Age group
|
Total
|
Girl
|
Boy
|
< 1 yr old
|
1-5 yrs old
|
> 5 yrs old
|
Underweight
|
13 (12.50)
|
2 (1.92)
|
15 (14.42)
|
2 (1.92)
|
5 (4.81)
|
8 (7.70)
|
15 (14.42)
|
Normal
|
59 (56.72)
|
4 (3.86)
|
63 (60.58)
|
23 (22.11)
|
17 (16.34)
|
23 (22.12)
|
63 (60.57)
|
Overweight
|
16 (15.38)
|
1 (0.96)
|
17 (16.34)
|
6 (5.77)
|
9 (8.66)
|
2 (1.92)
|
17 (16.35)
|
Obese
|
7 (6.74)
|
2 (1.92)
|
9 (8.66)
|
5 (4.81)
|
2 (1.92)
|
2 (1.92)
|
9 (8.66)
|
Total
|
95 (91.34)
|
9 (8.66)
|
104 (100)
|
36 (34.61)
|
33 (31.73)
|
35 (33.66)
|
104 (100)
|
a Frequency was represented as: count (percentage)
|
The minimum and maximum hospitalization stay were 2 days (n = 9) and 16 days (n = 1), respectively (Table 1). In general, 75% of the patients with AP were symptomatic. A high number of girls (78.9%) in this study were symptomatic, while most boys (66.7%) were asymptomatic (Fig. 1a). This finding indicates that UTIs may occur in boys with fewer clinical symptoms, thus, this population group needs further laboratory investigations. Also, the percentage of asymptomatic children in three age groups of < 1, 1-5, and > 5 years old were 47.2, 12.1, and 14.3%, respectively (Fig. 1b). Hence, asymptomatic is more common at younger ages.The symptomatology rate was increasedwith increasing age, although there was no significant difference in this index between age groups of 1-5 and > 5 years old. As 20.19% (n = 21) of the patients with AP complained of constipation, this symptom can be considered as a risk factor for UTIs. Fever as the main inclusion criteria for all the patients averagely was at 39.4°C at the admission time, while the minimum and maximum fever degrees were 38.5 and 41.0°C, respectively.The shortest and longest fever durations before the treatment were 1 day (n = 10) and 7 days (n = 6), respectively (Table 1). Although the duration of the child's fever before starting the antimicrobial therapy does not play a role in confirming or rejecting a UTI, a delay in beginning the treatment can significantly have consequences likeRS. Three cases did not show any fever after the treatment, while fever in the two other cases continued for up to five days after treatment, showing a necessity to change the used antibiotic type. Dysuria was observed among 30 patients with AP (28.84%), which shows the absence of dysuria does not rule out a UTI. Abdominal pain and vomiting were detected in 33.6% (n = 35) and 40.3%(n = 42) of the subjects, respectively(Table 4).Based on the Pearson's Chi-square analysis, there were significant associations between patients' age and symptoms of dysuria (p = 0.003) and abdominal pain (p = 0.0001).
Pyuria and hematuriaare usually defined as the presence of ≥10 WBCs/mm3and ≥5RBCs/HPFin a urine specimen,respectively. Pyuria,hematuria,and positive nitrite were respectively diagnosedin 88.46% (n = 92), 38.46% (n = 40) and 45.19% (n = 47) of urine tests of patients with AP (Table 4). As a result, not only pyuria can be one of the most important symptoms of a UTI, but also not having hematuria and urine nitrite do not rule out this disease. Fig. 1c shows that theseabnormal urinary changeswere increased by increasing the age from less than one year old to over five years old. In addition, there was a negative correlation between and eGFR and patients' age (r = 0.754, p = 0.001). Results proved that this increase in the urine nitrite (50.0%) was more evident than hematuria (36.36%) and pyuria (10.12%) (Fig. 1c). E. coli was the most frequent pathogen in urine samples (n = 96). so that this bacterium was present in samples of 59 patients (88.05%). Other bacteria such asGram-negative Bacillus(2 cases), Group-B Streptococcus (2 cases), Klebsiellapneumoniae(1 case), Acinetobacter (1 case), Enterococcus (1 case), andStaphylococcusaureus(1 case) were observed in urine samples taken from patients less than one-year-old (Table 4).Ceftizoxime was the most common intravenous antibiotic to treat patients with AP (n = 78, 75.0%). Other used antibiotics were ceftriaxone(n = 12, 11.53%), amikacin (n = 7, 6.73%), cefotaxime (n = 2, 1.92%), cefepime (n = 2, 1.92%), vancomycin (n = 1, 0.96%), meropenem (n = 1, 0.96%), and gentamicin (n = 1, 0.96%) (Table 4). Patients receiving two antibiotics of vancomycin and meropenemhad abnormal ultrasound results. But, the administration of other antibiotics led to more normal sonographic findings. The Pearson's Chi-square analysis also showed that there were significant correlations betweengender andantibiotic type (p = 0.0001) and hospitalization stay (p = 0.001). Thus, a proper choice of used antibiotic can significantly reduce fever degree and duration, and subsequently, hospitalization stay in children with AP.
Overall, the ESR and CRP values had recorded for 91 and 99 patients with AP, respectively. The minimum, mean, and maximum levels of ESR and CRP were 3 mm/h and 1 mg/L, 46.5 mm/h and 58.7 mg/L, and 108 mm/h and 118 mg/L, respectively (Table 1). The elevated ESR (>10 mm/h) and CRP (> 10 mg/L) levels [23] were observed among 84 (92.30%) and 82 (82.82%) patients, respectively. Therefore, only 7 and 17 patients had an ESR and CRP within a normal range. Accordingly, high amounts of these hematological factors may be effective in the diagnosis of patients with AP. The minimum, mean, and maximum amounts of BUN and SCr were 5 and 0.05 mg/dL, 11.31 and 0.057 mg/dL, and 62 and 2.4 mg/dL, respectively. Also, the minimum and maximum eGFR amounts respectively were 17.2 and 134 mL/min/1.73 m2, while the average value of this index was calculated to be 68.9 mL/min/1.73 m2 (Table 1). Also, the lowest, average, and highest values of WBCs and Hb were 3.6/mm3and 7.6 ng/mL, 14.9/mm3and 11.02 ng/mL, and 34/mm3and 14.7 ng/mL, respectively (Table 1). The leukocytosisand anemia frequency in the studied population was 81.7% (n = 85) and 36.5% (n = 38), respectively. The mean Na and K amounts in blood samples were 140.7 and 4.36 mEq/L, respectively. The lowest and highest values of Na and K were 131 and 3.5 mEq/L, and 152 and 5.8mEq/L, respectively (Table 1).
In general, 67.3% of patients had normal sonographic examinations.Sonographic findings showed that the presence of hydronephrosis, cystitis, and renal anomalies in 22 (21.15%), 9 (8.65%), and 2 (1.92%) patients with AP, respectively (Table 4). However, none of the patients showed ureteral stones on their ultrasound images. Consequently, hydronephrosis was the most common abnormality in the kidney and urinary tract ultrasonography. Since sonography results of 70 patients (67.30%) were not in favor of pyelonephritis, this diagnosis alone cannot be a valid diagnosis technique for this disease.
Table 3
A summary of urine markers, clinical complications, and ultrasound findings of children with AP
Findings
|
Observed
|
Non-observed
|
Frequency (n)
|
Percentage (%)
|
Frequency (n)
|
Percentage (%)
|
Urine marker
|
|
Pyuria
|
92
|
88.46
|
12
|
11.54
|
Hematuria
|
40
|
38.46
|
64
|
61.54
|
Positive nitrite
|
47
|
45.19
|
57
|
54.81
|
Clinical complication
|
|
|
|
|
Abdominal pain
|
35
|
33.65
|
69
|
66.35
|
Constipation
|
21
|
20.19
|
83
|
79.81
|
Dysuria
|
30
|
28.84
|
74
|
71.16
|
Vomiting
|
42
|
40.38
|
62
|
59.62
|
Ultrasound
|
|
Hydronephrosis
|
22
|
21.15
|
82
|
78.85
|
Cystitis
|
9
|
8.65
|
95
|
91.35
|
Stone
|
0
|
0.00
|
104
|
100
|
Anomaly
|
2
|
1.92
|
102
|
98.08
|
Table 4
The type of identified pathogens and used antibiotics to treat 104 children with AP
Pathogen type
|
Frequency (n [%])
|
Antibiotic therapy type
|
Frequency (n [%])
|
Escherichia coli
|
96 [92.30]
|
Ceftizoxime
|
78 [75.0]
|
Gram-negative Bacillus
|
2 [1.92]
|
Ceftriaxone
|
12 [11.53]
|
GroupB Streptococcus
|
2 [1.92]
|
Amikacin
|
7 [6.73]
|
Acinetobacter
|
1 [0.96]
|
Cefotaxime
|
2 [1.92]
|
Enterococcus
|
1 [0.96]
|
Cefepime
|
2 [1.92]
|
Klebsiella
|
1 [0.96]
|
Vancomycin
|
1 [0.96]
|
Staphylococcus aureus
|
1 [0.96]
|
Meropenem
|
1 [0.96]
|
|
|
Gentamicin
|
1 [0.96]
|