However, may incur adverse consequences, the pediatric UTI, cases are often under-diagnosed or neglected due to non-specific clinical presentations and of clinical practice—relying upon in-vitro culture report. Therefore, a precise diagnosis is crucial for clinical management. In this perspective, our study underscores the insufficiencies in SUC protocol in detecting significant etiologies, possibly MDR and XDR isolates, and advocates for a slight modification concerning the sample volume being inoculated.
Among the study population, the incidence of urinary tract infection was 16.14%; where E. coli (68.5%) was the commonest pathogen. The analogous rates have been reported earlier from neighboring hospitals(5)(4)(6)and studies of other nations(9)(10). Alongside, significantly more females(72.0%) were found with UTI substantiating with other similar studies(5)(6). The children of the age group 1-4 years were more prone to the infection. Our premise is comparable to findings conducted in a nearby hospital where less than six years were high-risk age categories(6)(4). The immune status, sanitation, and ascending infection with fecal flora possibly are the reasons behind for such upshots in this age group.
The EQUC technique, a simple but effective technique, was embraced to determine the uropathogen and its resistant pattern in the clinically suspected UTI children. The same technique was applied to the women experiencing UTI like symptoms, before(3). As reported “no growth” with the standard urine culture protocol, EQUC detected all possible etiologies, contributing UTIs. Of total 92 detected cases as UTI, 73 were isolated with SUC, conceding 20.6% being missed. Similar findings comparing supremacy to EQUC parallels with our findings; however, the study population was clinically suspected women with UTI.
Among 69 E. coli isolated, highest resistance (77% each) were attributed to ampicillin followed by ciprofloxacin (65.07%). Our findings are nearly similar as observed by Parajuli et al.(87%) to ampicillin and (78%) to ciprofloxacin. Likewise, our findings are coherent, regarding resistance trend of the isolate against ampicillin and ciprofloxacin, to that of Ansari et al. (74%) and (77%); the age-group of study subjects was different, however(11). The isolate, E. coli, found resistant to cefixime (22.2%) and ceftriaxone (22.2%). Among antimicrobials tested, colistin(100%), imipenem (nearly 99%) were sensitive. Therefore, a second and third-generation cephalosporin (cefixime and ceftriaxone) could be choices; polymyxin (colistin) and carbapenem (imipenem) could better be opted-in treating childhood UTI.
The etiology, Staphylococcus aureus, in pediatric UTI is commonly associated as acquired infection preceding from in-dwelling catheters or other devices(12). Of 7 isolates of Staphylococcus aureus, 5 were recovered from the patient after catheterization; 2 of the isolates were resistant to ampicillin and cotrimoxazole; while one each found resistant to ofloxacin, cloxacilline, cefoxitine, cephalexine and nitrofurantoin. The single isolate was Methicillin-resistant Staphylococcus aureus(MRSA); as reported by some authors in pediatric population (13)(14).
The uropathogens (Candida albicans, Provedencia retegerii, and Morganella morganii) were isolated with EQUC while missed on SUC; although, these pathogen are cited, as the significant etiologies contributing childhood UTI (15)(16)(17)(18). Hence from our study, it can be clinched that each uropathogen, possibly significant causative agent, may have its’ own unique threshold bacterial load, concerning the volume to be inoculated on culture media.
Apart from these, our study underscores 5.5% of ESBL, 12.6% MDR, and 1.4% of XDR isolates were about to be missed if only SUC has opted. In this study, MDR and XDR isolates were found 56.5% and 1.4% respectively while 46% of uropathogen were found ESBL. Nevertheless, an increasing pattern of resistance trend in uropathogen, along with MDR rates has been reported, among pediatric isolates, from Nepal (19)(6)(5). The level of drug-resistant uropathogen among the children in this study is of serious concern; nevertheless, the exact figures with exact anti-microbial resistance status (that possibly missed with SUC) were not analyzed before.
In most developing countries and Nepal, the higher antimicrobial burden preceding inapt therapeutic guidelines for pediatric patients might be attributable to this intimidating scenario(4)(6)(5). Existing higher rates of ESBL, MDR, and XDR; necessitates the use of carbapenem, colistin, tigecycline, and other mono-antimicrobial therapies (cephamycins, fosfomycin and nitrofurantoin); however, the resistance to these potent therapeutic options may not be stood robust till longer against the emerging MDR strains (11)(20)(21)(22)(23).