URINARY TRACT INFECTION IN FEBRILE UNDER-FIVES SEEN AT THE UNIVERSITY OF CALABAR TEACHING HOSPITAL, CALABAR, NIGERIA

Abstract

Background: Urinary tract infection (UTI) is a cause of fever in children and contributes to
morbidity and mortality. Symptoms of UTI in infants and younger children are non-specific,
but fever is almost always present. Thus, the diagnosis of UTI may be overlooked in young
children and could predispose to renal scarring and the risk of progression to hypertension
and chronic renal failure.
Objective: This study was undertaken to determine the prevalence of UTI, its aetiology,
antimicrobial susceptibility pattern of the isolates, risk factors and diagnostic accuracy of
urine dipstick in febrile under-five children seen at the Children Emergency Room (CHER)
of the University of Calabar Teaching Hospital, Calabar.
Method: One hundred and eighty-two consecutive febrile children aged between one month
and 59 months who met the inclusion criteria were recruited into the study. Each child had a
questionnaire filled for him/her and demographic data collected. A history was taken from
each child and a physical examination performed with the aim of localizing the focus of the
fever (if any). Two urine specimens were collected by the researcher, one for dipstick
urinalysis done by the researcher and the other for microscopy, culture and sensitivity done
by the researcher assisted by a Consultant Microbiologist at Microbiology Research
Laboratory. A double disc synergy test (DDST) was performed to determine extended
spectrum beta-lactamase (ESBL) production for the highly resistant P. Mirabilis isolate.
Results: Eight (4.4%) out of the 182 children had culture proven UTI. They were made up of
five males and three females given a male:female ratio of 1.7:1. The youngest patient was six
months while the oldest was 44 months. One hundred and four (57.1%) of the children were
from the upper social class. The sensitivity, specificity, positive and negative predictive
values of urine dipstick were 100%, 94.8%, 47.1% and 100% respectively. Leukocyte
esterase has sensitivity of 75% and nitrite test of 62.5%. However, nitrite test had a positive
predictive value (PPV) of 74.1% compared with 46.1% for leukocyte esterase. All the eight
isolates were Gram negative organisms, Escherichia coli (5, 62.5%), Klebsiella pneumonia
(2, 25%) and Proteus mirabilis (1, 12.5%). The P. mirabilis isolated was resistant to all
cephalosporins except cefoxitin and suspicion of an extended-spectrum β-lactamase (ESBL)
production was confirmed by detection of a positive “keyhole effect” using DDST. Majority
of the isolates (87.5%) were sensitive to gentamicin while all (100%) of the isolates were
resistant to co-trimoxazole.
Conclusion: The prevalence of UTI in under-five children was 4.4% in UCTH with a male
preponderance. The commonest isolate was E. coli and most of the organisms were sensitive
to gentamicin. A highly resistant strain of P. mirabilis with extended-spectrum beta
lactamase producing activity was among the isolates. Predictive value of dipstick urine test in
diagnosing UTI increased when both leukocyte esterase (LE) and nitrite tests were positive in
one subject.
It is recommended that gentamicin can be used as preferred choice for empirical in-patient
treatment for UTI in UCTH. Combined leukocyte esterase and nitrite dipstick test is a useful
screening test for UTI especially when urine culture cannot be done.

URINARY TRACT INFECTION IN FEBRILE UNDER-FIVES SEEN AT THE UNIVERSITY OF CALABAR TEACHING HOSPITAL, CALABAR, NIGERIA