1. Poster produced by Faculty & Curriculum Support (FACS), Georgetown University School of Medicine Resistance (%)Antibiotic P value Non E coli spp ** n=43(19%) E coli spp* n=187 (81%) ALL n= 230 (100%) 0.435 79 74 Ampicillin 0.090 50 3739Augmentin 0.002 13 36Amikacin 0.339 10 13 Ciprofloxacin 0.047 43 3033Cefotaxime 0.055 42 3033Ceftriaxone 0.004 51 3135Cefuroxime <0.001 46 18Nitrofurantoin 0.010 19 1012Gentamicin <0.001 6 01Meropenem 0.001 6 01Imipenem 0.487 41 4443Cotrimoxasole # 0.004 17 58Tazocin @ 0.679 50 4445Tetracycline 0.498 14 109Norfloxacin 0.646 31 2830Ceftazidime 0.950 27 Cefipime <0.001 16 47Colistin 0.251 6 34Levofloxacin URINARY TRACT INFECTION IN OMANI CHILDREN: ETIOLOGY AND ANTIMICROBIAL RESISTANCE. A COMPARISON BETWEEN FIRST EPISODE AND RECURRENT INFECTION. Mohamed El-Naggari 1, Sharef Waadallah 2, Dana Al Nabhani 1, Fatma Rabah 1 Zakaria Al Muharrmi 3, Ibtisam El Nour 1. Abstract Sultan Qaboos University Hospital; Pediatric Nephrology (1), General pediatric. (2) Sultan Qaboos University ; Microbiology Department. (3) Muscat; Sultanate Of Oman. Corresponding Author: mnaggari@yahoo.com ; mnaggari@squ.edu.om. Introduction Conclusions References 1. Hoberman A, Charron M, Hickey RW, Baskin M, Kearney DH, Wald ER. Imaging studies after a first febrile urinary tract infection in young children. N Engl J Med 2003; 348:195-202. 2. Livermore DM,Pearson A. Antibiotic resistance: location, location, location.Clin Microbiol Infect 2007; 2: 6-17. 3. Magliano E, Grazioli V, Deflorio L, Leuci A, Mattina R, Romano P, et al. Gender and Age-Dependent Etiology of Community-Acquired Urinary Tract Infections. ScientificWorldJournal. 2012; 2012: 349597. 4. Ghorashi Z, Ghorashi S, Soltani-Ahari H, Nezami N. Demographic features and antibiotic resistance among children hospitalized for urinary tract infection in northwest Iran. Infect Drug Resist 2011;4: 171–176. 5. Subcommittee on Urinary Tract Infection, Steering Committee on Quality Improvement and Management, Roberts KB. Urinary tract infection: clinical practice guideline for the diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months. Pediatrics 2011; 128: 595-610. Results Urinary tract infection (UTI) is a common cause of fever and one of the most common community-acquired infections. Due to possible complications of upper UTI (pyelonephritis) such as renal scarring, hypertension, and end-stage renal disease, treatment with proper antibiotic is a crucial step of management. (1) Different organisms can be the cause of UTI in children, with resistance to antibiotics becoming a significant problem in the choice of treatment. Frequent use of wide-spectrum antibiotics may change the intestinal flora, and as a consequence, induce bacterial resistance. Regular surveillance of local uropathogens as well as their antibiotic susceptibility is considered useful to guide empirical therapy, as the prevalence of uropathogens and their features may vary according to the time and geographical area. (2) Worldwide studies have documented the prevalence of uropathogens in different countries. (3,4) However, there is no previous study documenting the incidence of different uropathogens in Oman. In this study, we aim to report the most common uropathogens, and their antibiotic sensitivity pattern, in children presented with first and recurrent UTI, at a tertiary hospital in Oman. In addition, we aim to describe the clinical presentation and laboratory evaluation in those children. E.coli and ESBL were more common in recurrent UTI, while K.pneumonia were found more in first-UTI. Meropenem, Imepenem, Amikacin, and Piperacillin/Tazobactam can be used as a first line, while Cefotaxime and Ceftriaxone cannot be used in both groups. Our report shows high resistance rates to Ampicillin, Cefuroxime, and Amoxicillin/Clavulanate. First-generation cephalosporin is not recommended for use as empiric therapy. We recommend the use of Nitrofurantoin as empiric treatment in both UTI groups. A retrospective analysis of all Omani children with the first documented or recurrent UTI, who presented to Sultan Qaboos University Hospital (SQUH) over 4 years duration between September 2008 and August 2012. All patients below 14 years of age with positive urine culture were evaluated for inclusion in the study. Exclusion criteria included: patients with neurological impairment (bed ridden patients), immune deficiencies and hematological malignancies, as these patients might have recurrent UTI or recurrent exposure to antibiotics which may affect the antibiotic resistance pattern. Patients with deficient data were also excluded from the study. Clinical and laboratory characteristics during presentation with the UTI were collected for each patient. These included age, gender, clinical presentation such as fever, chills, decreased activity, nausea and/or vomiting, abdominal pain, poor feeding, constipation, frequency or urination, dysuria, flank pain, secondary enuresis, gross hematuria and foul-smelling urine. Laboratory results during the episode of UTI included presence of leukocytosis, neutophilia, high CRP, as well as the identified uropathogen and its antibiotic sensitivity. Urine culture method: In clean catch samples, significant bacteriuria was defined as growth of ≥100,000 colony forming units (CFU)/mL of a single uropathogenic bacteria. In catheter urine samples, we defined significant bacteriuria as growth of ≥50,000 CFU/mL of a single uropathogenic bacteria. (5) Data was entered in SSPS. Analysis included the distribution of UTI among different age group and gender categories. Different uropathogens causing UTI and their antibiotic sensitivity were reported. Descriptive statistics were used including frequencies and percentages for categorical variables, in addition to mean (± standard deviation) or median (and interquartile ratio IQR) for numerical variables. Differences between different groups were analyzed using Chi-squared (χ2) test or student’s t-test and Wilcoxon-Mann-Whitney test as appropriate. An a priori two-tailed level of significance was set at 0.05. Table 1: Incidence and comparison between uropathogens in patients with recurrent UTI and single UTI (n=405) Table 2: Percentage of antibiotic resistance of the isolated uropathogens in patients with recurrent UTI (n=230) * 16 out of the 271 isolated E coli (9%) were ESBL. # Cotrimoxasole = Trimethoprim/Sulfamethoxazole @ Tazocin = Piperacillin/Tazobactam Urinary tract infection (UTI) is common in infants and children, and Escherichia coli (EC) is the leading pathogen. The aims of this study were to compare first episode of UTI with recurrent infection, reveal organisms that cause UTI, uropathogen resistance, and presence of bacteria producing extended-spectrum β-lactamase (ESBL). A retrospective study included Omani children with any documented UTI presented to SQUH between September 2008 and August 2012. Comparison was made between both groups using Chi-squared (χ2) test as appropriate. The first-UTI group included 175 children. EC was the leading pathogen (69%), Klebsiella pneumonia (17%;P<0.001), and ESBL (3%). 230 isolated uropathogens from 74 patients with recurrent UTI. The most common isolated pathogen was EC 187 (81.3%; P<0.001), followed by K.pneumonia 12 (5.1%), and ESBL (7%; P=0.042). Overall resistance to IV antibiotics was less evident than oral antibiotics, with least resistance to Meropenem and Imepenem (1% each). Higher resistance was found in recurrent UTI to Augmentin, Cefuroxime, Ceftriaxone, Cefotaxime. Oral Nitrofurantoin showed least resistance in first and recurrent UTI, but increased in non- E.Coli uropathogens. E.coli and ESBL were more common in recurrent UTI, while K.pneumonia were found more in first-UTI. Meropenem, Imepenem, Amikacin, and Piperacillin/Tazobactam can be used as a first line, while Cefotaxime and Ceftriaxone cannot be used in both groups. Our report shows high resistance rates to Ampicillin, Cefuroxime, and Amoxicillin/Clavulanate. First- generation cephalosporin is not recommended for use as empiric therapy. We recommend the use of Nitrofurantoin as empiric treatment in both UTI groups. Methods P Value Single UTIRecurrent UTI Uropathogens 0.001120 (69%)187 (81%)Escherichia coli, n(%) <0.00130 (17%)12 (5)Klebsiella pneumonia, n(%) 0.0425 (3%)17 (7%)ESBL, n(%) 0.6257 (4%)7 (3%)Enterococcus, n(%) 0.4762 (1%)5 (2%)Pseudomonas, n(%) 0.6815 (3%)5 (2%)Proteus, n(%) 1.0003 (2%)4 (2%)Enterobacter, n(%) 0.2600 (0%)3 (1%)Coliform, n(%) 0.1724 (2%)1 (0.5%)Staphylococcus, n(%) 0.3223 (2%)1 (0.5%)Citrobacter, n(%) P value Single episode UTI (n=175) Recurrent UTI (n=230) Medical history <0.001 4 years (IQR 1 - 7) 7 years (IQR 3.9 - 9) Age, median (IQR) 0.26473% 80% Female ratio * <0.001 0.059 88 (50%) 38.7 (±0.8) 57 (25%) 38.4 (±0.7) Fever, n (%) Degree of temperature in febrile patients, Mean (± SD) 0.001 0.306 11 (6%) 3 (2%) 1 (0.4%) 8 (4%) Fever > 40 degrees, n (%) Chills, n (%) <0.00170 (40%)25 (11%) Nausea and/or Vomiting, n (%) <0.00151 (29%)31 (14%) Nonspecific abdominal pain, n (%) 0.77545 (26%)57 (25%) Frequency, urgency, dysuria, n (%) 0.00920 (11%)13 (6%) Reduced food intake/Poor feeding, n(%) <0.00121 (12%)6 (3%) Decreased activity, n (%) 0.5707 (4%)11 (5%) Flank pain, n (%) 0.0138 (5%)28 (12%) Secondary enuresis, n (%) 0.4396 (3%)5 (2%) Gross hematuria, n (%) 0.3557 (4%)19 (8%) Foul-smelling urine, n (%) 0.6006 (3%)11 (5%)Constipation, n (%) Table 4: Comparison of presenting clinical features between patients with recurrent UTI versus those with single UTI (n=405) Laboratory Finding Recurrent UTISingle UTI P value WBC ( In 131 patients) Leukocytosis *, n (%) WBC (x10^9/L), range WBC (x10^9/L), mean (±SD) (n=95) 31 (33%) 3-29 12.6(±5.4) (n=131) 31 (24%) 2-31 11.9(±5.7) 0.353 ANC (In 131 patients) (x10^9/L) Neutrophilia *, n (%) Neutrophil count, range Neutrophil count, mean (±SD) (n=95) 32 (34%) 1-19 7.1 (±4.8) (n=131) 38 (29%) 1-24 6.2 (±4.7) 0.508 CRP (In 73 patients) High CRP **, n (%) CRP range CRP count (mg/L), median (IQR) (n=61) 43 (71%) 1-344 24 (5-85) (n=73) 51 (70%) 2-319 24 (3-99) 0.573 P Value Single UTI – E.C. (n=120) Recurrent UTI - E.C. (n=187) Antibiotics 0.6897674Ampicillin 0.0192437Augmentin 0.08503Amikacin 0.2631813Ciprofloxacin 0.0141830Cefotaxime 0.0141830Ceftriaxone 0.0291931Cefuroxime 0.61621Nitrofurantoin 0.4731110Gentamicin NA00Meropenem 0.0315044Cotrimoxasole # 0.13825Tazocin @ Table 3: Comparison between AB resistance of Escherichia coli isolated from patients with recurrent UTI versus those with single UTI. (n=307) Table 5: Comparison of laboratory findings between patients with recurrent UTI and those with single UTI (n=226). Children with positive urine culture n= 438 Children with positive urine culture at SQUH n=438 Patient with first episode UTI n= 175 Patient with recurrent UTI n=230 33 patient were excluded: 11CNS disability 9 Hemat. Malignancy 3 immune deficiency Figure 1: Flowchart and demographics of children with urinary tract infection (UTI)