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N ephrotic syndrome (NS) results in proteinuria of more than 3.5 g of a single Gram-negative bacillus or (b) isolation of ≥103 CFUs/
protein per day and is characterized by edema, hyperlipidemia, mL of a single Gram-positive cocci; (2) midstream clean-voided
hypoproteinemia and other metabolic disorders.1 The course of NS is specimens in symptomatic patients with isolation of ≥105 CFUs/
often complicated by frequent relapses, steroid resistance, thrombosis mL of a single organism and (3) midstream specimens in sympto-
and infections.2 The common infections seen in NS are pneumonia, matic patients with ≥103 CFUs/mL of a single organism.5
urinary tract infection (UTI), bacteremia, peritonitis and cellulitis.3 Of Data were expressed as mean ± standard deviation. Statisti-
these, UTI is often underdiagnosed in NS and may also be responsible cal significance was defined at a P value of 0.05 by using IBM
for poor response to steroid therapy.4 Some studies have shown that SPSS 24 version (IBM Corporation, Armonk, NY).
UTI is the most common infectious complication of NS.5,6 However,
some others suggest that the incidence of UTI is low in the first episode RESULTS
and higher following the relapses in NS.7–10 The aim of this retrospec- During the period between January 2000 and November 2016,
tive study is to analyze the incidence of UTI, its predisposing factors the aforesaid children with NS were registered in the Nephrology Out
along with its bacterial and fungal etiologies in patients with NS. door patient department, Allahabad. Out of these 2880 children, 844
(29.3%) developed various infections (UTI: 15.00%, Lower respira-
tory tract infection: 8.33%, Upper respiratory tract infection: 4.28%,
MATERIALS AND METHODS
diarrhea: 0.59%, septicemia: 0.31%, Tuberculosis: 0.04, skin lesion:
Between January 2000 and November 2016, we retrospec- 0.21%, peritonitis: 0.55%) and the rest 2036 (70.7%) did not show
tively analyzed the data of 2880 children, under 16 years of age, any signs of infections. Out of the 844 patients, 432 (51%) patients
fulfilling all the necessary criteria required for the International developed UTI of which 363 (84.03%) developed bacterial UTI and
Study of Kidney Disease in Children suffering from NS.11 69 (15.97%) developed fungal UTI. A point to be noted, however,
These 2880 children were treated using standard Arbeitsge- was that there was no case of genitourinary tuberculosis.
meinschaft für Pädiatrische Nephrologie protocol.12 The initial epi- Their demographic and baseline data were described as fol-
sode was treated with prednisolone in doses of 60 mg/m2 daily for lows. Out of the 432 cases, the mean age of patients with UTI was
7.8 ± 2.1 years with males being about 77% and females about 23%.
Accepted for publication August 12, 2017. The mean duration of the follow-up was 16.7 months. The age and
From the *Department of Microbiologist and Immunologist, Tejas Microdiag- sex distribution in children who developed UTI were similar to the
nostics, and †Division of Nephrology, Moti Lal Nehru Medical College, control group comprising 2036 children with no infection. This is
Allahabad, Uttar Pradesh, India.
The authors have no funding or conflicts of interest to disclose.
depicted in Table 1 along with the laboratory values.
Address for correspondence: Upma Narain, DPhil, Department of Microbiolo- In our case series, the other clinical features that were noted
gist and Immunologist, Tejas Microdiagnostics, 62, Jawaharlal Nehru Road, were dysuria, fever, abdominal pain and gross hematuria. None of
Tagore Town, Allahabad, Uttar Pradesh, India 211002. E-mail: upmanarain@ the children exhibited any signs of pyelonephritis. Out of the 432
gmail.com.
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
episodes observed in all (432) children, 96 developed recurrent
ISSN: 0891-3668/18/3702-0144 episodes of UTI later on. An ultrasound was carried out for the
DOI: 10.1097/INF.0000000000001747 432 children, while a micturating cystourethrogram was performed
144 | www.pidj.com The Pediatric Infectious Disease Journal • Volume 37, Number 2, February 2018
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
The Pediatric Infectious Disease Journal • Volume 37, Number 2, February 2018 Urinary Tract Infection in Children
FIGURE 1. Spectrum of bacteria isolated from the urine of children with NS.
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Narain and Gupta The Pediatric Infectious Disease Journal • Volume 37, Number 2, February 2018
FIGURE 2. Spectrum of fungi isolated from the urine of children with NS.
has such a varied bacterial spectrum been isolated in the cases of 6. Gulati S, Kher V, Gupta A, et al. Spectrum of infections in Indian children
UTI. Fungal isolates have not been mentioned as of yet. This is the with nephrotic syndrome. Pediatr Nephrol. 1995;9:431–434.
largest series and widest etiologic review. 7. Adeleke SI, Asani MO. Urinary tract infection in children with nephrotic
syndrome in Kano, Nigeria. Ann Afr Med. 2009;8:38–41.
Out of the 432 patients that were tested, we did not find any
congenital anomaly as the causative factor for UTI and 56.2% 8. Song SN, Zhang BL, Wang WH, et al. [Spectrum and drug sensitivity of
pathogenic bacteria in children with nephrotic syndrome complicated by
episodes were asymptomatic with UTI being detected as a part urinary tract infection: an analysis of 97 cases]. Zhongguo Dang Dai Er Ke
of the screening investigation for relapse or steroid resistant. Za Zhi. 2012;14:657–660.
Patients who had developed UTI while taking steroid therapy 9. Moorani KN, Khan KM, Ramzan A. Infections in children with nephrotic
and had previously been considered as resistant became steroid syndrome. J Coll Physicians Surg Pak. 2003;13:337–339.
responsive after the eradication of UTI. All children were treated 10. Adedoyin OT, Ojuawo IA, Odimayo MS, et al. Urinary tract infections in
with antibiotics for 7 days on the basis of culture and sensitivity children with primary nephrotic syndrome and acute glomerulonephritis.
report. They were subsequently treated using oral prednisolone West Afr J Med. 2010;29:235–238.
as per Arbeitsgemeinschaft für Pädiatrische Nephrologie proto- 11. Barnett HL. International study of kidney disease in children. Nihon Jinzo
col. Hence, asymptomatic UTI may be one of the underdiagnosed Gakkai Shi. 1979;21:1141–1144.
causes of relapse in a child with NS. 12. Short versus standard prednisone therapy for initial treatment of idiopathic
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isms of UTI, although important is often left undiagnosed in chil-
13. Kliegman RM, Stanton BF, St Geme JW, et al. Nelson Textbook of Pediatrics.
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happening, children suffering from NS exhibiting relapse or 14. Arcana INP. Infeksi Saluran Kemih Pada Sindrom Nefrotik [Thesis].
those exhibiting no response toward any form of steroid therapy Semarang, Indonesia: Fakultas Kedokteran Universitas Diponegoro; 1999.
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in mind is the fact that during screening, apart from the bacte- nephrotic children. J Pediatr. 1973;82:166–167.
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