From the Department of Pediatrics, School of Medicine, Morehouse University, Atlanta, GA.
Division of Pediatric Infectious Diseases, School of Medicine, Emory University, Atlanta, GA.
Pediatr Infect Dis J. 2020 Mar;39(3):211-216. doi: 10.1097/INF.0000000000002531.
Urinary tract infections (UTI) are the most common bacterial infections among infants and young children with fever without a source. Extended-spectrum β-lactamases (ESBLs) have emerged as emerging cause of UTI globally; however, data about risk factors and clinical features of children with ESBL-UTI have been scarce.
To describe the predisposing risk factors, clinical and microbiologic features associated with pediatric UTIs caused by ESBL-producing bacteria (ESBL-PB).
Our nested case-control study ran from January 1, 2012 to December 31, 2016. Pediatric patients with ESBL-PB UTI were compared with patients with non-ESBL-PB UTI matched for age and year of diagnosis.
A total of 720 children were enrolled (240 cases and 480 controls). Patients with ESBL-PB UTI were more likely to have a history of prior intensive care unit (ICU) admission (22.5% vs. 12.3%, P < 0.001), at least one underlying comorbidity (19.2% vs. 5.8%, P < 0.001), prior hospitalization (47.1% vs. 32.9%, P < 0.001), exposure to a cephalosporin antibiotic within 30 days before culture (7.5% vs. 4.2%, P = 0.035), and to have cystostomy (7.9% vs. 1.5%, P < 0.001) compared with those with non-ESBL-PB UTI. Patients with ESBL-PB UTI were more likely to present with hypothermia (48.8% vs. 38.5%, P = 0.009); had significantly longer average hospital stays {8.7 days [95% confidence interval (CI): 3.2-14.3] vs. 4.0 days (95% CI: 2.5-5.5)} and were more likely to be admitted to the ICU [odds ratio (OR) 1.8; 95% CI: 1.1-2.9). Multivariate analysis determined that only having cystostomy (OR 3.7; 95% CI: 1.4-9.4] and at least one underlying comorbidity (OR 2.4; 95% CI: 1.3-4.3) were the independent risk factors for ESBL-PB UTI. All ESBL-PB isolates tested against meropenem were susceptible, majority were resistant to multiple non-beta-lactam antibiotics.
Children with underlying comorbidities and cystostomy are at higher risk for ESBL-PB UTI, but majority of ESBL cases were patients without any known risk factors. Clinical signs/symptoms and commonly used biochemical markers were unreliable to differentiate cases caused by ESBL-PB from those caused by non-ESBL-PB. Further research is needed to elucidate the conditions most associated with ESBL-PB UTIs among children to properly guide empirical therapy in patients at-risk for these infections, to improve the outcomes, and finally, to determine strategies for rational antimicrobial use.
尿路感染（UTI）是发热无明确病因的婴幼儿最常见的细菌感染。超广谱β-内酰胺酶（ESBLs）已成为全球 UTI 的新兴病因；然而，有关产 ESBL 菌导致 UTI 的危险因素和临床特征的数据仍很有限。
描述与产 ESBL 菌（ESBL-PB）引起的小儿 UTI 相关的易患危险因素、临床和微生物学特征。
我们的巢式病例对照研究于 2012 年 1 月 1 日至 2016 年 12 月 31 日进行。将 ESBL-PB UTI 患儿与年龄和诊断年份相匹配的非 ESBL-PB UTI 患儿进行比较。
共纳入 720 例患儿（240 例病例和 480 例对照）。ESBL-PB UTI 患儿更有可能有 ICU 入住史（22.5% vs. 12.3%，P < 0.001）、至少有一种基础合并症（19.2% vs. 5.8%，P < 0.001）、既往住院治疗（47.1% vs. 32.9%，P < 0.001）、在培养前 30 天内接触头孢菌素类抗生素（7.5% vs. 4.2%，P = 0.035）和行膀胱造口术（7.9% vs. 1.5%，P < 0.001）。与非 ESBL-PB UTI 患儿相比，ESBL-PB UTI 患儿更可能出现低体温（48.8% vs. 38.5%，P = 0.009）；住院时间平均明显延长[8.7 天（95%CI：3.2-14.3）vs. 4.0 天（95%CI：2.5-5.5）]，更可能入住 ICU[比值比（OR）1.8；95%CI：1.1-2.9]。多变量分析确定，仅存在膀胱造口术（OR 3.7；95%CI：1.4-9.4）和至少有一种基础合并症（OR 2.4；95%CI：1.3-4.3）是 ESBL-PB UTI 的独立危险因素。对美罗培南进行药敏试验的所有 ESBL-PB 分离株均敏感，多数对多种非β-内酰胺类抗生素耐药。
有基础合并症和膀胱造口术的儿童患 ESBL-PB UTI 的风险更高，但大多数 ESBL 病例是没有任何已知危险因素的患者。临床体征/症状和常用生化标志物不能可靠地区分 ESBL-PB 引起的病例和非 ESBL-PB 引起的病例。需要进一步研究阐明儿童中与 ESBL-PB UTI 最相关的情况，以正确指导这些感染高危患者的经验性治疗，改善结局，并最终确定合理使用抗生素的策略。
