Late onset jaundice and urinary tract infection in neonates
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《美国医学杂志》
Al Zahra Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
Objective. To determine the prevalence and the associated parameters of urinary tract infection (UTI) in infants with late onset jaundice. Methods. This prospective analytic study was conducted among 400 cases, selected by simple sampling from neonates with late onset jaundice admitted in two referral hospitals of Isfahan during a 9-month period. The information including the age, sex and feeding type, as well as the results of physical examination, treatment, radiology studies, etc were recorded. The etiology of jaundice was assessed by laboratory tests. Urine analysis and urine culture were performed for all subjects. XZ and t-test were used for analysis of the data in- SPSS software. Results. Of the 400 icteric neonates, 147 (36.8%) were female and 253 (63.3%) were male ; 23 (5.8%) were diagnosed to have UTI, 5 cases (1.3%) had G6PD deficiency, 19 (4.8%) had dysmorphic red blood cell and 3(0.75%) had ABO or RH incompatibility. The relation between the type of feeding, circumcision and UTI was significant (P<0.05). Of the 23 neonates with UTI,4 cases (17. 39%) were found to have urogenital abnormality. Conclusion. UTI was found in 5.8% of infants with late onset jaundice. The study revealed significant association between breast feeding, circumcision and lower prevalence of UTI in icteric neonates. It is suggested that evaluation for UTI should be considered as a screening test in all cases of neonatal late onset jaundice.
Keywords: Urinary tract infection; Late onset jaundice; Neonate
Urinary tract infection (UTI) is the most common disease of the urogenital system and one of the most important bacterial infections in the pediatric age group.[1],[2],[3] Its incidence varies from 0.1 to 1% among neonates.[2],[4] and from 5 to 11% among febrile infants aged less than 8 weeks.[5] In the first 3 months of life, it is more prevalent in males,[1],[4],[10] especially in the uncircumcised ones.[1],[2],[6],[10],[11],[12]
In infants, the clinical presentations of UTI varies from non-specific sign and symptoms such as poor weight gain, vomiting , fever, poor feeding and jaundice to severe illness.[1],[11],[12] The major clinical presentation of UTI among young infants is acute pyelonephritis. Between 30 to 55% of infants with UTI are reported to have urinary tract congenital abnormalities, of which vesicouretral reflux is the most common.[13],[14],[15],[16]
Some investigators have suggested that unexplained hyperbilirubinemia in newborns may be associated with bacterial infection especially UTI, but the current scientific guidelines, e.g. that of the American Academy of Pediatrics (AAP) do not recommend any evaluation for UTI among infants with late onset hyperbilirubinemia.[17] This is study aimed to determine the prevalence and the associated parameters of UTI in infants with late onset jaundice.
Material and Methods
In this prospective study, conducted from July 2001 to February 2002, 400 neonates with late onset jaundice were selected by simple sampling from among the patients admitted to the two major referral hospitals for neonatal care in Isfahan, the second large city in Iran. All premature neonates were excluded from the study. Clinical jaundice was defined as any yellow or yellow green discoloration of the skin, mucus membranes and or sclera that prolonged for more than 7-10 days.
The age, sex and the type of feeding of the neonates, findings of the physical examination, e.g., any evidence of hemolysis or cephalhematoma and circumcision, as well as the history of vomiting, abdominal distention in the neonate, and or icterus in the family members were recorded.
Blood samples were taken from all the cases and their hemoglobin (Hb), hematocrit (Hct), reticulocyte count, blood group and RH , bilirubin (direct and total), Coombs test, and G6PD level were evaluated. Urine analysis and urine culture were performed on specimens collected from clean voided urine. Suprapubic aspiration specimen was obtained if more than 10,000 bacteria were isolated, and its result was considered as positive in case of detection of any bacteria. After initial evaluation and treatment of the neonates, sonography and voiding cystourethrogram were requested in case of positive results for UTI.
The data were analyzed using SPSS soft ware. Descriptive data were reported as mean ± standard deviation, and were analyzed with XZ and t-tests. Statistical significance was defined as p value <0.05.
Results
The mean age of the neonates studied was 10.79±4.68 days. Of them, 147 (36.8%) were female and 253(63.2%) were male. All of the subjects studied had an Iranian nationality. Overall 23 out of 400(5.8%) icteric neonates were diagnosed to have UTI (based on positive urine culture). The most common (74%) bacterial pathogen was E-coli. Overall, 5 infants (1.3%) had G6PD deficiency, 19(4.8%) had dysmorphic red blood cell, and 3(0.75%) of them had ABO or RH incompatibility. Positive urine culture was less frequent in females than in males (5 vs 8, respectively, p< 0.05). From these cases, 105 males were circumcised, 2 of the circumcised and 16 of uncircumcised male neonates had UTI [Table - 1]. The mean age of infants with and without UTI was not significantly different (10.91 ± 4.66 days vs 10.6 + 4.71 days, respectively, p>0.05). No significant relationship between UTI and age, was noticed, but the relation between feeding type, circumcision and UTI was significant [Table - 2].
Imaging studies for the infected infants discovered congenital urinary tact abnormalities in 4 of 23 (17.39%) patients, which included vesicoureteral reflux, hydronephrosis and pelvic ectasis , and only one patient had abnormal voiding cystourethrogram (VCUG).
Discussion
In the present study, the prevalence of UTI among neonates with late onset jaundice was 5.8%, and the most common (74%) pathogen isolated was E-coli. These findings are consistent with some previous studies that reported a prevalence of 5 to 11% for UTI in febrile infants aged less than 2-3 months.[6] Previous investigations have documented an association between jaundice and UTI in neonatal period[18] but to the best of authors knowledge, the prevalence of UTI has not been studied in asymptomatic icteric infants.
In this study, 31 infants (7.8%) were formula -fed and 369 (92.2%) were breast- fed. Positive urine culture was significantly more frequent in formula -fed infants than in breast- fed infants (38.7% vs 3%). These results are in line with the study of Kring and Maiselse.[19] This difference is suggested to be due to the immunologic factors of the breast milk.[2],[3] This must be further studied.
Another protective factor for UTI was circumcision. In 1982, Ginsberg and mc Cracken[17] observed that 95% of 62 infant boys with UTI were uncircumcised.This frequency in the present study was 58.4%. In a recent prospective study of infants younger than 3 months diagnosed with UTI, 22 of 45 infants (46%) had urinary tract abnormalities.[20] Other studies have reported nearly similar prevalence,[17],[18],[19],[20] but in the present study it was 17.39%. This difference may be due to the smaller sample size.
Conclusion
UTI can be present in asymptomatic icteric infants. The present study finding of the incidence of UTI in infants with late onset jaundice was the same as in febrile infants of the same age group, suggesting that the authors may have determined infants with UTI before any sign or symptoms become evident. It is suggested that performing urine analysis and urine culture as screen tests in neonates with late onset jaundice, is important. Also, the relation between feeding type, circumcision and UTI were significant
References
1.Long S, Klein JO. Bacterial infection of the urinary tract In Remington, Klein, eds. Infection Disease of the Fetus and Newborn Infants, Philadelphia, WB. Saunders, 2001; 1035-1046.
2.Elder JS. Urologic disorder in infants and children In Behrman, Kleigman, eds. Nelson Text Book of Pediatrics. Philadelphia; WB. Saunders, 2004; 1812-1814.
3.Gary M, Lum. Kidney and urinary tract infection In Hay W, Levin MJ, Hayward A, eds. Current Pediatric Diagnosis & Treatment. Colorado; Mc. Graw-Hill, 2001; 630-631.
4.Maisels MJ. Mixed forms of jaundice In Mac Donald, ed. Avery's Neonatology Pathophysiology & Management of the Newborn. Lippincott; Williams & Wilkins, 2005; 807-808.
5.Ghaemi S. Neonatal urinary tract infection In Common Infectious Diseases of the Newborns. Isfahan Maani, 1999; 153-159.
6.HA, Warld ER. Urinary tract infection in young febrile children. Pediatr Infect Dis J 1997; 16 : 11-17.
7.Robert J.A. Factors predisposing to UTI in children. Pediatr Nephrol 1998; 10 : 517-521.
8.Wiswell TW, Enzenaner RW, Declining frequency of circumcision : implication for changes in the absolute incidence and male to female ratio of UTI in early infancy. Pediatrics J 1987; 79 : 338-342.
9.Daucher JN. UTI in infant in spite of prenatal diagnosis of hydronephrosis. Peditrics Radiol 1992; 22(6) : 401-405.
10.Rushon HG. UTI, incidence, epidemiology, evaluation and management. Peditr Clin North Am 1997; 44 : 1133-1137.
11.Martin RJ. UTI in : Fanaroff A, Martin RJ, eds. Neonatal Perinatal Medicine. London - Philadelphia; Mosby, 2002; 730-735.
12.Camilia R, Martin, John P. Cloherty. Neonatal hyperbilirubinemia In Cloherty, Eichenwald, stark, eds. Manual of Neonatal Care . Philadelphia; Lippincott and Williams, 2005; 185-219.
13.Chandra A, Baudon JJ. Transient urodynamic dysfunction of infancy; relationship to UTI and VUR. J Urol 1996; 155 : 673-677.
14.Ginsberg CM, Mc Cracken GH.UTI in young infants. Pediatrics 1982; 69 : 409-412.
15.Fine RN. Diagnosis & treatment of fetal urinary tract abnormalities. J Pediatr 1992; 121 : 333-339.
16.Greenfeld SP, Wam J. Vesicoureteral reflux:practical aspects of evaluation and management. Pediatr Nephrol 1996; 10 : 174-189.
17.American Academy of Pediatrics, Provisional Committee for Quality Improvement and Subcommittee on Hyperbilirubinemia. Practice Paramater : management of hyperbilirubinemia in healthy term newborn. Pediatrics 1994; 94 : 558-565.
18.Hannams S, MC Donell M. Investigation of prolonged neonatal Jaundice. Acta Pediatr 2000; 89 : 694-697.
19.Maisels MJ, Kring E. Risk of sepsis in newborns with severe hyperbilirubinemia. Pediatrics 1992; 90 : 741-743.
20.Goldman M, Lahat E, Strauss S. Imaging after urinary tract infection in male neonates. Pediatrics 2000; 105 : 1232-1235.(Ghaemi Sedigheh, Fesharaki Reyhaneh Jafa)
Objective. To determine the prevalence and the associated parameters of urinary tract infection (UTI) in infants with late onset jaundice. Methods. This prospective analytic study was conducted among 400 cases, selected by simple sampling from neonates with late onset jaundice admitted in two referral hospitals of Isfahan during a 9-month period. The information including the age, sex and feeding type, as well as the results of physical examination, treatment, radiology studies, etc were recorded. The etiology of jaundice was assessed by laboratory tests. Urine analysis and urine culture were performed for all subjects. XZ and t-test were used for analysis of the data in- SPSS software. Results. Of the 400 icteric neonates, 147 (36.8%) were female and 253 (63.3%) were male ; 23 (5.8%) were diagnosed to have UTI, 5 cases (1.3%) had G6PD deficiency, 19 (4.8%) had dysmorphic red blood cell and 3(0.75%) had ABO or RH incompatibility. The relation between the type of feeding, circumcision and UTI was significant (P<0.05). Of the 23 neonates with UTI,4 cases (17. 39%) were found to have urogenital abnormality. Conclusion. UTI was found in 5.8% of infants with late onset jaundice. The study revealed significant association between breast feeding, circumcision and lower prevalence of UTI in icteric neonates. It is suggested that evaluation for UTI should be considered as a screening test in all cases of neonatal late onset jaundice.
Keywords: Urinary tract infection; Late onset jaundice; Neonate
Urinary tract infection (UTI) is the most common disease of the urogenital system and one of the most important bacterial infections in the pediatric age group.[1],[2],[3] Its incidence varies from 0.1 to 1% among neonates.[2],[4] and from 5 to 11% among febrile infants aged less than 8 weeks.[5] In the first 3 months of life, it is more prevalent in males,[1],[4],[10] especially in the uncircumcised ones.[1],[2],[6],[10],[11],[12]
In infants, the clinical presentations of UTI varies from non-specific sign and symptoms such as poor weight gain, vomiting , fever, poor feeding and jaundice to severe illness.[1],[11],[12] The major clinical presentation of UTI among young infants is acute pyelonephritis. Between 30 to 55% of infants with UTI are reported to have urinary tract congenital abnormalities, of which vesicouretral reflux is the most common.[13],[14],[15],[16]
Some investigators have suggested that unexplained hyperbilirubinemia in newborns may be associated with bacterial infection especially UTI, but the current scientific guidelines, e.g. that of the American Academy of Pediatrics (AAP) do not recommend any evaluation for UTI among infants with late onset hyperbilirubinemia.[17] This is study aimed to determine the prevalence and the associated parameters of UTI in infants with late onset jaundice.
Material and Methods
In this prospective study, conducted from July 2001 to February 2002, 400 neonates with late onset jaundice were selected by simple sampling from among the patients admitted to the two major referral hospitals for neonatal care in Isfahan, the second large city in Iran. All premature neonates were excluded from the study. Clinical jaundice was defined as any yellow or yellow green discoloration of the skin, mucus membranes and or sclera that prolonged for more than 7-10 days.
The age, sex and the type of feeding of the neonates, findings of the physical examination, e.g., any evidence of hemolysis or cephalhematoma and circumcision, as well as the history of vomiting, abdominal distention in the neonate, and or icterus in the family members were recorded.
Blood samples were taken from all the cases and their hemoglobin (Hb), hematocrit (Hct), reticulocyte count, blood group and RH , bilirubin (direct and total), Coombs test, and G6PD level were evaluated. Urine analysis and urine culture were performed on specimens collected from clean voided urine. Suprapubic aspiration specimen was obtained if more than 10,000 bacteria were isolated, and its result was considered as positive in case of detection of any bacteria. After initial evaluation and treatment of the neonates, sonography and voiding cystourethrogram were requested in case of positive results for UTI.
The data were analyzed using SPSS soft ware. Descriptive data were reported as mean ± standard deviation, and were analyzed with XZ and t-tests. Statistical significance was defined as p value <0.05.
Results
The mean age of the neonates studied was 10.79±4.68 days. Of them, 147 (36.8%) were female and 253(63.2%) were male. All of the subjects studied had an Iranian nationality. Overall 23 out of 400(5.8%) icteric neonates were diagnosed to have UTI (based on positive urine culture). The most common (74%) bacterial pathogen was E-coli. Overall, 5 infants (1.3%) had G6PD deficiency, 19(4.8%) had dysmorphic red blood cell, and 3(0.75%) of them had ABO or RH incompatibility. Positive urine culture was less frequent in females than in males (5 vs 8, respectively, p< 0.05). From these cases, 105 males were circumcised, 2 of the circumcised and 16 of uncircumcised male neonates had UTI [Table - 1]. The mean age of infants with and without UTI was not significantly different (10.91 ± 4.66 days vs 10.6 + 4.71 days, respectively, p>0.05). No significant relationship between UTI and age, was noticed, but the relation between feeding type, circumcision and UTI was significant [Table - 2].
Imaging studies for the infected infants discovered congenital urinary tact abnormalities in 4 of 23 (17.39%) patients, which included vesicoureteral reflux, hydronephrosis and pelvic ectasis , and only one patient had abnormal voiding cystourethrogram (VCUG).
Discussion
In the present study, the prevalence of UTI among neonates with late onset jaundice was 5.8%, and the most common (74%) pathogen isolated was E-coli. These findings are consistent with some previous studies that reported a prevalence of 5 to 11% for UTI in febrile infants aged less than 2-3 months.[6] Previous investigations have documented an association between jaundice and UTI in neonatal period[18] but to the best of authors knowledge, the prevalence of UTI has not been studied in asymptomatic icteric infants.
In this study, 31 infants (7.8%) were formula -fed and 369 (92.2%) were breast- fed. Positive urine culture was significantly more frequent in formula -fed infants than in breast- fed infants (38.7% vs 3%). These results are in line with the study of Kring and Maiselse.[19] This difference is suggested to be due to the immunologic factors of the breast milk.[2],[3] This must be further studied.
Another protective factor for UTI was circumcision. In 1982, Ginsberg and mc Cracken[17] observed that 95% of 62 infant boys with UTI were uncircumcised.This frequency in the present study was 58.4%. In a recent prospective study of infants younger than 3 months diagnosed with UTI, 22 of 45 infants (46%) had urinary tract abnormalities.[20] Other studies have reported nearly similar prevalence,[17],[18],[19],[20] but in the present study it was 17.39%. This difference may be due to the smaller sample size.
Conclusion
UTI can be present in asymptomatic icteric infants. The present study finding of the incidence of UTI in infants with late onset jaundice was the same as in febrile infants of the same age group, suggesting that the authors may have determined infants with UTI before any sign or symptoms become evident. It is suggested that performing urine analysis and urine culture as screen tests in neonates with late onset jaundice, is important. Also, the relation between feeding type, circumcision and UTI were significant
References
1.Long S, Klein JO. Bacterial infection of the urinary tract In Remington, Klein, eds. Infection Disease of the Fetus and Newborn Infants, Philadelphia, WB. Saunders, 2001; 1035-1046.
2.Elder JS. Urologic disorder in infants and children In Behrman, Kleigman, eds. Nelson Text Book of Pediatrics. Philadelphia; WB. Saunders, 2004; 1812-1814.
3.Gary M, Lum. Kidney and urinary tract infection In Hay W, Levin MJ, Hayward A, eds. Current Pediatric Diagnosis & Treatment. Colorado; Mc. Graw-Hill, 2001; 630-631.
4.Maisels MJ. Mixed forms of jaundice In Mac Donald, ed. Avery's Neonatology Pathophysiology & Management of the Newborn. Lippincott; Williams & Wilkins, 2005; 807-808.
5.Ghaemi S. Neonatal urinary tract infection In Common Infectious Diseases of the Newborns. Isfahan Maani, 1999; 153-159.
6.HA, Warld ER. Urinary tract infection in young febrile children. Pediatr Infect Dis J 1997; 16 : 11-17.
7.Robert J.A. Factors predisposing to UTI in children. Pediatr Nephrol 1998; 10 : 517-521.
8.Wiswell TW, Enzenaner RW, Declining frequency of circumcision : implication for changes in the absolute incidence and male to female ratio of UTI in early infancy. Pediatrics J 1987; 79 : 338-342.
9.Daucher JN. UTI in infant in spite of prenatal diagnosis of hydronephrosis. Peditrics Radiol 1992; 22(6) : 401-405.
10.Rushon HG. UTI, incidence, epidemiology, evaluation and management. Peditr Clin North Am 1997; 44 : 1133-1137.
11.Martin RJ. UTI in : Fanaroff A, Martin RJ, eds. Neonatal Perinatal Medicine. London - Philadelphia; Mosby, 2002; 730-735.
12.Camilia R, Martin, John P. Cloherty. Neonatal hyperbilirubinemia In Cloherty, Eichenwald, stark, eds. Manual of Neonatal Care . Philadelphia; Lippincott and Williams, 2005; 185-219.
13.Chandra A, Baudon JJ. Transient urodynamic dysfunction of infancy; relationship to UTI and VUR. J Urol 1996; 155 : 673-677.
14.Ginsberg CM, Mc Cracken GH.UTI in young infants. Pediatrics 1982; 69 : 409-412.
15.Fine RN. Diagnosis & treatment of fetal urinary tract abnormalities. J Pediatr 1992; 121 : 333-339.
16.Greenfeld SP, Wam J. Vesicoureteral reflux:practical aspects of evaluation and management. Pediatr Nephrol 1996; 10 : 174-189.
17.American Academy of Pediatrics, Provisional Committee for Quality Improvement and Subcommittee on Hyperbilirubinemia. Practice Paramater : management of hyperbilirubinemia in healthy term newborn. Pediatrics 1994; 94 : 558-565.
18.Hannams S, MC Donell M. Investigation of prolonged neonatal Jaundice. Acta Pediatr 2000; 89 : 694-697.
19.Maisels MJ, Kring E. Risk of sepsis in newborns with severe hyperbilirubinemia. Pediatrics 1992; 90 : 741-743.
20.Goldman M, Lahat E, Strauss S. Imaging after urinary tract infection in male neonates. Pediatrics 2000; 105 : 1232-1235.(Ghaemi Sedigheh, Fesharaki Reyhaneh Jafa)