Examination Of Urinary Tract Infection In Primary School Children

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Examination Of Urinary Tract Infection In Primary School Children


Abstract


This study involves an examination of urinary tract infections in primary school children. The prevalence of urinary tract infection (UTI) among children attending primary schools in Maiduguri was investigated in this study. The study was carried out between January and April 2011 among apparently healthy pupils. One hundred and twenty (120) clean-catch urine samples were obtained from the pupils using standard procedures. Microbial culture on Cystein Lactose Electrolyte Deficient (CLED) ager and subsequent Biochemical tests revealed 31.7% of the samples with significant bacterial growth (≥ 105 CFU/ml). Among the identified organisms Escherichia coli were more prevalent (8.3%) among the identified organisms, while Proteus and Klebsiella species were less prevalent (1.6% each). Other species that were identified include Staphylococcus aureus (6.7%), Streptococcus faecalis (4.2%), Staphylococcus saprophyticus (3.3%) and Corynebacterium species (5.8%). Urinalysis to detect haematuria as presumptive test for UTI was insignificant (P > 0.05). Only 2 (out of 5) samples showed bacteriuria in culture plates. Association of gender, previous history of UTI, bedwetting and presence of blood in urine related prevalence were tested, only sex was strongly associated with UTI (p < 0.05). The incidence of UTI in females (19.5%) was higher than males (12.5%). Therefore, government needs to increase efforts toward creating awareness among the people, for effective treatment, control and prevention of the disease.


Table of Content


  • Title Page
  • Certification
  • Dedication
  • Acknowledgement
  • Table of Content
  • List of Tables
  • Abstract

Chapter One:

Introduction

  • 1.1 Background of the Study
  • 1.2 Statement of the Problem
  • 1.3 Objective of the Study
  • 1.4 Research Questions
  • 1.5 Significance of the Study
  • 1.6 Scope of the Study
  • 1.7 Limitation of the Study
  • 1.8 Definition of Terms
  • 1.9 Organization of the Study

Chapter Two:

Review of Literature

  • 2.1 Conceptual Framework
  • 2.2 Theoretical Framework
  • 2.3 Empirical Review

Chapter Three:

Research Methodology

  • 3.1 Research Design
  • 3.2 Population of the Study
  • 3.3 Sample Size Determination
  • 3.4 Sample Size Selection Technique and Procedure
  • 3.5 Research Instrument and Administration
  • 3.6 Method of Data Collection
  • 3.7 Method of Data Analysis
  • 3.8 Validity of the Study
  • 3.9 Reliability of the Study
  • 3.10 Ethical Consideration

Chapter Four:

Data Presentation and Analysis

  • 4.1 Data Presentation
  • 4.2 Analysis of Data
  • 4.3 Answering Research Questions
  • 4.4 Discussion of Findings

Chapter Five:

Summary, Conclusion and Recommendation

  • 5.1 Summary
  • 5.2 Conclusion
  • 5.3 Recommendation
  • References
  • APPENDIX
  • QUESTIONNAIRE

Chapter One


Introduction

1.1 Background of the Study

Urinary Tract Infections (UTI) is known to affect millions of people annually and can lead to serious health problem issues (Tajbakhsh, 2015. Globally, seven million patients visit the outpatient department, one million visits the emergency department visit, and one hundred thousand patients visits the in-patient department annually, from symptomatic UTI (Foxman, 2003). Although Urinary Tract Infections in men occur rarely, when they do occur, they come with very severe implications to the health of the male patient (Tajbakhsh, 2015). There are several factors that lead to men having UTI, they include sex, age, diseases like diabetes, men who have sex with men, men with neurologic disorders, men with defects in the bladder and prostate as well as immune-compromised men (Hsueh, 2011). The reported number of new infections yearly is lower than in women except infections where the patient in catheterized and children (Noor, 2013).

Urinary tract infections in men may clinically present with typical or atypical presentation. Typical irritative lower urinary tract symptoms will be presented by most men with symptoms such as frequency, dysuria, urgency and nocturia. Others may complain of a foul smell in the urine, blood in urine or suprapubic pain (Anuli, 2016). Atypical presentation is frequently seen in older men and may have involuntary leakage of urine and confusion (Foxman, 2014). Different pathogens have been found to cause UTI among male patients. Uropathogenic E. coli (UPEC), a Gram-negative, facultative anaerobe is the predominant isolate (Betsy, 2010).

The UPEC strain that causes UTI is different from the one found in the gastrointestinal tract in that it has a mechanism that enables it to elude the host defense system and attach to the urinary tract by forming biofilms invading the urothelial cell. The Streptococci and Staphylococci are species among the members of enterobacteriaceae that also cause urinary tract infections (Foxman, 2003).

Urinary Tract Infections in the world today has and continues to cause a big economic impact because of high antibiotic use (Hsueh, 2011). In Africa not much has been documented about the effects of UTI to the economy and the health care system. There is inadequate data concerning the occurrences of various UTI’s, how they affect quality of life of that population. For proper monitoring of UTI’s, such data is required from the public health system (Kurt, 2010). The independent review on antimicrobial resistance estimated that by 2050, infections that are resistant to most antibiotics could cost the global economy 100 trillion dollars killing around 10 million people annually (World Economic Forum, 2014).

Antibiotic resistance is becoming a worldwide cause of alarm, Kenya is no exception. The resistance can arise naturally or due to misappropriation of the antibiotics. Misuse and overuse are the primary causes (WHO, 2018), in Kenya antibiotics can bought by men without a prescription from a trained practitioner. This is usually the chief cause of misuse of antibiotics. Shortage of right and accurate facts about antibiotics also adds to the misappropriation of antibiotics. A survey carried out across 12 countries by (WHO, 2015) showed that 64% of the public believe that an antibiotic can also treat viral infections like common cold and influenza.

Self-diagnosis is another reason for wrong use of antibiotics (Lee, 2015) with the availability of internet, this problem has increased. Thirty-five per cent of American adults have at one point in their lives used internet to diagnose a UTI either for themselves or someone they know. Younger people, especially those with a college degree, have the highest chances of going online to diagnose their infections (Fox, 2013).

Urinary Tract Infection (UTI) is a serious bacterial infection causing illness in infants, and children (Raya, 2009). It is a term generally applied to variety of clinical infections ranging from asymptomatic bacteriuria to severe kidney damage and sepsis (Tanagho and Mcaninch, 2004). Urinary tract infections (UTIs) are one of the most frequent bacterial infections in children (Moses et al., 2012). UTIs have been reported to be the most commonly encountered bacterial infections that pose a health threat to infants and children (Eltigani and Amira, 2009). Several authors defined UTI, but all the definition fall along one line, that is UTI is described as significant growth of organisms of single species in the urine, accompanied with symptoms (Reddy, 2006). Significant bacteriuria is growth with colony count of ≥100, 000 CFU/mL of clean catch midstream urine (Brian and Sarah 2005). The prevalence is age and gender dependent (Nadi, et al., 2006). Living condition has also been recognized to play an important role (Heffner and Gorelick, 2008). Every about 150 million cases of UTI have been reported worldwide in 2001 (Stamm and Norrby, 2001). Incidence in children however is difficult to estimate, particularly because young children with UTI may only have non-specific symptoms or signs, such as fever (Nadi, et al., 2006). The disease situation is commonly identified by fever, vomiting, pyuria, haematouria, pain sensation, and neonatal jaundice. Different symptoms and signs may be observed among different age groups (Reddy, 2006). In Nigeria, apart from the infections of the upper respiratory tract, UTI are the most important clinical abnormalities for which medical intervention is sought (Ejaz et al., 2006).

It is acquired mainly through ascending hematogenous route especially in neonates (Raya, 2009). The ascending infections are as a result of colonization of bacteria present in the gastrointestinal tract. The colonization is attributed to disturbance of normal flora by prolonged administration of antibiotics or transient organisms emerging from the environment or medical instruments such as invasive catheter. Lymphatic route of UTI is however speculated (Reddy, 2006). Risk factors associated with UTI are anatomical and physiological. Any anatomical or physiological abnormality of the urinary tract that impedes urinary flow can increase the host susceptibility (Tanagho and Mcaninch, 2004). Others may include age, race, gender, genetic and sexual activities in teenage girls and circumcision in boys. Nocturnal enuresis and some unhealthy condition have also been indicated (Heffner and Gorelick, 2008).

Similarly occurrence of UTI in adult has also been reported. Aiyegoro et al. (2007) showed that 36% of 301 patients (comprising children and adolescence) studied for UTI were positive. Moreover, Obiogbolu and Okonko, (2009) reported the bacteriological etiology and incidence of UTI among pregnant women in Akwa metropolis, south eastern Nigeria. Elderly individual also develop UTI due to decrease in activity of immune system (Akinduti et al., 2009). Irrespective of the age, the incidence and susceptibility in females are always higher than in their male counterparts (Reddy, 2006; Akinduti et al., 2009; Raya, 2009). This may be linked to the proximity of the urinary tract in females to the external environment compared to that of males. In males however, circumcised individuals show lower vulnerability than uncircumcised (Watson et al., 2004). The etiology of UTI is made up of several organisms. Bacteria, viruses, protozoa and fungi are known to cause UTI. Most infections however are caused by facultative anaerobes of the enterobacteria group (Bagga and Sharma, 2000). E coli has been considered as a prominent urinary tract pathogen (Gafencu et al., 2007; Younis et al., 2010; Jombo et al., 2010; Obiogbolu et al., 2009). Other species include Klebsiella, Proteus mirabilis, Pseudomonas aeruginosa, Acinetobacter and Serratia species (Jombo et al., 2010; Bay and Amdeto, 2010; Akinduti et al., 2008). The common gram positive species are Staphylococcus and Beta hemolytic Streptococci (Aiyegoro et al., 2007). Other species like Candida albicans that originate from vagina or perianal skin can cause UTI in women (Reddy et al., 2006).

Treatment of UTI depends on the age of the child, location of the infection, etiology of the disease, degree of illness in the child, efficacy of antibiotic and resistance profile within the community (Romolo et al., 2005). The prognosis of UTI is usually favorable, but it relies on timely administration of appropriate treatment (Elder, 2004). Despite the advances in diagnosis and prophylaxis of infections, many incidence of UTI may remain unnoticed due to mild or asymptomatic manifestation. That is why treatment of identified cases of bacteriuria in all young children is advised in addition to preventing permanent renal scarring due to reflux (Reddy, 2006).


1.2 Statement of the Problem

Urinary tract infection (UTI) is one of the commonest communicable disease and second in antibiotic prescription in many Kenyan hospitals after respiratory infections. The most frequently cited etiology is E. coli which causes 90% of the UTIs in anatomically-normal unobstructed urinary tracts. Although UTI in males younger than 50 years is not common, the frequency increases afterwards. Treatment of UTI is easy if antibiotics are used rationally. All male UTI’s are normally considered complicated with the consideration that the infection has ascended to the upper urinary tract. Therefore, culture and analysis of antibiotic susceptibility pattern is more effective in the management of UTI in males because it aids in modification of the treatment plan. The emergence of antibiotic resistance against commonly prescribed antibiotics in the treatment of UTIs is an ongoing concern worldwide.

Several factors including; inappropriate use of antibiotics, availability of counterfeit drugs in the market, nonadherence to the standard treatment guidelines by clinicians and lack of laboratory resources for culture and sensitivity, have been attributed to the growing resistance to antibiotics among men. In Kenya, the prevalence of urinary tract infections is high with poor treatment outcomes due to prescription of low sensitive drugs coupled with inappropriate diagnosis. Most patients are normally treated based on clinical judgment and urine culture done when patients are refractory to antibiotic treatment, this is partly due to the perception that culture and sensitivity tests are expensive and time consuming by clinicians. Poor monitoring of antibiotic prescription and use in the treatment of UTI is a major contributor to antibiotic resistance.


1.3 Objective of the Study

The main objective of this study is an examination of urinary tract infection in primary school children. Specific objectives include to:

  1. Investigate the Incidence of UTI among primary school children.
  2. Examine the risk factor distribution of UTI among primary school children.
  3. Assess the Bacterial species isolated and identified from urine culture amomg primary school children.

1.4 Research Questions

  1. What is the extent of the Incidence of UTI among primary school children?
  2. What is the risk factor distribution of UTI among primary school children?
  3. What are the Bacterial species isolated and identified from urine culture amomg primary school children?

1.5 Significance of the Study

The data on prevalence of UTI among male patients gave an insight as to the extent of infection and age distribution, which is useful for effective management of the infections. The antibiotic sensitivity profile gave a feedback to Ministry of health; Nairobi, county health Department, Pharmacy and Poisons Board and other stakeholders. The study findings on drug sensitivity of enteric bacteria were useful in informing policy makers and help improve standard of UTI diagnostic accuracy by clinicians, hence allowing for appropriate antibiotic therapy. Any male patient found to have urinary tract infection was treated at the Centre.


1.6 Scope of the Study

This research work focused on an examination of urinary tract infection in primary school children. The study also covered the extent of the Incidence of UTI among primary school children, the risk factor distribution of UTI among primary school children and the Bacterial species isolated and identified from urine culture among primary school children.


1.7 Limitation of the Study

This study was constrained by some factors. Firstly, the time frame allocated for the completion of this study was not enough for the researcher to extensively carry out research based on the theme of this research work. On the other hand, the research participants were not willing to participate in responding to the administered questionnaire of this study. Also, the required materials like journals and articles needed for the proper completion of this study were not readily available online and offline. All these constraint put together, ultimately determined the extent to which the researcher was able to go in this study.


1.8 Definition of Terms

Urinary Tract Infection (UTI):

An infection that affects part of the urinary tract. When it affects the lower urinary tract it is known as a bladder infection (cystitis) and when it affects the upper urinary tract it is known as a kidney infection (pyelonephritis).

Diagnosis:

The identification of the nature and cause of a certain phenomenon. Diagnosis is used in many different disciplines, with variations in the use of logic, analytics, and experience, to determine “cause and effect”. In systems engineering and computer science, it is typically used to determine the causes of symptoms, mitigations, and solutions.

Child:

A human being between the stages of birth and puberty,[1][2] or between the developmental period of infancy and puberty.[3]

Disease:

A particular abnormal condition that negatively affects the structure or function of all or part of an organism, and that is not immediately due to any external injury Diseases are often known to be medical conditions that are associated with specific signs and symptoms

Pandemic:

An epidemic of an infectious disease that has spread across a large region, for instance multiple continents or worldwide, affecting a substantial number of individuals. Public health: “the science and art of preventing disease, prolonging life and promoting health through the organized efforts and informed choices of society, organizations, public and private, communities and individuals”.

Pharmacist:

Also known as a chemist or a druggist , is a healthcare professional who deals with the preparation, properties, effects, use and distribution of medications.


1.9 Organisations of the Study

This research work is categorized in five chapters, for easy understanding, as follows.

  1. Chapter one is concern with the introduction, which consist of the, background to the study, statement of problem, objectives of the study, research questions, significance of the study, scope and limitation of the study, definition of terms.
  2. Chapter two encompasses the conceptual review theoretical review and empirical reviews on which the study is based.
  3. Chapter three deals on the research design and methodology adopted in the study.
  4. Chapter four concentrate on the data collection and analysis and presentation of finding.
  5. Chapter five gives summary, conclusion, and recommendations made of the study.

Chapter Five


Summary, Conclusion and Recommendation

5.1 Summary of Findings

In the Maiduguri metropolitan, the incidence rate of UTI was reported to be 31.7%, with a significant gender difference (p 0.05). This study’s findings are consistent with the percentage reported by Anis et al. (2008) from Pakistan’s Hazara division, where 37.5% of a sample size of 1000 people were evaluated. The number of male and female subjects in the current study is equal, however there is a significant difference in prevalence between the sexes (P 0.05). This revealed a male to female ratio of 2: 3. This is comparable to a study done in Egypt, where 1.7% and 2.7% of male and female primary school students, respectively, tested positive for UTI (Eltigani and Amira, 2009).The highest occurrence of E coli in the urine samples is not unprecedented. Among the 38 identified isolates, 10(26.3%) were E coli. Many authors have indicated the organism as the prominent uropathogen in children (Watson, 2004). In Nigeria alone, most studies on UTI revealed the predominance of E coli in positive urine cultures (Aiyegoro et al., 2007; Okonko et al., 2009 and Akinduti et al., 2008). Staphylococcus aureus is the second most occurring organism. The organism had been reported as one of the gram positive urinary tract pathogens (Anis et al., 2008). Moreover, another important pathogen observed in this study is Corynebacterium species. It is associated mainly with acute or chronic entrusted UTI when observed in urine (Brooks et al., 2010). The least organisms that occurred in the urine samples were Proteus and Klebsiella species with 5.3% each.

Although recorded in few instances, their presence is of concern. However, the microbial culture revealed only two cases with bacteriuria. Five (5) out of thirteen (13) of those pupils reported for bed wetting have significant bacteriuria. Conversely, the association between UTI and previous history of UTI was insignificant (P > 0.05) as shown in Table 1. Although apparently healthy subjects were involved in this study, the presence of these Uropathogen is not surprising. This is due to the fact that many UTI lack overt clinical features thus, may remain unnoticed or cause febrile illness only. However, the detected cases of Haematuria with negative cultures may be attributed to nonbacterial cause or rather noninfectious urinary tract diseases. This is obvious due to the fact that; parasites especially the Schistomes are commonly associated with consistent bloody urine (IAMAT, 2010) and obstruction of bladder leading to secondary bacterial infection (Brooks et al., 2010). Therefore, due to high temperature in the area (410C) and limited supply of potable water, the incidences may be linked to living conditions or nonbacterial causes.


5.2 Conclusion

This study revealed the prevalence of UTI in children attending primary school. The frequency is however alarming considering the fact that, apparently healthy subjects were used in the study rather than those with clinical manifestations. The work elucidated the danger of asymptomatic prevalence and the need for parent/ guardian to carefully monitor the health status of their children/wards. It also supported the mono microbial nature of UTI, similar to those mentioned elsewhere.


5.3 Recommendation

Thus, it is recommended that medical practioners intensify efforts to unravel the degree of incidence of UTI in Nigerian population, with a view to prevent serious complications that may be debilitating or lethal. This however can only be achieved with support from local, federal and non-governmental organizations. Further research is also important for the identification of other causes or factors that influence the prevalence of UTI in children.


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