Intravesical gentamicin instillation in the prevention of recurrent urinary tract infections in children with neurogenic bladder- a single-center retrospective observational study.

BACKGROUND: Recurrent urinary tract infections (UTI) in children with neurogenic bladder (NGB) put them at high risk of morbidity and mortality from urosepsis and end-stage renal disease (ESRD). Since the efficacy of low-dose prophylactic antibiotics to prevent these recurrences has been declining since the emergence of extended-spectrum beta-lactamase (ESBL) organisms, intravesical gentamicin instillation has also been used, but only scarce data in children is available in the literature. OBJECTIVE: We evaluate the efficacy of intravesical gentamicin instillation to reduce UTIs in children with NGB, compare it with oral antibiotic prophylaxis and determine its effect on pathogens resistance to antibiotics. STUDY DESIGN: Retrospective observational study of 17 children with NGB managed in a tertiary center. Intravesical gentamicin instillation followed an initial period of oral antibiotic prophylaxis. In a conditional negative binomial regression model, a matched comparison of the rate of UTIs, the identified pathogens and their antibiotics susceptibility between the two therapies was performed for each individual child, RESULTS: When compared to antibiotic prophylaxis, intravesical gentamicin instillation showed no significant difference in the yearly rate of UTI, symptomatic UTI, or admissions for intravenous antibiotic therapy. However, it was associated with a 38% reduction in the incidence rate ratio of UTI (p = 0.04) and 75% of asymptomatic UTI (p = 0.006) After intravesical gentamicin instillation, five children (31%) had a gentamicin-resistant UTI, similar to before that treatment (p = 0.76). DISCUSSION: Although the overall rate of UTI and of asymptomatic infections were significantly lower with intravesical gentamicin instillation than during oral antibiotic therapy, there was no significant difference in the rate of symptomatic UTIs or UTIs requiring admissions, probably because of the small sample size. In addition, neither an emergence of ESBL pathogens nor the rate of pathogens resistance to gentamicin was observed with intravesical gentamicin instillation. As to the potential nephrotoxicity of aminoglycosides, the calculated GFR for all children remained normal. Strengths of our study include the use of a matched paired comparison of each participant with him/herself with each treatment modality, thus eliminating potential confounding by some individual characteristics. In addition, and unlike previous studies, we have also used a robust multivariate statistical analysis to compare counts and rates of outcomes. Limitations include the absence of gentamicin serum levels monitoring, of hearing testing, and also the small sample size. CONCLUSION: Intravesical gentamicin instillation decreases the overall rate of UTI and asymptomatic infections in children with NGB without increasing the rate of bacterial resistance to gentamicin.

Epidemiology of Bronchiolitis in Hospitalized Infants at Tawam Hospital, Al Ain, United Arab Emirates.

BACKGROUND: Bronchiolitis is the commonest lower respiratory tract infection, found worldwide in children < 2 years of age. Over sixty percent of cases are caused by Respiratory Syncytial Virus (RSV). The disease is known to have significant morbidity, mortality and health care costs. Its seasonal variability, manifestations and complications vary between countries. The aim of this study was to determine the epidemiological and clinical characteristics of infants hospitalized with bronchiolitis in Al Ain City, United Arab Emirates. METHODS: Retrospective observational chart review was made of an unselected cohort of infants ≤ 2 years admitted to the pediatric department of Tawam hospital over a 3-year period and discharged with the diagnosis of bronchiolitis. Epidemiological data and risk factors were analyzed. RESULTS: RSV was the commonest pathogen (51%). Hospitalizations occurred year-round but increased significantly in December and January. The patients' median age was 5.8 months with a male predominance (male:female ratio of 1.5:1.0). The mean age at admission was 6.6 months and presentation occurred, on average, 2.9 days after the onset of the symptoms. The majority (94%) had respiratory distress on presentation. Chest x-ray was performed in 80% of the patients. Most children received bronchodilator therapy and oxygen therapy was administered to 42%. The mean duration of hospital stay was 3 days. CONCLUSION: Bronchiolitis remains a common reason for hospital admission and carries significant morbidity. RSV is the primarily responsible virus for hospital admissions and morbidity.A better understanding of the burden of bronchiolitis in our setting would enable better planning and use of hospital resources to minimize its short and long-term sequelae.

Case Report: BCG-Triggered Hemophagocytic Lymphohistiocytosis in an Infant With X-Linked Recessive Mendelian Susceptibility to Mycobacterial Disease Due to a Variant of Chronic Granulomatous Disease.

In the United Arab Emirates, BCG (Bacillus Calmette-Guérin) is administered to all newborns. We present here a young infant with an inborn error of immunity (IEI) who developed fatal adverse events to this live-attenuated vaccine. This male infant received BCG (Serum Institute of India Pvt., Ltd., India) on Day 11 of life. On Day 25, he developed fever, followed by cervical lymphadenitis and bilateral otitis media with fluid drainage. On Day 118, he was admitted with severe hemophagocytic lymphohistiocytosis (HLH), and passed away on Day 145. The diagnostic exome sequencing test identified a hemizygous nonsense variant, NM_000397.3(CYBB):c.676C>T, p.Arg226* (rs137854592). Pathogenic variants of CYBB [cytochrome b(-245), beta subunit; Mendelian Inheritance in Man [MIM] accession code, 300481] are known to cause "immunodeficiency 34, mycobacteriosis, X-linked" (IMD34, MIM#300645) and "chronic granulomatous disease, X-linked" (CGDX, MIM#306400). The natural history of his illness is consistent with "X-linked recessive Mendelian susceptibility to mycobacterial disease (MSMD)." This entity is responsible for his BCG disease and is a likely trigger of his HLH. This disastrous event underlines the importance of developing worldwide policies that target BCG disease prevention, especially in communities with high prevalence of IEI. Moreover, screening for genetic causes of MSMD in the community could pave the way, at least partially, for scale-up of tuberculosis (TB) prevention.

Severe Presentation of Nontypeable Haemophilus influenzae (NTHi) Infection in a Previously Healthy Toddler.

BACKGROUND: Cellulitis is the inflammation of the skin and subcutaneous tissue. It is usually caused by Gram-positive organisms such as Staphylococcus and Streptococcus pyogenes infection. Nontypeable Haemophilus influenzae (NTHi) is an uncommon cause of cellulitis. Hence, we report on this case. CASE PRESENTATION: A previously healthy 19-month-old girl presented with a fever and two-day history of progressive right leg swelling and redness. Her physical examination revealed significant induration and swelling of her right lower leg but no obvious signs of abscess formation. Given the clinical picture, she was admitted as a case of cellulitis. Parenteral clindamycin was started empirically, as the blood culture preliminary report showed Gram-negative rods. Ceftriaxone was added to broaden the coverage. Final blood culture grew NTHi. Despite the use of proper antibiotics (amoxicillin clavulanic acid), the clinical course was complicated with abscess formation that required surgical intervention. CONCLUSIONS: We are reporting a previously healthy child who developed NTHi cellulitis of the lower leg. To the best of our knowledge, there have been no formal reports pertaining to leg cellulitis following infection by NTHi, yet published in UAE, and reports of HIB cellulitis of the extremities still appear to be rare; hence, we report on this case.

Hyponatraemia and neurological complications in children admitted with bronchiolitis.

BACKGROUND: Hyponatraemia occurs during bronchiolitis, sometimes with neurological manifestations. The prevalence of the latter differs widely and little is known about the time of occurrence and associated factors. This study was undertaken to investigate these complications. METHODS: This was a retrospective observational chart review of a cohort of 233 infants under 2 years of age admitted with bronchiolitis to a teaching hospital in the United Arab Emirates. RESULTS: Hyponatraemia (serum sodium <135 mmol/L) occurred in 105 infants (45%, 95% CI 38-51). Hyponatraemia was present on admission in 84 infants (80%) with 90% of cases occurring within 6 days of the onset of illness. It was mild (130-135) in 100 infants (95%) and severe (<130) in five (5%). It was not significantly associated with age, duration of illness before admission, viral aetiology, white cell count or serum C-reactive protein concentrations, or the volume of administered intravenous fluid or use of 0.18% sodium chloride (NaCl). Neurological manifestations occurred in a 29-day-old child with a serum sodium level of 123 mmol/L while receiving two-thirds intravenous maintenance fluids (0.18% NaCl). His developmental milestones remained normal on follow-up to the age of 5 years. CONCLUSION: Hyponatraemia is common in infants with bronchiolitis and occurs in the majority within 6 days of onset of symptoms. There was a significant association between the presence of fever (>38°C) on admission and the duration of hospitalisation.

Renal tract abnormalities missed in a historical cohort of young children with UTI if the NICE and AAP imaging guidelines were applied.

OBJECTIVE: In a historical cohort of children with a urinary tract infection (UTI) who had already undergone all the imaging procedures, the aim was to determine renal tract abnormalities which would have been missed had we implemented the new guidelines from the National Institute for Health and Care Excellence in the United Kingdom (NICE) or the American Academy of Pediatrics (AAP). MATERIAL AND METHODS: After a UTI episode, forty-three children (28 females, 65%) aged between 2 months and 2 years presenting at two general hospitals with a febrile UTI before 2008 underwent all the recommended imaging studies predating the new guidelines. Hydronephrosis was defined and graded according to the Society for Fetal Urology (SFU) classification. Hydronephrosis grade II (mild pelvicalyceal dilatation), grade III (moderate dilatation), and grade IV (gross dilatation with thinning of the renal cortex), duplication, vesicoureteral reflux (VUR) grade II and above, renal scarring and reduced renal uptake (<45%) on technetium-99m-labeled dimercaptosuccinic acid (DMSA) scintigraphy were considered significant abnormalities. We calculated the proportion of abnormalities which would have been missed had the new guidelines been used instead. RESULTS: The median of age was 7.6 months (mean 8.7, range 2-24 months), with the majority (n = 37, 86%) being under 1 year of age. Ultrasound (US) showed hydronephrosis in 14 (32%), all grade II. A voiding cystourethrogram (VCUG) was performed in all and showed VUR ≥ grade II in 16 (37%), including eight children (19%) where it was bilateral. DMSA scan showed scarring in 25 children (58%) of whom 11 (26%) had bilateral scars. Reduced differential renal uptake was present in 10 children (23%). Of the 29 children with normal US, 18 (62%) had renal scarring and nine (31%) had VUR ≥ grade II. The NICE guidelines would have missed 63% of the children with VUR ≥ grade II, including a high proportion of grades IV and V VUR, 44% of the children with renal scarring, and 20% of the children with decreased renal uptake, including some children with bilateral renal scarring and with decreased renal uptake. The AAP guidelines would have missed 56% of the children with VUR ≥ grade II, including a high proportion of grades IV and V VUR, and all children with renal scarring as well as those with decreased renal uptake. CONCLUSION: The prevalence of renal tract abnormalities missed by the new guidelines is high. They should be used with full awareness of their limitations.