Indian ft. Pediatr. 44 :
1'76, t977
A S Y M P T O M A T I C B A C T E R I U R I A IN S C H O O L C H I L D R E N * V.K. SRIVASTAVA, S.K. AGARWAL AND A.K. RATHI Lucknow
Though a majority of urinary infections produce symptoms, a significant percentage remains asymptomatic and the recurrence of symptomatic infection is more c o m m o n l y asymptomatic. Such infections, therefore, can only be diagnosed by routine urinary screening (Kunin 1970). Females, due to the anatomical peculiarities of the bladder and urethra are more prone to ascending urinary infection. T h e relationship of bacterial colonization in the vulval region and recurrent urinary infection has been well established suggesting that poor perineal hygiene have important contribution in causation of such infections (Vosti et al. 1964, Gruneberg 1969 and Stamey eta/. 1971). The present study attempted to assess the m a g n i t u d e of the problem of asymptomatic bacteriuria in Indian school children and to study various socio-clinical factors responsible for the persistence of such infection. Material and Method
The children for the present study were selected from four different schools of Lucknow city. A detailed clinical examination including the examination of the perineal region was carried out in most of the subjects. *From the Upgraded Departments of Social and Preventive Medicine and Pathology and Bacteriology and Department of Paediatrics, K.G's Medical College, Lucknow. Received on FebruaTy 10, 19"/7
The growth of children was assessed by considering their weight for age, Information was collected regarding the socioeconomic background of the students. A history suggestive of urinary tract infection in these children was also recorded. Children wi~h a history suggestive of antibiotic administration in the recent past were excluded from tile study. Parents were interviewed in those ~ubjects who failed to give appropriate information. A mid-stream urine sample was collected from each subject in a thoroughly sterilized container after properly cleaning the genitalia. The specimen was taken to the laboratory within half an hour of collection. The samples were examined for the presence of albumin by 3% sulphosalicylic acid. 10 ml. of the urine sample was centrifuged for 10 minutes at 2500 r.p.m, and the deposits were examined for the presence of leucocytes, red blood cells and casts. For urinary culture, serial ten-fold dilutions of each urine sample were m a d e in nutrient broth and from 1 in I000 dilution of urine, 0.1 m[. was spread on the surface of blood agar and lactose bromthyreel blue agar plates. Bacterial count was done after 18 hours of incubation at 37~ and bacteria were identified by the usual methods of identification (Cruickshank 1965). Observations The study was carried out in 1286 school children enrolled from the nursery
sRIVASTAVA ET AL.--ASYMPTOMATIC
BACTERIURIA
IN SGHOOL
177
CHILDREN
T a b l e 1, Bacteriuria in relation to sex of the children. Bacteriuric children No. screened
Asymptomatie
Symptomatic
Total
No.
%
No.
%
No.
%
Boys
500
2
0.4
4
0.8
6
1.2
Girls
786
29
3.6
22
2.8
51
6.4
Total
1286
31
2.4
26
2.02
57
4.4
to Class VIII, 500 (38.8%) being males and 786 (61.2%) females. Children ranged in age from 5 to 16 years. A higher prevalence of bacteriuria was observed in girls (6.4%) than boys (1.2%) (Table I). Asymptomatie bacterluria was higher amongst girls (3.6%) than boys (0.4%), the difference being statistically significant (X2=4.2, P < 0.05). Table 2 shows that about half ot the
symptomatic bacteriurics either showed a poor growth or poor growth associated with unexplained intermittent fever. Others had symptoms like eneuresis, frequency of micturition or their combinations. The study showed a higher prevalence of bacteriuria amongst Muslims (5.8%) than in Hindu children (4.2%); however, no significant association was observed (X 2 0.98, P > 0.05).
Table 2. Clinical features in 26 children. Symptoms
Number
Poor growth
7
Eneuresis
4
Unexplained intermittent fever + poor growth
6
Unexplained intermittent fever
2
Eneuresis ~ poor growth
2
Frequency of mlcturition
1
Frequency of rnicturition ~ poor growth
2
Frequency with unexplained intermittent fever
2 Total
26
178
\rOE. 44, No. 354.
I N D I A N . J O U R N A L OF P E D I A ' F R I C S
T a b l e 3. Bacteritvia and religion of the children.
Hindu
children
Bacteriuric
Muslim
children
children
Bacteriuric
Total
children
Total N,).
,/i
No.
%
Girls
674
40
5.9
112
9
8.4
Boys
422
6
1.4
78
2
2.5
Total
1096
46
4.2
190
Il
5.8
A s y m p t o m a t i c bacteriuria increased with the increase in the age of children; however this increase was not found to be significant (X9~=3.6, P > 0.05). A decrease
in the prevalence of symptomatic infection was noted with increasing age and this was also not found to be statistically significant (X~= 1.03, P > 0 . 0 5 ) .
T a b l e t . Bacteriuria in relation to age of the children. Bacteriurics
Age group in years
No. of children
Asymptomatic
No.
%
Symptomatic
No.
Total
%
No.
%
5--8
542
9
1.6
13
2.3
22
4.0
9--12
450
11
2,4
9
2.0
20
4.4
13--16
294
11
3.7
4
1.3
15
5.1
1286
31
2.4
26
2.02
57
4.4
Total
St,IIVASq_'AVA ET
AL.---ASYMPTOMATIC
T a b l e 5. Social class (Prasad 1970)
179
IN S C H O O L C H I L D R E N
Bacteriuria in relation to socio-cconomic status of children.
No. of children
I
BACTERIURIA
Total No. and %
34
Bacteriutie children Symptomaric No. and %
2
Nil
(2.9)
Asymptolnalic No. and % 1
(100.0)
II
141
4 (2.8)
1 (25.0)
3 (75.0)
III
296
11 (3.7)
4 (36.4.)
7 (63.6)
IX'
536
26
13
13
(4.8)
(50.0)
(50.0)
279
15 (5.3)
8 (53.3)
7 (46.7)
1286
57 (4.4)
26 (45.6)
31 (54..4.)
V Total
Figures in parentheses denote percentage. Bacteriuria was less fi'equent (2.8%) in the children belonging to social classes I and II as compared to children belonging to social class I I I (3.70/o) and social classes IV and V (5.030/0). However, this difference was not found to be statistically significant (X 2 ~-- 2.01, P > 0.05). The frequency of asymptomatic bacteriuria was higher (80.0%) in social classes I and II as T a b l e 6. Organisms
compared to social class I I I (63.6%) and social classes IV and V (48.7%). In no instance was more than one organism isolated. E. coli (59.6%) was the commonest isolate (Table 6) followed by Klebsiella (24.6%) and Proteus (5.3%). Other organisms isolated were Strept. faecalis and Providence (3.5% each) and Staph. aureus and Alkaligenes faecalis (1.75% each).
Organisms isolated on bacteriological cultures. Number
Percentage
E. coli
34
59.6
Klebsiella
14
24.6
Proteus species
3
5.3
Streptococcus faecalis
2
3.5
Providence
2
3.5
Stap@lococcus aureus
1
1.75
Alkaligenesfaecalis Total
1
1.75
57
100.00
]80
INDIAN
JOURNAL OF PEDIATRICS
Discussion Urinary tract infections are common amongst children specially in females and a significant proportion remains asymptomatic. The recurrence of symptomatic infection is more commonly asymptomatic while asymptomatie infection may become symptomatic later (Norden and Kass 1968, Kunin 1972, Cohen 1972), the maximum risk being at the time of marriage and pregnancy (Norden and Kunin 1968). Evidence now suggests that presistent asymptomatic infections may result in progressive deterioration of renal functions with decreasing renal size (Smellie and Normand 1968 and Kunin 1972). The prevalence of asymptomatic urinary infection has been extensively studied, Kunin et al. (1962 and 1964) observed a prevalence of 0.04% in school boys and 1.2% in school girls. In a 7-yearfollow up study of school girls, Kunin (1969) reported an annual increment of 0.32% in bacteriuric girls. The author also noted that by 18 years of age, 5% of the girls developed urinary infection. Savage et al. (1969) in his study on 5-year-old school girls found 2.1% to be bacteriurics of whom 70% were symptomatic. The symptoms in them were not considered significant by the parents. In another study Savage et al. (1973) noted the prevalence of covert bacteriuria to be 0.6%. Meadow and Johnston (1969) observed the prevalence of bacteriuria to be 0.8%, 90% of whom were symptomatic. Recently, in a study carried out in a paediatric out patients' department (Marr and Traisman 1975) the prevalence of bacteriuria was reported to be as high as 5.0%. A higher prevalence of bacteriuria in school children has been observed in the
\7OL.
4,4, No. 354
present study as compared to the studies reviewed earlier. The overall prevalence of bacteriuria in the present study was 4.4% being 1.2% in boys and 6.4% in girls. Only 45.6% of bacteriurics were symptomatic. The asymptomatic prevalence was 0.4~o in boys and 3.6% in girls. The symptoms in symptomatic cases were considered insignificant by the parents and no medical advice was sought for that. This observation is in line with Savage el el.
(1969). Kunin el al. (1964) reported a significant increase in the incidence bacteriurics with increasing age. Similar findings were also noted in the present study. Asymptomatic bacteriuria increased with increase in age whereas symptomatic bacteriuria decreased. However, these differences were not found to be statistically significant. A higher percentage (5.030/0) of bacteriuric children were observed in social classes IV and V, about half of them (48.8%) being asymptomatic. Only 2.8% children belonging to social classes I and II were bacterlurics, 80.0O/o of them being asymptomatic. Kunin and associates (1964, 1968 and 1970) on the basis of their study on white and Negro girls concluded that environmental factors and the availability of medical care rather than personal hygiene is important in the genesis of bacteriuria. The relation of bacterial colonization in the vulval region and recurrent urinary infection is well known (Vosti et el. 1964, Gruneberg 1969 and Stamey and Miller 1971). In the present study, the personal hygiene of children in the lower socio-economic groups was generally poor and this might have accentuated the prevalence rate of bacteriuria in social classes IV and V. The higher prevalence
SRIVASTAVA ET AL,--ASYMPTOMATIC BACTERIURtA IN SCHOOL CHILI)REN
of bacteriuria in Muslim children (5.8%) than Hindu children (4.2%) might be largely due to comparatively poor socioeconomic conditions, the Muslim population in the study area being generally very poor. A relatively poor personal hygiene noted amongst Muslim children might have also contributed in the genesis of infection to some extent. E. coli was the commonest organism (59.6%) isolated followed by Klebsiella (24.6%), compared to other studies (Kunin 1970, Marr and Traisman 1975), the prevalence of Klebsiella was higher than that of E. coll.
Proteinuria and pyuria were not helpfitl in the diagnosis of urinary infection. Proteinuria was observed only in 6% of baeteriurics and only 43.7~ of bacteriurics had significant pyuria. Similar observations have also been reported by other workers (Pryles 1971, X'Iarr and Traisman 1975). On the basis of his study, Kunin (1972) has recommended routine urinary screening ot girls at the time of schooling and one year later. The American Academy of Paediatrics (1974) has also lately recommended routine evaluation of girls at the age of 3 years, 4 to 5 years, 8 to 9 years and I1 to 12 years. With our limited resources, routine bacteriological screening of school children is not possible. However, ~i history suggestive of urinary infection should be taken in every child and the children with suspicious symptoms should be subjected to bacteriological screening. Further, children with imperfect health without any demonstrable cause should also be screened for urinary infection.
] (]l
References Andriok, V.J.(1972). Diagnosis o; urinary tract inlection by urine culture. In " U r i n a r y tract infection and its management." l-'d. Kaye C.V. Mosby Co. St. Louis, P. 42. Crulckshank, R. (1965). Medical Microbiology. E. & S. Livingstone, Edinburg. Cohen, M. (1972). Urinary tract infection in children. Females aged 2 through i4, first two infections. Pediatrics, 42,271. Committee on Standards (1974). Suggestive mintmum schedule for preventive health care of chiklren and youth. Evanston, Illinois. American Academy of Paediatries. Gruneberg, R.N. (1969). Relation of infecting urinary organisms to the faecal flora in patients with symptomatic urinary infections. Lancet2, 766. Kunin. C.M., Zaeha, E. and Paquin, A J. (1962). Urinary tract infection in school children: Prevalence of bacteriuria and associated urologic findings. New Eng. J. Med. 266, 1287. Kunin, C.M., Deutscher, R. and Paquin, A.J. (1964), Urinary tract infection in school children. An epidemiologic, clinical and laboratory study. Medicine, 43, 91. Kunin C.M. and McCormack (1968). An epidemiologic study of bacteriuries and blood pressure among nuns and working women. Nero Eng. J. Med. 278, 635. Kunin, C.M. (1969). Emergence of bacteriuria and symptomatic urinary tract infection among population of school girls followed for 7 years. Pediatrics, 41,968. Kunln C.M. (1970). A 10 years study of bacteriuria in school girls. Final Report of bacteriologic urologic and epidemiologic studies. J. Inf. Dis., 122, 382. Kunin C.M. (1972). Detection, PrevaIence and Management of Urinary Tract Infection. Philadelphia, Lea and Febizer, p. 62. Meadow R.S, and Johnston, N.M. (1969). Prevalence of symptomatic urinary tract disease in Birmingham school children. Pyurla and bacteriuria. Brit. Med. j , 3, 8l. M a r r , ' F . J . and Traisman, H.S. (1975). Detection of bacteriuria in paediatric out patients. Amer. ft. Dis. Child. 129, 9t0. Norden, C.W. and Kass, E.H. (1968). Bacteriuria of pregnancy. A critical appraisal. Amer. Rev. Med. 19, 431.
1~2
INDIAN JOURNAL OF PEI)IATRICS
Prasad, B.G. (1970). Changes proposed in the social classification of Indian families, yr. Indian Med. Ass. 55, 198. Pryles, C.V. (1971). Laboratory diagnosis of u:inary tract infection. Pediat. Clin. North Amer. 18, 238. Stamey, T.A. and Miller, M. (1971). Recurrent urinary infections in adult women: Role of intestinal enterobacteria. Calif. Med, 115, 1. Smellie, J . M . and Normand, I.C.S. (1968). Experience of follow up of children in urinary tract infection. In Urinary tract Infection. Ed. F.O. Grady and W. Brumfitt. P. 1211, Oxford UniversOyPress.
VOlo. ,14, N o . 35,t Savage, D.C.I,., Wilson, M.I., Ross, E.M. and Fee, M.W. (1969). Asymptomatic bacteriurla in glrl entrants to Dundee Primary School. Brit. Med..7. 3, "15. Savage, D.C.L., Wilson, M.I., McSteady, D. (1978). Covert bacteriuria in childhood. Arch. Dis. Child 48, 2. Vostl. K..L., Goldberg, I.M., Monto, A.S. and Rantz, L.A. (1964). Host parasite interaction in patients wilh infections due to Esch. coll. I. Sero. grouping of Esch. coli from intestinal and extra intestinal sources. 07. Clin. Invest. 43, 2377.
1'76, t977
A S Y M P T O M A T I C B A C T E R I U R I A IN S C H O O L C H I L D R E N * V.K. SRIVASTAVA, S.K. AGARWAL AND A.K. RATHI Lucknow
Though a majority of urinary infections produce symptoms, a significant percentage remains asymptomatic and the recurrence of symptomatic infection is more c o m m o n l y asymptomatic. Such infections, therefore, can only be diagnosed by routine urinary screening (Kunin 1970). Females, due to the anatomical peculiarities of the bladder and urethra are more prone to ascending urinary infection. T h e relationship of bacterial colonization in the vulval region and recurrent urinary infection has been well established suggesting that poor perineal hygiene have important contribution in causation of such infections (Vosti et al. 1964, Gruneberg 1969 and Stamey eta/. 1971). The present study attempted to assess the m a g n i t u d e of the problem of asymptomatic bacteriuria in Indian school children and to study various socio-clinical factors responsible for the persistence of such infection. Material and Method
The children for the present study were selected from four different schools of Lucknow city. A detailed clinical examination including the examination of the perineal region was carried out in most of the subjects. *From the Upgraded Departments of Social and Preventive Medicine and Pathology and Bacteriology and Department of Paediatrics, K.G's Medical College, Lucknow. Received on FebruaTy 10, 19"/7
The growth of children was assessed by considering their weight for age, Information was collected regarding the socioeconomic background of the students. A history suggestive of urinary tract infection in these children was also recorded. Children wi~h a history suggestive of antibiotic administration in the recent past were excluded from tile study. Parents were interviewed in those ~ubjects who failed to give appropriate information. A mid-stream urine sample was collected from each subject in a thoroughly sterilized container after properly cleaning the genitalia. The specimen was taken to the laboratory within half an hour of collection. The samples were examined for the presence of albumin by 3% sulphosalicylic acid. 10 ml. of the urine sample was centrifuged for 10 minutes at 2500 r.p.m, and the deposits were examined for the presence of leucocytes, red blood cells and casts. For urinary culture, serial ten-fold dilutions of each urine sample were m a d e in nutrient broth and from 1 in I000 dilution of urine, 0.1 m[. was spread on the surface of blood agar and lactose bromthyreel blue agar plates. Bacterial count was done after 18 hours of incubation at 37~ and bacteria were identified by the usual methods of identification (Cruickshank 1965). Observations The study was carried out in 1286 school children enrolled from the nursery
sRIVASTAVA ET AL.--ASYMPTOMATIC
BACTERIURIA
IN SGHOOL
177
CHILDREN
T a b l e 1, Bacteriuria in relation to sex of the children. Bacteriuric children No. screened
Asymptomatie
Symptomatic
Total
No.
%
No.
%
No.
%
Boys
500
2
0.4
4
0.8
6
1.2
Girls
786
29
3.6
22
2.8
51
6.4
Total
1286
31
2.4
26
2.02
57
4.4
to Class VIII, 500 (38.8%) being males and 786 (61.2%) females. Children ranged in age from 5 to 16 years. A higher prevalence of bacteriuria was observed in girls (6.4%) than boys (1.2%) (Table I). Asymptomatie bacterluria was higher amongst girls (3.6%) than boys (0.4%), the difference being statistically significant (X2=4.2, P < 0.05). Table 2 shows that about half ot the
symptomatic bacteriurics either showed a poor growth or poor growth associated with unexplained intermittent fever. Others had symptoms like eneuresis, frequency of micturition or their combinations. The study showed a higher prevalence of bacteriuria amongst Muslims (5.8%) than in Hindu children (4.2%); however, no significant association was observed (X 2 0.98, P > 0.05).
Table 2. Clinical features in 26 children. Symptoms
Number
Poor growth
7
Eneuresis
4
Unexplained intermittent fever + poor growth
6
Unexplained intermittent fever
2
Eneuresis ~ poor growth
2
Frequency of mlcturition
1
Frequency of rnicturition ~ poor growth
2
Frequency with unexplained intermittent fever
2 Total
26
178
\rOE. 44, No. 354.
I N D I A N . J O U R N A L OF P E D I A ' F R I C S
T a b l e 3. Bacteritvia and religion of the children.
Hindu
children
Bacteriuric
Muslim
children
children
Bacteriuric
Total
children
Total N,).
,/i
No.
%
Girls
674
40
5.9
112
9
8.4
Boys
422
6
1.4
78
2
2.5
Total
1096
46
4.2
190
Il
5.8
A s y m p t o m a t i c bacteriuria increased with the increase in the age of children; however this increase was not found to be significant (X9~=3.6, P > 0.05). A decrease
in the prevalence of symptomatic infection was noted with increasing age and this was also not found to be statistically significant (X~= 1.03, P > 0 . 0 5 ) .
T a b l e t . Bacteriuria in relation to age of the children. Bacteriurics
Age group in years
No. of children
Asymptomatic
No.
%
Symptomatic
No.
Total
%
No.
%
5--8
542
9
1.6
13
2.3
22
4.0
9--12
450
11
2,4
9
2.0
20
4.4
13--16
294
11
3.7
4
1.3
15
5.1
1286
31
2.4
26
2.02
57
4.4
Total
St,IIVASq_'AVA ET
AL.---ASYMPTOMATIC
T a b l e 5. Social class (Prasad 1970)
179
IN S C H O O L C H I L D R E N
Bacteriuria in relation to socio-cconomic status of children.
No. of children
I
BACTERIURIA
Total No. and %
34
Bacteriutie children Symptomaric No. and %
2
Nil
(2.9)
Asymptolnalic No. and % 1
(100.0)
II
141
4 (2.8)
1 (25.0)
3 (75.0)
III
296
11 (3.7)
4 (36.4.)
7 (63.6)
IX'
536
26
13
13
(4.8)
(50.0)
(50.0)
279
15 (5.3)
8 (53.3)
7 (46.7)
1286
57 (4.4)
26 (45.6)
31 (54..4.)
V Total
Figures in parentheses denote percentage. Bacteriuria was less fi'equent (2.8%) in the children belonging to social classes I and II as compared to children belonging to social class I I I (3.70/o) and social classes IV and V (5.030/0). However, this difference was not found to be statistically significant (X 2 ~-- 2.01, P > 0.05). The frequency of asymptomatic bacteriuria was higher (80.0%) in social classes I and II as T a b l e 6. Organisms
compared to social class I I I (63.6%) and social classes IV and V (48.7%). In no instance was more than one organism isolated. E. coli (59.6%) was the commonest isolate (Table 6) followed by Klebsiella (24.6%) and Proteus (5.3%). Other organisms isolated were Strept. faecalis and Providence (3.5% each) and Staph. aureus and Alkaligenes faecalis (1.75% each).
Organisms isolated on bacteriological cultures. Number
Percentage
E. coli
34
59.6
Klebsiella
14
24.6
Proteus species
3
5.3
Streptococcus faecalis
2
3.5
Providence
2
3.5
Stap@lococcus aureus
1
1.75
Alkaligenesfaecalis Total
1
1.75
57
100.00
]80
INDIAN
JOURNAL OF PEDIATRICS
Discussion Urinary tract infections are common amongst children specially in females and a significant proportion remains asymptomatic. The recurrence of symptomatic infection is more commonly asymptomatic while asymptomatie infection may become symptomatic later (Norden and Kass 1968, Kunin 1972, Cohen 1972), the maximum risk being at the time of marriage and pregnancy (Norden and Kunin 1968). Evidence now suggests that presistent asymptomatic infections may result in progressive deterioration of renal functions with decreasing renal size (Smellie and Normand 1968 and Kunin 1972). The prevalence of asymptomatic urinary infection has been extensively studied, Kunin et al. (1962 and 1964) observed a prevalence of 0.04% in school boys and 1.2% in school girls. In a 7-yearfollow up study of school girls, Kunin (1969) reported an annual increment of 0.32% in bacteriuric girls. The author also noted that by 18 years of age, 5% of the girls developed urinary infection. Savage et al. (1969) in his study on 5-year-old school girls found 2.1% to be bacteriurics of whom 70% were symptomatic. The symptoms in them were not considered significant by the parents. In another study Savage et al. (1973) noted the prevalence of covert bacteriuria to be 0.6%. Meadow and Johnston (1969) observed the prevalence of bacteriuria to be 0.8%, 90% of whom were symptomatic. Recently, in a study carried out in a paediatric out patients' department (Marr and Traisman 1975) the prevalence of bacteriuria was reported to be as high as 5.0%. A higher prevalence of bacteriuria in school children has been observed in the
\7OL.
4,4, No. 354
present study as compared to the studies reviewed earlier. The overall prevalence of bacteriuria in the present study was 4.4% being 1.2% in boys and 6.4% in girls. Only 45.6% of bacteriurics were symptomatic. The asymptomatic prevalence was 0.4~o in boys and 3.6% in girls. The symptoms in symptomatic cases were considered insignificant by the parents and no medical advice was sought for that. This observation is in line with Savage el el.
(1969). Kunin el al. (1964) reported a significant increase in the incidence bacteriurics with increasing age. Similar findings were also noted in the present study. Asymptomatic bacteriuria increased with increase in age whereas symptomatic bacteriuria decreased. However, these differences were not found to be statistically significant. A higher percentage (5.030/0) of bacteriuric children were observed in social classes IV and V, about half of them (48.8%) being asymptomatic. Only 2.8% children belonging to social classes I and II were bacterlurics, 80.0O/o of them being asymptomatic. Kunin and associates (1964, 1968 and 1970) on the basis of their study on white and Negro girls concluded that environmental factors and the availability of medical care rather than personal hygiene is important in the genesis of bacteriuria. The relation of bacterial colonization in the vulval region and recurrent urinary infection is well known (Vosti et el. 1964, Gruneberg 1969 and Stamey and Miller 1971). In the present study, the personal hygiene of children in the lower socio-economic groups was generally poor and this might have accentuated the prevalence rate of bacteriuria in social classes IV and V. The higher prevalence
SRIVASTAVA ET AL,--ASYMPTOMATIC BACTERIURtA IN SCHOOL CHILI)REN
of bacteriuria in Muslim children (5.8%) than Hindu children (4.2%) might be largely due to comparatively poor socioeconomic conditions, the Muslim population in the study area being generally very poor. A relatively poor personal hygiene noted amongst Muslim children might have also contributed in the genesis of infection to some extent. E. coli was the commonest organism (59.6%) isolated followed by Klebsiella (24.6%), compared to other studies (Kunin 1970, Marr and Traisman 1975), the prevalence of Klebsiella was higher than that of E. coll.
Proteinuria and pyuria were not helpfitl in the diagnosis of urinary infection. Proteinuria was observed only in 6% of baeteriurics and only 43.7~ of bacteriurics had significant pyuria. Similar observations have also been reported by other workers (Pryles 1971, X'Iarr and Traisman 1975). On the basis of his study, Kunin (1972) has recommended routine urinary screening ot girls at the time of schooling and one year later. The American Academy of Paediatrics (1974) has also lately recommended routine evaluation of girls at the age of 3 years, 4 to 5 years, 8 to 9 years and I1 to 12 years. With our limited resources, routine bacteriological screening of school children is not possible. However, ~i history suggestive of urinary infection should be taken in every child and the children with suspicious symptoms should be subjected to bacteriological screening. Further, children with imperfect health without any demonstrable cause should also be screened for urinary infection.
] (]l
References Andriok, V.J.(1972). Diagnosis o; urinary tract inlection by urine culture. In " U r i n a r y tract infection and its management." l-'d. Kaye C.V. Mosby Co. St. Louis, P. 42. Crulckshank, R. (1965). Medical Microbiology. E. & S. Livingstone, Edinburg. Cohen, M. (1972). Urinary tract infection in children. Females aged 2 through i4, first two infections. Pediatrics, 42,271. Committee on Standards (1974). Suggestive mintmum schedule for preventive health care of chiklren and youth. Evanston, Illinois. American Academy of Paediatries. Gruneberg, R.N. (1969). Relation of infecting urinary organisms to the faecal flora in patients with symptomatic urinary infections. Lancet2, 766. Kunin. C.M., Zaeha, E. and Paquin, A J. (1962). Urinary tract infection in school children: Prevalence of bacteriuria and associated urologic findings. New Eng. J. Med. 266, 1287. Kunin, C.M., Deutscher, R. and Paquin, A.J. (1964), Urinary tract infection in school children. An epidemiologic, clinical and laboratory study. Medicine, 43, 91. Kunin C.M. and McCormack (1968). An epidemiologic study of bacteriuries and blood pressure among nuns and working women. Nero Eng. J. Med. 278, 635. Kunin, C.M. (1969). Emergence of bacteriuria and symptomatic urinary tract infection among population of school girls followed for 7 years. Pediatrics, 41,968. Kunln C.M. (1970). A 10 years study of bacteriuria in school girls. Final Report of bacteriologic urologic and epidemiologic studies. J. Inf. Dis., 122, 382. Kunin C.M. (1972). Detection, PrevaIence and Management of Urinary Tract Infection. Philadelphia, Lea and Febizer, p. 62. Meadow R.S, and Johnston, N.M. (1969). Prevalence of symptomatic urinary tract disease in Birmingham school children. Pyurla and bacteriuria. Brit. Med. j , 3, 8l. M a r r , ' F . J . and Traisman, H.S. (1975). Detection of bacteriuria in paediatric out patients. Amer. ft. Dis. Child. 129, 9t0. Norden, C.W. and Kass, E.H. (1968). Bacteriuria of pregnancy. A critical appraisal. Amer. Rev. Med. 19, 431.
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Prasad, B.G. (1970). Changes proposed in the social classification of Indian families, yr. Indian Med. Ass. 55, 198. Pryles, C.V. (1971). Laboratory diagnosis of u:inary tract infection. Pediat. Clin. North Amer. 18, 238. Stamey, T.A. and Miller, M. (1971). Recurrent urinary infections in adult women: Role of intestinal enterobacteria. Calif. Med, 115, 1. Smellie, J . M . and Normand, I.C.S. (1968). Experience of follow up of children in urinary tract infection. In Urinary tract Infection. Ed. F.O. Grady and W. Brumfitt. P. 1211, Oxford UniversOyPress.
VOlo. ,14, N o . 35,t Savage, D.C.I,., Wilson, M.I., Ross, E.M. and Fee, M.W. (1969). Asymptomatic bacteriurla in glrl entrants to Dundee Primary School. Brit. Med..7. 3, "15. Savage, D.C.L., Wilson, M.I., McSteady, D. (1978). Covert bacteriuria in childhood. Arch. Dis. Child 48, 2. Vostl. K..L., Goldberg, I.M., Monto, A.S. and Rantz, L.A. (1964). Host parasite interaction in patients wilh infections due to Esch. coll. I. Sero. grouping of Esch. coli from intestinal and extra intestinal sources. 07. Clin. Invest. 43, 2377.
