URINARY TRACT INFECTIONS BLACK FEMALE JAMES ROBERT
From the Departments of Surgery and Pediatrics, University of Mississippi Medical Center, Jackson, Mississippi
ABSTRACT - It has been demonstrated in several studies that prepubertal blackfemales have a lower incidence of urinary tract infection than do white females of the same age. Other racial differences in the natural history of urinary tract infection have been suggested, but thus far very few young black girls with urinary tract infection have been thoroughly studied. The records of 56 black female children with urinary tract infections were reviewed and the clinical, laboratory, and radiologic manifestations of their disease documented. No attempt was made to compare data from blacks to that from whites since many studies composed primarily of white children are available in recent literature. This study is offered as baseline data on black female children to which future studies of black or white children may be compared.
Infection of the urinary tract in female children is common. In an extensive survey, Kunin, Deutscher, and Paquin, l and Kunin2 determined that 1.2 per cent of young white school girls had significant bacteriuria. The incidence in black females of the same age group was 0.5 per cent. There was no racial difference in incidence in a recent review by Dodge, West, and Travis.3 Studies comparing clinical, radiologic, and laboratory manifestations of urinary tract infections in black and white females are scant and usually contain few black girls; for example, Kunin’s review included only 22 black girls and Dodge’s 26. Our study was initiated because of the suggestion that in this disease there may be racial differences and because few studies have been done to document the manifestations of urinary tract infection in black female children to see if differences exist. No attempt was made to compare black and white girls in our study. We chose to study the manifestations of urinary tract infection in a significant number of prepubertal black females and offer this as a baseline to which other studies may be compared to examine racial differences.
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Methods The records of 56 black female children with urinary tract infection were reviewed. Ages ranged from three days to twelve years. The patients were found by review of admission diagnoses to this center from May, 1965, through January, 1974. A few were found in a review of outpatient records of the pediatric clinic at this center from May, 1972, through July, 1974. Patients were requested from the urologists in Mississippi, and 4 patients were referred. Children were excluded unless a significant growth of a pathogenic organism was found on urine culture. In most cases this was confirmed by colony count, but in some instances the number of colonies was not specified. When there was not a colony count, the patients were accepted only if the growth was described as “heavy” as opposed to “moderate” or “light.” The method of specimen collection was usually not described in the records. Children with other primary diseases were excluded. These diseases included myelomeningocele with neurogenic bladder, diabetes mellitus, burns, and any history of an indwelling catheter.
TABLE I. Symptoms 0 - 1 mo. Failure
1 mo. - 2 yrs.
Diorrheo Vomiting Fever Convulsions
at presentation 2-syrs.
12 5 1
Fifty-two patients had positive urine cultures at this center, and 4 patients had positive urine cultures at another hospital and were under treatment when seen at this center. Information from each patient included age, presenting symptoms, urinalysis results, urine culture results, medical therapy, follow-up, radiologic investigation, and surgical therapy. Results Ages ranged from three days to twelve years (Fig. 1). The series is dominated by patients in preschool years with greater than one-half under the age of four. Symptoms varied with age and were analyzed in groups according to age (Table I). Fever was the most common symptom regardless of age. Patients of the newborn age group had less specific symptoms, but with increasing age the more classic symptoms of urinary tract infection were found. Two of the children had growth of Escherichia coli on blood culture. One of these was two weeks of age, the other seven months. In both instances, the urine culture grew E. coli. Routine urinalysis was available in 52 of the patients. Pyuria (greater than 5 white blood cells per high-power field) was the only abnormality Eight had pyuria and found in 31 urinalyses. hematuria (greater than 5 red blood cells per high-power field). Four patients had hematuria alone. Nine urinalyses were normal. The infecting organism found most frequently was E. coli (35 cases), followed by KlebsiellaAerobacter (8), Proteus (3), Pseudomonas (l), Enterococcus (l), and Enterobacter (2). Two patients had a mixture of E. coli and Klebsiella and each was confirmed by a second culture. Four patients had a sterile urine when seen at this
Enumsis Abdominal pain Asymptomoti c
center but had significant growth of a pathogenic organism at another hospital and were under treatment when first seen by us. Since the study covered nine years and many different physicians were responsible for these patients, a variety of antibacterial agents were used. During the newborn period, penicillin and kanamycin were the most commonly used drugs. In the older groups, oral antibacterials such as ampicillin, and nitrofurantoins sulfonamides, predominated. No attempt was made to correlate sensitivities with drugs or to compare results of various drugs. Twenty-four of these patients had sterile urine after cessation of treatment. The longest follow-up period was for one year after the initial infection. Thirteen children had recurrence or persistence of infection on follow-up culture. No follow-up cultures were available on 19 children. Intravenous pyelograms were done in 36 patients, 6 demonstrating some anatomic abnormality. One child had pyelonephritic atrophy
FIGURE 1. Distribution tion of 56 patients.
by age at time of presenta-
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of one kidney; this was confirmed histologically since this kidney was removed surgically. The voiding cystogram on this patient showed total vesicoureteral reflux on the side of the damaged kidney. One patient had unilateral hydronephrosis secondary to congenital ureteropelvic This kidney was also rejunction obstruction. moved surgically. There were 2 patients with hypoplastic kidneys with normal collecting systems. One patient had caliectasis with no apparent obstruction and no loss of renal parenchyma, and 1 patient had unilateral incomplete duplication. Voiding cystourethrograms were done in 20 patients and 7 demonstrated abnormalities. Three patients had total vesicoureteral reflux with dilatation and 2 without dilatation. Two patients had fleeting or slight reflux, one of which was bilateral. The patient with slight bilateral reflux had the cystogram while infected. One of the patients had total ureterovesical reflux at age three, and a repeat study at age five showed no reflux. One patient with reflux at age two still had reflux when studied six months later. Only 1 patient with reflux had an abnormal intravenous pyelogram, this being the aforementioned patient with pyelonephritic atrophy of one kidney. Eleven patients were cystoscoped, and in 6 an abnormality was found. Two patients had an abnormality of one ureteral orifice described as “golfhole,” and 1 patient had an orifice described as “very patulous. ” All 3 patients with abnormalities of the ureteral orifice showed reflux on voiding cystogram. All of the patients who were cystoscoped had an internal urethrotomy or urethral dilatation, but major surgery was done in only 4 patients. There were two nephrectomies, one Y-V-plasty of the bladder neck with meatotomy, and one ureteroneocystostomy. A follow-up cystogram on the patient who underwent reimplant showed no reflux. Comment Discussions of clinical, laboratory, and radiologic manifestations and effects of urinary tract infection in black children are lacking, primarily in number of patients involved. As noted previously Kunin’s study included 22 school age black females and Dodge’s study 26. Our review consists of 56 black female children dominated by preschool age and is not an attempt to compare black children with white children. It is rather a retrospective review done to document the
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various manifestations and effects of urinary tract infection in black female children. Other series will be needed for comparison to this baseline. It would be valid, however, to compare our data with series consisting of white female children of a similar age. The symptoms, urinalysis results, and types of infecting organisms did not differ appreciably from previous reviews of white female children. The incidence of reflux is 30 per cent even with exclusion of the case which was infected at the time of the voiding cystogram. This is in line with the reported incidence of reflux in studies done in white female children.‘J,4-7 However, the 17 per cent incidence ofabnormal intravenous pyelograms from our study is lower than the 3S per cent incidence reported by Smellie et n1.4 and the 29 per cent incidence reported by Silverberg et nl. 5 Kunin’s review in 1964 showed no abnormal intravenous pyelograms in 22 black female children and no reflux in 18. Dodge did not give specific numbers of patients with radiologic abnormalities; however, he stated that there was no racial difference. Our review, dominated by younger children, does not show a lower incidence of reflux in the black female child. However, the reported lower incidence of reflux in the older child by Kunin suggests that while preschool black females reflux with frequency equal to that of whites, there could be a higher incidence of spontaneous regression of reflux in blacks. Also, it may be that the reflux in these younger black children was not severe since there was a low incidence of abnormalities on intravenous pyelogram. It should be noted that studies have shown a lower incidence of abnormalities of the urinary tract in younger children and our review has a large number of preschool children. 8,g Some racial differences in clinical manifestations of urinary tract infection may be attributed to socioeconomic factors. However, it is well known that racial differences exist for other diseases and many of these are known to be on a genetic basis. Sickle cell disease is an example. Essential hypertension, though poorly understood, differs in frequency between races also. There has recently been shown a racial difference in serum immunoglobulins, specifically IgA, IgG, and IgM. lo The immunoglobulins were significantly higher in black children. If the lower incidence of urinary tract infections in black female children is real, an immune mechanism could conceivably be responsible.
Further studies are needed to compare the natural history of urinary tract infections in blacks and whites, and if differences are found, to investigate possible causes. This review is offered as a record of some of our experience with blacks to which other reviews may be compared. Department of Surgery 2500 North State Street Jackson,
Mississippi 39216 (DR. KEETON)
References KUNIN, C. M., DEUTSCHER, R., and PAQUIN, A. J.: Urinary tract infection in school children: an epidemiologic, clinical and laboratory study, Medicine 43: 91 (1964). KUNIN, C. M.: A ten-year study of bacteriuria in school girls. Final report of bacteriologic, urologic, and epidemiologic findings, J. Infect. Dis. 122: 382 (1970). DODGE, W. F., WEST, E. F., and TRAVIS, L. B.:
Bacteriuria in school children, Am. J. Dis. Child. 127: 364 (1974). SMELLIE, J. M., HOBSON, C. J.. EDWARDS, D., and NORMAND, I. C. S.: Clinical and radiological features of urinary infection in childhood, Br. Med. J. 2: 1222 (1964). SILVERBERG, D. S., et al.: City-wide screening of urinary abnormalities in schoolgirls, Can. Med. Assoc. J. 109: 981 (1973). MAIR, M. I.: High incidence of “asymptomatic” urinary tract infection in infant school girls, Scot. Med. J. 18: 51 (1973). SAVAGE, D. C. L., et al.: Covert bacteriuria of childhood: a clinical and epidemiological study, Arch. Dis. Child. 48: 8 (1973). LIT~LEWOOD, J. M.: Sixty-six infants with urinary tract infection in first month of life, ibid. 47: 218 (1972). ASSCHER, A. W., et al. : Screening for asymptomatic urinary tract infection in schoolgirls, Lancet 2: 7819 (1973). GRANDBACKER, F. J.: Heritability estimates and genetic and environmental correlation for human immunoglobulins G, M, and A, Am. J. Hum. Genet. 26: 142 (1974).
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VOLUME VI, NUMBER 1