Introduction: Urinary tract infection can result in many complications such as abscess, hypertension, renal failure, renal scar, reflux, etc. Since there is no general agreement on the administration of additional fluid (1.5 times maintenance) for the early treatment of UTI, this study was conducted to evaluate the effect of additional fluid therapy.Materials and Methods: In This clinical trial study, 206 children with UTI who were admitted at Amir Kabir Hospital (Arak, Iran) from March 2012 to March 2013 were divided into two groups of 103. One group received the usual amount of maintenance fluid while the other group received 1.5 times more than usual maintenance. The course of the resolution of dysuria, frequency, malodorous urine, abdominal pain, and fever was compared between the two groups. Urine culture was performed for all patients 2, 7-10, and 90 days after admission. The patients were age and sex matched. The data was analyzed using descriptive statistics and the X2 method based on independent sample t-test.Results: Additional fluid had a significant effect on malodorous urine dysuria. However, it had an inverse effect on the treatment of fever and urinary frequency as it made them last longer. There was no difference in other parameters like abdominal pain and urine culture in 3 stages.Conclusions: Based on our study, the intake of excessive amounts of water has no significant effects on the results of the UTI treatment. However, due to lack of adequate evidence, further studies should be conducted in this field.Keywords: Urinary Tract Infection; Child; Fluid Therapy

Arjmand, Ali

Cyrus, Ali

Dorreh, Fatemeh

Sharafkhah, Mojtaba

Yousefichaijan, Parsa

English

Journals Portal, Shahid Beheshti University of Medical Sciences

 Additional Fluid Therapy in Urinary Tract Infection- Yousefichaijan P et al                                  Journal of Pediatric Nephrology | Volume 4 | Number 1| 2016 25  Research Article  J Ped. Nephrology 2016;4(1):25-29 http://journals.sbmu.ac.ir/jpn DOI: http://dx.doi.org/10.20286/jpn-040125  Is Additional Fluid Therapy Effective in the Treatment of Children with Urinary Tract Infection?  How to Cite This Article: Yousefichaijan P, Sharafkhah M, Cyrus A, Dorre F, Arjmand A. Is Additional Fluid Therapy Effective in the Treatment of Children with Urinary Tract Infection? J Ped. Nephrology 2016;4(1):25-29. Parsa Yousefichaijan,¹ Mojtaba Sharafkhah,2* Ali Cyrus,3  Fateme Dorre,4 Ali Arjmand4   1 Pediatric Nephrologist, Department of      Pediatrics,  AmirKabir Hospital, School      of Medicine, Arak University of Medical      Sciences, Arak, Iran.  2 Students Research Committee, School      of Medicine, Arak University of  Medical      Sciences, Arak, Iran. 3 Department of Surgery,  Valiasr  Hospital,      School of Medicine, Arak University of      Medical Sciences, Arak, Iran.  4 Department of Pediatrics, AmirKabir      Hospital, School of Medicine, Arak      University of Medical Sciences, Arak, Iran  *Corresponding Author Mojtaba Sharafkhah, MD. Students Research Committee, School of Medicine, Arak University of Medical Sciences, Arak, Iran. Tel:+98 9119180298 Fax: +9808633133193 Email: sharafkhah@arakmu.ac.ir Introduction: Urinary tract infection can result in many complications such as abscess, hypertension, renal failure, renal scar, reflux, etc. Since there is no general agreement on the administration of additional fluid (1.5 times maintenance) for the early treatment of UTI, this study was conducted to evaluate the effect of additional fluid therapy.  Materials and Methods: In This clinical trial study, 206 children with UTI who were admitted at Amir Kabir Hospital (Arak, Iran) from March 2012 to March 2013 were divided into two groups of 103. One group received the usual amount of maintenance fluid while the other group received 1.5 times more than usual maintenance. The course of the resolution of dysuria, frequency, malodorous urine, abdominal pain, and fever was compared between the two groups. Urine culture was performed for all patients 2, 7-10, and 90 days after admission. The patients were age and sex matched. The data was analyzed using descriptive statistics and the X2 method based on independent sample t-test.  Results: Additional fluid had a significant effect on malodorous urine dysuria. However, it had an inverse effect on the treatment of fever and urinary frequency as it made them last longer. There was no difference in other parameters like abdominal pain and urine culture in 3 stages.  Conclusions: Based on our study, the intake of excessive amounts of water has no significant effects on the results of the UTI treatment. However, due to lack of adequate evidence, further studies should be conducted in this field.  Keywords: Urinary Tract Infection; Child; Fluid Therapy.   Received: Nov-2015 Revised: Dec-2015 Accepted: Dec-2015  Running Title: Additional Fluid Therapy in Urinary Tract Infection  Introduction  Urinary tract infection (UTI) is a common childhood infection. About 3 – 5 % of the girls and boys suffer from UTI. The mean age at the first UTI episode is 5 years old and it is most common during infancy among girls. In boys, it is mostly observed during the first year of infancy in those who have not been circumcised. Unlike adults, UTI does not have clear symptoms in children and sometimes occurs with unusual manifestations  such as weight loss, FTT (failure to thrive), anorexia, jaundice, and pyrexia with an unknown   origin. Therefore, it attracts the physician’s attention less often [1, 2]. UTI can be asymptomatic or part of a disseminated infection [3]. Due to its complications including early ones such as sepsis and bacteremia, and late complications like hypertension, chronic renal failure, and reflux nephropathy, early diagnosis and timely treatment of this disease is of great importance [1]. In the studies conducted in the U.S. in 1994, pyelonephritis and reflux nephropathy comprised about 8.3 % of the cases  Additional Fluid Therapy in Urinary Tract Infection- Yousefichaijan P et al                                  Journal of Pediatric Nephrology | Volume 4 | Number 1| 2016 26  of chronic renal failure [4]. Hypertension is a long-term complication of pyelonephritis. Pyelonephritic scarring is the most common unilateral renal parenchymal injury and one of the common causes of hypertension in children and adolescents [5]. Therefore, considering the high percentage of UTI resulting from chronic renal failure and since renal scarring can be prevented by early diagnosis and timely treatment, and also due to financial and social problems of renal failure for patients, the necessity of appropriate and practical strategies for timely diagnosis and treatment of UTI and prevention of long-term complications is felt. There is no consensus on whether oral or intravenous (IV) treatment should be used on which extensive researches have been already conducted. In many cases, no difference has been found between oral and IV treatment [6]. There is also disagreement on fluid consumption during UTI treatment. It has been traditionally taken for granted that UTI is better controlled by abundant water consumption. This hypothesis seems to be true due to decreased urinary stop and increased urinary flow. However, some researchers have noted that increased water consumption decreases the concentration of the antibiotics in the urine and its acidity. They believe that abundant water consumption can prevent good recovery from UTI [7-9]. We decided to conduct this investigation because there is still no consensus on whether additional fluid should be consumed (1.5 times more than maintenance fluid).  Materials and Methods This clinical trial study was conducted on children aged 3 – 13 years old who were diagnosed with UTI and admitted based on the pediatrician’s advice and did not suffer from underlying diseases such as renal and liver failure. Overall, 206 patients were studied in two groups with 103 members. The inclusion criteria were pyrexia of higher than 38.5˚C, clinical symptoms, and abnormalities on urinalysis and a positive urine culture. The cases with renal insufficiency were excluded from the study. The criteria for a positive urine culture were either more than 105 colony counts of a single pathogen in a urine sample collected with a urine bag or any count of individual bacterial growth in the suprapubic sample. Moreover, the findings of urinalysis included hematuria, pyuria (the presence of more than 3–5 WBCs (Wight Blood Cells) in a microscopic field at ×40 magnification), positive nitrite, and low specific gravity of the urine considering the age of the child, bacteriuria, and WBC cast and clump. Furthermore, symptoms such as the patient’s illness, inability to receive fluids orally, nausea and emesis, symptoms of sepsis, and abdominal pain were among admission criteria. The randomized block design method was used in two-level blocks in order to randomly assign the subjects to groups. Accordingly, UTI patients were randomly assigned into two groups of treatment with additional fluid (1.5 times more than the usual maintenance fluid) and treatment with maintenance fluid. The patients in both groups were completely matched in terms of age and gender. They were examined for urinary symptoms such as dysuria, urinary frequency, malodorous urine, urinary urgency, abdominal pain, pyrexia during hospitalization every day. After discharge, outpatient treatment was continued for up to 14 days. Moreover, urine culture was requested 48 hours after the start of treatment and 7–10 days and within 3 months after its completion. The examiner of the symptoms had no knowledge about the type of fluid regimen prescribed for the patient. The patients were included in the study after receiving their parents’ consent. The patients who did not adhere to the protocol of the study were replaced and excluded from the study. With regards to the fact that the type of antibiotic treatment was different based on the results of antibiogram, it was decided to examine the cases in whom antibiogram in the urine culture was sensitive to ceftriaxone and cefixime. Overall, 206 patients were studied in two groups of 130. The amount of the maintenance fluid was calculated based on the 17th edition of Nelson Textbook of Pediatrics. The same serum was selected for both groups (1:3 and 2:3 serums). Moreover, in patients who suffered from pyrexia, the maintenance fluid was increased by 12% per every degree of temperature rise above 38˚C. In terms of antibiotic treatment before the culture and antibiogram results were available, ceftriaxone 50-75mg/kg/24h/div was used in 2 doses until 48 hours after the improvement of pyrexia. Furthermore, treatment was continued orally often with cefixime 8 mg/kg/24h/div in 2 doses for 14 days. The total IV and oral treatment duration was 14 days. In addition, in case of hyperthermia, first UTI in boys, recurrent UTI in girls, family background of vesicoureteral reflux, lack of response to treatment after 48 hours, and increased creatinine, imaging studies such as  Additional Fluid Therapy in Urinary Tract Infection- Yousefichaijan P et al                                  Journal of Pediatric Nephrology | Volume 4 | Number 1| 2016 27  ultrasonography were requested. The X2 method was employed for statistical analysis based on the independent sample t-test at a confidence level of 95% and alpha of 0.5 using SPSS18. The study was approved by the Ethics Committee of Arak Medical Sciences University and written consent was obtained from all the patients’ parents or guardians. The patients could also withdraw from the study at any time. The researchers were committed to the Declaration of Helsinki throughout the research.  Results Of the participants, 164 were girls (79.6%) and 42 were boys (20.4%). The average improvement of the clinical symptoms in both 103-member groups after 24, 48, 72, and 96 hours is presented in Table 1. The frequency of a positive urine culture 24 hours after the completion of treatment in both groups is presented in Table 2.  Urine culture 48 hours after treatment: About 85.4 % and 14.6 % of the patients had negative and positive cultures, respectively. All of them had negative cultures 7–10 days and during 3 months after the treatment.  Dysuria: There was a significant difference in the mean duration of recovery from dysuria between the two groups. Therefore, receiving fluid had a significant effect on the dysuria recovery time (p<0.05).  Urinary frequency: A significant difference was observed in the mean duration of recovery from urinary frequency between the two groups (p<0.05) which increased from 24 hours to 48-72 hours in the group receiving additional fluid.  Abdominal pain: There was no significant difference in the mean duration abdominal pain improvement. Malodorous urination: The mean duration of recovery from malodorous urination decreased after receiving additional fluid (p<0.05).  Pyrexia: Receiving additional fluid had a negative effect on pyrexia and increased its recovery time (p<0.05).  Urine culture: There was no significant difference in culture results between groups 48 hours after the start of treatment and 7–10 days and during three months after its completion (p<0.05)Table 1. Comparison of the mean recovery time of clinical symptoms between 2 groups of patients diagnosed with UTI Time  Recovery from Pyrexia Recovery from Frequent Urination Recovery from Malodorous Urination Recovery from Abdominal Pain Recovery from Dysuria   Group 1 Group 2 Group 1 Group 2 Group 1 Group 2 Group 1 Group 2 Group 1 Group 2 24 hours later Frequency 11 6 44 33 24 42 11 49 19 25 percent 10.9 5.8 62.9 36.7 35.8 46.2 10.9 52.7 19.6 25.5 48 hours later Frequency 65 52 18 37 15 30 65 27 39 48 percent 64.4 50.5 25.7 41.1 22.4 33 64.4 29 40.2 49 72 hours later Frequency 21 34 7 19 21 16 21 16 29 23 percent 20.8 33 10 21.1 31.3 17.6 20.8 17.2 29.2 23.5 96 hours later Frequency 4 11 1 1 7 3 4 1 10 2 percent 4 10.7 1.4 1.1 10.4 3.3 4 1.1 10.3 2 Total Frequency 101 103 70 90 67 91 101 93 97 98 percent 100 100 100 100 100 100 100 100 100 100  Group 1. The group that did not receive additional fluid. Group 2. The group that received additional fluid.   It should be noted that according to the urine culture results of 206 patients, 183 cases suffered from E. coli, 17  cases  from Proteus,  and  6  ones   from  Klebsiella.  Moreover, according to  the X2  statistical test, no significant relationship was observed between age and gender and the mean  duration of recovery from dysuria, urinary frequency, malodorous  urination, abdominal pain,   Additional Fluid Therapy in Urinary Tract Infection- Yousefichaijan P et al                                  Journal of Pediatric Nephrology | Volume 4 | Number 1| 2016 28  and urine culture. Furthermore, the type of the pathogen in the initial urine culture did not have any impact on the above cases.   Table 2. Comparison between the mean negative urine cultures 48 hours after treatment completion of 2 groups of patients diagnosed with UTI  Urine culture The group which did not receive additional fluid The group which received additional fluid Frequency Net percentage Frequency Net percentage Negative urine culture after 48 hours 93 90.3 88 85.4 Positive urine culture after 48 hours 10 9.7 15 14.6 Total 103 100 103 100  Discussion UTI patients are usually encouraged to drink as much fluid as possible [7]. Removal of the bacteria from the epithelium of the urinary tract due to abundant fluid consumption can decrease their count and temporarily improve the patient’s symptoms [10]. In some cases, abundant fluid consumption can kill infection transiently. However, the urine flow usually decreases after reduced fluid consumption. Consequently, bacterial grow in the urine and symptoms recur [11]. Furthermore, abundant fluid consumption can cause problems in the urine acidity, decrease antibiotic concentration in the urine, and result in aggravated obstruction and vesicoureteral reflux [12].  In previous studies on UTI conducted by Wennerstorm, it was stated that increased fluid consumption could be harmful due to the decreased concentration of antimicrobial drugs in the urine [13]. On the other hand, abundant fluid consumption during UTI treatment was recommended in another research. In another UTI comparison made by another group, the additional liquid was recommended to be intravenously received 1–1.5 times more than the maintenance fluid [14].  Based on researches by scientists, fluid consumption has no effect on UTI early recovery [15]. None of the above studies were trial ones and no statistical data was provided. According to the results of our study, receiving additional fluid has a positive effect on recovery from dysuria and malodorous urination. Therefore, it is recommended for the improvement of these two symptoms. However, it is not recommended for other symptoms such as abdominal pain and at the time of negative urine culture since it has no effect on these parameters. Pyrexia and frequent urination improved faster in the group that did not receive additional fluid. Therefore, receiving additional fluid has an inverse effect on frequent urination and pyrexia and increases their recovery duration.  Conclusions Based on our study, the intake of excessive amounts of water has no significant effect on the results of the UTI treatment. However, due to lack of adequate evidence, it is recommended to conduct further studies in this field.  Acknowledgments The research team wish to thank vice chancellor of research of Arak University of Medical Sciences and AmirKabir Hospital for their financial support and also children and their parents who contributed to this research.   Conflict of Interest The author declared no competing interests.  Financial Support None declared  References 1- Jodal u, Sverker H. Urinary tract infection. In: Barratt M, editor. Pediatric Nephrology 4th ed. Philadelphia: Lippincott Williams &wilkins company, 1999. p. 835-850. 2- Kliegman RM, Behrman RE, Jenson HB, Stanton BF.Nelson Textbook of Pediatrics. 19th ed. Philadelphia, PA: Saunders; 2011. 3- Kaplan S. Urinary tract infection. In: Feigin F, Cherry J, Demmler G, editors. Pediatric infectious disease, 5th ed. Philadelphia: W.B. Saunders, 2004. P.541-553. 4- Hansson S, Jodal U. Urinary tract infection. In: Avner ED, Harmon WE, Niaudet P, editors. Pediatric Nephrology, 5th ed. Philadelphia: Lippincott Williams & Wilkins. 2003.p 1007-1021. 5- Jacobson S, Eklof O, Lins LE. Long-term prognosis of post-infectious renal scarring in relation to radiological findings in childhood a 27 year follow up. pediatrNephrol. 1992; 6 : 19-24. 6- Levtchenko E, lahy C, leuy J. Treatment of children with acute pyelonephritis a prospective randomized study. Pediatric Nephrology.2001; 16: 878-884.  Additional Fluid Therapy in Urinary Tract Infection- Yousefichaijan P et al                                  Journal of Pediatric Nephrology | Volume 4 | Number 1| 2016 29  7- Rushton HG. The evaluation of acute pyelonephritis and renal scarring with technetium 99mdimercaptosuccinic acid Rend scintigraphy (DMSA): evolving concepts and future directions. Pediatric Nephrology.1997; 11: 108-0120. 8- Baker PC, Nelson DS, schunl JE. The addition of ceftriaxone to oral therapy does not improve outcome in febrile children with urinary tract infections, Arch pediatric Adolescent Med. 2001; 155: 135 -139. 9- Hellerstein S, Kennedy E, Nussbaum L, Rice K. Localization of the site of urinary tract infections by means of antibody- coated bacteria in the urinary sediments. J Pediatr.1978; 92: 188-193. 10- Hoberman A, Wald ER, Hichey RW. Oral versus initial intravenous therapy for urinary tract infections in young febrile children.Pediatrics. 1999: 104: 79-86. 11- Wennerstrom M, Hansson S, Todal U. Renal function 16-26 years after the first urinary tract infection in childhood. Arch pediatric Adolescents Med. 2000; 154: 339-345. 12- Rushton HG, Majd M, Jantausch B. Renal Scarring following reflux and nonreflux pyelonephritis in children: evaluation with 99m-technetium- dimercaptosuccinic acid scintigraphy (DMSA): J Urology. 1992; 147: 1327-1332. 13- Wennerstrom M, Hansson S, Jodal U. Primary and acquired Rend scarring in boys and girls with urinary tract infection. J Pediatric.2000; 136-34. 14- Abrahamsson K, Hansson S, Larsson P. Antibiotic treatment for five days in effective in children with acute cystitis. Acta Pediatric.2002; 91: 55-58. 15- Jodal U. suprapubic aspiration of urine in the diagnosis of urinary tract infection in infants.Acta Pediatric. 2002;  

Is Additional Fluid Therapy Effective in the Treatment of Children with Urinary Tract Infection?

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Is Additional Fluid Therapy Effective in the Treatment of Children with Urinary Tract Infection?

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