A STUDY OF URINARY TRACT INFECTION IN CHILDRENS UNDER FIVE YEARS IN KARBLA.

Muneer Al Tuama. Al Hussen Medical City. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History Received: 22 May 2019 Final Accepted: 24 June 2019 Published: July 2019 A study of urinary tract infection in childrens under 5years had been planned to identify the bacterial causes ,antibiotics sensitivity results and also immunological response to these bacteria .This study extend from 1/12/2004 to 1/12/2005 in pediatric hospital in Karbala .The methods of investigation used in this study were the standard criteria for urinalysis to look for puree which mean presence of more than 5 pus cells in centrifuged urine in high power field (WHO,2001) ,Also the color, cloudiness ,acidity of urine were registered for each sample . A urine culture was performed to detect the presence of any types of bacteria as well as their antibiotic sensitivity test were performed .The specific immunological response to bacterial types were assessed by immunodiffusion test . The standard criteria of this study were the age range from birth to five years, sex, previous urinary tract infection in the child, residence, type of feeding, chief complaint of child, congenital abnormalities if present, and past medical history of child. The total randomly selected cases in this study were 385 childrens (156 boys and 229 girls), Pyuria were diagnosed in 100 cases of them .they were 37 boys and 63 girls . 56 positive urine cultures for boys and girls of which 21(13.5%) from 156 cases for boys and the results for girls were 35(15.3%) from 229 cases .The numbers of positive urine cultures for E .coli were 37(66%),10(18%) for Proteus, 3(5.4%) Klebsiella, 1(1.8%) Pseudomonas,4(7.1%) Staphylococcus saprophyticus ,1(1.8%) for Enterobacter . in 44 cultures we couldn't isolate any bacteria although the cultures incubated for more than 48 hours , 20 culture for boys and 24 for girls and considered negative due to the use of antibiotics. E .coli susceptibility to antibiotics was characterized by high resistance to amoxicillin, cotrimaxazole, and where considered susceptible to nitrofurantoin, nalidixic acid , cefotaxime, gentamicin. The high resistance among Klebsiella pneumonia also toward amoxicillin and for cefotaxime, where considered susceptible toward nitrofurantoin , cotrimaxazole . The high resistance of proteus toward amoxicillin and sensitive for nalidixic acid and cefotaxime. The sensitive antibiotics of Staphylococcus saprophyticus were for cefotaxime, nalidixic acid , nitrofurantoin . The sensitive antibiotics of Pseudomonas and for Enterobacter were

A study of urinary tract infection in childrens under 5years had been planned to identify the bacterial causes ,antibiotics sensitivity results and also immunological response to these bacteria .This study extend from 1/12/2004 to 1/12/2005 in pediatric hospital in Karbala .The methods of investigation used in this study were the standard criteria for urinalysis to look for puree which mean presence of more than 5 pus cells in centrifuged urine in high power field (WHO,2001) ,Also the color, cloudiness ,acidity of urine were registered for each sample . A urine culture was performed to detect the presence of any types of bacteria as well as their antibiotic sensitivity test were performed .The specific immunological response to bacterial types were assessed by immunodiffusion test . The standard criteria of this study were the age range from birth to five years, sex, previous urinary tract infection in the child, residence, type of feeding, chief complaint of child, congenital abnormalities if present, and past medical history of child. The total randomly selected cases in this study were 385 childrens (156 boys and 229 girls), Pyuria were diagnosed in 100 cases of them .they were 37 boys and 63 girls . 56 positive urine cultures for boys and girls of which 21(13.5%) from 156 cases for boys and the results for girls were 35(15.3%) from 229 cases .The numbers of positive urine cultures for E .coli were 37(66%),10(18%) for Proteus, 3(5.4%) Klebsiella, 1(1.8%) Pseudomonas,4(7.1%) Staphylococcus saprophyticus ,1(1.8%) for Enterobacter . in 44 cultures we couldn't isolate any bacteria although the cultures incubated for more than 48 hours , 20 culture for boys and 24 for girls and considered negative due to the use of antibiotics. E .coli susceptibility to antibiotics was characterized by high resistance to amoxicillin, cotrimaxazole, and where considered susceptible to nitrofurantoin, nalidixic acid , cefotaxime, gentamicin. The high resistance among Klebsiella pneumonia also toward amoxicillin and for cefotaxime, where considered susceptible toward nitrofurantoin , cotrimaxazole . The high resistance of proteus toward amoxicillin and sensitive for nalidixic acid and cefotaxime. The sensitive antibiotics of Staphylococcus saprophyticus were for cefotaxime, nalidixic acid , nitrofurantoin . The sensitive antibiotics of Pseudomonas and for Enterobacter were 726 number of lactic acid bacteria. The resulting low pH of the vaginal epithelium prevents establishment of most bacteria as well as the potentially-pathogenic yeast, Candida albicans. This is a striking example of the protective effect of the normal bacterial flora for their human host (Todar,2002).

Pathophysiology
Almost all UTIs are ascending in origin and are caused by bacteria in the GI tract that have colonized the periurethral area. After birth, the periurethral area, including the distal urethra, becomes colonized with aerobic and anaerobic microorganisms (Bollgren and Winberg .1989). These organisms appear to function as a defense barrier against colonization by potential pathogens. Disturbance of the normal periurethral flora, such as may occur when an upper respiratory tract infection is treated with a broad-spectrum antibiotic, predisposes to colonization of the periurethral area by potential uropathogens (Lidefelt .1991).
Data from studies of women with recurrent UTIs support the concept that periurethral colonization with a uropathogen plays an important role in the pathogenesis of recurrent infections (Stamm.1984). These findings have not been confirmed in children (Schlager,et,al.1993).
However, children recently treated with antibiotics do have an increased risk of a febrile UTI compared with children with a non-UTI febrile illness who did not have recent antibiotic exposure ( Mårild,et,al.1989). The pathophysiology of UTI reflects a complex interaction between virulence factors of the microorganisms and the host defense( Barnett and Stephens.1997).
The perineal flora are normal inhabitants of the distal urethra. Urine in the proximal urethra, the urinary bladder, and more proximal sites within the urinary tract is normally sterile. Uropathogens must gain access to the urinary bladder and proliferate if infection is to occur. Bacteria in the distal urethra may gain access to the bladder because of turbulent urine flow during normal voiding, as a consequence of voiding dysfunction, or as a result of the use of instrumentation. In any case, normal voiding results in essentially complete washout of contaminating bacteria. Therefore, urinary bladder colonization does not usually occur unless bladder defense mechanisms are impaired or a virulent strain of bacteria has gained access to the bladder. In the absence of normal bladder emptying, there is proliferation of bacteria in bladder urine and the risk of a UTI. Even with normal bladder emptying, adherence to uroepithelial cells by virulent organisms such as P-fimbriated Escherichia coli may result in a UTI. P fimbriae (or pili) are organelles on E coli that mediate attachment to specific receptors on uroepithelial cells and impair washout of the bacteria (Roberts,et,al.1985).
The majority of UTIs in neurologically and anatomically intact children are caused by E coli. Children with intestinal carriage of P-fimbriated E coli are at increased risk for UTI because of colonization of the periurethral area by these pathogens (Plos,et,al.1995).

Epidemiology
1. The urinary tract infection is not uncommon in childhood. about 8% or more of girls and about 2% of boys will have a urinary tract infection at some time during childhood. The majority of urinary tract infections occur in the first year of life. 2. Most UTI are due to normal bowel flora. E. coli is the causative organism in 80% of cases. Other common causative organisms are Klebsiella ,Pseudomonas and other gram-negative organisms. 3. Urinary tract infections are much more common in girls than boys (at least 10:1)-this is true for all age groups except the newborn where the higher incidence of congenital abnormalities of urinary tract in the male, makes the reverse true(Larcombe .1999) .

Diagnosis
Urine sample collection the specimen for urinalysis and culture should be obtained by catheter or suprapubic aspiration in the infant or child unable to void on request .suprapubic aspiration is the method of choice in the uncircumcised male .a midstream clean catch specimen may be obtained from the child with urinary control. A bagged specimen of urine that show no growth or fever than 10000 colony-forming units(CFU) per ml is evidence of the absence of a UTI .if the child who not yet achieved urinary control has symptoms that mandate immediate treatment ,and analysis of the urine specimen obtained by bag shows pyuria ,a urine sample should be obtained by suprapubic aspiration or catheter 727 before stating antibiotic therapy because of high incidence of false positive urine culture (Ginsburg,et,al.1982) .So the ways of collection of urine was recommended as follow. 1. Urine bag collection (not recommended 2. High incidence of contamination. 3. Clean catch urine of first morning void. 4. Urine catheter specimen. 5. Recommended if child under age 2 years. 6. Suprapubic aspirate. 7. consider for child under age 6 months old (Bulloch.et.al,2000).

Microscopic Urinalysis
A urinalysis involve physical and chemical examination of urine. In addition, the urine is spun in a centrifuge 10-15 ml at 1500 to 3000 rpm for 5 minutes to allow sediments containing blood cells, bacteria, and other particles to collect . This sediment is then examined under a microscope. A urinalysis then, offers a number of valuable clues for an accurate diagnosis: 1. Simply observing the urine for color and cloudiness can be important. 2. Acidity is measured . 3. White blood cells (leukocytes) are counted. A high count in the urine is referred as pyuria. (A leukocytes count of over 10 per micro liter of urine indicates pyuria. Pyuria is usually sufficient for a diagnosis of UTI in non hospitalized patient if standard symptoms (or just fever in small children) are also present (Harvey,2002).

Urine culture
A urine culture is a urine specimen observed for 24 to 48 hours in a laboratory for the presence of any bacterial growth. It is not routinely performed but may be conducted under certain circumstances 1. If urinalysis is negative but the patient has severe UTI symptoms, particularly in hospitatalized patients who have a catheter and who develop fever or other signs infection. 2. If the infection is recurrent. 3. if the physician suspects complications. 4. if girls younger than two years have a high fever of unknown origin that lasts two days or more (Harvey,2002).

Blood sample
to assess the renal function including blood urea and serum creatinine (Baum.. et. al, 1985 ). Renal ultrasonography images may show size, scarring of kidney, and the calculi if present (farmor. et. al, 2002).

Intravenous Urography (IVU)
It helps to establish the diagnosis of pyelonephritis because t h e y reveal caliceal dilatation and blunting with cortical scars. Ureteral dilatation and reduced renal size also may be evident. There: may be also cortical thinning over pelvo-calyceal lesions (Teplick , 1988).

Computerized Tomographic scan (CT scan):
It is the procedure of choice to help diagnose c hr o nic pyelonephritis (Gerzof and Gale, 1982).

Voiding cystourethrogram (VCUG);
The findings may document the reflux of urine to the renal pelvis and ureteral dilatation in children with gross reflux (liyas .et.al., 2002). Radio isotopic scanning with technetium dimercaptosuccinic acid: It is more sensitive than int ravenous urography for helping detect renal scars. This is the preferred test for many pediatric nephrologists and radiologists because it is sensitive and easy to perform and can detect VUR and renal scarring (Carroll. et.al., 1981).

Cystoscopy:
It showes the evidence of reflux at the ureteral orifices or site of kidney stone (liyas. et.al, 2002).

728
The quantitation of serum proteins as an aid in diagnosing deficiency disorders.

Summary
Single radial immunodiffusion tests have evolved from the work of (Fahey .et.al,1965). They are specific for the various proteins in serum or other fluids and depend on the reaction of each protein with its specific antibody.
When the wells in antibody containing gels are completely filled with the antigen, the precipitin rings which develop after 10-20 hours at room temperature are measured. The diameter of the ring and the logarithm (base 10) of the protein concentration are related in a linear fashion. Using appropriate reference standards, the concentration of unknown samples may be measured.

Principle
Radial immunodiffusion is based on the diffusion of antigen from a circular well radial into a homogeneous gel containing specific antiserum for each particular antigen. A circle of precipitated antigen and antibody forms, and continues to grow until equilibrium is reached. The diameters of the rings are a function of antigen concentration. After overnight incubation, the zone diameters of reference sera are plotted against the logarithm (base 10) of the antigen concentration. If equilibrium is reached, the reference sera zone diameters are squared and plotted against their concentration (linear). At intervals in between, a linear relationship does not occur. Unknown concentrations are measured by reference to the standard curve.

Antibiotics for Patients with urinary tract infection: Amoxicillin :
It is semi synthetic antibiotic from penicillin group that interferes with synthesis of cell wall mucopeptides during active multiplication of bacteria, resulting in bactericidal activity against gram-positive and gram-negative bacteria. In past, it has been used frequently for treatment of UTI. Now, most bacteria presented in UTI have high resistance to amoxicillin as shown by (Sakran.et.al,2003) who observed that only 52% of bacterial UTI responded to amoxicillin. In addition, (Leblebicioglu and Esen ,2003) and (Aggarwal. et. al, 2003) showed that more than 73% of E .coli and 88.5% of K .pneumonia isolated from patients with UTI were resistant to amoxicillin. Enterobacter, Acinetobacter and Corynebacterium spp. have a high resistance to amoxicillin (Zhou. et. al, 2002;Savov. et. al, 2002;Suarez. et. al, 2002).

Cephalosporin's
All first three generations of cephalosporin's have oral preparations that have been used for treatment of recurrent UTI (Wilhelm and Edson , 1987). First generation cephalosporin's: They arrest bacterial growth by inhibiting bacterial cell wall synthesis. The bactericidal activity is against grampositive bacteria and the administration is either oral (cefadroxil, cephalexin and cephradine) or parenteral (cephalothin, cephazolin and cephradine). Now; the usage of first generation cephalosporins is limited because of high resistance to it (Martinez et.al. 1995).

Second generation cephalosporin's:
They have bactericidal activity that inhibits bacterial cell wall synthesis. It has greater activity against anaerobic bacteria and the administration is either oral (cefaclor and cefuroxime axetile) or parenteral (cefamandole, cefmetazole, cefotetan, cefoxitin and cefuroxime). Second generation cephalosporins has limited use that Dumpis. et. al, (2003) showed that only 26% of patients with hospital-acquired UTI responded to second-generation cephalosporin's.

Third generation cephalosporin's:
They have bactericidal action that inhibits cell wall synthesis. They are highly stable in the presence of B-lactamase enzyme and they are effective in wide range of hospital-acquired and nosocomial bacterial infections. The administration is either oral (cefixime, cefpodoxime and ceftibuten) or parenteral (cefotaxime, ceftriaxone, ceflazidime and ceftizoxime). These drugs are excreted in bile, therefore they may use for patients with renal insufficiency (Katzung, 2002).The third generation cephalosporin's have been found affected in bacterial UTI that more than 80% and 71% of bacteria isolated from patients with UTI were sensitive to cefotaxime and ceftriaxone respectively (Gordon and Jones, 2003 ). In addition, 78% of * Acinetobacter isolated from patients with 729 UTI were also sensitive to cefotaxime (Irgbu et. al., 2003) but Zhou et. al,. (2003 showed that Enterobacter were highly resistance to cefotaxime.

Trimethoprim-sulfamethoxazole (TMP-SMX)
A combination of trimethoprim and sulfamethoxazole inhibits bacterial growth by inhibiting synthesis of dihydrofolic acid. It is represented the essential co-factor of purine, pyrimidine and amino acid synthesis. Its antibacterial activity includes most common urinary tract pathogens except Pseudomonas aeruginosa. The combination is contributed to the efficacy in treatment of upper UTI via synergistic bactericidal effect and may diminish the emergence of resistance (Burman, 1986). Nowadays, the resistance to TMP-SMX is slightly increased that 45% of bacterial UTI were resistant to it including 11% of E .coli and 42% of S.epidermidis isolated from patients with UTI (Ghiro et. al,2002 andJureen et. al,2003).

Nitrofurantoin
It is synthetic nitrofuran that interferes with bacterial carbohydrate metabolism by inhibiting acetyl coenzyme A. It is bacteriostatic at low concentrations, bactericidal at higher concentrations, and effective against most uropathogens but not Pseudomonas and Proteus species. It is presented for brief periods at high concentrations in the urine and leads to repeated elimination of bacteria from urine (Stamey et. al,1987). The risk of adverse reaction increases with age and long-term therapy; therefore, should be monitored (Holmberg . et. al,1980). Nitrofurantoin has lower resistant rate than other old antibiotics that only 4% of bacteria isolated from patients with recurrent UTI were resistant to it (Leblebicioglu and Esen, 2003).

Aminoglycosides
It is bacteriostatic action such as streptomycin, gentamicin,amikacin, netilmicin and tobramycin. Gentamicin is effective but it isassociated with a risk of nephrotoxicity and ototoxicity, making tobramycin possible alternatives. Because gentamicin is stored in renal tissues, it can prevent acute retrograde pyelonephritis. Since different aminoglycosides accumulate and persist to various degrees in the kidney parenchyma, they have protective activity of aminoglycosides against renal scarring (chronic pyelonephritis). These results suggest that renal accumulation and persistence of aminoglycosides may be used to advantage in the prophylaxis or in the treatment of kidney infections (Robert, 1999). Gentamycin is cost-effective parenteral therapy because only oncedaily dosing needed and has a good sensitivity against gram-negative uropathogens (90%) and it can be in combination with TMP-SMX against gram-positive uropathogens (70%) (Ghiro. et. al,2002).

Fluoroquinolones
They are bactericidal drugs that act as inhibitors of bacterial DNA gyrase enzyme (which responsible for supercoiling of bacterial DNA). They affected against gram-positive and gram-negative bacteria. Recently, the oral administration of fluoroquinolones like nalidixic acid, ciprofloxacillin, levofloxacillin, ofloxacillin, norfloxacillin and others used for empirical treatment of UT1. They increased considerably for managing of complicated UTI particularly chronic pyelonephritis.due to the ability to treat difficult pathogens with high antibiotic resistance like Pseudomonas. They can be administered parentefally, and then they can easily switch to oral administration and have limited use in patients with renal insufficiency (Dalkin and Schaeffer, 1988).

Bacteriological Agents Enterobacteriaceae
They are gram-negative bacilli; normally habituate in the intestinal tract of human being. Some of them act as a part of a normal flora and incidentally causes the diseases while others are pathogenic for humans. They possessed a complex antigenic structure and produced a variety of enzymes and toxins with other virulence factors (Mims , 2004).

E .coli
It is a member of Enterobacteriaceae and it is the most common cause of urinary tract infections arising outside of a hospital setting. These strains have PAP pili as well as CFA's (CFA/I, CFA/II, CFA/III). The pili are responsible for adherence in the urinary tract epithelium that the adhesin has important role in pathogenesis of chronic pyelonephritis and associated with severity of disease (Malsumoto. et. al,1990). The capsule of E .coli represented the antigenic structure (K antigen) and it is highly associated with the pathogenicity of pyelonephritis, so that K antigen of E .coli help in the attachment of bacteria to the epithelial cells prior to the urinary tract invasion. Nephropathogenic E .coli may produce hemolysin as a part of the virulence factors in the complicated UTI and this is not well clear on blood agar (Eisenstein and Azaleznik, 2000). Some strains are urease-producing E .coli and they are commonly presented in complicated UTI (Collins and Falkow, 1990. The antibiotic resistance of E .coli isolated from UTI is highly increased due to the abuse of antibiotics from the patients in addition to the toxins and enzymes like endotoxin and p-lactamase that play an important role in the virulence of bacteria. The recent studies showed that 47% of patients with UTI have E .coli in their cultures (Gordon and Jones, 2003). The incidence of urinary tract infection with E .coli is decreased due to the increase of the nosocomial infection of urinary tract (Schrier and Gottschalk, 1996). Proteus species produce urease resulting in rapid hydrolysis of urea with librations of ammonia .thus , in urinary tract infections with proteus ,the urine becomes alkaline promoting stone formation and making acidification virtually impossible .the rapid motility of proteus may contribute to its invasion of urinary tract . Strains of proteus vary greatly in antibiotic sensitivity .P mirabilis is often inhibited by penicillin's ,the most active antibiotics for other members of the group are aminoglycosides and cephalosporin's (Abbott,2003) .

Klebsiella pneumonia
Klebsiella is a member of the family Enterobacteriaceae . Colonies are large and highly mucoid. It is most common cause of hospital-acquired urinary tract infections or burn wound infections. The autoimmune disease (ankylosing spondylitis/ is thought to be a possible sequel of Klebsiella infection (Abbott, 1999) but the virulence of Klebsiella is not well understood, but its antiphagocytic capsule plays a role in the infections by preventing phagocytosis. It is thought that" aerobactin, an iron-binding protein, and the production of B-lactamase enzyme contribute to pathogenicity and antibiotic resistance of bacteria. Some strains of Klebsiella produced hemagglutinins (may be a mannose-sensitive phenotype) and they may be associated with the pathogenicity endotoxin has an important role in virulence and antibiotic resistance of bacteria (Gilchrist, 1995). Enterobacter can produce antibacterial substance that has antagonistic activity against a wide range of bacteria except Acinetobacter and Pseudomonas (Yaping . et. al,2003).

Serratia spp.
They are lactose-fermenter gram-negative short rods Enterobacteriaceae with one to two flagella. They represented 731 as opportunistic pathogens with wide ranges of infectivity in nosocomial infections like respiratory or urinary tracts infections. The virulence of bacteria commonly associated with the production of urease enzyme, hemolysin enzyme, siderophore and extracellular protease like gelatinase enzyme with presence of fimbriae help in adhesion of bacteria (either mannose-sensitive or mannose-resistant fimbriae) (Marumo. et. al,1990). Swarming motility characterized to the bacteria on solid or viscous media due to presence of flagella. The production of B-lactamase enzyme has given to bacteria high resistance to several antibiotics like that in Pseudomonas bacteria (Kouda. et.al, 1990).

Staphylococcal spp.
They are gram-positive spherical bacteria usually arranged in grap like irregular clusters. They are a normal flora of human skin and mucous membranes and their spread is either endogenously or from infected skin. They included many species but the main three species are S.aureus, S.epidermidis and S.saprophyticus. The pathogenicity of Staphylococci is contributed to hemolysis of the blood, coagulation of the plasma and production of extracellular enzymes and toxins (Mims et.al, 2004). Hemolysin + -± * Novobiocin used only to distinguish between S.epidermidis and S.saprophyticus.

S.epidermidis
It is a coagulase negative Staphylococci and a common member of the normal flora of skin and mucous membranes. Its large numbers and ubiquitous distribution make it one of the most commonly isolated organisms in the clinical laboratory. The first appearance of S.epidermidis in clinical material could dismiss as contamination; it is now one of the most important agents of hospital-acquired infections. Immunosuppressed patients are particularly at risk, as are individuals with indwelling catheters or prosthetic devices (Baron et.al., 1996). The hydrophobic nature of the organism's cell surface facilitates its adherence to synthetic devices. Following initial colonization, a copious amount of extracellular polysaccharide or slime is synthesized that forming a protective biofilm around the colony. Because many isolates are multiple antibiotic resistant, these infections are very serious and can even be fatal. In complicated UTI, S.epidermidis is represented more than 20% as a nosocomial infection (Guirguilzova . et. al, 2002).

S.saprophyticus
It is coagulase negative Staphylococci, commonly isolated from uncomplicated urinary tract infection in nonhospitalized patients, notably sexually active woman. S.saprophyticus may also be involved in recurrent infection and in stone formation that the incidence of S.saprophyticus in urinary tract infection varies according to the institutions and the geographical areas (Todar, 2001). It is resistant to several antibiotics such as novobiocin and nalidixic acid. Although the species do not produce number of extracellular products but it may produce hemolysin and the antiphagocytic capsule that the production of the slime may correlate with pathogenicity and bacterial adherence (Baron et.al., 1996).

S.aureus
It is coagulase positive Staphylococci, presented significantly in greater percentage of people in the hospital setting that the carrier state serves as reservoir for infection of hospitalized patients (Todar, 2001). S.aureus has a polysaccharide capsule to protect it from phagocytosis and the cell wall composed of peptidoglycan and teichoic acid moieties that protect it from lyses by osmotic condition and aid the bacteria to attach to mucosal surfaces. The virulence of the bacteria occurred by secretion of toxins and enzymes which act on host cell membrane and mediated the cell destruction. It is penicillin-resistance bacteria due to production of B-lactamase enzyme that is chromosomally resistance (Takahaski.et.al,1999).

Pseudomonas aeruginosa
It is non-fermenter aerobic gram-negative bacilli. It has one of the broadest ranges of infectivity among all pathogenic microorganisms as opportunistic pathogens. It is a significant cause of burn wound infection and nosocomial infection in human body like respiratory tract infection in patients with cystic fibrosis, eye infection and genitourinary tract infection in immuno-compramized patients (Bodey, 1983).
The pathogenicity of the bacteria contributed to the virulence factors of it. The capsule or slime layer is associated in adherence and effectively protected the bacteria from phagocytosis. The productions of extracellular protease, cytotoxins and hemolysin have an important role in virulence; in addition, the siderophore production under low iron condition helps the growth of pathogen (Woods and Iglewski, 1983).

Management
If treatment is injected before the results of a culture and sensitivity are available , a 3-to 5-day course of therapy with trimethoprim -sulfamethoxazole is effective against most strains of E.coli. Nitrofuratoin (5-7 mg/kg/24 hr in three to four divided doses) is also effective and has the advantage of being active against Klebsiella-Enterobacter organisms. Amoxicillin (50 mg/kg/24 hr) is also effective as initial treatment but has no clear advantages over the sulfonamides or nitrofuratoin.
In acute febrile infections suggestive of pyelonephritis, a 14-day course of broad-spectrum antibiotics capable of reaching significant tissue levels is preferable. If the child is acutely ill, parenteral treatment with ceftriaxone (50-75 mg/kg/24 hr. not to exceed 2 g) or ampicillin (100 mg/kg/24 hr) with an aminoglycosides such as gentamicin (3 to 5 mg/kg/24 hr in three divided doses) is preferable. The potential ototoxicity and nephrotoxicity of aminoglycosides should be considered and serum creatinine levels must be obtained prior to initiating treatment as well as daily thereafter as long as treatment continues treatment with aminoglycosides is particularly against pseudomonas(Rushton,1997).

Materials And Methods:-Patients And Materials Patients
This study began from 1/12/2004 to 1/12/2005. 100 children's patient with pyuria were taken in pediatric hospital of karballa from 385 children's who had complaints related to UTI. Their age range between birth to 5 years. 63 females and 37 males. The investigations were made to children's, GUE. urine culture and antibiotic sensitivity results and also the immunodiffusion test to some patients serum with specific types of bacteria.

Materials
Many types of instruments and chemical materials in addition to biological materials were used in this thesis to complete the research. The materials were taken from different sources and companies which listed in tables 1, 2, 3 Methyl red,a-Naphthol ,Tetramethyl-p-paraphenylene diamine dihydrochloride.  organisms that did not ferment lactose remain uncolored. This purple color was due to the absorption of the esoinmethylene blue complex, which formed in the presence of acid. Certain members of the coliform group, especially Escherichia coli, exhibited a greenish metallic sheen in the reflected light (Collee et.al., 1996).

Biochemical Tests Catalase Test :
It was prepared by dissolving of 0.1 gm of Tetra-P-fJ paraphenylene diamine dihydrochloride in 10 ml of distill water and stored in a dark container (Baron et.al, 1996). A colony of the organism was transferred to a drop of 3% H 2 O 2 on a microscope slide. The presence of catalase was meant that the formation of gas bubbles has occurred which indicated the positive result (Collee et.al.,l996).

Oxidase Test:
It was prepared by dissolving 3 gm of H 2 O 2 to 100ml of distill water and was stored it in dark container (Baron et.al., 1996).
A piece of filter paper was saturated in a petri dish with oxidase reagent then a colony of organism was spread onto the filter paper. When the color around the smear turned from rose to purple, the oxidase test was positive (Collee. et.al, 1996).

Coagulase Test:
Several colonies of bacteria were transferred with a loop to a tube containing 0.5 ml of plasma. The tube was covered to prevent evaporation and incubated at 37°C overnight. The test was read by tilting the tube and observing for clot formation in the plasma. Negative test results in the plasma remained free-flowing with no evidence of a clot (Collee. et.al., 1996).

Methyl red reagent :
0.1 gm of Methyl red was dissolved in 300 ml of 99% ethanol and then the volume was completed to 500 ml by distill water (Macfaddin, 2000).

Methyl Red Test:
The test was performed on 5 ml of MR-VP broth cultured by the organism and then it was incubated for 24 hours at 37°C. After that 6-8 drops of Methyl Red reagent were added to culture. The change of color to orange-red was a positive reaction (Collee et.al.,1996).

Voges-Proskaur Test:
The test was performed on 5 ml of MR-VP broth cultured by the organism and then it was incubated for 24 hours at 37°C. After that 15 drops of 5% alpha naphthol (reagent A) were added followed by 10 drops of 40% KOH (reagent B) and shaken well and allowed to stand for up to 30 minutes before calling a reaction negative. The positive culture was turning to red at the surface of the liquid, and the color was spread gradually throughout the tube (Baron et.al., 1996).

Indol Test:
A 1% solution of tryptone broth was prepared in the tubes then it was sterilized into the autoclave at 121 C for 15 minutes. After that the broth inoculated with bacterial colonies and it was incubated for 48-72 hours at 37°C. Testing for indole production was done by adding 6-8 drops of Kovac's Reagent (p-dimethylaminobenzaldehyde in amyl alcohol). The formation of red color ring at top of broth was a positive reaction.
A yellow color ring was a negative result (Macfaddin , 2000). well and allowed standing for up to 30 minutes before calling a reaction negative. The positive culture was turning to red at the surface of the | liquid, and the color was spread gradually throughout the tube (Baron et.al., 1996).

Simon Citrate Test:
After the sterilization of Simon citrate slants by autoclave at 121 C for 15 minutes then cooled to 50 C and inoculated with the bacterial cultures and incubated for 24-48 hours at 37°C. The positive result was a change of the color of media from green to blue. The unchanging of the color was a negative reaction (Benson, 1998).

Urease Test:
The urea base agar was sterilized by autoclave at 121 C for 15 minutes. After cools it to 50°C, the urea substrate was added to it and was poured in sterile tubes; then inoculated by bacterial cultures and it incubated them for 24-48 hours at 37°C. The positive result was a deep pink color. Failure of deep pink color to develop was a negative reaction (Benson, 1998).

Kliglar Iron Agar (KIA) Test:
The aim is to differentiate the Enterobacteriaceae according to carbohydrate fermentation and hydrogen sulfide production. The organism was grown on KIA slant by stab and streak and then it was inoculated at 37°C" for 24-48 hours. The changing of the color of the media from orange-red to yellow was due to carbohydrate fermentation with or without gas formation at butt of slant. In addition, the formation of Hydrogen sulfide was given a black color precipitation at butt (Macfaddin, 2000).

Motility test by using semisolid media:
According to the method described by (Macfaddin,2000).10 mls of semisolid media were dispensed in the tubes and left to set at the vertical position ,I had inoculated with a straight wire, making a single stab down the center of the tube to about half the depth of the medium. The tubes were incubated at 37°C and examine at 6 hours, 24 and 48 hours. Non-motile bacteria had generally confined to the stab-line and given sharply defined margins with leaving the surrounding medium clearly transparent. Motile bacteria were typically given diffuse hazy growths that spread through out the medium rendering it slightly opaque .

The modified Kirby-Bauer method
Mueller-Hinton agar 1. Mueller-Hinton agar should be prepared from a dehydrated base according to the manufacturer's (Mast lab ,uk) recommendations. 2. the medium was cooled to 45-50 ْC and pour into the plates. Allow to set on a level surface, to a depth of approximately 4 mm. A 9-cm plate requires approximately 25 ml of medium. 3. after agar had solidified, the plates placed in the upright position in the incubator with the lids tilted at 35c for 30 minute to dry.. 4. Any unused plates may be stored in a plastic bag as the recommendation of (vandepitte,et.al ), which should be sealed and placed in the refrigerator. Plates stored in this way will keep for 2 weeks.

Antibiotic discs
Antibiotics discs of (Iraq,Razi) with the proper diameter and potency which had be used. Stocks of antibiotic discs should preferably be kept at -20 °C; the freezer.
Antibiotics discs can be kept in the refrigerator for up to 1 month. On removal from the refrigerator, the containers should be left at room temperature for about 1 hour to allow the temperature to equilibrate.

Procedure
As the way of (Macfaddin,2000).The modified Kirby-Bauer method was performed by using a pure culture of previously identified bacterial organism .the inoculum to be used in this test was prepared by adding growth from 5 isolated colonies grown on a blood agar plate to 5ml of broth. This culture was then incubated for 2 hours to produce a bacterial suspension of moderate turbidity. A sterile swab used to obtain an inoculum from the standardized culture .this inoculum was then streaked on a Mueller-Hinton plate.
The antibiotics discs were placed on the surface of the medium at evenly spaced intervals with flamed forceps or a disc applicator. incubation was usually overnight with an optimal time being 14 hours at 37c .antibiotics inhibition zones were measured using a caliber. Zone size was compared to standard zones to determine the susceptibility or resistance of the organism to each antibiotic. 737

Results:-
Determine the concentration of each unknown or specimen protein by reading its zone diameter on the reference curve and the corresponding concentration. Zone diameter must be squared for End Point calibration.

Results
The study included 385 children's who had complaints related to UTI (259 girls and 126 boys ) from birth to 5 years old age came to pediatric hospital of karballa and general urine examination were done for them and found the pyuria in 100 children's (63 girls and 37 boys) as show in table (1) .we found that 56 of them with positive urine culture ( 35 girls and 21 boys) as show in table (2) . Table 2 demonstrated the distribution of cases according to their sexes. It show the prevalence of urinary tract infection among girl higher than boys (62.5 % VS 37.5 % ) Table 3 Show distribution of cases according 5 age groups.

Age distribution
( group 1 from birth to 1 year ) 20 (group 2 from 1 to 2 year ) 18 (group 3 from 2 to 3 year ) 7 (group 4 from 3 to 4 year ) 4 (group 5 from 4 to 5 year ) 7 Brest feeding effect. Table 4 Show the number and percentage of cases according to breast feeling effect.
Circumcision affect on UTI in boys under 2 years . Table 5 Show the Distribution of cases of UTI in boys in the first two years of age according to the circumcision affect .

D 2 20
738 Recurrent urinary tract infection in children's under 5 years . Table 6 Show Distribution of cases of recurrent urinary tract infection in the children's under 5 years according to the sex.. Table 7 Show the numbers and percentage of bacterial cases of urinary tract infection in the children's under 5 years .

Table 8
Show the numbers of bacterial cases of urinary tract infection in children's under 5 years according to sex and age groups .
Antibiotic sensitivity Result . Table 9 Show the numbers and percentage of resistance of bacterial isolates to several antibiotic's. Immune response for urinary tract infection We took in this study 21 children's with pyuria 7 cases with E .coli,7 cases of Proteus and 7 cases with negative urine culture and we measured for them serum IgG ,IgM antibodies and compared with means of concentrations of these three groups and we founded that the mean of serum IgG,IgM antibodies of E .coli was higher than Proteus mirabilis and for Proteus was higher than negative cases as seen in figure (2) .
So the immune response of E .coli bacteria was higher than proteus bacteria and for proteus bacteria was higher than negative cases.