Frequency of Urinary Tract Infection among Neonates with Persistent Jaundice at Lady Reading Hospital, Peshawar

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Original Article
Jaundice is a medical condition characterized by the yellow-orange discoloration of the skin and sclera, resulting from an excess of bilirubin in the skin and mucous membranes [1].In neonates' jaundice, indirect neonatal hyperbilirubinemia (INH), is a common nding and frequent reason for neonatal hospitalization worldwide1.Physiologic jaundice typically manifests between days 2 to 4 after birth, reaches its peak around days 4 to 5, and resolves within a two-week period [2].Physiologic jaundice is not observed within the initial 24-hours period.Likewise, t h e e t i o l o g y o f p a t h o l o g i c a l u n -c o n j u g a t e d hyperbilirubinemia is attributed to heightened bilirubin production, diminished bilirubin clearance, and increased Frequency of Urinary Tract Infection among Neonates with Persistent Jaundice at Lady Reading Hospital, Peshawar the context of UTI.The clinician faces substantial obstacles due to the high frequency, recurrence tendency, morbidity association, and di culties in obtaining an uncontaminated urine specimen [7].Breastfed infants have a higher prevalence of prolonged jaundice compared to formula milk fed infants, as indicated by previous research [8] Neonates with unexplained indirect hyperbilirubinemia in the rst 2 weeks of life should be tested for UTI [5].It is recommended to screen for UTI in neonates with prolonged hyperbilirubinemia and direct bilirubinemia.Ad d i t i o n a l l y, n e o n a t e s a d m i t t e d w i t h i n d i r e c t hyperbilirubinemia should be evaluated for UTI, as the frequency of UTI is high in this population.The most common pathogens associated with UTI in neonates with jaundice are Escherichia coli and Klebsiella pneumoniae [11].A comprehensive clinical evaluation is necessary for all infants with prolonged jaundice; yet, the speci c criteria and scope of diagnostic procedures remain ambiguous.The identi cation of predisposing variables in Asian nations, such as Pakistan, is crucial in facilitating prompt diagnosis and treatment of jaundice, leading to enhanced results and decreased complications.For this purpose, we performed this study to ascertain the prevalence of urinary tract infection among early infants exhibiting prolonged jaundice at Lady Reading Hospital in Peshawar.
The distribution of patients by gender is presented in table 2, with males accounting for 58.6% and females comprising 41.4% of all included patients.

M E T H O D S
The present study, a cross-sectional design, was carried out at the Department of Pediatrics, Lady Reading Hospital, Peshawar, spanning from June 20th, 2022 to December 20th, 2022.The study included a total of 87 neonates, encompassing both genders, who presented with persistent jaundice.The selection process adhered to strict inclusion criteria.The study used a non-probability consecutive sampling method, and the sample size was

R E S U L T S
determined using the WHO sample size software.A 95% con dence interval, 5% margin of error, and an estimated frequency of urinary tract infection of 6% in neonates with prolonged jaundice were considered [9].Upon obtaining approval from the ethics committee, IRB No; 128/LRH/MTI dated 28 May 2021, study was commenced and patients who met the predetermined inclusion criteria were enrolled in the study.During study obtained informed consent from the parents, so ensuring con dentiality and con rming the absence of any risks to the patient during their participation.We collected basic demographic data from the patients, including age, gender, duration of complaint, and weight as measured on a weighing scale.Two samples of mid-stream urine were collected from neonates and sent to the hospital laboratory to test for the presence of urinary tract infection.The two samples were acquired at least two hours apart and were free from contamination.All laboratory studies were conducted under the supervision of a consultant microbiologist with post FCPS experience more than ve years.Data pertaining to urinar y tract infection, as de ned operationally was recorded on a specially constructed form.The data were then analyzed using the statistical software SPSS version 21.0.Mean and standard deviation were used to measure quantitative characteristics such as age, duration of complaint, and weight.The frequency percentages of categorical variables, such as gender and urinary tract infection, were assessed.
The age range of patients in this study ranged from 14 to 28 days, with a mean age of 20.597 ± 4.50 days.The mean duration of complaint (jaundice) was also 18.20 ± 4.077 days, and the mean weight was 2.855 ± 0.27 Kg, as indicated in table 1.   [24].A potential constraint of the research lies in the absence of urine culture for all instances under investigation.Our approach involved doing urine analysis, which encompassed leukocyte esterase (LE) and nitrite tests, as well as microscopic examination to detect the presence of pyuria, for all newborns included in the study.The restriction in question was a result of the local policy in the NICU and microbiology laboratory, which dictates that urine culture should only be conducted in cases of sepsis, abnormal urine analysis, or pyuria.Never theless, the utilization of aseptic urinar y catheterization technique has been found to enhance the speci city of urine sample collection.Additionally, the inclusion of aggregate urine analysis, which involves assessing the presence of leukocyte esterase (LE), nitrite, or pyuria (> 5 white blood cells per high-power eld), has been shown to signi cantly increase the sensitivity for detecting urinary tract infections (UTIs) in infants below 60 days of age, with a reported accuracy of 99.4% according to a study conducted by Tzimenatos et al. [25].The relationship between urinary tract infection (UTI) and jaundice in neonates is not yet fully understood, and further research is needed to investigate potential reasons [26].Jaundice seems to be result of direct effect of bacteria, enhanced by its toxins and host response through proin ammatory cytokines.These bacteria also secret hemolysin, which cause haemoglobin destruction and it, is then converted to bilirubin by liver enzymes [27].A total of 87 patients with persistent neonatal jaundice were studied and of them 11.5 % were found to have UTI.
Our study concludes that a signi cant number of patients with persistent jaundice have urinary tract infections.Thus, it can be inferred that UTI may be a contributing factor to the occurrence of unexplained indirect hyperbilirubinemia in neonates.Hence, it is recommended . Studies conducted in developed countries, speci cally focusing on infants who are not breastfed, have suggested that a thorough investigation should be conducted for formula fed infants with prolonged jaundice [8].Pashapour et al., conducted a study which revealed a 6% incidence of urinary tract infection in neonates with persistent jaundice [9].Similarly, Harb et al., conducted a separate study which found an incidence of urinary tract infection in neonates with persistent jaundice as 8.9% [10].

Table 2 :
Frequency and percentage of patients according to gender (n=87) The age range of patients in our study ranged from 14 to 28 days, with a mean age of 20.597 ± 4.50 days.Tawfeek et al., reported age range of 14 to 49 days with mean age of 19.3 ± 5.3.The mean duration of complaint in our study was also 18.20 ± 4.077 days, and the mean weight was 2.855 ± 0.27 Kg.However, the mean weight of 3.275 ± 0.459 was noted byTawfeek et al., in her study.The distribution of patients by gender was males as 58.6% and females comprising 41.4% of all included patients.Similar distribution was observed byTawfeek et ( U T I s ) i n n e o n a t e s w i t e x p l a i n e d i n d i r e c t hyperbilirubinemia of large magnitude has been noted[17].Our study revealed that the prevalence of urinary tract infections (UTIs) among the infants with persistent jaundice in our sample was found to be 11.5%.The