Study regarding esbl from kanchi kamakoti hospital
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ESBL "Kanchi Kamakoti"
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ESBL study Kanchi Kamakoti CHILDS Trust Hospital Chennai
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PMID: 30581265
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https://pmc.ncbi.nlm.nih.gov/articles/PMC6276311
Here is a detailed summary of the ESBL study from Kanchi Kamakoti CHILDS Trust Hospital (KKCTH), Chennai:
ESBL Study from Kanchi Kamakoti CHILDS Trust Hospital
Citation: Balasubramanian S, Kuppuswamy D, Padmanabhan S, Chandramohan V, Amperayani S. "Extended-spectrum Beta-lactamase-producing Community-acquired Urinary Tract Infections in Children: Chart Review of Risk Factors." Journal of Global Infectious Diseases. 2018 Oct-Dec;10(4):222-226. PMID: 30581265 | PMC Full Text
Background
Community-acquired UTI (CA-UTI) caused by ESBL-producing organisms is rising globally. Traditionally recognized risk factors include:
- Age <1 year
- Children on uro-prophylaxis
- Recurrent UTI
- Recent antibiotic usage
- Male gender
The study aimed to evaluate whether these risk factors actually predict ESBL UTI in Indian children.
Study Design
- Type: Retrospective chart review
- Setting: Kanchi Kamakoti CHILDS Trust Hospital & CHILDS Trust Medical Research Foundation, Nungambakkam, Chennai
- Population: 100 children aged 1 month to 12 years with community-acquired UTI
- Inclusion criteria: Significant bacteriuria (>10^5 CFU for clean-catch; >10^4 for catheter samples), within 48 hours of admission, followed up for 3 months
- Exclusion criteria: Age <1 month or >12 years, urine collected >48 hrs after admission
Microbiology Findings
| Organism | Frequency |
|---|---|
| Escherichia coli | 80% |
| Klebsiella pneumoniae | 12% |
| Pseudomonas aeruginosa | 2% |
| Klebsiella oxytoca | 2% |
| Proteus mirabilis | 2% |
| Morganella morganii | 1% |
| Citrobacter spp. | 1% |
Antibiotic Susceptibility Pattern
High resistance observed to:
- Third-generation cephalosporins
- Trimethoprim-sulfamethoxazole (cotrimoxazole)
- Amoxicillin-clavulanic acid
- Fluoroquinolones
Good sensitivity retained for:
- Aminoglycosides
- Piperacillin-tazobactam
- Carbapenems
Key Findings & Conclusions
- No statistically significant risk factor was identified that predisposes a child to ESBL UTI - this was the most notable and somewhat surprising finding.
- The study negates the common assumption that recent antibiotic use, uroprophylaxis, or male gender significantly predispose to ESBL UTI.
- Children with ESBL UTI who are clinically responding to cephalosporins may continue to be treated with the same class, even though the organism tests ESBL-positive in vitro (a clinically important practical point).
- Empiric treatment for high-risk cases should consider aminoglycosides, piperacillin-tazobactam, or carbapenems given the high resistance rates to commonly used agents.
Significance
This is a pediatric-specific study from a leading tertiary care children's hospital in South India. Its key strength is that it challenges the routine practice of escalating antibiotics solely based on risk factor profiles, since no single risk factor reliably predicted ESBL UTI in this cohort. This has implications for empiric antibiotic prescribing guidelines in children with CA-UTI.
Incidence of esbl uti according to this study
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https://pmc.ncbi.nlm.nih.gov/articles/PMC6276311
Here are the incidence/prevalence figures for ESBL UTI from this study:
Incidence of ESBL UTI - Kanchi Kamakoti Study (2018)
Overall Incidence
40% of all uropathogens isolated were ESBL producers (40 out of 100 Gram-negative isolates)
This figure is consistent with other Indian studies, which reported ESBL rates ranging from 26.9% to 48.3%.
Organism-wise ESBL Breakdown
| Organism | ESBL Producer Rate |
|---|---|
| E. coli | 46.25% (of all E. coli isolates) |
| Klebsiella pneumoniae | 25% (of all Klebsiella isolates) |
Resistance Context
- 68% of all isolates were resistant to third-generation cephalosporins overall (ESBL + other mechanisms like AmpC)
- Of those resistant to 3rd-gen cephalosporins, 58.8% (40/68) were confirmed ESBL producers; the remaining resistance was due to other mechanisms (e.g., plasmid-mediated AmpC)
Comparison with Other Studies
| Study | ESBL Rate |
|---|---|
| KKCTH (this study) | 40% |
| Other Indian studies | 26.9% - 48.3% |
| South India (adults, Eshwarappa et al.) | 52% |
Clinical Implication
Despite 40% ESBL positivity, about 32.5% of ESBL-positive cases responded clinically to cephalosporins, suggesting that in vitro ESBL positivity does not always mean in vivo treatment failure - an important nuance for clinical decision-making.
Search for latest treatment guidelines for pediatric ESBL UTI
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"ESBL" AND "urinary tract infection" AND "children" AND "treatment"
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pediatric ESBL UTI treatment guidelines 2024 2025 children carbapenem alternatives
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ESBL UTI pediatric treatment carbapenem oral stepdown
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https://pmc.ncbi.nlm.nih.gov/articles/PMC12466793
Here is a synthesis of the latest (2024-2025) treatment guidelines and evidence for pediatric ESBL UTI:
Latest Treatment Guidelines: Pediatric ESBL UTI (2024-2025)
1. Guiding Principles
- Local antibiogram first - Empiric therapy must be guided by local resistance patterns, not generic protocols.
- De-escalate early - Once culture and sensitivity are available, narrow therapy to the most targeted agent.
- Carbapenem stewardship - Reserve carbapenems for severe/septic presentations; avoid routine use to prevent carbapenem-resistant organism emergence.
- The WikiGuidelines 2024 consensus (JAMA Network Open) and EAU 2024 guidelines both reinforce this framework.
2. Definitive (Culture-Directed) Treatment
A. Severe / Febrile ESBL UTI / Pyelonephritis (IV phase)
| Agent | Notes |
|---|---|
| Meropenem / Ertapenem | Drug of choice for septic or high-risk ESBL UTI in children |
| Piperacillin-tazobactam | Acceptable option if MIC is favorable; some controversy in bacteremic ESBL (caution with the MERINO trial data) |
| Amikacin | Good activity against ESBL producers; useful as IV step-down or combination |
| Imipenem | Alternative carbapenem; used in ESBL + AmpC co-producers |
B. Mild-to-Moderate / Non-septic ESBL UTI (oral step-down or outpatient)
| Agent | Notes |
|---|---|
| Fosfomycin | Excellent activity (100% susceptibility in ESBL E. coli in recent studies); oral granules available; emerging preferred oral option |
| Nitrofurantoin | Very high susceptibility (~99%); oral suspension available; suitable for lower UTI only (NOT pyelonephritis - does not achieve tissue levels) |
| Amikacin (IM) | Used in India (including KKCTH study) for oral-intolerant step-down; 14-day total course |
| TMP-SMX | Only if confirmed susceptible on culture; high rates of resistance (40-70%) make it unreliable empirically |
| Oral ciprofloxacin | Only if susceptible; avoid empirically due to high resistance; not first-line in children <18 yrs |
3. What to AVOID in ESBL UTI
| Agent | Reason to Avoid |
|---|---|
| Amoxicillin-clavulanate | High resistance (72% in recent studies); ESBL enzymes hydrolyze despite inhibitor |
| 3rd-gen cephalosporins | High resistance; even if clinical response seen, risk of failure especially in pyelonephritis |
| TMP-SMX (empirically) | ~40-70% resistance in ESBL producers; only use if susceptibility confirmed |
| Fluoroquinolones (empirically) | ~30-50% co-resistance in ESBL strains; restricted use in children |
4. 2025 IDSA Update - Key Points Relevant to Pediatrics
The 2025 IDSA complicated UTI update introduced a 4-step framework:
- Assess severity (sepsis vs. non-sepsis)
- Review prior culture history for resistant organisms
- Check local antibiogram
- De-escalate at 48-72 hrs once cultures return
For ESBL with sepsis: IV carbapenem (ertapenem preferred for outpatient parenteral) is the standard start.
For ESBL without sepsis: Piperacillin-tazobactam or carbapenem; early oral switch if susceptible agent available.
5. Newer Agents (Adults Only - Pediatric Data Pending)
- Cefepime-enmetazobactam - EMA-approved for adults; Phase I/II pediatric trial ongoing (NCT05826990), results expected 2026. NOT yet recommended for children.
- Ceftazidime-avibactam, Cefiderocol - For carbapenem-resistant ESBL/AmpC; off-label in children.
6. Relating Back to the KKCTH Study
The KKCTH study's practice of:
- IV piperacillin-tazobactam for ESBL UTI not responding to cephalosporins
- Step-down to IM amikacin to complete 14 days
- Continuing cephalosporins in ESBL cases with clinical response
...aligns with current evidence, though 2024-2025 guidelines lean more toward carbapenems for severe cases and fosfomycin/nitrofurantoin for mild lower UTI as safer, better-studied oral options.
Bottom line: For pediatric ESBL UTI in 2025 - carbapenem (IV) for febrile/septic cases, fosfomycin or nitrofurantoin (oral) for lower tract infection, amikacin as a useful alternative, and always de-escalate based on culture results. Empiric use of cephalosporins, amoxicillin-clavulanate, and TMP-SMX should be avoided until susceptibility is confirmed.
Find current Indian pediatric UTI management protocols from major centers
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pediatric UTI management India protocol guidelines
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Indian pediatric UTI management protocol AIIMS PGI KKCTH IAP guidelines 2024 2025
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PMID: 39372614
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ESBL UTI children India antibiotic treatment resistance
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Indian Society Pediatric Nephrology UTI guidelines 2023 ESBL antibiotic empiric therapy
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https://pmc.ncbi.nlm.nih.gov/articles/PMC11450833
Here is a detailed summary of current Indian pediatric UTI management protocols:
Current Indian Pediatric UTI Management Protocols
Primary Reference: ISPN (Indian Society of Pediatric Nephrology) Guidelines 2023
Authors: Hari P, Meena J, Bagga A et al. (AIIMS New Delhi) - published in Pediatric Nephrology & Indian Pediatrics 2024 | PMID: 39372614
These are the most authoritative and current Indian-specific evidence-based guidelines on this topic, replacing the previous ISPN 2011 guidelines.
A. Diagnosis
- Start antibiotics within 48-72 hours of fever onset - delay significantly increases risk of kidney scarring
- Febrile UTI in young children = treat as acute pyelonephritis unless proven otherwise
- Urine culture mandatory before starting therapy; culture need not be repeated after completion if child responds clinically
- Asymptomatic bacteriuria: do NOT treat with antibiotics (reemphasized strongly)
B. Empiric Antibiotic Therapy
| Situation | Recommended Empiric Agent |
|---|---|
| Febrile UTI / Pyelonephritis (children) | 3rd-generation cephalosporins OR co-amoxiclav (amoxicillin-clavulanate) |
| Cystitis (adolescents) | 1st-generation cephalosporin (cephalexin, cefadroxil) OR co-amoxiclav |
| Infants <2 months, severely ill, oral-intolerant | IV therapy (3rd-gen cephalosporin IV or aminoglycoside) |
Grade of evidence: 2⊕○○○ (weak recommendation, low quality evidence) - reflecting the challenge of high local ESBL resistance rates making any single empiric choice imperfect
C. Route & Duration
| Situation | Route | Duration |
|---|---|---|
| Most febrile UTI / pyelonephritis | Oral preferred | 7-10 days |
| Cystitis | Oral | 3-7 days |
| Infants <2 months / severely ill / vomiting | IV initially, then switch to oral | 7-10 days total |
The guidelines moved away from routine IV therapy - oral treatment is now preferred for most febrile UTI as evidence shows equivalent outcomes.
D. For ESBL UTI Specifically
The ISPN 2023 guidelines make a critical practical point directly echoing the KKCTH study:
"Patients showing clinical response to initial therapy do NOT require a change of antibiotic therapy, as considerable discrepancy in in-vivo susceptibility and in-vitro clinical response has been reported."
This means: if a child is improving on cephalosporins, do not switch just because the lab reports ESBL positivity. De-escalation or change is only needed for clinical non-response.
For non-responders at 48-72 hrs:
- Repeat urine culture
- Ultrasound KUB (to exclude pyonephrosis, congenital anomaly)
- Change antibiotic according to sensitivity results (typically piperacillin-tazobactam or carbapenem for ESBL)
E. Antibiotic Prophylaxis (for Recurrent UTI)
| Situation | Recommendation |
|---|---|
| High-grade VUR (grades 3-5) | Use prophylaxis (cotrimoxazole or nitrofurantoin) |
| Recurrent febrile UTI + bladder-bowel dysfunction | Consider prophylaxis |
| Antenatally detected hydronephrosis awaiting workup | Do NOT use prophylaxis |
| Drug of choice (>3 months) | Cotrimoxazole or nitrofurantoin |
| Infants <3 months | Cephalexin |
| Avoid for prophylaxis | Amoxicillin-clavulanate (promotes resistance) |
F. Imaging Protocol
| Investigation | When |
|---|---|
| Ultrasound KUB | All children with febrile UTI |
| DMSA scan (acute phase) | NOT recommended routinely; use only for equivocal diagnosis |
| DMSA scan (late, at 4-6 months) | To detect scarring in recurrent/complicated UTI |
| MCU (Micturating cystourethrogram) | For recurrent febrile UTI or abnormal ultrasound; NOT routine after first UTI |
G. Comparison: ISPN 2023 vs. KKCTH Study Practice
| Aspect | KKCTH Study (2018) | ISPN 2023 Guideline |
|---|---|---|
| Empiric agent | 3rd-gen cephalosporins | 3rd-gen cephalosporins / co-amoxiclav |
| ESBL + clinical response | Continue cephalosporins | Same - continue if responding |
| ESBL + non-response | Pip-tazo IV, then IM amikacin | Change per sensitivity (carbapenem/pip-tazo) |
| Oral vs IV | IV for most hospitalized | Oral preferred for most |
| Duration | 14 days (for resistant UTI) | 7-10 days (standard) |
Key takeaway: The ISPN 2023 guidelines from AIIMS New Delhi are the governing Indian protocol. They prioritize early treatment, oral route, local antibiogram-guided empiric therapy, and the important principle that in vitro ESBL resistance does not always mandate antibiotic change if the child is responding clinically - a finding strongly supported by the KKCTH study.
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