Unexplained neonatal

jaundice as an early
diagnostic sign of urinary
tract infection
Oleh:
Dwi Rizki Fadhilah 1210313026

Preseptor
Dr. Nice Rahmawati, SpA (K)
Introduction

Hyperbilirubinemia is a common disorder during

the neonatal period.
About 60% of full term and 80% of premature
neonates develop clinical jaundice in the first
week of life
Some studies have reported that unexplained
hyperbilirubinemia may be associated with
bacterial infections in the newborn, such as
urinary tract infection (UTI).
The clinical manifestations of UTI in neonates
are extremely variable
from severe illnesses to nonspecific signs
symptoms such as growth failure or
jaundice
The aims of this study were to determine:
(1)the prevalence of UTI in neonates with
asymptomatic, unexplained unconjugated
hyperbilirubinemia in the first 4 weeks of life;
(2) if urine culture should be considered a
necessary evaluation in asymptomatic
jaundiced neonates younger than 4 weeks of
age
 Materials and methods
One hundred and twenty asymptomatic jaundiced
neonates younger than 4 weeks of age, admitted to the
newborn unit of Nemazee Hospital, affiliated with Shiraz
University of Medical Sciences (intervention group),
122 healthy neonates without jaundice who presented to
the outpatient clinic (control group) from June 2007
through August 2008
Patients jaundiced in the first 48 h of life with signs of
hemolysis, or cases with documented fever >38 8C and
signs of sepsis (vomiting, poor feeding, lethargy, etc.) were
excluded
prenatal events, such as gestational age, maternal
nfections, mode of delivery, and prolonged rupture
of the membranes, were recorded
Postnatal events including neonatal fever, onset of
jaundice, and whether the infant was breastfed or
formula-fed, were also collected
The following tests: complete blood count, peripheral
blood smear, glucose-6-phosphate dehydrogenase
(G6PD), direct Coombs test, blood typing of the
neonate and mother, total and direct bilirubin, and
reticulocyte count. A urine sample was collected
from each neonate by bladder catheterization
 For microscopic analysis, urine specimens were centrifuged
at 2000 revolutions per min for 5 min, resuspended, stained,
and examined microscopically under highpower field (HPF)
for pyuria, which was defined as 10 white blood cells
(WBC)/HPF
The urine culture obtained by bladder catheterization was
considered positive if a single pathogen with more than 10
000 colony forming units per milliliter (CFU/ml) was isolated
A urine culture by urine bag was taken as positive if a single
pathogen with more than 100 000 CFU/ml was detected.
control group:
all the positive urine cultures were
repeated by bladder catheterization,
in positive cases (104 CFU/ml) the
patients were contacted
instructed to return to the hospital for
admission and sepsis evaluation
 Neonates with UTI were perform:
A renal function test
renal ultrasound
voiding cystourethrogram

SPSS version 15 was used for the statistical analysis.

Descriptive data were reported as mean standard
deviation, and the associations between
categorical variables were analyzed using Fishers
exact test
 Results
120 asymptomatic jaundiced neonates as the intervention group
122 healthy neonates as the control group

In the intervention group:

the mean age was 74 days
95 neonates (79%) had a birth weight more than 2500 g and
92 neonates (77%) were born at term (3742 weeks of
gestation)
73 (61%) neonates were male and 47 (39%) were female
 Results
120 asymptomatic jaundiced neonates as the intervention group
122 healthy neonates as the control group

In the control group, the mean age was 5 6 days

97 neonates (80%) had a birth weight more than 2500 g
112 (92%) were term neonates
95 (78%) neonates were male and 27 (22%) were female
Positive urine cultures were obtained for 15
(12.5%) of the 120 asymptomatic jaundiced
infants enrolled (p < 0.001). Positive urine cultures
were obtained from the urine bags of eight of
the 122 healthy neonates however on
reevaluation, the results of urine culture from
bladder catheterization were negative
 Discussion

jaundice may be one Other studies, jaundice

of the first signs of is the first sign of a
bacterial sepsis newborn with a UTI
 Bilgen et al. reported the
Garcia and Nager, found UTI results of a series of 102
in 12 of 160 (7.5%) neonates with asymptomatic,
asymptomatic jaundiced unexplained unconjugated
neonates (to an emergency hyperbilirubinemia in the first 2
department weeks of life. A UTI was present
in eight (8%) cases
In the present study, UTI was found in 12.5% of
the asymptomatic jaundiced infants younger
than 4 weeks

UTI was found more frequently among males

As none of the male neonates in the current study had

been circumcised, we could not compare its effects on UTI
Pyuria (10 WBC/HPF) was present in
five (33%) patients with UTI
there were no statistically significant differences
between positive and negative urine cultures in
jaundiced neonates (p = 0.9)
its presence nor absence can serve as
completely reliable evidence for or against UTI
In the present study, a positive urine culture is
not indicative of incidental asymptomatic
bacteriuria
None of our jaundiced patients with
UTI had a high conjugated bilirubin
level
Garcia and Nager reported that all patients
with an increase in the conjugated bilirubin
fraction were diagnosed with UTI
Lee et al, infants with UTI may present with
unconjugated hyperbilirubinemia in the early
stages, and that after the age of 6 weeks it is
always conjugated hyperbilirubinemia
 these organisms had 10%
the most common was K. sensitivity to gentamicin,
pneumoniae, followed by imipenem, and
Enterobacter, E. coli, and
Serratia ciprofloxacin, and 100%
resistance to ampicillin
 Writers found urinary
tract abnormalities in
three (20%) of the 15 normal voiding
patients evaluated by cystourethrogram
renal ultrasound, which
included hydronephrosis
Limitation

none of the neonates were circumcised

not all the infants with UTI and hydronephrosis had a

dimercaptosuccinic acid renal scintigraphy
radionuclide scan.
 Conclusion
UTI can occur in asymptomatic, afebrile neonates presenting
with unconjugated hyperbilirubinemia in the first weeks of life

prevalence of UTI in asymptomatic jaundiced neonates was

12.5%,

jaundice may be the first sign of UTI before other signs become
evident

We suggest that urine culture should be considered as a part of

the diagnostic evaluation of neonates older than 3 days with
hyperbilirubinemia of unknown etiology