Do Not Miss the Diagnosis of Urinary Tract Infection in Infants With COVID-19

To the Editors:

We read with great interest the article by Böncüoğlu et al¹ presenting a case of COVID-19 with bacterial sepsis caused by Enterobacter cloacae in a 34-day-old infant. We agree with their conclusion that clinicians should be aware of the development of bacterial sepsis during severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in infants. However, pediatricians should also be aware of urinary tract infections (UTIs). Here, we present the case of a 20-day-old female infant with COVID-19 and UTI.

A 20-day-old Japanese female infant with no previous perinatal history was admitted to our hospital with fever and irritability. The patient and her parents had COVID-19, which was confirmed by a positive polymerase chain reaction (PCR) test 6 days and 10 days before admission, respectively. When they underwent PCR test, her parents had fever and cough; however, she was asymptomatic, therefore, remained at home without any medical support. After becoming febrile and irritable, she was transferred to our hospital for treatment and investigation. On arrival, her body temperature, heart rate, respiratory rate, and blood pressure were 38.2°C, 180 bpm, 33/min, and 80/43 mm Hg, respectively. Furthermore, the physical examination revealed no notable findings, and her blood and cerebrospinal fluid test results were within the normal range. However, urinalysis showed 10–19 white blood cells per high power field, and Gram staining of her urine sample showed Gram-negative rods.

Intravenous ampicillin and cefotaxime were administered, and she became afebrile on the following day. In addition, the urine culture of a sample obtained through catheterization revealed Escherichia coli and Enterococcus faecalis (1 × 10⁴ colony-forming unit/mL), and the blood and cerebrospinal fluid cultures were negative. On day 4, cefotaxime was stopped, but ampicillin was continued for 7 days because the causative pathogens were susceptible to ampicillin. Subsequently, renal and bladder ultrasonography showed no abnormal findings.

Böncüoğlu et al have mentioned that nonspecific symptoms, such as fever, lethargy, poor feeding, vomiting, tachypnea, and tachycardia, were similar in COVID-19 and bacterial sepsis.^1,2 In addition, UTI in infants presents the same nonspecific findings.³ In the case presented by Böncüoğlu et al, the patient had bacterial sepsis with Enterobacter cloacae, which is known to cause UTI.⁴ UTI can progress to bacteremia.⁵ Even if the SARS-CoV-2 diagnostic test is positive, clinicians should be aware of bacterial infections, such as bacteremia and UTI, especially in cases where the patient becomes ill a few days after the diagnosis of COVID-19.

ACKNOWLEDGMENTS

We thank Editage [http://www.editage.com] for editing and reviewing this manuscript for the English language.