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Kamal Akl MDAssoc Professor of Pediatrics/Nephrology - JUHFebruary 5th 2011
GOALS
To review the recent advances in the diagnosis and management of childhood UTIs
NICE guidelines 2007 AUA guidelines 2010
Prevalence
The prevalence of UTIs in children aged 2
months to 2 yrs is approximately 5% In circumcised boys, it is 0.2% to 0.4% In uncircumcised boys, it is up to 20
times higher. In girls, it is between 6.5% and 8.1%
when there is no other fever source evident.
Pediatrics. 1999;103:843-852.
Pathogens
E coli : the cause of UTI in 82.7% of
patients followed by Enterococcus spp,
Staphylococcus spp, and then Proteus mirabilis/ Klebsiella/
Streptococcus. Shah P et al Clin Pediatr 2008
Diagnosis
Urine culture : Gold standard Urinalysis : supportive
Symptoms & signs
< 1 year : unexplained fever check for UTI
< 1 year with UTI Rx as pyelonephritis
Urine collection
Suprapubic Catheter Midstream urine
bag
suprapubic
If a urinary tract infection is present, any organism except 2000-3000 CFU/mL coagulase-negative staphylococci.
Catheterization in a girl or midstream clean-void collection in a circumcised
boy
Febrile infants and children with urinary tract infection usually have >50,000 CFU/mL of a single urinary pathogen; however, urinary tract infection may be present with 10,000-50,000 CFU/mL of a single organism.*
Midstream clean-void collection in
a girl or uncircumcised boy
Urinary tract infection is indicated when >100,000 CFU/mL of a single urinary pathogen is present in a symptomatic patient. Pyuria usually present. A urinary tract infection may be present with 10,000-50,000 CFU/mL of a single bacterium.*
Urine culture result
Patients with urinary frequency decreased bladder incubation time
most likely to have bacteria
proliferating in the urinary bladder in the presence of low colony counts.
Urine presevation
Refrigerate if urine sample cannot be cultured within 4 hours or preserved with boric acid immediately
Ten to the power what ?
Coulthard MG et al : suggest diagnostic urine culture be changed
from > 10(5) 10(6) 1 sample decreased false + from
7,2% 4.8% 2 samples decreased false + from
3.6% 0.6%
Pediatrics 2010
Urine testing for >3 months but < 3 years
Urine microscopy and culture Urinary symptoms start Abx Positive microscopy or nitrite start
Abx
NICE guidelines 2007
Urine testing in >3 years If leucocyte esterase and nitrite are positive
regard as UTI If leucocyte esterase and nitrite are negative
should not be regarded as having UTI If leucocyte esterase is negative & nitite is
positive Abx rx should be started untill culture results
If leucocyte esterase is positive & nitrite is negative Do not start Abx . No need for culture
NICE guidelines 2007
Risk factors for UTI
Poor urine flow Previous confirmed UTI Recurrent FUO Antenatal renal abnormality Family history of VUR/renal disease Constipation Dysfunctional voiding Enlarged bladder
Risk factors for UTI - contin
Evidence of spinal lesion Poor growth High blood pressure
NICE guidelines 2007
Upper vs lower UTI
< 1 year with bacteriuria & fever of 38 degrees C consider as upper UTI
< 1 year & children with fever < 38 degrees C & flank pain/tenderness upper UTI
All others lower UTI
NICE guidelines 2007
Atypical UTI
Seriously ill Poor urine flow Abdominal or bladder mass Raised serum creatinine Septicemia Failure to respond to treatment with
suitable antibiotics within 48 hours Infection with non-E coli organisms
Acute management
< 3 months > 3 months with APN > 3 months with cystitis
Long term management
Prevention of recurrence Antibiotic prophylaxis Imaging tests
Prevention of recurrence
Dysfunctional elimination syndromes and constipation should be addressed in infants and children who have had a UTI
Antibiotic prophylaxis
Should not be routinely recommended in infants and children following first-time UTI
May be considered in infants & children with recurrent UTI
Asymptomatic bacteriuria in infants & children should not be treated with prophylactic antibiotics
NICE guidelines 2007
Imaging
Infants < 6 months with first time UTI that responds to treatment US within 6 weeks
Infants & children with first time UTI that responds to treatment routine US not recommended unless UTI is atypical
Infants & children with lower UTI US ( within 6 weeks ) only if <6 months or had recurrent UTI
NICE guideline 2007
Imaging for infants < 6 months
Responds well to treatment within 48 hours No DMSA , No MCUG
Atypical UTI DMSA yes , MCUG yes Recurrent UTI DMSA yes , MCUG
no
Imaging for infants & children > 6 months but < 3 years
Responds well to treatment within 48 hours No imaging
Atypical UTI US during acute infection , DMSA
Recurrent UTI US within 6 weeks , DMSA
NICE guidelines 2007
Recommended imaging for children > 3 years
Responds well to treatment within 48 hours No imaging
Atypical UTI US during acute infection
Recurrent UTI US within 6 weeks , DMSA in 4-6 months
NICE guidelines 2007
VUR
Significantly increases risk of renal
scarring in the setting of acute pyelonephritis .
Resolution of VUR decreased
incidence of febrile UTI , but overall incidence of UTI remains unchanged
AUA 2010
CAP
Not proven to reduce the incidence of febrile UTI in children with VUR
Garin EH et al Pediatrics 2006 Montini G et al Pediatrics 2008 Roussey-Kesler G et al J Urol 2008
CAP
Long-term , low dose trimethoprim-sulfamethoxazole was associated with a decreased number of UTIs in predisposed children .
Craig JC , et al NEJMed 2009
Antibiotic Agents to Prevent Reinfection
Agent Single DailyDose
Nitrofurantoin* 1-2 mg/kg PO
Sulfamethoxazole and trimethoprim* 1-2 mg/kg TMP, 5-10 mg/kg SMZ PO Trimethoprim 1-2 mg/kg PO
CAP
Age < 6 weeks : Avoid nitrofurantoin or sulfa drugs Reduced doses of an oral first-
generation cephalosporin, such as cephalexin at 10 mg/kg .
Ampicillin or amoxicillin are not recommended because of the high incidence of resistant E coli.
Management of VUR in the child > 1 year of age with no BBD On detection of VUR evaluate for renal disease
and symptoms suggestive of BBD If CAP is used MCUG after 12-24 months Therapy with intention to cure : Open or
endoscopic surgery is recommended for recurrent infections , new renal abnormalities determined by DMSA scanning , and parental preference .
AUA 2010
Management of VUR in the child > 1 year of age with no BBD Success rates :Open surgery 98%
Endoscopic surgery 83%
Following surgery Do US to exclude obstruction
Cystography : an option
Following endoscopic surgery Do Cystography
AUA 2010
Management of infant < 1 year of age with VUR
Use CAP Resolution occurrs in 50% of these
children within 24 months Recommendation : Rx of BBD as an
integral part of reflux Rx
AUA 2010
Management of the child with VUR and BBD
Presence of BBD (1)reduces rates of VUR resolution & increase incidence of UTI in patients managed with CAP.
(2) reduces cure rate of endoscopic therapy .
(3) increases incidence of UTI after definitive reflux cure
AUA 2010
Screening the siblings and offspring of patients with VUR
Incidence of reflux in siblings : 27% Incidence of reflux in offspring :
35.7% Screening : option AUA 2010
Screening infants with a history of prenatally detected hydronephrosis for VUR
infants with prenatally detected hydronephrosis : incidence of VUR 16.2% & not predicted by grade of hydronephrosis .
Recommendation : No benefit from screeining
AUA 2010
Conclusions
Recent advances in the diagnosis and management of childhood UTI were reviewed , including :
NICE guidelines 2007 AUA guidelines 2010
MOST IMPORTANT
Is the patient Individualize Avoid guideline prison
Conclusions
Thank you