The surgical significance of urinary tract infections (UTIs) in

children

Marisa SeepersaudMarisa Seepersaud

MBBS MRCS DMMBBS MRCS DM

2011 (Sarah Amin) Brandon Seepersaud Records were poorRecords were poor

22 patients , age 5 and under , who 22 patients , age 5 and under , who were treated for UTI at the GPHCwere treated for UTI at the GPHC

Urinalysis: AllUrinalysis: All Urine culture: 4/22 (18%) Urine culture: 4/22 (18%)

Abdominal ultrasound: 7/22 (32%) Abdominal ultrasound: 7/22 (32%) (2 “enlarged kidneys”, 5 Normal (2 “enlarged kidneys”, 5 Normal study)study)

2 referrals to urology2 referrals to urology1 PUV1 PUV

Urinary Tract Infection (UTI)

UTIs are among the most common bacterial UTIs are among the most common bacterial infections in children under 2 yrs oldinfections in children under 2 yrs old

The diagnosis is often missed on history The diagnosis is often missed on history and physical examinationand physical examination

Recent Recommendations

AAP, American Academy of Pediatrics , AAP, American Academy of Pediatrics , (1999) 2013(1999) 2013

Consensus Document, Management of UTI Consensus Document, Management of UTI in Jamaican Children, (2005), August 2011in Jamaican Children, (2005), August 2011

NICE, National Institute for Health and Care NICE, National Institute for Health and Care Excellence, UK (2007) May 2011Excellence, UK (2007) May 2011

Incidence

~1% of children below age 1~1% of children below age 1

~ 5 % of febrile children*, 2- 24 months of ~ 5 % of febrile children*, 2- 24 months of ageage

7.5% girls, 10% uncircumcised males, 2.5% of 7.5% girls, 10% uncircumcised males, 2.5% of circumcised males who present with a fever under 2yrs circumcised males who present with a fever under 2yrs

Clinical significance of UTI

Associated with life-threatening sepsis in Associated with life-threatening sepsis in the newbornthe newborn

Increased rates of renal scarring in young Increased rates of renal scarring in young childrenchildren

hypertensionhypertension

chronic kidney diseasechronic kidney disease

pregnancy induced hypertensionpregnancy induced hypertension

Urinary tract infections may occur as Urinary tract infections may occur as a result of structural anomalies of the a result of structural anomalies of the

urinary tracturinary tract

The diagnosis of urinary tract infection in a The diagnosis of urinary tract infection in a young child is an important marker for young child is an important marker for urinary tract abnormalitiesurinary tract abnormalities

Mandates investigationMandates investigation

Important to accurately make the diagnosis

Under-diagnosing UTI may Under-diagnosing UTI may lead to under-treatment, under-lead to under-treatment, under-investigation, and risks investigation, and risks permanent renal damagepermanent renal damage

Risk of renal scarring with recurrent UTIJodul U. The natural history of bacteriuria in childhood. Infect Dis Clin North Am. 1987;1(4):713–729

Important to accurately make the diagnosis

Over-diagnosing UTI may Over-diagnosing UTI may result in the development of result in the development of resistant organisms, the use of resistant organisms, the use of limited resources for un-limited resources for un-necessary and expensive necessary and expensive investigations, investigations, (uncomfortable/painful/ scary (uncomfortable/painful/ scary for patient; distressing for the for patient; distressing for the parents)parents)

Age group Symptoms and signs

Most common Least common

Infants younger than 3 monthsFeverVomitingLethargyIrritability

Poor feedingFailure to thrive

Infants older than 3 months, and children

Preverbal Fever Abd painVomitingPoor feedingLoin tenderness

LethargyIrritabilityHaematuriaMalodorous urineFailure to thrive

Verbal FrequencyDysuria

Dysfunctional voidingSec enuresisAbd painLoin tenderness

FeverMalaiseVomitingHaematuriaMalorous urineCloudy urine

Who should be screened for a UTI?

Infants and children with symptoms and signs of UTIInfants and children with symptoms and signs of UTI

Infants* with 1 or more of the following:Infants* with 1 or more of the following:

temperature of at least 38°Ctemperature of at least 38°C

fever for at least 2 daysfever for at least 2 days

absence of another obvious source of infectionabsence of another obvious source of infection

Option

If the patient does not require immediate If the patient does not require immediate antimicrobial treatment antimicrobial treatment

period of observation prior to investigation period of observation prior to investigation and treatment for UTIand treatment for UTI

Dipstick screening of fresh urine

Both leukocyte esterase and nitrite POSITIVE

UTISend urine for cultureMay start antibiotics

Leukocyte esterase : negativeNitrite : positive Send urine for culture

Leukocyte esterase : positiveNitrite : negative Send urine for culture

Leukocyte esterase : negativeNitrite : negative UTI unlikely

Diagnosis

Must involve urine cultureMust involve urine culture

Traditionally: >100,000 cfu/mlTraditionally: >100,000 cfu/ml

Issues: contamination, false negatives, false Issues: contamination, false negatives, false positivespositives

Asymptomatic bacteriuriaAsymptomatic bacteriuria

Asymptomatic Bacteriuria (AS)Colonization of the urinary tract with non-pathogenic organismsColonization of the urinary tract with non-pathogenic organisms

Study of 3581 infantsStudy of 3581 infants 2.5% male infants, 0.9% female infants2.5% male infants, 0.9% female infants 2 patients with AS developed symptomatic UTI soon after 2 patients with AS developed symptomatic UTI soon after None of the other patients who developed UTI in the first year of life None of the other patients who developed UTI in the first year of life

were found to have AS at initial screeningwere found to have AS at initial screening

Another study involving school aged girls with ASAnother study involving school aged girls with AS No difference in renal growth or function when patients were No difference in renal growth or function when patients were

randomised to treatment vs observation randomised to treatment vs observation But the treated group appeared to be more likely to develop But the treated group appeared to be more likely to develop

pyleonephritis after antibiotics were stoppedpyleonephritis after antibiotics were stopped

Diagnosis of UTI: 2013 AAP recommendations

Presence of both >50 000cfu/ml of a single Presence of both >50 000cfu/ml of a single organism/uropathogen organism/uropathogen ANDAND

PyuriaPyuria

In an appropriately collected specimenIn an appropriately collected specimen

Febrile 2-24 month olds who have no obvious neurologic or anatomic abnormalities Febrile 2-24 month olds who have no obvious neurologic or anatomic abnormalities known to be associated with rec UTI or renal damage (may be extrapolated to known to be associated with rec UTI or renal damage (may be extrapolated to under 5yr old)under 5yr old)

Investigation of UTI: Culture

Urine collected in a bagUrine collected in a bag

- only valid if - only valid if NEGATIVENEGATIVE

- cannot be used to make a diagnosis of UTI- cannot be used to make a diagnosis of UTI

- positive culture is likely to be false positive (88%) !- positive culture is likely to be false positive (88%) !

- positive culture requires confirmation, which is impossible if - positive culture requires confirmation, which is impossible if antibiotics were started*antibiotics were started*

REMEMBER: REMEMBER: You want the most accurate test to be done initially since You want the most accurate test to be done initially since

urine may be rapidly sterilisedurine may be rapidly sterilised

Appropriate methods

Catheter specimen urine (CSU)Catheter specimen urine (CSU)

sensitivity: 95%sensitivity: 95%

specificity: 99%specificity: 99%

difficult in young girls*difficult in young girls*

Suprapubic Aspiration/ Bladder Tap (SPA)Suprapubic Aspiration/ Bladder Tap (SPA)

MSU in older patientsMSU in older patients

Diagnosis

Urinalysis is Positive when:Urinalysis is Positive when:

DipstickDipstick

nitritenitrite

leukocyte esterase testleukocyte esterase test

MicroscopyMicroscopy

white blood cells/pus cellswhite blood cells/pus cells

+/- bacteria+/- bacteria

The urinalysis may be negative despite a positive culture: ContaminationContamination Asymptomatic bacteriuriaAsymptomatic bacteriuria Urinalysis is not sensitive enoughUrinalysis is not sensitive enough

Requires 4 hrs of “stasis” in the bladderRequires 4 hrs of “stasis” in the bladder Young children, infants and neonates may void more oftenYoung children, infants and neonates may void more often

Treatment

Initiating treatment orally or parenterally is equally Initiating treatment orally or parenterally is equally efficacious, so choice is based on practical considerations.efficacious, so choice is based on practical considerations.

Choice of drug should be based on local sensitivity Choice of drug should be based on local sensitivity patterns, adjusted according to sensitivity of particular patterns, adjusted according to sensitivity of particular uropathogenuropathogen

Duration of treatment: 7–14 daysDuration of treatment: 7–14 days

EVERY CHILD, who has had a diagnosis of a EVERY CHILD, who has had a diagnosis of a

urinary tract infection, must be investigated for the urinary tract infection, must be investigated for the presence of a predisposing anatomic abnormality presence of a predisposing anatomic abnormality

of the urinary tractof the urinary tract

Investigation

~5% of patients will be found to have some ~5% of patients will be found to have some abnormality on investigationabnormality on investigation

~16% of patients with febrile UTI~16% of patients with febrile UTI

Overall about 1-2% of cases will be Overall about 1-2% of cases will be determined to have “actionable” findings determined to have “actionable” findings which require some intervention.which require some intervention.

Should patients be put on prophylaxis while awaiting investigations?

YESYES

NoNo

Parental education

Implications/complications of a UTIImplications/complications of a UTI

Symptoms/signs of a recurrent UTISymptoms/signs of a recurrent UTI

Need for a urine culture for future febrile illnesses , even Need for a urine culture for future febrile illnesses , even when there is an apparent source of fever when there is an apparent source of fever

Instructed to seek prompt medical evaluation for future Instructed to seek prompt medical evaluation for future febrile illnesses to ensure that recurrent infections can be febrile illnesses to ensure that recurrent infections can be detected and treated promptlydetected and treated promptly

Imaging Investigations for UTI

Abdominal UltrasoundAbdominal Ultrasound

MCUG/VCUGMCUG/VCUG

Renal scan (DMSA)Renal scan (DMSA)

Intravenous Pyelogram (IVP)Intravenous Pyelogram (IVP)

Investigation: KUB USS

All patients diagnosed with UTI should All patients diagnosed with UTI should undergo kidney/ureter/bladder sonography undergo kidney/ureter/bladder sonography (KUB USS)(KUB USS)

Timing: 6weeks post treatmentTiming: 6weeks post treatment

Exception: Exception: if patient is not responding to treatment as if patient is not responding to treatment as expected, unusually ill expected, unusually ill KUB USS within 48hrs KUB USS within 48hrs

Micturating/Voiding cystourethrogram (MCUG/VCUG)

MCUG is not recommended routinely after the first MCUG is not recommended routinely after the first febrile UTI if KUB USS is normal.febrile UTI if KUB USS is normal.

Schroeder AR, Abidari JM, Kirpekar R, et al. Impact of a more restrictive approach to urinary tract Schroeder AR, Abidari JM, Kirpekar R, et al. Impact of a more restrictive approach to urinary tract

imaging after febrile urinary tract infection. imaging after febrile urinary tract infection. Arch Pediatr Adolesc MedArch Pediatr Adolesc Med. 2011;165(11):1027–1032. 2011;165(11):1027–1032

Recommended in the presence ofRecommended in the presence of

an abnormal KUB USSan abnormal KUB USS

recurrent UTIrecurrent UTI

atypical UTIatypical UTI

MCUG done 4-6 weeks after the UTIMCUG done 4-6 weeks after the UTI Look at the films , incl post micturation filmsLook at the films , incl post micturation films

Renal Scan/ Radionucleotide Scan (RNC)

May be used in the acute setting to diagnose pyleonephritisMay be used in the acute setting to diagnose pyleonephritis

Helpful in distinguishing between obstructive and non- Helpful in distinguishing between obstructive and non- obstructive causes of hydronephrosisobstructive causes of hydronephrosis

Provides information on differential functionProvides information on differential function

Indentify renal cortical defects (DMSA)Indentify renal cortical defects (DMSA)

IVP is useful in the absence of the RNCIVP is useful in the absence of the RNC

All patients with UTI’s should have: Urine cultureUrine culture UrinalysisUrinalysis Abdominal UltrasoundAbdominal Ultrasound

+/- MCUG+/- MCUG +/- Renal scan+/- Renal scan +/- IVP (in the absence of renal scan)+/- IVP (in the absence of renal scan)

What about long term urinary prophylaxis following UTI?

Urinary prophylaxis is dictated by the underlying Urinary prophylaxis is dictated by the underlying pathologypathology

Antibiotic prophylaxis should not be recommended in Antibiotic prophylaxis should not be recommended in infants and children after the first UTI (if no underlying infants and children after the first UTI (if no underlying abnormality was found )abnormality was found )

May be considered in infants and children with recurrent May be considered in infants and children with recurrent UTIUTI

Dysfunctional elimination syndromes and Dysfunctional elimination syndromes and constipation should be addressed in constipation should be addressed in

infants and children who have had a UTI. infants and children who have had a UTI.

Normal Cystogram (MCUG)

Normal Bladder and Urethra

Posterior urethral valves (PUV)

Posterior urethral valves

Bladder Diverticulum

Bladder diverticuli

Detrusor Instability

Grade I Vesicoureteric Reflux (VUR)

Grade II Vesicoureteric Reflux (VUR)

Grade IV Vesicoureteric Reflux (VUR)

Contrary to previous beliefs

““VUR with UTI without structural abnormalities in the VUR with UTI without structural abnormalities in the kidneys seems not to cause CKD.”kidneys seems not to cause CKD.”

““Active treatment of VUR seems not to reduce the Active treatment of VUR seems not to reduce the occurrence of CKD and, in large prospective follow-up occurrence of CKD and, in large prospective follow-up studies, the renal function of patients with VUR has been studies, the renal function of patients with VUR has been well preserved.”well preserved.”

Salo J, Ikäheimo R, Tapiainen T, et al. Childhood urinary tract infections as a cause of Salo J, Ikäheimo R, Tapiainen T, et al. Childhood urinary tract infections as a cause of

chronic kidney disease. chronic kidney disease. PediatricsPediatrics. 2011;128(5):840–847. 2011;128(5):840–847

Recurrence of UTI in patients with VURprophylaxis vs observation

Reflux Grade N

Prophylaxis NoProphylaxis

P

# of Recurrences / Total N

# of Recurrences / Total N

None 373 7 / 210 11 / 163 0.15

Grade I 72 2 / 37 2 / 35 1.00

Grade II 257 11 / 133 10 / 124 0.95

Grade III 285 31 / 140 40 / 145 0.29

Grade IV 104 16 / 55 21 / 49 0.14

Grade V Vesicoureteric Reflux (VUR)

Recurrence rate of febrile UTI in ages 2-24 months

0%

20%

40%

60%

80%

100%

None Grade I Grade II Grade III Grade IV

Prophylaxis

No Prophylaxis

Normal Intravenous Pyelogram (IVP)

Pelviureteric Junction (PUJ) Obstruction

Urolithiasis

Who should be referred to the paediatric nephrologist/ paediatric urologist/ paediatric surgeon?

Poor response to treatment of UTI/uncertainties of MxPoor response to treatment of UTI/uncertainties of Mx Recurrent UTIRecurrent UTI Neurogenic bladderNeurogenic bladder Voiding dysfunctionVoiding dysfunction Symptoms of dysfunctional elimination syndromeSymptoms of dysfunctional elimination syndrome Hydronephrosis (obstructive or non obstructive; intrauterine or post Hydronephrosis (obstructive or non obstructive; intrauterine or post

natal)natal) Abnormal radiology (KUB USS, MCUG, Renal scan)Abnormal radiology (KUB USS, MCUG, Renal scan) Suspicious looking radiology even if reported as normalSuspicious looking radiology even if reported as normal Renal scarringRenal scarring Obstructive uropathy (antenatally or postnatally diagnosed)Obstructive uropathy (antenatally or postnatally diagnosed)

Role of Circumcision

Presence of foreskin does not worsen UTI Presence of foreskin does not worsen UTI or increase risk of UTI once there is proper or increase risk of UTI once there is proper hygienehygiene

Role of Circumcision

Circumcision has a limited role in treatment Circumcision has a limited role in treatment of UTI:of UTI:

1.1. Recurrent UTI with no other abnormalityRecurrent UTI with no other abnormality

2.2. Solitary hydronephrotic kidneySolitary hydronephrotic kidney

Summary: Diagnosis/Mx UTI

DiagnosisDiagnosis– Abnormal urinalysis as well as positive cultureAbnormal urinalysis as well as positive culture– Positive culture = ≥50,000 colony-forming units (cfu)/mlPositive culture = ≥50,000 colony-forming units (cfu)/ml

TreatmentTreatment - Oral as effective as parenteral - Oral as effective as parenteral ImagingImaging - KUB USS for all patients - KUB USS for all patients

- Voiding cystourethrography (VCUG) not recommended - Voiding cystourethrography (VCUG) not recommended

routinely after first febrile UTI; required if KUB USS is routinely after first febrile UTI; required if KUB USS is

abnormal; necessary for recurrent and atypical UTIabnormal; necessary for recurrent and atypical UTI Follow upFollow up – Emphasis on urine testing with subsequent febrile illnesses – Emphasis on urine testing with subsequent febrile illnesses ReferralReferral – Early referral to paediatric surgery (paedi urology – Early referral to paediatric surgery (paedi urology

/nephrology)/nephrology)

Thank You.