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Childhood UTI : an Update

Kamal Akl MD Assoc Professor of Pediatrics/Nephrology - JUH February 5 th 2011. Childhood UTI : an Update. GOALS. To review the recent advances in the diagnosis and management of childhood UTIs NICE guidelines 2007 AUA guidelines 2010. Prevalence.

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Childhood UTI : an Update

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  1. Kamal Akl MD Assoc Professor of Pediatrics/Nephrology - JUH February 5th 2011 Childhood UTI : an Update

  2. GOALS • To review the recent advances in the diagnosis and management of childhood UTIs • NICE guidelines 2007 • AUA guidelines 2010

  3. 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.

  4. 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

  5. Diagnosis • Urine culture : Gold standard • Urinalysis : supportive

  6. Symptoms & signs • < 1 year : unexplained fever check for UTI • < 1 year with UTI Rx as pyelonephritis

  7. Urine collection • Suprapubic • Catheter • Midstream urine • bag

  8. suprapubic • If a urinary tract infection is present, any organism except 2000-3000 CFU/mL coagulase-negative staphylococci.

  9. 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.*

  10. 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.*

  11. 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.

  12. Urine presevation • Refrigerate if urine sample cannot be cultured within 4 hours or preserved with boric acid immediately

  13. 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

  14. 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

  15. 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

  16. 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

  17. Risk factors for UTI - contin • Evidence of spinal lesion • Poor growth • High blood pressure • NICE guidelines 2007

  18. 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

  19. 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

  20. Acute management • < 3 months • > 3 months with APN • > 3 months with cystitis

  21. Long term management • Prevention of recurrence • Antibiotic prophylaxis • Imaging tests

  22. Prevention of recurrence • Dysfunctional elimination syndromes and constipation should be addressed in infants and children who have had a UTI

  23. 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

  24. 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

  25. 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

  26. 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

  27. 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

  28. 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

  29. 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

  30. CAP • Long-term , low dose trimethoprim-sulfamethoxazole was associated with a decreased number of UTIs in predisposed children . • Craig JC , et al NEJMed 2009

  31. 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

  32. 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.

  33. 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

  34. 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

  35. 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

  36. 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

  37. 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

  38. 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

  39. Conclusions • Recent advances in the diagnosis and management of childhood UTI were reviewed , including : • NICE guidelines 2007 • AUA guidelines 2010

  40. MOST IMPORTANT • Is the patient • Individualize • Avoid guideline prison

  41. Conclusions Thank you

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