UTI

1. UTI January 14, 2009 Lindsay Chase MD

2. Why do we care between 5 and 10% of children 2 months to 2 years with fever will have UTI Girls>boys About 1/3 with 1st UTI will go on to have another About 30% have Vesicoureteral reflux

3. Why do we care Risk of renal scarring between 10 and 20% 10 to 30% of these develop hypertension

4. When should we think about UTI 3week old with fever to 101.5 2 week old with jaundice 7month old with fever 11month old with vomiting and loose stools 2yo with abdominal pain 3yo previously toilet trained now with daytime accidents 12yo spina bifida patient with fever 17yo with frequent painful urination 6week old with RSV now with fever to 102 ALL OF THE ABOVE

5. Risk factors for UTI +/- serious underlying pathology Poor urine flow Previous UTI (by history or documented) Recurrent FUO Abnormal prenatal US� renal Family history of VUR or renal disease Constipation Dysfunctional voiding Enlarge bladder Abdominal mass Weakness or other evidence of spinal lesion Poor growth High blood pressure

6. Definitions Lower Cystitis Improves quickly with antibiotics, possibly shorter treatment Upper Pyelonephritis Flank pain, costovertebral angle tenderness Vomiting Fevers after on antibiotics 24-48hrs

7. Definitions Atypical Seriously ill Poor urine flow Mass Bacteremia Raised creatinine Failure to respond to appropriate antibiotics treatment within 48hrs Infection with non E-coli organisms Recurrent 2 or more pyelonephritis 1 pyelo + 1 or more lower UTI 3 or more lower UTI

8. WorkUp Obtain urine How? Depends on age and other factors Bag- helpful if negative Clean catch Cath Suprapubic aspiration

9. WorkUp UA Nitrites- produced by reduction of dietary nitrates by urinary gram negative bacteria (E coli, Klebsiella, Proteus) leukocyte esterase- produced from breakdown of leukocytes, indirect test for WBC Micro (don�t forget to order it) WBC RBC Casts Bacteria gram stain Epithelial cells Culture

10. So when is it a UTI Dipstick (nitrite+LE) is 70% sensitive, 98% specific Nitrite + = UTI - = confusion; false neg if not enough dietary nitrites, not enough time for bacteria proliferation, large volume dilute urine, bacteria non-nitrate reducing species (gram positives like Enterococcus, mycobacteria, fungi) LE += supportive of UTI - = does not r/o UTI

11. So when is it a UTI Dipstick + Micro is 80% sensitive, 94% specific WBC >5 WBC/hpf spun urine suggests UTI Sterile pyuria Bacteria on micro gram stain 1organism/hpf on unspun urine represents 105 colonies/ml Significance of casts Upper vs lower, Cystitis vs pyelonephritis

12. Culture Significant culture grows only 1 organism How sample obtained matters Lab will count colonies may not ID if small amount or mixed

13. Culture

14. Culture More simply: Suprapubic aspiration >1,000 cfu/ml Cath >10,000 cfu/ml Clean catch>100,000 cfu/ml

15. Other testing If atypical, ill appearing, less than 2 months need to do more CBCdiff Blood culture BUN/Cr +/-electrolytes depending on hydration status CSF Neonates are at risk for bacteremia and meningitis reactive CSF pleiocytosis with UTI so get CSF BEFORE giving antibiotics or will have to treat 21days

16. Other Testing In ill appearing patients strongly consider blood work: Urosepsis HUS

17. Asymptomatic Bacteruria Interpret your culture result within the clinical context of your patient and with the UA result UA+, patient with UTI symptoms growth on a culture is likely significant UA-, patient without specific UTI symptoms, culture grows gram positives likely not significant Also colonization in patients with neurogenic bladder

18. Treatment: Empiric vs Focused Need to know most common organisms in your patient population and the susceptibility profiles E coli, E coli, E coli, Klebsiella, Proteus, Staph saprophyticus, Staph aureus. In Houston a 3rd generation cephalosporin is generally good broad 1st line coverage Not amoxicillin

19. Treatment: Outpatient Studies show an all PO course is equivalent to 3 days IV plus 11 days PO If tolerating PO, not toxic, ok to go home on empiric treatment For Texas Medicaid: Suprax (cefixime), but in TCH: Vantin (cefpodoxime)

20. Treatment: Inpatient vs Outpatient Inpatient if: <1month, consider 4 to 8weeks Vomiting, dehydration Need IV pain control �Upper� or �atypical�-- toxic, ill, etc. Poor follow-up Fever alone is NOT a criteria for admission

21. Treatment Outpatient Length of treatment controversial, no conclusive studies AAP recommends 7-14days for all UTIs (IV/PO) If uncomplicated, lower UTI- 7days (sometimes shorter in teenagers) If upper or atypical 10-14 days

22. Treatment: Inpatient Initial treatment with cefotaxime Unless special population: neonate, spina bifida Change from IV to PO when looking better, tolerating PO, etc. Hopefully will have culture to guide you Fever can last for days with pyelonephritis even on appropriate therapy.

23. Treatment: Special populations� spina bifida- pseudomonas, enterococcus. Check previous cultures Neonates- GBS Enterobacter, Citrobacter, Pseudomonas all inducible resistant to ALL cephalosporins Enterococci inducible resistance to most classes so need double coverage usually with amp and gent to start

24. Should we check to make sure infection is gone? If responding appropriately then repeat culture not routinely indicated Consider if not responding as expected BUT always should follow-up final culture to make sure patient sent with appropriate antibiotics from office, ER, and inpatient

25. Imaging Renal ultrasound VCUG Nuclear imaging DMSA mag3

26. Imaging Renal US Not with doppler routinely Looking for anatomic anomalies and hydronephrosis Duplicated collecting systems, ureteroceles, UPJ obstruction, etc. Some of what is seen may need surgical correction May be done outpatient If hospitalized most would get while hospitalized

27. Imaging VCUG= Voiding Cysto Urethro Gram Looking to see flow of urine as bladder contracts� does it �reflux� Also can help further define urethral and ureteral anatomy May be done outpatient Often try to get done while inpatient because concern for loss to follow-up Consider calling renal 4-3800 to enroll in RIVUR study

28. Imaging Nuclear Imaging DMSA, Mag3 give information on renal function Will show areas of renal scarring Consider in patients with recurrent UTI, abnormal renal US, abnormal VCUG or other risk factors Usually performed after acute infection treated

29. Imaging Very controversial AAP guidelines outdated Evidence lacking to support routine prophylactic antibiotic use and usefulness of imaging studies If not effectively preventing something (renal scarring) why are we screening AAP revising guidelines, hopefully will come out soon

30. Current AAP Guidelines Renal US and VCUG in ALL: male patients with 1st UTI female patients <5years with UTI Children with recurrent UTI

31. TCH EBM Imaging Guidelines Children 2-24 months Renal US and VCUG No need for repeat UA prior to VCUG if fever decreasing and on antibiotics

32. TCH EBM Imaging Guidelines Females 2-6years, Males 2-12years Renal US If renal US abnormal or has one of the following risk factors get VCUG Sibling with VUR Decreased renal function Proteinuria hypertension

33. TCH EBM Imaging Guidelines Females 6 to 12 years Renal US at discretion of physician

34. Imaging If abnormal US or VCUG contact urology for recommendations and follow-up Prophylaxis is controversial and evidence is lacking for routine use Prophylaxis will depend on attending provider

35. Take Home Points Always consider UTI in febrile child UA with micro and culture Clean catch if toilet-trained otherwise cath NO BAGS Empiric treatment with suprax/vantin outpatient, cefotaxime inpatient then adjust as indicated by culture Inpatient if dehydrated, not tolerating PO� not just for fever

36. Take Home Points Renal US for almost everyone VCUG if <2 years or abnormal US Nuclear scan if abnormal studies, recurrent infection or risk factors

37. Questions Yare are evaluating a 5yo girl who has a UTI. She has had 4 in the past 2 years, all of which resolved with antibiotics. She denies urgency or frequency. The only significant finding on medical history is constipation. Results of renal US and VCUG are normal. Growth parameters and PE are normal. You prescribe oral antibiotics. Of the following the MOST appropriate additional step to help reduce the incidence of further UTI is: A. begin immunodeficiency workup B. perform renal scintigraphy C. precribe stool softener and bowel routine D. prescribe oral oxybutynin E. Referral to pediatric nephrologist

38. Questions A mother brings in her 3yo daughter because of daytime urinary incontinence and abdominal pain. The mother exlpains that the girl was toilet trained at 2years of age. On PE growth parameters and VS are normal. She has mild suprapubic tenderness without costovertebral angle tenderness or sacral dimples. UA shows sg 1.025, pH 6.5, 2+blood, 1+protein, 3+ LE, +nitrite. Micro 20-50WBC, 5-10 RBC and 3+ bacteria. Of the following the MOST likely etiologic agent is A. Enterococcus faecalis B. Escherichia coli C. Klebsiella pneumoniae D. Proteus mirabilis E. Staphylococcus saprophyticus

39. Questions A 4yo female presents with fever, chills, and vomiting. She has had abdominal pain and dysuria for 3 days. Temperature is 104.2, She has left side CVAT. Lab eval reveals WBC of 18.7 (85% segs, 5% bands). UA 1.025/ 6.5/ 2+blood/ 1+protein/ 3+LE/ +nitrite/ 5-10 RBC/ 50-100WBC. Renal US is normal. After 3 days of IV antibiotics she is to go home to complete course PO. The MOST appropriate study to complete her evaluation is: A. Abd CT scan B. cystoscopy C. intravenous pyelography D. MAG3 renal scan E. voiding cystourethrography

40. Questions You are seeing a newborn boy for the first time. Prenatal US showed bilateral hydronephrosis which is confirmed by US after birth. Length, weight and PE are unremarkable. The MOST likely cause of the hydronephrosis is: A. Polycystic kidney disease B. Posterior urethral valves C. UPJ obstruction D. Vesicoureteral reflux E. Wilms tumor

41. Questions 3yo boy with myelomeningocele and history of recurrent UTI presents with 1 day of fever to 102 and cloudy urine. Labs show WBC of 15. Urine by cath is cloudy with strong odor and +nitrites, +LE and blood. Micro show too numerous to count WBC. 1 day later culture grows pseudomonas. Most appropriate therapy for treatment is A. ampicillin B. ceftazidime C. cefuroxime D. bactrim E. vancomycin

42. Questions 3 month old male recently treated for UTI. US shows mild left hydronephrosis. VCUG shows left grad IV VUR. After completion of antibiotics for UTI, the MOST appropriate course of management is. A. antibiotic prophylaxis B. Deflux surgery C. no therapy D. probiotics E. surgical reimplantation

43. Questions 5yo male referred for frequent UTI. Parents report at least 7 infections. Each time treated at local EC with antibiotics which provided almost immediate relief of symptoms. He was toilet trained at 4yo but still has frequent day and night wetting. PE unremarkable except height and weight are at 5% and parents are >50%. Now has fever, eneuresis and dysuria. UA +nitrites, +LE, 25-50 WBC. Urine culture sent. Renal US shows bilateral hydronephrosis. VCUG shows dilated proximal urethra and narrow distal. Electrolytes normal except Creatinine 1.2, After antibiotic treatment the next BEST step in management is to A. initiate antibiotics prophylaxis B. Measure electrolytes and re-evaluate in 6months C. immediately refer to pediatric urologist D. repeat the US E. repeat Ua and culture