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 optionFollowing 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