First Urinary Tract Infection Episode in Children

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First Urinary Tract Infection Episode in Children: Are Procalcitonin Values & US Examination of Importance in the Diagnosis of Upper Urinary Tract Infection ?

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First Urinary Tract Infection Episode in Children

  1. 1. “ First urinary tract infection episode in children: Are procalcitonin values & ultrasound examination of importance in the diagnosis of upper urinary tract infection ? ” S.P. Deftereos, A. Kotoula, E. Vranou, A. Zisimopoulos, A. Chadjimichail, P. Prassopoulos Democritus University of Thrace, Department of Radiology, Alexandroupolis, Greece
  2. 2. URINARY TRACT INFECTIONS  Differential diagnosis between upper and lower urinary tract infection  Acute pyelonefritis  Scars  Hypertension  C.R.D
  3. 3. GENERAL APPROACH until today… Clinical evaluation Temperature ≥38oC, presence of vomiting or diarrhea, decreased oral intake  Laboratory investigation  ESR, CRP, leukocyte count, positive culture of urine speciment
  4. 4.  116-amino-acid propeptide of calcitonin  New marker of bacterial infections  Under physiological conditions undetectable  Very high levels in response to bacterial infections  Decreases within 48h of the administration of antibiotics PROCALCITONIN (PCT)
  5. 5. DMSA Gold standard method but Costs Limit availability Inability to differentiate old scarring from acute Exposure of patients to radiation ULTRASOUND Noninvasive with no risk to the patient Easily performed method No exposure to radiation but  Strongly dependent on the operator  Children are not always cooperative VCUG Information for VUR but Performed after UTI treatment Radiation exposure (gonads) Invasive method
  6. 6. DMSA ULTRASOUND PCT WBC ESR CRP UUTI
  7. 7. AIM To examine the efficacy of ultrasonography (US) findings in combination with procalcitonin (PCT) values in predicting renal parenchymal involvement (RPI) in children with urinary tract infection (UTI)
  8. 8. PATIENTS AND METHODS Prospective study 57 children (mean age: 12months, range: 2 - 108months) First episode of UTI Children with a history of prior UTI were not included N=43 N=14
  9. 9. Clinical evaluation:  Temperature ≥38oC, vomiting / diarrhea, decrease oral intake Laboratory investigation includes:  Urine specimens culture  Leukocyte count  Erythrocyte sedimentation rate (ESR)  C-reactive protein (CRP) and  serum PCT PATIENTS AND METHODS
  10. 10. Imaging evaluation includes: US: within 48h DMSA: within 7 days and VCUG: after 4-5 weeks (n:51/57pts) A follow up DMSA was performed after 6 months to examine possible persistent renal lesions PATIENTS AND METHODS
  11. 11. RESULTS  Upper UTI (group A, n: 27 children) DMSA positive, abnormal US (n=15, 55.6%)  Lower UTI (group B, n: 30 children) DMSA negative, US no abnormalities (except 4 pts with urinary bladder thickening) N=8 N=21 N=18 N=12 N=27 N=30 PCT + +
  12. 12. DMSA + US + Follow Up RESULTS
  13. 13. RESULTS
  14. 14. Hyperechoic renal parenchyma Collecting system dilatation Increased total kidney volume Scars (congenital, others) CDS- irregular vascularity ULTRASOUND FINDINGS
  15. 15. All infection markers, except LC, have the same diagnostic value PROGNOSTIC VALUE ? Group A (N=27) median (range) Group B (N=30) median (range) P value Leukocyte count (/μl) 19,000 (8,000-27,000) 12,750 (4,500-23,500) 0.056 ESR (mm/h) 40 (27-98) 17.5 (2-75) <0.001 CRP (mg/dl) 9 (1.9-35) 0.5 (0.1-6.5) <0.001 PCT (ng/ml) 4.8 (0.5-13.2) 0.3 (0.1-0.9) <0.001 RESULTS
  16. 16. PCT levels were significantly higher in patients with persistent renal lesions or/and VUR (n=8) * than in those with total regression of RPI (n=15) (p=0,004) *Vesicoureteral reflux (VUR) was disclosed by VCUGin 14/51(27,4%, 8 group A, 6 group B) cases PCT cut off: >0.5ng/ml NPV >0.85ng/ml NPPV >1.2ng/ml PPV RESULTS
  17. 17. DMSA is required in patients with high PCT levels and negative US examined CONCLUSIONS The combination of high PCT levels and positive US findings is an indication of upper UTI
  18. 18. CONCLUSIONS Normal US and PCT levels can exclude upper UTI …and thus protect small patient from unnecessary DMSA

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