Recurrent Uti, Vijayawada

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  • 1. Recurrent Urinary Tract Infections Dr. Mehul A. Shah M.D.(Ped.), DCH (Bom.), M.D.(USA) Diplomate of Am Board of Ped. Nephrology Consultant Pediatric Nephrologist Rainbow Children’s Hospital Hyderabad
  • 2. “ A lecture is the transfer of information from the lecturer’s notes to the student’s notes without passing thru the brains of either”
  • 3. “ Conference is the confusion of one man multiplied by the number present” TOI
  • 4. UTI: Definition
    • UTI is the common term for a group of conditions in which there is growth of bacteria within the urinary tract
    • Bacteriuria is the presence of bacteria in the urine
    • Growth of 100,000 colony forming units in freshly voided sample of urine - cutoff between UTI and contamination
  • 5. UTI: Epidemiology
    • 3-5% girls and 1-2% boys
    • First UTI - < 1 year
    • Recurrence rate – 40% in 1 year and 50% in 5 years
    • VUR – 30-65 %
    • Obstructive malformations – 10%
  • 6. UTI: Clinical Features
    • Depends upon the age of the child and level of infection
    • Young children (less than 2 years of age)
    • Nonspecific symptoms- fever, irritability, vomiting, diarrhoea, not gaining weight
    • Older children- burning sensation, increased frequency, bedwetting (new onset), backache
    • Upper UTI- high fever, vomiting, abd. pain
  • 7. UTI: Diagnosis
    • Depends upon Urine culture
    • No positive findings on clinical exam
    • Positive findings on CUE – pyuria and positive nitrite test
    • Pyuria is WBC > 10 cells/microL, and is present in 85% of symptomatic children.
    • Pyuria is NOT SPECIFIC for UTI
    • Positive nitrite test – 50% of cases
    • Urine for general exam in NOT adequate for diagnosis
  • 8. UTI: Diagnosis Method of collection Quantitative culture- UTI present Suprapubic aspiration Growth of urinary pathogens in any number Catheterization in females or midstream void in circumcised males Febrile infants or children usually have >/= 50 x 10 3 CFU/mL of a single urinary pathogen Midstream clean void Symptomatic patients: usually >/= 10 5 CFU/mL of a single urinary tract pathogen Bag specimen Useful only if the culture is negative
  • 9. UTI: Treatment
    • Initial treatment may include
    • Bactrim (8mg/kg/day of TMP in BID),
    • Cefixime (8mg/kg/day),
    • Amox-clavulinic acid (20-30mg/kg/day in BID)
    • Nalidixic acid (40-50 mg/kg/day in TID)
    • IV treatment is indicated in infants < 6 months of age or in children with persistent vomiting
    • Hydration, hygiene, treating constipation
  • 10. UTI
    • Does the treatment of UTI stop here?
      • Answer - NO
    • Question to be answered- Why did the child get UTI?
  • 11. UTI: Protective Factors
    • Urine is an excellent medium for bacterial growth.
    • The defense mechanisms include
    • - Regular bladder emptying, which flushes out any bacteria which may have ascended up the urethra
    • That is why our urinary bladder is NOT
    • a big tank and we do not pass urine ONCE a day
    • - Killing of bacteria by bladder wall lining
    • - Antibacterial properties of urine
  • 12. UTI: Predisposing Factors
    • Any factor which causes retention of urine predisposes to UTI
    • In children, the most common causes of urinary retention are:
    • -Vesico-Ureteral Reflux (VUR); 40%
    • -Obstruction in plumbing system; 10%
    • -Bladder dysfunction, which could be due to neurogenic problem or Dysfunctional voiding syndrome
    • Bacterial properties - adhesins, fimbriae, hemolysins, etc. can cause Upper UTI even in absence of Reflux.
  • 13. UTI: Complications
    • Recurrent UTI’s
    • -increased discomfort to child
    • -anxieties in parents
    • -increased medical costs
    • Reflux Nephropathy, in 30% of patients with VUR
    • - kidney failure (10%), dialysis and kidney transplant
    • -Hypertension, in 10-30% of cases with RN
    • Hypertension (High BP)
    • -paralysis
    • -heart failure
    • -kidney failure
  • 14. UTI: Complications
    • Renal scarring-
      • VUR
      • Host susceptibility
      • Urinary tract obstruction
      • Host inflammatory response
      • Therapeutic delay
  • 15.  
  • 16. VUR & Reflux Nephropathy
      • - 30-60% of children with symptomatic UTI have Reflux
      • 30% of patients with VUR will have RN (scarring)
      • Scarring is predominantly seen at both poles in children < 5 years of age
      • Incidence of HTN is 5-30% with scarring
      • Conversely, 30% of patient’s with HTN have RN as their etiology
      • - 10% of ESRD in children is due to RN
  • 17. Recurrent UTI
    • Anatomic abnormalities
    • Vesico-ureteric reflux (VUR)
    • Dysfunctional voiding syndrome
    • 4) Hypercalciuria
  • 18.
    • Vesico-Ureteric Reflux
  • 19.  
  • 20. VUR & Reflux Nephropathy International Classification of Vesico-Ureteral Reflux.
  • 21. VUR & RN: Diagnosis
    • 1) Radiocontrast MCUG
      • To be done the first time when evaluating any child below 5 years to look for associated anatomic abnormalities, bladder trabeculation and urethral obstruction in boys
      • Sedation or GA to be avoided
      • False negative in about 20% of cases
    • 2) Direct Radionuclide Cystography (DRC)
      • Advantages- much lower radiation exposure to gonads (100-200 fold lower) and it is more sensitive
  • 22. VUR: Treatment
    • A} Medical:
      • Cornerstone in initial management, based on scientific data from Lenaghan and Smellie in mid 1970’s
      • Continuous antibacterial prophylaxis, either with
        • Bactrim (2 mg/kg of TMP as a single dose at bedtime)
        • Nitrofurantoin (2-3 mg/kg)
        • Nalidixic acid (10 mg/kg in bid doses)
        • Cephalexin (10mg/kg in bid doses) in infants less than 6 months of age
      • Prophylaxis is continued until reflux resolves or until the risk of reflux is considered to be low (6 years)
  • 23. VUR: Treatment
    • B} Surgical:
      • Open surgical management to create 4-5:1 ratio of length of intramural urete to ureter diameter (Ureteric reimplantation)
      • >95% success rate and <2% risk of obstruction as a complication
      • Endoscopic repair, (STING) subtrigonal injection of PTFE or collagen, success rate – 70%, often needs to be redone and long term safety of Teflon not established.
  • 24.
    • Dysfunctional voiding syndrome
  • 25.
    • “ Sorely neglected in most recommended protocols for evaluating urinary infection is an investigation for micturition disturbances which may be responsible for the infections.Treatment of these conditions may actually prevent recurrence of infection. Controversy surrounding the proper imaging evaluation for UTI appears to be misdirected. Instead of arguing about which imaging study should be performed or which child with a first UTI should have a cystogram, our patients might be better served it we wondered why traditional protocols for evaluating UTI deal only with imaging studies.”
    • Koff SA, Pediatr Nephrology 1991;5:398-400
  • 26. Dysfunctional voiding syndrome
    • More frequently a cause of recurrent UTI in older children, in absence of anatomic abnormalities or VUR
    • Acquired condition, due to imbalance between bladder contraction and sphincter function. Often due to “lazy” attitude
    • Girls > Boys, 2-10 years of age
    • pass urine infrequently or frequency, urgency, “holding” postures
    • secondary incontinence of urine
    • often associated with constipation
  • 27.  
  • 28.  
  • 29. Dysfunctional voiding
    • Diagnosis
      • Age group- 2-10 years
      • Usually based on typical history- incomplete and infrequent bladder emptying, secondary daytime enuresis, posturing etc
      • H/o constipation (in 80%)
      • Residual urine on USG (may be helpful)
      • Investigations (rarely needed)- MCUG, and urodynamic study
  • 30. Dysfunctional voiding syndrome
    • Treatment
      • Voiding schedule so that the child passes urine every 2-3 hours to retrain the urinary bladder.
      • Double or Triple voiding
      • Avoid ‘holding’ urine
      • Aggressive treatment of constipation
      • Positive re-inforcement technique
      • Anticholinergics (Oxybutinin) may be required in some cases after Urodynamic studies.
      • Usually takes 3-6 months for bladder re-training.
  • 31.
    • Hypercalciuria
  • 32. Hypercalciura
    • An important but less common cause of UTI
    • To be considered in a child with normal MCUG and recurrent UTI with a background family h/o renal stones
    • Hypercalciuria can cause UTI, recurrent abdominal pain, hematuria, lower tract symptoms, and renal stones
    • Spot urine calcium to creatinine ratio of <0.18 in children > 18 months age
    • Treatment is simple – dietary modification and alkylating agents, thiazides
  • 33. UTI: Work-up
    • Whom?
    • Children less than 5 years of age, with first UTI – USG & MCUG
    • Boys with symptomatic UTI
    • Older girls with recurrent UTI
  • 34. UTI: Work-up
    • Why?
      • Non-specific s/s in young infants
      • Renal scarring may occur even after one episode of UTI
      • 50% risk of recurrence in first 6 months after the initial episode of UTI
      • Incidence of renal scarring is higher in children with recurrent UTI’s
      • Risk of renal scarring is maximum in the first 5 years of life
  • 35. UTI: Work-up
    • What?
    • USG of kidney, ureter and bladder
    • MCUG (Micturiting Cysto Urethro Gram)
    • Thorough voiding and stooling history to rule out Dysfunctional elimination syndrome
    • Other investigations as needed like IVP, DTPA, DMSA renal scan, spot U Ca / creat etc.
  • 36. UTI: prophylaxis
    • For whom?
      • VUR
      • Anatomic abnormalities
      • Dysfunctional voiding
      • Recurrent UTI’s
      • In children less than 2 years of age, in
      • absence of radiological abnormalities
  • 37. UTI: prophylaxis
    • Which drug?
      • Bactrim (2 mg/kg of TMP as a single dose at bedtime)
      • Nitrofurantoin (2-3 mg/kg)
      • Nalidixic acid (10 mg/kg in bid doses)
      • Cephalexin (10mg/kg in bid doses) in infants less than 6 months of age
  • 38. UTI: prophylaxis
    • How long?
      • Until the risk of scarring is minimal
      • Usually up to 6 years of age
      • Primary problem is resolved
  • 39. UTI: Prevention
    • Other measures-
    • Hygiene
    • Circumcission
    • Plenty of liquids
    • Complete and regular bladder emptying
    • Treat constipation
  • 40.
    • Case 1
    • 1-1/2 years, boy with recurrent episodes of moderate fever since 3 months of age
    • Diagnosed to have UTI at 1-1/2 years of age
    • Renal USG was reported normal
    • Should MCUG be performed ?
    • Renal scan - Result ?
  • 41.  
  • 42.  
  • 43. Case 2
    • 7 years, girl with failure to thrive and history s/o UTI
    • Weight of 14 kgs, height of 95 cms
    • BP – 118 / 80, 126 / 82
    • Renal USG – reported normal
    • MCUG – Bilateral grade 3 VUR
    • DMSA scan – bilateral renal scarring (R>L)
    • After prophylaxis and anti-hypertensive therapy, better with weight gain of 2 kg in 3 months
  • 44. Case 3
    • 3 years old girl, with recurrent UTI’s since 1 year of age, with increased frequency of infections over the past 6 months
    • Classical history of dysfunctional elimination syndrome
    • Renal USG – normal
    • DRCG
    • DMSA scan – No scarring
  • 45. VUR and Dysfunctional voiding Pre-treatment
  • 46. VUR and Dysfunctional Voiding- Post-treatment
  • 47. Message
    • Think of UTI in an infant with fever without focus of infection
    • Diagnose UTI with a urine culture
    • Treat UTI’s promptly to minimize risk of scarring
    • Investigate EVERY child with UTI with at-least a renal USG AND MCUG
    • Normal USG does-not rule out VUR
    • Dysfunctional voiding is an important risk factor for recurrent UTI in an older child
    • Once a scar is formed, it will stay for ever and then the child has a risk for developing HTN and ESRD
  • 48. Message
    • Think
    • Prompt therapy
    • Investigate
    • Prevent scars
    • (HTN & ESRD)
  • 49. Prevent Renal Scars – Prevent Hypertension, and ESRD
  • 50. THANK YOU