Pediatric Uti

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  • Other organisms: proteus, klebsiella, enterococcus, coag neg staph
  • Dilute urine may produce false negative results U/A does not allow one to make the dx because too many false positives
  • Michael M, et al. Short versus standard duration oral antibiotic therapy for acute UTI in children. Cochrane Database Syst Rev 2004;(4)CD003966. Short vs long- 2004 cochrane review- 2-4 days appears to be as effective as 7-14 days in eradicating lower UTI in children;
  • Amox is recommended first line in infants < 2 months old
  • Williams GJ, et al. Long-term antibiotics for preventing recurrent UTI in children. Cochrane Database Syst Rev. 2004;(4):CD001534. Prophylactic abx use- 2004 Cochrane review and 2000 systematic review looked at this practice- studies of very poor quality- only evidence exists to support use if normal urinary tract but weak- no evidence in VUR Abx prophylaxis- 2001 Cochrane review- efficacy unknown- studies poorly designed with biases known to overestimate tx effect, large well done studies needed to determine efficacy
  • Routine imaging has not been shown to decrease # of recurrent utis or renal damage. However, routine use of prophylactic abx is increased 6 fold with use.
  • 2004 prospective study renal us did not change management of uti in any of 255 kids < 5yo admitted with first uncomplicated febrile UTI DMSA not mentioned in AAP guidelines. Cincinnati Children’s Hospital recs only if identification of acute pyelo or renal scarring will change management (better at identifying scarring than us).
  • RNC does not recognize anatomy of urethra and bladder well so cannot identify posterior urethral valves in boys
  • The film was taken during voiding. The bladder is full and contrast is seen to travel in retrograde fashion up both ureters (reflux). Notice that there is no nephrogram (no contrast in the renal parenchyma). This tells us that this image was obtained by putting contrast into the bladder, not by injecting contrast intravenously
  • Grade I- into distal ureter Grade II- up ureter into pelvis and calyces. No dilatation, normal calyceal fornicies Grade III- same as II but mild dilatation of pelvis and calyces Grade IV- same as III but ureter and pelvis are moderately dilated, and the calyces are moderately blunted Grade V- gross dilatation and tortuosity of ureter, pelvis, and calyces with significant blunting of the majority of the calyces Less common in African Americans
  • Wheeler DM, et al. Interventions for primary VUR. Cochrane Database Syst Rev. 2004(3):CD001532.
  • Pediatric Uti

    1. 1. Pediatric Urinary Tract Infections dr shabeel pn www.hi-dentfinishingschool.blogspot.com
    2. 2. Overview <ul><li>Background </li></ul><ul><li>Diagnosis </li></ul><ul><li>Treatment </li></ul><ul><li>Follow up </li></ul><ul><li>Prevention </li></ul><ul><li>Imaging </li></ul><ul><li>Vesiculoureteral reflux (VUR) </li></ul><ul><li>Summary </li></ul>
    3. 3. Background <ul><li>Most common serious bacterial infection in young children </li></ul><ul><ul><li>5% of febrile infants </li></ul></ul><ul><li>Prevalence </li></ul><ul><ul><li>By age 7: 8% girls, 2% boys </li></ul></ul><ul><ul><li>Highest rate in first year of life </li></ul></ul><ul><ul><li>Higher in Caucasians </li></ul></ul><ul><ul><li>Higher in uncircumcised boys </li></ul></ul><ul><li>Most common organism: E. coli- 80% </li></ul>
    4. 4. Background <ul><li>Symptoms systemic in early childhood </li></ul><ul><ul><li>Fever* </li></ul></ul><ul><ul><li>Irritability </li></ul></ul><ul><ul><li>Lethargy </li></ul></ul><ul><ul><li>Anorexia </li></ul></ul><ul><ul><li>Emesis </li></ul></ul><ul><li>Potential sequelae </li></ul><ul><ul><li>Renal scarring </li></ul></ul><ul><ul><li>Chronic renal failure </li></ul></ul><ul><ul><li>HTN </li></ul></ul>
    5. 5. Background <ul><li>Anatomic risk factors </li></ul><ul><ul><li>Vesiculoureteral reflux (VUR) </li></ul></ul><ul><ul><ul><li>More common in girls </li></ul></ul></ul><ul><ul><li>Obstruction </li></ul></ul><ul><ul><li>Posterior urethral valves </li></ul></ul><ul><ul><ul><li>Boys </li></ul></ul></ul><ul><ul><li>Voiding dysfunction </li></ul></ul><ul><ul><li>Bladder diverticulum </li></ul></ul>
    6. 6. Background <ul><li>Associated risk factors </li></ul><ul><ul><li>Constipation </li></ul></ul><ul><ul><li>Encoporesis </li></ul></ul><ul><ul><li>Bladder instability </li></ul></ul><ul><ul><li>Infrequent voiding </li></ul></ul><ul><li>Unsubstantiated risks </li></ul><ul><ul><li>Bathing </li></ul></ul><ul><ul><li>Back-to-front wiping </li></ul></ul>
    7. 7. Diagnosis <ul><li>Single organism identified on culture </li></ul><ul><ul><li>Suprapubic aspirate > 1,000 cfu/mL </li></ul></ul><ul><ul><li>Catheter specimen > 10,000 cfu/mL </li></ul></ul><ul><ul><li>Clean catch specimen > 100,000 cfu/mL </li></ul></ul><ul><ul><li>Urine bags not recommended </li></ul></ul>
    8. 8. Diagnosis <ul><li>Urinalysis </li></ul><ul><ul><li>Not helpful if clinical suspicion high </li></ul></ul><ul><ul><ul><li>i.e. older children with classic symptoms </li></ul></ul></ul><ul><ul><li>Useful if low likelihood of UTI </li></ul></ul><ul><ul><ul><li>Non-dilute urine (sg > 1.005) </li></ul></ul></ul><ul><ul><ul><li>Neg nitrate and leuk esterase </li></ul></ul></ul><ul><ul><ul><li>Negative predictive value > 95% </li></ul></ul></ul><ul><li>Blood cultures not useful </li></ul>
    9. 9. Treatment <ul><li>Initiate immediately after culture drawn </li></ul><ul><ul><li>Reduces severity of renal scarring </li></ul></ul><ul><li>Oral route preferred </li></ul><ul><li>7-14 day course is standard </li></ul><ul><ul><li>2-4 days appears to be as effective </li></ul></ul><ul><ul><ul><li>Not yet recommended </li></ul></ul></ul>
    10. 10. Treatment 6-12mg/kg & 30-60mg/kg In 2 doses Trimethoprim/ Sulfamethoxazole (Bactrim) 120-150mg/kg in 4 doses Sulfisoxazole (Gantrisin) 15-30mg/kg in 2 doses Loracarbef (Lorabid) 50-100mg/kg in 4 doses Cephalexin (Keflex) 30mg/kg in 2 doses Cefprozil (Cefzil) 10mg/kg in 2 doses Cefpodoxime (Vantin) 8mg/kg in 2 doses Cefixime (Suprax) 20-40mg/kg in 3 doses Amoxicillin* Daily Dosage Antibiotic
    11. 11. Follow Up <ul><li>AAP Recommendation: 48 hours </li></ul><ul><ul><li>If not improving repeat culture & immediate renal ultrasound </li></ul></ul><ul><ul><li>No evidence to support repeat culture/test of cure </li></ul></ul>Committee on Quality Improvement, Subcommittee on Urinary Tract Infection. Practice parameter: the diagnosis, treatment, and evaluation of the initial urinary tract infection in febrile infants and young children. Pediatrics 1999;103:843-52.
    12. 12. Prevention <ul><li>Rates of recurrence </li></ul><ul><ul><li>12% of children < 5 years old </li></ul></ul><ul><ul><li>18% of infants < 6 months </li></ul></ul><ul><li>Prophylactic antibiotics </li></ul><ul><ul><li>Recommended by AAP while waiting for imaging </li></ul></ul><ul><ul><li>Efficacy questioned </li></ul></ul>
    13. 13. Prevention 2mg/kg & 10mg/kg nightly or 5mg/kg & 25mg/kg 2x/week Trimethoprim/ sulfamethoxazole (Bactrim) 10-20mg/kg in 2 doses Sulfisoxazole (Gantrisin) 1-2mg/kg once per day Nitrofurantoin (Macrobid) 30mg/kg in 2 doses Nalidixic acid (NegGram) 75mg/kg in 2 doses Methenamine mandelate (Mandelamine) Daily Dosage Antibiotic
    14. 14. Prevention <ul><li>Circumcision </li></ul><ul><ul><li>Lowers UTI rate in boys </li></ul></ul><ul><ul><ul><li>NNT = 111 to prevent one UTI </li></ul></ul></ul><ul><ul><li>Surgical complication rate = 1% </li></ul></ul><ul><ul><li>Benefit does not outweigh risk and not recommended </li></ul></ul>
    15. 15. Imaging <ul><li>Who to image? </li></ul><ul><ul><li>AAP </li></ul></ul><ul><ul><ul><li>All children 2 months to 2 years of age with first UTI </li></ul></ul></ul><ul><ul><ul><li>Renal ultrasound </li></ul></ul></ul><ul><ul><ul><li>Cystogram </li></ul></ul></ul><ul><ul><ul><ul><li>Voiding cystourethrogram (VCUG) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Radionuclide cystogram (RNC) </li></ul></ul></ul></ul>
    16. 16. Imaging <ul><li>Who to image? </li></ul><ul><ul><li>Cincinnati Children’s Hospital </li></ul></ul><ul><ul><ul><li>All boys </li></ul></ul></ul><ul><ul><ul><li>Girls < 36 months </li></ul></ul></ul><ul><ul><ul><li>Girls 3-7 with fever > 38.5 º C (101.3 º F) </li></ul></ul></ul><ul><ul><ul><li>Same modalities recommended as AAP </li></ul></ul></ul>Evidence based clinical practice guideline for medical management of first time acute urinary tract infection in children 12 years of age or less. Cincinnati, Ohio: Cincinnati Children’s Hospital Medical Center, 2005.
    17. 17. Imaging <ul><li>Renal ultrasound </li></ul><ul><ul><li>GU tract anatomy </li></ul></ul><ul><ul><li>Evaluate renal scarring </li></ul></ul><ul><li>DMSA (renal cortical scan) </li></ul><ul><ul><li>Differentiates pyelonephritis from cystitis </li></ul></ul><ul><ul><li>Assesses renal scarring </li></ul></ul>
    18. 18. Imaging <ul><li>Cystogram- identify and grade vesicoureteral reflux (VUR) </li></ul><ul><ul><li>Voiding cystourethrogram (VCUG) </li></ul></ul><ul><ul><ul><li>OK for girls and boys </li></ul></ul></ul><ul><ul><ul><li>Demonstrates GU anatomy plus VUR </li></ul></ul></ul><ul><ul><li>Radionuclide cystogram (RNC) </li></ul></ul><ul><ul><ul><li>Low amount of radiation </li></ul></ul></ul><ul><ul><ul><li>Girls only </li></ul></ul></ul><ul><ul><ul><ul><li>Little anatomic detail </li></ul></ul></ul></ul>
    19. 21. Vesicoureteral Reflux (VUR) <ul><li>Concern for pyelonephritis & renal scarring </li></ul><ul><li>Prevalence in females < 18 yo </li></ul><ul><ul><li>Grade I- 7% </li></ul></ul><ul><ul><li>Grade II- 22% </li></ul></ul><ul><ul><li>Grade III- 6% </li></ul></ul><ul><ul><li>Grade IV- 1% </li></ul></ul><ul><ul><li>Grade V- <1% </li></ul></ul>
    20. 22. Vesicoureteral Reflux <ul><li>Standard treatment options </li></ul><ul><ul><li>Antibiotics </li></ul></ul><ul><ul><ul><li>Studies of prophylactic antibiotics have not included children with VUR </li></ul></ul></ul><ul><ul><li>Surgery </li></ul></ul><ul><ul><li>Antibiotics + surgery </li></ul></ul>
    21. 23. Vesicoureteral Reflux <ul><li>Unclear if clinical benefits to treating VUR </li></ul><ul><ul><li>Only severe VUR (Grades IV & V) associated with recurrent UTI and pyelonephritis </li></ul></ul><ul><ul><ul><li>< 2% of all cases of VUR </li></ul></ul></ul><ul><ul><ul><li>No causal relationship with scarring </li></ul></ul></ul><ul><ul><li>Risk of UTI = between surgical & medical groups </li></ul></ul><ul><ul><li>Abx + surgery reduced # of UTIs and pyelo but no renal damage noted in either group at 5 years </li></ul></ul>Wheeler DM, et al. Interventions for primary VUR. Cochrane Database Syst Rev. 2004(3):CD001532
    22. 24. Summary <ul><li>Urine culture necessary for diagnosis </li></ul><ul><li>Short courses of antibiotics may be as effective as longer courses </li></ul><ul><li>Prophylactic antibiotics are an option but may not provide much clinical benefit </li></ul><ul><li>Routine imaging does not appear to affect outcomes </li></ul><ul><li>Diagnosing VUR does not appear to affect outcomes </li></ul>
    23. 25. References <ul><li>Alper BS, Curry SH. Urinary tract infection in children. Am Fam Physician 2005;72:2483-8. </li></ul><ul><li>Committee on Quality Improvement, Subcommittee on Urinary Tract Infection. Practice parameter: the diagnosis, treatment, and evaluation of the initial urinary tract infection in febrile infants and young children. Pediatrics 1999;103:843-52. </li></ul><ul><li>Currie ML, et al. Follow-up urine cultures and fever in children with urinary tract infection. Arch Pediatr Adolesc Med 2003;157:1237-40. </li></ul><ul><li>Evidence based clinical practice guideline for medical management of first time acute urinary tract infection in children 12 years of age or less. Cincinnati, Ohio: Cincinnati Children’s Hospital Medical Center, 2005. </li></ul><ul><li>Michael M, et al. Short versus standard duration oral antibiotic therapy for acute urinary tract infection in children. Cochrane Database Syst Rev 2004;(4):CD003966 </li></ul>
    24. 26. References <ul><li>Roberts KB. The AAP practice parameter on urinary tract infections in febrile infants and young children. Am Fam Physician 2000;62:1815-22. </li></ul><ul><li>Le Saux N, Pham B, Mohoer D. Evaluating the benefits of antimicrobial prophylaxis to prevent urinary tract infections in children: a systematic review. CMAJ 2000; 163:523-9. </li></ul><ul><li>Michael M, et al. Short compared with standard duration of antibiotics treatment for urinary tract infection: a systematic review of randomised controlled trials. Arch Dis Child 2002;87:118-23. </li></ul><ul><li>Singh-Grewal D, Macdessi J, Craig J. Circumcision for the prevention of urinary tract infection in boys: a systematic review of randomized trials and observational studies. Arch Dis Child 2005;90:853-58. </li></ul><ul><li>Williams GJ, Lee A, Craig JC. Long-term antibiotics for preventing recurrent urinary tract infection in children. Cochrane Database Syst Rev 2004;(4):CD001534. </li></ul><ul><li>Wheeler DM, et al. Interventions for primary vesicoureteric reflux. Cochrane Database Syst Rev 2004;(3):CD001532. </li></ul>

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