Pediatric UTI and Reflux By Brent Lee Lechner, DO MAJ, MC, USA

Epidemiology Different for different ages Neonatal 5-8 X > in males than females Infants: F>M, 1.4% > 0.2% 4 Months, F>>M by 10 X White > Black and Hispanic 3-6 % Febrile Infants without source Circumcised vs Uncircumcised Males 5-20 X in uncircumcised below 12 months

UTI - risk factors Constipation Bubble Baths Sexual activity Infrequent voiding Poor hygiene Non-circumcision Sexual Abuse Female

Pathogenesis Organisms on perineum - ascending up the urethra. 85 % E. coli adherence factor Bacteremia associated with UTI. 31 % Neonatal 18 % 1-3 months 6 % 3-8 months

Organisms Gram Negative Gram Positive Hemorrhagic Cystitis E. Coli Klebsiella Proteus Pseudomonas H. Flu Gram Positive Enterbacter Entercoccus Staph Saprophyticus Hemorrhagic Cystitis Adenovirus H. Flu

Signs and Symptoms Fever Dysuria Nausea and Vomiting Abdominal Pain Flank Pain Frequency and Urgency

Signs and Symptoms in Infants Irritability - 80% Vomiting - 40% Diarrhea - 30% Poor feeding -65% FTT Lethargy

DDx Chemical Irritant Vaginitis Viral Infection Urethritis Pyelonephritis Glomerulonephritis Appendicitis Diabetes STD Diabetes Insipidus Bacteremia

Lab Studies Urinalysis Nitrate (+) and LE (+) WBCs - greater than 5 on hpf Unspun urine - Any Bacteria then positive. UA noted to be negative on 20-30 % of positive cultures.

Urine Culture Suprapubic Tap Urine Cath. Urine Clean Catch Bag Urine Any Growth - Positive Urine Cath. Greater than 100,000 colonies of a single organism Urine Clean Catch Greater then 100,000 colonies If two CC, increase by 80-90% Bag Urine Worthless

Treatment Antibiotic Cephalosporin (third generation without sensitivity): Rocephin, Fortaz PO: Vantin, Suprax Bactrim Amoxicillin Pediatrics - No keflex.

Management Adult - 3-5 days Children -- 7-10 days Infants Under 3 months (admission) po intolerance (admission) 12 months ? Admission

Management Renal Ultrasound VCUG DMSA All Patients Look at Anatomy Look for Hydronephrosis Perirenal abscess VCUG Shows reflux Must have clean urine to obtain 4-6 weeks out DMSA Gold standard for pyelo and scarring

Urinary Reflux Grade I - Reflux in Ureter Grade II - Reflux to the Upper Collecting System, No dilation Grade III - Reflux into dilated ureter and/or blunted calyces Grade IV - Grossly dilated ureter Grade V - Tortuosity

Urinary Reflux VUR prophylaxis until Free of reflux for 1 year by VCUG. Prophylaxis medications: bactrim or macrodantin Grade III- IV need Surgery Grade II - please refer to Urology Consider screening siblings.