Marisa Seepersaud MBBS MRCS DM The surgical significance of urinary tract infections (UTIs) in children Marisa Seepersaud MBBS MRCS DM

2011 (Sarah Amin) Brandon Seepersaud Records were poor 22 patients , age 5 and under , who were treated for UTI at the GPHC Urinalysis: All Urine culture: 4/22 (18%) Abdominal ultrasound: 7/22 (32%) (2 “enlarged kidneys”, 5 Normal study) 2 referrals to urology1 PUV

Urinary Tract Infection (UTI) UTIs are among the most common bacterial infections in children under 2 yrs old The diagnosis is often missed on history and physical examination

Recent Recommendations AAP, American Academy of Pediatrics , (1999) 2013 Consensus Document, Management of UTI in Jamaican Children, (2005), August 2011 NICE, National Institute for Health and Care Excellence, UK (2007) May 2011

Incidence ~1% of children below age 1 ~ 5 % of febrile children*, 2- 24 months of age 7.5% girls, 10% uncircumcised males, 2.5% of circumcised males who present with a fever under 2yrs

Clinical significance of UTI Associated with life-threatening sepsis in the newborn Increased rates of renal scarring in young children hypertension chronic kidney disease  pregnancy induced hypertension

Urinary tract infections may occur as a result of structural anomalies of the urinary tract There are many factors which potentially contribute to the development of UTIs in children. They include bacteriological factors (type of organism, virulence factors) as well as host factors (colonisation of the perineum with uropathogens, dysfunctional voiding, immunologic factors as well as anatomic abnormalities of the urianry tract.

The diagnosis of urinary tract infection in a young child is an important marker for urinary tract abnormalities Mandates investigation Minimize the risk of development of chronic kidney disease secondary to urological abnormalities

Important to accurately make the diagnosis Under-diagnosing UTI may lead to under-treatment, under-investigation, and risks permanent renal damage

Risk of renal scarring with recurrent UTI Jodul U Risk of renal scarring with recurrent UTI Jodul U. The natural history of bacteriuria in childhood. Infect Dis Clin North Am. 1987;1(4):713–729

Important to accurately make the diagnosis Over-diagnosing UTI may result in the development of resistant organisms, the use of limited resources for un-necessary and expensive investigations, (uncomfortable/painful/ scary for patient; distressing for the parents)

Most common  Least common Infants younger than 3 months Fever Age group Symptoms and signs Most common  Least common Infants younger than 3 months Fever Vomiting Lethargy Irritability Poor feeding Failure to thrive Infants older than 3 months, and children Preverbal Abd pain Loin tenderness Haematuria Malodorous urine Verbal Frequency Dysuria Dysfunctional voiding Sec enuresis Malaise Malorous urine Cloudy urine

Who should be screened for a UTI? Infants and children with symptoms and signs of UTI Infants* with 1 or more of the following: temperature of at least 38°C fever for at least 2 days absence of another obvious source of infection children with urinary catheters in situ, children with neurogenic bladders, children already known to have significant pre-existing uropathies, children with underlying renal disease (

Option If the patient does not require immediate antimicrobial treatment  period of observation prior to investigation and treatment for UTI Because the clinical presentation tends to be nonspecific in infants and reliable urine specimens for culture cannot be obtained without invasive methods.BUT! age less than 12 months, temperature of at least 39°C, fever for at least 2 days, and absence of another source of infection

Dipstick screening of fresh urine Both leukocyte esterase and nitrite POSITIVE UTI Send urine for culture May start antibiotics Leukocyte esterase : negative Nitrite : positive Send urine for culture Leukocyte esterase : positive Nitrite : negative UTI unlikely

Diagnosis Must involve urine culture Traditionally: >100,000 cfu/ml Issues: contamination, false negatives, false positives Asymptomatic bacteriuria Based on studies done on adult females with pyleonephritis

Asymptomatic Bacteriuria (AS) Colonization of the urinary tract with non-pathogenic organisms Study of 3581 infants 2.5% male infants, 0.9% female infants 2 patients with AS developed symptomatic UTI soon after None of the other patients who developed UTI in the first year of life were found to have AS at initial screening Another study involving school aged girls with AS No difference in renal growth or function when patients were randomised to treatment vs observation But the treated group appeared to be more likely to develop pyleonephritis after antibiotics were stopped Scandinavia, long term screening study. Another study of 116 school aged girls with AS: no difference in renal growth or function in those randomised to treatment vs observation. None who were observed developed

Diagnosis of UTI: 2013 AAP recommendations Presence of both >50 000cfu/ml of a single organism/uropathogen AND Pyuria In an appropriately collected specimen Febrile 2-24 month olds who have no obvious neurologic or anatomic abnormalities known to be associated with rec UTI or renal damage (may be extrapolated to under 5yr old) AAP sub committee on UTI, 2009, 2011. Revision of AAP guidelines 1999 *who have no obvious neurologic or anatomic abnormalities known to be associated with recurrent UTI or renal damage. In the past: 100 000cfu/ml (women diagnosed with pyleonephritis)

Investigation of UTI: Culture Urine collected in a bag - only valid if NEGATIVE - cannot be used to make a diagnosis of UTI - positive culture is likely to be false positive (88%) ! - positive culture requires confirmation, which is impossible if antibiotics were started* REMEMBER: You want the most accurate test to be done initially since urine may be rapidly sterilised You want the most accurate test to be done initially since urine may be rapidly sterilised

Appropriate methods Catheter specimen urine (CSU)  sensitivity: 95%  specificity: 99%  difficult in young girls* Suprapubic Aspiration/ Bladder Tap (SPA) MSU in older patients *Requires some skill

Diagnosis Urinalysis is Positive when: Dipstick nitrite Microscopy leukocyte esterase test Microscopy  white blood cells/pus cells  +/- bacteria Esterase + nitrite Bacteria + pus cells***

The urinalysis may be negative despite a positive culture: Contamination Asymptomatic bacteriuria Urinalysis is not sensitive enough Requires 4 hrs of “stasis” in the bladder Young children, infants and neonates may void more often

Treatment Initiating treatment orally or parenterally is equally efficacious, so choice is based on practical considerations. Choice of drug should be based on local sensitivity patterns, adjusted according to sensitivity of particular uropathogen Duration of treatment: 7–14 days Pts who are systemically ill, immunocompromised, typically those under 3 months old, those unable to tolerate oral medication, if there are any concerns regarding compliance.

EVERY CHILD, who has had a diagnosis of a urinary tract infection, must be investigated for the presence of a predisposing anatomic abnormality of the urinary tract

Investigation ~5% of patients will be found to have some abnormality on investigation ~16% of patients with febrile UTI Overall about 1-2% of cases will be determined to have “actionable” findings which require some intervention. The seriousness of the potentially correctable abnormalities in 1% to 2%, coupled with the absence of physical harm, was judged sufficiently important to tip the scales in favor of testing.

Should patients be put on prophylaxis while awaiting investigations? YES No

Parental education Implications/complications of a UTI Symptoms/signs of a recurrent UTI Need for a urine culture for future febrile illnesses , even when there is an apparent source of fever Instructed to seek prompt medical evaluation for future febrile illnesses to ensure that recurrent infections can be detected and treated promptly

Imaging Investigations for UTI Abdominal Ultrasound MCUG/VCUG Renal scan (DMSA) Intravenous Pyelogram (IVP) All children irrespective of age, gender should be investigated after their 1st UTI. Over all about 5% of patients will be found to have some abnormality on investigation. About 16% of patients will febrile UTI.

Investigation: KUB USS All patients diagnosed with UTI should undergo kidney/ureter/bladder sonography (KUB USS) Timing: 6weeks post treatment Exception: if patient is not responding to treatment as expected, unusually ill  KUB USS within 48hrs In the literature, in the first world…there is a high rate of antenatal diagnosis and there is a high incidence of UTI in the first year and a high rate of detection of abnormalities <1 yr…our practice must be coloured by our reality…we are not there..yet.

Micturating/Voiding cystourethrogram (MCUG/VCUG) MCUG is not recommended routinely after the first febrile UTI if KUB USS is normal. Schroeder AR, Abidari JM, Kirpekar R, et al. Impact of a more restrictive approach to urinary tract imaging after febrile urinary tract infection. Arch Pediatr Adolesc Med. 2011;165(11):1027–1032 Recommended in the presence of  an abnormal KUB USS  recurrent UTI  atypical UTI MCUG done 4-6 weeks after the UTI Look at the films , incl post micturation films

Renal Scan/ Radionucleotide Scan (RNC) May be used in the acute setting to diagnose pyleonephritis  Helpful in distinguishing between obstructive and non- obstructive causes of hydronephrosis Provides information on differential function  Indentify renal cortical defects (DMSA) IVP is useful in the absence of the RNC

All patients with UTI’s should have: Urine culture Urinalysis Abdominal Ultrasound +/- MCUG +/- Renal scan +/- IVP (in the absence of renal scan)

What about long term urinary prophylaxis following UTI? Urinary prophylaxis is dictated by the underlying pathology Antibiotic prophylaxis should not be recommended in infants and children after the first UTI (if no underlying abnormality was found ) May be considered in infants and children with recurrent UTI

Dysfunctional elimination syndromes and constipation should be addressed in infants and children who have had a UTI. In the interest of prevention

Normal Cystogram (MCUG)

Normal Bladder and Urethra

Posterior urethral valves (PUV)

Posterior urethral valves

Bladder Diverticulum

Bladder diverticuli

Detrusor Instability

Grade I Vesicoureteric Reflux (VUR)

Grade II Vesicoureteric Reflux (VUR) Vesicoureteric reflux is defined as the non-physiological back-flow of urine from the urinary bladder into the ureter or the renal pelvis and the calyces.

Grade IV Vesicoureteric Reflux (VUR)

Contrary to previous beliefs “VUR with UTI without structural abnormalities in the kidneys seems not to cause CKD.” “Active treatment of VUR seems not to reduce the occurrence of CKD and, in large prospective follow-up studies, the renal function of patients with VUR has been well preserved.” Salo J, Ikäheimo R, Tapiainen T, et al. Childhood urinary tract infections as a cause of chronic kidney disease. Pediatrics. 2011;128(5):840–847 *new and growing body of evidence questioning the effectiveness of antimicrobial prophylaxis to prevent recurrent febrile UTI in children with VUR Randomized Intervention for Children With Vesicoureteral Reflux (RIVUR) study. (US) UTI Study (Ja)

Recurrence of UTI in patients with VUR prophylaxis vs observation Reflux Grade N Prophylaxis No Prophylaxis P # of Recurrences / Total N None 373 7 / 210 11 / 163 0.15 Grade I 72 2 / 37 2 / 35 1.00 Grade II 257 11 / 133 10 / 124 0.95 Grade III 285 31 / 140 40 / 145 0.29 Grade IV 104 16 / 55 21 / 49 0.14

Grade V Vesicoureteric Reflux (VUR)

Recurrence rate of febrile UTI in ages 2-24 months

Normal Intravenous Pyelogram (IVP)

Pelviureteric Junction (PUJ) Obstruction

Urolithiasis

Who should be referred to the paediatric nephrologist/ paediatric urologist/ paediatric surgeon? Poor response to treatment of UTI/uncertainties of Mx Recurrent UTI Neurogenic bladder Voiding dysfunction Symptoms of dysfunctional elimination syndrome Hydronephrosis (obstructive or non obstructive; intrauterine or post natal) Abnormal radiology (KUB USS, MCUG, Renal scan) Suspicious looking radiology even if reported as normal Renal scarring Obstructive uropathy (antenatally or postnatally diagnosed)

Role of Circumcision Presence of foreskin does not worsen UTI or increase risk of UTI once there is proper hygiene

Role of Circumcision Circumcision has a limited role in treatment of UTI: Recurrent UTI with no other abnormality Solitary hydronephrotic kidney

Summary: Diagnosis/Mx UTI Abnormal urinalysis as well as positive culture Positive culture = ≥50,000 colony-forming units (cfu)/ml Treatment - Oral as effective as parenteral Imaging - KUB USS for all patients - Voiding cystourethrography (VCUG) not recommended routinely after first febrile UTI; required if KUB USS is abnormal; necessary for recurrent and atypical UTI Follow up – Emphasis on urine testing with subsequent febrile illnesses Referral – Early referral to paediatric surgery (paedi urology /nephrology)

Thank You.