Childhood UTI : an Update Kamal Akl MD Assoc Professor of Pediatrics/Nephrology - JUH February 5th 2011 Childhood UTI : an Update

GOALS To review the recent advances in the diagnosis and management of childhood UTIs NICE guidelines 2007 AUA guidelines 2010

Prevalence The prevalence of UTIs in children aged 2 months to 2 yrs is approximately 5% In circumcised boys, it is 0.2% to 0.4% In uncircumcised boys, it is up to 20 times higher. In girls, it is between 6.5% and 8.1% when there is no other fever source evident. Pediatrics. 1999;103:843-852.

Pathogens E coli : the cause of UTI in 82.7% of patients followed by Enterococcus spp, Staphylococcus spp, and then Proteus mirabilis/ Klebsiella/ Streptococcus. Shah P et al Clin Pediatr 2008

Diagnosis Urine culture : Gold standard Urinalysis : supportive

Symptoms & signs < 1 year : unexplained fever check for UTI < 1 year with UTI Rx as pyelonephritis

Urine collection Suprapubic Catheter Midstream urine bag

suprapubic If a urinary tract infection is present, any organism except 2000-3000 CFU/mL coagulase-negative staphylococci.

Catheterization in a girl or midstream clean-void collection in a circumcised boy Febrile infants and children with urinary tract infection usually have >50,000 CFU/mL of a single urinary pathogen; however, urinary tract infection may be present with 10,000- 50,000 CFU/mL of a single organism.*

Midstream clean-void collection in a girl or uncircumcised boy Urinary tract infection is indicated when >100,000 CFU/mL of a single urinary pathogen is present in a symptomatic patient. Pyuria usually present. A urinary tract infection may be present with 10,000-50,000 CFU/mL of a single bacterium.*

Urine culture result Patients with urinary frequency  decreased bladder incubation time  most likely to have bacteria proliferating in the urinary bladder in the presence of low colony counts.

Urine presevation Refrigerate if urine sample cannot be cultured within 4 hours or preserved with boric acid immediately

Ten to the power what ? Coulthard MG et al : suggest diagnostic urine culture be changed  from > 10(5) 10(6) 1 sample  decreased false + from 7,2% 4.8% 2 samples  decreased false + from 3.6% 0.6% Pediatrics 2010

Urine testing for >3 months but < 3 years Urine microscopy and culture Urinary symptoms  start Abx Positive microscopy or nitrite  start Abx NICE guidelines 2007

Urine testing in >3 years If leucocyte esterase and nitrite are positive  regard as UTI If leucocyte esterase and nitrite are negative  should not be regarded as having UTI If leucocyte esterase is negative & nitite is positive  Abx rx should be started untill culture results If leucocyte esterase is positive & nitrite is negative  Do not start Abx . No need for culture NICE guidelines 2007

Risk factors for UTI Poor urine flow Previous confirmed UTI Recurrent FUO Antenatal renal abnormality Family history of VUR/renal disease Constipation Dysfunctional voiding Enlarged bladder

Risk factors for UTI - contin Evidence of spinal lesion Poor growth High blood pressure NICE guidelines 2007

Upper vs lower UTI < 1 year with bacteriuria & fever of 38 degrees C  consider as upper UTI < 1 year & children with fever < 38 degrees C & flank pain/tenderness  upper UTI All others  lower UTI NICE guidelines 2007

Atypical UTI Seriously ill Poor urine flow Abdominal or bladder mass Raised serum creatinine Septicemia Failure to respond to treatment with suitable antibiotics within 48 hours Infection with non-E coli organisms

Acute management < 3 months > 3 months with APN > 3 months with cystitis

Long term management Prevention of recurrence Antibiotic prophylaxis Imaging tests

Prevention of recurrence Dysfunctional elimination syndromes and constipation should be addressed in infants and children who have had a UTI

Antibiotic prophylaxis Should not be routinely recommended in infants and children following first-time UTI May be considered in infants & children with recurrent UTI Asymptomatic bacteriuria in infants & children should not be treated with prophylactic antibiotics NICE guidelines 2007

Imaging Infants < 6 months with first time UTI that responds to treatment  US within 6 weeks Infants & children with first time UTI that responds to treatment  routine US not recommended unless UTI is atypical Infants & children with lower UTI  US ( within 6 weeks ) only if <6 months or had recurrent UTI NICE guideline 2007

Imaging for infants < 6 months Responds well to treatment within 48 hours No DMSA , No MCUG Atypical UTI  DMSA yes , MCUG yes Recurrent UTI  DMSA yes , MCUG no

Imaging for infants & children > 6 months but < 3 years Responds well to treatment within 48 hours  No imaging Atypical UTI US during acute infection , DMSA Recurrent UTI  US within 6 weeks , DMSA NICE guidelines 2007

Recommended imaging for children > 3 years Responds well to treatment within 48 hours  No imaging Atypical UTI US during acute infection Recurrent UTI US within 6 weeks , DMSA in 4-6 months NICE guidelines 2007

VUR Significantly increases risk of renal scarring in the setting of acute pyelonephritis . Resolution of VUR decreased incidence of febrile UTI , but overall incidence of UTI remains unchanged AUA 2010

CAP Not proven to reduce the incidence of febrile UTI in children with VUR Garin EH et al Pediatrics 2006 Montini G et al Pediatrics 2008 Roussey-Kesler G et al J Urol 2008

CAP Long-term , low dose trimethoprim- sulfamethoxazole was associated with a decreased number of UTIs in predisposed children . Craig JC , et al NEJMed 2009

Antibiotic Agents to Prevent Reinfection Agent Single DailyDose Nitrofurantoin* 1-2 mg/kg PO Sulfamethoxazole and trimethoprim* 1-2 mg/kg TMP, 5-10 mg/kg SMZ PO Trimethoprim 1-2 mg/kg PO

CAP Age < 6 weeks : Avoid nitrofurantoin or sulfa drugs Reduced doses of an oral first-generation cephalosporin, such as cephalexin at 10 mg/kg . Ampicillin or amoxicillin are not recommended because of the high incidence of resistant E coli.

Management of VUR in the child > 1 year of age with no BBD On detection of VUR evaluate for renal disease and symptoms suggestive of BBD If CAP is used  MCUG after 12-24 months Therapy with intention to cure : Open or endoscopic surgery is recommended for recurrent infections , new renal abnormalities determined by DMSA scanning , and parental preference . AUA 2010

Management of VUR in the child > 1 year of age with no BBD Success rates : Open surgery 98% Endoscopic surgery 83% Following surgery  Do US to exclude obstruction Cystography : an option Following endoscopic surgery  Do Cystography AUA 2010

Management of infant < 1 year of age with VUR Use CAP Resolution occurrs in 50% of these children within 24 months Recommendation : Rx of BBD as an integral part of reflux Rx AUA 2010

Management of the child with VUR and BBD Presence of BBD (1)reduces rates of VUR resolution & increase incidence of UTI in patients managed with CAP. (2) reduces cure rate of endoscopic therapy . (3) increases incidence of UTI after definitive reflux cure AUA 2010

Screening the siblings and offspring of patients with VUR Incidence of reflux in siblings : 27% Incidence of reflux in offspring : 35.7% Screening : option AUA 2010

Screening infants with a history of prenatally detected hydronephrosis for VUR infants with prenatally detected hydronephrosis : incidence of VUR 16.2% & not predicted by grade of hydronephrosis . Recommendation : No benefit from screeining AUA 2010

Conclusions Recent advances in the diagnosis and management of childhood UTI were reviewed , including : NICE guidelines 2007 AUA guidelines 2010

MOST IMPORTANT Is the patient Individualize Avoid guideline prison

Conclusions Thank you