Happy Friday! Morning Report July 8 th, 2011

Urinary Tract Infections AMERICAN ACADEMY OF PEDIATRICS 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

Recommendation 1 The presence of UTI should be considered in infants and young children with unexplained fever

Why? ▫Prevalence is 5% ▫Risk of renal damage is greatest in this age group ▫Diagnosis can be challenging  Most common clinical findings:  Fever 20 to 40%  Failure to thrive 15 to 43%  Jaundice 3 to 41%  Vomiting 9 to 41%  Loose stools 3 to 5%  Poor feeding 3 to 5%

Girls vs Boys Newborn period ▫Occurs 1.5 to 5 times more in BOYS First 6 months ▫Decreases in boys, increases in girls By 1 year ▫3 times more common in GIRLS

Circ vs Uncirc Uncircumcised males are: ▫A▫A. 2x more likely than circumcised to get UTI ▫B▫B. Equal incidence of UTI ▫C▫C. 5 to 20x more likely than circumcised to get UTI ▫D▫D. Protected from UTI Increased rate of bacterial colonization and enhanced bacterial adherence Absolute risk of developing UTI is low, at most ~1%

Recommendation 2 In infants and young children with unexplained fever, the degree of toxicity, dehydration, and ability to retain oral intake must be carefully assessed

Additional work-up 1/3 of infants with UTI have bacteremia with the same organism Some have meningitis Blood culture should be obtained in all infants Culture of CSF should be considered

Recommendation 3 If an infant or young child with unexplained fever is assessed as being sufficiently ill to warrant immediate antimicrobial therapy, a urine specimen should be obtained by suprapubic aspiration or transurethral bladder catheterization; the diagnosis of UTI cannot be established by a culture of urine collected in a bag

Recommendation 4 If an infant or young child with unexplained fever is assessed as not being so ill as to require immediate antimicrobial therapy, there are two options: ▫1. Obtain and culture a urine specimen collected by SPA or cath ▫2. Obtain a urine specimen by the most convenient means and perform urinalysis  If suggests UTI- SPA or cath and culture  If no UTI suspected- follow clinical course

Urinalysis Most useful components ▫Leukocyte esterase  Detects esterases released from broken-down leukocytes (which may or may not be present) ▫Nitrite  Detects conversion of nitrate to nitrite by gram-neg  Specificity 98% ▫Microscopy: WBCs  >5 per high-power field ▫Microscopy: bacteria present on unspun Gram- stained specimen

Recommendation 5 Diagnosis of UTI requires a culture of the urine

MethodColony CountProbability of Infection (%) Suprapubic aspirationGram-negative bacilli: any number Gram-positive cocci: more than a few thousand >99 Transuretheral catheterization >100,000 10, ,000 1,000-10,000 <1, Infection likely Suspicious; repeat Infection unlikely Clean-voided (boy)>10,000Infection likely Clean-voided (girl)3 specimens >100,000 2 specimens >100,000 1 specimen >100,000 50, ,000 10,000-50,000 <10, Suspicious; repeat Symptomatic, suspicious; repeat Asymptomatic; infection unlikely Infection unlikely

*The most common bacterial cause of UTI is: ▫E. coli- 80% ▫Other gram negatives:  Klebsiella  Proteus  Enterobacter  Citrobacter ▫Gram-positives:  Staph saprophyticus  Enterococcus  Staph aureus (rare)

Recommendation 6 If the infant or young child with suspected UTI is assessed as toxic, dehydrated, or unable to retain oral intake, initial antimicrobial therapy should be administered parenterally and hospitalization should be considered

Indications for Hospitalization Age < 2 months Clinical urosepsis or potential bacteremia Immunocompromised patient Vomiting or inability to tolerate oral medication Lack of adequate follow-up Failure to respond to outpatient therapy

Recommendation 7 In the infant or young child who may not appear ill but who has a culture confirming UTI, antimicrobial therapy should be initiated, parenterally or orally

Empiric therapy 6 week old male with acute vomiting and decreased po intake, has UA with 3+ leukocyte esterase, positive nitrite, and 15 WBC/hpf. You obtain urine cx and want to start empiric abx. What do you choose? ▫A▫A. Ampicillin ▫B▫B. Ceftriaxone ▫C▫C. Nitrofurantoin ▫D▫D. TMP-SMX ▫E▫E. Ciprofloxacin

Choice of agent 50% of E. coli are resistant to amoxicillin or ampicillin 2 nd and 3 rd gen cephalosporins and aminoglycosides are good first-line agents ▫Remember: don’t cover Enterococcus, so add ampicillin Can switch to po when oral intake tolerated ▫Augmentin, TMP-SMX, or 3 rd gen cephalosporin ▫Nitrofurantoin does not achieve good serum concentrations

Recommendation 8 Infants and young children with UTI who have not had the expected clinical response with 2 days of antimicrobial therapy should be reevaluated and another urine specimen should be cultured

Re-culture? Routing reculturing is generally not necessary ▫If expected response  Urine should be sterile within 48 hours of treatment ▫Bug is sensitive to abx being administered

Recommendation 9 Infants and young children including those whose treatment initially was administered parenterally, should complete a 7 to 14 day antimicrobial course orally

Recommendation 10 After a 7 to 14 day course of antimicrobial therapy and sterilization of the urine, infants and young children with UTI should receive antimicrobials in therapeutic or prophylactic dosages until the imaging studies are completed

Imaging studies A 1 year old girl was admitted to Purple Team 2 days ago with fever and a urine culture is now growing E. coli. Her fever has resolved and she is now back to baseline per mom. What, if any, imaging studies do you want to order, and when will you order them? ▫A▫A. None, send her home, she’s cured! ▫B▫B. Renal U/S now, and VCUG in 6 weeks ▫C▫C. Renal U/S and VCUG in 6 weeks ▫D▫D. Renal U/S and VCUG now

Recommendation 11 Infants and young children with UTI who do not demonstrate the expected clinical response within 2 days of antimicrobial therapy should undergo U/S promptly. Voiding cystourethrography (VCUG) is stongly encouraged to be performed at the earliest convenient time. Those with expected response should have U/S and VCUG at earliest convenient time.

Updated recs Image the following: ▫Girls < 3 with a first UTI ▫Boys of any age with first UTI ▫Children of any age with febrile UTI ▫Children with recurrent UTI ▫First UTI in child with family hx of renal disease, abnormalities of urinary tract

Updated recs No difference in results if VCUG performed within a week of UTI vs waiting However, only 48% of those scheduled later than 1wk were actually performed

Grade I — Reflux only fills the ureter without dilation. Grade II — Reflux fills the ureter and the collecting system without dilation. Grade III — Reflux fills and mildly dilates the ureter and the collecting system with mild blunting of the calyces. Grade IV —Grossly dilates the collecting system with blunting of the calyces. Some tortuosity of the ureter. Grade V — Massive reflux grossly dilates the collecting system. All the calyces are blunted with a loss of papillary impression.