DOES UTI CAUSE PROLONGED JAUNDICE IN OTHERWISE WELL INFANTS? Eur J pediatr Feb 2015 Mairi Gillespie

Background UTI as a major cause of prolonged hyperbilirubinaemia comes from case series of 6 infants presenting with jaundice and UTI * Age range: 12/7 – 8/52, all 6 infants were unwell with other symptoms Conclusion was to consider urine and blood cultures in infants with pyrexia and jaundice * Arch Dis Child (1971) 46: Ng SH, Rawstron JR

Question Is prolonged jaundice really a presenting symptom for urinary tract infection in an otherwise healthy infant with no other features? i.e. Does urine culture and microscopy need to be part of the prolonged jaundice screen in otherwise healthy infants?

NICE Guidance Clinical examination – pale chalky stool, dark urine? FBC Blood group and DCT Urine culture Routine metabolic screen been performed

NICE guidelines – Prolonged Jaundice UK study –154 babies (92% breast fed) prospective review Ix for prolonged jaundice – 5.9% referred for further investigations – included 2 x cases of UTI, 3 x G6PD, 1 x giant cell hepatitis, 1 x hepatoblastoma

NICE guidelines – Prolonged Jaundice Turkish study –case series including 26 patients –No UTI identified Turkish study –Conjugated hyperbilirubinaemia –90% pathology (35% sepsis)

Other guidance BSPGHN ◦ No specific guidance on prolonged jaundice – specific guidance on conjugated jaundice NASPGHN ◦ specific guidance for cholestatic jaundice ◦ If breast fed with no history of chalky stool/dark urine then review at 3/52 for SBR

Current SCH guidelines for Prolonged Jaundice If a well baby → a. FBC, blood film, group, direct Coombs ‟ test. b. Bilirubin – total and conjugated. c. RBC gal-1-P uridyl transferase. d. Free T4 e. Urine Urine results ◦ 1 st MxBG, min WCC → repeat ◦ 2 nd MxBG – if thriving, all bloods normal → may not treat ◦ Any sig growth, min WCC → prompt repeat if well

Previous studies UTI in prolonged jaundice N Am J Med Sci 2011 – 32/152 cases UTI Urol J infants with PJ: 6/100 UTI Pak J Bio Sci 2010 UTI in 7% of infants with PJ > 2/52 → suggest incidence of UTI in patients with UTI 6 – 8%

Previous studies UK study * –Prospective study of 198 infants –2 groups: 105: investigated according to current protocol, 92: split SBR, G6PD –Compared eventual outcome – no significant pathology detected –Reduction in repeat Ix and appointment in 2 nd group * Arch Dis Child (2011) 96:

Conclusion Mixed opinion as to whether UTI is associated with prolonged jaundice and the value of investigating otherwise well, thriving infants with urine at risk of repeat investigations and appointments.....

DOES UTI CAUSE PROLONGED JAUNDICE IN OTHERWISE WELL INFANTS? EUR J PEDIATR FEB 2015

Aim Aim of the study was to investigate how common a proven UTI was in a group of well infants with prolonged jaundice

Method Retrospective study of case notes and microbiology database of urine cultures All well infants with prolonged jaundice over 5 year period All infants were thriving and no history of fever Reviewed all urine results, further treatment given and further investigations

Definitions UTI = presence of > 5 x10 6 /l WC and growth >10 5 /ml of a single organism in the urine; considered contaminated if growth of multiple organisms in sample * * Differs from current SCH guidelines to repeat 1 st MxBG

Results Total of 319 infants → 22 (6.9%) – any bacterial growth → 13 (4%) – MxBG, of which 1/13 WC > 5 x 10 6 → 9 (2.9%) showed growth > 10 5 /ml *1 of which 4/9 had WC > 5 x 10 6 *1 Table 1

Results Repeat cultures sent on 9 patients 6 further pure growths; only 1 with WC > 10 6 /l Further urine sent on 6 → 1 pure growth *2 4th culture sent – remained positive and treated *2 Table 2

Conclusion Low incidence of UTI in otherwise healthy infants with prolonged jaundice Inappropriate to send urine on all infants with prolonged jaundice as NICE suggests More streamlined investigation may be more efficient and cost effectice

DISCUSS