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

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

3. 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:

4. 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

5. Diagnosis
Urine culture : Gold standard
Urinalysis : supportive

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

7. Urine collection
Suprapubic
Catheter
Midstream urine
bag

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

9. 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 CFU/mL of a single organism.*

10. 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.*

11. 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.

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

13. 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

14. 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

15. 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

16. 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

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

18. 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

19. 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

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

21. Long term management Prevention of recurrence Antibiotic prophylaxis
Imaging tests

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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

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

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

32. 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.

33. 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 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

34. 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

35. 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

36. 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

37. 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

38. 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

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

40. MOST IMPORTANT
Is the patient
Individualize
Avoid guideline prison

41. Conclusions
Thank you