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Kamal Akl MDAssoc Professor of Pediatrics/Nephrology - JUHFebruary 5th 2011
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GOALS
To review the recent advances in the diagnosis and management of childhood UTIs
NICE guidelines 2007 AUA guidelines 2010
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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.
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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
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Diagnosis
Urine culture : Gold standard Urinalysis : supportive
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Symptoms & signs
< 1 year : unexplained fever check for UTI
< 1 year with UTI Rx as pyelonephritis
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Urine collection
Suprapubic Catheter Midstream urine
bag
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suprapubic
If a urinary tract infection is present, any organism except 2000-3000 CFU/mL coagulase-negative staphylococci.
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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.*
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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.*
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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.
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Urine presevation
Refrigerate if urine sample cannot be cultured within 4 hours or preserved with boric acid immediately
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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
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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
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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
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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
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Risk factors for UTI - contin
Evidence of spinal lesion Poor growth High blood pressure
NICE guidelines 2007
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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
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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
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Acute management
< 3 months > 3 months with APN > 3 months with cystitis
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Long term management
Prevention of recurrence Antibiotic prophylaxis Imaging tests
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Prevention of recurrence
Dysfunctional elimination syndromes and constipation should be addressed in infants and children who have had a UTI
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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
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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
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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
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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
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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
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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
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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
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CAP
Long-term , low dose trimethoprim-sulfamethoxazole was associated with a decreased number of UTIs in predisposed children .
Craig JC , et al NEJMed 2009
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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
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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.
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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
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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
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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
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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
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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
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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
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Conclusions
Recent advances in the diagnosis and management of childhood UTI were reviewed , including :
NICE guidelines 2007 AUA guidelines 2010
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MOST IMPORTANT
Is the patient Individualize Avoid guideline prison
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Conclusions
Thank you