pediatric uti: making sense of local data and the new aap guidelines heidi román, md and alan...
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Pediatric UTI: Pediatric UTI: Making Sense of Making Sense of
Local Data and the Local Data and the New AAP GuidelinesNew AAP Guidelines
Heidi Román, MD and Alan Heidi Román, MD and Alan Schroeder, MDSchroeder, MD
SCVMCSCVMCPediatric Grand RoundsPediatric Grand Rounds
March 13, 2013March 13, 2013
ObjectivesObjectives
To review diagnosis and management of To review diagnosis and management of UTI in infants and young children UTI in infants and young children
To be aware of changes in management To be aware of changes in management suggested by 2011 AAP CPGsuggested by 2011 AAP CPG
To review recent clinical research To review recent clinical research projects at VMC examining:projects at VMC examining: imaging protocols imaging protocols diagnosis and management of bacteremic diagnosis and management of bacteremic
UTIsUTIs
Why Do We Care About Why Do We Care About UTI?UTI?
UTI now most common site for SBI UTI now most common site for SBI in infantsin infants
More than 1 million office visits More than 1 million office visits per yearper year
$180M/year for hospitalization $180M/year for hospitalization alonealone
Freedman, J. Urology, 2005
When should urine be When should urine be tested?tested?
Consider UTI in all infants < 24 mos with FWS
Consider UTI in all infants < 24 mos with FWS
Not ill and “low risk” monitorNot ill and “low risk” monitor
Ill enough to require abx obtain urine for UA/culture prior
to initiation
Ill enough to require abx obtain urine for UA/culture prior
to initiation
“Not low risk” urine for UA/culture
and act based on results
“Not low risk” urine for UA/culture
and act based on results
AAP CPG, Pediatrics, 2011
What constitutes “not What constitutes “not low risk”?low risk”?
2011 AAP CPG: “low risk” = febrile 2011 AAP CPG: “low risk” = febrile infant with < 3% risk of UTIinfant with < 3% risk of UTI
Factors known to change riskFactors known to change risk AgeAge GenderGender Circumcision statusCircumcision status Duration of feverDuration of fever Lack of other sourceLack of other source
Factors Modifying Risk Factors Modifying Risk for UTIfor UTI
From Marmor “Updates in Management of UTI in Febrile Infants/Children < 24 mo of Age” 2012
How should urine be How should urine be tested?tested?
•SPA
•Catheterization
•Bag
•Clean Catch
What defines a “UTI”?What defines a “UTI”?
2011 AAP CPG:2011 AAP CPG: At least 50K CFU/ml of At least 50K CFU/ml of
uropathogen via cath or SPAuropathogen via cath or SPA ANDAND UA suggesting infection UA suggesting infection
(pyuria and/or bacteruria)(pyuria and/or bacteruria)
How can UA help you?How can UA help you?
AAP CPG, Pediatrics, 2011
Urine CultureUrine Culture
When to sendWhen to send Definitely “positive”?Definitely “positive”?
UA + and Cath Ucx + if > 50k CFU/mLUA + and Cath Ucx + if > 50k CFU/mL UA + and Bag Ucx + if > 100K CFU/ml UA + and Bag Ucx + if > 100K CFU/ml
single orgsingle org Possibly +:Possibly +:
high clinical suspicion andhigh clinical suspicion and UA + and > 10K org ORUA + and > 10K org OR UA – and > 50K single orgUA – and > 50K single org
UTI ManagementUTI Management
When/how long to hospitalize?When/how long to hospitalize? Abx: what, how and how long?Abx: what, how and how long? Prophylaxis?Prophylaxis? Imaging?Imaging?
Inpatient vs outpatientInpatient vs outpatient
Hoberman cefixime study Hoberman cefixime study (Pediatrics, 1999)(Pediatrics, 1999) 306 children 1-36 months306 children 1-36 months PO Cefixime x 14 d vs IV cefotax x 3 d + PO Cefixime x 14 d vs IV cefotax x 3 d +
PO Cefixime x 11 dPO Cefixime x 11 d No difference in readmission, scarringNo difference in readmission, scarring
Duration of IV AbxDuration of IV Abx
PHIS study on UTI practice variation PHIS study on UTI practice variation (Brady, Pediatrics, 2010)(Brady, Pediatrics, 2010)
12,333 infants < 6 months 12,333 infants < 6 months Treatment failure:Treatment failure:
≤≤3 days = 1.6%3 days = 1.6% ≥≥4 days = 2.2%4 days = 2.2% 1000 kids (~30%) < 1 month got short 1000 kids (~30%) < 1 month got short
course!course!
AAP recsAAP recs
““Initiating treatment orally or Initiating treatment orally or parenterally is equally efficacious”parenterally is equally efficacious”
““Adjust choice according to Adjust choice according to sensitivity testing”sensitivity testing”
7-14 days total7-14 days total ““Outcomes of short courses (1-3 days) Outcomes of short courses (1-3 days)
are inferior to those of 7-14 day are inferior to those of 7-14 day courses”courses” No reference!!No reference!!
Our recs (if well)Our recs (if well)
> 1 month: outpatient, IM/PO> 1 month: outpatient, IM/PO < 1 month: inpatient, IV x 48 hours< 1 month: inpatient, IV x 48 hours 5-7 day course total (sooner if side 5-7 day course total (sooner if side
effects)effects)
AmpicilAmpicillinlin
41%41%
CefazoliCefazolinn
88%88%
CTXCTX 94%94%
GentGent 91%91%
SXTSXT 66%66%
E coli susceptibilities 2011, VMC 5th floor
Prophylactic AbxProphylactic Abx
• Mid-2000’s Practice questioned by handful of RCTs
PRIVENT trialPRIVENT trial[Craig, NEJM, 2009][Craig, NEJM, 2009]
576 Children age 0-18 years with 576 Children age 0-18 years with first febrile UTIfirst febrile UTI
Renal US, VCUG, DMSA in most Renal US, VCUG, DMSA in most patientspatients DMSA again at 1 yearDMSA again at 1 year
Daily TMP/SMXDaily TMP/SMX
Still PendingStill Pending
600 children 2 months – 6 years600 children 2 months – 6 years Grades I-IV VURGrades I-IV VUR TMP/SMX vs placeboTMP/SMX vs placebo
Our recsOur recs
No prophylaxis unless high-grade, No prophylaxis unless high-grade, persistent VURpersistent VUR
ImagingImaging
Imaging makes sense Imaging makes sense if…if…
Abnormalities are commonAbnormalities are common Abnormalities lead to recurrent UTIs Abnormalities lead to recurrent UTIs
and/or long-term damageand/or long-term damage Detection of the abnormalities Detection of the abnormalities
improves outcomesimproves outcomes
Andrea Marmor, MDhttp://www.ucsfcme.com/2012/slides/MFC13003/3a%20-%20Marmor,%20Andrea%20REF.pdf
1.) Abnormalities are 1.) Abnormalities are commoncommon
VUR same prevalence (~35%) in VUR same prevalence (~35%) in patients with true UTIs and false patients with true UTIs and false UTIs UTIs [Hanula, Pediatr Nephrol 2010][Hanula, Pediatr Nephrol 2010]
Abnormalities lead to Abnormalities lead to recurrent UTIs and/or long-recurrent UTIs and/or long-
term damageterm damage
• Literature review: 0/1576 reviewed CKD Literature review: 0/1576 reviewed CKD cases had UTI as primary causecases had UTI as primary cause• Own institution: 13/366 had h/o childhood Own institution: 13/366 had h/o childhood UTI – all 13 had abnl kidney anatomyUTI – all 13 had abnl kidney anatomy
• Recurrent UTI Recurrent UTI CKD 1/366 CKD 1/366
Crunching the #’sCrunching the #’s
Craig, Pediatrics 2011
UTI incidenceUTI incidence 50,000 per 50,000 per millionmillion
Incidence of Incidence of ESRD from VURESRD from VUR
5 per million5 per million
UTI UTI ESRD ESRD 1/10,0001/10,000
Prophylactic Abx?Prophylactic Abx? VUR surgery?VUR surgery? Other anatomic abnormalities?Other anatomic abnormalities?
3. Detection of the 3. Detection of the abnormalities improves abnormalities improves
outcomesoutcomes
2008: Initiation of new 2008: Initiation of new guidelines at SCVMCguidelines at SCVMC
Grand RoundsGrand Rounds Meeting of inter-disciplinary groupMeeting of inter-disciplinary group Discussed at faculty meetingDiscussed at faculty meeting Radiologist remindersRadiologist reminders
New AAP recsNew AAP recs
US on everyone, VCUG if abnormal US on everyone, VCUG if abnormal or if recurrenceor if recurrence
Take Home PointsTake Home Points
Diminishing urgency to detect/treat Diminishing urgency to detect/treat UTIs in healthy childrenUTIs in healthy children
Knowledge of risk factors can help Knowledge of risk factors can help stratify riskstratify risk
Management of UTIManagement of UTI Selective imaging OKSelective imaging OK Cost/benefit of prophylaxis too highCost/benefit of prophylaxis too high
Questions?Questions?