Pediatric Urinary Tract Infections

Pediatric Urinary Tract Infections Joshua A. Hodge, Maj, USAF, MC Staff Family Physician Andrews AFB, MD Overview • • • • • • • • Background Diagnosis Treatment Follow up Prevention Imaging Vesiculoureteral reflux (VUR) Summary Background • Most common serious bacterial infection in young children – 5% of febrile infants • Prevalence – By age 7: 8% girls, 2% boys – Highest rate in first year of life – Higher in Caucasians – Higher in uncircumcised boys • Most common organism: E. coli- 80% Background • Symptoms systemic in early childhood – Fever* – Irritability – Lethargy – Anorexia – Emesis • Potential sequelae – Renal scarring – Chronic renal failure – HTN Background • Anatomic risk factors – Vesiculoureteral reflux (VUR) • More common in girls – Obstruction – Posterior urethral valves • Boys – Voiding dysfunction – Bladder diverticulum Background • Associated risk factors – Constipation – Encoporesis – Bladder instability – Infrequent voiding • Unsubstantiated risks – Bathing – Back-to-front wiping Diagnosis • Single organism identified on culture – Suprapubic aspirate > 1,000 cfu/mL – Catheter specimen > 10,000 cfu/mL – Clean catch specimen > 100,000 cfu/mL – Urine bags not recommended Diagnosis • Urinalysis – Not helpful if clinical suspicion high • i.e. older children with classic symptoms – Useful if low likelihood of UTI • Non-dilute urine (sg > 1.005) • Neg nitrate and leuk esterase • Negative predictive value > 95% • Blood cultures not useful Treatment • Initiate immediately after culture drawn – Reduces severity of renal scarring • Oral route preferred • 7-14 day course is standard – 2-4 days appears to be as effective • Not yet recommended Treatment Antibiotic Amoxicillin* Cefixime (Suprax) Cefpodoxime (Vantin) Cefprozil (Cefzil) Cephalexin (Keflex) Daily Dosage 20-40mg/kg in 3 doses 8mg/kg in 2 doses 10mg/kg in 2 doses 30mg/kg in 2 doses 50-100mg/kg in 4 doses Loracarbef (Lorabid) Sulfisoxazole (Gantrisin) 15-30mg/kg in 2 doses 120-150mg/kg in 4 doses Trimethoprim/ 6-12mg/kg & 30-60mg/kg Sulfamethoxazole (Bactrim) In 2 doses Follow Up • AAP Recommendation: 48 hours – If not improving repeat culture & immediate renal ultrasound – No evidence to support repeat culture/test of cure 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. Pediatrics 1999;103:843-52. Prevention • Rates of recurrence – 12% of children < 5 years old – 18% of infants < 6 months • Prophylactic antibiotics – Recommended by AAP while waiting for imaging – Efficacy questioned Prevention Antibiotic Methenamine mandelate (Mandelamine) Nalidixic acid (NegGram) Nitrofurantoin (Macrobid) Sulfisoxazole (Gantrisin) Trimethoprim/ sulfamethoxazole (Bactrim) Daily Dosage 75mg/kg in 2 doses 30mg/kg in 2 doses 1-2mg/kg once per day 10-20mg/kg in 2 doses 2mg/kg & 10mg/kg nightly or 5mg/kg & 25mg/kg 2x/week Prevention • Circumcision – Lowers UTI rate in boys • NNT = 111 to prevent one UTI – Surgical complication rate = 1% – Benefit does not outweigh risk and not recommended Imaging • Who to image? – AAP • All children 2 months to 2 years of age with first UTI • Renal ultrasound • Cystogram –Voiding cystourethrogram (VCUG) –Radionuclide cystogram (RNC) Imaging • Who to image? – Cincinnati Children’s Hospital • All boys • Girls < 36 months • Girls 3-7 with fever > 38.5º C (101.3º F) • Same modalities recommended as AAP Evidence based clinical practice guideline for medical management of first time acute urinary tract infection in children 12 years of age or less. Cincinnati, Ohio: Cincinnati Children’s Hospital Medical Center, 2005. Imaging • Renal ultrasound – GU tract anatomy – Evaluate renal scarring • DMSA (renal cortical scan) – Differentiates pyelonephritis from cystitis – Assesses renal scarring Imaging • Cystogram- identify and grade vesicoureteral reflux (VUR) – Voiding cystourethrogram (VCUG) • OK for girls and boys • Demonstrates GU anatomy plus VUR – Radionuclide cystogram (RNC) • Low amount of radiation • Girls only –Little anatomic detail Vesicoureteral Reflux (VUR) • Concern for pyelonephritis & renal scarring • Prevalence in females < 18 yo – Grade I- 7% – Grade II- 22% – Grade III- 6% – Grade IV- 1% – Grade V- <1% Vesicoureteral Reflux • Standard treatment options – Antibiotics • Studies of prophylactic antibiotics have not included children with VUR – Surgery – Antibiotics + surgery Vesicoureteral Reflux • Unclear if clinical benefits to treating VUR – Only severe VUR (Grades IV & V) associated with recurrent UTI and pyelonephritis • < 2% of all cases of VUR • No causal relationship with scarring – Risk of UTI = between surgical & medical groups – Abx + surgery reduced # of UTIs and pyelo but no renal damage noted in either group at 5 years Wheeler DM, et al. Interventions for primary VUR. Cochrane Database Syst Rev. 2004(3):CD001532 Summary • Urine culture necessary for diagnosis • Short courses of antibiotics may be as effective as longer courses • Prophylactic antibiotics are an option but may not provide much clinical benefit • Routine imaging does not appear to affect outcomes • Diagnosing VUR does not appear to affect outcomes References • • Alper BS, Curry SH. Urinary tract infection in children. Am Fam Physician 2005;72:2483-8. 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. Pediatrics 1999;103:843-52. Currie ML, et al. Follow-up urine cultures and fever in children with urinary tract infection. Arch Pediatr Adolesc Med 2003;157:1237-40. Evidence based clinical practice guideline for medical management of first time acute urinary tract infection in children 12 years of age or less. Cincinnati, Ohio: Cincinnati Children’s Hospital Medical Center, 2005. Michael M, et al. Short versus standard duration oral antibiotic therapy for acute urinary tract infection in children. Cochrane Database Syst Rev 2004;(4):CD003966 • • • References • • • • • • Roberts KB. The AAP practice parameter on urinary tract infections in febrile infants and young children. Am Fam Physician 2000;62:1815-22. Le Saux N, Pham B, Mohoer D. Evaluating the benefits of antimicrobial prophylaxis to prevent urinary tract infections in children: a systematic review. CMAJ 2000; 163:523-9. Michael M, et al. Short compared with standard duration of antibiotics treatment for urinary tract infection: a systematic review of randomised controlled trials. Arch Dis Child 2002;87:118-23. Singh-Grewal D, Macdessi J, Craig J. Circumcision for the prevention of urinary tract infection in boys: a systematic review of randomized trials and observational studies. Arch Dis Child 2005;90:853-58. Williams GJ, Lee A, Craig JC. Long-term antibiotics for preventing recurrent urinary tract infection in children. Cochrane Database Syst Rev 2004;(4):CD001534. Wheeler DM, et al. Interventions for primary vesicoureteric reflux. Cochrane Database Syst Rev 2004;(3):CD001532.