Pediatrics Urinary Tract Infections by mikeholy

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									Pediatric Urinary Tract
      Infections
    Eddie Needham, MD, FAAFP
          Program Director
   Emory Family Medicine Residency
              Program
                    Objectives
   Define Urinary Tract Infection (UTI)
   List antibiotic treatment options for UTI
   List the workup after a first febrile UTI
   Be familiar with the rationale for using
    prophylactic antibiotics after the first febrile
    UTI
                       Case 1
   A four year old previously healthy girl presents
    to clinic with c/o dysuria.
   She has no fever and has a stable home with
    reliable parents.
   Immunizations are UTD.
   UA shows + Nitrites and + LE
   WBC – unknown because we don’t currently
    spin our own urines at Dunwoody.
             What is your plan?
   Urine culture?
   Antibiotics?
     Rocephin in clinic?
     Oral antibiotics?

   Admit to the hospital?
   Work up (We’ll define this later)?
                     Case 2
   An 18 month old female presents with increased
    irritability x 3 days, subjective fevers, and
    decreased appetite.
   PMHx – usual childhood illnesses – AOM x 1,
    URIs x 2, AGE x 1. Benign recoveries.
   Immunizations are up-to-date (UTD)
   Good social support
                Case 2 - Exam
   Vital Signs – normal for age except T 102.5
   General appearance – fussy, easily consolable,
    nontoxic
   HEENT – normal with clear pharynx and TMs
    AU
   Lungs - CTA
   CV – normal
   Abdomen – soft
   Skin – no rash
 Fever
without a
 Source
Guideline
            Clinic Management
   Draw blood for CBC and potentially a blood
    culture?
   Urine culture?
   Antibiotics?
     Rocephin in clinic?
     Oral antibiotics?

   Admit to the hospital?
   Work up (We’ll define this later)?
                Clinic workup
   Are you able to draw blood?
   Can you perform a bladder catheterization?
   Two Q-tip technique for little girls
                  Evaluation
   Your catheter UA confirms the diagnosis.
   You send the urine for culture.
   What now?
     Child admitted?
     Child goes home?

   What does the evidence say?
          Pediatric UTIs and EBM
   Up to 7% of girls and 2% of boys experience a
    symptomatic culture-proven UTI prior to 6
    years of age.
   Of febrile neonates, up to 7% have UTIs.
       (See Fever without a source guidelines)
   Most UTIs in children are from ascending
    bacteria
       E. coli (60-80%), Proteus, Klebsiella, Enterococcus,
        and coag. neg. staph.
                   Epidemiology
   The overall prevalence of UTI is approximately 5
    percent in febrile infants but varies widely by race and
    sex.
   Caucasian children had a two- to fourfold higher
    prevalence of UTI as compared to African-American
    children
   Females have a two- to fourfold higher prevalence of
    UTI than do circumcised males
   Caucasian females with a temperature of 39 ºC have a
    UTI prevalence of 16 percent
 Approximate probability of urinary tract infection
     in febrile infants and young children by
                demographic group

                                           Prevalence (pretest
Demographic group                                                                     Odds
                                           probability)

Circumcised boys >1 yr                     <1 percent                                 .01 (1 in 100)

Circumcised boys <1 yr                     2 percent                                  .02 (1 in 50)

Black girls                                4 percent                                  .04 (1 in 25)
Uncircumcised boys <2
                                           8 percent                                  .09 (1 in 12)
yr
White girls <2 yr                          16 percent                                 .19 (1 in 5)

Data from:
Hoberman, A, Chao, HP, Keller, DM, et al. Prevalence of urinary tract infection in febrile infants. J Pediatr 1993; 123:17.
Shaw, KN, Gorelick, M, McGowan, KL, et al. Prevalence of urinary tract infection in febrile young children in the emergency
department. Pediatrics 1998; 102:e16.
        Definition of UTI on culture

Method of urine collection                     Diagnostic threshold
Clean-catch in voiding girls                   100,000 CFU per mL
                                               10,000 – 100,000  repeat culture
Clean-catch in voiding boys                    10,000 CFU per mL
Catheter                                       10,000 CFU
                                               1,000 – 10,000  repeat culture
Suprapubic aspiration                          Any colonies of GNRs
                                               More than a few thousand GPCs




Hillerstein S. Recurrent urinary tract infections in children. Pediatr Infect Dis 1982; 1:275.
                       Symptoms
   Classic UTI symptoms in older children
       Dysuria, frequency, urgency, small-volume voids,
        lower abdominal pain.
   Infants with UTIs have nonspecific symptoms
       Fever, irritability, vomiting, poor appetite
   Neonatal hematuria?




Nope, it’s uric acid crystals
                   Evaluation
   In children with a high likelihood of UTI, a
    urine culture is required.
   In children with a low likelihood, a negative
    dipstick in a clear urine reduces the need for
    culture.
   If the dipstick shows (+) LE and/or (+)
    Nitrites, send a urine culture.
   The dipstick is not sufficient to diagnose UTI’s
    because false positives can occur.
                Urine dipsticks
   In a cohort study with an 18% baseline
    prevalence of UTI, negative LE and nitrates on
    dipstick had a negative predictive value of 96%.

   NPV =        True negative
             _________________
          True negative + false negative
Leukocyte Esterase and Nitrites
   LE is produced from the breakdown of
    leukocytes. Not always indicative of infection
       Vaginitis/vulvitis can lead to inflammation without
        infection  + LE
   Nitrites are produced by bacteria that metabolize
    nitrates: E. coli, Klebsiella, Proteus (GNRs)
     Much more predictive of UTI
     GPCs do not produce nitrites
                Blood cultures
   Blood cultures are generally unnecessary in most
    children with UTI.
   They are more frequently positive in children
    younger than two months whose urine grows
    Group B strep or Staph. Aureus.
   In general, we’ll send febrile children less than
    two months old to the ER for emergent
    evaluation/labs.
                       Treatment of UTIs
     The efficacy of oral regimens is as effective as
      parenteral regimens - this is great news for
      outpatient therapy 
     If the child is not responding the empiric
      treatment within two days while awaiting culture
      results, repeat the urine culture and perform a
      renal ultrasound.
Hoberman A, Wald ER, Hickey RW, Baskin M, Charron M, Majd M, et al. Oral versus initial
intravenous therapy for urinary tract infections in young febrile children. Pediatrics 1999;104:79-86.

Baker PC, Nelson DS, Schunk JE. The addition of ceftriaxone to oral therapy does not improve
outcome in febrile children with urinary tract infections. Arch Pediatr Adolesc Med 2001;155:135-9.
                 Antibiotic Choices
   Trimethoprim-sulfamethoxizole is a good choice
    after two months of life
   Other choices:
     Amoxicillin – some resistance with E. coli
     Cephalosporins: cefixime (Suprax), cefpodoxime
      (Vantin), cefprozil (Cefzil), loracarbef (Lorabid)
           No cephalosporins cover enterococcus
   Treat for 7-14 days. One day course not
    effective.
        Further testing/work-up



   After the UTI resolves, what type of workup
    should ensue?
  1999 Clinical Practice Guidelines
            from the AAP
   Routine imaging for children two months to two
    years of age is recommended.
       Ultrasound all children with febrile UTIs
       Consider VCUG/Renal scintigraphy




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. [published corrections appear in Pediatrics
2000;105:141, 1999;103:1052, and 1999;104:118]. Pediatrics 1999;103:843-52.
                    Newer information

    255 children < 5 years old admitted with their
     first uncomplicated febrile UTI (pyelo)
    Renal ultrasound did not change management




Zamir G, Sakran W, Horowitz Y, Koren A, Miron D. Urinary tract infection: is there a
need for routine renal ultrasonography? Arch Dis Child 2004;89:466-8
                         Newer Information
        150 children 2 – 10 years old with first UTI were
         randomized to routine imaging (U/S and VCUG) or to
         selective imaging (for recurrent UTI or persistent
         problems)
        21 % (1 in 5) in the selective group had imaging
         performed
        Routine imaging increased the use of prophylactic
         antibiotics (28% vs 5%)
        No change in rate of recurrent UTIs (26% vs 21%)
        No change in rate of renal scarring (9% vs 9%)
Dick PT. Annual Meeting of Canadian Pediatric Society, June 12-16, 2002. Pediatric Notes 2002;26(27):105
          Vesicoureteral Reflux and
                 Treatment
   Approximately 40% of children with febrile UTIs have
    VUR.
   Approximately 8% of children with febrile UTIs
    demonstrate renal scarring when studied.
   Treatment recommendations are made to stop the
    progression of VUR with medications/antibiotics
    and/or surgery.
   No data/EBM demonstrate that treatment of VUR
    prevents renal scarring, hypertension and CKD
Nuutinen M, Uhari M. Recurrence and follow-up after urinary tract infection under the
age of 1 year. Pediatr Nephrol 2001;16:69-72
          Antibiotic prophylaxis
   Children with VUR are treated prophylactically
    with antibiotics to prevent potential renal
    scarring.
     Nitrofurantoin or trimethoprim-sulfamethoxizole
     Half the standard dose administered at bedtime

   Family physicians would generally have a
    pediatric urologist involved to assist in making
    treatment decisions.
         How long to continue Abx?
   Although the evidence is not conclusive, it appears the
    risk of scarring diminishes with age.
   Accordingly, some experts recommend cessation of
    prophylaxis after age 5 to 7 years, even if low-grade
    VUR persists.
   In one study of 51 low-risk (no voiding abnormalities
    or renal scarring) older children (mean age 8.6 years)
    with grades I to IV VUR, cessation of prophylactic
    antibiotics resulted in no new renal scarring on annual
    DMSA
Cooper CS, et al. The outcome of stopping prophylactic antibiotics in older children
with vesicoureteral reflux. J Urol 2000 Jan;163(1):269-72; discussion 272-3.
    Indications to order radiologic
               studies
   Children younger than 5 years of age with a
    febrile UTI
   Girls younger than 3 years of age with a first
    UTI
   Males of any age with a first UTI (PUV)
   Children with recurrent UTI
   Children with UTI who do not respond
    promptly to therapy
    Up To Date – accessed September 12, 2007
                 Studies to consider
   Renal Ultrasound
     Will evaluate for perinephric abscess in patients not
      responding to antibiotics.
     Can evaluate for hydronephrosis/hydroureter

     Of note, dilation of the kidneys and ureters can
      easily be seen on routine anatomy scans during
      pregnancy.
     Picking up vesicoureteral reflux while asymptomatic
           Does this help or hurt? Staging of VUR, antibiotics, etc...
Hydronephrosis
Male with the findings below.
           Cause?
             Studies to consider
   Voiding cystourethrogram – two techniques
     One involves fluoroscopic contrast – more radiation
      but better delineation of anatomy for grading VUR
     The other uses a radionuclide – less radiation and
      more sensitive than contrast
Normal VCUG
Vesicoureteral reflux (VUR)
Megaureter
             Studies to consider
   Renal scintigraphy using dimercaptosuccinic acid
    (DMSA)
     Can detect scarring in the kidneys.
     Renal cells take up the tracer.

     Those cells damaged by pyelonephritis or scarring
      do not take up the tracer.
     Management or followup of patients does not
      change in most cases.
     Thus, not generally used for initial evaluation.
  Scar in the
 superior and
inferior pole of
   the right
    kidney
                     Myths
   Bathing in bubble baths causes UTIs
   Wiping back-to-front causes UTIs
   Cranberry juice helps UTIs – only proven to be
    of minimal benefit in adult women. No proven
    benefit to children
           VUR Treatment 1997 AUA
                 guidelines
    Children younger than 1 year of age, regardless of grade of reflux, should be
     treated medically, as they have a high likelihood of spontaneous resolution.
     Surgery is a reasonable option if they have grade V reflux and renal scarring.
    All patients with grade I or II reflux, either with unilateral or bilateral disease,
     should be treated medically, as they have high likelihood of spontaneous
     resolution.
    Children between 1 and 5 years of age with grade III or IV reflux, either
     unilateral or bilateral disease, should be treated medically. Surgery is a
     reasonable option if there is bilateral reflux and renal scarring.
    Children between 1 and 5 years of age with grade V, either unilateral or
     bilateral disease, without renal scarring, can be treated medically. If there is
     renal scarring, surgery is recommended for both unilateral and bilateral
     disease.
Elder JS, et al. Pediatric Vesicoureteral Reflux Guidelines Panel summary report on the
management of primary vesicoureteral reflux in children, J Urol 1997 May;157(5):1846-51.
                  VUR Treatment
   Children 6 years or older with unilateral grade III to IV reflux
    without renal scarring can be treated medically. If the reflux is
    bilateral and/or there is renal scarring, surgical treatment is
    recommended.
   Children 6 years or older with grade V reflux should be treated
    surgically with or without evidence of renal scarring, as their
    reflux is unlikely to resolve spontaneously.
   Surgery also should be considered if medical therapy fails either
    because of poor compliance, breakthrough infections on account
    of antibiotic resistance, or significant antibiotic side effects.
    Finally, consideration of patient and parent preference is
    important in the final decision.
So, back to our cases…
                       Case 1
   A four year old previously healthy girl presents
    to clinic with c/o dysuria.
   She has no fever and has a stable home with
    reliable parents.
   Immunizations are UTD.
   UA shows + Nitrites and + LE
   WBC on UA– unknown.
             What is your plan?
   Urine culture?
   Antibiotics?
     Rocephin in clinic?
     Oral antibiotics?

   Admit to the hospital?
   Work up (We’ll define this later)?
                  EBM answer
   She is afebrile – no need for radiologic studies
   Send the urine for culture
   Start empiric antibiotics for 7-14 days
                     Case 2
   An 18 month old female presents with increased
    irritability x 3 days, subjective fevers, and
    decreased appetite.
   PMHx – usual childhood illnesses – AOM x 1,
    URIs x 2, AGE x 1. Benign recoveries.
   Immunizations are up-to-date (UTD)
   Good social support
                Case 2 - Exam
   Vital Signs – normal for age except T 102.5
   General appearance – fussy, easily consolable,
    nontoxic
   HEENT – normal with clear pharynx and TMs
    AU
   Lungs - CTA
   CV – normal
   Abdomen – soft
   Skin – no rash
 Fever
without a
 Source
Guideline
            Clinic Management
   Draw blood for CBC and potentially a blood
    culture?
   Urine culture?
   Antibiotics?
     Rocephin in clinic?
     Oral antibiotics?

   Admit to the hospital?
   Work up (We’ll define this later)?
                Clinic workup
   Are you able to draw blood?
   Can you perform a bladder catheterization?
   Two Q-tip technique for little girls
                  Evaluation
   Your catheter UA confirms the diagnosis.
   You send the urine for culture.
   What now?
     Child admitted?
     Child goes home?

   What does the evidence say?
    Case # 2 EBM vs reality answer
   Option #1 – young child with potential serious
    bacterial illness – send to ER for expedited
    evaluation.
   Option #2 – not on a Friday afternoon
     Draw blood for CBC and blood culture in clinic
     Obtain a UA

     Consider antibiotics

     Bring the child back in 24 hours for re-evaluation
      and review of labs.
           Case #2 EBM answer
   If the UA shows a UTI
     If you have a good social support/parents
     If child is tolerating oral intake

     If the child is nontoxic

   You may start oral antibiotics with follow up the
    next day.
   Not a good solution on Fridays – no follow-up
    on Saturday.
                            Objectives
   Define Urinary Tract Infection (UTI)
      >100,000 CFU in clean catch girls

      >10,000 CFU clean catch guys

      >10,000 catheter specimen

   List antibiotic treatment options for UTI
      Amoxicillin, Bactrim, Cephalosporins

   List the workup after a first febrile UTI
      Consider renal U/S and VCUG

   Be familiar with the rationale for using prophylactic antibiotics
    after the first febrile UTI
        Prevent renal complications/scarring/pyelonephritis

								
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