Pediatric Urinary Tract Infections
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Transcript of Pediatric Urinary Tract Infections
Pediatric Urinary Pediatric Urinary Tract InfectionsTract Infections
Dr.Fahad Gadi, MDDr.Fahad Gadi, MDPediatrics DemonstratorPediatrics Demonstrator
King Abdulaziz UniversityKing Abdulaziz UniversityRabigh Medical SchoolRabigh Medical School
ObjectivesObjectives Define Urinary Tract Infection (UTI)Define Urinary Tract Infection (UTI) List antibiotic treatment options for List antibiotic treatment options for
UTIUTI List the workup after a first febrile List the workup after a first febrile
UTIUTI Be familiar with the rationale for Be familiar with the rationale for
using prophylactic antibiotics after using prophylactic antibiotics after the first febrile UTIthe first febrile UTI
Pediatric UTIs and EBMPediatric UTIs and EBM Up to 7% of girls and 2% of boys Up to 7% of girls and 2% of boys
experience a symptomatic culture-proven experience a symptomatic culture-proven UTI prior to 6 years of age.UTI prior to 6 years of age.
Of febrile neonates, up to 7% have UTIs.Of febrile neonates, up to 7% have UTIs. (See Fever without a source guidelines)(See Fever without a source guidelines)
Most UTIs in children are from Most UTIs in children are from ascending bacteriaascending bacteria E. coli (60-80%), Proteus, Klebsiella, E. coli (60-80%), Proteus, Klebsiella,
Enterococcus, and coag. neg. staph.Enterococcus, and coag. neg. staph.
EpidemiologyEpidemiology The overall prevalence of UTI is The overall prevalence of UTI is
approximately 5 percent in febrile infants approximately 5 percent in febrile infants but varies widely by race and sex. but varies widely by race and sex.
Caucasian children had a two- to fourfold Caucasian children had a two- to fourfold higher prevalence of UTI as compared to higher prevalence of UTI as compared to African-American children African-American children
Females have a two- to fourfold higher Females have a two- to fourfold higher prevalence of UTI than do circumcised males prevalence of UTI than do circumcised males
Caucasian females with a temperature of 39 Caucasian females with a temperature of 39 ºC have a UTI prevalence of 16 percentºC have a UTI prevalence of 16 percent
Approximate probability of urinary tract infection Approximate probability of urinary tract infection in febrile infants and young children by in febrile infants and young children by
demographic group demographic group
Demographic group Prevalence (pretest probability) Odds
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 yr 8 percent .09 (1 in 12)
White girls <2 yr 16 percent .19 (1 in 5)
Definition of UTI on Definition of UTI on cultureculture
Method of urine collection Diagnostic thresholdClean-catch in voiding girls 100,000 CFU per mL
10,000 – 100,000 repeat culture
Clean-catch in voiding boys 10,000 CFU per mLCatheter 10,000 CFU
1,000 – 10,000 repeat cultureSuprapubic aspiration Any colonies of GNRs
More than a few thousand GPCs
SymptomsSymptoms Classic UTI symptoms in older Classic UTI symptoms in older
childrenchildren Dysuria, frequency, urgency, small-Dysuria, frequency, urgency, small-
volume voids, lower abdominal pain.volume voids, lower abdominal pain. Infants with UTIs have nonspecific Infants with UTIs have nonspecific
symptomssymptoms Fever, irritability, vomiting, poor Fever, irritability, vomiting, poor
appetiteappetite
Neonatal hematuria?Neonatal hematuria?
Nope, it’s uric acid Nope, it’s uric acid crystalscrystals
EvaluationEvaluation In children with a high likelihood of UTI, In children with a high likelihood of UTI,
a urine culture is required.a urine culture is required. In children with a low likelihood, a In children with a low likelihood, a
negative dipstick in a clear urine negative dipstick in a clear urine reduces the need for culture.reduces the need for culture.
If the dipstick shows (+) LE and/or (+) If the dipstick shows (+) LE and/or (+) Nitrites, send a urine culture.Nitrites, send a urine culture.
The dipstick is not sufficient to diagnose The dipstick is not sufficient to diagnose UTI’s because false positives can occur.UTI’s because false positives can occur.
Urine dipsticksUrine dipsticks In a cohort study with an 18% In a cohort study with an 18%
baseline prevalence of UTI, negative baseline prevalence of UTI, negative LE and nitrates on dipstick had a LE and nitrates on dipstick had a negative predictive value of 96%.negative predictive value of 96%.
NPV = NPV = True negativeTrue negative __________________________________ True negative + false negativeTrue negative + false negative
Leukocyte Esterase and Leukocyte Esterase and NitritesNitrites
LE is produced from the breakdown of LE is produced from the breakdown of leukocytes. Not always indicative of leukocytes. Not always indicative of infectioninfection Vaginitis/vulvitis can lead to inflammation Vaginitis/vulvitis can lead to inflammation
without infection without infection + LE + LE Nitrites are produced by bacteria that Nitrites are produced by bacteria that
metabolize nitrates: E. coli, Klebsiella, metabolize nitrates: E. coli, Klebsiella, Proteus (GNRs)Proteus (GNRs) Much more predictive of UTIMuch more predictive of UTI GPCs do not produce nitritesGPCs do not produce nitrites
Blood culturesBlood cultures Blood cultures are generally Blood cultures are generally
unnecessary in most children with UTI.unnecessary in most children with UTI. They are more frequently positive in They are more frequently positive in
children younger than two months children younger than two months whose urine grows Group B strep or whose urine grows Group B strep or Staph. Aureus.Staph. Aureus.
In general, we’ll send febrile children In general, we’ll send febrile children less than two months old to the ER for less than two months old to the ER for emergent evaluation/labs.emergent evaluation/labs.
Treatment of UTIsTreatment of UTIs The efficacy of oral regimens is as The efficacy of oral regimens is as
effective as parenteral regimens - this effective as parenteral regimens - this is great news for outpatient therapy is great news for outpatient therapy
If the child is not responding the If the child is not responding the empiric treatment within two days empiric treatment within two days while awaiting culture results, repeat while awaiting culture results, repeat the urine culture and perform a renal the urine culture and perform a renal ultrasound.ultrasound.
Antibiotic ChoicesAntibiotic Choices Trimethoprim-sulfamethoxizole is a good Trimethoprim-sulfamethoxizole is a good
choice after two months of lifechoice after two months of life Other choices:Other choices:
Amoxicillin – some resistance with E. coliAmoxicillin – some resistance with E. coli Cephalosporins: cefixime (Suprax), Cephalosporins: cefixime (Suprax),
cefpodoxime (Vantin), cefprozil (Cefzil), cefpodoxime (Vantin), cefprozil (Cefzil), loracarbef (Lorabid)loracarbef (Lorabid) No cephalosporins cover enterococcusNo cephalosporins cover enterococcus
Treat for 7-14 days. One day course not Treat for 7-14 days. One day course not effective.effective.
Further testing/work-upFurther testing/work-up
After the UTI resolves, what type of After the UTI resolves, what type of workup should ensue?workup should ensue?
Vesicoureteral Reflux Vesicoureteral Reflux and Treatmentand Treatment
Approximately 40% of children with febrile Approximately 40% of children with febrile UTIs have VUR.UTIs have VUR.
Approximately 8% of children with febrile UTIs Approximately 8% of children with febrile UTIs demonstrate renal scarring when studied.demonstrate renal scarring when studied.
Treatment recommendations are made to stop Treatment recommendations are made to stop the progression of VUR with the progression of VUR with medications/antibiotics and/or surgery.medications/antibiotics and/or surgery.
No data/EBM demonstrate that treatment of No data/EBM demonstrate that treatment of VUR prevents renal scarring, hypertension and VUR prevents renal scarring, hypertension and CKDCKD
Antibiotic prophylaxisAntibiotic prophylaxis Children with VUR are treated Children with VUR are treated
prophylactically with antibiotics to prophylactically with antibiotics to prevent potential renal scarring.prevent potential renal scarring. Nitrofurantoin or trimethoprim-Nitrofurantoin or trimethoprim-
sulfamethoxizolesulfamethoxizole Half the standard dose administered at Half the standard dose administered at
bedtimebedtime Family physicians would generally have Family physicians would generally have
a pediatric urologist involved to assist in a pediatric urologist involved to assist in making treatment decisions.making treatment decisions.
How long to continue How long to continue Abx?Abx?
Although the evidence is not conclusive, it Although the evidence is not conclusive, it appears the risk of scarring diminishes with appears the risk of scarring diminishes with age. age.
Accordingly, some experts recommend Accordingly, some experts recommend cessation of prophylaxis after age 5 to 7 years, cessation of prophylaxis after age 5 to 7 years, even if low-grade VUR persists. even if low-grade VUR persists.
In one study of 51 low-risk (no voiding In one study of 51 low-risk (no voiding abnormalities or renal scarring) older children abnormalities or renal scarring) older children (mean age 8.6 years) with grades I to IV VUR, (mean age 8.6 years) with grades I to IV VUR, cessation of prophylactic antibiotics resulted cessation of prophylactic antibiotics resulted in no new renal scarring on annual DMSA in no new renal scarring on annual DMSA
Indications to order Indications to order radiologic studiesradiologic studies
Children younger than 5 years of age Children younger than 5 years of age with a febrile UTI with a febrile UTI
Girls younger than 3 years of age with Girls younger than 3 years of age with a first UTI a first UTI
Males of any age with a first UTI (PUV)Males of any age with a first UTI (PUV) Children with recurrent UTI Children with recurrent UTI Children with UTI who do not respond Children with UTI who do not respond
promptly to therapypromptly to therapy
Studies to considerStudies to consider Renal UltrasoundRenal Ultrasound
Will evaluate for perinephric abscess in Will evaluate for perinephric abscess in patients not responding to antibiotics.patients not responding to antibiotics.
Can evaluate for hydronephrosis/hydroureterCan evaluate for hydronephrosis/hydroureter Of note, dilation of the kidneys and ureters can Of note, dilation of the kidneys and ureters can
easily be seen on routine anatomy scans easily be seen on routine anatomy scans during pregnancy. during pregnancy.
Picking up vesicoureteral reflux while Picking up vesicoureteral reflux while asymptomaticasymptomatic
Does this help or hurt? Staging of VUR, antibiotics, Does this help or hurt? Staging of VUR, antibiotics, etc...etc...
HydronephrosisHydronephrosis
Male with the findings Male with the findings below.below.Cause?Cause?
Studies to considerStudies to consider Voiding cystourethrogram – two Voiding cystourethrogram – two
techniquestechniques One involves fluoroscopic contrast – One involves fluoroscopic contrast –
more radiation but better delineation of more radiation but better delineation of anatomy for grading VURanatomy for grading VUR
The other uses a radionuclide – less The other uses a radionuclide – less radiation and more sensitive than radiation and more sensitive than contrastcontrast
Normal VCUGNormal VCUG
Vesicoureteral reflux Vesicoureteral reflux (VUR)(VUR)
MegaureterMegaureter
Studies to considerStudies to consider Renal scintigraphy using Renal scintigraphy using
dimercaptosuccinic acid (DMSA)dimercaptosuccinic acid (DMSA) Can detect scarring in the kidneys.Can detect scarring in the kidneys. Renal cells take up the tracer.Renal cells take up the tracer. Those cells damaged by pyelonephritis or Those cells damaged by pyelonephritis or
scarring do not take up the tracer. scarring do not take up the tracer. Management or followup of patients does Management or followup of patients does
not change in most cases.not change in most cases. Thus, not generally used for initial Thus, not generally used for initial
evaluation.evaluation.
Scar in the Scar in the superior superior
and and inferior inferior
pole of the pole of the right right
kidneykidney
MythsMyths Bathing in bubble baths causes UTIsBathing in bubble baths causes UTIs Wiping back-to-front causes UTIsWiping back-to-front causes UTIs Cranberry juice helps UTIs – only Cranberry juice helps UTIs – only
proven to be of minimal benefit in proven to be of minimal benefit in adult women. No proven benefit to adult women. No proven benefit to childrenchildren
VUR TreatmentVUR Treatment Children 6 years or older with unilateral grade III to IV Children 6 years or older with unilateral grade III to IV
reflux without renal scarring can be treated medically. If reflux without renal scarring can be treated medically. If the reflux is bilateral and/or there is renal scarring, the reflux is bilateral and/or there is renal scarring, surgical treatment is recommended. surgical treatment is recommended.
Children 6 years or older with grade V reflux should be Children 6 years or older with grade V reflux should be treated surgically with or without evidence of renal treated surgically with or without evidence of renal scarring, as their reflux is unlikely to resolve scarring, as their reflux is unlikely to resolve spontaneously. spontaneously.
Surgery also should be considered if medical therapy fails Surgery also should be considered if medical therapy fails either because of poor compliance, breakthrough either because of poor compliance, breakthrough infections on account of antibiotic resistance, or significant infections on account of antibiotic resistance, or significant antibiotic side effects. Finally, consideration of patient and antibiotic side effects. Finally, consideration of patient and parent preference is important in the final decision.parent preference is important in the final decision.
ObjectivesObjectives Define Urinary Tract Infection (UTI)Define Urinary Tract Infection (UTI)
>100,000 CFU in clean catch girls>100,000 CFU in clean catch girls >10,000 CFU clean catch guys>10,000 CFU clean catch guys >10,000 catheter specimen>10,000 catheter specimen
List antibiotic treatment options for UTIList antibiotic treatment options for UTI Amoxicillin, Bactrim, CephalosporinsAmoxicillin, Bactrim, Cephalosporins
List the workup after a first febrile UTIList the workup after a first febrile UTI Consider renal U/S and VCUGConsider renal U/S and VCUG
Be familiar with the rationale for using prophylactic Be familiar with the rationale for using prophylactic antibiotics after the first febrile UTIantibiotics after the first febrile UTI Prevent renal complications/scarring/pyelonephritisPrevent renal complications/scarring/pyelonephritis