pediatrics utis 8-07

7/31/2019 Pediatrics UTIs 8-07

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Pediatric Urinary Tract

InfectionsEddie Needham, MD, FAAFP

Program DirectorEmory Family Medicine Residency

Program


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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


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Case 1

A four year old previously healthy girl presentsto clinic with c/o dysuria.

She has no fever and has a stable home withreliable parents.

Immunizations are UTD.

UA shows + Nitrites and + LEWBCunknown because we dont currently

spin our own urines at Dunwoody.


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What is your plan?

Urine culture?

Antibiotics?

Rocephin in clinic? Oral antibiotics?

Admit to the hospital?

Work up (Well define this later)?


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Case 2

An 18 month old female presents with increasedirritability x 3 days, subjective fevers, anddecreased appetite.

PMHxusual childhood illnessesAOM x 1,URIs x 2, AGE x 1. Benign recoveries.

Immunizations are up-to-date (UTD)

Good social support


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Case 2 - Exam

Vital Signsnormal for age except T 102.5 General appearancefussy, easily consolable,

nontoxic

HEENTnormal with clear pharynx and TMsAU

Lungs - CTA

CVnormal

Abdomensoft

Skinno rash


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Fever

without a

Source

Guideline


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Clinic Management

Draw blood for CBC and potentially a bloodculture?

Urine culture?

Antibiotics?

Rocephin in clinic?

Oral antibiotics?




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Clinic workup

Are you able to draw blood?

Can you perform a bladder catheterization?

Two Q-tip technique for little girls


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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?


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Pediatric UTIs and EBM

Up to 7% of girls and 2% of boys experience asymptomatic culture-proven UTI prior to 6years of age.

Of febrile neonates, up to 7% have UTIs.

(See Fever without a source guidelines)

Most UTIs in children are from ascendingbacteria

E. coli (60-80%), Proteus, Klebsiella, Enterococcus,and coag. neg. staph.


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Epidemiology

The overall prevalence of UTI is approximately 5percent in febrile infants but varies widely by race andsex.

Caucasian children had a two- to fourfold higherprevalence of UTI as compared to African-Americanchildren

Females have a two- to fourfold higher prevalence ofUTI than do circumcised males

Caucasian females with a temperature of 39 C have aUTI prevalence of 16 percent


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Approximate probability of urinary tract infection

in febrile infants and young children by

demographic group

Demographic groupPrevalence (pretest

probability)Odds

Circumcised boys >1 yr


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Definition of UTI on culture

Method of urine collection Diagnostic threshold

Clean-catch in voiding girls 100,000 CFU per mL

10,000100,000

repeat cultureClean-catch in voiding boys 10,000 CFU per mL

Catheter 10,000 CFU

1,00010,000 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.


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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


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Neonatal hematuria?

Nope, its uric acid crystals


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Evaluation

In children with a high likelihood of UTI, aurine culture is required.

In children with a low likelihood, a negativedipstick in a clear urine reduces the need forculture.

If the dipstick shows (+) LE and/or (+)Nitrites, send a urine culture.

The dipstick is not sufficient to diagnose UTIs

because false positives can occur.


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Urine dipsticks

In a cohort study with an 18% baselineprevalence of UTI, negative LE and nitrates ondipstick had a negative predictive value of 96%.

NPV = True negative

_________________True negative + false negative


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Blood cultures

Blood cultures are generally unnecessary in mostchildren with UTI.

They are more frequently positive in childrenyounger than two months whose urine growsGroup B strep or Staph. Aureus.

In general, well send febrile children less than

two months old to the ER for emergentevaluation/labs.


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Treatment of UTIs

The efficacy of oral regimens is as effective asparenteral regimens - this is great news for

outpatient therapy

If the child is not responding the empirictreatment within two days while awaiting cultureresults, 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.


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Antibiotic Choices

Trimethoprim-sulfamethoxizole is a good choiceafter two months of life

Other choices:

Amoxicillinsome 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 noteffective.


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Further testing/work-up

After the UTI resolves, what type of workupshould ensue?


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1999 Clinical Practice Guidelines

from the AAP

Routine imaging for children two months to twoyears of age is recommended.

Ultrasound all children with febrile UTIs

Consider VCUG/Renal scintigraphy

Committee on Quality Improvement, Subcommittee on Urinary Tract Infection. Practiceparameter: the diagnosis, treatment, and evaluation of the initial urinary tract infection infebrile infants and young children. [published corrections appear in Pediatrics2000;105:141, 1999;103:1052, and 1999;104:118]. Pediatrics 1999;103:843-52.


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Newer information

255 children < 5 years old admitted with theirfirst 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


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Newer Information

150 children 210 years old with first UTI wererandomized to routine imaging (U/S and VCUG) or toselective imaging (for recurrent UTI or persistent

problems) 21 % (1 in 5) in the selective group had imaging

performed

Routine imaging increased the use of prophylacticantibiotics (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


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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/antibioticsand/or surgery.

No data/EBM demonstrate that treatment of VURprevents 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


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Antibiotic prophylaxis

Children with VUR are treated prophylacticallywith antibiotics to prevent potential renalscarring.

Nitrofurantoin or trimethoprim-sulfamethoxizole

Half the standard dose administered at bedtime

Family physicians would generally have a

pediatric urologist involved to assist in makingtreatment decisions.


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How long to continue Abx?

Although the evidence is not conclusive, it appears therisk of scarring diminishes with age.

Accordingly, some experts recommend cessation ofprophylaxis after age 5 to 7 years, even if low-grade

VUR persists.

In one study of 51 low-risk (no voiding abnormalitiesor renal scarring) older children (mean age 8.6 years)

with grades I to IV VUR, cessation of prophylacticantibiotics resulted in no new renal scarring on annualDMSA

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.


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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 firstUTI

Males of any age with a first UTI (PUV)

Children with recurrent UTI

Children with UTI who do not respondpromptly to therapy

Up To Date

accessed September 12, 2007


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Studies to consider

Renal Ultrasound

Will evaluate for perinephric abscess in patients notresponding to antibiotics.

Can evaluate for hydronephrosis/hydroureter

Of note, dilation of the kidneys and ureters caneasily be seen on routine anatomy scans during

pregnancy. Picking up vesicoureteral reflux while asymptomatic

Does this help or hurt? Staging of VUR, antibiotics, etc...


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Hydronephrosis
http://medinfo.ufl.edu/~bms5191/renal/images/hydronephrosis.jpg


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Male with the findings below.

Cause?
http://www.uhrad.com/pedsarc/peds070e2.jpghttp://www.uhrad.com/pedsarc/peds070d2.jpghttp://www.uhrad.com/pedsarc/peds070c2.jpghttp://www.uhrad.com/pedsarc/peds070b2.jpghttp://www.uhrad.com/pedsarc/peds070a2.jpg


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Studies to consider

Voiding cystourethrogramtwo techniques

One involves fluoroscopic contrastmore radiationbut better delineation of anatomy for grading VUR

The other uses a radionuclideless radiation andmore sensitive than contrast


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Normal VCUG


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Vesicoureteral reflux (VUR)


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Megaureter


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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 scarringdo not take up the tracer.

Management or followup of patients does notchange in most cases.

Thus, not generally used for initial evaluation.


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Scar in the

superior andinferior pole of

the rightkidney


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Myths

Bathing in bubble baths causes UTIs

Wiping back-to-front causes UTIs

Cranberry juice helps UTIsonly proven to beof minimal benefit in adult women. No provenbenefit to children

VUR Tre tment 1997 AUA


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VUR Treatment 1997 AUA

guidelines

Children younger than 1 year of age, regardless of grade of reflux, should betreated 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 spontaneousresolution.

Children between 1 and 5 years of age with grade III or IV reflux, eitherunilateral or bilateral disease, should be treated medically. Surgery is areasonable option if there is bilateral reflux and renal scarring.

Children between 1 and 5 years of age with grade V, either unilateral orbilateral disease, without renal scarring, can be treated medically. If there isrenal scarring, surgery is recommended for both unilateral and bilateraldisease.

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.


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VUR Treatment

Children 6 years or older with unilateral grade III to IV refluxwithout renal scarring can be treated medically. If the reflux isbilateral and/or there is renal scarring, surgical treatment isrecommended.

Children 6 years or older with grade V reflux should be treatedsurgically with or without evidence of renal scarring, as theirreflux is unlikely to resolve spontaneously.

Surgery also should be considered if medical therapy fails either

because of poor compliance, breakthrough infections on accountof antibiotic resistance, or significant antibiotic side effects.Finally, consideration of patient and parent preference isimportant in the final decision.


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So, back to our cases


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Case 1

A four year old previously healthy girl presentsto 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 UAunknown.


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What is your plan?

Urine culture?

Antibiotics?

Rocephin in clinic?

Oral antibiotics?




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EBM answer

She is afebrileno need for radiologic studies

Send the urine for culture

Start empiric antibiotics for 7-14 days


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Case 2

An 18 month old female presents with increasedirritability x 3 days, subjective fevers, anddecreased appetite.

PMHxusual childhood illnessesAOM x 1,URIs x 2, AGE x 1. Benign recoveries.

Immunizations are up-to-date (UTD)

Good social support

C 2 E


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Case 2 - Exam

Vital Signsnormal for age except T 102.5 General appearancefussy, easily consolable,

nontoxic

HEENTnormal with clear pharynx and TMsAU

Lungs - CTA

CVnormalAbdomensoft

Skinno rash


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Fever

without a

Source

Guideline


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Clinic Management

Draw blood for CBC and potentially a bloodculture?

Urine culture?

Antibiotics?

Rocephin in clinic?

Oral antibiotics?




54/58

Clinic workup

Are you able to draw blood?

Can you perform a bladder catheterization?

Two Q-tip technique for little girls


55/58

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?


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Case # 2 EBM vs reality answer

Option #1young child with potential seriousbacterial illnesssend to ER for expeditedevaluation.

Option #2not 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-evaluationand review of labs.


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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 thenext day.

Not a good solution on Fridaysno follow-upon Saturday.


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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

pediatrics utis 8-07

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