Pediatric UTI

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Pediatric Urinary Tract Infections Joshua A. Hodge, Maj, USAF, MC Staff Family Physician  Andrews AFB, MD

 

Over view  Background  Diagnosis  Treatment  Follow up  Prevention  Imaging  Ve Vesi sicu culo lour uret eter eral al re refl flux ux (V (VUR UR))  Summary

 

Background  Most Most comm common on seri serious ous bac bacteri terial al inf infect ection ion in young children  ± 5% of of febril febrile e infants infants

 Prevalence

 ± By age 7: 8% girls girls,, 2% boy boys s  ± High Highest est rate rate in first first year year of life life  ± Hig Highe herr in Caucas Caucasian ians s  ± High Higher er in uncircu uncircumcised mcised boy boys s

 Most com omm mon or orga gani nism sm:: E. co colli- 80%

 

Background  Sy Symp mptom toms s syste systemi mic c in ear early ly chi childh ldhood ood  ± Fever*  ± Ir Irri rita tabi bilility ty  ± Le Leth thar argy gy  ± An Anor orex exia ia  ± Eme mesi sis s

 Pote tent ntiial se sequ quel elae ae  ± Re Rena nall scarr scarrin ing g  ± Chr Chron onic ic rena renall failure failure  ± H T N

 

Background  Anat atom omic ic ri ris sk fac facto tors rs  ± Vesicu Vesiculour lourete eteral ral refl reflux ux (VUR) (VUR)  Mo More re co comm mmon on in in gir girls ls

 ± Obstruction

 ± Pos Poste terio riorr ureth urethral ral valves  Boys

 ± Voi Voidin ding g dy dysfu sfunct nction ion  ± Bl Blad adde derr di verticulum

 

Background  As Asso soci ciat ated ed ri risk sk fa fact ctor ors s  ± Co Cons nsti tipa pati tion on  ± En Enco copo pore resi sis s  ± Bla Bladd dder er instab instabili ility ty  ± In Infr freq eque uent nt voiding

 Un Unsu subs bsta tant ntia iate ted d risk risks s  ± Ba Bath thiing

 ± Bac Back-t k-to-f o-fro ront nt wiping wiping

 

Diagnosis  Si Singl ngle e orga organis nism m ide identi ntifie fied d on cul cultur ture e  ± Supr Suprapu apubic bic aspira aspirate te > 1,000 1,000 cfu/mL cfu/mL  ± Ca Cath thet eter er spec specime imen n > 10 10,0 ,000 00 cfu/ cfu/mL mL  ± Clea Clean n catch speci specimen men > 100,0 100,000 00 cfu/mL cfu/mL  ± Urine bag bags s not not recommend recommended ed

 

Diagnosis  Urinalysis  ± Not helpf helpful ul if clinical clinical suspicion suspicion high high  i.e. olde olderr children children with with classic classic sym symptom ptoms s

 ± Usefu Usefull if low likelih likelihood ood of of UTI  Non Non-di -dilu lute te urine urine (sg > 1.005 1.005))  Neg ni nitra trate te and and leuk leuk este esteras rase e

 Negative predictive value > 95%

 Bl Bloo ood d cul cultu ture res s not not us usef eful ul

 

Treatment  Ini Initia tiate te im imme media diatel tely y after after cul cultur ture e draw drawn n  ± Re Red duc uces es severity of renal scarring

 Oral route preferred  7-14 7-14 da day y cou cours rse e is is stan standa dard rd  ± 2-4 day days s appears appears to be be as effect effectiive  Not yet rec recomme ommend nded ed

 

Treatment Antibiotic

Daily Dosage

 Amoxicillin*

20-40mg/kg in 3 doses

Cefixime (Suprax) Cefpodoxime (Vantin)

8mg/kg in 2 doses 10mg/kg in 2 doses

Cefprozil (Cefzil)

30mg/kg in 2 doses

Cephalexin (Keflex)

50-100mg/kg in 4 doses

Loracarbef (Lorabid)

15-30mg/kg in 2 doses

Sulfisoxazole (G (Gantrisin)

120-150mg/kg in in 4 doses

Trimethoprim/

6-12mg/kg & 30-60mg/kg

Sulfamethoxazole Sulfametho xazole (Bactrim) In 2 doses

 

Follow Up  AA AAP P Re Reco comme mmend ndati ation on:: 48 hou hours rs  ± If not im impro proving repeat culture & immediate renal ultrasound  ± No e vidence to support repeat culture/test of cure

Committee on Quality Improvement, Subcommittee Subcom mittee on Urinary Tract Tract Infection. Practice parameter: theinfants diagnosis, treatment, treatment, and evaluation the initial urinary  tract infection in febrile and young children. Pediatrics of 1999;103:843-52.

 

Prevention  Rat ates es of re recu curr rren ence ce  ± 12% of child children ren < 5 years years old  ± 18% of of infants infants < 6 months months

 Pr Prop ophy hyla lact ctic ic ant antib ibio ioti tics cs  ± Recommende Recommended d by AAP while while waiting waiting for  imaging  ± Effic Efficacy acy ques questione tioned d

 

Prevention Antibiotic

Daily Dosage

Methenamine mandelate

75mg/kg in 2 doses

(Mandelamine) Nalidixic acid (NegGram)

30mg/kg in 2 doses

Nitrofurantoin (Macrobid)

1-2mg/kg once per day

Sulfisoxazole (Gantrisin)

10-20mg/kg in 2 doses

Trimethoprim/

2mg/kg & 10mg/kg nightly or  5mg/kg & 25mg/kg 2x/week

sulfamethoxazole sulfamethox azole (Bactrim)

 

Prevention  Circumcision  ± Low Lowers ers UTI rate in boy boys s  NN NNT T = 111 111 to pr pre event one UTI  ± Surg Surgical ical compli complicatio cation n rate rate = 1% 1%  ± Bene Benefit fit does does not outw outweigh eigh risk and and not recommended

 

Imaging  Who to image?  ±AAP  All childre children n 2 months months to 2 years years of age age with with first UTI  Re Rena nall ultr ultras asou ound nd  Cyst Cysto ogra ram m  ±Voiding cystourethrogram (VCUG)  ±Radionuclide cystogram (RNC)

 

Imaging  Who to image?  ± Cinci Cincinnati nnati Children¶ Children¶s s Hospital  All boys  Gi Girl rls s < 36 36 mont months hs  Gi Girl rls s 33-7 7 wit with h fever > 38.5 .5ºº C (1 (10 01.3 .3ºº F)  Same mod modali alitie ties s recommend recommended ed as as AAP

E vidence vidence

based clinical practice guideline for medical management of first time

acute urinary tract tract infection in children 12 years of age or less. Cincinnati, Ohio: Cincinnati Children¶s Hospital Medical Center Center,, 2005.

 

Imaging  Renal ultra ras sound  ± GU tra tract ct an anato atomy my  ± Evaluate renal scarring

 DM DMSA SA (re (rena nall cor corti tica call sca scan) n)  ± Diffe Differen rentiat tiates es pyelonep pyelonephriti hritis s from cystitis cystitis  ± Asse Assesse sses s rena renall scar scarrin ring g

 

Imaging  Cyst Cystog ogra ram m- ide den nti tify fy and gra rad de vesicoureteral reflux (VUR)  ± Vo Void idin ing g cy cyst stou oure reth thro rogr gram am (V (VCUG CUG))  OK for girls and boys  Demon Demonstrat strates es GU anat anatomy omy plu plus s VUR  ± Ra Radi dion onuc uclilide de cy cyst stog ogra ram m (R (RNC) NC)  Lo Low w amoun amountt of rad radiat iation ion  Gi Girl rls s only  ±Little anatomic detail

 

Vesicoureteral Reflux (VUR)  Con Concer cern n for for py pyelo elonep nephri hritis tis & renal renal sca scarri rring ng  Prevalence in females < 18 yo  ± Grade I- 7%  ± Grade II II- 22%  ± Grade II III- 6%  ± Grade IV- 1%  ± Grade VV- <1%

 

Vesicoureteral Reflux  St Stan anda dard rd tre treat atme ment nt opt ptio ions ns  ± An Anti tibi biot otic ics s  Studies Studies of prop prophyla hylactic ctic antib antibioti iotics cs have not included children with VUR

 ± Su Surg rge ery  ± Ant Antib ibiot iotics ics + surge surgery ry

 

Vesicoureteral Reflux  Unc Unclea learr ifif clin clinica icall bene benefit fits s to tre treat ating ing VUR  ± Only severe VUR (Grades IV & V) associated with recurrent UTI and pyelonephritis  < 2% 2% of of all all cases cases of VUR  No causa causall relati relationsh onship ip with with scarring scarring  ± Risk of of UTI = between between surgical surgical & medical group groups s  ± Abx + surgery surgery reduced reduced # of UTIs and and pyelo pyelo but no renal damage noted in either group at 5 years W heeler heeler

DM, et al. Interventions for primary VUR. Cochrane Database Syst Rev. Rev. 2004(3):CD001532 

 

Summary  Uri Urine ne cul culture ture nec necess essary ary for dia diagno gnosis sis  Sh Short ort cou course rses s of anti antibi bioti otics cs ma may y be be as as effective as longer courses  Pro Prophy phylac lactic tic anti antibi bioti otics cs are an opti option on but may not provide much clinical benefit  Rou Routin tine e imag imaging ing doe does s not not appe appear ar to affec affectt outcomes  Dia Diagno gnosin sing g VUR doe does s not not app appear ear to affe affect ct outcomes

 

References  

 



Alper BS, Cur Alper Curry ry SH. Uri Urinar nary y tra tract ct infe infecti ction on in chil childre dren. n. Am Fam Physician 2005;72:2483-8. Comm Co mmiitt ttee ee on Qua uali lity ty Im Impr pro ovement, 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. Curr Cu rrie ie ML ML,, et et al al.. Fol Follo loww-up up ur urine ine cu cult ltur ures es an and d fever in children with urinary tract infection. Arch Pediatr Adolesc Med 2003;157:1237-40. Evidence based clinical practice guideline for medical management managem ent of first time acute urinary tract infection in children 12 years of age or  less. Cincinnati, Ohio: Cincinnati Children¶s Hospital Medical Center, 2005. Mic ich hael M, et al. Sh Sho ort versus standard duration oral antibiotic therapy for acute urinary tract infection in children. Cochrane Database Syst Rev 2004;(4):CD003966

 

References    

 

Roberts Robert s KB. The AAP pra practi ctice ce par paramet ameter er on uri urinar nary y tra tract ct infe infecti ctions ons in febrile infants and young children. Am Fam Physician Physician 2000;62:1815-22. Le Sa Saux ux N, Ph Pham am B, Mo Moho hoer er D. Evaluating the benefits of  antimicrobial prophylaxis to prevent urinary tract infections in children: a systematic review. CMAJ 2000; 163:523-9. Michae Mic haell M, et al. Shor Shortt comp compare ared d wit with h stan standar dard d dur durati ation on of  antibiotics treatment for urinary tract infection: a systematic re review of randomised controlled trials. Arch Dis Child 2002;87:118-23. Singh Sin gh-G -Gre rewa wall D, D, Mac Macde dess ssii J, J, Crai Craig g J. J. Cir Circu cumci mcisi sion on for th the e prevention of urinary tract infection in boys: boys: a systematic re review of  randomized trials and obser vational studies. Arch Dis Child 2005;90:853-58. Williams Willi ams GJ, Lee A, Cra Craig ig JC. Lon Long-t g-term erm ant antibi ibioti otics cs for preventing recurrent urinary tract infection in children. Cochrane Database Syst Rev 2004;(4):CD001534. Whe Wh eeler DM DM,, et al. Inter ventions for primary vesicoureteric reflux. Cochrane Database Syst Rev 2004;(3):CD001532.

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