First UTI dr elizabeth

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Pediatric Urinary Tract Infections - First UTI : 

Pediatric Urinary Tract Infections - First UTI Dr Elizabeth K E, PhD, MD, DCH, FIAP Professor of Pediatrics, SATH, Govt. Medical College, TVM

Overview : 

Overview Background Diagnosis Imaging Vesico-ureteric reflux (VUR) Treatment Follow up Prevention Summary

Urinary System : 

Urinary System

Nephron : 

Nephron

Glomerular Filtration : 

Glomerular Filtration

Ureters : 

Ureters

Definitions : 

Definitions “UTI” represents a wide range of clinical syndromes Bacteriuria: the presence of bacteria in urine - does not necessarily imply infection Asymptomatic bacteriuria: presence of bacteria in the urinary tract in the absence of symptoms Unknown clinical significance - pregnant women - patients undergoing invasive procedures of the urinary tract Lower Tract UTI – cystitis with urgency and dysuria especially in females

Definitions : 

Definitions Simple UTI - with resolution on treatment without recurrences and renal scarring Complicated UTI - underlying abnormality that predisposes patient to UTI or makes UTI more difficult to treat effectively Recurrent UTI Relapse - recurrence of infection by same organism after discontinuation of treatment Reinfection - recurrence of infection by a different organism after discontinuation of treatment

Background : 

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 : 

Background Symptoms in early childhood Fever* Chills & Rigor, Febrile Fit Irritability Lethargy Anorexia Vomiting Potential sequelae Renal scarring Chronic renal failure Hypertension

Background : 

Background Anatomic risk factors Vesico-ureteric reflux (VUR) More common in girls Obstruction Posterior urethral valves in Boys Voiding dysfunction Bladder diverticulum

Background : 

Background Associated risk factors Constipation, Encoporesis Bladder instability Infrequent voiding Pin worm infestation Unsubstantiated risks Back-to-front wiping Inspect for phimosis, balanoposthitis, adherent labia

Diagnosis : 

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 especially in girls - >10,000 CFU clean catch boys Urine bags not recommended

Community-Acquired UTI : 

Community-Acquired UTI E.coli K.pneumoniae Proteus S.saprophyticus S.epi & gm - enterics Enterococcus

Uro-pathogens : 

Uro-pathogens E.coli, Klebsiella spp.-intrinsic gut organisms-highly motile-produce fimbriae (pili) >>attachment Proteus, Morganella, Providencia- urease producing organisms- increases urinary pH - leads to crystal formation >>biofilms>>colonization of catheter>>protects bacteria from host defenses & antibiotics

Nosocomial UTIcatheter associated : 

Nosocomial UTIcatheter associated Short Term Long Term E.coli E.coli Pseudomonas Pseudomonas Proteus Proteus Enterobacter Candida Providencia Morganella S.aureus Enterococcus

Diagnosis : 

Diagnosis Urinalysis usually have increased numbers of WBC leukocyte esterase test is often positive nitrate test is often positive Blood cultures not useful

Urinalysis : 

Urinalysis Urine culture: significant bacteriuria usually defined as > 105 bacteria / ml. (108 / litre) lower numbers may be significant in children especially in boys and in catheter collected specimens

Specimen collection : 

Specimen collection Clean catch mid stream specimens - most frequently used method - urethra cleaned prior to collection - first void urine allowed to pass to clear urethra, may be used for RE - mid-stream collected in sterile container Collection bags (children) - used in young children lacking bladder control - often contaminated - most meaningful result is a negative culture

Specimen collection : 

Specimen collection Suprapubic aspiration / straight catheters - invasive - specimen obtained directly from bladder Indwelling catheters - urine obtained by inserting needle into catheter or through diaphram - preferable to obtain specimen from new catheter, rather than old catheter

Specimen transport : 

Specimen transport Send to lab as quickly as possible- Require: method of collection time of collection patient’s antibiotics Specimens not received by lab in 1-2 hours MUST be refrigerated Urines not received within 24 hours or not refrigerated will be rejected by laboratory

Treatment : 

Treatment Initiate immediately after culture drawn Reduces severity of renal scarring IV route preferred 7-14 day course is standard

Treatment : 

Treatment

Follow Up : 

Follow Up AAP Recommendation: Initiate antibiotic after C&S Wait for 48 hours If not improving repeat culture & immediate renal ultrasound Repeat urine cultures – every month in 1st 3 months, then 3 monthly in 1st year 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 : 

Prevention Rates of recurrence 12% of children < 5 years old 18% of infants < 6 months Prophylactic antibiotics Recommended by AAP waiting for imaging, Efficacy questioned by some, --Duration -for 2 yrs or till the age of 4 – 5

Prevention : 

Prevention

Prevention : 

Prevention Circumcision Lowers UTI rate in boys Surgical complication rate = 1% Benefit does not outweigh risk and not universally recommended Treatment of constipation, pin worms Plenty of oral fluids Frequent voiding, Double voiding

Imaging : 

Imaging Who to image? AAP Recdommendation All children 2 months to 2 years of age with first UTI Renal ultrasound Cystogram Voiding/ Micturiting cystourethrogram (VCUG/ MCU) Radionuclide cystogram (RNC)

Imaging : 

Imaging Who to image?- Alternate Suggestions All boys Girls < 36 months Girls with fever > 38.5º C (101.3º F) As recommended by IAP Nephro Group 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.

Slide 30: 

First attack of childhood UTI (IAP Nephro Group) Normal <5yrs >5yrs MCU and DMSA scan No further evaluation Abnormal MCU and DMSA scan USG

Imaging : 

Imaging Renal ultrasound GU tract anatomy Pelvi calyceal dilatation, hydronephrosis Evaluate renal scarring Cystogram VCU/MCU Radionuclide Renal scan

USS of Normal Kidney : 

USS of Normal Kidney

Hydronephrosis : 

Hydronephrosis

Imaging : 

Imaging Cystogram- identify and grade vesicoureteral reflux (VUR) Voiding cystourethrogram (VCUG) OK for girls and boys Demonstrates GU anatomy plus VUR

Bladder : 

Bladder

Megaureter : 

Megaureter

Vesicoureteric Reflux (VUR) : 

Vesicoureteric 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%

Vesicoureteric Reflux : 

Vesicoureteric Reflux Standard treatment options Antibiotics Surgery Antibiotics + Surgery Deflux – an alternative therapy for severe grades of VUR. Subureteric injection of deflux , retained in position will resolve VUR, avoid surgery and long term uroprophylaxis

Vesicoureteric Reflux : 

Vesicoureteric Reflux Unclear if clinical benefits support treating all VUR Only severe VUR (Grades IV & V) associated with recurrent UTI and pyelonephritis Ie.,< 2% of all cases of VUR No causal relationship with scarring Risk of UTI still there in those without reflux Antibiotic + surgery reduced UTIs & pyelonephritis no renal damage noted in either group at 5 yrs Wheeler DM, et al. Interventions for primary VUR. Cochrane Database Syst Rev. 2004(3):CD001532

Imaging : 

Imaging Radionuclide cystogram (RNC) Low amount of radiation, Little anatomic detail DMSA (Static renal cortical scan using di mercapto succinic acid) Differentiates pyelonephritis from cystitis Assesses renal scarring Renal cells take up the tracer. Those cells damaged by pyelonephritis or scarring do not take up the tracer.

Imaging- Dyamic DTPA Scan : 

Imaging- Dyamic DTPA Scan (3 mCi Tc99m DTPA)This investigation gives information about the blood flow to the kidneys and how well each kidney is functioning for the production of urine. The test also shows if there are any obstructions in urine output

Gross Anatomy of Kidney : 

Gross Anatomy of Kidney

Scar in the superior and inferior pole of the right kidney : 

Scar in the superior and inferior pole of the right kidney

Case 1 : 

Case 1 A four year old previously healthy girl presents to clinic with c/o dysuria. She has no fever Immunizations are UTD. UA shows + Nitrites and + LE WBC on UA– present.

What is your diagnosis & plan? : 

What is your diagnosis & plan? Urine culture? Antibiotics? Oral antibiotics? Admit to the hospital? Work up ?

Answer: Lower Tract Infection : 

Answer: Lower Tract Infection She is afebrile – no need for radiologic studies if culture -ve Send the urine for culture Start empiric antibiotics for 7-14 days

Case 2 : 

Case 2 An 18 month old female presents with increased irritability x 3 days, subjective fever, and decreased appetite. PM Hx – usual childhood illnesses – AOM x 1, URIs x 2, AGE x 1. Benign recoveries. Immunizations are up-to-date (UTD)

Case 2 - Exam : 

Case 2 - Exam Vital Signs – normal except T 102.5 General appearance – fussy, easily consolable, nontoxic Throat – normal with clear pharynx and TMs Skin – no rash Systems - Normal

Fever without a Source/ Focus Guide-line : 

Fever without a Source/ Focus Guide-line

Plan of action : 

Plan of action Draw blood for CBC and potentially a blood culture? Urine culture? Antibiotics? Oral antibiotics? Admit to the hospital? Work up ?

Clinic workup : 

Clinic workup Complete Blood Counts Blood C&S Urine RE , C&S

Evaluation : 

Evaluation Your UA confirms the diagnosis. You have send the urine for culture. What now? Child admitted? Child goes home? What does the evidence say?

Case # 2 EBM vs reality answer : 

Case # 2 EBM vs reality answer Option #1 – young child with potential serious bacterial illness – send to ER for admission & IV antibiotics Option #2 – Draw blood for CBC and blood culture in clinic Obtain a UA Consider antibiotics, antipyretics Bring the child back in 24 hours for re-evaluation and review of labs.

Possible UTI : 

Possible UTI 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. Revise antibiotic as per C&S Admit & start IV antibiotic if not better

Lessons – post test : 

Lessons – post test Define Urinary Tract Infection (UTI) >100,000 CFU in clean catch specimens >10,000 catheter specimen & in boys 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

Take home Messages : 

Take home Messages Urine culture is essential for diagnosis Short courses of antibiotics may be as effective as longer courses Prophylactic antibiotics are an option but lack clarity regarding duration of treatment Imaging is mandatory in culture positive UTI Diagnosing VUR warrants long term antibiotics/interventions

References : 

References 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. Indian Pediatric Nephrology group: Indian Academy of Pediatrics; consensus statement on managing UTI. Indian Pediatrics 2001, 38; 1106 – 1115.

Slide 61: 

Thank you….

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