Download - Donald McLaren, MD Seventh International Symposium in Continuing Nursing Education/March 2014
UPDATE ON DIAGNOSIS AND
MANAGEMENT OF PEDIATRIC UTI
Donald McLaren, MD
Seventh International Symposium in Continuing Nursing Education/March
2014
OBJECTIVES Discuss latest AAP guidelines for
diagnosis and treatment of UTIs in febrile infants
Discuss UTI symptoms, diagnosis and treatment in children of all ages except newborns
To discuss some causes recurrent UTI and prevention of UTI and kidney damage in children with recurrent UTI
GENERAL COMMENTS In febrile infants and small children, the
urinary tract is the most common site of bacterial infection – about 5% of children 2-24 months will get at least one UTI
Some recommend UC in all 2-24 mo girls and uncircumcised males with fever >39o with no source and < 6 moa for a circumcised male (their risk much lower) (2-4 % vs. 10-25%)
AAP CLINICAL PRACTICE GUIDELINES The AAP periodically has put out
guidelines for diagnosis and management of UTI in children.
The 2011 guidelines updating the 1999 guidelines: “Urinary Tract Infection: Clinical Practice Guideline for the Diagnosis and Management of the Initial UTI in Febrile Infants and Children 2-24 months” found at: http://pediatrics.aappublications.org/content/early/2011/08/24/peds.2011-1330
AAP GUIDELINES CONTINUED This has significant recommendation
changes concerning diagnosis and evaluation of febrile UTIs in this age group.
We will discuss these guidelines. While there has been some controversy, the guidelines are very useful for us on the field as we work with children with possible UTI. They will decrease the amount of travel required for work-up after the initial febrile UTI in this age group over the 1999 guidelines
A LITTLE HISTORY I presented this topic in 2009. At that time
the recommendation was that children with a first time febrile UTI needed an evaluation including a Renal Bladder US (RBUS) and VCUG (Voiding cystourethrogram)
This was because 33% had an underlying condition or vesicoureteral reflux (VUR) to explain the UTI AND
It was felt that repeated febrile UTIs in someone with VUR would result in significant sequelae – renal scarring, HTN, and eventual RF and as evidence see the next 2 slides
AMERICAN ACADEMY OF PEDIATRICS: PRACTICE PARAMETER: THE DIAGNOSIS, TREATMENT, AND EVALUATION OF THE INITIAL URINARY TRACT INFECTION IN FEBRILE INFANTS AND YOUNG CHILDREN. PEDIATRICS. 1999;103:843-852
When 1999 guidelines written, belief was that renal scarring occurred with UTI ONLY if VUR allowed infected urine reflux back up to the kidneys
But some then were already questioning whether this was true? Was this aggressive approach really indicated? I ended with this:Medicine is fun, exhilarating, maddening,
frustrating, challenging, ever changingWe in the profession must keep up as best
we can to offer our patients the best care. What is dogma now may become wrong
tomorrowWe often don’t know what we don’t know.
So, as I present the 2011 guidelines, realize there is some controversy – some still think a first time UTI in a febrile child needs to be evaluated with a RUS and VCUG
But these new guidelines give us some much needed guidance for patients living overseas in deciding who needs to travel for further evaluation. They providing excellent guidance for diagnosis, treatment and work-up of UTI in this group of children.
DISCLAIMER IN ARTICLE WITH GUIDELINES “This clinical practice guideline is not
intended to be the sole source of guidance for the treatment of febrile infants with UTIs. Rather, it is intended to assist clinicians in decision making. It is not intended to replace clinical judgment or to establish an exclusive protocol for the care of all children with this condition.”
ACTION STATEMENT 1 – EVIDENCE QUALITY A, STRONG RECOMMENDATION Action Statement 1: If a clinician
decides that a febrile infant with no apparent source for the fever requires antimicrobial therapy because of ill appearance or another pressing reason, the clinician should ensure that a urine specimen is obtained for UA AND UC by catheterization or SPA (suprapubic urine) before antimicrobials given.
BUT DON’T FORGET THE URINE
http://pedemmorsels.com/hyperpyrexia-2/hyperpyrexia-2/
Pediatric EM Morsels © 2010-2014
HOW TO COLLECT THE URINE To tx first would obscure diagnosis of UTI SPA gold standard but many consider it
invasive and is more painful. May be only option in some (phimosis, labial adhesions)
Catheterization urine culture 95% sensitive, 99% specific compared to SPA
A bagged urine specimen not adequate in this age - has very high false positive rate (88% false + rate) and is only useful if negative
ACTION STATEMENT 2 – EVIDENCE QUALITY A; STRONG REC If a clinician assesses a febrile
infant with no apparent source for fever as not being so ill as to require immediate antimicrobial therapy, then the clinician should assess the likelihood of UTI
2a If clinician determines the febrile infant to have a low likelihood of UTI, then clinical follow-up monitoring without testing is sufficient
2B EVIDENCE QUALITY C; RECOMMENDATION 2b If clinician determines that the
febrile infant not in a low-risk group then either: Option 1 is to obtain a urine specimen
through cath or SPA for UA and UC. OROption 2: Obtain urine specimen by most
convenient means and perform UA. If the UA results suggest UTI (+ leukocyte esterase or nitrite test; + microscopic analysis for leukocytes or bacteria), obtain the urine by cath or SPA for UA and UC (fresh < 1 hour old specimen or if refrigerated < 4 hours old)
DETERMINING RISK OF UTI UTI prevalence among febrile girls > 2X that
of infant boys. Rate for uncircumcised boys 4-20X that of
circumcised boys who only have 0.2-0.4% risk
Presence of another source (i.e. OM) lowers risk by half.
New guidelines has a system based on studies to determine if risk is < 1% or at least 2%
Risk grid not absolute – if patient unlikely to keep F/U or lives in a remote location it is wise to check for UTI even if risk very low
PROBABILITY OF UTI: INFANT GIRLS
Individual FactorsProbability of
UTI# of Factors
Present
• Race: White• Age: <12 months• Temperature: ≥39⁰C• Fever: ≥2 days• Absence of another
source of infection
≤1% No more than 1
≤2% No more than 2
PROBABILITY OF UTI: INFANT BOYS
Individual FactorsProbability
of UTI
# of Factors Present
• Race: Nonblack• Temperature: ≥39⁰C• Fever: >24 hours• Absence of another
source of infection
CircumcisedNo Yes
≤1% * No more than 2
≤2% None No more than 3
*Probability of UTI exceeds 1% even with no risk factors other than being uncircumcised.
ACTION STATEMENT 3: EVIDENCE QUALITY C; RECOMMENDATION To establish the diagnosis of UTI,
clinicians should require both UA results suggesting infection (pyuria and/or bacteriuria) and the presence of at least 50 000 colony-forming units (CFUs) per mL of a uropathogen cultured from a urine specimen obtained through catheterization or SPA
URINALYSIS + UA AND UC now considered essential to
diagnosis – UA essential, not sufficient alone
If only a + UC with - UA, considered to be either asymptomatic bacteriuria or contamination as inflammation should lead to an abnormal UA also
Asymptomatic bacteriuria known to occur in older children. 0.7% of afebrile girls had 3 cultures with a single uropathogen
Lack of pyuria distinguishes true UTI from asymptomatic bacteriuria
WHAT IS NEEDED TO CONSIDER A UA POSITIVE FOR UTI? Dipstick
Positive leukocyte esterase is a marker for pyuria Sensitivity 94% in context of clinically
suspected UTI Reported as 83% in other studies Specificity much less – 64-92% - false positives
Positive Nitrite (converted from dietary nitrates in presence of most gram negative bacteria but requires 4 hours in bladder) Not sensitive but very few false positives
(specific) so if positive almost certainly have bacteria in the urine
URINE MICRO AND CULTURE > 5 WBC / hpf (25 WBC / microliter) > 10 WBC/microliter in counting
chamber Unspun gram stained urine – 1 gm –
bacteria / 10 hpf = 105 bacteria UC of fresh or refrigerated specimen
Significant > 50,000 CFUs/ml of a single urinary pathogen
Lower number for SPA (> 1000 CFU/ml)Always do sensitivity if grows urinary
pathogen
http://www.impactednurse.com/?p=2144
http://library.aua.edu.ag/webpath/webpath/tutorial/urine/urine.htm
ACTION STATEMENT 4A: QUALITY A; STRONG RECOMMENDATION Action Statement 4a When initiating
treatment, the clinician should base the choice of route of administration on practical considerations. Oral and parenteral are equally efficacious. The choice of agent should be based on local antimicrobial sensitivity patterns (if available) and should adjust the choice according to sensitivity testing of the uropathogen
4B: EVIDENCE QUALITY B; RECOMMENDATION 4b One can choose 7 to 14 days as
the duration of antimicrobial therapy
TREATMENT Goals of treatment
Eliminate infection and relieve symptomsPrevent complicationsReduce likelihood of renal damage
“Most experimental and clinical data support the concept that delays in the institution of appropriate treatment of pyelonephritis increase the risk of renal damage.”
TREATMENT Most can be treated orally
Treat parenterally if toxic appearingOr if cannot hold down meds due to N/VPossibly if not responding or cannot get F/U
Duration of treatment 7-14 daysData comparing 7,10,14 days not availableEvidence 1-3 days of treatment inferior
CHOICE OF ANTIBIOTICS Based on local resistance patterns if
possible Must cover E. coli (80% of UTIs in this
age) and other gram negative organisms
Significant degree of resistance in many places to TMP-SMP and Cephalexin
Those with multiple previous episodes of UTI often seem to be resistant to more drugs
© 2013 Answers in Genesis www.AnswersInGenesis.org.
ORAL ANTIBIOTIC OPTIONS Amoxicillin/clavulanate 20-40 mg/kg/day
q8hr Sulfisoxazole or TMP-SMX: 6-12 mg/kg
TMP and 30-60 mg/kg SMX daily in 2 doses
Cephalosporins Cefixime – 8 mg/kg/ day in 1 dose Cefpodoxime – 10 mg/kg/day in 2 doses Cefprozil – 30 mg/kg/day in 2 doses Cefuroxime axetil – 20-30 mg/kg/day in 2
doses Cephalexin – 50-100 mg/kg/day in 4 doses
PARENTERAL ANTIBIOTIC CHOICES Ceftriaxone 75 mg/kg every 24 hours Cefotaxime 150 mg/kg/day divided q 6-
8 hr Ceftazidime 100-150 mg/kg/day divided
q 8 hr Gentamycin 7.5 mg/kg/day divided q 8
hours Tobramycin 5 mg/kg/day divided q 8
hours Pipercillin 300 mg/kg/day, divided q 6-8
hours
ACTION STATEMENT 5: EVIDENCE QUALITY C; RECOMMENDATION Febrile infants with UTIs should
undergo renal and bladder ultrasonography (RBUS)
RBUS While not super useful, helpful in some
cases Non-invasive and no radiation To detect anatomic abnormalities that
require further evaluation and abscesses
Evaluate renal parenchyma Assess renal size as baseline so as to
monitor Less useful now as many already had
RBUS as prenatal screening (but often uncertain timing and quality of US during pregnancy)
RBUS TIMING Timing of RBUS within 2 days if severe
or not improving Otherwise, later better as 2 days into a
UTI would not be a true baseline as E-coli endotoxin can cause edema
DMSA scan shows if patient has pyelonephritis much better but rarely changes initial treatment. Not recommended at early stage
© 2014 RemakeHealth Inc.™ All Rights Reserved. http://www.remakehealth.com
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ACTION STATEMENT 6A: EVIDENCE QUALITY B; RECOMMENDATION Action Statement 6a: VCUG should not
be performed routinely after the first febrile UTI; VCUG is indicated if there is hydronephrosis, scarring or other findings that would suggest high grade VUR or obstructive uropathy on RBUS as well as in other atypical or complex clinical circumstances
Action Statement 6b: Further evaluation should be conducted if there is a recurrence of febrile UTI (evidence quality: X; recommendation).
SIGNIFICANT CHANGE IN RECOMMENDATIONS Strategy for 40 years
Prevent further damage after initial UTI by determining which had treatable GU abnormalities which would increase risk of renal damage with recurrent UTI
Antimicrobial prophylaxis with Bactrim or Nitrofurantoin to prevent further UTI if VUR
Or if high grade VUR or failed trial of prophylactic antibiotics, VUR surgery
However several studies have shown that one can get renal scarring/damage without VUR
Some studies indicate that antibiotic prophylaxis is not effective except in grade V reflux
If prophylaxis is not usually helpful AND one can get pyelonephritis, renal damage without VUR, then rationale for VCUG is questionable for VUR grades I-IV.
Grade V is not common among those with UTI (1/100) so by waiting reduce need for invasive VCUG testing after first febrile by UTI 90%
Study now underway to determine effects of prophylaxis in children 2 months – 6 years “The Randomized Intervention for Children with VUR study” (TMP-SMX in 607 children with grade I-V VUR following UTI)
RECURRENCE RATE OF FEBRILE UTI BY REFLUX GRADE, 1,091 INFANTS 2–24 MONTHS
0%
20%
40%
60%
80%
100%
None Grade I Grade II Grade III Grade IV
Prophylaxis
No Prophylaxis
Pediatric Care OnlineTM ©American Academy of Pediatrics
N=373 N=100 N=257 N=285 N=104
NS NS NS
NS
NS
RECURRENCE RATE OF FEBRILE UTI BY REFLUX GRADE, 1,091 INFANTS 2–24 MONTHS
0
50
100
150
200
250
None Grade I Grade II Grade III Grade IV
Prophylaxis
No Prophylaxis
Pediatric Care OnlineTM ©American Academy of Pediatrics
After First UTI(N=100)
After Recurrence(N=10)
No VUR 65 (65%) 2.6 (26%)
Grade I–III VUR 29 (29%) 5.6 (56%)
Grade IV VUR 5 (5%) 1.2 (12%)
Grade V VUR 1 (1%) 0.6 (6%)
Pediatric Care OnlineTM ©American Academy of Pediatrics
N=103 “By restricting urinary tract imaging after an initial
febrile UTI [based on NICE guidelines, 2007], rates of voiding cystourethrography and prophylactic antibiotic use decreased substantially without increasing the risk of UTI recurrence within 6 months and without an apparent decrease in detection of high-grade VUR.”
Schroeder AR, Abidari JM, Kirpekar R, et al. Impact of a more restrictive approach to urinary tract imaging after febrile urinary tract infection. Arch Pediatr Adolesc Med. 2011;165(11):1027–1032
Impact of a More Restrictive Approach to Urinary Tract Imaging After Febrile Urinary Tract Infection
EVIDENCE QUALITY C; RECOMMENDATION Action statement 7: After confirmation
of first UTI, parents should be instructed to seek prompt (ideally within 48 hours) for future febrile illnesses to ensure that recurrent infections are detected and treated promptly.Why? (Early treatment limits renal damage
better than late treatment and risk of renal scarring increases with number of recurrences)
AREAS FOR RESEARCH (8)1. Relationship between UTIs and
reduced renal function / hypertension
2. Alternatives to invasive collection of urine and culture
3. Role of VUR (and, thus, VCUG)4. Role of prophylaxis (RIVUR study)5. Genetics6. Hispanics7. Further treatment: What and for
whom?8. Duration of treatment
AAP Guideline for theDiagnosis and Management
of UTIs in Febrile InfantsUnanswered Questions and Unquestioned
Answers
Kenneth B. Roberts, MD, FAAP Professor of Pediatrics (Emeritus) University of North Carolina
TM
Roberts KB. “AAP Guideline for the Diagnosis and Management of UTIs in Febrile infants.” Pediatric Care Online Accessed 1/17/2014 at www2.aap.org/pcorss/webinars/pco/AAP%20Webinar_UTI-Roberts-Final.ppt
UTI – BACTERIOLOGY AND CAUSE 80% E. coli but also Klebsiella, Proteus,
Enterobacter, Citrobacter, etc. Gram + rare.
Non-E.coli more common with anomalies of UT, younger age, previous tx with antibiotic
Few bacteremic except newborns. Beyond newborn period due to bacteria
ascending up urethra to bladder Newborn hematogenous or ascending Most UTIs due to UPEC (uropathogenic E.
Coli); most E. Coli pyelo have P. pili fimbriae.
RISK FACTORS (UTD) Younger age, Being female, white race Lack of circumcision Genetic factors Urinary tract obstruction or VUR Bowel/bladder dysfunction Sexual activity Bladder catheterization Risk of renal scarring: recurrent UTI,
delay in treatment of acute UTI, bladder/bowel dysfunction, obstruction, VUR, ? young age
SYMPTOMS IN YOUNGER CHILDREN Very non-specific in younger children First 2 months high fever, jaundice,
apnea, many more – often with sepsis After 1-2 months: fever (especially > 39o
and if >48 hours) and suprapubic tenderness
Some irritability or fussiness and other non-specific signs: poor feeding, FTT
Foul smelling urine and GI symptoms not found to be helpful in diagnosis
SYMPTOMS IN OLDER CHILDREN Classic sx: fever and urinary symptoms
(frequency, dysuria, urgency, incontinence, hematuria, abd. pain)
For pyelonephritis in older children fever, chills, flank pain and abdominal pain
Not all with sx have UTI: ddx of urethritis include vulvovaginitis, irritant or chemical, urethritis, urinary calculi, STD, vaginal FB
In past it was said and I always presume if UTI + fever = pyelonephritis. Not always true but cannot do a DMSA scan in all of them
http://nutravize.com
IMPORTANT HISTORY AND PHYSICAL FINDINGS History -Determine if chronic symptoms,
constipation, previous UTIs or undiagnosed febrile illnesses, VUR, FH, antenatally diagnosed renal abnormality, high Bp, poor growth, sexual activity and spermicides
Physical: Bp, Temp, growth parameters, tenderness of abdomen, external genitalia, low back exam, other sources of fever
LAB Lab – Need + UA AND UC to confirm UTI Usually no need for BC after 2 months No need for creatinine unless recurrent If potty trained can do CCUA specimen
> 100,000 CFU/ml for CCUA> 1000 CFU/ml for SP>50,000 CFU/ml for cath culture
If 10-50,000 repeat If same result of same and only one uropathogen
treat
TREATMENT 50% E. Coli resistant to Amoxicillin, Amp;
increasing resistance to TMP-SMX,cephalexin, Amoxacillin-clavulanate, Amp-sulbactam
If suspect enterococcus don’t use monotherapy – add Ampicillin (urinary catheter, anatomical abnormality)
3rd gen. cephalosporins best starting drug. Oral as good as IV for time to symptom
resolution, sterilization of urine, reinfection rate, renal scarring at 6 months
TREATMENT FLQs effective but increasing resistance. ?
safety in children - limit to Pseudomonas and multidrug resistant gram negative organisms
Should improve within 24-48 hours. No need to reculture unless not improving 24
hr Studies conflict on whether prophylaxis
useful for recurrent UTI – some say only if grade V reflux – others if III-V reflux
Would try after 2nd UTI + VUR as trial Study ongoing to see if steroids prevent
renal damage with UTI
WORK-UP AFTER UTI RBUS: Children < 2 with 1st UTI, any age with
recurrent febrile UTIs, children with FH of kidney issues, HTN, poor antibiotic response.
VCUG if < 2 yo with 2 or more febrile UTIs, FH of renal/urological disease, poor growth or HTN, perhaps those with organism other than E.Coli and prophylaxis if grade > III VUR
DMSA not routine – shows pyelonephritis, most VUR III or higher, as well as scarring.
F/u with growth, weight and Bp – not UA, UC
WHEN TO REFER Refer if dilating VUR (III-V) or obstructive
uropathy, renal abnormalities, impaired kidney function, elevated Bp, bowel or bladder dysfunction that is refractory to primary care measures
PROGNOSIS Most have no long term sequelae < 19 with first UTI – 25% had VUR, 2.5%
had grade IV or V reflux. VUR increases risk of acute
pyelonephritis and renal scarring and 15% showed evidence of renal scarring at F/U
8% had at least one recurrence
LONG TERM MANAGEMENT 8-30% have > one symptomatic reinfections. Evaluate for, tx bowel/bladder dysfunction No need for F/U cultures Inform parents after febrile UTI they need to
seek care soon if symptoms or fever develop Consider prophylaxis for those without VUR if
3 febrile UTIs in 6 months or 4 in year. With VUR grade 3-5 after second febrile UTI.
TMP-SMX 2 mg TMP/kg or Nitrofurantoin 1-2 mg/kg
6 months and if no UTIs can stop and resume if another recurrence
ACUTE CYSTITIS IN CHILDREN 2 YEARS THROUGH ADOLESCENCE 90% E. coli (then other gm - organisms) >100,000 CFU/ml uropathogen Ddx- bladder dysfunction, vaginal FB, drug,
chemical, nonspecific vulvovaginitis, cervicitis, urethritis, prostatitis, epididymo-orchitis, nephrolithiasis, urethral stricture, interstitial (autoimmune), neoplasm
Treat empirically If > 13, uncomplicated include coverage for
staph saprophyticus – TMP-SMX or cephalosporin
In older children if not complicated treat 5-7 days. If younger or complicated 7-14 days
VESICO-URETERAL REFLUX (VUR)
© 2005-2014 All Rights Reserved http://www.childrenshospital.org
VUR Retrograde passage of urine into upper
urinary tract from the bladder 1% newborns; 30-45% young children with
UTI Most common urological finding in children Can be primary or secondary due to
abnormally high pressures in bladder More common in whites, girls, younger. Strong genetic component Diagnose by VCUG or radionuclide
cystogram (RNC)
30-60% of those with IV or V reflux have primary renal scarring – may be developmental issue
? if scarring result of developmental issue or due to infections ascending up to kidney due to VUR; many continue to believe latter
> ½ resolve on their own – more likely with milder degrees (I-II 80% resolve in 5 years)
High grade rarely resolve on own Evaluate all with VUR and F/U for renal
status, growth parameters, Bp, creatinine (initially) and UA for pyuria and proteinuria
MANAGEMENT OF VUR Unknown benefits of treatment. UpToDate
management based on available data, prevention of pyelonephritis, likelihood of renal scarring and of spontaneous resolution of VUR, and patient/family preference Screen for voiding dysfunction III-V either treat (prophylaxis) or surveillance and
prompt treatment if UTI I,II observation vs. antibiotic prophylaxis with
family inputTrials so far display no difference in
outcome between antibiotic prophylaxis, surgical VUR repair - get family input
VUR MANAGEMENT CONTINUED
Surgery recommended if unlikely to resolve (family input); Grade V reflux + scarring, Grade V > 6 YOA, III-V with failed medical tx
Dx and tx promptly if symptoms or febrile illness.
Yearly RBUS. DMSA if RBUS suggests renal scarring, poor renal growth, those with recurrent UTI and with Grade III-V VUR
F/u yearly growth, Bp and UA
BLADDER OR VOIDING DYSFUNCTION Essential to determine in children with
UTI or VUR if have bladder dysfunction - problems with bladder filling or emptying which can predispose to repeated infections.
Can be from neurogenic, anatomic (ectopic ureter, obstruction) or functional causes
WHEN TO EVALUATE FOR BLADDER/BOWEL DYSFUNCTION Hx, Px, UA, UC – Suspect if:
Daytime urinary incontinence in school age or previously toilet trained children
Urinary sx: urgency, dribbling, dysuria, daytime frequency, nocturia, hesitancy, holding maneuvers to avoid voiding, abnormal or intermittent flow or stream, incontinence, abdominal straining, holding maneuvers, post void residual, if VUR or recurrent infections
Dysfunctional Voiding Symptoms Survey questionnaire or voiding diary very helpful
R/O neurological or anatomical causes
http://fmymind.com/urine-trouble/
Many types beyond scope of talk. Will discuss only daytime wetting due to dysfunctional voiding - occurs in 20% of 4-6 years old- causesOveractive bladder (urgency)Voiding postponement and underactive
bladder (Valsalva to urinate large volume post void residual)
Dysfunctional voiding (Inability to relax urethral sphincter and/or pelvic floor musculature during voiding. Detrusor contractions during voiding against a closed external urinary sphincter. Get interrupted staccato flow pattern, prolonged voiding time)
Other
DYSFUNCTIONAL VOIDING
http://www.vcu.edu/urology/patients/conditions/peds_urology/dys_voiding.html
TREATMENT OF DYSFUNCTIONAL VOIDING Can reduce symptoms in as many as 40-
70% Take care of constipation Explain to parents, patient if appropriate Voiding behavior modification if age
appropriate Educate family including how child’s voiding
patterns deviate from normal Timed voiding schedule and 72 hr voiding diary Frequent voiding q 2-3 hours all day Try to empty bladder fully and use double voids Reward for following program, not for staying
dry
REFERRAL FOR DYSFUNCTIONAL VOIDING If not working refer to urologist MD for
testing and treatment which might include RBUS, VCUG, MRI, urinary flow measurement,
urodynamic testing Medication Pelvic floor relaxation techniques Biofeedback Electrical stimulation therapy, botox injection,
surgery,, intermittent clean catheterization If not treated risk high pressures, complications
thereof – some feel all need urologist
SOURCES Subcommittee on Urinary Tract Infection and
Steering Committee on Quality Improvement and Management. “Urinary Tract Infection: Clinical Practice Guideline for the Diagnosis and Management of the Initial UTI in Febrile Infants and Children 2 to 24 months.” Pediatrics accessed 1/20/2014 at http://pediatrics.aappublications.org/content/early/2011/08/24/peds.2011-1330
Allen HA. “Fever without a source in children 3 to 36 months of age.” UpToDate accessed 1/17/2014 http://www.uptodate.com/contents/fever-without-a-source-in-children-3-to-36-months-of-age?source=search_result&search=fever+without+a+source&selectedTitle=1%7E15
McLorie G, Herrin JT. “Management of vesicoureteral reflux. UpToDate accessed 1/16/2014 at http://www.uptodate.com/contents/management-of-vesicoureteral-reflux?source=search_result&search=Management+of+vesicoureteral&selectedTitle=1%7E68
McLorie G, Herrin JT. “Presentation, diagnosis and clinical course of vesicoureteral reflux.” UpToDate accessed 1/16/2014 at http://www.uptodate.com/contents/presentation-diagnosis-and-clinical-course-of-vesicoureteral-reflux?source=search_result&search=presentation%2C+diagnosis+adn+clinical+course+of+vesicoureteral+reflux&selectedTitle=1%7E150
Nepple KG, Cooper CS. “Etiology and clinical features of bladder dysfunction in children.” UpToDate accessed 1/16/2014 at http://www.uptodate.com/contents/etiology-and-clinical-features-of-bladder-dysfunction-in-children?source=search_result&search=bladder+dysfunction&selectedTitle=3%7E150
Nepple KG, Cooper CS. “Evaluation and diagnosis of bladder dysfunction in children.” UpToDate accessed 1/16/2014 at http://www.uptodate.com/contents/evaluation-and-diagnosis-of-bladder-dysfunction-in-children?source=search_result&search=bladder+dysfunction&selectedTitle=4%7E150
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O’Donovan DJ. “Urinary tract infections in newborns.” Uptodate accessed 1/20/2014 at http://www.uptodate.com/contents/urinary-tract-infections-in-newborns?source=search_result&search=urinary+tract+infection+in+newborns&selectedTitle=1%7E150
Palazzi DL and Campbell JR. “Acute cystitis in children older than two years and adolescents.” UpToDate accessed 1/20/2014 at http://www.uptodate.com/contents/acute-cystitis-in-children-older-than-two-years-and-adolescents?source=search_result&search=acute+cystitis&selectedTitle=2%7E74
Roberts KB. “AAP Guideline for the Diagnosis and Management of UTIs in Febrile infants.” Pediatric Care Online Accessed 1/17/2014 at www2.aap.org/pcorss/webinars/pco/AAP%20Webinar_UTI-Roberts-Final.ppt
Shaikh N, Hoberman A. “Urinary tract infections in Infants and children older than one month: acute management, imaging, and prognosis.” UpToDate accessed 1/20/2014 at http://www.uptodate.com/contents/urinary-tract-infections-in-infants-and-children-older-than-one-month-acute-management-imaging-and-prognosis?source=search_result&search=uti+in+children&selectedTitle=1%7E150
Shaikh N, Hoberman A. “Long-term management and prevention of urinary tract infections in children. UpToDate accessed 1/20/2014 at http://www.uptodate.com/contents/long-term-management-and-prevention-of-urinary-tract-infections-in-children?source=search_result&search=uti+in+children&selectedTitle=5%7E150
Shaikh N, Hoberman A. “Urinary tract infections in infants and children older than one month: clinical features and diagnosis.” UpToDate Accessed 1/20/2014 at http://www.uptodate.com/contents/urinary-tract-infections-in-infants-and-children-older-than-one-month-clinical-features-and-diagnosis?source=search_result&search=uti+in+children&selectedTitle=2%7E150
Shaikh N, Hoberman A. “Urinary tract infections in children: epidemiology and risk factors.” UpToDate accessed 1/20/2014 at http://www.uptodate.com/contents/urinary-tract-infections-in-children-epidemiology-and-risk-factors?source=search_result&search=uti+in+children&selectedTitle=3%7E150
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