egyptian society of pediatric nephrology and renal
TRANSCRIPT
Egyptian Society of Pediatric Nephrology and
Renal Transplantation(ESPNT)
UPDATED PROTOCOLS ( INCLUDING ALGORITHMS )
FOR MANAGEMENT OF URINARY TRACT INFECTION IN
INFANTS AND CHILDREN
BY
Moftah M RabeeaProf. of Pediatrics and Pediatric
NephrologyAl-Azhar University
UTI
Ü UTI: Combination of clinical features andpresence of bacteria in the urine.
Ü Asymptomatic bacteriuria : presence ofbacteria in the urine but no symptoms ofupper or lower UTI .
Ü Bacterial persistence: Re-infection withthe same organism after sterilization of theurine has been documented(-ve culture).
Ü Recurrent UTI: Re-infection by differentorganisms documented on proper urine culture witheach new UTI. You should suspect UT abnormalitiesspecially in infants and young children.
Ü Recurrence of infection:
Ø Two or more episodes of acute pyelonephritis(upper UTI).
Ø Three or more episodes of cystitis (lower UTI).
Ø One episode of upper UTI + one or moreepisodes of cystitis.
Complicated UTI includes :A. Children with known mechanical or functional
obstruction of the UT ( eg . PUJO, PUV, VUR… ).
B. All febrile infants especially neonates withsuspected UTI are likely to be complicated andshould be treated as such.
Uncomplicated UTI:Ü Lower UTI ® easily managed.
Atypical UTI includes:1. Seriously ill child or infant.
2. Poor urine flow.
3. Raised creatinine.
4. Palpable kidneys .
5. Septicaemia.
6. Failure to respond to treatment withsuitable antibiotics within 48 hours.
7. Infection with non E-coli organisms .
Assess symptoms and signs of UTI
Infants and children younger than 3 years
Children 3 years or older
Mainly gen. nonspecific symptoms
Mainly specific symptom and localizing signs
Unexplained fever is one of the commonest presenting symptoms of UTI .
Nonspecific symptoms : Fever, vomiting ,, lethargy ,irritability , poor feeding , failure to thrive…. etc.
Specific symptoms and signs :Ø Lower UTI : Dysuria , frequency ,
incontinence , voiding dysfunctionØ Upper UTI : ,abdominal pain, loin pain
and tenderness , fever ,chills …..etc.
Urine sample collection for diagnosisToilet trained Non toilet trained
• Clean voided midstream is themethod of choice (All recent GLs)
• Suprapubic aspiration or urethral catheter
• Some GLs use the Quick Wee method to get midstream sample
Wee method: Gentle suprapubic stimulation for few minutes using gauze soaked in cold saline urine voiding
NB: Don’t use bag, pads, cotton or sanitary towels.
Urine testing (cont.) Children > 3 years of age
↓ Perform urine dipstick
Positive for LE and nitrite
↓ Diagnose UTI
↓ • Send urine for C/S • Start antibiotic
treatment • Subsequent
treatment is according to result of urine C/S
Positive for nitrite and
negative for LE ↓
Like No.1
Positive for LE and negative for nitrite
↓ • Send urine for C/S • Start antibiotic
treatment only if the patient is clinically unwell
• Treatment depends on the result of urine C/S
Negative for both LE and nitrite
↓ • Unlikely UTI • Explore other
causes of illness
Urine testing for children > 3 years Perform urine dipstick
§ Start ttt§ Send urine
for C/S
If both tests are negative &
no clinical evidence of UTI
other causes of illness should be explored .
Culture interpretationMethod of collection Threshold for diagnosis of UTI
(single organism)
Suprapubic aspiration. Any count/1000CFU/ml
Catheter of bladder. 50,000CFU/ml
Clean catch midstream 50,000CFU/ml
Bagged urine Unreliable.
N.B: Pyuria should be present to
differentiate between true infection andcolonization (AAP- GLs updated).
Some guidelines consider CFU of >10,000/mlobtained by catheter sufficient to diagnose UTIin the presence of pyuria .
Important pointsq You should maintain a high index of suspicion
to diagnose UTI specially in neonates andinfants.
q UTI should be suspected in any infant or childwith unexplained fever (38°C or more).
q UTI must be considered in all children withserious illness even if the infection is outsidethe UT.
q Some cases need to be individuallyevaluated .
q Consider urology consultation if indicatedq (In the presence of UT anomalies
obstruction or voiding dysfunction)q Don’t give empiric antibiotic pending
urine C/S except if the child is clinicallyunwell.
q Don’t treat asymptomatic bacteruria withantibiotics.
Empiric Antibiotics commonly used to treat upper UTIs :
Parenteral
?
Dose (mg/kg/day)Drug
60/12Trimethoprim-Sulfamethoxazole
10Nitrofurantoin
100Amoxicillin-clavulanate
16Cephalosporin – Cefixime
Some empiric oral antibiotics for TTT of cystitis
II - Infants 3mo or older:
consider referral to a pediatric
specialist
Oral treatment is as effective as IV one
for a total of 14 days provided that theinfant is not seriously ill , can tolerate
oral intake and presence of good
compliance to medications
Most recent studies issued for infant with
APN did not show any difference inresponse between infant treated with oral
therapy and those treated with either IV
antibiotics (total course) or those startedIV for 2-3 days and completed a total
course of 14 days with oral therapy.
Ø For infants and children who receive
aminoglycosides (gentamicin or amikacin), once daily dosing is recommended with
serum creatinine estimation
Ø If parenteral treatment is required and IV
treatment is not possible, intramuscular treatment should be considered.
ØAsymptomatic bacteriuria in infants and
children should not be treated with
antibiotics.
ØLaboratories should monitor resistancepatterns of urinary pathogens and make
this information routinely available to
prescribers.
Imaging tests for assessing UTI:
1) Ultrasound à structure of UT.
2) MCUG and indirect radionuclide cystography à detection of VUR & PUV.
3) DMSA (done for 4-6mo after APN) àdetection of renal parenchymal defects or scarring .
4) DTPA and MAG3 for split function of the kidneys , renal scarring and obstruction
indication of Imaging
Renal U/S :all children following febrile UTI
VCUG : recommended in 1- Significant abnormalities on U/S.2- Recurrent UTI
2- Patient with risk factors *.??
Risk factors *
Abnormal prenatal US of the urinary tractFamily history of VUR.Septicemia.Renal failure.Age <6 months in a male infantNo clinical response to correct antibiotic treatment within 48-72 hr.Non-E. coli infection
DMSA scan ( late ), considered in : n Atypical / reccurent UTIn High grade VUR on VCUG .n
Imaging studies
First febrile UTI ↓
Ultrasound (RBUS)
Decide accordingly
DMSA
Follow up
&
Referral
Follow up &
Referral
Good response to tttNo U/S Abnormalities
No routine Follow Up
Abnormal Imaging Recurrent UTI
Pediatric specialist
Severe illness Impaired kidney functionHTNProteinuria Bil. Renal abnormalities
Pediatric Nephrologist
qIf any indicated investigation is
not available, refer the patient
immediately
qAsymptomatic bacteriuria with
normal UT is not an indication
for regular follow-up.
Urological consultation
Renal anomalies
Obstruction
Voiding dysfunction
Antibiotic prophylaxis :
Prophylactic TTT can be considered in :
1- Recurrent UTI 2- High grade VUR (IV-V)…..?3- Immunocompromised children
ReferencesMost recent guidelines for management and
imaging studies of UTI (2015 – 2018)nNational Institute of Clinical Excellence (NICE, 2017).nAmerican Academy of Pediatrics (AAP updated).nAmerican Academy of Family Physicians nNorth California GLs of ped. UTI (2018)nCanadian Pediatric Society GLs (2017).nAustralian College of Pediatricians (2016).nRoyal cornwall hospitals : NHS-trust (2017).nClin. Ped. Nephr. (2017).nItalian Society of Ped. Nephr. (ISPN 2016).nEur. Society of Ped. Urology (ESPU 2015)
MCQ
A- Which one of the following manifestations can differentiate between upper and lower UTI:
1- frequency of micturation2- Abdominal pain3- Marked crying4- Fever
B- During routine screening of a healthy preschool boy, klebsiellabacteruria was found and no other findings. Wich one of the following therapy is recommended for TTT:
1- Amoxicilline2- Cefexime3- cefotaxime4- No TTT
C- VCUG is considered in the following conditions except:
1- Recurrent UTI2- U/S showing HU and HN3- Renal scarring detected by DMSA
scan4- Perinephric abscess