Pediatric Urinary Pediatric Urinary Tract InfectionsTract Infections

Dr.Fahad Gadi, MDDr.Fahad Gadi, MDPediatrics DemonstratorPediatrics Demonstrator

King Abdulaziz UniversityKing Abdulaziz UniversityRabigh Medical SchoolRabigh Medical School

ObjectivesObjectives

Define Urinary Tract Infection (UTI)Define Urinary Tract Infection (UTI) List antibiotic treatment options for List antibiotic treatment options for

UTIUTI List the workup after a first febrile List the workup after a first febrile

UTIUTI Be familiar with the rationale for Be familiar with the rationale for

using prophylactic antibiotics after using prophylactic antibiotics after the first febrile UTIthe first febrile UTI

Pediatric UTIs and EBMPediatric UTIs and EBM

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

Of febrile neonates, up to 7% have UTIs.Of febrile neonates, up to 7% have UTIs. (See Fever without a source guidelines)(See Fever without a source guidelines)

Most UTIs in children are from Most UTIs in children are from ascending bacteriaascending bacteria E. coli (60-80%), Proteus, Klebsiella, E. coli (60-80%), Proteus, Klebsiella,

Enterococcus, and coag. neg. staph.Enterococcus, and coag. neg. staph.

EpidemiologyEpidemiology

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

Caucasian children had a two- to fourfold Caucasian children had a two- to fourfold higher prevalence of UTI as compared to higher prevalence of UTI as compared to African-American children African-American children

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

Caucasian females with a temperature of 39 Caucasian females with a temperature of 39 ºC have a UTI prevalence of 16 percentºC have a UTI prevalence of 16 percent

Approximate probability of urinary tract infection Approximate probability of urinary tract infection in febrile infants and young children by in febrile infants and young children by

demographic group demographic group

Demographic groupPrevalence (pretest probability)

Odds

Circumcised boys >1 yr <1 percent .01 (1 in 100)

Circumcised boys <1 yr 2 percent .02 (1 in 50)

Black girls 4 percent .04 (1 in 25)

Uncircumcised boys <2 yr

8 percent .09 (1 in 12)

White girls <2 yr 16 percent .19 (1 in 5)

Definition of UTI on Definition of UTI on cultureculture

Method of urine collection Diagnostic threshold

Clean-catch in voiding girls 100,000 CFU per mL10,000 – 100,000 repeat culture

Clean-catch in voiding boys 10,000 CFU per mL

Catheter 10,000 CFU1,000 – 10,000 repeat culture

Suprapubic aspiration Any colonies of GNRsMore than a few thousand GPCs

SymptomsSymptoms

Classic UTI symptoms in older Classic UTI symptoms in older childrenchildren Dysuria, frequency, urgency, small-Dysuria, frequency, urgency, small-

volume voids, lower abdominal pain.volume voids, lower abdominal pain. Infants with UTIs have nonspecific Infants with UTIs have nonspecific

symptomssymptoms Fever, irritability, vomiting, poor Fever, irritability, vomiting, poor

appetiteappetite

Neonatal hematuria?Neonatal hematuria?

Nope, it’s uric acid Nope, it’s uric acid crystalscrystals

EvaluationEvaluation

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

In children with a low likelihood, a In children with a low likelihood, a negative dipstick in a clear urine negative dipstick in a clear urine reduces the need for culture.reduces the need for culture.

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

The dipstick is not sufficient to diagnose The dipstick is not sufficient to diagnose UTI’s because false positives can occur.UTI’s because false positives can occur.

Urine dipsticksUrine dipsticks

In a cohort study with an 18% In a cohort study with an 18% baseline prevalence of UTI, negative baseline prevalence of UTI, negative LE and nitrates on dipstick had a LE and nitrates on dipstick had a negative predictive value of 96%.negative predictive value of 96%.

NPV = NPV = True negativeTrue negative

__________________________________

True negative + false negativeTrue negative + false negative

Leukocyte Esterase and Leukocyte Esterase and NitritesNitrites

LE is produced from the breakdown of LE is produced from the breakdown of leukocytes. Not always indicative of leukocytes. Not always indicative of infectioninfection Vaginitis/vulvitis can lead to inflammation Vaginitis/vulvitis can lead to inflammation

without infection without infection + LE + LE Nitrites are produced by bacteria that Nitrites are produced by bacteria that

metabolize nitrates: E. coli, Klebsiella, metabolize nitrates: E. coli, Klebsiella, Proteus (GNRs)Proteus (GNRs) Much more predictive of UTIMuch more predictive of UTI GPCs do not produce nitritesGPCs do not produce nitrites

Blood culturesBlood cultures

Blood cultures are generally Blood cultures are generally unnecessary in most children with UTI.unnecessary in most children with UTI.

They are more frequently positive in They are more frequently positive in children younger than two months children younger than two months whose urine grows Group B strep or whose urine grows Group B strep or Staph. Aureus.Staph. Aureus.

In general, we’ll send febrile children In general, we’ll send febrile children less than two months old to the ER for less than two months old to the ER for emergent evaluation/labs.emergent evaluation/labs.

Treatment of UTIsTreatment of UTIs The efficacy of oral regimens is as The efficacy of oral regimens is as

effective as parenteral regimens - effective as parenteral regimens - this is great news for outpatient this is great news for outpatient therapy therapy

If the child is not responding the If the child is not responding the empiric treatment within two days empiric treatment within two days while awaiting culture results, while awaiting culture results, repeat the urine culture and perform repeat the urine culture and perform a renal ultrasound.a renal ultrasound.

Antibiotic ChoicesAntibiotic Choices

Trimethoprim-sulfamethoxizole is a good Trimethoprim-sulfamethoxizole is a good choice after two months of lifechoice after two months of life

Other choices:Other choices: Amoxicillin – some resistance with E. coliAmoxicillin – some resistance with E. coli Cephalosporins: cefixime (Suprax), Cephalosporins: cefixime (Suprax),

cefpodoxime (Vantin), cefprozil (Cefzil), cefpodoxime (Vantin), cefprozil (Cefzil), loracarbef (Lorabid)loracarbef (Lorabid) No cephalosporins cover enterococcusNo cephalosporins cover enterococcus

Treat for 7-14 days. One day course not Treat for 7-14 days. One day course not effective.effective.

Further testing/work-upFurther testing/work-up

After the UTI resolves, what type of After the UTI resolves, what type of workup should ensue?workup should ensue?

Vesicoureteral Reflux Vesicoureteral Reflux and Treatmentand Treatment

Approximately 40% of children with febrile Approximately 40% of children with febrile UTIs have VUR.UTIs have VUR.

Approximately 8% of children with febrile Approximately 8% of children with febrile UTIs demonstrate renal scarring when UTIs demonstrate renal scarring when studied.studied.

Treatment recommendations are made to stop Treatment recommendations are made to stop the progression of VUR with the progression of VUR with medications/antibiotics and/or surgery.medications/antibiotics and/or surgery.

No data/EBM demonstrate that treatment of No data/EBM demonstrate that treatment of VUR prevents renal scarring, hypertension VUR prevents renal scarring, hypertension and CKDand CKD

Antibiotic prophylaxisAntibiotic prophylaxis

Children with VUR are treated Children with VUR are treated prophylactically with antibiotics to prophylactically with antibiotics to prevent potential renal scarring.prevent potential renal scarring. Nitrofurantoin or trimethoprim-Nitrofurantoin or trimethoprim-

sulfamethoxizolesulfamethoxizole Half the standard dose administered at Half the standard dose administered at

bedtimebedtime Family physicians would generally have Family physicians would generally have

a pediatric urologist involved to assist a pediatric urologist involved to assist in making treatment decisions.in making treatment decisions.

How long to continue How long to continue Abx?Abx?

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

Accordingly, some experts recommend Accordingly, some experts recommend cessation of prophylaxis after age 5 to 7 years, cessation of prophylaxis after age 5 to 7 years, even if low-grade VUR persists. even if low-grade VUR persists.

In one study of 51 low-risk (no voiding In one study of 51 low-risk (no voiding abnormalities or renal scarring) older children abnormalities or renal scarring) older children (mean age 8.6 years) with grades I to IV VUR, (mean age 8.6 years) with grades I to IV VUR, cessation of prophylactic antibiotics resulted cessation of prophylactic antibiotics resulted in no new renal scarring on annual DMSA in no new renal scarring on annual DMSA

Indications to order Indications to order radiologic studiesradiologic studies

Children younger than 5 years of age Children younger than 5 years of age with a febrile UTI with a febrile UTI

Girls younger than 3 years of age with Girls younger than 3 years of age with a first UTI a first UTI

Males of any age with a first UTI Males of any age with a first UTI (PUV)(PUV)

Children with recurrent UTI Children with recurrent UTI Children with UTI who do not respond Children with UTI who do not respond

promptly to therapypromptly to therapy

Studies to considerStudies to consider

Renal UltrasoundRenal Ultrasound Will evaluate for perinephric abscess in Will evaluate for perinephric abscess in

patients not responding to antibiotics.patients not responding to antibiotics. Can evaluate for hydronephrosis/hydroureterCan evaluate for hydronephrosis/hydroureter Of note, dilation of the kidneys and ureters Of note, dilation of the kidneys and ureters

can easily be seen on routine anatomy scans can easily be seen on routine anatomy scans during pregnancy. during pregnancy.

Picking up vesicoureteral reflux while Picking up vesicoureteral reflux while asymptomaticasymptomatic

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

HydronephrosisHydronephrosis

Male with the findings Male with the findings below.below.Cause?Cause?

Studies to considerStudies to consider

Voiding cystourethrogram – two Voiding cystourethrogram – two techniquestechniques One involves fluoroscopic contrast – One involves fluoroscopic contrast –

more radiation but better delineation of more radiation but better delineation of anatomy for grading VURanatomy for grading VUR

The other uses a radionuclide – less The other uses a radionuclide – less radiation and more sensitive than radiation and more sensitive than contrastcontrast

Normal VCUGNormal VCUG

Vesicoureteral reflux Vesicoureteral reflux (VUR)(VUR)

MegaureterMegaureter

Studies to considerStudies to consider

Renal scintigraphy using Renal scintigraphy using dimercaptosuccinic acid (DMSA)dimercaptosuccinic acid (DMSA) Can detect scarring in the kidneys.Can detect scarring in the kidneys. Renal cells take up the tracer.Renal cells take up the tracer. Those cells damaged by pyelonephritis or Those cells damaged by pyelonephritis or

scarring do not take up the tracer. scarring do not take up the tracer. Management or followup of patients does Management or followup of patients does

not change in most cases.not change in most cases. Thus, not generally used for initial Thus, not generally used for initial

evaluation.evaluation.

Scar in the Scar in the superior superior

and and inferior inferior

pole of the pole of the right right

kidneykidney

MythsMyths

Bathing in bubble baths causes UTIsBathing in bubble baths causes UTIs Wiping back-to-front causes UTIsWiping back-to-front causes UTIs Cranberry juice helps UTIs – only Cranberry juice helps UTIs – only

proven to be of minimal benefit in proven to be of minimal benefit in adult women. No proven benefit to adult women. No proven benefit to childrenchildren

VUR TreatmentVUR Treatment Children 6 years or older with unilateral grade III to IV Children 6 years or older with unilateral grade III to IV

reflux without renal scarring can be treated medically. If reflux without renal scarring can be treated medically. If the reflux is bilateral and/or there is renal scarring, the reflux is bilateral and/or there is renal scarring, surgical treatment is recommended. surgical treatment is recommended.

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

Surgery also should be considered if medical therapy Surgery also should be considered if medical therapy fails either because of poor compliance, breakthrough fails either because of poor compliance, breakthrough infections on account of antibiotic resistance, or infections on account of antibiotic resistance, or significant antibiotic side effects. Finally, consideration significant antibiotic side effects. Finally, consideration of patient and parent preference is important in the final of patient and parent preference is important in the final decision.decision.

ObjectivesObjectives Define Urinary Tract Infection (UTI)Define Urinary Tract Infection (UTI)

>100,000 CFU in clean catch girls>100,000 CFU in clean catch girls >10,000 CFU clean catch guys>10,000 CFU clean catch guys >10,000 catheter specimen>10,000 catheter specimen

List antibiotic treatment options for UTIList antibiotic treatment options for UTI Amoxicillin, Bactrim, CephalosporinsAmoxicillin, Bactrim, Cephalosporins

List the workup after a first febrile UTIList the workup after a first febrile UTI Consider renal U/S and VCUGConsider renal U/S and VCUG

Be familiar with the rationale for using prophylactic Be familiar with the rationale for using prophylactic antibiotics after the first febrile UTIantibiotics after the first febrile UTI Prevent renal complications/scarring/pyelonephritisPrevent renal complications/scarring/pyelonephritis