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Urinary tract infection: old concepts and new concepts

Urinary tract infection: old concepts and new concepts. NCKU medical center Department of Pediatric, division of nephrology Yuan-Yow Chiou. Urinary Tract Infection Epidemiology: Measurement Concerns. Incidence of Urinary Tract Infection Among Children. Am J Med. 2002;113(1A):5S–13S.

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Urinary tract infection: old concepts and new concepts

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  1. Urinary tract infection: old concepts and new concepts NCKU medical center Department of Pediatric, division of nephrology Yuan-Yow Chiou

  2. Urinary Tract Infection Epidemiology: Measurement Concerns

  3. Incidence of Urinary Tract Infection Among Children Am J Med. 2002;113(1A):5S–13S.

  4. Urinary Tract Infection in Pediatric Patients Am J Med. 2002;113(1A):55S–66S.

  5. Recurrence and follow-up after UTI under age of 1year Pediatr Nephrol (2001) :69-72

  6. Recurrence and follow-up after UTI under age of 1year Pediatr Nephrol (2001) :69-72

  7. Sequence of recurrent UTI in Pediatric Girls Am J Med. 2002;113(1A):55S–66S.

  8. Financial Implications of Urinary Tract Infection (UTI) Am J Med. 2002;113(1A):5S–13S.

  9. The approach to the diagnosis and management of Pediatric UTI • Age: neonate~3m/o: catheterized urinalysis or bladder aspiration is part of the standard work-up for fever Age:2 to 3 m/o~2 to 3 y/o: urine culture with a fever greater than 39C Older children: may be less complicated Children on prophylactic antibiotics for reflux or with a history of reflux should have a urinalysis and culture checked with each febrile episode.

  10. Diagnosis of Pediatric UTI Am J Med. 2002;113(1A):55S–66S.

  11. Inherited or Acquired Host Susceptibility Factors Am J Med. 2002;113(1A):14S–19S.

  12. APN, VUR, and severity of reflux during acute phase of first febrile UTI in three Age groups Group I: 1y/o; Group II: 1-5 y/o; Group III: 5y/o Pediatr Nephrol (2003) 18:362–365

  13. The Foreskin and Urinary Tract Infections • Wiswell and associates: • The incidence of UTI in uncircumcised males (≦6m/o) was 1 to 4 percent. • The incidence in circumcised males was 0.1 to 0.2 percent. • Routine circumcision or selective circumcision? Pediatrics 1985;75:901-3. Pediatrics 1989;83:1011-5. Pediatrics 1986;78:96-9. Clin Pediatr [Phila] 1993;32:130-4.

  14. Etiology of Uncomplicated Versus Complicated UTI Adult women Am J Med. 2002;113(1A):14S–19S.

  15. Asymptomatic bacteriuria • Def: growth of bacteria in culture without symptoms of infection or abnormalities on urinalysis. • Tx: • Unnecessary – except…. • Neonate and perhaps in children with known urologic abnormalities.

  16. Pathogenesis of UTI • The sequence of events in the untreated animal leads to a loss of approximately 20% of total renal function, with the damage all having begun within 24 h of renal inoculation but continuing for 1-2 weeks after infection. J. Urol. (1989) 143:150-154

  17. Pathogenesis of UTI colonization Ascending infection inflammation Tissue ischemia and reperfusion Reanl parenchymal damage

  18. Inflammation process

  19. Ischemia and reperfusion

  20. Complicating that diagnosis of upper tract infection is the fact that there is no gold standard test for pyelonephritis. Fever as a marker for upper tract infection: sensitivities (53-84%) and specificities (44- 92%). Antibody-coated bacteria, and renal nuclear scanning have been used as indicators of PAN. However, the utility of these tests is still limited.

  21. a.DMSA renal scan in a 3-year-old girl with an acute febrile UTI (arrowhead). b Followup DMSA renal scan 2 years later (arrowhead). Typical findings of APN are demonstrated by this DMSA renal scan from a 10-month-old boy with a febrile UTI.

  22. Role of Technetium 99m-dimercaptosuccinic acid (DMSA) scintigraphyin children • The imaging agent of choice for the detection and evaluation of acute pyelonephritis and renal cortical scarring. Confirmed the primary role of the acute inflammatory response, associated with both reflux and nonreflux pyelonephritis, in the etiology of irreversible renal scarring.

  23. Dimercaptosuccinic acid (DMSA) renal scan findings in different age groups positive negative Pediatr Nephrol (2002) 17:30–34

  24. APN, VUR, and severity of reflux during acute phase of first febrile UTI in three Age groups Group I: 1y/o; Group II: 1-5 y/o; Group III: 5y/o Pediatr Nephrol (2003) 18:362–365

  25. Association of APN with VUR, severity of reflux, and renal scar in all three groups Pediatr Nephrol (2003) 18:362–365

  26. APN or scar formation according to presence of low grade or absence of VUR Pediatr Nephrol (2003) 18:362–365

  27. Relationship of inflammatory volume and renal scar (sequelae) by DMSA renal SPECT Radioactivity ratio between abnormal and normal renal tissue (L/N ratio) 45% 1.2 39%1.4 Lesion volume of the sequelae group and the nonsequelae group. 15.0 2.0ml 2.5 1.2ml Radiology. 2001; 221:366-370.

  28. Evolution of differential renal function(DRF) after APN Nuclear Medicine Communications, 2002, 23, 1005-1008

  29. How about of comparison of ultrasound and DMSA changes in APN Pediatr Nephrol (1999) 13:219–222

  30. Distribution of renal US findings in normal and positive DMSA renal scans. normal abnormal normal abnormal Renal ultrasonography (US) findings in different age groups. Pediatr Nephrol (2002) 17:30–34

  31. positive negative Distribution of vesicoureteral reflux (VUR) in different age groups No VUR Low grade VUR Distribution of VUR in children with normal and abnormal DMSA renal scans. High grade VUR Pediatr Nephrol (2002) 17:30–34

  32. Compare the result of initial US and acute DMSA in APN kidney (n=90) Compare the result of initial US and followed DMSA in previous APN kidney (n=65) Sensitivity: 49.2% Specificity:88.0% Positive predictive value:91.4% Negative predictive value:40.0% Sensitivity: 59.4% Specificity: 60.6% Positive predictive value: 59.4% Negative predictive value: 60.6%

  33. Compare the initial positive US with high CRP(>80) and acute DMSA in previous APN kidney (n=90) Compare initial positive US with high CRP and followed DMSA in previous APN kidney (n=65) P<0.005 P<0.005 Sensitivity: 33.9% Specificity:95.8% Positive predictive value:95.5% Negative predictive value:35.9% Sensitivity: 51.6% Specificity: 83.9% Positive predictive value: 76.2% Negative predictive value: 63.4%

  34. Relationship of DMSAinflammatory volume and renal US 11.0±2.4ml 3.0±0.8ml

  35. Role of Tc-99m DMSA scintigraphy in the diagnosis of culture negative pyelonephritis? ●(A prospective study) 15(9%)had negative or equivocal urine culture despite clinical and scintigraphic evidence of APN -> US: normal in 7 children VCUG: VUR in 9 children -> follow up DMSA 6 months later: 8 disappear 4 partial improvement Pediatr Nephrol (2001) 16:503–506

  36. Other factors to predict APN? • Procalcitonin as a marker of acute pyelonephritis in infants and children Pediatr Nephrol (2002) 17:409–412 Urinary interleukin-6 and interleukin-8 in children with urinary tract infection Pediatr Nephrol (2000) 15:236–240 Urinary microalbumin and β2-microglobulin Acta Paediatrica Sinica (2001) 42:84-89 DMSA positive patients have elevated urinary 1-microglobulin excretion and DMSA negative have normal level. • European Urology. (1998) 34(6):486-91

  37. Therapeutic Management of Pediatric UTI Am J Med. 2002;113(1A):55S–66S.

  38. Urinary Tract Infection Isolates: 1999 National Outpatient Data Am J Med. 2002;113(1A):29S–34S.

  39. Risk Factors for Trimethoprim-Sulfamethoxazole (TMP-SMX) Resistance Am J Med. 2002;113(1A):29S–34S.

  40. Efficacy of 7 days’ (group A) and 3 days’ (group B) IV antibiotics, both followed by an oral treatment in APN ? • When the patients were stratified according to the delay of treatment, the percentage of patients with sequelae in group A was comparable, whether the delay of treatment was less or more than 1 week. In group B, the percentage of patients with sequelae was significantly higher (P<0.01) when the delay was more than 1 week. Pediatr Nephrol (2001) 16:878–884

  41. Complication and morbidity • Immediate complications: lobar nephronia, abscess formation, urosepsis. Long-term complications of APN: renal scar formation, ESRD, and hypertension • The risk of scar formation increases with each subsequent infection. • It is estimated that 15% of ESRD in children is caused by the combination of reflux and renal scarring.

  42. Conclusion • There are important medical and financial implications associated with UTIs. The extent of kidney involvement and the presence of VUR make the possible the identification of different categories of risk of scarring

  43. Thank you for your attention! Although most physicians are not responsible for the work-up after a UTI, the physician may want to educate the parents and stress the importance of follow-up and further work-up.

  44. Prophylactic antibiotics in children at risk for UTI • Lesser grades of VUR and constipation did not significantly increase the risk of UTI. Significantly increased risk of infection among those with voiding dysfunction and VUR of grade 3 or greater severity. Pediatric nephrology (2002) 17:506-510.

  45. Incidence of Bacteriuria and Urinary Infection in 128 Patients with Spinal Cord InjuryAccording to Method of Urinary Tract Drainage • Lesser grades of VUR and constipation didn’t significantly increase the risk of UTI. The overall rate of UTI: 2.5 episodes/p’t/year J Urol. 2000;164:1285–1289.

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