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A Few Salient Points About: Pediatric UTIs

A Few Salient Points About: Pediatric UTIs. Elizabeth Bogel, MD 10/18/2011. Ashlee’s febrile 5-weeker. Term boy to GBS neg mom Cc: fever x 3 days, T max 103 o rectal CSF, CXR neg UA: small leukocyte esterase, neg nitrite, 11-30 WBC, few bacteria VFA, UCx, BCx, CSF Cx sent off

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A Few Salient Points About: Pediatric UTIs

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  1. A Few Salient Points About: Pediatric UTIs Elizabeth Bogel, MD 10/18/2011

  2. Ashlee’s febrile 5-weeker • Term boy to GBS neg mom • Cc: fever x 3 days, Tmax 103o rectal • CSF, CXR neg • UA: small leukocyte esterase, neg nitrite, 11-30 WBC, few bacteria • VFA, UCx, BCx, CSF Cx sent off • Empiric CTX x 1 in ED • Hospitalist: “Change to Amp and Cefotaxime for better Enterococcus coverage”

  3. Urinalysis is helpful but can’t make the diagnosis

  4. Quick Antibiotic Slide • 80% of pediatric UTIs are E. coli • 50% of E. coli is resistant to ampicillin/amoxicillin • Growing resistance to Bactrim and 1st gen cephalosporins • Empiric treatment: 2nd or 3rd gen cephalosporin or aminoglycoside • Cover for Enterococcus (add Amox/Amp) if indwelling catheter, recent instrumentation

  5. 3Reasons We Careabout UTIs in little kids: 1) Prevent urosepsis 2) Prevent recurrence and complications 3) Make him feel better • But… how do we do it?!

  6. Prevent recurrence and complications: are we doing this? • Very few kids have long-term consequences… but some do • By scintigraphy: • 60% of febrile UTIs are pyelo • 10-40% of these develop permanent scarring. • Unilateral scarring has NO bearing on future GFR • Bilateral renal scarring decreases GFR from 94 to 84but does not increase blood pressure • Treat quickly (empirically) because once the infection ascends to the kidney (febrile) we can’t prevent scarring.

  7. Renal and Bladder Ultrasound -May find indirect evidence of obstruction or reflux: -Urinary tract dilatation -Wall thickening (bladder, pelvis) -Sensitivity for Grade III-V reflux 22-86%* Does not detect: -Low-grade reflux -Pyelonephritis -Renal scarring.

  8. Grades of vesico-ureteral reflux

  9. VCUGVoiding CystoUrethroGraphy • Sensitive! • Detects VUR in 40% of first febrile UTIs • But… • 96% of those have grades I-III which self-resolves

  10. So when should I do what? AAP Sept 1, 2011 Revision to Clinical Practice Guidelines: • Febrile infants with UTIs should undergo renal and bladder ultrasonography (RBUS) (evidence quality: C) • VCUG if: a) US shows hydronephrosis, scarring, or other findings that would suggest either high-grade VUR or obstructive uropathy (evidence quality: B) b) In other atypical or complex clinical circumstances c) In recurrenceof febrile UTI

  11. Not everyone agrees… • UpToDate suggests RUS and VCUG in: • Girls younger than three years of age with a first UTI* • Boys of any age with a first UTI • Children of any age with a febrile UTI • Children with recurrent UTI (if not done previously) • First UTI in a child of any age with a family history of renal disease, abnormal voiding pattern, poor growth, hypertension, or abnormalities of the urinary tract

  12. Ashlee’s kid follow-up • VFA, UCx, CSF Cx negative • Urine culture (cath specimen): >100,000 GNR --> E. coli • Blood Culture: -On admit: Bacillus -Repeat on day 3 of Abx: negative • “Urosepsis” • Clinical course unremarkable, afebrile • What imaging should we get?

  13. AAP Diagnosis of UTI

  14. Our Baby’s Imaging • Renal ultrasound: NORMAL • Peds ID: “Probably doesn’t have Gd 4-5 VUR… VCUG PTDC” • Peds urology: “Will need VCUG before discharge to assess for possible VUR or posterior urethral valves… If the infant has VUR, he will need antibiotic prophylaxis after this treatment course and further follow-up in my office.” • PCP: “…similar outcomes with medical therapy vs. monitoring in grade I-II VUR… Will discuss with family.”

  15. Three Things 1)Treating UTI in little kids canprevent kidney injury and dangerous urosepsis • Kids need a urine culture for diagnosis • Imaging in controversial – AAP now says: RUS before potential VCUG in first febrile UTI

  16. References American Academy of Pediatrics, Committee on Quality Improvement, Subcommittee on Urinary Tract Infection. “The diagnosis, treatment, and evaluation of the initial urinary tract infection in febrile infants and young children.” Pediatrics 1999;103:843-852[Erratum, Pediatrics 1999;103:1052, 104:118, 2000;105:141.] (The old version: first febrile UTI needs VCUG eventually) American Academy of Pediatrics, Subcommittee on Urinary Tract Infection, 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 2011 128: 595-610 (The update: first febrile UTI needs VCUG only if US suggests it or something else is weird) Brandstrom P, Esbjorner E, Herthelius M, Swerkersson S, Jodal U, Hansson S. “The Swedish reflux trial in children. III. Urinary tract infection pattern.” J Urol 2010;184:286-291 (We can prevent renal damage by imaging, finding kids with grade III-IV reflux and treating) Hoberman A, Charron M, Hickey RW, Baskin M, Kearney DH, Wald ER. “Imaging studies after a first febrile urinary tract infection in young children.” N Engl J Med 2003;348:195-202 (You should do VCUG after a first febrile UTI) Lee HY, Soh BH, Hong CH, Kim MJ, Han SW. “The efficacy of ultrasound and dimercaptosuccinic acid scan in predicting vesicoureteral reflux in children below the age of 2 years with their first febrile urinary tract infection.” Pediatr Nephrol 2009;24:2009-2013 (Ultrasound is a weak diagnostic tool) Marks SD, Gordon I, Tullus K. Imaging in childhood urinary tract infections: time to reduce investigations. Pediatr Nephrol 2008;23:9-17 . (Informed the 2011 AAP update: “Chill on the VCUGs”) Montini, Giovanni M.D., Kjell Tullus, M.D., Ph.D., and Ian Hewitt, M.B., B.S. “Febrile Urinary Tract Infections in Children” N Engl J Med 2011; 365:239-250 July 21, 2011 (Really nice summary of current arguments and evidence) National Institute for Health and Clinical Excellence. “Urinary tract infection in children: diagnosis, treatment and long-term management. 2007.” (Informed the 2011 AAP update: “Chill on the VCUGs”) Stapleton, Bruder M.D. Editorial: “Imaging Studies for Childhood Urinary Infections” N Engl J Med 2003; 348:251-252January 16, 2003 (We image too much under the unproven assumption that prophylactic antibiotics will prevent future infections and clnically important renal damage)

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