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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

Urinary tract infection: old concepts and new concepts

NCKU medical center

Department of Pediatric, division of nephrology

Yuan-Yow Chiou

urinary tract infection in pediatric patients
Urinary Tract Infection in Pediatric Patients

Am J Med. 2002;113(1A):55S–66S.

sequence of recurrent uti in pediatric girls
Sequence of recurrent UTI in Pediatric Girls

Am J Med. 2002;113(1A):55S–66S.

the approach to the diagnosis and management of pediatric uti
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.

diagnosis of pediatric uti
Diagnosis of Pediatric UTI

Am J Med. 2002;113(1A):55S–66S.

inherited or acquired host susceptibility factors
Inherited or Acquired Host Susceptibility Factors

Am J Med. 2002;113(1A):14S–19S.

apn vur and severity of reflux during acute phase of first febrile uti in three age groups
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

the foreskin and urinary tract infections
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.

etiology of uncomplicated versus complicated uti
Etiology of Uncomplicated Versus Complicated UTI

Adult women

Am J Med. 2002;113(1A):14S–19S.

asymptomatic bacteriuria
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.
pathogenesis of uti
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

pathogenesis of uti1
Pathogenesis of UTI

colonization

Ascending infection

inflammation

Tissue ischemia and reperfusion

Reanl parenchymal damage

slide21

Ischemia and

reperfusion

slide22

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.

slide23

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.

role of technetium 99m dimercaptosuccinic acid dmsa scintigraphy in children
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.

dimercaptosuccinic acid dmsa renal scan findings in different age groups
Dimercaptosuccinic acid (DMSA) renal scan findings in different age groups

positive

negative

Pediatr Nephrol (2002) 17:30–34

apn vur and severity of reflux during acute phase of first febrile uti in three age groups1
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

association of apn with vur severity of reflux and renal scar in all three groups
Association of APN with VUR, severity of reflux, and renal scar in all three groups

Pediatr Nephrol (2003) 18:362–365

apn or scar formation according to presence of low grade or absence of vur
APN or scar formation according to presence of low grade or absence of VUR

Pediatr Nephrol (2003) 18:362–365

relationship of inflammatory volume and renal scar sequelae by dmsa renal spect
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.

evolution of differential renal function drf after apn
Evolution of differential renal function(DRF) after APN

Nuclear Medicine Communications, 2002, 23, 1005-1008

how about of comparison of ultrasound and dmsa changes in apn
How about of comparison of ultrasound and DMSA changes in APN

Pediatr Nephrol (1999) 13:219–222

slide32

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

slide33

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

slide34

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%

slide35

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%

slide36

Relationship of DMSAinflammatory volume

and renal US

11.0±2.4ml

3.0±0.8ml

slide37

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

other factors to predict apn
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
therapeutic management of pediatric uti
Therapeutic Management of Pediatric UTI

Am J Med. 2002;113(1A):55S–66S.

risk factors for trimethoprim sulfamethoxazole tmp smx resistance
Risk Factors for Trimethoprim-Sulfamethoxazole (TMP-SMX) Resistance

Am J Med. 2002;113(1A):29S–34S.

slide42
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

complication and morbidity
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.
conclusion
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

thank you for your attention

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.

prophylactic antibiotics in children at risk for uti
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.

slide47
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.