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Urinary tract infections in children What investigations?. Yves Heloury FRACS, Pediatric Urology. UTI- General considerations. 3 determinants in pediatrics Age Sex F ever UTI: 2 different situations Infants and young children with febrile UTI Toilet trained girls with afebrile UTI.

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Presentation Transcript
uti general considerations
UTI- General considerations
  • 3 determinants in pediatrics
    • Age
    • Sex
    • Fever
  • UTI: 2 different situations
    • Infants and young children with febrile UTI
    • Toilet trained girls with afebrile UTI

2

uti general considerations2
UTI- General considerations
  • UTI: 3 steps
    • Diagnosis of UTI
        • Pyuria > 10 WBCs per μL
        • Bacteriuria > 105 CFU per ml
    • Treatment
    • Etiology

and

4

uti general considerations3
UTI- General considerations
  • Precise diagnosis
  • Treatment of children WITH UTI
  • Limited investigations
  • Focused more on function than on anatomy
    • Kidneys +++
    • Bladder

5

uti children under 2 years
UTI- Children under 2 years
  • Guidelines AAP: Pediatrics 2011

http://pediatrics.aappublications.org/content/early/2011/08/24/peds.2011-1330

    • Infants and young children (2 to 24 months)
    • Fever > 38
    • In a child with fever and no other clinical source of infection, the risk of UTI is 5%

6

uti children under 2 years guidelines aap
UTI- Children under 2 years (Guidelines AAP)

Infant with fever

UTI 5%

Poor clinical tolerance

Good clinical tolerance

+

SPA or catheterization

Bag or Dipstick

+

-

Antibiotherapy

No UTI

7

uti guidelines aap
UTI- Guidelines AAP
  • Treatment
    • Oral antibiotherapy, except toxic child, digestive trouble
    • Duration: 7 to 14 days
    • After, no antibioprophylaxis if ultrasound normal
    • UTI in boys: discuss circumcision

9

uti guidelines aap1
UTI- Guidelines AAP

Investigations

  • Clinical examination
    • Abdomen (kidneys, bladder)
    • Genitalia
    • Sacrum

10

uti guidelines aap2
UTI- Guidelines AAP

Renal US

  • systematic except if high quality prenatal US at the third trimester
  • Why: detect dilatation ureters or pelvis; size of kidneys; renal abcess
  • When: not as emergency, except no clinical improvement after 2 days of ATB

US abnormal in 15% but action in only 2%

11

uti guidelines aap3
UTI- Guidelines AAP
  • First pyelonephritis
    • No other investigation, except dilatation of ureter and/or pelvis
  • Recurrent UTI (10%)
    • DMSA nuclear medicine
      • Scarring
      • 4 to 6 months after UTI
    • MCUG (VUR, Bladder, urethra)

12

uti in young children take home messages
UTI in young children- Take home messages
  • Diagnosis is difficult
  • First UTI: ultrasound
  • Recurrences: DMSA and MCUG
  • Early treatment decreases scarring
  • Renal alterations are for a large part related to prenatal dysplasia

13

uti in older children
UTI in older children
  • General considerations
    • Girls > 5 years
    • Cystitis with voiding disorders and/or constipation
    • Can be associated with episodes of pyelonephritis
    • Urinalysis only if pain
    • No urinalysis nor antibiotics for abnormal
      • color
      • odor

14

uti in older children1
UTI in older children
  • Clinical investigation
    • Previous history: toilet training, sexual abuse
    • Bladder function: fluid intake, dryness, diary
    • Bowell function: diet, soiling, consistency of poos
    • Abdomen, genitalia, sacrum
    • Neurological evaluation: Feet (tethered cord)

15

uti in older children2
UTI in older children
  • Paraclinic investigations
    • 1 or 2 cystitis: nothing
    • Recurrent cystitis
      • Uroflowmetry
      • Renal and bladder US
        • kidneys
        • pre and postvoiding volume
        • constipation
      • If associated pyelonephritis: DMSA nuclear medicine

16

uti in older children4
UTI in older children
  • Management
    • Bowell management: diet, fluid, movicol
    • Bladder management: urotherapy to improve bladder emptying (relaxation of pelvic floor, position on the toilets, double voiding)
    • Cranberry juice?
    • Medications
      • Antibiotics for symptomatic UTI
      • No long term antibioprophylaxis
      • Alpha blockers (bladder emptying)

18

uti in toilet trained children take home messages
UTI in toilet trained children- Take home messages
  • Cystitis mainly related to constipation and poor bladder emptying
  • Investigation and management: bowel and bladder
  • Conservative management as long as the upper urinary tract is normal
  • Management of familial anxiety

19