UWE Bristol. UTI in Children. Angie Green Visiting Lecturer March 2011

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1 UWE Bristol UTI in Children Angie Green Visiting Lecturer March 2011

2 Approx 2% children will develop acute febrile UTI Up to 10% girls will develop any kind of UTI Progressive scarring in children with recurrent UTI and VUR Scarring associated with hypertension, complications in pregnancy, renal failure Most renal scarring will occur in the first 6 years of life Most common reason for renal transplant in adults is renal scarring from undiagnosed and untreated recurrent UTI s in childhood

3 Lack of professional awareness re sequeliae Practical difficulties in obtaining appropriate urine specimen

4 Signs and Symptoms Infants < 3 months Fever Vomiting Lethargy Irritability Poor feeding Failure to thrive Infants and children > 3 months - preverbal Fever Abdo pain Vomiting Loin tenderness Poor feeding Abdo pain Jaundice Haematuria Offensive urine Lethargy Irritability Haematuria Offensive urine Failure to thrive

5 Verbal Frequency Dysuria Dysfunctional voiding Changes to continence Abdo pain Loin tenderness NICE (2007) Test urine sample in infants and children with an alternative site of infection but who remain unwell after hrs Fever Malaise Vomiting Haematuria Offensive urine Cloudy urine

Case study 1 An 8 week old baby boy is brought in by his parents - PMH 2 nd baby born at 41/40 No resuscitation at birth w ell since delivery No family history of renal disease / UTI Now 24 hr

6 Case study 1 An 8 week old baby boy is brought in by his parents - PMH 2 nd baby born at 41/40 No resuscitation at birth w ell since delivery No family history of renal disease / UTI Now 24 hr history of- Temp of 38.7, decreases to 38.2 with paracetamol, Mild tachycardia and tachypnoea Usually placid baby - irritable Ears, throat, chest NAD, no rash Method of urine collection? Urine tested? Management?

7 Case Study 2 An 18 month old female child attends with mum PMH Previous AOM nil else of note Now Unwell for 36 hrs Pyrexia of 38.2 degrees Not eating/drinking as much as usual Mild tachycardia No increased WOB or respiratory symptoms Throat NAD O/E- bulging tympanic membrane Do you test urine? Method? Resultnitrite negative leukocyte positive Treatment? Further Investigations?

Case Study 3 A 4 year old girl attends with mum PMH 2 previous known lower UTI s Now 1 day history of frequency, dysuria and abdominal pain Mild tachycardia, nil

8 Case Study 3 A 4 year old girl attends with mum PMH 2 previous known lower UTI s Now 1 day history of frequency, dysuria and abdominal pain Mild tachycardia, nil else of note Urine dip stix nitrite and leucocyte positive Any specific questions you would ask? Treatment? Urine for culture? Follow up/imaging? Classification of UTI?

9 History and Examination on confirmed UTI Poor urine flow Hx suggesting previous UTI Confirmed previous UTI Recurrent fever of unknown cause Antenatal diagnosed renal abnormality Family Hx of VUR or renal disease Lumbo-sacral abnormality Dysfunctional voiding Enlarged bladder Constipation Poor growth Abdominal mass High blood pressure

10 Voiding Dysfunction Up to 40% of paediatric Urology OPD visits Differentiate abnormal urological abnormality from benign conditions Daytime urinary control from approx age 4yrs Daytime wetting considered a problem in developmentally normal children aged 4 years or older who are wet several days each week and in previously continent children who develop daytime wetting.

11 Voiding Dysfunction Voiding symptoms (eg, urgency, frequency, incontinence) may be transient, intermittent, or persistent Transient voiding symptoms may occur as result of UTI, non specific urethritis, vaginitis Overactive bladder Main symptom of OAB is urgency May use posturing manoeuvres to prevent incontinence Retraining programme prior to pharmacological treatment

Daytime wetting Intense concentration of young children Giggling incontinence - normally age 5-7yrs Vaginal reflux of urine from voiding in a knees-closed position can cause dampness when the

12 Daytime wetting Intense concentration of young children Giggling incontinence - normally age 5-7yrs Vaginal reflux of urine from voiding in a knees-closed position can cause dampness when the child assumes an upright posture after voiding or post void dribbling. Daytime wetting in a previously continent child prompts the clinician to consider the possibility of sexual abuse or other trauma.

Vesicoureteral Reflux Primary- congenital, usually diagnosed antenatal USS Secondary- often caused by UTI, urinary tract abnormality or Daily low dose

13 Vesicoureteral Reflux Primary- congenital, usually diagnosed antenatal USS Secondary- often caused by UTI, urinary tract abnormality or Daily low dose appropriate antibiotics Surgical correction Follow-up obstruction Kidney damage highest in 1 st six years of life Familial tendency Treatment of underlying problem

Case study 4 4 year old female attends with mum- PMH Normally well nil of note Now Diagnosed UTI- treated with trimethoprim ( 3 rd day of course) Abdo pain, loin

15 Case study 4 4 year old female attends with mum- PMH Normally well nil of note Now Diagnosed UTI- treated with trimethoprim ( 3 rd day of course) Abdo pain, loin pain, lethargic Temp 37.7, P 100, all other observations within normal limits Urine- nitrite positive, leukocyte negative Treatment? Referral? Classification? Imaging?

16 Classifications Atypical UTI Seriously ill Poor urine flow Abdo or bladder mass Raised creatinine Sepsis Failure to respond to treatment with suitable atbx within 48 hrs Infection with non E coli organisms Recurrent UTI two or more episodes of UTI with acute pyelonephritis/upper urinary tract infection, or one episode of UTI with acute pyelonephritis/upper urinary tract infection plus one or more episode of UTI with cystitis/lower urinary tract infection, or three or more episodes of UTI with cystitis/lower urinary tract infection.

17 Imaging Micturating cystourethrogram (MCUG) The micturating cystourethrogram is the most common test used in the UK for the detection of vesicoureteric reflux (VUR) in children. It also provides good anatomic detail of the bladder and urethra. Radiographic contrast medium is instilled into the bladder through a urethral catheter and X-ray images are taken showing the bladder, urethra and any VUR present. Estimated radiation dose for a 1-year-old infant is equivalent to about 4 months of natural background radiation.

18 Imaging Dimercaptosuccinic acid (DMSA) scintigraphy DMSA scintigraphy is a radionuclide scan of the kidneys utilising dimercaptosuccinic acid. It is used to identify renal defects, some of which are due to chronic scarring IV injenction DMSA binds to the kidneys and emmits gamma rays that are detected by a camera Uptake of DMSA by each kidney can be compared to give an estimate of the relative function The radiation dose incurred is equivalent to 4 months of natural background radiation (40-50 CXR s).

19 Case Study 5 7 yr old female child AOM Routine urine- Urine dipstick positive to blood

20 References Cooper, S (2008) Voiding Dysfunction Grose, C (2008) DMSA renal Scans and the Top-Down approach to Urinary Tract Infection The Pediatric Infectious Disease Journal 27, 5 pp Keren, R (2007) Imaging and treatment strategies for children after first urinary tract infection Current opinion in Pediatrics 19 pp NICE (2007) Urinary tract infection in children diagnosis, treatment and long term management (available online )

21 References Owen et al (2003) Parent s opinions on the diagnosis of children under 2 years of age with urinary tract infection Family Practice 20, 5 pp Vaillancourt et al (2007) to clean or not to clean: effect on contamination rates in midstream urine collections in toilet trained children Pediatrics 119, 6 pp Wald, E (2004) Urinary Tract infections in infants and children: a comprehensive overview Current Opinions in Paediatrics 16 pp Zamir et al (2004) urinary tract infection: is there a need for routine renal ultrasonography? Archives of Disease in Childhood 89 pp

Clinical guideline Published: 22 August 2007 nice.org.uk/guidance/cg54

Urinary tract infection in under 16s: diagnosis and management Clinical guideline Published: 22 August 2007 nice.org.uk/guidance/cg54 NICE 2017. All rights reserved. Subject to Notice of rights (https://www.nice.org.uk/terms-and-conditions#notice-ofrights).