Medical Management of childhood UTI and VUR. Dr Patrina HY Caldwell Paediatric Continence Education, CFA 15 th November 2013

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1 Medical Management of childhood UTI and VUR Dr Patrina HY Caldwell Paediatric Continence Education, CFA 15 th November 2013

2 Terminology According to the current ICCS terminology guidelines Bladder and bowel dysfunction = combined bladder and bowel disturbance that encompasses lower urinary tract and bowel function. Dysfunctional voiding = habitually contracts the urethral sphincter during voiding UTI = urinary tract infection VUR = vesicoureteric reflux

3 UTIs Background UTIs are common in children 1/10 girls and 1/30 boys will have a UTI by 16 More common in boys in first year More common in girls after the first year Commonly caused by E coli (80%) Other organisms urinary tract anomalies, younger age, previous antibiotics

4 Risk for UTI Females (2-4X) Shaikh 2008 Ethnicity (white 2-4x) Shaikh 2008 Genetic factors Anatomical obstruction (70% present with UTI in first 2 months of life) Ring 1988 Functional obstruction (bladder and bowel dysfunction, neurogenic bladder)

5 Risk for Recurrent UTIs 10-30% will develop a further UTI Risk factors: <6/12 at first UTI Bladder and bowel dysfunction Renal damage at first UTI (DMSA defect) VUR Previous UTIs Female Bacterial virulence and host susceptibility Panaretto 1999

7 Typical UTIs Pyelonephritis/upper tract infection: Bacteriuria + fever >38 C Bacteriuria + any fever + loin pain 14% acute pyelonephritis had urinary tract abnormalities vs 3% with lower tract or asymptomatic bacteriuria (Pylkkanen 1981) Cystitis/ lower tract infection Bacteriuria + urgency, frequency, incontinence, dysuria Asymptomatic bacteriuria Bacteriuria + no symptoms

8 Atypical UTIs Seriously ill Poor urine flow Abdominal or bladder mass Raised creatinine Septicaemia Poor treatment response within 48/24 Non- E Coli infection Nice Guidelines on UTI in children

9 Recommended Tests Urine microscopy and culture Urinalysis (CRP, procalcitonin) Ultrasound infants < 6 months and those with atypical or recurrent UTIs DMSA atypical or recurrent UTI (Do not need MCUG) Nice Guidelines on UTI in children

10 Urine collection Clean catch urine Urine collection pads Suprapubic aspirate Catheter urine (Bag urine 50% contaminated Al-Orifi 2000)

11 Urinalysis leukocyte esterase and nitrites helpful Combination more helpful Less reliable in children 2 years

12 Antibiotics Acute management Parenteral AB for those <3 months Pyelonephritis oral AB for 7-10 days (or IV followed by oral AB) Cystitis oral AB for 3 days Do NOT treat asymptomatic bacteriuria If on prophylactic AB, use different AB Nice Guidelines on UTI in children

13 Long term management Recurrent pyelonephritis associated with renal scarring (5%) Wennerstrom 2000 Aim of long term management reduce risk for further UTI and renal damage Address inappropriate voiding patterns, dysfunctional voiding bowel management Encourage adequate fluid intake Access clean toilet, don t delay voiding (Antibiotic prophylaxis not routinely recommended) Nice Guidelines on UTI in children For recurrent UTI antibiotic prophylaxis may reduce risk (need to treat 14 children to prevent 1 UTI) Craig 2009 Circumcision also reduce risk (need 111 circumcisions to prevent 1 UTI) Singh-Grewal 2005

14 VUR: abnormal movement of urine from the bladder into the ureters or kidneys

15 Background VUR may be: primary (congenital) secondary (caused by UTI, obstruction, bladder and bowel dysfunction) Can be familial in 43% of infants of mothers with VUR 1/3 children with VUR have sibling with VUR North 2000 Found in 17-37% of prenatal U/S 11% boys and 8% girls have dilating VUR About ½ had bilateral VUR

16 Grades of VUR 5 grades of VUR (III to V = dilating) Spontaneous resolution or improvement in 31-84%, particularly for unilateral or low grade VUR

17 Treatment for VUR Usually not necessary Surgery vs Surgery + long term antibiotics vs Long term antibiotics alone vs Endoscope (deflux) (Hodson et al Cochrane 2007) Risk of UTI no different between medical and surgical group Combined Rx resulted in 50% reduction in febrile UTI, but no reduction in risk of renal damage 2 studies no difference between AB and no Rx

19 Relationship between VUR and UTI VUR most common abnormality in children with UTI (in 30% under 2 years) Associated with recurrent UTI (41% recurrent UTI vs 27% first time UTI) Panaretto 1999 Risk highest with bilateral VUR and high grades VUR Children with VUR and UTI more likely to have febrile UTI Smellie 1981 Parenchymal damage more common bilateral, dilating VUR

20 Dysfunctional voiding, UTI and VUR Does dysfunction voiding cause secondary VUR which may result in UTI? Of girls with dysfunctional voiding 67% developed UTI and 20% had VUR In those with dysfunctional voiding and VUR, ½ had constipation, ½ had bladder instability or infrequent voiding Dysfunctional voiding associated with increased time to resolution or nonresolution of VUR Koff 1998, Snodgrass 1991

21 Conclusion Bladder and bowel dysfunction can cause secondary VUR which increase the risk of UTI in children Recurrent pyelonephritis predispose children to permanent renal scarring, hypertension, impaired renal function and end stage renal disease This risk can be reduced by: Appropriate diagnosis and management of UTIs Treat dysfunctional voiding by addressing constipation, voiding posture and encourage regular timed voiding

22 References Craig JC, Simpson JM, Williams GJ, Lowe A, Reynolds GJ, McTaggart SJ, Hodson EM, Carapetis JR, Cranswick NE, Smith G, Irwig LM, Caldwell PH, Hamilton S, Roy LP, Prevention of Recurrent Urinary Tract Infection in Children with Vesicoureteric Reflux and Normal Renal Tracts (PRIVENT) Investigators. Antibiotic prophylaxis and recurrent urinary tract infection in children. N Engl J Med. 2009;361(18):1748 Koff SA, Wagner TT and Jayanthi VR. The relationship among dysfunctional elimination syndromes, primary vesicoureteral reflux and urinary tract infections in children. Journal of Urology 1998;160(3 Pt 2): National Collaborating Centre for Women's and Children's Health. Urinary Tract Infection in Children: Diagnosis, Treatment and Long-term Management. National Institute for Health and Clinical Excellence Clinical Guideline. London, United Kingdom: RCOG Press; 2007 North RA, Taylor RS and Gunn TR. Pregnancy outcome in women with reflux nephropathy and the inheritance of vesico-ureteric reflux. Australian & New Zealand Journal of Obstetrics & Gynaecology. 2000;40(3):280 5 Panaretto KS, Craig JC, Knight JF, et al. Risk factors for recurrent urinary tract infection in preschool children. Journal of Paediatrics and Child Health 1999;35(5): Pylkkanen J, Vilska J and Koskimies O. The value of level diagnosis of childhood urinary tract infection in predicting renal injury. Acta Paediatrica Scandinavica 1981;70(6): Ring E and Zobel G. Urinary infection and malformations of urinary tract in infancy. Archives of Disease in Childhood.1988;63(7): Shaikh N, Morone NE, Bost JE, Farrell MH. Prevalence of urinary tract infection in childhood: a meta-analysis.pediatr Infect Dis J. 2008;27(4):302. Smellie JM, Normand IC and Katz G. Children with urinary infection: a comparison of those with and those without vesicoureteric reflux. Kidney International 1981;20(6): Snodgrass W. Relationship of voiding dysfunction to urinary tract infection and vesicoureteral reflux in children. Urology 1991;38(4): Wennerström M, Hansson S, Jodal U, Stokland E. Primary and acquired renal scarring in boys and girls with urinary tract infection. J Pediatr. 2000;136(1):30.

Why is the management of UTI so controversial? Kjell Tullus Consultant Paediatric Nephrologist

Why is the management of UTI so controversial? Kjell Tullus Consultant Paediatric Nephrologist Diagnosing a UTI More difficult then most people realise Contaminating culture Bacterial numbers Confusion