UTIs in children ( with controversies ) By Dr. Lindokuhle Mahlase

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Irma Marsh
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1 UTIs in children ( with controversies ) By Dr. Lindokuhle Mahlase

2 Epidemiology By age 7 years, 8 % of girls and 2 % of boys will have had a UTI. Most infections occur in the first 2 years of life ; boys during the first 6 months and girls thereafter.

3 Epidemiology USA Inpatient database identified that about 10 % of admissions for UTIs. Total hospital charges exceeded $ 520 million = R6.7 billion!

4 Clinical presentation Child : BOM & Frequency +/- Fever. Toddlers : Diarrhoea, vomiting, irritability, anorexia, FTT and fever. Neonates : Temperature instability, feeding intolerance, glucose instability and conjugated hyperbilirubinaemia.

5 Predisposing factors Anatomical abnormalities of the urinary tract Neurogenic/ Dysfunctional bladder Immunocompromised host Other (s): Constipation, Uncircumcised male, lack of breastfeeding & sexual intercourse

6 Facts about circ& UTI UTI is an ascending infection and circumcision reduces periurethral contamination with UTIforming organisms. Circumcision prevents UTI

7 Prophylactic Circ

8 UTI vs Circ Singh-Grewal et al concluded that the risk of complication outweighed the benefits in boys without UTI who undergo prophylactic circumcission.

9 Circumcision&UTIs in abnormal urinary tract Risk of UTI: Grade 3-5 VUR= 30% VUJ obstruction = 40 % PUJ obstruction = 14 % ( 1st year of life ) PUV= 50 %

11 No RCT published on circumcision reducing the risk of UTIs in boys with VUJ and PUJ obstruction. Circumcision and PUV : 1 large study = reduces risk by 83 % in PUV with circumcision vs control, but timing matters.

12 Diagnosis of UTI

13 Diagnosis of UTI Urine dipsticks Microscope Urine culture ( Catheter, SPU and Mid stream )

14 Urine dipsticks Leukocyte esterase: sensitivity 88%when compared with culture results False positive:- Fever, Kawasaki, vigorous exercise, SICC Negative : Asymptomatic pyuria

15 Urine dipsticks Nitrites: Conversion of nitrate to nitrites Req 4 hrs for conversion ( negative in frequent voiding) Helpful if positive

16 Microscope/Culture AAP def pyuria as > 3 WBC on HPF and > CFU Question : Can we make a presumptive diagnosis of UTI base on urine dipsticks and microscope before the culture results.

17 Collected UA of 245 infants < 3 months with Bacteraemic UTI and 115 with negative urine culture. Results: + Urine Culture correlation with positive microscope and dipsticks.( 97.6 % sensitivity ) 93.9 % specificity

18 Specimen Collection Catheter SPU < 15 months Midstream once toilet trained

19 Compared 202 episodes of cystitis in women years ( Paired MSU vs Cath specimens ) Results: 25 % of the patients who had a positive urine culture on their MSU specimen had no growth on their matched catheter specimen ( False positive )? Value of MSU

20 Consequences of UTI

21 Renal Scarring 99TC DMSA scan is the gold standard for assessing effect of UTI in the upper urinary tract. Scarring leads to reflux nephropathy: Hypertension Proteinuria Renal dysfunction ESRD

22 Risk of scarring after febrile UTI

23 Analysed 33 articles involving 4891 children with first febrile UTI. 57 % had abnormal DMSA scan ( 1.5 times more in children with VUR) 18 % had renal scars on DMSA at 5 months and 2 years repeat scan ( 2.6 times more likely with VUR)

24 Are scars assoc with VUR congenital or acquired?

25 34 infants with non obstructive VUR detected by prenatal sonar DMSA scan detected 50 % scars with grade III VUR and 75 % with IV-V VUR. Conclusion: Scarring was present despite the absence of prior infections.

26 Long-term consequences of UTI and scarring

27 Analysis of adults who had UTIs and VUR as children. 226 adults with VUR at mean age of 27 years Followed up for years Presented with prior UTI at 5 years

28 Results: 84( 27%) had renal scarring at presentation 1 Boy developed a new scar at 7 years No new scars were noted in adults after a mean follow up of 19 years

29 Conclusion: New scars DO NOT develop in late childhood or adulthood despite persistence of VUR and recurrent UTIs.

30 Investigating initial UTI

31 Investigating UTI In 1999, the AAP recommended a renal US and VCU as standard diagnostic procedure. NICE US only < for 6 months of age in uncomplicated UTI. APP 2011 ( initial febrile UTI ) US for 2-24months VCU should NOT be done as routine for first UTI VCU / MAG3 should be reserved for children with abnormal US

32 Treatment of UTI Simple cystitis ( amoxiclav ) for 10 days Uper urinary tract ( Ampicillin and Amik ) 10 days

33 Prevention of recurrence Prophylactic antibiotic for high grade VUR

34 RIVUR trial

37 Cranberry Juice Proanthocyanidins found in cranberry inhibit the adhesion of uropathogenic E. coli to uroepithelium.

38 Conclusion UTIs are more common than we think Urine dipsticks is good screening tool Exclude anatomical abnormalities on patients with established UTIs. Jury still out on antibiotic prophylaxis in children with VUR Consider in children with grossly dilated systems / PUV

Nicolette Janzen, MD Texas Children's Hospital

Which UTIs Need a VCUG? Applying AAP Guidelines Nicolette Janzen, MD Texas Children's Hospital Goals 1 2 3 4 5 Review the guidelines Present clinical scenarios Discuss VCUG and nuclear cystogram Discuss