Scott Williams, MD Pediatric Nephrology OLOL Children s Hospital September 29, 2013 Controversies in Urinary Tract Infections
Disclaimer I have no affiliations with any pharmaceutical or equipment company This talk isn t being supported by any grant or financial institution I have not taken any performance enhancing drugs I don t think I have a UTI
The Problem Newman et al, Arch Pediat Adolesc Med 2002;156:44-54 studied 3066 infants 3 months or younger with fever >38 Of the 54% tested for UTI, 10% (167 infants) were infected 17 of the infants with UTI also had bacteremia Newman et al, Arch Pediat Adolesc Med 2002;156:44-54
Incidence of UTI is substantial mean incidence was 1.0% for both boys and girls (range, 0.3%-3.0% and 0.4%-2.9%, respectively). The minimum cumulative incidence at 2 years of age was estimated to be 2.2% for boys and 2.1% for girls. (survey data) Pediatrics. 1999 Aug;104(2 Pt 1):222-6 high incidence of urinary infection, confirmed by urine culture, was found (145 (8.4%) in the 1719 girls and 32 (1.7%) in the 1834 boys) (questionnaire in Sweden) Arch Dis Child. 1991 Feb;66(2):232-4.
Case study IB is a 9month old with fever (38.3 ) for 2 days, fussiness, mildly diminished oral intake and rhinorrhea Urinalysis shows negative blood, trace protein, small leukocyte esterase
AAP evidence strengths. Pediatrics 2011;128:595-610 2011 by American Academy of Pediatrics
When Should We Test?
What does this mean? Every patient under 24 months doesn t need a urinalysis and urine culture If pneumonia or otitis media was diagnosed, then we could have effectively treated a UTI A culture must be obtained via catheter or supra-pubic aspiration The urine dip doesn t however
Clinical Practice Guidelines Action Statement 2 If decision to hold antibiotics is made, likelihood of UTI should be assessed Overall risk is 5% without taking risk factors into account Prevalence in febrile infant girls is double that of febrile infant boys Uncircumcised boys are 4-20 times more likely than circumcised boys to have UTI (biggest risk in first year) Presence of a clinically obvious source for fever reduces the likelihood of UTI by half
RSV and UTI can occur together 2004 study of 1248 kids less than 60 days old Full septic workup was done 5.4% of RSV, 10% RSV negative had UTI Pediatrics Vol. 113 No. 6 June 1, 2004 pp. 1728-1734
Clinical Practice Guidelines Action Statement 2 If decision to hold antibiotics is made, likelihood of UTI should be assessed Risk factors (girls) White race, age < 12 months, temp > 39C, fever more than 2 days, absence of another source Risk factors (boys) Uncircumcised, nonblack race, temp > 39C, fever > 24 hours, absence of another source
Pediatrics 2011;128:595-610 2011 by American Academy of Pediatrics
The most confusing Guideline ever Action Statement 2b If it is determined that a patient does not have a low risk of UTI, there are 2 options: 1. Obtain urine specimen via catheter or SPA for culture and urinalysis 2. Obtain urine specimen for urinalysis via bag and base decision to send catheter or SPA specimen for culture on those results Negative UA does not rule out UTI with certainty Patient must obtain appropriate follow-up
Case study IB is a 9month old with fever (38.3 ) for 2 days, fussiness, mildly diminished oral intake and rhinorrhea Urinalysis shows negative blood, trace protein, small leukocyte esterase Urine culture shows 10-50K colonies of gram negative rods
What qualifies as an UTI?
Which tests are helpful?
The culprits Are the organisms changing? It seems that we see more enterococcus Pennesi M, Jan 2012, Ped Nephro Pediatrics Vol. 113 No. 6 June 2004 pp. 1728-1734
How should we treat?
If tolerated oral antibiotics are adequate (1-24 months)
There was no difference in renal scarring Time to resolution of fever Treatment failures Hoberman A et al. Pediatrics 1999;104:79-86 1999 by American Academy of Pediatrics
Case study IB is a 9month old with fever (38.3 ) for 2 days, fussiness, mildly diminished oral intake and rhinorrhea Urinalysis shows negative blood, trace protein, small leukocyte esterase Urine culture shows 10-50K colonies of gram negative rods Should IB have a renal and bladder ultrasound?
Who Should get an ultrasound?
The urologists agree
Case study IB is a 9 month old with fever (38.3 ) for 2 days, fussiness, mildly diminished oral intake and rhinorrhea Urinalysis shows negative blood, trace protein, small leukocyte esterase Urine culture shows 10-50K colonies of gram negative rods Should IB have a contrast VCUG?
Are VCUGs indicated?
Copyright 1999 American Academy of Pediatrics Vesico-Ureteral Reflux Downs, S. M. Pediatrics 1999;103:e54
VCUG and UTI Hoberman A; N Engl J Med. 2003 Jan 16;348(3):195-202
What about VCU
Relationship between renal scarring and number of bouts of pyelonephritis. Pediatrics 2011;128:595-610 2011 by American Academy of Pediatrics
NICE 2007 Guidelines NICE (National Institute for Health and clinical excellence) Guidelines designed to minimize excessive imaging by grouping UTI as typical or atypical (in infants less than 6 months) Atypical treated (US, VCUG and late DMSA) Typical (US and VCUG if abnormal US) Atypical defined as serious illness, poor urine flow, abdominal or bladder mass, raised serum creatinine, septicemia, non E. Coli organism, poor response to antibiotics NICE, London. http://guidance.nice.org.uk/cg054
NICE Guidelines
Prophylactic antibiotics don t prevent infections
European Urology Guidelines
A Simple Protocol Pennesi M, Jan 2012, Ped Nephro
What about the siblings?
Now that we cleared that up Cultures need to be SPA or catheter obtained Urine dip findings or urine microscopy and urine culture are necessary for diagnosis Strongly consider renal ultrasound Attempt oral antibiotics if possible VCUGs aren t universally indicated Worry about older boys, frequent otitis media, family history of reflux
Thank you