UTI and VUR practical points and management Søren Rittig, Prof., DMSc Child and Adolescent Medicine, Aarhus University Hospital Aarhus, Denmark
Outline Definition and diagnosis of UTI Treatment of UTI (peroral vs. i.v.) UTI VUR relationship Infants Older children Follow-up strategy US/DMSA/MAG3/VCUG Antibiotic prophylaxis in VUR Take home messages
UTI - definition and diagnosis Definition of UTI Symptoms of UTI and: Two midstream urines with growth of same bacteria (>10 4 cfu/ml). Growth of bacteria 10 3-10 4 cfu/ml by urethral catheter. Any growth of bacteria by suprapubic bladder puncture. Pediatric Kidney Disease 2016
UTI - definition and diagnosis Diagnosis 0-1½ years Bag-urine; only of value if negative never send for culture! Dipstick/mic pos Midstream-urine; also risk of false-positive results Dipstick/mic pos Bladder puncture: the golden standard
UTI - definition and diagnosis Dip-stick investigation Pediatric Kidney Disease 2016
UTI peroral vs. i.v. antibiotics Pediatric Kidney Disease 2016
Follow-up after UTI in children - Relationship between VUR and UTI in infants Pediatric Kidney Disease 2016
Follow-up after UTI in children - Relationship between VUR and UTI in infants Montini et al, 2011
Follow-up after UTI in children - Relationship between VUR and UTI in older children Constipation Urinary tract infection Bladder-sphincter dysfunction (residual urine) Vesico-ureteral reflux Pediatric Kidney Disease 2016
CASE boy 3 months old UTI DMSA Follow-up US + VCUG Unhappy Vomits Poor thrive Low grade fever > 10x5 E. Coli in SPA
Follow-up after UTI in children - How? Which investigations, when and who should have them? Ultrasound DMSA/MAG 3 VCUG (IV-urography) (MR-urography)
Follow-up investigations after UTI - Ultrasound examination US cannot diagnose upper UTI reliably - sensitivity: 49%, specificity: 88% (Wang 2005) - US and DMSA agree in 58% (Jakobsson 1992) US cannot predict permanent nephropathy (DMSA 1 year) US cannot diagnose VUR (Müller, 2009)
Follow-up after UTI in children - DMSA Risk factors Obstruction Reflux with dilatation Young age Delayed tx (> 48 h) Number of infections Atypical bacteriae App. 10-15 % risk of scar after upper UTI
Follow-up after UTI in children DMSA timing? Acute or late DMSA scan? UTI 6 months 1. Normal (app. 1/3) 2. Abnormal (app. 2/3)
Follow-up after UTI in children - Follow-up in 424 DK patients with first UTI All patients had a renal ultrasound in the acute phase. Follow-up DMSA scintigraphy after 6 months. VCUG in patients with reduced split function. N = 424, 297 girls, mean age: 2,3 yrs 18% had pathological renal ultrasound. 14% had scarring 8% had uneven DRF (>40/60%). Clinical relevant VUR in app. 7%. Risk factors: bacterial agent, treatment response time, renal ultrasound abnormalities. Breinbjerg et al. In prep.
Follow-up after UTI in children - Multiple guidelines
Follow-up after UTI in children - NICE guidelines - 2007
Follow-up after UTI in children - NICE guidelines DMSA VCUG < 3 yrs > 3 yrs < 6 mth > 6 mth Typical No No Typical No No Atypical Yes No Recurr. Yes Yes Atypical Yes No Recurrent Yes No
Follow-up after UTI in children - Multiple opinions Pediatric Kidney Disease 2016
Follow-up after UTI in children - Multiple opinions Pediatric Kidney Disease 2016
Follow-up after UTI in children Consequence of new guidelines? Pros Differentiated approach (investigating the right children) Significant reduction of invasive procedures and admissions Significant reduction of costs Cons Overlook/miss scars (50%) and high grade VUR (4/5 trials) Underestimate the potential risk of UTI Increased long-term nephron loss
UTI antibiotic prophylaxis AIMS: 1. to prevent UTI recurrence 2. To prevent new renal scarring
UTI antibiotic prophylaxis evidence regarding recurrent infections? 7 RCT trials in 2,297 children and adolescents 2006-14. Primary endpoint: recurrent UTI 4 studies on absent/low grade VUR: no effect of prophylaxis. The Swedish reflux trial (203 infants with dilating VUR): significant reduction in febrile UTI in girls only (19 vs. 57%). RIVUR and PRIVENT (> 1100 pts, placebo controlled) showed clinical insignificant effect of prophylaxis.
UTI antibiotic prophylaxis evidence regarding scars? 6 RCT trials used scars as secondary endpoints. The Swedish reflux trial (203 infants with dilating VUR): significant reduction in new scars in girls only. RIVUR trial unable to support this (but almost no girls in this cohort).
UTI antibiotic prophylaxis (RIVUR) Hoberman et al, NEJM 2014
Take home messages The diagnosis of UTI in infants is not easy due to difficult sampling and unspecific clinical picture. Peroral treatment seems to be safe in uncomplicated UTI. The risk of developing new renal damage after UTI and the role of VUR has undergone significant changes (downscaled). The value of detecting VUR and scarring is not clear. New guidelines result in a significant reduction in number of follow-up investigations but the long-term consequences are unknown.
Q & A session 1: 1. Are there any practical tricks of how to perform a suprapubic bladder puncture?
Q & A session 1: 1. Thorough explanation of the procedure to the parents. 2. Use an ultrasound machine to verify location of bladder and filling state. 3. Use a long (green) needle with a 5-10 ml syringe. 4. Pull the handle of the syringe slightly back so you can see if urine is flowing into the syringe. 5. Insert needle in the direction you have determined by US. 6. Try to wait with aspiration until you see urine in the syringe.
Q & A session 2: 1. In children 2-24 months with first time upper UTI should have a VCUG?
Q & A session 2: 1. Children with severe abnormalities on US. 2. Children with recurrent upper UTI despite antibiotic prophylaxis. 3. Children with uneven differential function (< 40%) on DMSA/Mag3. 4. Children with falling differential function on DMSA/Mag3. 5. Others?.
Q & A session 3: 1. In children with VUR, - is conservative treatment (antibiotic prophylaxis + other) better than surgery?
Q & A session 3: 1. Same number of new infections and scars. 2. AB requires good adherence. 3. AB is long-lasting whereas surgery is quick. 4. Often necessary to perform more than one sting procedure. 5. Need of post-op VCUG.