Pediatric Urinary Tract Infections

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Pediatric Urinary Tract Infections

• Eddie Needham, MD, FAAFP
• Program Director
• Emory Family Medicine Residency Program

2
Objectives

• Define Urinary Tract Infection (UTI)
• List antibiotic treatment options for UTI
• List the workup after a first febrile UTI
• Be familiar with the rationale for using
  prophylactic antibiotics after the first febrile
  UTI

3
Case 1

• A four year old previously healthy girl presents
  to clinic with c/o dysuria.
• She has no fever and has a stable home with
  reliable parents.
• Immunizations are UTD.
• UA shows Nitrites and LE
• WBC unknown because we dont currently spin our
  own urines at Dunwoody.

4
What is your plan?

• Urine culture?
• Antibiotics?
• Rocephin in clinic?
• Oral antibiotics?
• Admit to the hospital?
• Work up (Well define this later)?

5
Case 2

• An 18 month old female presents with increased
  irritability x 3 days, subjective fevers, and
  decreased appetite.
• PMHx usual childhood illnesses AOM x 1, URIs
  x 2, AGE x 1. Benign recoveries.
• Immunizations are up-to-date (UTD)
• Good social support

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Case 2 - Exam

• Vital Signs normal for age except T 102.5
• General appearance fussy, easily consolable,
  nontoxic
• HEENT normal with clear pharynx and TMs AU
• Lungs - CTA
• CV normal
• Abdomen soft
• Skin no rash

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Fever without a Source Guideline
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Clinic Management

• Draw blood for CBC and potentially a blood
  culture?
• Urine culture?
• Antibiotics?
• Rocephin in clinic?
• Oral antibiotics?
• Admit to the hospital?
• Work up (Well define this later)?

9
Clinic workup

• Are you able to draw blood?
• Can you perform a bladder catheterization?
• Two Q-tip technique for little girls

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Evaluation

• Your catheter UA confirms the diagnosis.
• You send the urine for culture.
• What now?
• Child admitted?
• Child goes home?
• What does the evidence say?

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Pediatric UTIs and EBM

• Up to 7 of girls and 2 of boys experience a
  symptomatic culture-proven UTI prior to 6 years
  of age.
• Of febrile neonates, up to 7 have UTIs.
• (See Fever without a source guidelines)
• Most UTIs in children are from ascending bacteria
• E. coli (60-80), Proteus, Klebsiella,
  Enterococcus, and coag. neg. staph.

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Epidemiology

• The overall prevalence of UTI is approximately 5
  percent in febrile infants but varies widely by
  race and sex.
• Caucasian children had a two- to fourfold higher
  prevalence of UTI as compared to African-American
  children
• Females have a two- to fourfold higher prevalence
  of UTI than do circumcised males
• Caucasian females with a temperature of 39 ºC
  have a UTI prevalence of 16 percent

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Approximate probability of urinary tract
infection in febrile infants and young children
by demographic group
Demographic group Prevalence (pretest probability) Odds
Circumcised boys gt1 yr lt1 percent .01 (1 in 100)
Circumcised boys lt1 yr 2 percent .02 (1 in 50)
Black girls 4 percent .04 (1 in 25)
Uncircumcised boys lt2 yr 8 percent .09 (1 in 12)
White girls lt2 yr 16 percent .19 (1 in 5)
Data fromHoberman, A, Chao, HP, Keller, DM, et
al. Prevalence of urinary tract infection in
febrile infants. J Pediatr 1993 12317.Shaw,
KN, Gorelick, M, McGowan, KL, et al. Prevalence
of urinary tract infection in febrile young
children in the emergency department. Pediatrics
1998 102e16.
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Definition of UTI on culture
Method of urine collection Diagnostic threshold
Clean-catch in voiding girls 100,000 CFU per mL 10,000 100,000 ? repeat culture
Clean-catch in voiding boys 10,000 CFU per mL
Catheter 10,000 CFU 1,000 10,000 ? repeat culture
Suprapubic aspiration Any colonies of GNRs More than a few thousand GPCs
Hillerstein S. Recurrent urinary tract infections
in children. Pediatr Infect Dis 1982 1275.
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Symptoms

• Classic UTI symptoms in older children
• Dysuria, frequency, urgency, small-volume voids,
  lower abdominal pain.
• Infants with UTIs have nonspecific symptoms
• Fever, irritability, vomiting, poor appetite

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Neonatal hematuria?
Nope, its uric acid crystals
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Evaluation

• In children with a high likelihood of UTI, a
  urine culture is required.
• In children with a low likelihood, a negative
  dipstick in a clear urine reduces the need for
  culture.
• If the dipstick shows () LE and/or () Nitrites,
  send a urine culture.
• The dipstick is not sufficient to diagnose UTIs
  because false positives can occur.

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Urine dipsticks

• In a cohort study with an 18 baseline prevalence
  of UTI, negative LE and nitrates on dipstick had
  a negative predictive value of 96.
• NPV True negative
• _________________
• True negative false negative

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Leukocyte Esterase and Nitrites

• LE is produced from the breakdown of leukocytes.
  Not always indicative of infection
• Vaginitis/vulvitis can lead to inflammation
  without infection ? LE
• Nitrites are produced by bacteria that metabolize
  nitrates E. coli, Klebsiella, Proteus (GNRs)
• Much more predictive of UTI
• GPCs do not produce nitrites

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Blood cultures

• Blood cultures are generally unnecessary in most
  children with UTI.
• They are more frequently positive in children
  younger than two months whose urine grows Group B
  strep or Staph. Aureus.
• In general, well send febrile children less than
  two months old to the ER for emergent
  evaluation/labs.

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Treatment of UTIs

• The efficacy of oral regimens is as effective as
  parenteral regimens - this is great news for
  outpatient therapy ?
• If the child is not responding the empiric
  treatment within two days while awaiting culture
  results, repeat the urine culture and perform a
  renal ultrasound.

Hoberman A, Wald ER, Hickey RW, Baskin M, Charron
M, Majd M, et al. Oral versus initial intravenous
therapy for urinary tract infections in young
febrile children. Pediatrics 199910479-86. Bake
r PC, Nelson DS, Schunk JE. The addition of
ceftriaxone to oral therapy does not improve
outcome in febrile children with urinary tract
infections. Arch Pediatr Adolesc Med
2001155135-9.
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Antibiotic Choices

• Trimethoprim-sulfamethoxizole is a good choice
  after two months of life
• Other choices
• Amoxicillin some resistance with E. coli
• Cephalosporins cefixime (Suprax), cefpodoxime
  (Vantin), cefprozil (Cefzil), loracarbef
  (Lorabid)
• No cephalosporins cover enterococcus
• Treat for 7-14 days. One day course not
  effective.

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Further testing/work-up

• After the UTI resolves, what type of workup
  should ensue?

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1999 Clinical Practice Guidelines from the AAP

• Routine imaging for children two months to two
  years of age is recommended.
• Ultrasound all children with febrile UTIs
• Consider VCUG/Renal scintigraphy

Committee on Quality Improvement, Subcommittee on
Urinary Tract Infection. Practice parameter the
diagnosis, treatment, and evaluation of the
initial urinary tract infection in febrile
infants and young children. published
corrections appear in Pediatrics 2000105141,
19991031052, and 1999104118. Pediatrics
1999103843-52.
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Newer information

• 255 children lt 5 years old admitted with their
  first uncomplicated febrile UTI (pyelo)
• Renal ultrasound did not change management

Zamir G, Sakran W, Horowitz Y, Koren A, Miron D.
Urinary tract infection is there a need for
routine renal ultrasonography? Arch Dis Child
200489466-8
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Newer Information

• 150 children 2 10 years old with first UTI were
  randomized to routine imaging (U/S and VCUG) or
  to selective imaging (for recurrent UTI or
  persistent problems)
• 21 (1 in 5) in the selective group had imaging
  performed
• Routine imaging increased the use of prophylactic
  antibiotics (28 vs 5)
• No change in rate of recurrent UTIs (26 vs 21)
• No change in rate of renal scarring (9 vs 9)

Dick PT. Annual Meeting of Canadian Pediatric
Society, June 12-16, 2002. Pediatric Notes
200226(27)105
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Vesicoureteral Reflux and Treatment

• Approximately 40 of children with febrile UTIs
  have VUR.
• Approximately 8 of children with febrile UTIs
  demonstrate renal scarring when studied.
• Treatment recommendations are made to stop the
  progression of VUR with medications/antibiotics
  and/or surgery.
• No data/EBM demonstrate that treatment of VUR
  prevents renal scarring, hypertension and CKD

Nuutinen M, Uhari M. Recurrence and follow-up
after urinary tract infection under the age of 1
year. Pediatr Nephrol 20011669-72
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Antibiotic prophylaxis

• Children with VUR are treated prophylactically
  with antibiotics to prevent potential renal
  scarring.
• Nitrofurantoin or trimethoprim-sulfamethoxizole
• Half the standard dose administered at bedtime
• Family physicians would generally have a
  pediatric urologist involved to assist in making
  treatment decisions.

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How long to continue Abx?

• Although the evidence is not conclusive, it
  appears the risk of scarring diminishes with age.
  
• Accordingly, some experts recommend cessation of
  prophylaxis after age 5 to 7 years, even if
  low-grade VUR persists.
• In one study of 51 low-risk (no voiding
  abnormalities or renal scarring) older children
  (mean age 8.6 years) with grades I to IV VUR,
  cessation of prophylactic antibiotics resulted in
  no new renal scarring on annual DMSA

Cooper CS, et al. The outcome of stopping
prophylactic antibiotics in older children with
vesicoureteral reflux. J Urol 2000
Jan163(1)269-72 discussion 272-3.
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Indications to order radiologic studies

• Children younger than 5 years of age with a
  febrile UTI
• Girls younger than 3 years of age with a first
  UTI
• Males of any age with a first UTI (PUV)
• Children with recurrent UTI
• Children with UTI who do not respond promptly to
  therapy

Up To Date accessed September 12, 2007
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Studies to consider

• Renal Ultrasound
• Will evaluate for perinephric abscess in patients
  not responding to antibiotics.
• Can evaluate for hydronephrosis/hydroureter
• Of note, dilation of the kidneys and ureters can
  easily be seen on routine anatomy scans during
  pregnancy.
• Picking up vesicoureteral reflux while
  asymptomatic
• Does this help or hurt? Staging of VUR,
  antibiotics, etc...

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Hydronephrosis
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Male with the findings below.Cause?
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Studies to consider

• Voiding cystourethrogram two techniques
• One involves fluoroscopic contrast more
  radiation but better delineation of anatomy for
  grading VUR
• The other uses a radionuclide less radiation
  and more sensitive than contrast

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Normal VCUG
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Vesicoureteral reflux (VUR)
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Megaureter
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Studies to consider

• Renal scintigraphy using dimercaptosuccinic acid
  (DMSA)
• Can detect scarring in the kidneys.
• Renal cells take up the tracer.
• Those cells damaged by pyelonephritis or scarring
  do not take up the tracer.
• Management or followup of patients does not
  change in most cases.
• Thus, not generally used for initial evaluation.

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Scar in the superior and inferior pole of the
right kidney
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Myths

• Bathing in bubble baths causes UTIs
• Wiping back-to-front causes UTIs
• Cranberry juice helps UTIs only proven to be of
  minimal benefit in adult women. No proven
  benefit to children

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VUR Treatment 1997 AUA guidelines

• Children younger than 1 year of age, regardless
  of grade of reflux, should be treated medically,
  as they have a high likelihood of spontaneous
  resolution. Surgery is a reasonable option if
  they have grade V reflux and renal scarring.
• All patients with grade I or II reflux, either
  with unilateral or bilateral disease, should be
  treated medically, as they have high likelihood
  of spontaneous resolution.
• Children between 1 and 5 years of age with grade
  III or IV reflux, either unilateral or bilateral
  disease, should be treated medically. Surgery is
  a reasonable option if there is bilateral reflux
  and renal scarring.
• Children between 1 and 5 years of age with grade
  V, either unilateral or bilateral disease,
  without renal scarring, can be treated medically.
  If there is renal scarring, surgery is
  recommended for both unilateral and bilateral
  disease.

Elder JS, et al. Pediatric Vesicoureteral Reflux
Guidelines Panel summary report on the management
of primary vesicoureteral reflux in children, J
Urol 1997 May157(5)1846-51.
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VUR Treatment

• Children 6 years or older with unilateral grade
  III to IV reflux without renal scarring can be
  treated medically. If the reflux is bilateral
  and/or there is renal scarring, surgical
  treatment is recommended.
• Children 6 years or older with grade V reflux
  should be treated surgically with or without
  evidence of renal scarring, as their reflux is
  unlikely to resolve spontaneously.
• Surgery also should be considered if medical
  therapy fails either because of poor compliance,
  breakthrough infections on account of antibiotic
  resistance, or significant antibiotic side
  effects. Finally, consideration of patient and
  parent preference is important in the final
  decision.

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So, back to our cases
47
Case 1

• A four year old previously healthy girl presents
  to clinic with c/o dysuria.
• She has no fever and has a stable home with
  reliable parents.
• Immunizations are UTD.
• UA shows Nitrites and LE
• WBC on UA unknown.

48
What is your plan?

• Urine culture?
• Antibiotics?
• Rocephin in clinic?
• Oral antibiotics?
• Admit to the hospital?
• Work up (Well define this later)?

49
EBM answer

• She is afebrile no need for radiologic studies
• Send the urine for culture
• Start empiric antibiotics for 7-14 days

50
Case 2

• An 18 month old female presents with increased
  irritability x 3 days, subjective fevers, and
  decreased appetite.
• PMHx usual childhood illnesses AOM x 1, URIs
  x 2, AGE x 1. Benign recoveries.
• Immunizations are up-to-date (UTD)
• Good social support

51
Case 2 - Exam

• Vital Signs normal for age except T 102.5
• General appearance fussy, easily consolable,
  nontoxic
• HEENT normal with clear pharynx and TMs AU
• Lungs - CTA
• CV normal
• Abdomen soft
• Skin no rash

52
Fever without a Source Guideline
53
Clinic Management

• Draw blood for CBC and potentially a blood
  culture?
• Urine culture?
• Antibiotics?
• Rocephin in clinic?
• Oral antibiotics?
• Admit to the hospital?
• Work up (Well define this later)?

54
Clinic workup

• Are you able to draw blood?
• Can you perform a bladder catheterization?
• Two Q-tip technique for little girls

55
Evaluation

• Your catheter UA confirms the diagnosis.
• You send the urine for culture.
• What now?
• Child admitted?
• Child goes home?
• What does the evidence say?

56
Case 2 EBM vs reality answer

• Option 1 young child with potential serious
  bacterial illness send to ER for expedited
  evaluation.
• Option 2 not on a Friday afternoon
• Draw blood for CBC and blood culture in clinic
• Obtain a UA
• Consider antibiotics
• Bring the child back in 24 hours for
  re-evaluation and review of labs.

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Case 2 EBM answer

• If the UA shows a UTI
• If you have a good social support/parents
• If child is tolerating oral intake
• If the child is nontoxic
• You may start oral antibiotics with follow up the
  next day.
• Not a good solution on Fridays no follow-up on
  Saturday.

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Objectives

• Define Urinary Tract Infection (UTI)
• gt100,000 CFU in clean catch girls
• gt10,000 CFU clean catch guys
• gt10,000 catheter specimen
• List antibiotic treatment options for UTI
• Amoxicillin, Bactrim, Cephalosporins
• List the workup after a first febrile UTI
• Consider renal U/S and VCUG
• Be familiar with the rationale for using
  prophylactic antibiotics after the first febrile
  UTI
• Prevent renal complications/scarring/pyelonephriti
  s