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Managing children under 36 months of age with febrile urinary tract infection: A new approach

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Recent guidelines on urinary tract infection (UTI) agree on reducing the number of invasive procedures. None of these has been validated by a long-term study. We describe our 11-years experience in the application of a diagnostic protocol that uses a reduced number of invasive procedures. We reviewed retrospectively the records of 406 children aged between 1 and 36 months at their first UTI. All patients underwent renal ultrasound (RUS). Children with abnormal RUS and those with UTI recurrences underwent voiding cystourethrography (VCUG) and dimercaptosuccinic acid (DMSA) renal scans. RUS after the first UTI was pathological in 7.4% children; 4.4 % had a second UTI. We performed 48 VCUG: 14 patients (29%) had vesicoureteral reflux (VUR), 12 of which showed an abnormal RUS while 2 had recurrent UTI. After DMSA renal scan renal damage appeared in only 6 of them (12.5%); all these children showed grade IV VUR. The application of our guidelines leads to a decrease in invasive examinations without missing any useful diagnoses or compromising the child's health.
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ORIGINAL ARTICLE
Managing children under 36 months of age with febrile
urinary tract infection: a new approach
Marco Pennesi &Ines LErario &Laura Travan &
Alessandro Ventura
Received: 2 May 2011 / Revised: 24 November 2011 / Accepted: 24 November 2011 / Published online: 11 January 2012
#IPNA 2011
Abstract
Background Recent guidelines on urinary tract infection
(UTI) agree on reducing the number of invasive procedures.
None of these has been validated by a long-term study. We
describe our 11-years experience in the application of a
diagnostic protocol that uses a reduced number of invasive
procedures.
Methods We reviewed retrospectively the records of 406
children aged between 1 and 36 months at their first UTI.
All patients underwent renal ultrasound (RUS). Children
with abnormal RUS and those with UTI recurrences under-
went voiding cystourethrography (VCUG) and dimercapto-
succinic acid (DMSA) renal scans.
Results RUS after the first UTI was pathological in 7.4%
children; 4.4 % had a second UTI. We performed 48 VCUG:
14 patients (29%) had vesicoureteral reflux (VUR), 12 of
which showed an abnormal RUS while 2 had recurrent UTI.
After DMSA renal scan renal damage appeared in only 6 of
them (12.5%); all these children showed grade IV VUR.
Conclusions The application of our guidelines leads to a
decrease in invasive examinations without missing any useful
diagnoses or compromising the childshealth.
Keywords Urinary tract infection .Renal scars .
Vesicoureteral reflux .Antibiotic prophylaxis
Introduction
The National Institute for Health and Clinical Excellence
(NICE) guidelines on urinary tract infections (UTI) in child-
hood, published in 2007 [1], may lead to an epochal change
in the management of children with UTI. The application of
these guidelines could decrease significantly the use of
instrumental evaluations in children with UTI in the first
years of life. Based on these protocols other guidelines have
been developed such as the recent American Academy of
Pediatrics guidelines (AAP) [2].
One of the main objections against these more conserva-
tive approaches is that these guidelines derive from an
inadequate review of the literature, reflecting an opinion
rather than a fact[3]. Also, according to some authors, the
generalized application of these protocols could lead to a
lack of prevention of kidney damage in children with UTI
and vesicoureteral reflux (VUR) [4].
Since 1997 we have been using a diagnostic protocol
similar to that proposed by the recent NICE guidelines [5].
The main difference between our approach and the NICE
guidelines is that while NICE recommends renal ultrasound
(RUS) after a first UTI only in children younger than
6 months, and in the case of an atypical UTI (for a detailed
description of the definition of atypical UTI see Mori et al.
[1]), our protocol prefigures RUS on all patients regardless
of age, as also suggested by the AAP guidelines and Craig et
al. [2,6]. The aim of this study was to describe 11 years
experience of applying our protocol in children up to
36 months with febrile UTI.
M. Pennesi (*):I. LErario :A. Ventura
Department of Pediatrics, Institute for Child and Maternal Health,
IRCCS Burlo Garofolo,
Via dellIstria 65/1,
34137 Trieste, Italy
e-mail: pennesi@burlo.trieste.it
L. Travan
Department of Neonatal Intensive Care Unit,
Institute for Child and Maternal Health, IRCCS Burlo Garofolo,
Via dellIstria 65/1,
34137 Trieste, Italy
Pediatr Nephrol (2012) 27:611615
DOI 10.1007/s00467-011-2087-3
Materials and methods
Subjects
We reviewed the medical records of all children seen at the
Emergency Room of the Institute for Child and Maternal
Health, IRCCS Burlo Garofolo in Trieste, Italy, for their first
episode of symptomatic UTI. All patients were referred to the
Pediatric Nephrology Department for further assessment.
All recurrences were referred to us by the primary care
pediatricians or the Emergency Room. Overall, 510 patients
were identified. One hundred and four were excluded be-
cause they were lost at follow-up or because they lacked
some information (i.e., bacterium type or incomplete med-
ical records). Therefore, 406 patients (79.6% of the total),
aged between 1 and 36 months with symptomatic UTI, were
included in the study.
Symptomatic UTI was defined as fever (rectal temperature
>38°C), positive result to urinalysis (presence of leukocytes
50/mm
3
and bacteria10/mm
3
at optical microscopy), and
positive results to urine culture (1 million colony-forming
units/mL) for the same bacterium in two different samples.
Urine for urinalysis and urine culture was collected using
clean catch or bladder catheterization [1,2,7].
All children were treated with conventional antibiotic ther-
apy (oral ceftibuten, cefaclor, or amoxicillin/clavulanate for
10 days). None of the children had antibiotic prophylaxis.
Diagnostic protocol
All children underwent an RUS (Ansaldo Idea, with a multi-
frequency 7.5-MHz to 10-MHz probe for children younger
than 1 year or a convex multi-frequency for older chil-
dren) performed by skilled radiologists 1 month after the
first UTI. Those with normal RUS did not undergo any
further investigations and did not start any prophylactic
antibiotic therapy. Those with abnormal RUS (either
abnormal renal lengthmaximum longitudinal diameter
<5th percentileureteral dilatation, pelvic dilatation or
abnormal cortico-medullary differentiation) underwent a
voiding cystourethrography (VCUG) 2 months after the
acute episode. In all of these children a dimercaptosuc-
cinic acid (DMSA) renal scan was also performed
6 months after the acute episode. A DMSA renal scan
was performed with 99mTC-dimercaptosuccinic acid at a
dosage of 0.5 MBq/kg body weight (minimum 10 MBq);
image acquisition (6 projectionsSPECT) was performed at
least 3 h after injection. DMSA scans were considered abnor-
mal when one area of decreased cortical DMSA uptake was
observed (suggesting the presence of renal scars, paying at-
tention to avoid considering central defects located over the
pelvicalyceal system as abnormal. Separate renal function
<45% with or without focal defects was considered abnormal.
At each episode of fever after the first UTI episode or
when symptoms of UTI occurred (e.g., change in the smell
of urine, anorexia, irritability), urinalysis and urine culture
were performed. All children with UTI recurrence and initial
normal RUS, were subjected to a second RUS, VCUG (after
2 months) and to a renal DMSA scan (after 6 months).
Figure 1shows the diagnostic flow chart. All children with
an abnormal RUS were monitored echographically once a
year, in order to evaluate the growth of the kidneys. Children
with an abnormal renal DMSA repeated the examination after
2and6years.
12 VUR (6 IV grade)
(4 III d )
Abnormal RUS VCUG III grade)
(2 I grade)
(30)and
DMSA
Ig
()
4 abnormal DMSA
(all with IV grade VUR)
First febrile UTI
(406)
Normal RUS UTI recurrence
2 VUR (2 IV grade)
VCUG
(376) (18) 2 abnormal DMSA
Follow-up and
(all with IV grade VUR)
DMSA (g)
No UTI recurrence
Fig. 1 Diagnostic flow chart. In each box is reported the number of patients for each step of the protocol. UTI urinary track infection, RUS renal
ultrasound, VUR vesicoureteral reflux, VCUG voiding cystourethrogram, DMSA dimercaptosuccinic acid
612 Pediatr Nephrol (2012) 27:611615
Results
Of the 406 children evaluated at the first UTI, 32% (130)
were boys and 68% (276) were girls. Mean age was
9.5 months (range 136 months, Table 1). Mean follow-up
period was 47.3 months (range 12133 months). The bac-
teria causing the infections are described in Table 2. Forty-
six patients out of 406 had atypical UTI.However, in our
study it was not considered to be a risk factor because we
performed RUS on all febrile UTI, as nowadays recommen-
ded by AAP guidelines. All children, regardless of age,
underwent RUS 1 month after the first episode of UTI,
376 out of 406 children (92.6%) exhibited a normal RUS
while in 30 (20 under 6 months of age) out of 406 patients
RUS was abnormal (7.4%; Table 3).
Eighteen patients (all with a normal RUS) had a second
episode of UTI during follow-up (4.4%), 5 out of 18 were
males, mean age was 12.4 months (range 816 months) and
the mean interval between the first and the second episode
was 3.6 months (range 1-10 months). The second RUS,
performed 2 months after the recurrence, was normal in all
18 patients.
We performed 48 VCUGs: 30 in children with abnormal
RUS and 18 because of UTI recurrences. Fourteen out of 48
children (29%; 4 boys and 8 under 6 months of age)had VUR:
12 were from the 30 children with an abnormal RUS while 2
had recurrent UTI. The same 48 children underwent DMSA
renal scans: renal damage (decreased cortical DMSA uptake)
appeared in 6 children (12.5%; 4 out of 6 were under 6 months
of age); all of these showed VUR of grade IV.
Of the 30 patients who showed an abnormal RUS, 4
(13.3%) had renal scars and a VUR of grade IV. Of the 18
patients with UTI recurrence 2 (11.1%) showed renal scars
and a VUR of grade IV (Table 4, Fig. 1). None of the 6
children positive for DMSA showed worsening of the renal
damage during the follow-up.
Discussion
Recent guidelines [1,2,6] developed from analysis of the
literature on VUR and UTI, radically changed the approach
to this problem, simplifying the diagnostic and therapeutic
pathway for children with UTI. This study shows that the
application of our guidelines (although created in 1997 long
before recent protocols) leads to a significant saving of
invasive evaluations after the first UTI episode, without
compromising the childs health.
UTI recurrence
Our data show that only 4.4% of children had a recurrence
after the first UTI, and this usually occurred shortly after the
first episode of infection (average 3.6 months). VUR was
found in only 2 out of 18 children who relapsed (11%). If we
had performed VCUG on all patients at the first UTI, we
could have expected about 120 VUR (30%) [8]; however,
only2ofthesepossiblemisseddiagnosesresultedina
relapse and both patients had a high grade of VUR (IV).
It is likely that most of the undiagnosed VURs are of
lower grade and children presenting with them are not
expected to have higher rates of recurrence. Moreover, these
Table 2 Germ type at first urinary tract infection (UTI) and number of
UTI recurrences
Germ type Number of patients
at first UTI (%)
Number of UTI
recurrence (%)
Escherichia coli 366 (90.2) 15 (83)
Enterococcus 16 (4) 2 (11)
Proteus 13 (3.2) 1 (6)
Klebsiella 5 (1.2) 0 (0)
Pseudomonas aeruginosa 4 (0.9) 0 (0)
Streptococcus aureus 2 (0.5) 0 (0)
Table 3 Abnormality of renal ultrasound (RUS) and grade of vesi-
coureteral reflux (VUR) at voiding cystourethrography (VCUG)
Abnormality
of RUS
Number of patients
(under 6 months)
VCUG
(grade of VUR)
Pyelectasis 18 (10) 4 (2 III, 2I)
Pelvicalyceal system dilatation 2 (2) 2 (2 IV)
Hydronephrosis 6 (6) 6 (4 IV, 2 III)
Medical kidney4 (0) 0 (0)
Table 4 Dimercaptosuccinic acid (DMSA) renal scans and voiding
cystourethrography (VCUG)
Selection criteria VCUG VUR (grade) DMSA (scar)
Abnormal RUS (30) Positive (12) 6 (IV) 4
4 (III) 0
2 (I) 0
UTI recurrence (18) Positive (2) 2 (IV) 2
Table 1 Age at first urinary tract infection (UTI; months)
Age at first UTI Number of patients Percentage
16 178 43.8
712 136 33.5
1324 66 16.3
2536 26 6.4
Pediatr Nephrol (2012) 27:611615 613
low and medium grade (grades IIII) VURs have a high
probability of spontaneous resolution in the first years of life
[9] and would not even require antibiotic prophylaxis [2,7,
10]. These considerations suggest that it is unreasonable to
perform VCUG at the first UTI occurrence.
Age
As in the NICE [1] guidelines, age under 6 months was not
considered to be a risk factor by itself. VCUG does not seem
to be justified in the first instance in the absence of any
proven recurrence. In fact, none of the 178 children under
6 months (96 boys and 82 girls) had UTI recurrences. Eight
of these children (4 boys and 4 girls) had VUR and all of
them had an abnormal RUS with pyelectasis or pelvicalyceal
system dilatation.
Renal damage
In our sample group renal damage was restricted to children
with a high grade of VUR (IV), while all but 2 of the
children who presented with a recurrence of UTI did not
show decreased cortical uptake on the DMSA scan. These
data, according to recent literature [1113], show that VUR
is associated with congenitalrenal dysplasia, and does not
determine renal damage itself. In fact, it has by now been
largely demonstrated that renal dysplasia is associated with
grade IV/V VUR and has its own natural progression to renal
failure independently of pyelonephritis recurrences [14].
Renal ultrasound
As underlined before, the only difference between our pro-
tocol and the NICE guidelines [1] is in the selection of
which patients should undergo RUS. While NICE recom-
mends RUS only in patients aged under 6 months if no other
risk factor is present, we have been performing it on all
patients with UTI, as also suggested in the AAP guidelines
[2]. In fact the AAP recommended RUS in all febrile UTI
cases to detect anatomical abnormalities that require further
evaluation, such as additional imaging or urological consul-
tation. We performed 178 RUS in children under 6 months
and 228 in children over 6 months. Among younger chil-
dren, 18 were abnormal, while in those older than 6 months,
12 showed alterations. Following NICE guidelines we
would have spared 228 renal ultrasounds, while losing 2
children out of 4 VUR diagnosed in this age group (the rest
were diagnosed because of UTI recurrence). These data
suggest that RUS in children older than 6 months could be
limited only to those with atypical UTI (as in the NICE
guidelines).
We have demonstrated that the application of our guide-
lines results in a substantial saving of invasive investigations
(88% of VCUG in our sample), without any evident clinical
risk for the child in terms of renal damage and/or UTI
recurrences. As suggested by Coulthard [15], it is possible
that the diagnosis of UTI defined as fever >38.5°C (rectal)
and positive urine specimen, may lead to an overestimation
of pyelonephritis in febrile UTI episodes. However, it is
equally true that, as many studies have demonstrated
[1618], the best approach for preventing renal damage is
not searching for VUR itself, but rather early diagnosis and
treatment of the infection. From this perspective the possible
over-diagnosis of pyelonephritis is a small price to pay
compared with the substantial simplification of the proce-
dures and with the reduction of invasive evaluations
obtained by using our flow chart. Recently, Coulthard [19]
and Venhola and Uhari [20], despite their diametrically
opposed viewpoints on VUR, reached the same conclusion:
the only reasonable strategy for preventing renal scars is the
prompt diagnosis and correct treatment of UTI.
As suggested by recent guidelines [1,2], our study seems
to confirm that a diagnosis of pyelonephritis with normal
RUS does not require searching for VUR. Perhaps in the
future, only DMSA will be necessary in febrile UTI follow-up,
and searching for VUR will become unnecessary.
Conclusion
We believe that the application of our guidelines to everyday
clinical practice will help to reduce the need for invasive
medical examinations while preserving childrens health.
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... The current practice of a restrictive approach in radiological investigations is supported by evidence from several studies that assessed the clinical importance of renal imaging. [30][31][32][33] The top-down approach in renal imaging, which forms the basis for the recommendations in the NICE and revised AAP guidelines, is supported by the findings of other studies. [34][35][36] Although UTI in children usually resolves with no sequelae, the fact that some children are predisposed to recurrence may partly be a reflection of an underlying congenital anomaly of the kidney and urinary tract and urinary tract obstruction, justifying the recommendation for RBUS as the initial imaging study following a first UTI. ...
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Infections of the urinary tract are one of the most prevalent bacterial infections in developing countries. It is a challenge that is most often encountered in pediatrics. Uncontrolled use of antimicrobial drugs has led to the development of drug-resistant organisms. Hence, this study was aimed at isolating, characterizing, and identifying the pathogens associated with urinary tract infection (UTI) in children attending Tertiary Health Care Centre in Enugu metropolis and to determine their antimicrobial susceptibility profiles. Urine samples were collected from 260 patients with signs and symptoms suggestive of urinary tract infection (UTI). The children were seen in children out-patients, children emergency departments of the hospital, and pediatric ward. Their ages ranged from 0-17 years. The urine samples were analyzed in the laboratory using standard bacteriological methods. Antibiotic sensitivity of the isolates was determined by the Kirby-Bauer disc diffusion technique. Of the 260 urine samples, significant bacterial agents were recorded in 98(37.7%). Escherichia coli ranked highest with 30(32.6%) followed by Klebsiella spp. 17(18.5%) and the least was Enterococcus fecalis 1(1.1%). Gender distribution showed a higher prevalence in females (p <0.05). The highest positive result was obtained from children between 0-5years. Most of the isolates were sensitive to Imipenem, Nitrofurantoin, Ceftriaxone, and Ciprofloxacin but resistant to Augmentin and Amoxicillin. There is a need to regularly monitor the antimicrobial susceptibility profile of these etiological agents to keep track of the effectiveness of certain therapeutic agents.
... The incidence of UTI is 1%-2% in boys and 3%-7%in girls in the US [4]. The range of UTI prevalence is 2%-8% among children [5]. In Iran, it has been reported that at least 1% of boys and 3% of girls have their first episode of UTI before reaching the age of 11 years [3]. ...
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Objective To study the culture and sensitivity patterns of urinary tract infections in patients presenting with urinary symptoms in a tertiary care hospital. Study design A cross-sectional study. Place and duration of the study The departments of General Medicine, Nephrology, and Urology at Nishtar Hospital, Multan, from May 5, 2019, to November 5, 2019. Methodology A total of 120 patients suffering from complicated urinary tract infection (UTI) between 20 and 60 years of age were selected for the study. Mid-stream samples of urine were collected in sterile containers and immediately processed for further procedures. MacConkey agar (Oxoid, England) was used to subculture the colonies to get pure growth of the microorganisms. The Kirby-Bauer disk diffusion method was used to determine the antibiotic susceptibility of the isolated colonies. Müller-Hinton agar plates were used to identify the sensitivity pattern. After this, the measurement of the zone of inhibition of bacterial growth was performed and comparison was done with the guidelines of the Clinical and Laboratory Standards Institute (CLSI, 2013). Results Among 53 positive urine cultures, Escherichia coli was detected in 21 (39.6%), Enterococcus species were detected in 18 (33.9%), and Pseudomonas was detected in seven (13.2%). Methicillin-resistant Staphylococcus aureus (MRSA), Coliform, Streptococci, and Klebsiella were detected in 03 (5.7%), 02 (3.8%), 01 (1.9%), and 01 (1.9%) of the positive cultures, respectively. Conclusion The current study shows E. coli to be the most common pathogen in UTI, with very high antibiotic resistance. This warrants the careful selection and conservative use of antibiotics.
... Due to the popularity of prenatal ultrasound in recent years, CAKUT are often detected before the occurrence of UTI. In the last decade, imaging guidelines in the United Kingdom and the United States have changed [6,7,16,17]. The number of indications for performing a VCUG has been reduced, particularly in children who already had a normal prenatal RUS. ...
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Background: The strong association between kidney and urinary tract anomalies and childhood urinary tract infection (UTI) often leads to imaging tests being performed. -Objective: To describe the epidemiology, characteristics, and imaging findings in Thai children with UTI and compare results between boys and girls. Methods: We retrospectively reviewed the medical records of children with UTI aged < 15 years. Demographic characteristics and findings of investigations are presented. Results: One hundred seventy-eight boys and 170 girls with 432 UTI episodes were identified. The median (interquartile range) age at presentation was 1.4 (0.6-3.4) years, 1.0 for boys and 2.1 for girls (p < 0.001). Renal ultrasound, voiding cystourethrogram and 99mTc dimercaptosuccinic acid (DMSA) renal scans were performed in 273, 223 and 113 children, respectively. Overall, 283 children (81.3%) had at least one imaging study done and anomalies of the kidney and urinary tract were detected in 158 (45.4%). Primary vesicoureteral reflux was detected in 73 (32.7%) children. The remaining abnormalities were hydronephrosis (n = 54). DMSA scans detected 54 children with dysplastic or scarred kidneys. Conclusions: First UTI in a group of Thai children occurred in approximately equal proportion in boys and girls but boys were younger at diagnosis. Kidney and urinary tract anomalies were detected in half of the children.
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CONTEXT Urinary tract infections (UTIs) are common in young infants, yet there is no guidance on the optimal duration of intravenous (IV) treatment. OBJECTIVE To determine if shorter IV antibiotic courses (≤7 days) are appropriate for managing UTIs in infants aged ≤90 days. METHODS PubMed, the Cochrane Library, Medline, and Embase (February 2021) were used as data sources. Included studies reported original data for infants aged ≤90 days with UTIs, studied short IV antibiotic durations (≤7 days), and described at least 1 treatment outcome. The Preferred Reporting Items for Systematic Reviews and Meta-analyses guideline was followed. Studies were screened by 2 investigators, and bias was assessed by using the Newcastle-Ottawa Scale and the Revised Cochrane Risk-of-Bias Tool. RESULTS Eighteen studies with 16 615 young infants were included. The largest 2 studies on bacteremic UTI found no difference in the rates of 30-day recurrence between those treated with ≤7 vs >7 days of IV antibiotics. For nonbacteremic UTI, there was no significant difference in the adjusted 30-day recurrence between those receiving ≤3 vs >3 days of IV antibiotics in the largest 2 studies identified. Three studies of infants aged ≥30 days used oral antibiotics alone and reported good outcomes, although only 85 infants were ≤90 days old. CONCLUSIONS Shorter IV antibiotic courses of ≤7 days and ≤3 days with early switch to oral antibiotics should be considered in infants aged ≤90 days with bacteremic and nonbacteremic UTI, respectively, after excluding meningitis. Further studies of treatment with oral antibiotics alone are needed in this age group.
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Objective This review aimed to provide a critical overview on the pathogenesis, clinical findings, diagnosis, imaging investigation, treatment, chemoprophylaxis, and complications of urinary tract infection in pediatric patients. Source of data Data were obtained independently by two authors, who carried out a comprehensive and non‐systematic search in public databases. Summary of findings Urinary tract infection is the most common bacterial infection in children. Urinary tract infection in pediatric patients can be the early clinical manifestation of congenital anomalies of the kidney and urinary tract (CAKUT) or be related to bladder dysfunctions. E. coli is responsible for 80–90% of community‐acquired acute pyelonephritis episodes, especially in children. Bacterial virulence factors and the innate host immune systems may contribute to the occurrence and severity of urinary tract infection. The clinical presentation of urinary tract infections in children is highly heterogeneous, with symptoms that can be quite obscure. Urine culture is still the gold standard for diagnosing urinary tract infection and methods of urine collection in individual centers should be determined based on the accuracy of voided specimens. The debate on the ideal imaging protocol is still ongoing and there is tendency of less use of prophylaxis. Alternative measures and management of risk factors for recurrent urinary tract infection should be emphasized. However, in selected patients, prophylaxis can protect from recurrent urinary tract infection and long‐term consequences. According to population‐based studies, hypertension and chronic kidney disease are rarely associated with urinary tract infection. Conclusion Many aspects regarding urinary tract infection in children are still matters of debate, especially imaging investigation and indication of antibiotic prophylaxis. Further longitudinal studies are needed to establish tailored approach of urinary tract infection in childhood.
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Objective This review aimed to provide a critical overview on the pathogenesis, clinical findings, diagnosis, imaging investigation, treatment, chemoprophylaxis, and complications of urinary tract infection in pediatric patients. Source of data Data were obtained independently by two authors, who carried out a comprehensive and non-systematic search in public databases. Summary of findings Urinary tract infection is the most common bacterial infection in children. Urinary tract infection in pediatric patients can be the early clinical manifestation of congenital anomalies of the kidney and urinary tract (CAKUT) or be related to bladder dysfunctions. E. coli is responsible for 80-90% of community-acquired acute pyelonephritis episodes, especially in children. Bacterial virulence factors and the innate host immune systems may contribute to the occurrence and severity of urinary tract infection. The clinical presentation of urinary tract infections in children is highly heterogeneous, with symptoms that can be quite obscure. Urine culture is still the gold standard for diagnosing urinary tract infection and methods of urine collection in individual centers should be determined based on the accuracy of voided specimens. The debate on the ideal imaging protocol is still ongoing and there is tendency of less use of prophylaxis. Alternative measures and management of risk factors for recurrent urinary tract infection should be emphasized. However, in selected patients, prophylaxis can protect from recurrent urinary tract infection and long-term consequences. According to population-based studies, hypertension and chronic kidney disease are rarely associated with urinary tract infection. Conclusion Many aspects regarding urinary tract infection in children are still matters of debate, especially imaging investigation and indication of antibiotic prophylaxis. Further longitudinal studies are needed to establish tailored approach of urinary tract infection in childhood.
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Objective: The objective of this study was to determine the frequency of pathogens and their drug sensitivity pattern in children presenting with urinary tract infections. Study Design: It was a cross sectional study. Place and Duration of Study: The study was conducted in 6 months from Nov 01, 2013 to Apr 30, 2014 at casualty and outpatient departments of Pediatrics at Benazir Bhutto Hospital, Rawalpindi. Materials and Methods: All the children between 1‐12 years of age with one or more symptoms of UTI were included in study. The collected urine samples of the patients were transported immediately to the laboratory for urinalysis, culture and sensitivity. Cultures were done directly on CLED agar medium and incubated for 480hours at 37 C. Sensitivities were checked for Trimethoprim‐Sulfamethoxazole, Amoxycillin‐Clavulanic acid, Nalidixic acid and others. All data were entered and analyzed in SPSS version 16.Results: Out of 155 children, 72.26% (n=112) had E.Coli, 14.84% (n=23) had Klebsiella Pneumoniae, 10.32%(n=16) had Staphylococcus Saprophyticus and 2.58% (n=4) had others. These bacterial pathogens weresensitive to Amoxycillin‐Clavulanic acid and Trimethoprim‐Sulfamethoxazole. Conclusion: The results of the study revealed that Escherichia coli followed by Klebsiella and Staphylococcus saprophyticus are the leading pathogens of urinary tract infection in children. Out of three antimicrobials studied, Amoxycillin‐Clavulanic acid and Trimethoprim‐Sulfamethoxazole have been found to be superior inefficacy as compared to Nalidixic acid.
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Febrile urinary tract infections are common in children and associated with the risk for renal scarring and long-term complications. Antimicrobial prophylaxis has been used to reduce the risk for recurrence. We performed a study to determine whether no prophylaxis is similar to antimicrobial prophylaxis for 12 months in reducing the recurrence of febrile urinary tract infections in children after a first febrile urinary tract infection. The study was a controlled, randomized, open-label, 2-armed, noninferiority trial comparing no prophylaxis with prophylaxis (co-trimoxazole 15 mg/kg per day or co-amoxiclav 15 mg/kg per day) for 12 months. A total of 338 children who were aged 2 months to <7 years and had a first episode of febrile urinary tract infection were enrolled: 309 with a confirmed pyelonephritis on a technetium 99m dimercaptosuccinic acid scan with or without reflux and 27 with a clinical pyelonephritis and reflux. The primary end point was recurrence rate of febrile urinary tract infections during 12 months. Secondary end point was the rate of renal scarring produced by recurrent urinary tract infections on technetium 99m dimercaptosuccinic acid scan after 12 months. Intention-to-treat analysis showed no significant differences in the primary outcome between no prophylaxis and prophylaxis: 12 (9.45%) of 127 vs 15 (7.11%) of 211. In the subgroup of children with reflux, the recurrence of febrile urinary tract infections was 9 (19.6%) of 46 on no prophylaxis and 10 (12.1%) of 82 on prophylaxis. No significant difference was found in the secondary outcome: 2 (1.9%) of 108 on no prophylaxis versus 2 (1.1%) of 187 on prophylaxis. Bivariate analysis and Cox proportional hazard model showed that grade III reflux was a risk factor for recurrent febrile urinary tract infections. Whereas increasing age was protective, use of no prophylaxis was not a risk factor. For children with or without primary nonsevere reflux, prophylaxis does not reduce the rate of recurrent febrile urinary tract infections after the first episode.
Article
OBJECTIVE: To revise the American Academy of Pediatrics practice parameter regarding the diagnosis and management of initial urinary tract infections (UTIs) in febrile infants and young children. METHODS: Analysis of the medical literature published since the last version of the guideline was supplemented by analysis of data provided by authors of recent publications. The strength of evidence supporting each recommendation and the strength of the recommendation were assessed and graded. RESULTS: Diagnosis is made on the basis of the presence of both pyuria and at least 50 000 colonies per mL of a single uropathogenic organism in an appropriately collected specimen of urine. After 7 to 14 days of antimicrobial treatment, close clinical follow-up monitoring should be maintained to permit prompt diagnosis and treatment of recurrent infections. Ultrasonography of the kidneys and bladder should be performed to detect anatomic abnormalities. Data from the most recent 6 studies do not support the use of antimicrobial prophylaxis to prevent febrile recurrent UTI in infants without vesicoureteral reflux (VUR) or with grade I to IV VUR. Therefore, a voiding cystourethrography (VCUG) is not recommended routinely after the first UTI; VCUG is indicated if renal and bladder ultrasonography reveals hydronephrosis, scarring, or other findings that would suggest either high-grade VUR or obstructive uropathy and in other atypical or complex clinical circumstances. VCUG should also be performed if there is a recurrence of a febrile UTI. The recommendations in this guideline do not indicate an exclusive course of treatment or serve as a standard of care; variations may be appropriate. Recommendations about antimicrobial prophylaxis and implications for performance of VCUG are based on currently available evidence. As with all American Academy of Pediatrics clinical guidelines, the recommendations will be reviewed routinely and incorporate new evidence, such as data from the Randomized Intervention for Children With Vesicoureteral Reflux (RIVUR) study. CONCLUSIONS: Changes in this revision include criteria for the diagnosis of UTI and recommendations for imaging.
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Primary vesicoureteral reflux (VUR), one of the principal causes of chronic renal failure (CRF), occurs as a result of two distinct and sex-related mechanisms: congenital renal hypoplasia, which is prevalent in males, and acquired renal scarring in females.
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Renal parenchymal defects may be congenital, usually associated with dilated vesicoureteric reflux (VUR), or they may appear in previously normal kidneys and be caused by reflux nephropathy due to VUR combined with urinary tract infection (UTI). A piglet model defined that the 70% of children with VUR and vulnerable pyramids would scar rapidly with their first UTI. Because most defects are present at first imaging after a UTI, and from the lack of benefit from apparently reasonable clinical interventions, many now believe that most defects are congenital, their association with VUR being a shared dysplasia rather than causal. Consequently, guidelines now argue for less assiduous management. These conclusions ignore adult human transplant evidence, adult pig studies, and clinical anecdotes, which indicate that scars may develop in infant kidneys quicker than urine culture can confirm the diagnosis, and that reflux nephropathy has no age limit. Its rarity over 4 years suggests that most vulnerable children develop scars before then, despite all medical efforts. I argue that preventing such scarring will require better diagnosis of infant UTI, quicker treatment, reliable imaging of scars and VUR, and subsequent protection until VUR resolves. To make a difference, we need more assiduous management, not less, and cannot afford to consider VUR to be a benign condition.
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The aim of the study reported here was to determine whether kidney scarring after urinary tract infections (UTI) in children can be prevented and to identify the risk factors for developing scars. We identified children in the Northern health region of the UK who had been seen to develop scars, identified as new defects on dimercapto-succinic acid (DMSA) scanning. Risk factors were sought by reviewing case-notes and interviews with parents. Twenty girls were identified whose new scarring was strongly associated with having both vesicoureteric reflux (VUR) and a UTI (p = 0.0001); 19/23 (83%) of kidneys exposed to both of these factors developed scars. Children were much more likely to be febrile (94 vs. 30%, p < 0.0001) or unwell (82 vs. 10%, p < 0.0001) during their earlier UTIs when they were of median age 2.8 years (range 0.3-5.0 years) and did not scar, compared to their later UTIs at age 7.3 years (1.2-12.5 years), when they did scar. However, most patients were treated within 1 day of their symptoms for their early UTIs, compared to a wait >or=7 days for later UTIs (p = 0.001). Being febrile or unwell during a UTI does not predict the development of scars, but prompt treatment appears to prevent scarring in children with VUR.
A young child presents to their primary health provider with fever and irritability. How likely is a urinary tract infection? How should a urine sample be collected? How accurate are urinary dipsticks and microscopy compared with culture for the diagnosis? What route and type of antibiotics should be used? What imaging is indicated? Diagnosing and treating children with urinary tract infection presents many questions. This review summarises the most relevant recent primary studies, systematic reviews and guidelines.
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In the NICE guideline on childhood urinary tract infection (UTI), it is assumed that the presence or severity of systemic symptoms, especially fever, predicts for renal scarring, and different management is recommended accordingly. We aimed to test this hypothesis by retrospective case note analysis. Notes of children aged under 5 years referred with a first UTI who were assessed for scarring were reviewed. MAIN OUTCOME CRITERIA: Ability to predict for single or multiple scarring from age, sex, fever, vomiting or anorexia or malaise, or need for hospitalisation, within the age bands used by NICE. There were 51 (65% girls) scarred and 140 (69% girls) unscarred children. Fever, systemic symptoms and hospitalisation were all commoner among younger children (<6 months vs 6 months-3 years vs >3 years; fever 0.67 vs 0.38 vs 0.38; systemic symptoms 0.78 vs 0.62 vs 0.43; hospitalisation 0.67 vs 0.29 vs 0.19; p<0.001 for all). Having vomiting, anorexia or malaise at presentation correlated weakly with single or multiple renal scarring (R(2) = 0.03; p = 0.02), but sex, age, fever or hospitalisation did not (p>0.5 for all). Sensitivity and specificity data, and plots of proportionate reduction of uncertainty showed that none of these variables was useful for predicting any scarring in children aged <3 years and that they were only weakly predictive in older children. Clinical signs at presentation in childhood UTI cannot be used to predict for mild or multiple scarring, and should not be used to guide management. NICE's recommendation to do so is not justified.
Article
To examine the characteristics of primary vesico-ureteric reflux (VUR) in young infants following prenatal hydronephrosis. The study comprised 155 consecutive infants with VUR detected at a mean age of 8.7 weeks (SD 6.3). Reflux units (n = 236) were analysed for relationships between gender, severity of reflux, exposure to urinary tract infection (UTI) and the presence of focal and generalized types of kidney damage on imaging. Bladder wall thickness (from ultrasonography) was examined in comparison with a further group of 29 males without VUR. Male infants predominated (117 of 155, 75%); bilateral VUR affected the same proportion (52%) of males and females. Most kidneys exposed to VUR (158 of 236. 67%) were normal and of the 78 abnormal kidneys (57 without UTI), 53 showed generalized damage (only eight exposed to UTI) and 71 (91%) were associated with severe (grades IV and V) reflux that predominantly affected males (P < 0.001). Grade V reflux was almost exclusively a male disorder. Most female units (45 of 58, 78%) compared with 46% (82/178) of male units had mild (grades I to III) reflux that was independently associated with normal kidneys. The mean bladder wall thickness was significantly greater for males with VUR than for females with VUR and for males without VUR. Two distinct but not exclusive patterns of VUR were identified: (i) mild reflux associated with normal kidneys that affected most females and a proportion of males; (ii) severe reflux combined with kidney damage, most likely fetal in origin, that is almost exclusively a male disorder.