Professional Documents
Culture Documents
TM
AAP Guideline for the Diagnosis and Management of UTIs in Febrile Infants
Unanswered Questions and Unquestioned Answers
Kenneth B. Roberts, MD, FAAP Professor of Pediatrics (Emeritus) University of North Carolina
TM
Disclaimers
Statements and opinions expressed are those of the authors and not necessarily those of the American Academy of Pediatrics.
Mead Johnson sponsors programs such as this to give healthcare professionals access to scientific and educational information provided by experts. The presenter has complete and independent control over the planning and content of the presentation, and is not receiving any compensation from Mead Johnson for this presentation. The presenters comments and opinions are not necessarily those of Mead Johnson. In the event that the presentation contains statements about uses of drugs that are not within the drugs' approved indications, Mead Johnson does not promote the use of any drug for indications outside the FDA-approved product label.
TM
TM
TM
Evidence Quality
Recommendation
Option No Recommendation
TM
Evidence Quality
X. Exceptional situations
where validating studies cannot be performed and there is a clear preponderance of benefit or harm
Recommendation
TM
TM
TM
TM
2. Treatment: Oral as effective as parenteral 3. Imaging: Voiding cystourethrography (VCUG) not recommended routinely after first febrile UTI 4. Follow-up: Emphasis on urine testing with subsequent febrile illnesses
TM
Population Addressed
Infants and young children, 224 months of age, with unexplained fever
Rate of UTI: ~5% Rate of scarring: Higher than in older children
TM
Population Addressed
Infants and young children, 224 months of age, with unexplained fever Rate of UTI: ~5% Rate of scarring: Higher than in older children Excludes: <2 months of age Excludes: >24 months of age
TM
Content
Action Statements: 7 Diagnosis: 3 Treatment: 1 Imaging: 2 Follow-up: 1 Areas for Research: 8
TM
Action Statement 1
If a clinician decides that a febrile infant with no apparent source for the fever requires antimicrobial therapy because of ill appearance or another pressing reason, a urine specimen should be obtained by catheterization for both culture and urinalysis before an antimicrobial is given.
TM
TM
Positive culture requires confirmation, which is not possible once antibiotic is started.
TM
Requires some skill, particularly in small infant girls. (Tip: If unsuccessful, leave catheter in.)
TM
Action Statement 2
If a febrile infant is assessed as not requiring immediate antimicrobial therapy, then the likelihood of UTI should be assessed.
If likelihood is low (<1%, <2%), it is reasonable to follow the child clinically. If the likelihood is not low, there are two options:
Obtain specimen by catheter for culture and urinary analysis (UA). Obtain specimen by any means for UA and only culture those with positive UA.
TM
Race: White Age: <12 months Temperature: 39C Fever: 2 days Absence of another source of infection
No more than 1
No more than 2
2%
TM
2%
None
No more than 3
*Probability of UTI exceeds 1% even with no risk factors other than being uncircumcised.
TM
Action Statement 3
Diagnosis of UTI requires both:
Positive culture
50,000 cfu/mL of uropathogen cultured from catheter specimen, AND
Positive urinalysis
TM
Kass E. Asymptomatic infections of the urinary tract. Trans Assoc Am Phys. 1956;69:5664
TM
Urinalysis
Positive urinalysis required for diagnosis
Positive culture with negative urinalysis
Contamination Asymptomatic bacteriuria Urinalysis not sensitive enough
Positive
Dipstick: +LE (leukocyte esterase) and/or +nitrite Microscopy: White blood cells bacteria
TM
Action Statement 4
Choice of route: Initiating treatment orally or parenterally is equally efficacious, so choice is based on practical considerations.
TM
Action Statement 4
Choice of route: Initiating treatment orally or parenterally is equally efficacious, so choice is based on practical considerations.
Evidence quality: A Strong recommendation
Choice of drug: Based on local sensitivity patterns, adjusted according to sensitivity of particular uropathogen
TM
Action Statement 4
Choice of route: Initiating treatment orally or parenterally is equally efficacious, so choice is based on practical considerations.
Choice of drug: Based on local sensitivity patterns, adjusted according to sensitivity of particular uropathogen
TM
Action Statement 5
Febrile infants with UTIs should undergo renal and bladder ultrasonography (RBUS),
TM
Action Statement 5
Febrile infants with UTIs should undergo RBUS.
Why:
TM
Action Statement 5
Febrile infants with UTIs should undergo RBUS.
When:
Decide clinically: Within 48 hours if not responding to treatment as expected, unusually ill, or extenuating circumstances; otherwise, when convenient.
TM
Action Statement 6
VCUG is not recommended to be performed routinely after the first febrile UTI if RBUS is normal.
TM
TM
Action Statement 6
1. Garin EH, Olavarrio F, Garcia Nieto V, et al. Clinical significance of primary vesicoureteral reflux and urinary antibiotic prophylaxis after acute pyelonephritis: a multicenter, randomized controlled study. Pediatrics. 2006;117(3):626632 2. Pennesi M, Travan L, Peratoner L, et al. Is antibiotic prophylaxis in childrfen with vesicoureteral reflux effective in preventing pyelonephritis and renal scars? A randomized controlled trial. Pediatrics. 2008;121(6):e1489e1494 3. Montini G, Rigon L, Zuccheta P, et al. Prophylaxis after first febrile urinary tract infection in children? A multicenter, randomized, controlled, noninferiority trial. Pediatrics. 2008;122(5):10641071 4. Roussey-Kesler G, Gadjos V, Idres N, et al. Antibiotic prophylaxis for the prevention of recurrent urinary tract infection in children with low grade vesicoureteral reflux results from a prospective randomized study. J Urol. 2008;179(2):674679 5. Craig JC, Simpson JM, Williams GJ, et al. Antibiotic prophylaxis and recurrent urinary tract infection in children. N Engl J Med. 2009;361(18):17481759 6. Brandstrm P, Esbjrner E, Herthelius M, et al. The Swedish reflux trial in children: III. Urinary tract infection pattern. J Urol. 2010;184(1):286291
TM
Action Statement 6
Reflux Grade N Prophylaxis
# of Recurrences / Total N
No Prophylaxis
# of Recurrences / Total N
None
Grade I Grade II Grade III Grade IV
373
72 257 285 104 1,091
7 / 210
2 / 37 11 / 133 31 / 140 16 / 55
11 / 163
2 / 35 10 / 124 40 / 145 21 / 49
0.15
1.00 0.95 0.29 0.14
TM
NS
200 150 100 50 0 None Grade I
No Prophylaxis
NS
NS
NS
NS
Grade II
Grade III
Grade IV
TM
NS NS NS NS NS
Grade of VUR
TM
Action Statement 6
If RBUS is abnormal, VCUG may be part of additional imaging required to evaluate the abnormality.
TM
Action Statement 6
After First UTI (N=100) 65 (65%)
29 (29%)
5 (5%) 1 (1%)
TM
Action Statement 6
100% 80% 60% 40% 20% 0% 1 2 3 4 5
TM
Impact of a More Restrictive Approach to Urinary Tract Imaging After Febrile Urinary Tract Infection
N=103 By restricting urinary tract imaging after an initial febrile UTI [based on NICE guidelines, 2007], rates of voiding cystourethrography and prophylactic antibiotic use decreased substantially without increasing the risk of UTI recurrence within 6 months and without an apparent decrease in detection of high-grade VUR.
Schroeder AR, Abidari JM, Kirpekar R, et al. Impact of a more restrictive approach to urinary tract imaging after febrile urinary tract infection. Arch Pediatr Adolesc Med. 2011;165(11):10271032
TM
Childhood Urinary Tract Infections as a Cause of Chronic Kidney Disease N=1,576 VUR with UTI without structural abnormalities in the kidneys seems not to cause CKD. Active treatment of VUR seems not to reduce the occurrence of CKD and, in large prospective followup studies, the renal function of patients with VUR has been well preserved.
Salo J, Ikheimo R, Tapiainen T, et al. Childhood urinary tract infections as a cause of chronic kidney disease. Pediatrics. 2011;128(5):840847
TM
Action Statement 7
Following confirmation of UTI, parents or guardians should be instructed to seek prompt medical evaluation for future febrile illnesses to ensure that recurrent infections can be detected and treated promptly.
TM
TM
2. Treatment: Oral as effective as parenteral 3. Imaging: VCUG not recommended routinely after first febrile UTI 4. Follow-up: Emphasis on urine testing with subsequent febrile illnesses
TM