Pediatric Urinary Tract Infections

Joshua A. Hodge, Maj, USAF, MC Staff Family Physician Andrews AFB, MD

Overview
‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ Background Diagnosis Treatment Follow up Prevention Imaging Vesiculoureteral reflux (VUR) Summary

Background ‡ Most common serious bacterial infection in young children ± 5% of febrile infants ‡ Prevalence ± By age 7: 8% girls. coli. 2% boys ± Highest rate in first year of life ± Higher in Caucasians ± Higher in uncircumcised boys ‡ Most common organism: E.80% .

Background ‡ Symptoms systemic in early childhood ± Fever* ± Irritability ± Lethargy ± Anorexia ± Emesis ‡ Potential sequelae ± Renal scarring ± Chronic renal failure ± HTN .

Background ‡ Anatomic risk factors ± Vesiculoureteral reflux (VUR) ‡ More common in girls ± Obstruction ± Posterior urethral valves ‡ Boys ± Voiding dysfunction ± Bladder diverticulum .

Background ‡ Associated risk factors ± Constipation ± Encoporesis ± Bladder instability ± Infrequent voiding ‡ Unsubstantiated risks ± Bathing ± Back-to-front wiping .

000 cfu/mL ± Urine bags not recommended .000 cfu/mL ± Catheter specimen > 10.Diagnosis ‡ Single organism identified on culture ± Suprapubic aspirate > 1.000 cfu/mL ± Clean catch specimen > 100.

e.005) ‡ Neg nitrate and leuk esterase ‡ Negative predictive value > 95% ‡ Blood cultures not useful . older children with classic symptoms ± Useful if low likelihood of UTI ‡ Non-dilute urine (sg > 1.Diagnosis ‡ Urinalysis ± Not helpful if clinical suspicion high ‡ i.

Treatment ‡ Initiate immediately after culture drawn ± Reduces severity of renal scarring ‡ Oral route preferred ‡ 7-14 day course is standard ± 2-4 days appears to be as effective ‡ Not yet recommended .

Treatment Antibiotic Amoxicillin* Cefixime (Suprax) Cefpodoxime (Vantin) Cefprozil (Cefzil) Cephalexin (Keflex) Loracarbef (Lorabid) Sulfisoxazole (Gantrisin) Daily Dosage 20-40mg/kg in 3 doses 8mg/kg in 2 doses 10mg/kg in 2 doses 30mg/kg in 2 doses 50-100mg/kg in 4 doses 15-30mg/kg in 2 doses 120-150mg/kg in 4 doses Trimethoprim/ 6-12mg/kg & 30-60mg/kg Sulfamethoxazole (Bactrim) In 2 doses .

Subcommittee on Urinary Tract Infection. Practice parameter: the diagnosis.Follow Up ‡ AAP Recommendation: 48 hours ± If not improving repeat culture & immediate renal ultrasound ± No evidence to support repeat culture/test of cure Committee on Quality Improvement. .103:843-52. and evaluation of the initial urinary tract infection in febrile infants and young children. treatment. Pediatrics 1999.

Prevention ‡ Rates of recurrence ± 12% of children < 5 years old ± 18% of infants < 6 months ‡ Prophylactic antibiotics ± Recommended by AAP while waiting for imaging ± Efficacy questioned .

Prevention Antibiotic Methenamine mandelate (Mandelamine) Nalidixic acid (NegGram) Nitrofurantoin (Macrobid) Sulfisoxazole (Gantrisin) Trimethoprim/ sulfamethoxazole (Bactrim) Daily Dosage 75mg/kg in 2 doses 30mg/kg in 2 doses 1-2mg/kg once per day 10-20mg/kg in 2 doses 2mg/kg & 10mg/kg nightly or 5mg/kg & 25mg/kg 2x/week .

Prevention ‡ Circumcision ± Lowers UTI rate in boys ‡ NNT = 111 to prevent one UTI ± Surgical complication rate = 1% ± Benefit does not outweigh risk and not recommended .

Imaging ‡ Who to image? ± AAP ‡ All children 2 months to 2 years of age with first UTI ‡ Renal ultrasound ‡ Cystogram ±Voiding cystourethrogram (VCUG) ±Radionuclide cystogram (RNC) .

.Imaging ‡ Who to image? ± Cincinnati Children¶s Hospital ‡ All boys ‡ Girls < 36 months ‡ Girls 3-7 with fever > 38.5º C (101. Cincinnati. Ohio: Cincinnati Children¶s Hospital Medical Center. 2005.3º F) ‡ Same modalities recommended as AAP Evidence based clinical practice guideline for medical management of first time acute urinary tract infection in children 12 years of age or less.

Imaging ‡ Renal ultrasound ± GU tract anatomy ± Evaluate renal scarring ‡ DMSA (renal cortical scan) ± Differentiates pyelonephritis from cystitis ± Assesses renal scarring .

identify and grade vesicoureteral reflux (VUR) ± Voiding cystourethrogram (VCUG) ‡ OK for girls and boys ‡ Demonstrates GU anatomy plus VUR ± Radionuclide cystogram (RNC) ‡ Low amount of radiation ‡ Girls only ±Little anatomic detail .Imaging ‡ Cystogram.

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<1% .1% ± Grade V.7% ± Grade II.22% ± Grade III.Vesicoureteral Reflux (VUR) ‡ Concern for pyelonephritis & renal scarring ‡ Prevalence in females < 18 yo ± Grade I.6% ± Grade IV.

Vesicoureteral Reflux ‡ Standard treatment options ± Antibiotics ‡ Studies of prophylactic antibiotics have not included children with VUR ± Surgery ± Antibiotics + surgery .

Vesicoureteral Reflux ‡ Unclear if clinical benefits to treating VUR ± Only severe VUR (Grades IV & V) associated with recurrent UTI and pyelonephritis ‡ < 2% of all cases of VUR ‡ No causal relationship with scarring ± Risk of UTI = between surgical & medical groups ± Abx + surgery reduced # of UTIs and pyelo but no renal damage noted in either group at 5 years Wheeler DM. 2004(3):CD001532 . et al. Cochrane Database Syst Rev. Interventions for primary VUR.

Summary ‡ Urine culture necessary for diagnosis ‡ Short courses of antibiotics may be as effective as longer courses ‡ Prophylactic antibiotics are an option but may not provide much clinical benefit ‡ Routine imaging does not appear to affect outcomes ‡ Diagnosing VUR does not appear to affect outcomes .

Curry SH. and evaluation of the initial urinary tract infection in febrile infants and young children. 2005. Pediatrics 1999.157:1237-40. Arch Pediatr Adolesc Med 2003. Ohio: Cincinnati Children¶s Hospital Medical Center. et al. Subcommittee on Urinary Tract Infection. ‡ Evidence based clinical practice guideline for medical management of first time acute urinary tract infection in children 12 years of age or less. Follow-up urine cultures and fever in children with urinary tract infection. treatment. Short versus standard duration oral antibiotic therapy for acute urinary tract infection in children. Am Fam Physician 2005. Cincinnati. et al. Practice parameter: the diagnosis. ‡ Michael M. ‡ Committee on Quality Improvement. ‡ Currie ML.72:2483-8.(4):CD003966 .References ‡ Alper BS. Cochrane Database Syst Rev 2004. Urinary tract infection in children.103:843-52.

Lee A. Am Fam Physician 2000. Craig JC. ‡ Le Saux N. Macdessi J. et al. 163:523-9.References ‡ Roberts KB. et al. . ‡ Williams GJ. Circumcision for the prevention of urinary tract infection in boys: a systematic review of randomized trials and observational studies. Long-term antibiotics for preventing recurrent urinary tract infection in children.(3):CD001532. Cochrane Database Syst Rev 2004. ‡ Singh-Grewal D. Craig J. The AAP practice parameter on urinary tract infections in febrile infants and young children. CMAJ 2000. Pham B. Cochrane Database Syst Rev 2004. Arch Dis Child 2005. ‡ Wheeler DM.90:853-58.62:1815-22. ‡ Michael M. Mohoer D. Short compared with standard duration of antibiotics treatment for urinary tract infection: a systematic review of randomised controlled trials.87:118-23. Evaluating the benefits of antimicrobial prophylaxis to prevent urinary tract infections in children: a systematic review.(4):CD001534. Arch Dis Child 2002. Interventions for primary vesicoureteric reflux.