egyptian society of pediatric nephrology and renal

Egyptian Society of Pediatric Nephrology and

Renal Transplantation(ESPNT)

UPDATED PROTOCOLS ( INCLUDING ALGORITHMS )

FOR MANAGEMENT OF URINARY TRACT INFECTION IN

INFANTS AND CHILDREN

BY

Moftah M RabeeaProf. of Pediatrics and Pediatric

NephrologyAl-Azhar University

UTI

Ü UTI: Combination of clinical features andpresence of bacteria in the urine.

Ü Asymptomatic bacteriuria : presence ofbacteria in the urine but no symptoms ofupper or lower UTI .

Ü Bacterial persistence: Re-infection withthe same organism after sterilization of theurine has been documented(-ve culture).

Ü Recurrent UTI: Re-infection by differentorganisms documented on proper urine culture witheach new UTI. You should suspect UT abnormalitiesspecially in infants and young children.

Ü Recurrence of infection:

Ø Two or more episodes of acute pyelonephritis(upper UTI).

Ø Three or more episodes of cystitis (lower UTI).

Ø One episode of upper UTI + one or moreepisodes of cystitis.

Complicated UTI includes :A. Children with known mechanical or functional

obstruction of the UT ( eg . PUJO, PUV, VUR… ).

B. All febrile infants especially neonates withsuspected UTI are likely to be complicated andshould be treated as such.

Uncomplicated UTI:Ü Lower UTI ® easily managed.

Atypical UTI includes:1. Seriously ill child or infant.

2. Poor urine flow.

3. Raised creatinine.

4. Palpable kidneys .

5. Septicaemia.

6. Failure to respond to treatment withsuitable antibiotics within 48 hours.

7. Infection with non E-coli organisms .

Assess symptoms and signs of UTI

Infants and children younger than 3 years

Children 3 years or older

Mainly gen. nonspecific symptoms

Mainly specific symptom and localizing signs

Unexplained fever is one of the commonest presenting symptoms of UTI .

Nonspecific symptoms : Fever, vomiting ,, lethargy ,irritability , poor feeding , failure to thrive…. etc.

Specific symptoms and signs :Ø Lower UTI : Dysuria , frequency ,

incontinence , voiding dysfunctionØ Upper UTI : ,abdominal pain, loin pain

and tenderness , fever ,chills …..etc.

Urine sample collection for diagnosisToilet trained Non toilet trained

• Clean voided midstream is themethod of choice (All recent GLs)

• Suprapubic aspiration or urethral catheter

• Some GLs use the Quick Wee method to get midstream sample

Wee method: Gentle suprapubic stimulation for few minutes using gauze soaked in cold saline urine voiding

NB: Don’t use bag, pads, cotton or sanitary towels.

Urine testing (cont.) Children > 3 years of age

↓ Perform urine dipstick

Positive for LE and nitrite

↓ Diagnose UTI

↓ • Send urine for C/S • Start antibiotic

treatment • Subsequent

treatment is according to result of urine C/S

Positive for nitrite and

negative for LE ↓

Like No.1

Positive for LE and negative for nitrite

↓ • Send urine for C/S • Start antibiotic

treatment only if the patient is clinically unwell

• Treatment depends on the result of urine C/S

Negative for both LE and nitrite

↓ • Unlikely UTI • Explore other

causes of illness

Urine testing for children > 3 years Perform urine dipstick

§ Start ttt§ Send urine

for C/S

If both tests are negative &

no clinical evidence of UTI

other causes of illness should be explored .

Culture interpretationMethod of collection Threshold for diagnosis of UTI

(single organism)

Suprapubic aspiration. Any count/1000CFU/ml

Catheter of bladder. 50,000CFU/ml

Clean catch midstream 50,000CFU/ml

Bagged urine Unreliable.

N.B: Pyuria should be present to

differentiate between true infection andcolonization (AAP- GLs updated).

Some guidelines consider CFU of >10,000/mlobtained by catheter sufficient to diagnose UTIin the presence of pyuria .

Important pointsq You should maintain a high index of suspicion

to diagnose UTI specially in neonates andinfants.

q UTI should be suspected in any infant or childwith unexplained fever (38°C or more).

q UTI must be considered in all children withserious illness even if the infection is outsidethe UT.

q Some cases need to be individuallyevaluated .

q Consider urology consultation if indicatedq (In the presence of UT anomalies

obstruction or voiding dysfunction)q Don’t give empiric antibiotic pending

urine C/S except if the child is clinicallyunwell.

q Don’t treat asymptomatic bacteruria withantibiotics.

Empiric Antibiotics commonly used to treat upper UTIs :

Parenteral

?

Dose (mg/kg/day)Drug

60/12Trimethoprim-Sulfamethoxazole

10Nitrofurantoin

100Amoxicillin-clavulanate

16Cephalosporin – Cefixime

Some empiric oral antibiotics for TTT of cystitis

II - Infants 3mo or older:

consider referral to a pediatric

specialist

Oral treatment is as effective as IV one

for a total of 14 days provided that theinfant is not seriously ill , can tolerate

oral intake and presence of good

compliance to medications

Most recent studies issued for infant with

APN did not show any difference inresponse between infant treated with oral

therapy and those treated with either IV

antibiotics (total course) or those startedIV for 2-3 days and completed a total

course of 14 days with oral therapy.

Ø For infants and children who receive

aminoglycosides (gentamicin or amikacin), once daily dosing is recommended with

serum creatinine estimation

Ø If parenteral treatment is required and IV

treatment is not possible, intramuscular treatment should be considered.

ØAsymptomatic bacteriuria in infants and

children should not be treated with

antibiotics.

ØLaboratories should monitor resistancepatterns of urinary pathogens and make

this information routinely available to

prescribers.

Imaging tests for assessing UTI:

1) Ultrasound à structure of UT.

2) MCUG and indirect radionuclide cystography à detection of VUR & PUV.

3) DMSA (done for 4-6mo after APN) àdetection of renal parenchymal defects or scarring .

4) DTPA and MAG3 for split function of the kidneys , renal scarring and obstruction

indication of Imaging

Renal U/S :all children following febrile UTI

VCUG : recommended in 1- Significant abnormalities on U/S.2- Recurrent UTI

2- Patient with risk factors *.??

Risk factors *

Abnormal prenatal US of the urinary tractFamily history of VUR.Septicemia.Renal failure.Age <6 months in a male infantNo clinical response to correct antibiotic treatment within 48-72 hr.Non-E. coli infection

DMSA scan ( late ), considered in : n Atypical / reccurent UTIn High grade VUR on VCUG .n

Imaging studies

First febrile UTI ↓

Ultrasound (RBUS)

Decide accordingly

DMSA

Follow up

&

Referral

Follow up &

Referral

Good response to tttNo U/S Abnormalities

No routine Follow Up

Abnormal Imaging Recurrent UTI

Pediatric specialist

Severe illness Impaired kidney functionHTNProteinuria Bil. Renal abnormalities

Pediatric Nephrologist

qIf any indicated investigation is

not available, refer the patient

immediately

qAsymptomatic bacteriuria with

normal UT is not an indication

for regular follow-up.

Urological consultation

Renal anomalies

Obstruction

Voiding dysfunction

Antibiotic prophylaxis :

Prophylactic TTT can be considered in :

1- Recurrent UTI 2- High grade VUR (IV-V)…..?3- Immunocompromised children

ReferencesMost recent guidelines for management and

imaging studies of UTI (2015 – 2018)nNational Institute of Clinical Excellence (NICE, 2017).nAmerican Academy of Pediatrics (AAP updated).nAmerican Academy of Family Physicians nNorth California GLs of ped. UTI (2018)nCanadian Pediatric Society GLs (2017).nAustralian College of Pediatricians (2016).nRoyal cornwall hospitals : NHS-trust (2017).nClin. Ped. Nephr. (2017).nItalian Society of Ped. Nephr. (ISPN 2016).nEur. Society of Ped. Urology (ESPU 2015)

MCQ

A- Which one of the following manifestations can differentiate between upper and lower UTI:

1- frequency of micturation2- Abdominal pain3- Marked crying4- Fever

B- During routine screening of a healthy preschool boy, klebsiellabacteruria was found and no other findings. Wich one of the following therapy is recommended for TTT:

1- Amoxicilline2- Cefexime3- cefotaxime4- No TTT

C- VCUG is considered in the following conditions except:

1- Recurrent UTI2- U/S showing HU and HN3- Renal scarring detected by DMSA

scan4- Perinephric abscess