1. Workup of febrile UTI in a child Department of Urology and Renal Transplant Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow

2. Background Difficult to recognise UTI in children Non-specific symptoms, particularly in children under 3 years May be the first sign of upper tract abnormalities

3. Symptoms in pre school and schoolchildren In pre school child Fever Vomiting, diarrhea, abdominal pain Strong-smelling urine, enuresis, dysuria, urgency, frequency In a school going child All of the above may be present in a school going child also Flank pain New enuresis In adolescents – similar to adults

4. Physical findings associated with serious underlying pathology 1.Dribbling, poor stream, associated skin excoriation 2.Meatal stenosis/phimosis 3.Labial fusion 4.Diminished anal sphincter tone 5.Fecal accumulation 6.Examination of the lower spine: a)sacral agenesis b)evidence for occult spinal dysraphism i.hairy patch ii.sacral dimple or tract iii.abnormal gluteal fold iv.Lipoma v.bony irregularity 7.Hypertension 8.Abdominal tenderness or mass/palpable bladder 9.Costovertebral angle tenderness 10.Always look for signs of sexual abuse

5. Objectives of workup Who should be tested? Best method for collection of urine? Interpret the urinalysis/culture – how to diagnose? When is imaging needed?

6. Recommendations and Guidelines No universally accepted work-up for children with UTI’s Lack of consensus among different guidelines Complex approaches; Regional variations – Multiple tables dividing children into different age groups – Classifying UTI’s into different variants – Nature and timing of imaging studies

7. Objectives of workup 1.Who should be tested? 2.Best method for collection of urine? 3.Interpret the urinalysis/culture – how to diagnose? 4.When is imaging needed?

8. Diagnosis – Urine culture 1.Unexplained fever 38°C or higher # (for more than 2 days in girls and 24 hr in boys*) 2.Symptoms of UTI (in older children)  Must have a urine culture after 24 hours at the latest.  Assess the risk of serious illness.  Start antibiotics. No need to wait for culture results. # NICE 2007 *AAP 2011

9. AAP 2011 consensus statements 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.” 2.If a clinician assesses a febrile infant with no apparent source for the fever as not being so ill as to require immediate antimicrobial therapy, then the clinician should assess the likelihood of UTI* *This is a change from 1999 guidelines where clinical factors were not considered and all children were tested for UTI

10. Probability of UTI Among Febrile Infant Girls28 and Infant Boys30 According to Number of Findings Present. aProbability of UTI exceeds 1% even with no risk factors other than being uncircumcised. Subcommittee on Urinary Tract Infection, Steering Committee on Quality Improvement and Management Pediatrics 2011;128:595-610 ©2011 by American Academy of Pediatrics

11. AAP 2011 consensus statement 2 If likelihood of UTI 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.

12. Interpreting culture report The culture needs to be a quantitative culture mentioning colony counts A clean-catch urine sample – more than 50,000 colony-forming units* (CFU) of a single organism is classic criteria for UTI. If the specific gravity of the urine is low, even lower counts may be significant. – Therefore, Judgment must be used in interpreting a specimen that reports ANY growth. *AAP 2011 – A change from 1999 guidelines where Various thresholds for culture (10-100K) were proposed

13. Localization of UTI Generally a clinical process Bacteriuria and fever of 38°C or higher Acute pyelonephritis/upper urinary tract infection Bacteriuria, loin pain/tenderness and fever <38°C Acute pyelonephritis/upper urinary tract infection Bacteriuria but no systemic features Cystitis/lower urinary tract infection Not able to localize – can use ultrasound with doppler or DMSA scan. NICE guidelines

14. Radiologic evaluation of First UTI in children All children with proven UTI require an evaluation with imaging studies to look for – anatomic abnormalities – reflux.

15. Goals of imaging after 1 st UTI Identify significant urinary tract abnormalities Prevent recurrent UTI’s and further renal damage

16. Radiologic evaluation – When? Controversial – If obstruction is suspected – If not responding to treatment as expected, – Unusually ill, or extenuating circumstances Do within 48 hours* – Otherwise Do when convenient Typically delayed for 3-6 weeks after the infection as part of outpatient follow-up* AAP guidelines 2011

17. Ultrasound Ultrasound * – In UTI responding to antibiotics within 48 h Do within 6 weeks. Wait for acute episode to get over  If abnormal, do MCU. – In atypical UTI Do during the acute episode. – In recurrent UTI Do during the acute episode in a child <3 y Can wait till 6 weeks in a child >3 y * NICE guidelines

18. Ultrasound –Why? Febrile child with UTI should have an USG done – Why? Yield of abnormal findings: 12–16% Detect risk factor for permanent renal damage (typically occurs 1 year later). USG picks significant risk factor for permanent damage with – Sensitivity: 41% – Specificity: 81%

19. Normal USG To be considered normal, the US must demonstrate that – The kidneys are of normal and equal size, – without scarring – No hydro-(uretero)nephrosis. – The bladder must empty completely and not be thick walled.

20. Interpretation of a Normal USG Confidently excludes major urinary tract obstruction significant enough to cause most UTI Does not exclude vesico-ureteral reflux – This diagnosis is probably the most important therapeutic consideration for a child with UTI – VUR needs some type of intervention

21. Abnormal USG findings Dilatation of at least 1 calyx Anteroposterior (AP) diameter of the renal pelvis > 7 mm ureteral diameter > 5 mm Focal scarring Difference of > 10% of length between kidneys or renal length > 2 standard deviations above mean Bladder abnormality

22. Differential diagnoses on USG Ultrasound adequately depicts kidney size and shape But it poorly depicts ureters and provides no information on function. A renal ultrasound can diagnose – urolithiasis, – hydronephrosis, – hydroureter, – ureteroceles, – bladder distention – has replaced the intravenous pyelogram (IVP) in many cases

23. MCU Adequately depicts urethral and bladder anatomy Detects vesicoureteral reflux (VUR).

24. MCU in all is not justified. Disadvantages – Instrumentation – Cost – Over investigation in toilet trained girls with only cystitis But – VUR leads to renal injury – Anatomic abnormalities need to be ruled out in any case – Concern about delay in diagnosis and subsequent renal scarring

25. Indications for MCU – NICE guidelines MCU* – Do in atypical or recurrent UTI in infants <6 months. – In cases of abnormal ultrasound – hydronephrosis – Poor urine flow in age <3y – Non E.Coli infection in age <3y – Family history of VUR in age <3y *NICE guidelines

26. MCU – AAP guidelines Not recommended to be performed routinely after the first febrile UTI if USG is normal.* Indications – abnormal ultrasound – 2 nd episode of UTI Prophylactic antibiotics till the patient is waiting for MCU are not recommended. * *AAP 2011 – a change from 1999 guidelines where MCU was done in all, and prophylactic antibiotics were recommended till the patient was waiting for MCU

27. DMSA Normal Renal Scarring

28. DMSA – in whom and when? less than 3y age * – In cases of atypical or recurrent UTI, do following 4-6 months of acute infection More than 3y age* – do only in cases of recurrent UTI, following 4-6 months of acute infection Acute imaging – no. Why? Delayed DMSA is the Gold standard for detection of parenchymal defects *NICE Guidelines

29. DMSA top down approach MCU is an invasive investigation Most of the reflux will resolve So, do a DMSA first, and only if scars present, do an MCU. It will prevent unnecessary MCUs