Presentation on theme: "Unanswered Questions and Unquestioned Answers"— Presentation transcript:
1Unanswered Questions and Unquestioned Answers TMPrepared for your next patient.AAP Guideline for the Diagnosis and Management of UTIs in Febrile InfantsUnanswered Questions and Unquestioned AnswersKenneth B. Roberts, MD, FAAPProfessor of Pediatrics (Emeritus)University of North CarolinaWelcome slide for use during audience walk-in.
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3AAP 2011 Clinical Practice Guideline Diagnosis and Management of the Initial UTI in Febrile Infants and Children, 2 to 24 Months**Guideline: Pediatrics. 2011;128(3):595–610Technical report: Pediatrics. 2011;128(3):e749–e770
4Revision of 1999 GuidelineRoutine for American Academy of Pediatrics (AAP) to revise guidelinesNew evidence since 1999New explicit reporting format“Recommendations” now “Action Statements”Aggregate evidence qualityBenefitsHarms/risks/costsBenefit-harms assessmentValue judgmentsRole of patient preferencesExclusionsIntentional vaguenessPolicy level (strength of recommendation)
5Preponderance of Benefit or Harm Balance of Benefit and Harm Evidence QualityPreponderance of Benefit or HarmBalance of Benefit and HarmA. Well-designed RCTs or diagnostic studies on relevant populationStrong RecommendationB. RCTs or diagnostic studies with minor limitations; overwhelmingly consistent evidence from observational studiesC. Observational studies (case-control and cohort design)RecommendationD. Expert opinion, case reports, reasoning from first principlesOptionNo RecommendationOptionAbbreviation: RCTs, randomized controlled trials.
6Preponderance of Benefit or Harm Evidence QualityPreponderance of Benefit or HarmX. Exceptional situations where validating studies cannot be performed and there is a clear preponderance of benefit or harmStrong RecommendationRecommendation
7AAP Subcommittee on Urinary Tract Infection (UTI) Stephen M. Downs, MD, MS: Epidemiology/informaticsS. Maria E. Finnell, MD, MS: Epidemiology/informaticsStanley Hellerstein, MD: Pediatric nephrologyKenneth B. Roberts, MD, Chair: General pediatricsLinda D. Shortliffe, MD: Pediatric urologyEllen R. Wald, MD: Pediatric infectious diseasesJ. Michael Zerin, MD: Pediatric radiologyCaryn Davidson, MA: AAP staff
10What’s New in This Revision DiagnosisAbnormal urinalysis as well as positive culturePositive culture = ≥50,000 colony-forming units (cfu)/mLAssessment of likelihood of UTITreatment: Oral as effective as parenteralImaging: Voiding cystourethrography (VCUG) not recommended routinely after first febrile UTIFollow-up: Emphasis on urine testing with subsequent febrile illnesses
11Population AddressedInfants and young children, 2–24 months of age, with unexplained feverRate of UTI: ~5%Rate of scarring: Higher than in older children
12Population AddressedInfants and young children, 2–24 months of age, with unexplained feverRate of UTI: ~5%Rate of scarring: Higher than in older childrenExcludes: <2 months of ageExcludes: >24 months of age
14Action Statement 1If 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.Evidence quality: AStrong recommendation
15Methods of Collecting Specimen Suprapubic aspiration: “Gold standard,” butVariable success rates: 23–90% (higher with ultrasound guidance)Requires technical expertise and experienceOften viewed as invasiveMore painful than catheterizationMay be no alternative in boys with severe phimosis or girls with tight labial adhesions
16Methods of Collecting Specimen Bag urineCan’t avoid getting “vaginal wash” in girl or contamination in uncircumcised boy.Not suitable for culture.Negative culture rules out UTI, butPositive culture likely to be false-positive88% false-positive overall95% in boys99% in circumcised boysPositive culture requires confirmation, which is not possible once antibiotic is started.
17Methods of Collecting Specimen CatheterizationCompared to suprapubic aspiration:Sensitivity = 95%Specificity = 99%Requires some skill, particularly in small infant girls. (Tip: If unsuccessful, leave catheter in.)
18Action Statement 2If 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.
19Probability of UTI: Infant GIRLS Individual FactorsProbability of UTI# of Factors PresentRace: WhiteAge: <12 monthsTemperature: ≥39⁰CFever: ≥2 daysAbsence of another source of infection≤1%No more than 1≤2%No more than 2
20Probability of UTI: Infant BOYS Individual FactorsProbability of UTI# of Factors PresentRace: NonblackTemperature: ≥39⁰CFever: >24 hoursAbsence of another source of infectionCircumcisedNoYes≤1%*No more than 2≤2%NoneNo more than 3*Probability of UTI exceeds 1% even with no risk factors other than being uncircumcised.
21Action Statement 3 Diagnosis of UTI requires both: Positive culture ≥50,000 cfu/mL of uropathogen cultured from catheter specimen, ANDPositive urinalysisEvidence quality: CRecommendation
22Where Did 100,000 Come From?>106Kass E. Asymptomatic infections of the urinary tract. Trans Assoc Am Phys. 1956;69:56–64
23Urinalysis Positive urinalysis required for diagnosis Positive Positive culture with “negative” urinalysisContaminationAsymptomatic bacteriuriaUrinalysis not sensitive enoughPositiveDipstick: +LE (leukocyte esterase) and/or +nitriteMicroscopy: White blood cells ± bacteria
24Action Statement 4Choice of route: Initiating treatment orally or parenterally is equally efficacious, so choice is based on practical considerations.Evidence quality: AStrong recommendation
25Action Statement 4Choice of route: Initiating treatment orally or parenterally is equally efficacious, so choice is based on practical considerations.Evidence quality: AStrong recommendationChoice of drug: Based on local sensitivity patterns, adjusted according to sensitivity of particular uropathogen
26Action Statement 4Choice of route: Initiating treatment orally or parenterally is equally efficacious, so choice is based on practical considerations.Evidence quality: AStrong recommendationChoice of drug: Based on local sensitivity patterns, adjusted according to sensitivity of particular uropathogenDuration of treatment: 7–14 daysEvidence quality: BRecommendation
27Action Statement 5Febrile infants with UTIs should undergo renal and bladder ultrasonography (RBUS),Evidence quality: CRecommendation
28Action Statement 5 Febrile infants with UTIs should undergo RBUS. Why: Evidence quality: CRecommendationWhy:Yield of abnormal findings: 12–16%Permanent renal damage (1 year later)Sensitivity: 41%Specificity: 81%Actionable findings sufficient to warrant?
29Action Statement 5 Febrile infants with UTIs should undergo RBUS. Evidence quality: CRecommendationWhen:Decide clinically: Within 48 hours if not responding to treatment as expected, unusually ill, or extenuating circumstances; otherwise, when convenient.
30Action Statement 6VCUG is not recommended to be performed routinely after the first febrile UTI if RBUS is normal.Evidence quality: BRecommendation
31Vesico-Ureteral Reflux Law &OrderVesico-Ureteral Reflux
32Action Statement 6Garin 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):626–632Pennesi 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):e1489–e1494Montini 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):1064–1071Roussey-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):674–679Craig JC, Simpson JM, Williams GJ, et al. Antibiotic prophylaxis and recurrent urinary tract infection in children. N Engl J Med. 2009;361(18):1748–1759Brandström P, Esbjörner E, Herthelius M, et al. The Swedish reflux trial in children: III. Urinary tract infection pattern. J Urol. 2010;184(1):286–291
33Action Statement 6 Reflux Grade N Prophylaxis No Prophylaxis P None # of Recurrences / Total NNone3737 / 21011 / 1630.15Grade I722 / 372 / 351.00Grade II25711 / 13310 / 1240.95Grade III28531 / 14040 / 1450.29Grade IV10416 / 5521 / 490.141,091
34Grade of Vesico-Ureteral Reflux (VUR) Recurrence Rate of Febrile UTI By Reflux Grade, 1,091 Infants 2–24 MonthsNSNSNSNSNSGrade of Vesico-Ureteral Reflux (VUR)
35Recurrence Rate of Febrile UTI By Reflux Grade, 1,091 Infants 2–24 Months NSNSNSNSNS(N=373) (N=100) (N=257) (N=285) (N=104)Grade of VUR
36Action Statement 6If RBUS is abnormal, VCUG may be part of additional imaging required to evaluate the abnormality.Evidence quality: BRecommendationFurther evaluation should be conducted if there is a recurrence of febrile UTI.Evidence quality: X
37Action Statement 6 Grade IV VUR 5 (5%) 1.2 (12%) Grade V VUR 1 (1%) After First UTI(N=100)After Recurrence(N=10)No VUR65 (65%)2.6 (26%)Grade I–III VUR29 (29%)5.6 (56%)Grade IV VUR5 (5%)1.2 (12%)Grade V VUR1 (1%)0.6 (6%)
38Risk of Renal Scarring by Number of UTIs Action Statement 6Risk of Renal Scarring by Number of UTIsAdapted from Jodul U. The natural history of bacteriuria in childhood. Infect Dis Clin North Am. 1987;1(4):713–729
39Impact of a More Restrictive Approach to Urinary Tract Imaging After Febrile Urinary Tract Infection “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):1027–1032
40Childhood Urinary Tract Infections as a Cause of Chronic Kidney Disease “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 follow-up studies, the renal function of patients with VUR has been well preserved.”Salo J, Ikäheimo R, Tapiainen T, et al. Childhood urinary tract infections as a cause of chronic kidney disease. Pediatrics ;128(5):840–847
41Action Statement 7Following 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.Evidence quality: CRecommendation
42Areas for Research (8)Relationship between UTIs and reduced renal function / hypertensionAlternatives to invasive collection of urine and cultureRole of VUR (and, thus, VCUG)Role of prophylaxis (Randomized Intervention for Children with Vesicoureteral Reflux [RIVUR] study)GeneticsHispanicsFurther treatment: What and for whom?Duration of treatment
43Summary: What’s New . . . Diagnosis Abnormal urinalysis, as well as positive culturePositive culture = ≥50,000 cfu/mLAssessment of likelihood of UTITreatment: Oral as effective as parenteralImaging: VCUG not recommended routinely after first febrile UTIFollow-up: Emphasis on urine testing with subsequent febrile illnesses
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