1. Marisa Seepersaud MBBS MRCS DM
The surgical significance of urinary tract infections (UTIs) in children
Marisa Seepersaud
MBBS MRCS DM

2. 2011 (Sarah Amin) Brandon Seepersaud
Records were poor
22 patients , age 5 and under , who were treated for UTI at the GPHC
Urinalysis: All
Urine culture: 4/22 (18%)
Abdominal ultrasound: 7/22 (32%) (2 “enlarged kidneys”, 5 Normal study)
2 referrals to urology1 PUV

3. Urinary Tract Infection (UTI)
UTIs are among the most common bacterial infections in children under 2 yrs old
The diagnosis is often missed on history and physical examination

4. Recent Recommendations
AAP, American Academy of Pediatrics , (1999) 2013
Consensus Document, Management of UTI in Jamaican Children, (2005), August 2011
NICE, National Institute for Health and Care Excellence, UK (2007) May 2011

5. Incidence ~1% of children below age 1
~ 5 % of febrile children*, months of age
7.5% girls, 10% uncircumcised males, 2.5% of circumcised males who present with a fever under 2yrs

6. Clinical significance of UTI
Associated with life-threatening sepsis in the newborn
Increased rates of renal scarring in young children
hypertension
chronic kidney disease
 pregnancy induced hypertension

7. Urinary tract infections may occur as a result of structural anomalies of the urinary tract
There are many factors which potentially contribute to the development of UTIs in children. They include bacteriological factors (type of organism, virulence factors) as well as host factors (colonisation of the perineum with uropathogens, dysfunctional voiding, immunologic factors as well as anatomic abnormalities of the urianry tract.

8. The diagnosis of urinary tract infection in a young child is an important marker for urinary tract abnormalities Mandates investigation
Minimize the risk of development of chronic kidney disease secondary to urological abnormalities

9. Important to accurately make the diagnosis
Under-diagnosing UTI may lead to under-treatment, under-investigation, and risks permanent renal damage

10. Risk of renal scarring with recurrent UTI Jodul U
Risk of renal scarring with recurrent UTI Jodul U. The natural history of bacteriuria in childhood. Infect Dis Clin North Am. 1987;1(4):713–729

11. Important to accurately make the diagnosis
Over-diagnosing UTI may result in the development of resistant organisms, the use of limited resources for un-necessary and expensive investigations, (uncomfortable/painful/ scary for patient; distressing for the parents)

12. Most common  Least common Infants younger than 3 months Fever
Age group
Symptoms and signs
Most common  Least common
Infants younger than 3 months
Fever
Vomiting
Lethargy
Irritability
Poor feeding
Failure to thrive
Infants older than 3 months, and children
Preverbal
Abd pain
Loin tenderness
Haematuria
Malodorous urine
Verbal
Frequency
Dysuria
Dysfunctional voiding
Sec enuresis
Malaise
Malorous urine
Cloudy urine

13. Who should be screened for a UTI?
Infants and children with symptoms and signs of UTI
Infants* with 1 or more of the following:
temperature of at least 38°C
fever for at least 2 days
absence of another obvious source of infection
children with urinary catheters in situ, children with neurogenic bladders, children already known to have significant pre-existing uropathies, children with underlying renal disease (

14. Option
If the patient does not require immediate antimicrobial treatment
 period of observation prior to investigation and treatment for UTI
Because the clinical presentation tends to be nonspecific in infants and reliable urine specimens for culture cannot be obtained without invasive methods.BUT! age less than 12 months, temperature of at least 39°C, fever for at least 2 days, and absence of another source of infection

15. Dipstick screening of fresh urine
Both leukocyte esterase and nitrite POSITIVE
UTI
Send urine for culture
May start antibiotics
Leukocyte esterase : negative
Nitrite : positive
Send urine for culture
Leukocyte esterase : positive
Nitrite : negative
UTI unlikely

16. Diagnosis Must involve urine culture Traditionally: >100,000 cfu/ml
Issues: contamination, false negatives, false positives
Asymptomatic bacteriuria
Based on studies done on adult females with pyleonephritis

17. Asymptomatic Bacteriuria (AS)
Colonization of the urinary tract with non-pathogenic organisms
Study of 3581 infants
2.5% male infants, 0.9% female infants
2 patients with AS developed symptomatic UTI soon after
None of the other patients who developed UTI in the first year of life were found to have AS at initial screening
Another study involving school aged girls with AS
No difference in renal growth or function when patients were randomised to treatment vs observation
But the treated group appeared to be more likely to develop pyleonephritis after antibiotics were stopped
Scandinavia, long term screening study. Another study of 116 school aged girls with AS: no difference in renal growth or function in those randomised to treatment vs observation. None who were observed developed

18. Diagnosis of UTI: 2013 AAP recommendations
Presence of both >50 000cfu/ml of a single organism/uropathogen AND
Pyuria
In an appropriately collected specimen
Febrile 2-24 month olds who have no obvious neurologic or anatomic abnormalities known to be associated with rec UTI or renal damage (may be extrapolated to under 5yr old)
AAP sub committee on UTI, 2009, Revision of AAP guidelines 1999
*who have no obvious neurologic or anatomic abnormalities known to be associated with recurrent UTI or renal damage.
In the past: cfu/ml (women diagnosed with pyleonephritis)

19. Investigation of UTI: Culture
Urine collected in a bag
- only valid if NEGATIVE
- cannot be used to make a diagnosis of UTI
- positive culture is likely to be false positive (88%) !
- positive culture requires confirmation, which is impossible if antibiotics were started*
REMEMBER: You want the most accurate test to be done initially since
urine may be rapidly sterilised
You want the most accurate test to be done initially since urine may be rapidly sterilised

20. Appropriate methods Catheter specimen urine (CSU)  sensitivity: 95%
 specificity: 99%
 difficult in young girls*
Suprapubic Aspiration/ Bladder Tap (SPA)
MSU in older patients
*Requires some skill

21. Diagnosis Urinalysis is Positive when: Dipstick nitrite Microscopy
leukocyte esterase test
Microscopy
 white blood cells/pus cells
 +/- bacteria
Esterase + nitrite
Bacteria + pus cells***

22. The urinalysis may be negative despite a positive culture:
Contamination
Asymptomatic bacteriuria
Urinalysis is not sensitive enough
Requires 4 hrs of “stasis” in the bladder
Young children, infants and neonates may void more often

23. Treatment
Initiating treatment orally or parenterally is equally efficacious, so choice is based on practical considerations.
Choice of drug should be based on local sensitivity patterns, adjusted according to sensitivity of particular uropathogen
Duration of treatment: 7–14 days
Pts who are systemically ill, immunocompromised, typically those under 3 months old, those unable to tolerate oral medication, if there are any concerns regarding compliance.

24. EVERY CHILD, who has had a diagnosis of a urinary tract infection, must be investigated for the presence of a predisposing anatomic abnormality of the urinary tract

25. Investigation
~5% of patients will be found to have some abnormality on investigation
~16% of patients with febrile UTI
Overall about 1-2% of cases will be determined to have “actionable” findings which require some intervention.
The seriousness of the potentially correctable abnormalities in 1% to 2%, coupled with the absence of physical harm, was judged sufficiently important to tip the scales in favor of testing.

26. Should patients be put on prophylaxis while awaiting investigations?
YES No

27. Parental education Implications/complications of a UTI
Symptoms/signs of a recurrent UTI
Need for a urine culture for future febrile illnesses , even when there is an apparent source of fever
Instructed to seek prompt medical evaluation for future febrile illnesses to ensure that recurrent infections can be detected and treated promptly

28. Imaging Investigations for UTI
Abdominal Ultrasound
MCUG/VCUG
Renal scan (DMSA)
Intravenous Pyelogram (IVP)
All children irrespective of age, gender should be investigated after their 1st UTI. Over all about 5% of patients will be found to have some abnormality on investigation. About 16% of patients will febrile UTI.

29. Investigation: KUB USS
All patients diagnosed with UTI should undergo kidney/ureter/bladder sonography (KUB USS)
Timing: 6weeks post treatment
Exception: if patient is not responding to treatment as expected, unusually ill  KUB USS within 48hrs
In the literature, in the first world…there is a high rate of antenatal diagnosis and there is a high incidence of UTI in the first year and a high rate of detection of abnormalities <1 yr…our practice must be coloured by our reality…we are not there..yet.

30. Micturating/Voiding cystourethrogram (MCUG/VCUG)
MCUG is not recommended routinely after the first febrile UTI if KUB USS is normal.
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
Recommended in the presence of
 an abnormal KUB USS
 recurrent UTI
 atypical UTI
MCUG done 4-6 weeks after the UTI
Look at the films , incl post micturation films

31. Renal Scan/ Radionucleotide Scan (RNC)
May be used in the acute setting to diagnose pyleonephritis
 Helpful in distinguishing between obstructive and non- obstructive causes of hydronephrosis
Provides information on differential function
 Indentify renal cortical defects (DMSA)
IVP is useful in the absence of the RNC

32. All patients with UTI’s should have:
Urine culture
Urinalysis
Abdominal Ultrasound
+/- MCUG
+/- Renal scan
+/- IVP (in the absence of renal scan)

33. What about long term urinary prophylaxis following UTI?
Urinary prophylaxis is dictated by the underlying pathology
Antibiotic prophylaxis should not be recommended in infants and children after the first UTI (if no underlying abnormality was found )
May be considered in infants and children with recurrent UTI

34. Dysfunctional elimination syndromes and constipation should be addressed in infants and children who have had a UTI.
In the interest of prevention

36. Normal Cystogram (MCUG)

37. Normal Bladder and Urethra

38. Posterior urethral valves (PUV)

39. Posterior urethral valves

40. Bladder Diverticulum

41. Bladder diverticuli

42. Detrusor Instability

43. Grade I Vesicoureteric Reflux (VUR)

44. Grade II Vesicoureteric Reflux (VUR)
Vesicoureteric reflux is defined as the non-physiological back-flow of urine from the urinary bladder into the ureter or the renal pelvis and the calyces.

45. Grade IV Vesicoureteric Reflux (VUR)

46. Contrary to previous beliefs
“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. 2011;128(5):840–847
*new and growing body of evidence questioning the effectiveness of antimicrobial prophylaxis to prevent recurrent febrile UTI in children with VUR
Randomized Intervention for Children With Vesicoureteral Reflux (RIVUR) study. (US)
UTI Study (Ja)

47. Recurrence of UTI in patients with VUR prophylaxis vs observation
Reflux Grade N
Prophylaxis
No Prophylaxis P
# of Recurrences / Total N
None
373
7 / 210
11 / 163
0.15
Grade I 72
2 / 37
2 / 35
1.00
Grade II
257
11 / 133
10 / 124
0.95
Grade III
285
31 / 140
40 / 145
0.29
Grade IV
104
16 / 55
21 / 49
0.14

48. Grade V Vesicoureteric Reflux (VUR)

49. Recurrence rate of febrile UTI in ages 2-24 months

50. Normal Intravenous Pyelogram (IVP)

51. Pelviureteric Junction (PUJ) Obstruction

52. Urolithiasis

53. Who should be referred to the paediatric nephrologist/ paediatric urologist/ paediatric surgeon?
Poor response to treatment of UTI/uncertainties of Mx
Recurrent UTI
Neurogenic bladder
Voiding dysfunction
Symptoms of dysfunctional elimination syndrome
Hydronephrosis (obstructive or non obstructive; intrauterine or post natal)
Abnormal radiology (KUB USS, MCUG, Renal scan)
Suspicious looking radiology even if reported as normal
Renal scarring
Obstructive uropathy (antenatally or postnatally diagnosed)

54. Role of Circumcision
Presence of foreskin does not worsen UTI or increase risk of UTI once there is proper hygiene

55. Role of Circumcision
Circumcision has a limited role in treatment of UTI:
Recurrent UTI with no other abnormality
Solitary hydronephrotic kidney

56. Summary: Diagnosis/Mx UTI
Abnormal urinalysis as well as positive culture
Positive culture = ≥50,000 colony-forming units (cfu)/ml
Treatment - Oral as effective as parenteral
Imaging - KUB USS for all patients
- Voiding cystourethrography (VCUG) not recommended
routinely after first febrile UTI; required if KUB USS is
abnormal; necessary for recurrent and atypical UTI
Follow up – Emphasis on urine testing with subsequent febrile illnesses
Referral – Early referral to paediatric surgery (paedi urology /nephrology)

57. Thank You.