Presentation on theme: "Marisa Seepersaud MBBS MRCS DM"— Presentation transcript:
1 Marisa Seepersaud MBBS MRCS DM The surgical significance of urinary tract infections (UTIs) in childrenMarisa SeepersaudMBBS MRCS DM
2 2011 (Sarah Amin) Brandon Seepersaud Records were poor22 patients , age 5 and under , who were treated for UTI at the GPHCUrinalysis: AllUrine culture: 4/22 (18%)Abdominal ultrasound: 7/22 (32%) (2 “enlarged kidneys”, 5 Normal study)2 referrals to urology1 PUV
3 Urinary Tract Infection (UTI) UTIs are among the most common bacterial infections in children under 2 yrs oldThe diagnosis is often missed on history and physical examination
4 Recent Recommendations AAP, American Academy of Pediatrics , (1999) 2013Consensus Document, Management of UTI in Jamaican Children, (2005), August 2011NICE, 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 age7.5% 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 newbornIncreased rates of renal scarring in young childrenhypertensionchronic 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 investigationMinimize 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 groupSymptoms and signsMost common Least commonInfants younger than 3 monthsFeverVomitingLethargyIrritabilityPoor feedingFailure to thriveInfants older than 3 months, and childrenPreverbalAbd painLoin tendernessHaematuriaMalodorous urineVerbalFrequencyDysuriaDysfunctional voidingSec enuresisMalaiseMalorous urineCloudy urine
13 Who should be screened for a UTI? Infants and children with symptoms and signs of UTIInfants* with 1 or more of the following:temperature of at least 38°Cfever for at least 2 daysabsence of another obvious source of infectionchildren with urinary catheters in situ, children with neurogenic bladders, children already known to have significant pre-existing uropathies, children with underlying renal disease (
14 OptionIf the patient does not require immediate antimicrobial treatment period of observation prior to investigation and treatment for UTIBecause 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 POSITIVEUTISend urine for cultureMay start antibioticsLeukocyte esterase : negativeNitrite : positiveSend urine for cultureLeukocyte esterase : positiveNitrite : negativeUTI unlikely
16 Diagnosis Must involve urine culture Traditionally: >100,000 cfu/ml Issues: contamination, false negatives, false positivesAsymptomatic bacteriuriaBased on studies done on adult females with pyleonephritis
17 Asymptomatic Bacteriuria (AS) Colonization of the urinary tract with non-pathogenic organismsStudy of 3581 infants2.5% male infants, 0.9% female infants2 patients with AS developed symptomatic UTI soon afterNone of the other patients who developed UTI in the first year of life were found to have AS at initial screeningAnother study involving school aged girls with ASNo difference in renal growth or function when patients were randomised to treatment vs observationBut the treated group appeared to be more likely to develop pyleonephritis after antibiotics were stoppedScandinavia, 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 ANDPyuriaIn an appropriately collected specimenFebrile 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 sinceurine may be rapidly sterilisedYou 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 testMicroscopy white blood cells/pus cells +/- bacteriaEsterase + nitriteBacteria + pus cells***
22 The urinalysis may be negative despite a positive culture: ContaminationAsymptomatic bacteriuriaUrinalysis is not sensitive enoughRequires 4 hrs of “stasis” in the bladderYoung children, infants and neonates may void more often
23 TreatmentInitiating 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 uropathogenDuration of treatment: 7–14 daysPts 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 UTIOverall 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? YESNo
27 Parental education Implications/complications of a UTI Symptoms/signs of a recurrent UTINeed for a urine culture for future febrile illnesses , even when there is an apparent source of feverInstructed 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 UltrasoundMCUG/VCUGRenal 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 treatmentException: if patient is not responding to treatment as expected, unusually ill KUB USS within 48hrsIn 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):1027–1032Recommended in the presence of an abnormal KUB USS recurrent UTI atypical UTIMCUG done 4-6 weeks after the UTILook 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 hydronephrosisProvides 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 cultureUrinalysisAbdominal 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 pathologyAntibiotic 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
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 VURRandomized Intervention for Children With Vesicoureteral Reflux (RIVUR) study. (US)UTI Study (Ja)
47 Recurrence of UTI in patients with VUR prophylaxis vs observation Reflux GradeNProphylaxisNo ProphylaxisP# of Recurrences / Total NNone3737 / 21011 / 1630.15Grade I722 / 372 / 351.00Grade II25711 / 13310 / 1240.95Grade III28531 / 14040 / 1450.29Grade IV10416 / 5521 / 490.14
53 Who should be referred to the paediatric nephrologist/ paediatric urologist/ paediatric surgeon? Poor response to treatment of UTI/uncertainties of MxRecurrent UTINeurogenic bladderVoiding dysfunctionSymptoms of dysfunctional elimination syndromeHydronephrosis (obstructive or non obstructive; intrauterine or post natal)Abnormal radiology (KUB USS, MCUG, Renal scan)Suspicious looking radiology even if reported as normalRenal scarringObstructive uropathy (antenatally or postnatally diagnosed)
54 Role of CircumcisionPresence of foreskin does not worsen UTI or increase risk of UTI once there is proper hygiene
55 Role of CircumcisionCircumcision has a limited role in treatment of UTI:Recurrent UTI with no other abnormalitySolitary hydronephrotic kidney
56 Summary: Diagnosis/Mx UTI Abnormal urinalysis as well as positive culturePositive culture = ≥50,000 colony-forming units (cfu)/mlTreatment - Oral as effective as parenteralImaging - KUB USS for all patients- Voiding cystourethrography (VCUG) not recommendedroutinely after first febrile UTI; required if KUB USS isabnormal; necessary for recurrent and atypical UTIFollow up – Emphasis on urine testing with subsequent febrile illnessesReferral – Early referral to paediatric surgery (paedi urology /nephrology)