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

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Presentation on theme: "The surgical significance of urinary tract infections (UTIs) in children Marisa Seepersaud MBBS MRCS DM."— Presentation transcript:

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

2 2011 (Sarah Amin) Brandon Seepersaud Records were poor Records were poor 22 patients, age 5 and under, who were treated for UTI at the GPHC 22 patients, age 5 and under, who were treated for UTI at the GPHC Urinalysis: All Urinalysis: All Urine culture: 4/22 (18%) Urine culture: 4/22 (18%) Abdominal ultrasound: 7/22 (32%) (2 “enlarged kidneys”, 5 Normal study) Abdominal ultrasound: 7/22 (32%) (2 “enlarged kidneys”, 5 Normal study) 2 referrals to urology  1 PUV 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 UTIs are among the most common bacterial infections in children under 2 yrs old The diagnosis is often missed on history and physical examination The diagnosis is often missed on history and physical examination

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

5 Incidence ~1% of children below age 1 ~1% of children below age 1 ~ 5 % of febrile children*, months of age ~ 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 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 Associated with life-threatening sepsis in the newborn Increased rates of renal scarring in young children Increased rates of renal scarring in young children  hypertension  hypertension  chronic kidney disease  chronic kidney disease  pregnancy induced hypertension  pregnancy induced hypertension

7 Urinary tract infections may occur as a result of structural anomalies of the urinary tract

8 The diagnosis of urinary tract infection in a young child is an important marker for urinary tract abnormalities The diagnosis of urinary tract infection in a young child is an important marker for urinary tract abnormalities Mandates investigation Mandates investigation

9 Important to accurately make the diagnosis Under-diagnosing UTI may lead to under-treatment, under- investigation, and risks permanent renal damage 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. 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) 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 Age groupSymptoms 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 PreverbalFever Abd pain Vomiting Poor feeding Loin tenderness Lethargy Irritability Haematuria Malodorous urine Failure to thrive VerbalFrequency Dysuria Dysfunctional voiding Sec enuresis Abd pain Loin tenderness Fever Malaise Vomiting Haematuria Malorous urine Cloudy urine

13 Who should be screened for a UTI? Infants and children with symptoms and signs of UTI Infants and children with symptoms and signs of UTI Infants* with 1 or more of the following: Infants* with 1 or more of the following:  temperature of at least 38°C  temperature of at least 38°C  fever for at least 2 days  fever for at least 2 days  absence of another obvious source of infection  absence of another obvious source of infection

14 Option If the patient does not require immediate antimicrobial treatment If the patient does not require immediate antimicrobial treatment  period of observation prior to investigation and treatment for UTI

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

16 Diagnosis Must involve urine culture Must involve urine culture Traditionally: >100,000 cfu/ml Traditionally: >100,000 cfu/ml Issues: contamination, false negatives, false positives Issues: contamination, false negatives, false positives Asymptomatic bacteriuria Asymptomatic bacteriuria

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 2.5% male infants, 0.9% female infants 2 patients with AS developed symptomatic UTI soon after 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 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 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 But the treated group appeared to be more likely to develop pyleonephritis after antibiotics were stopped

18 Diagnosis of UTI: 2013 AAP recommendations Presence of both >50 000cfu/ml of a single organism/uropathogen AND Presence of both >50 000cfu/ml of a single organism/uropathogen AND Pyuria Pyuria In an appropriately collected specimen 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) 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)

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

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

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

22 The urinalysis may be negative despite a positive culture: Contamination Contamination Asymptomatic bacteriuria Asymptomatic bacteriuria Urinalysis is not sensitive enough Urinalysis is not sensitive enough Requires 4 hrs of “stasis” in the bladder Requires 4 hrs of “stasis” in the bladder Young children, infants and neonates may void more often 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. 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 Choice of drug should be based on local sensitivity patterns, adjusted according to sensitivity of particular uropathogen Duration of treatment: 7–14 days Duration of treatment: 7–14 days

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 ~5% of patients will be found to have some abnormality on investigation ~16% of patients with febrile UTI ~16% of patients with febrile UTI Overall about 1-2% of cases will be determined to have “actionable” findings which require some intervention. Overall about 1-2% of cases will be determined to have “actionable” findings which require some intervention.

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

27 Parental education Implications/complications of a UTI Implications/complications of a UTI Symptoms/signs of a recurrent 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 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 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 Abdominal Ultrasound MCUG/VCUG MCUG/VCUG Renal scan (DMSA) Renal scan (DMSA) Intravenous Pyelogram (IVP) Intravenous Pyelogram (IVP)

29 Investigation: KUB USS All patients diagnosed with UTI should undergo kidney/ureter/bladder sonography (KUB USS) All patients diagnosed with UTI should undergo kidney/ureter/bladder sonography (KUB USS) Timing: 6weeks post treatment Timing: 6weeks post treatment Exception: if patient is not responding to treatment as expected, unusually ill  KUB USS within 48hrs Exception: if patient is not responding to treatment as expected, unusually ill  KUB USS within 48hrs

30 Micturating/Voiding cystourethrogram (MCUG/VCUG) MCUG is not recommended routinely after the first febrile UTI if KUB USS is normal. 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 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 Recommended in the presence of  an abnormal KUB USS  an abnormal KUB USS  recurrent UTI  recurrent UTI  atypical UTI  atypical UTI MCUG done 4-6 weeks after the UTI MCUG done 4-6 weeks after the UTI Look at the films, incl post micturation films 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 Urine culture Urinalysis Urinalysis Abdominal Ultrasound Abdominal Ultrasound +/- MCUG +/- MCUG +/- Renal scan +/- Renal scan +/- IVP (in the absence of 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 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 ) 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 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. Dysfunctional elimination syndromes and constipation should be addressed in infants and children who have had a UTI.

35

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)

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.” “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.” “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 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

47 Recurrence of UTI in patients with VUR prophylaxis vs observation Reflux GradeN Prophylaxis No Prophylaxis P # of Recurrences / Total N None3737 / / Grade I722 / 372 / Grade II25711 / / Grade III28531 / / Grade IV10416 / 5521 /

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 Poor response to treatment of UTI/uncertainties of Mx Recurrent UTI Recurrent UTI Neurogenic bladder Neurogenic bladder Voiding dysfunction Voiding dysfunction Symptoms of dysfunctional elimination syndrome Symptoms of dysfunctional elimination syndrome Hydronephrosis (obstructive or non obstructive; intrauterine or post natal) Hydronephrosis (obstructive or non obstructive; intrauterine or post natal) Abnormal radiology (KUB USS, MCUG, Renal scan) Abnormal radiology (KUB USS, MCUG, Renal scan) Suspicious looking radiology even if reported as normal Suspicious looking radiology even if reported as normal Renal scarring Renal scarring Obstructive uropathy (antenatally or postnatally diagnosed) 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 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: 1. Recurrent UTI with no other abnormality 2. Solitary hydronephrotic kidney

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

57 Thank You.

58


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