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Urinary Infection in Children & Vesico Ureteric Reflux Dr. Ramesh Babu Srinivasan M.S., M.Ch.(Paed Surg), FRCS Glas, FRCS Edin, FRCS (Paed) Paediatric.

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Presentation on theme: "Urinary Infection in Children & Vesico Ureteric Reflux Dr. Ramesh Babu Srinivasan M.S., M.Ch.(Paed Surg), FRCS Glas, FRCS Edin, FRCS (Paed) Paediatric."— Presentation transcript:

1 Urinary Infection in Children & Vesico Ureteric Reflux Dr. Ramesh Babu Srinivasan M.S., M.Ch.(Paed Surg), FRCS Glas, FRCS Edin, FRCS (Paed) Paediatric Urologist Sri Ramachandra Medical Centre, Porur, Chennai, India

2 Why is UTI important in children ?

3 Childhood UTI 30-50% have underlying problems 30-50% have underlying problems Symptoms can be vague & diagnosis can be missed Symptoms can be vague & diagnosis can be missed Failure to treat scarring; hypertension; loss of function & renal failure Failure to treat scarring; hypertension; loss of function & renal failure

4 What is the Incidence ? 5% of girls and 2% of boys will have UTI during childhood 5% of girls and 2% of boys will have UTI during childhood Before 3m: Boys more susceptible Before 3m: Boys more susceptible After 3m: Boys = Girls After 3m: Boys = Girls

5 What is the pathogenesis? Host Bacteria

6 What are the symptoms ? Often non specific in neonates &infants Often non specific in neonates &infants Suspect in any infant with unexplained fever > 3 days Suspect in any infant with unexplained fever > 3 days Any neonate with fever, lethargy, seizures Any neonate with fever, lethargy, seizures Children: fever, diarrhea, abdominal pain Children: fever, diarrhea, abdominal pain Older Children: burning, urgency, frequency, flank pain, wetting, turbid or foul smelling urine. Older Children: burning, urgency, frequency, flank pain, wetting, turbid or foul smelling urine.

7 What is the essential history in a child with UTI?

8 History - underlying factors Constipation (pain, consistency / frequency) Bladder Instability (frequency, urgency) Dysfunctional voiding (holding, straining, Vincents Curtsey Sign) Toileting habits (position, wiping post void) Drinking history: quantity + quality; bladder stimulants (caffeine, black currant) Bathing habits: bubble baths, shampoo bath Family history/social history

9 How to diagnose a UTI? How to collect specimen? How to collect specimen? Rapid tests? Rapid tests? Confirmation? Confirmation?

10 Definition Significant Bacteriuria: presence of a pure growth of > 10 5 colony forming units of bacteria/ml Significant Bacteriuria: presence of a pure growth of > 10 5 colony forming units of bacteria/ml Lower counts may be important, in specimens obtained by urinary catheter Lower counts may be important, in specimens obtained by urinary catheter Any growth clinically important if obtained by suprapubic aspiration Any growth clinically important if obtained by suprapubic aspiration

11 Definitions Simple UTI: low grade fever, dysuria, frequency, urgency Simple UTI: low grade fever, dysuria, frequency, urgency Complicated UTI; fever >38.5, vomiting, dehydration, renal angle tenderness Complicated UTI; fever >38.5, vomiting, dehydration, renal angle tenderness Recurrent UTI: Second attack of UTI Recurrent UTI: Second attack of UTI Relapsing UTI: UTI with same strain Relapsing UTI: UTI with same strain Breakthrough UTI: UTI while on prophylaxis Breakthrough UTI: UTI while on prophylaxis

12 Initial Management Send FBC, BU, S Cr, Electrolytes; Urine Send FBC, BU, S Cr, Electrolytes; Urine Children with complicated UTI, infants < 3m and those with systemic signs are admitted for IV antibiotics Children with complicated UTI, infants < 3m and those with systemic signs are admitted for IV antibiotics Adequate hydration is essential during acute phase Adequate hydration is essential during acute phase USG and repeat urine culture are necessary if there is no improvement < 48hrs USG and repeat urine culture are necessary if there is no improvement < 48hrs If there is obstruction it needs to be relieved If there is obstruction it needs to be relieved (catheter in PUV; nephrostomy in pyonephrosis)

13 Initial Management Infants > 3m and those with simple UTI – oral antibiotics: amoxycillin; co trimoxazole or cephalosporin Infants > 3m and those with simple UTI – oral antibiotics: amoxycillin; co trimoxazole or cephalosporin Usual duration of treatment is days for complicated and 7-10 days for simple UTI Usual duration of treatment is days for complicated and 7-10 days for simple UTI After this course, start prophylactic antibiotic until further evaluation in all children < 2yrs After this course, start prophylactic antibiotic until further evaluation in all children < 2yrs

14 Investigations after First UTI USG (KUB) Normal Abnormal MCU, DMSA 5yr 5yr MCU, DMSA DMSA no further test MCU MCU (if scar + or DMSA not available) (if scar + or DMSA not available)

15 Role & timing of Investigations USG: helps to detect PC dilatation, ureter dilatation, bladder thickening, ureterocele, post void residual (useful in acute phase when obstruction suspected) USG: helps to detect PC dilatation, ureter dilatation, bladder thickening, ureterocele, post void residual (useful in acute phase when obstruction suspected) DMSA: ideally after 3m to detect scarring DMSA: ideally after 3m to detect scarring MCU: provides anatomical information of urethra / ureters; grading of reflux possible MCU: provides anatomical information of urethra / ureters; grading of reflux possible Nuclear Cystogram: Less invasive; less radiation; Older cooperative children required; poor anatomical information; grading difficult; not ideal as first investigation; useful for F/U of reflux Nuclear Cystogram: Less invasive; less radiation; Older cooperative children required; poor anatomical information; grading difficult; not ideal as first investigation; useful for F/U of reflux

16 Recurrent UTI Children with recurrent UTI irrespective of age require USG, DMSA & MCU

17 Antibiotic Prophylaxis Following First UTI in all children < 2yrs Following First UTI in all children < 2yrs Following complicated UTI in children > 5 yrs while waiting for imaging Following complicated UTI in children > 5 yrs while waiting for imaging Children with VUR (up to 5 yrs) Children with VUR (up to 5 yrs) Scars on DMSA even if there is no VUR (stop if repeat MCU or RNCU is normal) Scars on DMSA even if there is no VUR (stop if repeat MCU or RNCU is normal) Children with frequent febrile UTI (? Even if imaging is normal) Children with frequent febrile UTI (? Even if imaging is normal)

18 Antibiotic Prophylaxis Age of PtDuration First UTI Reflux All up to 5 yrs No reflux/ scar + All 6m, re evaluate No reflux/ scar + All 6m, re evaluate No reflux; no scar < 2 yrs 6m, re evaluate No reflux; no scar < 2 yrs 6m, re evaluate > 2 yrs no prophylaxis > 2 yrs no prophylaxis Recurrent UTI All six months (no reflux or scar) (no reflux or scar)

19 Antibiotic Prophylaxis Ideal: effective, non toxic with few side effects; does not alter natural flora; does not promote resistance Ideal: effective, non toxic with few side effects; does not alter natural flora; does not promote resistance Cephalexin 10 mg/kg nocte (ideal for < 3m) Cephalexin 10 mg/kg nocte (ideal for < 3m) Cotrimoxazole 2 mg/kg nocte (avoid <3m) Cotrimoxazole 2 mg/kg nocte (avoid <3m) Nitrofurantoin 1 mg/kg nocte (avoid in < 3m, renal impairment, GI upset) Nitrofurantoin 1 mg/kg nocte (avoid in < 3m, renal impairment, GI upset)

20 Measures to reduce recurrent UTI Avoid tight undergarments Avoid tight undergarments Plenty of fluids; avoid bladder irritants Plenty of fluids; avoid bladder irritants Regular voiding; double voiding Regular voiding; double voiding Perineal hygiene; avoid shampoo/ soap Perineal hygiene; avoid shampoo/ soap Control constipation Control constipation Circumcision in select group Circumcision in select group

21 Breakthrough UTI Resistant flora Resistant flora Poor compliance Poor compliance Inadequate dosing Inadequate dosing Poor bladder emptying Poor bladder emptying Host immunity Host immunity Address above issues Address above issues double prophylaxis double prophylaxis

22 Asymptomatic Bacteriuria 1% in girls; 0.05% in boys 1% in girls; 0.05% in boys Good history and examination Good history and examination USG to exclude abnormalities USG to exclude abnormalities Benign condition Benign condition Does not lead to scar Does not lead to scar Often non virulent strain Often non virulent strain Dont treat: may get UTI with virulent strain Dont treat: may get UTI with virulent strain

23 In the absence of UTI, isolated low pressure VUR does not lead to scar formation In the absence of UTI, isolated low pressure VUR does not lead to scar formation Uncomplicated primary reflux resolves spontaneously Uncomplicated primary reflux resolves spontaneously What are the principles in the management of VUR? UTIVUR Scarring

24 Treat acute episode of UTI Treat acute episode of UTI Start prophylactic antibiotics Start prophylactic antibiotics Investigations to exclude anatomical causes of secondary VUR Investigations to exclude anatomical causes of secondary VUR Treat factors like constipation, dysfunctional voiding and bladder instability Treat factors like constipation, dysfunctional voiding and bladder instability follow-up, parental commitment and patient compliance are essential for success follow-up, parental commitment and patient compliance are essential for success What is the medical management?

25 resolution rate: resolution rate: Grade I: 80%; II: 60%; III: 40%; IV: 10%; V 0% Grade I: 80%; II: 60%; III: 40%; IV: 10%; V 0% The duration to resolution since diagnosis: The duration to resolution since diagnosis: Grade I: 2.5 yrs, II: 5 years and Grade III and IV: 8 years Grade I: 2.5 yrs, II: 5 years and Grade III and IV: 8 years risk factors for new scarring: risk factors for new scarring: younger age, high-grade reflux, and previous scarring younger age, high-grade reflux, and previous scarring scarring rate with different grades: scarring rate with different grades: Grade I: 10%, II: 17% and III and above 60%. Grade I: 10%, II: 17% and III and above 60%. How long to continue prophylaxis?

26 Anatomical factors – duplex, para uret diverticulum Anatomical factors – duplex, para uret diverticulum Obstructed refluxing megaureter Obstructed refluxing megaureter Secondary VUR – treat underlying cause Secondary VUR – treat underlying cause Primary VUR – failure of conservative treatment Primary VUR – failure of conservative treatment Break through infection; worsening function; new scars Break through infection; worsening function; new scars Poor follow up; non compliance Poor follow up; non compliance High grade (IV or V) reflux; bilateral reflux; multiple scars High grade (IV or V) reflux; bilateral reflux; multiple scars Indications for Surgery

27 Circumcision Circumcision STING STING Teflon, macroplastique, deflux, chondrocytes Teflon, macroplastique, deflux, chondrocytes Ureteric reimplantation Ureteric reimplantation Cohen, Leadbetter, Lich Gregoir, laparoscopic Cohen, Leadbetter, Lich Gregoir, laparoscopic Transureteroureterostomy Transureteroureterostomy Heminephrectomy, common channel reimplant Heminephrectomy, common channel reimplant Nephrectomy Nephrectomy Surgical options

28 A ten-year-old girl, who was initially managed medically for grade III VUR (on MCUG), was referred to the urologist because she developed two episodes of UTI A ten-year-old girl, who was initially managed medically for grade III VUR (on MCUG), was referred to the urologist because she developed two episodes of UTI A DMSA scan revealed unscarred kidneys with normal function A DMSA scan revealed unscarred kidneys with normal function A repeat MCU confirmed persistent right-sided grade III reflux A repeat MCU confirmed persistent right-sided grade III reflux On history symptoms of bladder instability On history symptoms of bladder instability Treat bladder instability; still has symptoms Treat bladder instability; still has symptoms Urodynamics examination revealed normal compliance with no instability; still gets recurrent UTIs Urodynamics examination revealed normal compliance with no instability; still gets recurrent UTIs Extravesical reimplantation Extravesical reimplantation Scenario

29 Thank You!


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