1. Pediatric UTI: Making Sense of Local Data and the New AAP Guidelines Heidi Román, MD and Alan Schroeder, MD SCVMC Pediatric Grand Rounds March 13, 2013

2. Objectives To review diagnosis and management of UTI in infants and young children To review diagnosis and management of UTI in infants and young children To be aware of changes in management suggested by 2011 AAP CPG To be aware of changes in management suggested by 2011 AAP CPG To review recent clinical research projects at VMC examining: To review recent clinical research projects at VMC examining: imaging protocols imaging protocols diagnosis and management of bacteremic UTIs diagnosis and management of bacteremic UTIs

3. Why Do We Care About UTI? UTI now most common site for SBI in infants UTI now most common site for SBI in infants More than 1 million office visits per year More than 1 million office visits per year $180M/year for hospitalization alone $180M/year for hospitalization alone Freedman, J. Urology, 2005

4. When should urine be tested? Consider UTI in all infants < 24 mos with FWS Not ill and “low risk”  monitor Ill enough to require abx  obtain urine for UA/culture prior to initiation “Not low risk”  urine for UA/culture and act based on results AAP CPG, Pediatrics, 2011

5. What constitutes “not low risk”? 2011 AAP CPG: “low risk” = febrile infant with < 3% risk of UTI 2011 AAP CPG: “low risk” = febrile infant with < 3% risk of UTI Factors known to change risk Factors known to change risk Age Age Gender Gender Circumcision status Circumcision status Duration of fever Duration of fever Lack of other source Lack of other source

6. Factors Modifying Risk for UTI From Marmor “Updates in Management of UTI in Febrile Infants/Children < 24 mo of Age” 2012

7. How should urine be tested? SPA Catheterization Bag Clean Catch

8. What defines a “UTI”? 2011 AAP CPG: 2011 AAP CPG: At least 50K CFU/ml of uropathogen via cath or SPA At least 50K CFU/ml of uropathogen via cath or SPA AND UA suggesting infection (pyuria and/or bacteruria) AND UA suggesting infection (pyuria and/or bacteruria)

9. How can UA help you? AAP CPG, Pediatrics, 2011

10. Urine Culture When to send When to send Definitely “positive”? Definitely “positive”? UA + and Cath Ucx + if > 50k CFU/mL UA + and Cath Ucx + if > 50k CFU/mL UA + and Bag Ucx + if > 100K CFU/ml single org UA + and Bag Ucx + if > 100K CFU/ml single org Possibly +: Possibly +: high clinical suspicion and high clinical suspicion and UA + and > 10K org OR UA + and > 10K org OR UA – and > 50K single org UA – and > 50K single org

11. UTI Management When/how long to hospitalize? When/how long to hospitalize? Abx: what, how and how long? Abx: what, how and how long? Prophylaxis? Prophylaxis? Imaging? Imaging?

12. Inpatient vs outpatient Hoberman cefixime study (Pediatrics, 1999) Hoberman cefixime study (Pediatrics, 1999) 306 children 1-36 months 306 children 1-36 months PO Cefixime x 14 d vs IV cefotax x 3 d + PO Cefixime x 11 d PO Cefixime x 14 d vs IV cefotax x 3 d + PO Cefixime x 11 d No difference in readmission, scarring No difference in readmission, scarring

13. Duration of IV Abx PHIS study on UTI practice variation (Brady, Pediatrics, 2010) PHIS study on UTI practice variation (Brady, Pediatrics, 2010) 12,333 infants < 6 months 12,333 infants < 6 months Treatment failure: Treatment failure: ≤3 days = 1.6% ≤3 days = 1.6% ≥4 days = 2.2% ≥4 days = 2.2% 1000 kids (~30%) < 1 month got short course! 1000 kids (~30%) < 1 month got short course!

14. AAP recs “Initiating treatment orally or parenterally is equally efficacious” “Initiating treatment orally or parenterally is equally efficacious” “Adjust choice according to sensitivity testing” “Adjust choice according to sensitivity testing” 7-14 days total 7-14 days total “Outcomes of short courses (1-3 days) are inferior to those of 7-14 day courses” “Outcomes of short courses (1-3 days) are inferior to those of 7-14 day courses” No reference!! No reference!!

15. Our recs (if well) > 1 month: outpatient, IM/PO > 1 month: outpatient, IM/PO < 1 month: inpatient, IV x 48 hours < 1 month: inpatient, IV x 48 hours 5-7 day course total (sooner if side effects) 5-7 day course total (sooner if side effects) Ampicillin41% Cefazolin88% CTX94% Gent91% SXT66% E coli susceptibilities 2011, VMC 5 th floor

16. Prophylactic Abx Mid-2000’s  Practice questioned by handful of RCTs

17. PRIVENT trial [Craig, NEJM, 2009] 576 Children age 0-18 years with first febrile UTI 576 Children age 0-18 years with first febrile UTI Renal US, VCUG, DMSA in most patients Renal US, VCUG, DMSA in most patients DMSA again at 1 year DMSA again at 1 year Daily TMP/SMX Daily TMP/SMX

19. Still Pending 600 children 2 months – 6 years 600 children 2 months – 6 years Grades I-IV VUR Grades I-IV VUR TMP/SMX vs placebo TMP/SMX vs placebo

20. Our recs No prophylaxis unless high-grade, persistent VUR No prophylaxis unless high-grade, persistent VUR

21. Imaging

22. Imaging makes sense if… Abnormalities are common Abnormalities are common Abnormalities lead to recurrent UTIs and/or long-term damage Abnormalities lead to recurrent UTIs and/or long-term damage Detection of the abnormalities improves outcomes Detection of the abnormalities improves outcomes Andrea Marmor, MD http://www.ucsfcme.com/2012/slides/MFC13003/3a%20-%20Marmor,%20Andrea%20REF.pdf

23. 1.) Abnormalities are common VUR same prevalence (~35%) in patients with true UTIs and false UTIs [Hanula, Pediatr Nephrol 2010] VUR same prevalence (~35%) in patients with true UTIs and false UTIs [Hanula, Pediatr Nephrol 2010]

24. Abnormalities lead to recurrent UTIs and/or long-term damage Literature review: 0/1576 reviewed CKD cases had UTI as primary cause Literature review: 0/1576 reviewed CKD cases had UTI as primary cause Own institution: 13/366 had h/o childhood UTI – all 13 had abnl kidney anatomy Own institution: 13/366 had h/o childhood UTI – all 13 had abnl kidney anatomy Recurrent UTI  CKD 1/366 Recurrent UTI  CKD 1/366

25. Crunching the #’s Craig, Pediatrics 2011 UTI incidence 50,000 per million Incidence of ESRD from VUR 5 per million UTI  ESRD 1/10,000

26. Prophylactic Abx? Prophylactic Abx? VUR surgery? VUR surgery? Other anatomic abnormalities? Other anatomic abnormalities? 3. Detection of the abnormalities improves outcomes

27. 2008: Initiation of new guidelines at SCVMC Grand Rounds Grand Rounds Meeting of inter-disciplinary group Meeting of inter-disciplinary group Discussed at faculty meeting Discussed at faculty meeting Radiologist reminders Radiologist reminders

29. New AAP recs US on everyone, VCUG if abnormal or if recurrence US on everyone, VCUG if abnormal or if recurrence

30. Take Home Points Diminishing urgency to detect/treat UTIs in healthy children Diminishing urgency to detect/treat UTIs in healthy children Knowledge of risk factors can help stratify risk Knowledge of risk factors can help stratify risk Management of UTI Management of UTI Selective imaging OK Selective imaging OK Cost/benefit of prophylaxis too high Cost/benefit of prophylaxis too high

31. Questions?