1. CATHERINE M. BETTCHER, M.D. CME DIRECTOR, ASSISTANT PROFESSOR DEPARTMENT OF FAMILY MEDICINE UNIVERSITY OF MICHIGAN Pediatric UTI: Diagnosis and Management of UTI in Febrile Infants and Young Children (2-24 months)

2. Learning Objectives Determine when to send a urinalysis/urine culture in febrile infants and children Apply evidence-based recommendations to the treatment of UTI in children Determine the appropriate imaging studies in infants/children with UTI Implement strategies to prevent recurrent UTI

3. Background Occurs in 5% of infants and young children with fever and no apparent source  Highest risk in uncircumcised boys < 3 mo and girls <12 mo Untreated UTI can lead to renal scarring Overdiagnosis can lead to misuse of antibiotics and unnecessary imaging Roberts KB. Am Fam Phys. 2012; White B. Am Fam Phys. 2011.

4. History and Physical White B. Am Fam Phys. 2011 Signs and symptoms include fever, abdominal pain, vomiting, diarrhea, new onset of urinary incontinence, strong-smelling urine Ask about history of vesicoureteral reflux in parents and siblings

5. Diagnostic Criteria Roberts KB. Am Fam Phys. 2012. Urinalysis shows pyuria and/or bacteriuria Urine culture grows ≥50,000 CFU/ml of bacteria True UTI

6. Ways to Obtain Urine Culture Roberts KB. Pediatrics. 2011. Suprapubic aspiration  Invasive, requires expertise, painful  May be necessary in boys with phimosis and girls with labial adhesions Catheterization  Invasive  High sensitivity (95%), specificity (99%) Bag applied to perineum  False positive result 88-99% of the time!

7. Risk Factors for UTI Roberts KB. Am Fam Phys. 2012. GirlsBoys White raceNonblack race Temp of ≥ 102.2° F (39° C) Fever lasting ≥ 2 daysFever lasting > 24 hrs No other source of infection Age < 12 months

8. Roberts, KB. Revised AAP guideline on UTI in febrile infants and young children. Am Fam Phys. 2012;86(10):940-946.

10. Determining the Likelihood of UTI Roberts KB. Am Fam Phys. 2012. Lower likelihood of UTI  Clinically follow without testing Higher likelihood of UTI  Obtain urinalysis and culture by catheterization OR  Obtain urinalysis by bag or catheterization a. If urinalysis tests + for nitrites or leukocyte esterase, then obtain culture via catheterization b. If urinalysis tests negative, then follow clinically without antibiotic

11. Treatment Use oral or parenteral antibiotic Adjust the antibiotic based on sensitivities from urine culture Treat for 7-14 days for febrile UTI, 3-7 days for afebrile UTI Roberts KB. Am Fam Phys. 2012. Cayley WE. Am Fam Phys. 2013.

12. Treatment Regimens Roberts KB. Pediatrics. 2011. AntibioticDosing Amoxicillin/clavulanate (Augmentin)20-40 mg/kg/day, divided q 8 hrs Cefixime (Suprax)8 mg/kg/day Cefpodoxime10 mg/kg/day, divided q 12 hrs Cefproxil (Cefzil)30 mg/kg/day, divided q 12 hrs Cephalexin (Keflex)50-100 mg/kg/day, divided q 6 hrs Trimethoprim/sulfamethoxazole (Bactrim)6-12 mg/kg trimethoprim and 30-60 mg/kg sulfamethoxazole per day, divided q 12 hrs

13. Imaging Modalities Roberts KB. Am Fam Phys. 2012. Renal & Bladder U/S Pros: noninvasive, no radiation Cons: cannot reliably demonstrate inflammation, renal scarring; no info on renal function VCUG Pros: affects treatment decisions that theoretically reduce risk of renal scarring Cons: radiation, expense, discomfort

14. Imaging Recommendations Order renal and bladder U/S in febrile infants with confirmed UTI Order a VCUG if the U/S shows:  Hydronephrosis  Scarring  Other findings to suggest high-grade VUR or obstruction Perform a VCUG if a child develops a 2 nd UTI Roberts KB. Am Fam Phys. 2012.

15. Prevention of Recurrent UTIs White B. Am Fam Phys. 2011. Breastfeed Treat constipation Routine circumcision not recommended Use of daily prophylactic antibiotic is controversial

16. Antibiotic Prophylaxis Meta-analysis of six RCTs with a total of 1,091 children (aged 2-24 mo) compare prophylaxis vs. no prophylaxis  No benefit in those with Grade I-IV reflux Roberts, KB. Revised AAP guideline on UTI in febrile infants and young children. Am Fam Phys. 2012;86(10):940-946.

17. Antibiotic Prophylaxis RIVUR trial randomized 607 children (92% female) with grade I-IV reflux to trimethoprim- sulfamethoxazole vs. placebo  Reduction in recurrent UTI  No difference in risk of renal scarring  Increase in bacterial resistance Hoberman A, et al. Antimicrobial prophylaxis for children with vesicoureteral reflux. NEJM. 2014;370(25):2367-2376.

18. Conclusions Send urinalysis and urine culture to diagnose UTI Use 50,000 CFU/ml as threshold for positive urine culture Perform catheterization Order renal/bladder ultrasound after febrile UTI Test urine for infection with subsequent febrile illnesses

19. Choosing Wisely Do not perform VCUG routinely in first febrile UTI in children aged 2- 24 months. The risks associated with radiation (plus the discomfort and expense of the procedure) outweigh the risk of delaying the detection of the few children with correctable genitourinary abnormalities until their second UTI.

20. References Cayley WE. Optimal antibiotic regimen for treating lower UTI in children. Am Fam Phys. 2013;88(9):577. Hoberman A, et al. Antimicrobial prophylaxis for children with vesicoureteral reflux. NEJM. 2014;370(25):2367-2376. Lo V, Wah Y, Maggio L. Antibiotic prophylaxis to prevent recurrent UTI in children. Am Fam Phys. 2011;84(2):3-4. Roberts KB. Revised AAP guideline on UTI in febrile infants and young children. Am Fam Phys. 2012;86(10):940-946. Roberts KB. Urinary tract infection: clinical practice guideline for the diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months. Pediatrics. 2011;128(3):594-610. White B. Diagnosis and treatment of urinary tract infections in children. Am Fam Phys. 2011;83(4):409-415.