The surgical significance of urinary tract infections (UTIs) in children

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The surgical significance of urinary tract
infections (UTIs) in children

• Marisa Seepersaud
• MBBS MRCS DM

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2011 (Sarah Amin)
Brandon Seepersaud

• Records were poor
• 22 patients , age 5 and under , who were treated
  for UTI at the GPHC
• Urinalysis All
• Urine culture 4/22 (18)
• Abdominal ultrasound 7/22 (32) (2 enlarged
  kidneys, 5 Normal study)
• 2 referrals to urology?1 PUV

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Urinary Tract Infection (UTI)

• UTIs are among the most common bacterial
  infections in children under 2 yrs old
• The diagnosis is often missed on history and
  physical examination

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Recent Recommendations

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

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Incidence

• 1 of children below age 1
• 5 of febrile children, 2- 24 months of age
• 7.5 girls, 10 uncircumcised males, 2.5 of
  circumcised males who present with a fever under
  2yrs

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Clinical significance of UTI

• Associated with life-threatening sepsis in the
  newborn
• Increased rates of renal scarring in young
  children
• ?hypertension
• ?chronic kidney
  disease
• ? pregnancy
  induced hypertension

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

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

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Important to accurately make the diagnosis

• Under-diagnosing UTI may lead to
  under-treatment, under-investigation, and risks
  permanent renal damage

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Risk of renal scarring with recurrent UTIJodul
U. The natural history of bacteriuria in
childhood. Infect Dis Clin North Am.
19871(4)713729
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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)

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Age group Age group Symptoms and signs Most common ? Least common Symptoms and signs Most common ? Least common Symptoms and signs Most common ? Least common
Infants younger than 3 months Infants younger than 3 months Fever Vomiting Lethargy Irritability Poor feeding Failure to thrive
Infants older than 3 months, and children Preverbal Fever Abd pain Vomiting Poor feeding Loin tenderness Lethargy Irritability Haematuria Malodorous urine Failure to thrive
Verbal Frequency Dysuria Dysfunctional voiding Sec enuresis Abd pain Loin tenderness Fever Malaise Vomiting Haematuria Malorous urine Cloudy urine
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Who should be screened for a UTI?

• Infants and children with symptoms and signs of
  UTI
• Infants with 1 or more of the following
• ?temperature of at least 38C
• ?fever for at least 2 days
• ?absence of another obvious source of
  infection

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Option

• If the patient does not require immediate
  antimicrobial treatment
  
• ? period of observation prior to investigation
  and treatment for UTI

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

• Must involve urine culture
• Traditionally gt100,000 cfu/ml
• Issues contamination, false negatives, false
  positives
• Asymptomatic bacteriuria

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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 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
• Another study involving school aged girls with AS
• 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

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Diagnosis of UTI 2013 AAP recommendations

• Presence of both gt50 000cfu/ml of a single
  organism/uropathogen AND
• Pyuria
• 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)

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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 since
• urine may be rapidly
  sterilised

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Appropriate methods

• Catheter specimen urine (CSU)
• ? sensitivity 95
• ? specificity 99
• ? difficult in young girls
• Suprapubic Aspiration/ Bladder Tap (SPA)
• MSU in older patients

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Diagnosis

• Urinalysis is Positive when
• Dipstick
• ?nitrite
• ?leukocyte esterase test
• Microscopy
• ? white blood cells/pus cells
• ? /- bacteria

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The urinalysis may be negative despite a positive
culture

• Contamination
• Asymptomatic bacteriuria
• Urinalysis is not sensitive enough
• Requires 4 hrs of stasis in the bladder
• Young children, infants and neonates may void
  more often

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Treatment

• 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
• Duration of treatment 714 days

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• 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

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Investigation

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

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Should patients be put on prophylaxis while
awaiting investigations?

• YES
• No

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Parental education

• Implications/complications of a 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
• Instructed to seek prompt medical evaluation for
  future febrile illnesses to ensure that recurrent
  infections can be detected and treated promptly

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Imaging Investigations for UTI

• Abdominal Ultrasound
• MCUG/VCUG
• Renal scan (DMSA)
• Intravenous Pyelogram (IVP)

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Investigation KUB USS

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

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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.
  2011165(11)10271032
• Recommended in the presence of
• ? an abnormal KUB USS
• ? recurrent UTI
• ? atypical UTI
• MCUG done 4-6 weeks after the UTI
• Look at the films , incl post micturation films

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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

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All patients with UTIs should have

• Urine culture
• Urinalysis
• Abdominal Ultrasound
• /- MCUG
• /- Renal scan
• /- IVP (in the absence of renal scan)

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What about long term urinary prophylaxis
following UTI?

• 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 )
• May be considered in infants and children with
  recurrent UTI

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• Dysfunctional elimination syndromes and
  constipation should be addressed in infants and
  children who have had a UTI.

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Normal Cystogram (MCUG)
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Normal Bladder and Urethra
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Posterior urethral valves (PUV)
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Posterior urethral valves
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Bladder Diverticulum
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Bladder diverticuli
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Detrusor Instability
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Grade I Vesicoureteric Reflux (VUR)
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Grade II Vesicoureteric Reflux (VUR)
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Grade IV Vesicoureteric Reflux (VUR)
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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.
  2011128(5)840847

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Recurrence of UTI in patients with
VURprophylaxis vs observation
Reflux Grade N Prophylaxis NoProphylaxis P
Reflux Grade N of Recurrences / Total N of Recurrences / Total N P
None 373 7 / 210 11 / 163 0.15
Grade I 72 2 / 37 2 / 35 1.00
Grade II 257 11 / 133 10 / 124 0.95
Grade III 285 31 / 140 40 / 145 0.29
Grade IV 104 16 / 55 21 / 49 0.14
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Grade V Vesicoureteric Reflux (VUR)
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Recurrence rate of febrile UTI in ages 2-24
months
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Normal Intravenous Pyelogram (IVP)
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Pelviureteric Junction (PUJ) Obstruction
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Urolithiasis
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Who should be referred to the paediatric
nephrologist/ paediatric urologist/ paediatric
surgeon?

• Poor response to treatment of UTI/uncertainties
  of Mx
• Recurrent UTI
• Neurogenic bladder
• Voiding dysfunction
• Symptoms of dysfunctional elimination syndrome
• Hydronephrosis (obstructive or non obstructive
  intrauterine or post natal)
• Abnormal radiology (KUB USS, MCUG, Renal scan)
• Suspicious looking radiology even if reported as
  normal
• Renal scarring
• Obstructive uropathy (antenatally or postnatally
  diagnosed)

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Role of Circumcision

• Presence of foreskin does not worsen UTI or
  increase risk of UTI once there is proper hygiene

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Role of Circumcision

• Circumcision has a limited role in treatment of
  UTI
• Recurrent UTI with no other abnormality
• Solitary hydronephrotic kidney

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Summary Diagnosis/Mx UTI

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

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Thank You.
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