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Jayasimha S. Antibiotic prophylaxis in infants with Grade III, IV, or V vesicoureteral reflux. Indian J Urol 2024; 40:205-206. [PMID: 39100607 PMCID: PMC11296590 DOI: 10.4103/iju.iju_31_24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 06/01/2024] [Accepted: 06/19/2024] [Indexed: 08/06/2024] Open
Affiliation(s)
- Sudhindra Jayasimha
- Department of Paediatric Urology, Great Ormond Street Hospital, London, England
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Hari P, Meena J, Kumar M, Sinha A, Thergaonkar RW, Iyengar A, Khandelwal P, Ekambaram S, Pais P, Sharma J, Kanitkar M, Bagga A. Evidence-based clinical practice guideline for management of urinary tract infection and primary vesicoureteric reflux. Pediatr Nephrol 2024; 39:1639-1668. [PMID: 37897526 DOI: 10.1007/s00467-023-06173-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 08/27/2023] [Accepted: 09/17/2023] [Indexed: 10/30/2023]
Abstract
We present updated, evidence-based clinical practice guidelines from the Indian Society of Pediatric Nephrology (ISPN) for the management of urinary tract infection (UTI) and primary vesicoureteric reflux (VUR) in children. These guidelines conform to international standards; Institute of Medicine and AGREE checklists were used to ensure transparency, rigor, and thoroughness in the guideline development. In view of the robust methodology, these guidelines are applicable globally for the management of UTI and VUR. Seventeen recommendations and 18 clinical practice points have been formulated. Some of the key recommendations and practice points are as follows. Urine culture with > 104 colony forming units/mL is considered significant for the diagnosis of UTI in an infant if the clinical suspicion is strong. Urine leukocyte esterase and nitrite can be used as an alternative screening test to urine microscopy in a child with suspected UTI. Acute pyelonephritis can be treated with oral antibiotics in a non-toxic infant for 7-10 days. An acute-phase DMSA scan is not recommended in the evaluation of UTI. Micturating cystourethrography (MCU) is indicated in children with recurrent UTI, abnormal kidney ultrasound, and in patients below 2 years of age with non-E. coli UTI. Dimercaptosuccinic acid scan (DMSA scan) is indicated only in children with recurrent UTI and high-grade (3-5) VUR. Antibiotic prophylaxis is not indicated in children with a normal urinary tract after UTI. Prophylaxis is recommended to prevent UTI in children with bladder bowel dysfunction (BBD) and those with high-grade VUR. In children with VUR, prophylaxis should be stopped if the child is toilet trained, free of BBD, and has not had a UTI in the last 1 year. Surgical intervention in high-grade VUR can be considered for parental preference over antibiotic prophylaxis or in children developing recurrent breakthrough febrile UTIs on antibiotic prophylaxis.
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Affiliation(s)
- Pankaj Hari
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India.
| | - Jitendra Meena
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Manish Kumar
- Department of Pediatrics, Chacha Nehru Bal Chikitsalya, New Delhi, India
| | - Aditi Sinha
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India
| | | | - Arpana Iyengar
- Department of Pediatric Nephrology, St. Johns Medical College and Hospital, Bengaluru, India
| | - Priyanka Khandelwal
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Sudha Ekambaram
- Department of Pediatric Nephrology, Apollo Children's Hospital, Chennai, India
| | - Priya Pais
- Department of Pediatric Nephrology, St. Johns Medical College and Hospital, Bengaluru, India
| | - Jyoti Sharma
- Department of Pediatrics, KEM Hospital, Pune, India
| | | | - Arvind Bagga
- Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, 110029, India
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Chang CL, Yang SSD, Hsu CK, Chen CH, Chang SJ. Effectiveness of various treatment modalities in children with vesicoureteral reflux grades II-IV: a systematic review and network meta-analysis. BMJ Paediatr Open 2023; 7:e002096. [PMID: 37989356 PMCID: PMC10660918 DOI: 10.1136/bmjpo-2023-002096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 07/26/2023] [Indexed: 11/23/2023] Open
Abstract
BACKGROUND Vesicoureteral reflux (VUR) is one of the most common risk factors of urinary tract infection (UTI) among children. Various treatment modalities including antibiotic prophylaxis, surgical or endoscopic corrections and conservative treatment were used depending on the severity of VUR. The aim of this study is to compare the effectiveness of these treatment modalities in children with VUR grades II-IV by conducting a systematic review and network meta-analysis. METHODS A systematic search from different databases was performed from their earliest records to December 2022 without any language restriction. Only randomised controlled trials were included in this study. Effectiveness of treatment modalities was mainly compared by UTI. Other outcomes for renal scarring and resolution by renal units were also measured between treatments. RESULTS A total of 11 studies with 1447 children were included in this study. While comparing with antibiotic prophylaxis in network meta-analysis for UTI recurrence, surgical treatment probably lowers the rate of UTI recurrence (Log OR -0.26, 95% CI -0.54 to 0.02, high quality). However, endoscopic treatment (Log OR 0.2, 95% CI -1.41 to 1.81, high quality) and conservative treatment (Log OR 0.15, 95% CI -0.45 to 0.75, high quality) revealed probably inferior to antibiotic treatment. CONCLUSION Both pairwise and network meta-analytic results probably showed no difference between the treatments in terms of their impact on UTI recurrence, progression of previous renal scars, or formation of new renal scars in children with VUR grades II-IV. These findings may offer a better understanding of each treatment and evidence-based suggestions for the choice of treatment, which should be individualised and based on the patient's risk factors.
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Affiliation(s)
- Chia-Lun Chang
- Department of Urology, Taipei Tzu Chi General Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, Taiwan
| | - Stephen Shei-Dei Yang
- Department of Urology, Taipei Tzu Chi General Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, Taiwan
| | - Chun-Kai Hsu
- Department of Urology, Taipei Tzu Chi General Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, Taiwan
| | - Chun-Hua Chen
- Department of Neurology, Taipei Municipal Wanfang hospital, Taipei, Taiwan
| | - Shang-Jen Chang
- Department of Urology, Taipei Tzu Chi General Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, Taiwan
- Department of Urology, National Taiwan University Hospital, Taipei, Taiwan
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Buder K, Opherk K, Mazzi S, Rohner K, Weitz M. Non-surgical management in children with non-refluxing primary megaureter: a systematic review and meta-analysis. Pediatr Nephrol 2023; 38:3549-3558. [PMID: 36995462 PMCID: PMC10514100 DOI: 10.1007/s00467-023-05938-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 03/02/2023] [Accepted: 03/03/2023] [Indexed: 03/31/2023]
Abstract
BACKGROUND Children with non-refluxing primary megaureter are mostly managed by a watchful approach with close follow-up and serial imaging. OBJECTIVES This systematic review and meta-analysis aimed to determine whether there is sufficient evidence to support the current non-surgical management strategy in these patients. DATA SOURCES A comprehensive search including electronic literature databases, clinical trial registries, and conference proceedings was performed. DATA SYNTHESIS METHODS Outcomes were estimated as pooled prevalence. If meta-analytical calculations were not appropriate, outcomes were provided in a descriptive manner. RESULTS Data from 8 studies (290 patients/354 renal units) were included. For the primary outcome, differential renal function estimated by functional imaging, meta-analysis was impossible due to reported data not being precise. Pooled prevalence for secondary surgery was 13% (95% confidence interval: 8-19%) and for resolution 61% (95% confidence interval: 42-78%). The risk of bias was moderate or high in most studies. LIMITATIONS This analysis was limited by the low number of eligible studies with few participants and high clinical heterogeneity, and the poor quality of the available data. CONCLUSIONS The low pooled prevalence of secondary surgical intervention and high pooled prevalence of resolution may support the current non-surgical management in children with non-refluxing primary megaureter. However, these results should be interpreted cautiously due to the limited available body of evidence. Future studies should overcome existing limitations of imaging methods by using standardized, comparable criteria and report outcome parameters in a quantitative manner. This would allow more sufficient data synthesis to provide evidence-based recommendations for clinical decision-making and counseling. SYSTEMATIC REVIEW REGISTRATION The protocol was registered on PROSPERO under CRD42019134502.
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Affiliation(s)
- Kathrin Buder
- Department of General Pediatrics and Hematology/Oncology, University Hospital Tübingen, University Children's Hospital, Hoppe-Seyler-Str. 1, D - 72076, Tübingen, Germany.
| | - Kathrin Opherk
- Department of General Pediatrics and Hematology/Oncology, University Hospital Tübingen, University Children's Hospital, Hoppe-Seyler-Str. 1, D - 72076, Tübingen, Germany
| | - Sara Mazzi
- Pediatric Nephrology Department, University Children's Hospital Zurich, Steinwiesstr. 75, CH - 8032, Zurich, Switzerland
| | - Katharina Rohner
- Pediatric Nephrology Department, University Children's Hospital Zurich, Steinwiesstr. 75, CH - 8032, Zurich, Switzerland
| | - Marcus Weitz
- Department of General Pediatrics and Hematology/Oncology, University Hospital Tübingen, University Children's Hospital, Hoppe-Seyler-Str. 1, D - 72076, Tübingen, Germany
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Escolino M, Kalfa N, Castagnetti M, Caione P, Esposito G, Florio L, Esposito C. Endoscopic injection of bulking agents in pediatric vesicoureteral reflux: a narrative review of the literature. Pediatr Surg Int 2023; 39:133. [PMID: 36806763 PMCID: PMC9938816 DOI: 10.1007/s00383-023-05426-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/09/2023] [Indexed: 02/21/2023]
Abstract
In the last 20 years, endoscopic injection (EI) has affirmed as a valid alternative to open surgery for management of pediatric vesicoureteral reflux (VUR). This study aimed to investigate and discuss some debated aspects such as indications, bulking agents and comparison, techniques of injection and comparison, predictive factors of success, use in specific situations. EI is minimally invasive, well accepted by patients and families, with short learning curve and low-morbidity profile. It provides reflux resolution rates approaching those of open reimplantation, ranging from 69 to 100%. Obviously, the success rate may be influenced by several factors. Recently, it is adopted as first-line therapy also in high grade reflux or complex anatomy such as duplex, bladder diverticula, ectopic ureters. The two most used materials for injection are Deflux and Vantris. The first is absorbable, easier to inject, has lower risk of obstruction, but can lose efficacy over time. The second is non-absorbable, more difficult to inject, has higher risk of obstruction, but it is potentially more durable. The two main techniques are STING and HIT. To date, the ideal material and technique of injection has not yet clearly established, but the choice remains dependent on surgeon's preference and experience.
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Affiliation(s)
- Maria Escolino
- Pediatric Surgery Unit, Federico II University Hospital, Via Pansini 5, 80131, Naples, Italy.
| | - Nicolas Kalfa
- Pediatric Surgery Unit, University Hospital of Montpellier, Montpellier, France
| | | | - Paolo Caione
- Pediatric Urology Unit, Salvator Mundi International Hospital, Rome, Italy
| | | | - Luisa Florio
- Pediatric Surgery Unit, Federico II University Hospital, Via Pansini 5, 80131, Naples, Italy
| | - Ciro Esposito
- Pediatric Surgery Unit, Federico II University Hospital, Via Pansini 5, 80131, Naples, Italy
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Management of Pediatric Urinary Tract Infections: A Delphi Study. Antibiotics (Basel) 2022; 11:antibiotics11081122. [PMID: 36009990 PMCID: PMC9404756 DOI: 10.3390/antibiotics11081122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 08/09/2022] [Accepted: 08/16/2022] [Indexed: 11/17/2022] Open
Abstract
Urinary tract infection (UTI) is one of the most common infectious diseases in the pediatric population and represents a major cause of antibiotic consumption and hospitalization in children. Considering the ongoing controversies on the management of pediatric UTI and the challenges due to increasing antimicrobial resistance, the aim of the present study was to evaluate the level of agreement on UTI management in pediatric age in Emilia-Romagna Region, Italy, and to assess on the basis of recent studies whether there is the need to change current recommendations used by primary care pediatricians, hospital pediatricians, and pediatric surgeons in everyday clinical practice to possibly improve outcomes. This consensus provides clear and shared indications on UTI management in pediatric age, based on the most updated literature. This work represents, in our opinion, the most complete and up-to-date collection of statements on procedures to follow for pediatric UTI, in order to guide physicians in the management of the patient, standardize approaches, and avoid abuse and misuse of antibiotics. Undoubtedly, more randomized and controlled trials are needed in the pediatric population to better define the best therapeutic management in cases with antimicrobial resistance and real usefulness of long-term antibiotic prophylaxis.
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Olson P, Dudley AG, Rowe CK. Contemporary Management of Urinary Tract Infections in Children. CURRENT TREATMENT OPTIONS IN PEDIATRICS 2022; 8:192-210. [PMID: 37521173 PMCID: PMC9108690 DOI: 10.1007/s40746-022-00242-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 04/17/2022] [Indexed: 10/29/2022]
Abstract
Purpose of Review Urinary tract infection (UTI) in children is a major source of office visits and healthcare expenditure. Research into the diagnosis, treatment, and prophylaxis of UTI has evolved over the past 10 years. The development of new imaging techniques and UTI screening tools has improved our diagnostic accuracy tremendously. Identifying who to treat is imperative as the increase in multi-drug-resistant organisms has emphasized the need for antibiotic stewardship. This review covers the contemporary management of children with UTI and the data-driven paradigm shifts that have been implemented into clinical practice. Recent Findings With recent data illustrating the self-limiting nature and low prevalence of clinically significant vesicoureteral reflux (VUR), investigational imaging in children has become increasingly less frequent. Contrast-enhanced voiding urosonogram (CEVUS) has emerged as a useful diagnostic tool, as it can provide accurate detection of VUR without the need of radiation. The urinary and intestinal microbiomes are being investigated as potential therapeutic drug targets, as children with recurrent UTIs have significant alterations in bacterial proliferation. Use of adjunctive corticosteroids in children with pyelonephritis may decrease the risk of renal scarring and progressive renal insufficiency. The development of a vaccine against an antigen present on Escherichia coli may change the way we treat children with recurrent UTIs. Summary The American Academy of Pediatrics defines a UTI as the presence of at least 50,000 CFU/mL of a single uropathogen obtained by bladder catheterization with a dipstick urinalysis positive for leukocyte esterase (LE) or WBC present on urine microscopy. UTIs are more common in females, with uncircumcised males having the highest risk in the first year of life. E. coli is the most frequently cultured organism in UTI diagnoses and multi-drug-resistant strains are becoming more common. Diagnosis should be confirmed with an uncontaminated urine specimen, obtained from mid-stream collection, bladder catheterization, or suprapubic aspiration. Patients meeting criteria for imaging should undergo a renal and bladder ultrasound, with further investigational imaging based on results of ultrasound or clinical history. Continuous antibiotic prophylaxis is controversial; however, evidence shows patients with high-grade VUR and bladder and bowel dysfunction retain the most benefit. Open surgical repair of reflux is the gold standard for patients who fail medical management with endoscopic approaches available for select populations.
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Affiliation(s)
- Philip Olson
- Department of Urology, University of Connecticut School of Medicine, 200 Academic Way, Farmington, CT 06032 USA
| | - Anne G. Dudley
- Division of Pediatric Urology, Connecticut Children’s, 282 Washington Street, Hartford, CT 06106 USA
| | - Courtney K. Rowe
- Division of Pediatric Urology, Connecticut Children’s, 282 Washington Street, Hartford, CT 06106 USA
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Non-antibiotic Approaches to Preventing Pediatric UTIs: a Role for D-Mannose, Cranberry, and Probiotics? Curr Urol Rep 2022; 23:113-127. [PMID: 35441976 DOI: 10.1007/s11934-022-01094-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/01/2022] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW While antibiotics have been a staple in the management and even prevention of urinary tract infections (UTIs), it is not without significant consequences due to intolerance and development of antibiotic resistant bacteria. These concerns necessitate alternatives to antibiotic use in the management of pediatric UTIs. This review seeks to evaluate non-antibiotic means of preventing UTI in the pediatric population. RECENT FINDINGS The search for preventative alternatives to antibiotics has included D-mannose, cranberry, and probiotics. These products similarly work through competitive inhibition of uropathogens in the urinary tract. Pediatric studies exist highlighting the use of cranberry extract/juice and probiotics in UTI prevention, although significant heterogeneity amongst studies have limited overarching recommendations for their use. Data of D-mannose use is extrapolated from adult literature. More studies are required in the utility of each treatment, with some emphasis on larger sample sizes and clarifications regarding dosing and formulation.
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Zhao X, Tian Q, Fang E, Li N. Use of Urethral Sound to Facilitate Locating Retrovesical Ureter for Politano-Leadbetter Pneumovesicoscopic Ureteral Reimplantation. Front Pediatr 2022; 10:834465. [PMID: 35311041 PMCID: PMC8927294 DOI: 10.3389/fped.2022.834465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 01/18/2022] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Pneumovesicoscopic ureteral reimplantation (PVUR) has gained popularity due to its minimal invasiveness. However, most of the reported PVUR procedures were based on the Cohen technique. Only few studies reported their experience of PVUR using the Politano-Leadbetter technique (PVUR-PL). Here, we reported our experience of PVUR-PL using a novel technique to facilitate locating the retrovesical ureter during the procedure. MATERIALS AND METHODS The medical records of the patients who underwent PVUR-PL between January 2018 and December 2020 in our institution were retrospectively reviewed. The patients were classified into two groups: the modified group that accepted PVUR-PL using our novel technique (using urethral sound to facilitate identifying the retrovesical ureter) and the traditional group that accepted PVUR-PL not using the novel technique. Clinical data were collected retrospectively. RESULTS There were 22 patients who underwent PVUR-PL, with 13 in the traditional group and nine in the modified group. The mean operating time for unilateral cases in the modified group was significantly shorter than that in the traditional group (154.5 vs. 195.5 min, p < 0.001). For bilateral cases, the mean operating time was also significantly reduced (from 263.0 to 221.3 min, p = 0.022) in the modified group. There were no severe complications in each of the two groups. The peritoneum was perforated in one case from the traditional group, while no peritoneum perforation occurred in the modified group. CONCLUSION The use of urethral sound to help to identify the retrovesical ureter during PVUR-PL is a safe and effective technique. This simple but effective technique could shorten the operating time of PVUR-PL and reduce the risk of peritoneum perforation.
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Affiliation(s)
- Xiang Zhao
- Department of Pediatric Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Qingqing Tian
- Department of Pediatric Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Erhu Fang
- Department of Pediatric Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ning Li
- Department of Pediatric Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Meena J, Thomas CC, Kumar J, Raut S, Hari P. Non-antibiotic interventions for prevention of urinary tract infections in children: a systematic review and meta-analysis of randomized controlled trials. Eur J Pediatr 2021; 180:3535-3545. [PMID: 34156540 DOI: 10.1007/s00431-021-04091-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 04/22/2021] [Accepted: 04/25/2021] [Indexed: 11/28/2022]
Abstract
A considerable proportion of children experience a recurrence of urinary tract infection (UTI) following the first episode. While low-dose antibiotic prophylaxis has been the mainstay for the prevention of UTI, recent evidence raised concerns over their efficacy and safety. Hence, we aim to systematically synthesize evidence on the efficacy and safety of non-antibiotic prophylactic interventions for UTI. Using keywords related to study population (children) and intervention (non-antibiotic), we searched CENTRAL, Embase, PubMed, and Web of Science for randomized controlled trials (RCTs) published until August 2020. RCTs comparing any non-antibiotic interventions with placebo/antibiotics for prevention of UTIs in children were considered eligible. We used a random-effect model to provide pooled estimates. Sixteen trials evaluating 1426 participants were included. Cranberry was as effective as antibiotic prophylaxis (RR: 0.92; 95% CI: 0.56-1.50) but better than placebo/no therapy (RR: 0.48; 95% CI: 0.28-0.80) in reducing UTI recurrence. Probiotic therapy was more effective in reducing UTI recurrence (RR: 0.52; 95% CI: 0.29-0.94) when compared with placebo. While probiotic therapy was not better than antibiotics prophylaxis in preventing UTI (RR: 0.82; 95% CI: 0.56-1.21), they have a lower risk of antibiotic resistance (RR: 0.38; 95% CI: 0.21-0.69).Conclusion: Cranberry products and probiotics are the two non-antibiotic interventions that have been chiefly evaluated, reduce the risk of UTI recurrence when compared with placebo in children with a normal urinary tract. The findings from this systematic review suggest that while cranberry and probiotics may be used, there is a definite need to identify better and more acceptable non-antibiotic interventions. What is Known: • Efficacy of the low-dose antibiotic is controversial in preventing UTI and it is associated with increase in the risk of antimicrobial resistance. • Non-antibiotic interventions such as cranberry products are effective in preventing UTI recurrence in adults. What is New: • Cranberry products are effective in reducing the recurrence of UTI in children with normal urinary tract. • Low-quality evidence suggests that probiotics can be a potential prophylactic measure to reduce recurrence of UTI in the pediatric population.
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Affiliation(s)
- Jitendra Meena
- Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | | | - Jogender Kumar
- Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sumantra Raut
- Division of Pediatric Nephrology, Department of Pediatrics, NRS Medical College & Hospital, Kolkata, India
| | - Pankaj Hari
- Division of Nephrology, Department of Pediatrics, ICMR Center for Advanced Research in Nephrology, All India Institute of Medical Sciences, New Delhi, India.
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Effectiveness and risks of endoscopic management compared to vesicoureteral reimplantation in patients with high-grade vesicoureteral reflux: systematic review and network meta-analysis. Eur J Pediatr 2021; 180:1383-1391. [PMID: 33474581 DOI: 10.1007/s00431-021-03948-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 01/11/2021] [Accepted: 01/14/2021] [Indexed: 10/22/2022]
Abstract
The purpose of this study is to determine the effectiveness and safety of endoscopic management compared to ureterovesical reimplantation in pediatric patients with high-grade vesicoureteral reflux in terms of urinary tract infection. We performed a network meta-analysis. We searched in MEDLINE, EMBASE, LILACS, and CENTRAL. We included clinical experiments, quasi-experiments, and cohorts studies. The population was men and women between 1 month and 15 years old. Patients had primary high-grade VUR diagnosed by voiding cystourethrography. The interventions were subureteric bulking agent endoscopic injection (polytetrafluoroethylene, hyaluronic acid, collagen, Dx/Ha, and PPC) vs vesicoureteral reimplantation (Cohen, Politano-Leadbetter, Glenn-Anderson, and Lich-Gregoir), and the primary outcome was urinary infections. Nine studies accomplished the inclusion criteria (seven observational and two clinical experiments). A total of 1448 renal units underwent surgical treatments for the correction of high-grade VUR. Regarding the primary outcome, we compared Dx/Ha with Cohen, Lich-Gregoir, and PPC, finding an RD of -0.02 (95%CI -0.09 to 0.06), RD of -0.02 (95%CI -0.10 to 0.07), and an RD of -0.03 (- 0.13 to 0.07), respectively.Conclusion: Our study showed that there were no differences in UTI episodes after VUR correction in patients undergoing endoscopic management compared with vesicoureteral reimplantation. What is Known: • Primary vesicoureteral reflux is one of the most common congenital anomalies of the urinary tract. • The clinical practice guidelines recommend the surgical management of patients with high-grade VUR. What is New: • There were no differences in UTI episodes after VUR correction in patients undergoing endoscopic management compared with vesicoureteral reimplantation.
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Groen in 't Woud S, Westland R, Feitz WF, Roeleveld N, van Wijk JA, van der Zanden LF, Schreuder MF. Clinical Management of Children with a Congenital Solitary Functioning Kidney: Overview and Recommendations. EUR UROL SUPPL 2021; 25:11-20. [PMID: 34337499 PMCID: PMC8317823 DOI: 10.1016/j.euros.2021.01.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/05/2021] [Indexed: 11/25/2022] Open
Abstract
CONTEXT A congenital solitary functioning kidney (cSFK) is a common developmental defect that predisposes to hypertension and chronic kidney disease (CKD) as a consequence of hyperfiltration. Every urologist takes care of patients with a cSFK, since some will need lifelong urological care or will come with clinical problems or questions to an adult urologist later in life. OBJECTIVE We aim to provide clear recommendations for the initial clinical management and follow-up of children with a cSFK. EVIDENCE ACQUISITION PubMed and EMBASE were searched to identify relevant publications, which were combined with guidelines on related topics and expert opinion. EVIDENCE SYNTHESIS Initially, cSFK diagnosis should be confirmed and risk factors for kidney injury should be identified using ultrasound. Although more research into early predictors of kidney injury is needed, additional congenital anomalies of the kidney or urinary tract and absence of compensatory kidney hypertrophy have repeatedly been associated with a worse prognosis. The role of voiding cystourethrography and antibiotic prophylaxis remains controversial, and is complicated by the exclusion of children with a cSFK from studies. A yearly follow-up for signs of kidney injury is recommended for children with a cSFK. As masked hypertension is prevalent, annual ambulatory blood pressure measurement should be considered. During puberty, an increasing incidence of kidney injury is seen, indicating that long-term follow-up is necessary. If signs of kidney injury are present, angiotensin converting enzyme inhibitors are the first-line drugs of choice. CONCLUSIONS This overview points to the urological and medical clinical aspects and long-term care guidance for children with a cSFK, who are at risk of hypertension and CKD. Monitoring for signs of kidney injury is therefore recommended throughout life. Large, prospective studies with long-term follow-up of clearly defined cohorts are still needed to facilitate more risk-based and individualized clinical management. PATIENT SUMMARY Many children are born with only one functioning kidney, which could lead to kidney injury later in life. Therefore, a kidney ultrasound is made soon after birth, and other investigations may be needed as well. Urologists taking care of patients with a solitary functioning kidney should realize the long-term clinical aspects, which might need medical management.
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Affiliation(s)
- Sander Groen in 't Woud
- Department for Health Evidence, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
- Department of Pediatric Nephrology, Radboudumc Amalia Children’s Hospital, Radboud Institute for Molecular Life Sciences, Nijmegen, The Netherlands
| | - Rik Westland
- Department of Pediatric Nephrology, Amsterdam UMC, Amsterdam, The Netherlands
| | - Wout F.J. Feitz
- Division of Pediatric Urology, Department of Urology, Radboudumc Amalia Children’s Hospital, Radboud Institute for Molecular Life Sciences, Nijmegen, The Netherlands
| | - Nel Roeleveld
- Department for Health Evidence, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Joanna A.E. van Wijk
- Division of Pediatric Urology, Department of Urology, Radboudumc Amalia Children’s Hospital, Radboud Institute for Molecular Life Sciences, Nijmegen, The Netherlands
| | - Loes F.M. van der Zanden
- Department for Health Evidence, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Michiel F. Schreuder
- Department of Pediatric Nephrology, Radboudumc Amalia Children’s Hospital, Radboud Institute for Molecular Life Sciences, Nijmegen, The Netherlands
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Läckgren G, Cooper CS, Neveus T, Kirsch AJ. Management of Vesicoureteral Reflux: What Have We Learned Over the Last 20 Years? Front Pediatr 2021; 9:650326. [PMID: 33869117 PMCID: PMC8044769 DOI: 10.3389/fped.2021.650326] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 03/05/2021] [Indexed: 12/12/2022] Open
Abstract
Vesicoureteral reflux (VUR) is associated with increased risks of urinary tract infection, renal scarring and reflux nephropathy. We review advancements over the last two decades in our understanding and management of VUR. Over time, the condition may resolve spontaneously but it can persist for many years and bladder/bowel dysfunction is often involved. Some factors that increase the likelihood of persistence (e.g., high grade) also increase the risk of renal scarring. Voiding cystourethrography (VCUG) is generally considered the definitive method for diagnosing VUR, and helpful in determining the need for treatment. However, this procedure causes distress and radiation exposure. Therefore, strategies to reduce clinicians' reliance upon VCUG (e.g., after a VUR treatment procedure) have been developed. There are several options for managing patients with VUR. Observation is suitable only for patients at low risk of renal injury. Antibiotic prophylaxis can reduce the incidence of UTIs, but drawbacks such as antibiotic resistance and incomplete adherence mean that this option is not viable for long-term use. Long-term studies of endoscopic injection have helped us understand factors influencing use and the effectiveness of this procedure. Ureteral reimplantation is still performed commonly, and robot-assisted laparoscopic methods are gaining popularity. Over the last 20 years, there has been a shift toward more conservative management of VUR with an individualized, risk-based approach. For continued treatment improvement, better identification of children at risk of renal scarring, robust evidence regarding the available interventions, and an improved VUR grading system are needed.
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Affiliation(s)
- Göran Läckgren
- Section of Urology, Department of Pediatric Surgery, University Children's Hospital, Uppsala, Sweden
| | | | - Tryggve Neveus
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Andrew J Kirsch
- Pediatric Urology, Children's Healthcare of Atlanta and Emory University School of Medicine, Atlanta, GA, United States
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14
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Leigh J, Rickard M, Sanger S, Petropoulos J, Braga LH, Chanchlani R. Antibiotic prophylaxis for prevention of urinary tract infections in the first year of life in children with vesicoureteral reflux diagnosed in the workup of antenatal hydronephrosis: a systematic review. Pediatr Nephrol 2020; 35:1639-1646. [PMID: 32350666 DOI: 10.1007/s00467-020-04568-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 03/28/2020] [Accepted: 04/02/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Children with antenatal hydronephrosis (ANH) diagnosed with postnatal asymptomatic vesicoureteral reflux (VUR) are thought to be at higher risk of urinary tract infection (UTI). As such, continuous antibiotic prophylaxis (CAP) is empirically recommended until age of toilet training; however, there are limited data to support this. The objective of this systematic review was to summarize the existing data and compare UTI rates in infants with asymptomatic VUR on CAP during the first year of life, to those not on CAP. Secondary objectives were to determine associated risk factors with UTI development. METHODS A systematic search of all relevant studies and abstracts was conducted using 4 electronic databases by utilizing appropriate key words by an expert hospital librarian. Eligible studies included children with prenatal hydronephrosis, asymptomatic VUR with or without CAP, and reported on development of UTI in the first year. RESULTS Of 6903 citations screened, 18 were selected, giving a total population of 829 (69.4% male, median age 57 days) who met the inclusion criteria. Most studies were retrospective and of low-quality evidence. Overall, 15.4% of patients developed at least one breakthrough UTI and females had a higher risk of UTI (odds ratio (OR) 2.3, 95% CI 1.1-4.7). Comparison with children not taking CAP was not readily reported, and meta-analysis could not be completed. CONCLUSIONS Randomized controlled trials and standardized reporting of clinical variables are required to understand the protective effect of antibiotic prophylaxis in this cohort.
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Affiliation(s)
- Jennifer Leigh
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Canada
| | - Mandy Rickard
- Division of Paediatric Urology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | | | | | - Luis H Braga
- Department of Pediatric Urology, McMaster Children's Hospital, Hamilton, Canada
| | - Rahul Chanchlani
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada. .,Division of Pediatric Nephrology, Department of Pediatrics, McMaster Children's Hospital, Hamilton, Canada.
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15
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Current Management of Urinary Tract Infection and Vesicoureteral Reflux. Indian J Pediatr 2020; 87:625-632. [PMID: 31828601 DOI: 10.1007/s12098-019-03099-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 10/15/2019] [Indexed: 10/25/2022]
Abstract
Urinary tract infection (UTI) is defined as the growth of a significant number of microorganisms of a single species in the urine, in the presence of symptoms. Symptoms in young children are non-specific such as fever without focus; young infants may manifest with irritability, failure to thrive, jaundice, vomiting and diarrhea. Older children usually have symptoms of cystitis or pyelonephritis. Symptoms of cystitis are dysuria, frequency, new onset incontinence and malodorous urine while symptoms of pyelonephritis are high grade fever, flank pain and vomiting. Rapid urine testing by microscopy for pus cells, dipstick testing for leukocyte esterase and nitrite, and enhanced urinalysis are supportive tests. Urine culture samples should be collected with proper technique and results interpreted for significant growth accordingly. Antibiotic therapy for 7-14 d for complicated UTI and 3-4 d for uncomplicated UTI is adequate. Further evaluation is recommended clinically for bladder-bowel dysfunction and obvious anatomical defects and by imaging for vesicoureteral reflux (VUR), usually by micturating cystourethrography (MCU). Since MCU involves exposure to radiation and urethral catheterization, it is now reserved for children with parenchymal involvement or recurrent UTI. VUR is the backward flow of urine into one or both ureters. Clinical manifestations other than UTI include incidental diagnosis on antenatal ultrasonography. Reflux nephropathy, the renal scarring associated with VUR may manifest clinically as hypertension, proteinuria and renal failure. The management of VUR is primarily with antibiotic prophylaxis. Anatomical correction is indicated in case of breakthrough febrile UTI. No intervention has been shown to reduce renal scarring.
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16
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Andrioli V, Regacini R, Aguiar W. Primary Vesicoureteral reflux and chronic kidney disease in pediatric population. What we have learnt? Int Braz J Urol 2020; 46:262-268. [PMID: 32022517 PMCID: PMC7025841 DOI: 10.1590/s1677-5538.ibju.2020.02.02] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Affiliation(s)
- Veridiana Andrioli
- Divisão de Urologia e Departamento de Cirurgia, Escola Paulista de Medicina, Universidade Federal de São Paulo - UNIFESP, São Paulo, SP, Brasil
| | - Rodrigo Regacini
- Departamento de Imagem Médica e Divisão de Radiologia Pediátrica, Escola Paulista de Medicina, Universidade Federal de São Paulo - UNIFESP, São Paulo, SP, Brasil
| | - Wilson Aguiar
- Divisão de Urologia e Departamento de Cirurgia, Escola Paulista de Medicina, Universidade Federal de São Paulo - UNIFESP, São Paulo, SP, Brasil
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17
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Chang PW, Wang ME, Schroeder AR. Diagnosis and Management of UTI in Febrile Infants Age 0-2 Months: Applicability of the AAP Guideline. J Hosp Med 2020; 15:e1-e5. [PMID: 32118563 DOI: 10.12788/jhm.3349] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 10/30/2019] [Indexed: 11/20/2022]
Abstract
Urinary tract infections (UTIs) are the most common bacterial infection in young infants. The American Academy of Pediatrics' (AAP) clinical practice guideline for UTIs focuses on febrile children age 2-24 months, with no guideline for infants <2 months of age, an age group commonly encountered by pediatric hospitalists. In this review, we assess the applicability of the AAP UTI Guideline's action statements for previously healthy, febrile infants <2 months of age. We also discuss additional considerations in this age group, including concurrent bacteremia and routine testing for meningitis.
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Affiliation(s)
- Pearl W Chang
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Marie E Wang
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Alan R Schroeder
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California
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18
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Tendencies and Challenges in Worldwide Scientific Research on Probiotics. Probiotics Antimicrob Proteins 2019; 12:785-797. [DOI: 10.1007/s12602-019-09591-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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