1
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Wald ER, Eickhoff JC. Determining the Best Definition for a Positive Urine Culture in Young Children. Pediatrics 2023; 152:e2023062883. [PMID: 37691605 DOI: 10.1542/peds.2023-062883] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/06/2023] [Indexed: 09/12/2023] Open
Affiliation(s)
- Ellen R Wald
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Jens C Eickhoff
- Department of Biostatistics and Medical Informatics, American Family Children's Hospital, Madison, Wisconsin
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2
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Fang NW, Chiou YH, Chen YS, Hung CW, Yin CH, Chen JS. Nomogram for diagnosing acute pyelonephritis in pediatric urinary tract infection. Pediatr Neonatol 2022; 63:380-387. [PMID: 35568634 DOI: 10.1016/j.pedneo.2022.03.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 02/15/2022] [Accepted: 03/10/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND For risk stratification and individualized treatment for children with urinary tract infection (UTI), they must be assessed for the presence of acute pyelonephritis (APN). Our study aimed to combine variables that can predict APN and establish a nomogram for clinical use. METHODS In total, 111 children <5 years old hospitalized at Kaohsiung Veterans General Hospital for UTI were classified into APN and simple UTI groups based on a technetium-99 m dimercaptosuccinic acid scan. Their demographic, laboratory test, and renal and urinary bladder sonography (RUBS) data were compared. RESULTS Fever peak of >39 °C, serum procalcitonin (PCT) ≥ 0.52 pg/mL, C-reactive protein (CRP) ≥ 2.86 mg/dL, and abnormal RUBS findings were independent variables for predicting APN in children. The nomogram established using the aforementioned variables had an area under the receiver operating characteristic curve (AUC) of 0.89, which was higher than those of PCT and CRP alone (0.776 and 0.774, respectively). CONCLUSION The combination of four variables had the highest power in predicting APN in children with UTI. The established nomogram is practical for clinical use.
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Affiliation(s)
- Nai-Wen Fang
- Department of Pediatrics, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Yee-Hsuan Chiou
- Department of Pediatrics, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Yao-Shen Chen
- Department of Administration, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; Faculty of Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chi-Wen Hung
- Department of Pediatrics, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Chun-Hao Yin
- Department of Medical Education and Research, Kaohsiung Veterans General Hospital, Taiwan
| | - Jin-Shuen Chen
- Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung and School of Medicine, National Defense Medical Center, Taipei, Taiwan.
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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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Hudson RE, Job KM, Sayre CL, Krepkova LV, Sherwin CM, Enioutina EY. Examination of Complementary Medicine for Treating Urinary Tract Infections Among Pregnant Women and Children. Front Pharmacol 2022; 13:883216. [PMID: 35571128 PMCID: PMC9094615 DOI: 10.3389/fphar.2022.883216] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 04/12/2022] [Indexed: 01/27/2023] Open
Abstract
Urinary tract infections (UTIs) are a significant clinical problem that pregnant women and children commonly experience. Escherichia coli is the primary causative organism, along with several other gram-negative and gram-positive bacteria. Antimicrobial drugs are commonly prescribed to treat UTIs in these patients. Conventional treatment can range from using broad-spectrum antimicrobial drugs for empirical or prophylactic therapy or patient-tailored therapy based on urinary cultures and sensitivity to prospective antibiotics. The ongoing emergence of multi-drug resistant pathogens has raised concerns related to commonly prescribed antimicrobial drugs such as those used routinely to treat UTIs. Consequently, several natural medicines have been explored as potential complementary therapies to improve health outcomes in patients with UTIs. This review discusses the effectiveness of commonly used natural products such as cranberry juice/extracts, ascorbic acid, hyaluronic acid, probiotics, and multi-component formulations intended to treat and prevent UTIs. The combination of natural products with prescribed antimicrobial treatments and use of formulations that contained high amounts of cranberry extracts appear to be most effective in preventing recurrent UTIs (RUTIs). The incorporation of natural products like cranberry, hyaluronic acid, ascorbic acid, probiotics, Canephron® N, and Cystenium II to conventional treatments of acute UTIs or as a prophylactic regimen for treatment RUTIs can benefit both pregnant women and children. Limited information is available on the safety of natural products in these patients' populations. However, based on limited historical information, these remedies appear to be safe and well-tolerated by patients.
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Affiliation(s)
- Rachel E. Hudson
- Department of Pediatrics, Post-Doctoral Fellow, Division of Clinical Pharmacology, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Kathleen M. Job
- Department of Pediatrics, Research Assistant Professor, Division of Clinical Pharmacology, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Casey L. Sayre
- Department of Pediatrics, Research Assistant Professor, Division of Clinical Pharmacology, University of Utah School of Medicine, Salt Lake City, UT, United States
- College of Pharmacy, Roseman University of Health Sciences, South Jordan, UT, United States
| | - Lubov V. Krepkova
- Head of Toxicology Department, Center of Medicine, All-Russian Research Institute of Medicinal and Aromatic Plants (VILAR), Moscow, Russia
| | - Catherine M. Sherwin
- Department of Pediatrics, Vice-Chair for Research, Professor, Wright State University Boonshoft School of Medicine/Dayton Children’s Hospital, Dayton, OH, United States
| | - Elena Y. Enioutina
- Department of Pediatrics, Research Assistant Professor, Division of Clinical Pharmacology, University of Utah School of Medicine, Salt Lake City, UT, United States
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Mathias S, Greenbaum LA, Shubha AM, Raj JAM, Das K, Pais P. Risk factors for renal scarring and clinical morbidity in children with high-grade and low-grade primary vesicoureteral reflux. J Pediatr Urol 2022; 18:225.e1-225.e8. [PMID: 35094942 DOI: 10.1016/j.jpurol.2021.12.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 12/29/2021] [Accepted: 12/30/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Primary vesicoureteral reflux (VUR) is associated with urinary tract infections (UTIs) and renal damage. However, the importance of early diagnosis of VUR has been questioned. Moreover, most studies have few patients with high-grade VUR. Hence, we retrospectively analyzed a large cohort of patients with primary high-grade and low-grade VUR and assessed risk factors for renal damage and clinical morbidity. MATERIAL AND METHODS We included patients (<18 years) at diagnosis with low-grade (1-3) or high-grade (4-5) primary VUR and noted their clinical history and presence of hypertension, low eGFR (<60ml/in/1.73 m2), renal scarring (focal or generalised) and reduced differential renal function (DRF; <45%). Risk factors were assessed (in patients and renal units) by logistic regression and generalised estimating equation. RESULTS Of 399 primary VUR patients, 255 (64%) had high-grade VUR. Indications for voiding cystourethrogram were recurrent UTI (38%), first UTI (28%) and antenatal hydronephrosis (17%). At diagnosis, 252 (65%) had renal scars (focal in 170 [44%], generalised in 82 [21%]), and 188 (47%) had reduced DRF. High-grade VUR patients were more likely than low-grade VUR patients to have renal scarring (75% vs. 49%, p < 0.01), low eGFR (23% vs. 13%, p = 0.04) and significant hypertension (26% vs. 13%, p = 0.02). High-grade VUR was associated with generalised scars (odds ratio [OR] 11, p < 0.001), focal scars (OR 3.1, p < 0.001) and reduced DRF (OR 2.3, p < 0.001) shown in the table. Male sex was a risk factor for generalised scars (OR 2.3, p = 0.005). Focal scars were associated with recurrent UTIs (OR = 1.8, p = 0.004) and reduced DRF (OR 1.4, p = 0.027). Patients with multiple focal scars were diagnosed at an older age (2 years [1,4] than those with single scars (1.5 years [1,4] or no scars (1 year [0, 3]), p = 0.04). DISCUSSION The prevalence of renal damage and clinical morbidity at VUR diagnosis was higher than other studies. High-grade VUR patients had a greater prevalence of renal damage, low eGFR and hypertension than low-grade VUR patients and was a risk factor for focal scars, generalised scars and reduced DRF. Focal scars were independently associated with recurrent UTI. Those with multiple scars were diagnosed later than those with single scars or no scars. CONCLUSIONS High-grade VUR was associated with renal damage and clinical morbidity. Our study highlights the importance of diagnosing VUR early to identify patients who may warrant long-term follow-up and intervention to minimize morbidity.
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Affiliation(s)
- Sitarah Mathias
- St John's Medical College, St John's National Academy of Health Sciences, Bangalore 560034, India
| | - Larry A Greenbaum
- Division of Pediatric Nephrology, Emory University and Children's Healthcare of Atlanta, 2015 Uppergate Drive, Atlanta, GA, 30322, USA
| | - A M Shubha
- Department of Pediatric Surgery, St Johns Medical College, St Johns National Academy of Health Sciences, Bangalore, 560034, India
| | - John A Michael Raj
- Department of Biostatistics, St John's Medical College, St John's National Academy of Health Sciences, Bangalore, 560034, India
| | - Kanishka Das
- Department of Pediatric Surgery, All India Institute of Medical Sciences, Bhubaneswar, 751019, India
| | - Priya Pais
- Department of Pediatric Nephrology, St John's Medical College, St John's National Academy of Health Sciences, Bangalore, 560034, India.
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Arabska M, Girardin ML, Long L, Grillon A, Zaloszyc A. [Antimicrobial resistance patterns in pediatric febrile urinary tract infection and empirical antibacterial therapy. An epidemiological study in secondary and tertiary care centers in the north-east of France in 2019-2020]. Nephrol Ther 2022; 18:129-135. [PMID: 35260346 DOI: 10.1016/j.nephro.2021.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Revised: 10/25/2021] [Accepted: 11/02/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Febrile urinary tract infection (UTI) is a common health issue in pediatrics that can lead to serious infectious and renal complications, it requires early diagnosis and a targeted use of antibiotics. The aim of our study was to describe local bacterial agents causing febrile UTIs and their resistance patterns and confront the results with currently used empirical antibacterial therapy in pediatrics emergency departments in Strasbourg and Saverne. PATIENTS AND METHODS We used billing codes (international classification of diseases) to identify all inpatients treated for febrile UTIs in two French pediatric emergency departments between January 2019 and December 2020. Microbial results of urine cultures were retrieved from the laboratory information system. RESULTS Among 214 microbial results from 208 patients, the distribution of uropathogens was 82% Escherichia coli, with extended-spectrum beta-lactamase in 2.8%, 7% Enterococcus faecalis, 5% Klebsiella, 2% Proteus mirabilis. E. coli was resistant respectively to amoxicillin, amoxicillin/clavulanic acid and cotrimoxazol in 43, 33 and 14% of samples. A third-generation cephalosporin administered intravenously was mainly used (98%) as empirical treatment. Less than 2% of patients were treated with oral cephalosporin from the start. CONCLUSION We present the spectrum of uropathogens and susceptibility test results in pediatric UTIs as well as the susceptibility pattern of E. coli, a local treatment protocol was designed based on our results in conformity with national guidelines.
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Affiliation(s)
- Mathilde Arabska
- Service de pédiatrie, centre hospitalier Sainte-Catherine, 19, Côte de Saverne, 67700 Saverne, France.
| | - Marie-Laure Girardin
- Service de réanimation pédiatrique, hôpital de Hautepierre, CHU de Strasbourg, université de Strasbourg, 1, avenue Molière, 67000 Strasbourg, France
| | - Laurence Long
- Service de pédiatrie, centre hospitalier Sainte-Catherine, 19, Côte de Saverne, 67700 Saverne, France
| | - Antoine Grillon
- Institut de bactériologie, CHU de Strasbourg, 1, place de l'Hôpital, 67000 Strasbourg, France
| | - Ariane Zaloszyc
- Service de pédiatrie 1, hôpital de Hautepierre, CHU de Strasbourg, université de Strasbourg, 1, avenue Molière, 67000 Strasbourg, France
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Hain G, Goldbart A, Sagi O, Ben-Shimol S. High Rates of Antibiotic Nonsusceptibility in Gram-negative Urinary Tract Infection in Children With Risk Factors Occurring in the Preceding Month: Considerations for Choosing Empiric Treatment. Pediatr Infect Dis J 2021; 40:639-644. [PMID: 33872277 DOI: 10.1097/inf.0000000000003147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Choosing an empiric treatment for urinary tract infections (UTIs) requires epidemiologic data on antibiotic nonsusceptibility (ANS) rates, and risk factors for UTI and ANS in the individual patient. We assessed ANS in community-acquired UTI, and its association with risk factors exposure (previous antibiotic treatment, UTI and hospital visit) <1 month or 1-11 months before the current UTI episode. METHODS This was a retrospective, cohort study. Children <2 years with hospital visits and a positive urine culture obtained <48 hours from hospital admission whose culture yielded Gram-negative bacteria during the years 2015-2016, were included. RESULTS Of the overall 744 episodes, 80% were Escherichia coli. Overall ANS rates were 66% for ampicillin; 27%-29% for amoxicillin/clavulanic acid, cephalosporins (indicating extended-spectrum beta-lactamase) and trimethoprim-sulfamethoxazole; 14% for nitrofurantoin; 5%-6% for gentamicin, ciprofloxacin and piperacillin/tazobactam; and <1% for meropenem and amikacin. Higher ANS rates were associated with Bedouin (vs. Jewish) ethnicity, exposure to risk factors <1 month, and to a lesser extent during the 1-11 months before the studied UTI episode. In episodes with risk factors <1 month, ANS rates were 81% for ampicillin; 47%-58% for amoxicillin/clavulanic acid, cephalosporins and trimethoprim-sulfamethoxazole; 19% for nitrofurantoin; 12%-23% for gentamicin, ciprofloxacin and piperacillin/tazobactam; and 2% for meropenem and amikacin. CONCLUSIONS Previous antibiotic treatment, hospital admission and UTI, especially <1 month before the current episode, and Bedouin ethnicity, were all associated with high rates of ANS. These findings are important and may assist the treating physician in choosing an adequate empiric treatment for UTI.
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Affiliation(s)
- Gavriel Hain
- From the Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
- Pediatrics Department, Soroka University Medical Center, Beer Sheva, Israel
- Pediatric Infectious Disease Unit, Soroka University Medical Center, Beer Sheva, Israel
| | - Aviv Goldbart
- From the Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
- Pediatrics Department, Soroka University Medical Center, Beer Sheva, Israel
| | - Orli Sagi
- From the Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
- Microbiology Laboratory, Soroka University Medical Center, Beer Sheva, Israel
| | - Shalom Ben-Shimol
- From the Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
- Pediatric Infectious Disease Unit, Soroka University Medical Center, Beer Sheva, Israel
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Peñalver Penedo R, Rupérez Lucas M, Álvarez-Sala Walther LA, Torregrosa Benavent A, Casas Losada ML, Bañuelos Andrio L, Rebolledo Poves AB, Bueno Campaña M. MR-Proadrenomedullin as biomarker of renal damage in urinary tract infection in children. BMC Pediatr 2021; 21:292. [PMID: 34187408 PMCID: PMC8240321 DOI: 10.1186/s12887-021-02765-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 06/02/2021] [Indexed: 01/18/2023] Open
Abstract
Background Midregional-proadrenomedullin (MR-proADM) is a useful prognostic peptide in severe infectious pathologies in the adult population. However, there are no studies that analyze its utility in febrile urinary tract infection (fUTI) in children. An accurate biomarker would provide an early detection of patients with kidney damage, avoiding other invasive tests like renal scintigraphy scans. Our objective is to study the usefulness of MR-proADM as a biomarker of acute and chronic renal parenchymal damage in fUTI within the pediatric population. Methods A prospective cohort study was conducted in pediatric patients with fUTI between January 2015 and December 2018. Plasma and urine MR-proADM levels were measured at admission in addition to other laboratory parameters. After confirmation of fUTI, renal scintigraphy scans were performed during the acute and follow-up stages. A descriptive study has been carried out and sensitivity, specificity and ROC curves for MR-proADM, C-reactive protein, and procalcitonin were calculated. Results 62 pediatric patients (34 female) were enrolled. Scintigraphy showed acute pyelonephritis in 35 patients (56.5%). Of those patients, the median of plasmatic MR-proADM (P-MR-proADM) showed no differences compared to patients without pyelonephritis. 7 patients (11.3%) developed renal scars (RS). Their median P-MR-proADM levels were 1.07 nmol/L (IQR 0.66–1.59), while in patients without RS were 0.48 nmol/L (0.43–0.63) (p < 0.01). The AUC in this case was 0.92 (95% CI 0.77–0.99). We established an optimal cut-off point at 0.66 nmol/L with sensitivity 83.3% and specificity 81.8%. Conclusion MR-ProADM has demonstrated a poor ability to diagnose pyelonephritis in pediatric patients with fUTI. However, P-MR-proADM proved to be a very reliable biomarker for RS prediction. Supplementary Information The online version contains supplementary material available at 10.1186/s12887-021-02765-2.
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Affiliation(s)
- Rafael Peñalver Penedo
- Servicio de Pediatría, Hospital Santa Bárbara de Soria, Departamento de Medicina, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain.
| | - Marta Rupérez Lucas
- Servicio de Pediatría, Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | - Luis Antonio Álvarez-Sala Walther
- Departamento de Medicina, Facultad de Medicina, Servicio de Medicina Interna, Hospital General Universitario Gregorio Marañón, IiSGM, Instituto de Investigaciones Sanitarias Gregorio Marañón, Universidad Complutense de Madrid, Madrid, Spain
| | | | | | - Luis Bañuelos Andrio
- Servicio de Medicina Nuclear, Hospital Universitario Fundación Alcorcón, Madrid, Spain
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Anfigeno L, Sertorio F, Basso L, Fontana A, Bodria M, Pistorio A, Ghiggeri GM, Damasio MB. Diffusion-Weighted MRI in the Evaluation of Renal Parenchymal Involvement during Febrile Urinary Tract Infections in Children: Preliminary Data. J Clin Med 2021; 10:jcm10112239. [PMID: 34064114 PMCID: PMC8196731 DOI: 10.3390/jcm10112239] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Revised: 05/03/2021] [Accepted: 05/14/2021] [Indexed: 11/16/2022] Open
Abstract
Background: Urinary tract infection (UTI) is the most common infection in pediatric-age patients. Acute pyelonephritis (PNA) represents a worrying situation in pediatric patients due to the risk of sepsis and long-term cicatricial consequences. The purpose of this retrospective study is to evaluate the diagnostic role of DW-MRI in relation to clinical data, to understand if there are any clinical parameters useful in identifying which patients should undergo it. Methods: According to inclusion and exclusion criteria, we enrolled 51 patients ≤15 years old admitted to our Institute between September 2012 and April 2020 with a febrile UTI who underwent DW-MRI evaluation. Clinical, laboratory and imaging data were collected. Statistical analysis was performed. Results: 34 of 51 patients with an fUTI (66.7%) showed signs of acute parenchymal involvement at DW-MRI evaluation. In 27 of these 34 (79.4%), DW-MRI showed multiple areas of pyelonephritis. A statistically significant relationship (p = 0.0004) between older age at admission and pyelonephritis was demonstrated. No statistically significant relationship was found between the other clinical, anamnestic and laboratory parameters and the outcome of DWI. Only two ultrasound examinations allowed the identification of pathological areas on the renal parenchyma. Conclusions: From these preliminary investigations, we can say that selecting the patients with fUTI on whom to perform a DW-MRI is difficult. Nevertheless, thanks to the low cost, the very rare need for sedation and the accuracy in identifying pyelonephritic areas, the use of DW-MRI in patients with febrile UTI seems recommendable.
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Affiliation(s)
- Lorenzo Anfigeno
- Department of Health Sciences (DISSAL), Università degli Studi di Genova, 16132 Genova, Italy
- Radiology Department, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Giannina Gaslini, 16147 Genova, Italy; (F.S.); (L.B.); (M.B.); (M.B.D.)
- Correspondence:
| | - Fiammetta Sertorio
- Radiology Department, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Giannina Gaslini, 16147 Genova, Italy; (F.S.); (L.B.); (M.B.); (M.B.D.)
| | - Luca Basso
- Radiology Department, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Giannina Gaslini, 16147 Genova, Italy; (F.S.); (L.B.); (M.B.); (M.B.D.)
| | - Andrea Fontana
- Postgraduation School in Radiodiagnostics, Università degli Studi di Milano, 20122 Milan, Italy;
| | - Monica Bodria
- Radiology Department, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Giannina Gaslini, 16147 Genova, Italy; (F.S.); (L.B.); (M.B.); (M.B.D.)
| | - Angela Pistorio
- Epidemiology and Biostatistics Department, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Giannina Gaslini, 16147 Genova, Italy;
| | - Gian Marco Ghiggeri
- Nephrology Department, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Giannina Gaslini, 16147 Genova, Italy;
| | - Maria Beatrice Damasio
- Radiology Department, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Giannina Gaslini, 16147 Genova, Italy; (F.S.); (L.B.); (M.B.); (M.B.D.)
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10
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Diffusion-Weighted MRI in the Evaluation of Renal Parenchymal Involvement during Febrile Urinary Tract Infections in Children: Preliminary Data. J Clin Med 2021. [DOI: 10.3390/jcm10112239
expr 943224684 + 995609622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023] Open
Abstract
Background: Urinary tract infection (UTI) is the most common infection in pediatric-age patients. Acute pyelonephritis (PNA) represents a worrying situation in pediatric patients due to the risk of sepsis and long-term cicatricial consequences. The purpose of this retrospective study is to evaluate the diagnostic role of DW-MRI in relation to clinical data, to understand if there are any clinical parameters useful in identifying which patients should undergo it. Methods: According to inclusion and exclusion criteria, we enrolled 51 patients ≤15 years old admitted to our Institute between September 2012 and April 2020 with a febrile UTI who underwent DW-MRI evaluation. Clinical, laboratory and imaging data were collected. Statistical analysis was performed. Results: 34 of 51 patients with an fUTI (66.7%) showed signs of acute parenchymal involvement at DW-MRI evaluation. In 27 of these 34 (79.4%), DW-MRI showed multiple areas of pyelonephritis. A statistically significant relationship (p = 0.0004) between older age at admission and pyelonephritis was demonstrated. No statistically significant relationship was found between the other clinical, anamnestic and laboratory parameters and the outcome of DWI. Only two ultrasound examinations allowed the identification of pathological areas on the renal parenchyma. Conclusions: From these preliminary investigations, we can say that selecting the patients with fUTI on whom to perform a DW-MRI is difficult. Nevertheless, thanks to the low cost, the very rare need for sedation and the accuracy in identifying pyelonephritic areas, the use of DW-MRI in patients with febrile UTI seems recommendable.
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11
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Mattoo TK, Shaikh N, Nelson CP. Contemporary Management of Urinary Tract Infection in Children. Pediatrics 2021; 147:peds.2020-012138. [PMID: 33479164 DOI: 10.1542/peds.2020-012138] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/04/2020] [Indexed: 11/24/2022] Open
Abstract
Urinary tract infection (UTI) is common in children, and girls are at a significantly higher risk, as compared to boys, except in early infancy. Most cases are caused by Escherichia coli Collection of an uncontaminated urine specimen is essential for accurate diagnosis. Oral antibiotic therapy for 7 to 10 days is adequate for uncomplicated cases that respond well to the treatment. A renal ultrasound examination is advised in all young children with first febrile UTI and in older children with recurrent UTI. Most children with first febrile UTI do not need a voiding cystourethrogram; it may be considered after the first UTI in children with abnormal renal and bladder ultrasound examination or a UTI caused by atypical pathogen, complex clinical course, or known renal scarring. Long-term antibiotic prophylaxis is used selectively in high-risk patients. Few patients diagnosed with vesicoureteral reflux after a UTI need surgical correction. The most consequential long-term complication of acute pyelonephritis is renal scarring, which may increase the risk of hypertension or chronic kidney disease later in life. Treatment of acute pyelonephritis with an appropriate antibiotic within 48 hours of fever onset and prevention of recurrent UTI lowers the risk of renal scarring. Pathogens causing UTI are increasingly becoming resistant to commonly used antibiotics, and their indiscriminate use in doubtful cases of UTI must be discouraged.
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Affiliation(s)
- Tej K Mattoo
- Division of Pediatric Nephrology, Departments of Pediatrics and Urology, Wayne State University School of Medicine and Wayne Pediatrics, Detroit, Michigan;
| | - Nader Shaikh
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; and
| | - Caleb P Nelson
- Department of Urology, Boston Children's Hospital and Department of Surgery, Harvard Medical School, Harvard University, Boston, Massachusetts
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Diviney J, Jaswon MS. Urine collection methods and dipstick testing in non-toilet-trained children. Pediatr Nephrol 2021; 36:1697-1708. [PMID: 32918601 PMCID: PMC8172492 DOI: 10.1007/s00467-020-04742-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 07/03/2020] [Accepted: 07/16/2020] [Indexed: 11/03/2022]
Abstract
Urinary tract infection is a commonly occurring paediatric infection associated with significant morbidity. Diagnosis is challenging as symptoms are non-specific and definitive diagnosis requires an uncontaminated urine sample to be obtained. Common techniques for sampling in non-toilet-trained children include clean catch, bag, pad, in-out catheterisation and suprapubic aspiration. The pros and cons of each method are examined in detail in this review. They differ significantly in frequency of use, contamination rates and acceptability to parents and clinicians. National guidance of which to use differs significantly internationally. No method is clearly superior. For non-invasive testing, clean catch sampling has a lower likelihood of contamination and can be made more efficient through stimulation of voiding in younger children. In invasive testing, suprapubic aspiration gives a lower likelihood of contamination, a high success rate and a low complication rate, but is considered painful and is not preferred by parents. Urine dipstick testing is validated for ruling in or out UTI provided that leucocyte esterase (LE) and nitrite testing are used in combination.
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Affiliation(s)
- James Diviney
- Department of Paediatrics, Whittington Hospital, London, UK.
| | - Mervyn S. Jaswon
- grid.417095.e0000 0004 4687 3624Department of Paediatrics, Whittington Hospital, London, UK ,grid.22098.310000 0004 1937 0503Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
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13
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Ammenti A, Alberici I, Brugnara M, Chimenz R, Guarino S, La Manna A, La Scola C, Maringhini S, Marra G, Materassi M, Morello W, Nicolini G, Pennesi M, Pisanello L, Pugliese F, Scozzola F, Sica F, Toffolo A, Montini G. Updated Italian recommendations for the diagnosis, treatment and follow-up of the first febrile urinary tract infection in young children. Acta Paediatr 2020; 109:236-247. [PMID: 31454101 PMCID: PMC7004047 DOI: 10.1111/apa.14988] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 08/22/2019] [Accepted: 08/23/2019] [Indexed: 12/21/2022]
Abstract
AIM Our aim was to update the recommendations for the diagnosis, treatment and follow-up of the first febrile urinary tract infection in young children, which were endorsed in 2012 by the Italian Society of Pediatric Nephrology. METHODS The Italian recommendations were revised on the basis of a review of the literature published from 2012 to October 2018. We also carried out an ad hoc evaluation of the risk factors to identify children with high-grade vesicoureteral reflux or renal scarring, which were published in the previous recommendations. When evidence was not available, the working group held extensive discussions, during various meetings and through email exchanges. RESULTS Four major modifications have been introduced. The method for collecting urine for culture and its interpretation has been re-evaluated. We have reformulated the algorithm that guides clinical decisions to proceed with voiding cystourethrography. The suggested antibiotics have been revised, and we have recommended further restrictions of the use of antibiotic prophylaxis. CONCLUSION These updated recommendations have now been endorsed by the Italian Society of Pediatric Nephrology and the Italian Society for Pediatric Infectivology. They can also be used to compare other recommendations that are available, as a worldwide consensus in this area is still lacking.
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Affiliation(s)
- Anita Ammenti
- Pediatric Polyspecialistic GroupPoliambulatorio Medi‐SaluserParmaItaly
| | - Irene Alberici
- Department of Woman and Child's HealthUniversity of PadovaPadovaItaly
| | | | - Roberto Chimenz
- Pediatric Nephrology and Dialysis UnitDepartment of PediatricsG. Martino HospitalUniversity of MessinaMessinaItaly
| | - Stefano Guarino
- Department of WomanChild and of General and Specialized SurgeryUniversità degli Studi della Campania L. VanvitelliNaplesItaly
| | - Angela La Manna
- Department of WomanChild and of General and Specialized SurgeryUniversità degli Studi della Campania L. VanvitelliNaplesItaly
| | - Claudio La Scola
- Nephrology and Dialysis UnitDepartment of PediatricsAzienda Ospedaliero Universitaria Sant'Orsola‐MalpighiBolognaItaly
| | | | - Giuseppina Marra
- Pediatric NephrologyDialysis and Transplant UnitFondazione Ca'Granda, IRCCS Policlinico di MilanoMilanoItaly
| | | | - William Morello
- Pediatric NephrologyDialysis and Transplant UnitFondazione Ca'Granda, IRCCS Policlinico di MilanoMilanoItaly
| | | | - Marco Pennesi
- Department of PediatricsInstitute for Child and Maternal HealthIRCCS Burlo GarofoloTriesteItaly
| | | | | | | | | | | | - Giovanni Montini
- Pediatric NephrologyDialysis and Transplant UnitFondazione Ca'Granda, IRCCS Policlinico di MilanoMilanoItaly
- Giuliana and Bernardo Caprotti Chair of PediatricsDepartment of Clinical Sciences and Community HealthUniversity of MilanoMilanoItaly
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Storm DW, Braga LH, Cooper CS. Continuous Antibiotic Prophylaxis in Pediatric Urology. Urol Clin North Am 2018; 45:525-538. [PMID: 30316308 DOI: 10.1016/j.ucl.2018.06.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Continuous antibiotic prophylaxis (CAP) for urinary tract infection prevention in children with vesicoureteral reflux, hydronephrosis, and hydroureteronephrosis is reviewed. A more selective use of CAP is advocated based on a review of known individual risk factors in each of these conditions that subsequently helps identify the children most likely to benefit from CAP. Both short-term and potential long-term side effects of CAP are reviewed, including the impact of prophylactic antibiotics on bacterial resistance and the microbiome. Alternatives to continuous antibiotic prophylaxis including Vaccinium macrocarpon (Cranberry), probiotics, and vaccines are reviewed.
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Affiliation(s)
- Douglas W Storm
- Department of Urology, University of Iowa, Carver College of Medicine, 200 Hawkins Drive, 3RCP, Iowa City, IA 5224, USA
| | - Luis H Braga
- Department of Surgery, Division of Urology, Mcmaster University, McMaster Children's Hospital, 1200 Main Street West, Hamilton, Ontario L8N 3Z5, Canada
| | - Christopher S Cooper
- Department of Urology, University of Iowa, Carver College of Medicine, 200 Hawkins Drive, 3RCP, Iowa City, IA 5224, USA.
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Yamanouchi S, Kimata T, Kino J, Kitao T, Suruda C, Tsuji S, Kurosawa H, Hirayama Y, Saito A, Kaneko K. Urinary C-megalin for screening of renal scarring in children after febrile urinary tract infection. Pediatr Res 2018; 83:662-668. [PMID: 29211055 DOI: 10.1038/pr.2017.276] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Accepted: 10/06/2017] [Indexed: 12/26/2022]
Abstract
BackgroundFebrile urinary tract infection (fUTI) in children may cause renal scarring. This study aimed to investigate the usefulness of urinary biomarkers for diagnosing renal scarring after fUTI.MethodsThirty-seven children (median age: 1.36 years, range: 0.52-12.17 years, 25 boys) with a history of fUTI, who underwent renal scintigraphy for 4 months or longer after the last episode of fUTI, were analyzed. A spot urine sample was obtained on the day of renal scintigraphy to measure levels of total protein, N-acetyl-β-D-glucosaminidase (NAG), β2-microglobulin (BMG), neutrophil gelatinase-associated lipocalin (NGAL), liver-type fatty acid binding protein (L-FABP), and C-megalin (full-length megalin). Results were corrected for urinary creatinine (Cr) and compared between the group with renal scarring (n=23) and that without scarring (n=14). Urinary levels of C-megalin were also measured in healthy control subjects.ResultsNo significant differences in total protein, NGAL, L-FABP, NAG, and BMG levels were found between the groups. However, C-megalin levels were significantly higher in the renal scarring group than in the non-renal scarring group and healthy controls (P<0.001). A cutoff value of 6.5 pmol/nmol of urinary C-megalin/Cr yielded 73.9% of specificity and 92.9% of sensitivity.ConclusionUrinary C-megalin is useful for diagnosing renal scarring caused by fUTI.
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Affiliation(s)
| | - Takahisa Kimata
- Department of Pediatrics, Kansai Medical University, Hirakata, Japan
| | - Jiro Kino
- Department of Pediatrics, Kansai Medical University, Hirakata, Japan
| | - Tetsuya Kitao
- Department of Pediatrics, Kansai Medical University, Hirakata, Japan
| | - Chikushi Suruda
- Department of Pediatrics, Kansai Medical University, Hirakata, Japan
| | - Shoji Tsuji
- Department of Pediatrics, Kansai Medical University, Hirakata, Japan
| | | | | | - Akihiko Saito
- Department of Applied Molecular Medicine, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Kazunari Kaneko
- Department of Pediatrics, Kansai Medical University, Hirakata, Japan
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Hay AD, Birnie K, Busby J, Delaney B, Downing H, Dudley J, Durbaba S, Fletcher M, Harman K, Hollingworth W, Hood K, Howe R, Lawton M, Lisles C, Little P, MacGowan A, O'Brien K, Pickles T, Rumsby K, Sterne JA, Thomas-Jones E, van der Voort J, Waldron CA, Whiting P, Wootton M, Butler CC. The Diagnosis of Urinary Tract infection in Young children (DUTY): a diagnostic prospective observational study to derive and validate a clinical algorithm for the diagnosis of urinary tract infection in children presenting to primary care with an acute illness. Health Technol Assess 2018; 20:1-294. [PMID: 27401902 DOI: 10.3310/hta20510] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND It is not clear which young children presenting acutely unwell to primary care should be investigated for urinary tract infection (UTI) and whether or not dipstick testing should be used to inform antibiotic treatment. OBJECTIVES To develop algorithms to accurately identify pre-school children in whom urine should be obtained; assess whether or not dipstick urinalysis provides additional diagnostic information; and model algorithm cost-effectiveness. DESIGN Multicentre, prospective diagnostic cohort study. SETTING AND PARTICIPANTS Children < 5 years old presenting to primary care with an acute illness and/or new urinary symptoms. METHODS One hundred and seven clinical characteristics (index tests) were recorded from the child's past medical history, symptoms, physical examination signs and urine dipstick test. Prior to dipstick results clinician opinion of UTI likelihood ('clinical diagnosis') and urine sampling and treatment intentions ('clinical judgement') were recorded. All index tests were measured blind to the reference standard, defined as a pure or predominant uropathogen cultured at ≥ 10(5) colony-forming units (CFU)/ml in a single research laboratory. Urine was collected by clean catch (preferred) or nappy pad. Index tests were sequentially evaluated in two groups, stratified by urine collection method: parent-reported symptoms with clinician-reported signs, and urine dipstick results. Diagnostic accuracy was quantified using area under receiver operating characteristic curve (AUROC) with 95% confidence interval (CI) and bootstrap-validated AUROC, and compared with the 'clinician diagnosis' AUROC. Decision-analytic models were used to identify optimal urine sampling strategy compared with 'clinical judgement'. RESULTS A total of 7163 children were recruited, of whom 50% were female and 49% were < 2 years old. Culture results were available for 5017 (70%); 2740 children provided clean-catch samples, 94% of whom were ≥ 2 years old, with 2.2% meeting the UTI definition. Among these, 'clinical diagnosis' correctly identified 46.6% of positive cultures, with 94.7% specificity and an AUROC of 0.77 (95% CI 0.71 to 0.83). Four symptoms, three signs and three dipstick results were independently associated with UTI with an AUROC (95% CI; bootstrap-validated AUROC) of 0.89 (0.85 to 0.95; validated 0.88) for symptoms and signs, increasing to 0.93 (0.90 to 0.97; validated 0.90) with dipstick results. Nappy pad samples were provided from the other 2277 children, of whom 82% were < 2 years old and 1.3% met the UTI definition. 'Clinical diagnosis' correctly identified 13.3% positive cultures, with 98.5% specificity and an AUROC of 0.63 (95% CI 0.53 to 0.72). Four symptoms and two dipstick results were independently associated with UTI, with an AUROC of 0.81 (0.72 to 0.90; validated 0.78) for symptoms, increasing to 0.87 (0.80 to 0.94; validated 0.82) with the dipstick findings. A high specificity threshold for the clean-catch model was more accurate and less costly than, and as effective as, clinical judgement. The additional diagnostic utility of dipstick testing was offset by its costs. The cost-effectiveness of the nappy pad model was not clear-cut. CONCLUSIONS Clinicians should prioritise the use of clean-catch sampling as symptoms and signs can cost-effectively improve the identification of UTI in young children where clean catch is possible. Dipstick testing can improve targeting of antibiotic treatment, but at a higher cost than waiting for a laboratory result. Future research is needed to distinguish pathogens from contaminants, assess the impact of the clean-catch algorithm on patient outcomes, and the cost-effectiveness of presumptive versus dipstick versus laboratory-guided antibiotic treatment. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Alastair D Hay
- Centre for Academic Primary Care, National Institute for Health Research (NIHR) School of Primary Care Research, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Kate Birnie
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - John Busby
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Brendan Delaney
- Department of Primary Care and Public Health Sciences, National Institute for Health Research (NIHR) Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK
| | - Harriet Downing
- Centre for Academic Primary Care, National Institute for Health Research (NIHR) School of Primary Care Research, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Jan Dudley
- Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Stevo Durbaba
- Department of Primary Care and Public Health Sciences, Division of Health and Social Care Research, King's College London, London, UK
| | - Margaret Fletcher
- Centre for Health and Clinical Research, University of the West of England, Bristol, UK.,South West Medicines for Children Local Research Network, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Kim Harman
- Centre for Academic Primary Care, National Institute for Health Research (NIHR) School of Primary Care Research, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | | | - Kerenza Hood
- South East Wales Trials Unit (SEWTU), Institute for Translation, Innovation, Methodology and Engagement, School of Medicine, Cardiff University, Cardiff, UK
| | - Robin Howe
- Specialist Antimicrobial Chemotherapy Unit, Public Health Wales Microbiology Cardiff, University Hospital Wales, Cardiff, UK
| | - Michael Lawton
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Catherine Lisles
- South East Wales Trials Unit (SEWTU), Institute for Translation, Innovation, Methodology and Engagement, School of Medicine, Cardiff University, Cardiff, UK
| | - Paul Little
- Primary Care and Population Sciences Division, University of Southampton, Southampton, UK
| | | | - Kathryn O'Brien
- Cochrane Institute of Primary Care & Public Health, School of Medicine, Cardiff University, Cardiff, UK
| | - Timothy Pickles
- South East Wales Trials Unit (SEWTU), Institute for Translation, Innovation, Methodology and Engagement, School of Medicine, Cardiff University, Cardiff, UK
| | - Kate Rumsby
- Primary Care and Population Sciences Division, University of Southampton, Southampton, UK
| | - Jonathan Ac Sterne
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Emma Thomas-Jones
- South East Wales Trials Unit (SEWTU), Institute for Translation, Innovation, Methodology and Engagement, School of Medicine, Cardiff University, Cardiff, UK
| | - Judith van der Voort
- Department of Paediatrics and Child Health, University Hospital of Wales, Cardiff, UK
| | - Cherry-Ann Waldron
- South East Wales Trials Unit (SEWTU), Institute for Translation, Innovation, Methodology and Engagement, School of Medicine, Cardiff University, Cardiff, UK
| | - Penny Whiting
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Mandy Wootton
- Specialist Antimicrobial Chemotherapy Unit, Public Health Wales Microbiology Cardiff, University Hospital Wales, Cardiff, UK
| | - Christopher C Butler
- Cochrane Institute of Primary Care & Public Health, School of Medicine, Cardiff University, Cardiff, UK.,Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Sabetkish S, Sabetkish N, Talebi MA, Halimi S, Kajbafzadeh AM. The role of nonautologous and autologous adipose-derived mesenchymal stem cell in acute pyelonephritis. Cell Tissue Bank 2017; 19:301-309. [PMID: 29218427 DOI: 10.1007/s10561-017-9674-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2017] [Accepted: 12/02/2017] [Indexed: 01/22/2023]
Abstract
We compared the therapeutic effects of autologous and nonautologous adipose-derived mesenchymal stem cell (ADMSC), in ameliorating the renal function in a rabbit model of acute pyelonephritis. The difference of perirenal and neck subcutaneous ADMSCs were also evaluated. Twenty female rabbits were apportioned to 5 groups. In group I (n = 4), the rabbits were injected direct inoculation of Escherichia coli (E. coli) into the right kidney. In group II (n = 4), autologous ADMSCs obtained from nape adipose tissue were injected into the subcapsular space 1 week after E. coli injection, while nonautologous ADMSCs of the same origin (from male rabbits) were applied in group III (n = 4). In group IV (n = 4), autologous perirenal ADMSCs were applied with the same method, while perirenal nonautologous ADMSCs from male rabbits were used in group V (n = 4). Technetium-99m-DMSA renal scan was performed 1, 2 and 4 months post-injection in all groups. Kidneys were excised for the evaluation of histopathological changes in the same time points. PCR examination for detection of Y-chromosome (in group III and V) and fluorescent evaluation (in group II and IV) were also performed to determine the fate of injected cells. Injection of autologous ADMSCs resulted in more satisfactory outcomes in reduction of interstitial fibrosis, tubular, and glomerular atrophy as compared to nonautologous groups. However, histopathological ameliorations were significantly better in group IV in which autologous perirenal ADMSC was applied. Remarkably, two months after the injection, Technetium-99m-DMSA renal scan showed that right kidney reached to near normal cortical function (48 and 45%) in group IV and V, respectively as compared to groups II (41%) and III (37%). Autologous ADMSCs may have better results in cell therapy as compared to nonautologous cells. However, more satisfactory outcomes may be obtained when the cell source is selected from the surrounding adipose tissue.
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Affiliation(s)
- Shabnam Sabetkish
- Pediatric Urology and Regenerative Medicine Research Center, Section of Tissue Engineering and Stem Cells Therapy, Children's Hospital Medical Center, Tehran University of Medical Sciences, No. 62, Dr. Qarib's Street, Keshavarz Boulevard, Tehran, 1419433151, Islamic Republic of Iran
| | - Nastaran Sabetkish
- Pediatric Urology and Regenerative Medicine Research Center, Section of Tissue Engineering and Stem Cells Therapy, Children's Hospital Medical Center, Tehran University of Medical Sciences, No. 62, Dr. Qarib's Street, Keshavarz Boulevard, Tehran, 1419433151, Islamic Republic of Iran
| | - Mahba Ataei Talebi
- Pediatric Urology and Regenerative Medicine Research Center, Section of Tissue Engineering and Stem Cells Therapy, Children's Hospital Medical Center, Tehran University of Medical Sciences, No. 62, Dr. Qarib's Street, Keshavarz Boulevard, Tehran, 1419433151, Islamic Republic of Iran
| | - Shahnaz Halimi
- Department of Microbiology, School of Medicine, Tehran University of Medical Sciences, Tehran, Islamic Republic of Iran
| | - Abdol-Mohammad Kajbafzadeh
- Pediatric Urology and Regenerative Medicine Research Center, Section of Tissue Engineering and Stem Cells Therapy, Children's Hospital Medical Center, Tehran University of Medical Sciences, No. 62, Dr. Qarib's Street, Keshavarz Boulevard, Tehran, 1419433151, Islamic Republic of Iran.
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18
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Beetz R. Pyelonephritis und Urosepsis. Monatsschr Kinderheilkd 2017. [DOI: 10.1007/s00112-017-0402-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Mande PP, Bachhav SS, Devarajan PV. Bioenhanced advanced third generation solid dispersion of tadalafil: Repurposing with improved therapy in pyelonephritis. Asian J Pharm Sci 2017; 12:569-579. [PMID: 32104370 PMCID: PMC7032132 DOI: 10.1016/j.ajps.2017.07.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 04/12/2017] [Accepted: 07/02/2017] [Indexed: 11/26/2022] Open
Abstract
Tadalafil (TDL) a BCS-II drug is recently reported for repurposing nephroprotective effect in Pyelonephritis (PN). However, poor water solubility and dissolution rate limited oral bioavailability pose serious challenges in its therapeutic applications. We present an advanced third generation Solid Dispersion (SD) of TDL comprising a polymer in combination with a Self Micro-emulsifying Composition (SMEC) to achieve high drug loading, improved stability and rapid dissolution of TDL for enhancing bioavailability and efficacy in PN. TDL-SMEC-SD was coated onto rapidly disintegrating inert tablet cores which disintegrated rapidly in water to release SD as a film. TDL-SMEC-SD was evaluated for in-vivo oral bioavailability and in-vivo efficacy in lipopolysaccharide-induced PN in rats. TDL exhibited high solubility (45.6 mg/ml) in the SMEC. TDL-SMEC-SD exhibited remarkably high TDL loading (45%w/w), exceptionally low contact angle (9°), rapid in-vitro release (t50 7.3 min), microemulsion formation (globule size ~100 nm) in aqueous dispersion, and stability as per ICH guidelines. SEM, DSC, and XRD confirmed high physical stability. A relative bioavailability of 350% and 150% compared to TDL and TDL-SD without SMEC respectively, established the superiority of TDL-SMEC-SD. A significant reduction in serum creatinine, blood urea nitrogen and nitric oxide levels in the lipopolysaccharide-induced PN confirmed the benefit of the TDL-SMEC-SD. The advanced third generation SMEC SDs presents the possibility of platform technology for bioenhancement of poorly water soluble drugs.
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Affiliation(s)
- Prashant P Mande
- Department of Pharmaceutical Sciences and Technology, Institute of Chemical Technology, N. P. Marg, Matunga (E), Mumbai, Maharashtra, India
| | - Sagar S Bachhav
- Department of Pharmaceutical Sciences and Technology, Institute of Chemical Technology, N. P. Marg, Matunga (E), Mumbai, Maharashtra, India
| | - Padma V Devarajan
- Department of Pharmaceutical Sciences and Technology, Institute of Chemical Technology, N. P. Marg, Matunga (E), Mumbai, Maharashtra, India
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20
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Lee JW, Park JS, Park KB, Yoo GH, Kim SS, Lee SM. Prediction of renal cortical defect and scar using neutrophil-to-lymphocyte ratio in children with febrile urinary tract infection. Nuklearmedizin 2017; 56:109-114. [PMID: 28488726 DOI: 10.3413/nukmed-0878-17-01] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Accepted: 04/10/2017] [Indexed: 11/20/2022]
Abstract
AIM This study is aimed to evaluate the predictive value of the neutrophil-to-lymphocyte ratio (NLR) for cortical defect on initial and follow-up Tc-99m dimercaptosuccinic acid (DMSA) scan in children with the first febrile urinary tract infection (UTI). METHODS We retrospectively enrolled 179 children with the first febrile UTI who underwent DMSA scan and laboratory tests. In patients with abnormal DMSA scan findings, follow-up DMSA scan was performed at least 6 months after the initial scan. All DMSA scans were classified as negative and positive cortical defects. Multiple logistic regression analyses were performed to identify the risk factors for cortical defect on initial and follow-up DMSA scan. RESULTS Cortical defects on initial DMSA scan were noted in 133 patients. Vesicoureteral reflux (VUR), white blood cell count, absolute neutrophil count, NLR, and serum C-reactive protein level were independent predictive factors for positive cortical defect on initial DMSA scan (p < 0.050). On follow-up DMSA scan, 24 of the 133 patients showed persistent cortical defects, and only VUR was significantly associated with persistent cortical defect (p = 0.002). In 84 patients who showed cortical defect on initial scan and absence of VUR, only NLR was significantly associated with persistent cortical defect on follow-up scan (p = 0.025). CONCLUSION NLR was significantly associated with persistent cortical defect on follow-up DMSA scan in patients without VUR, as well as positive cortical defect on initial scan.
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Affiliation(s)
| | | | | | | | | | - Sang Mi Lee
- Sang Mi Lee, M.D., Ph.D., Soonchunhyang University Cheonan Hospital,, 23-20 Byeongmyeong-dong,, Dongnam-gu, Cheonan,, Chungcheongnam-do, 330-721, Korea, Tel: +82-41-570-3540, Fax: +82-41-572-4655, E-mail:
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21
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Lellig E, Apfelbeck M, Straub J, Karl A, Tritschler S, Stief CG, Riccabona M. [Urinary tract infections in children]. Urologe A 2017; 56:247-262. [PMID: 28154883 DOI: 10.1007/s00120-016-0316-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Urinary tract infections (UTI) are the most common bacterial infections in children. The symptoms are not very specific and range from abdominal pain, poor feeding to nocturnal urinary incontinence. The technique of collecting urine plays an important role for securing the diagnosis. The best way to obtain urine in non-toilet-trained children is catheterization or suprapubic bladder aspiration. In toilet-trained children midstream urine is an acceptable alternative after cleaning the foreskin or labia. In the case of an infection a prompt empirical antibiotic therapy is necessary to reduce the risk of parenchymal scarring of the kidneys. There are different approaches to diagnose vesicoureteral reflux in different countries. The commonly used standard approach in Germany is voiding cystourethrography. In the case of reflux dimercaptosuccinic acid (DMSA) scintigraphy should be performed additionally to exclude renal scarring (bottom-up approach).
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Affiliation(s)
- E Lellig
- Urologische Klinik und Poliklinik, Ludwig-Maximilians-Universität München, Campus Großhadern, Marchioninistr. 15, 81377, München, Deutschland.
| | - M Apfelbeck
- Urologische Klinik und Poliklinik, Ludwig-Maximilians-Universität München, Campus Großhadern, Marchioninistr. 15, 81377, München, Deutschland.
| | - J Straub
- Urologische Klinik und Poliklinik, Ludwig-Maximilians-Universität München, Campus Großhadern, Marchioninistr. 15, 81377, München, Deutschland
| | - A Karl
- Urologische Klinik und Poliklinik, Ludwig-Maximilians-Universität München, Campus Großhadern, Marchioninistr. 15, 81377, München, Deutschland
| | - S Tritschler
- Urologische Klinik und Poliklinik, Ludwig-Maximilians-Universität München, Campus Großhadern, Marchioninistr. 15, 81377, München, Deutschland
| | - C G Stief
- Urologische Klinik und Poliklinik, Ludwig-Maximilians-Universität München, Campus Großhadern, Marchioninistr. 15, 81377, München, Deutschland
| | - M Riccabona
- Urologische Klinik und Poliklinik, Ludwig-Maximilians-Universität München, Campus Großhadern, Marchioninistr. 15, 81377, München, Deutschland
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Antimicrobial Resistance Among Uropathogens That Cause Childhood Community-acquired Urinary Tract Infections in Central Israel. Pediatr Infect Dis J 2017; 36:113-115. [PMID: 27741093 DOI: 10.1097/inf.0000000000001373] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
In this retrospective study 829 positive urine cultures were analyzed. Escherichia coli bacterium was the leading uropathogen (86%). Almost 60% were resistant to ampicillin and first generation cephalosporins, and about 30% of them resistant to amoxicillin-clavulanic acid and trimethoprim-sulfamethoxazole. Almost none of them were resistant to second and third generation cephalosporins, aminoglycosides, ciprofloxacin or nitrofurantoin.
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Karavanaki KA, Soldatou A, Koufadaki AM, Tsentidis C, Haliotis FA, Stefanidis CJ. Delayed treatment of the first febrile urinary tract infection in early childhood increased the risk of renal scarring. Acta Paediatr 2017; 106:149-154. [PMID: 27748543 DOI: 10.1111/apa.13636] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Revised: 09/07/2016] [Accepted: 10/13/2016] [Indexed: 11/30/2022]
Abstract
AIM This study evaluated the controversial relationship between the duration of fever before treatment initiation (FBT) for a febrile urinary tract infection (UTI), with renal scarring based on dimercaptosuccinic acid scintigraphy (DMSA) findings. METHODS The inpatient records of 148 children under two years of age with a first episode of febrile UTI were analysed. Acute and repeat DMSA findings, and clinical and laboratory parameters were evaluated. RESULTS Acute DMSA showed that 76 of the 148 children with a febrile UTI had renal lesions: 20 were mild, and 56 were moderate or severe. Repeat DMSA showed renal scarring in 34 patients. The only factors associated with the development of renal scars in the repeat DMSA were FBT of more than 72 hours, the presence and severity of vesicoureteral reflux and increased procalcitonin levels and absolute neutrophil counts. Multiple regression analysis showed that an FBT above 72 hours was the only significant factor that predicted renal scars. CONCLUSION Delay in treatment initiation of 72 hours or more was a risk factor for permanent renal scars after the first episode of febrile UTI. Other associated factors were increased procalcitonin and absolute neutrophil count on admission and the presence and severity of vesicouretal reflux.
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Affiliation(s)
- Kyriaki A. Karavanaki
- Second Department of Pediatrics; National and Kapodistrian University of Athens, “P. and A. Kyriakou” Children's Hospital; Athens Greece
| | - Alexandra Soldatou
- Second Department of Pediatrics; National and Kapodistrian University of Athens, “P. and A. Kyriakou” Children's Hospital; Athens Greece
| | - Athina Maria Koufadaki
- Second Department of Pediatrics; National and Kapodistrian University of Athens, “P. and A. Kyriakou” Children's Hospital; Athens Greece
| | - Charalampos Tsentidis
- Second Department of Pediatrics; National and Kapodistrian University of Athens, “P. and A. Kyriakou” Children's Hospital; Athens Greece
| | - Fotis A. Haliotis
- Second Department of Pediatrics; “Aghia Sophia” Children's Hospital; Athens Greece
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Shaikh N, Spingarn RB, Hum SW. Dimercaptosuccinic acid scan or ultrasound in screening for vesicoureteral reflux among children with urinary tract infections. Cochrane Database Syst Rev 2016; 7:CD010657. [PMID: 27378557 PMCID: PMC6457894 DOI: 10.1002/14651858.cd010657.pub2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND There is considerable interest in detecting vesicoureteral reflux (VUR) because its presence, especially when severe, has been linked to an increased risk of urinary tract infections and renal scarring. Voiding cystourethrography (VCUG), also known as micturating cystourethrography, is the gold standard for the diagnosis of VUR, and the grading of its severity. Because VCUG requires bladder catheterisation and exposes children to radiation, there has been a growing interest in other screening strategies that could identify at-risk children without the risks and discomfort associated with VCUG. OBJECTIVES The objective of this review is to evaluate the accuracy of two alternative imaging tests - the dimercaptosuccinic acid renal scan (DMSA) and renal-bladder ultrasound (RBUS) - in diagnosing VUR and high-grade VUR (Grade III-V VUR). SEARCH METHODS We searched MEDLINE, EMBASE, BIOSIS, and the Cochrane Register of Diagnostic Test Accuracy Studies from 1985 to 31 March 2016. The reference lists of relevant review articles were searched to identify additional studies not found through the electronic search. SELECTION CRITERIA We considered published cross-sectional or cohort studies that compared the results of the index tests (DMSA scan or RBUS) with the results of radiographic VCUG in children less than 19 years of age with a culture-confirmed urinary tract infection. DATA COLLECTION AND ANALYSIS Two authors independently applied the selection criteria to all citations and independently abstracted data. We used the bivariate model to calculate summary sensitivity and specificity values. MAIN RESULTS A total of 42 studies met our inclusion criteria. Twenty studies reported data on the test performance of RBUS in detecting VUR; the summary sensitivity and specificity estimates were 0.44 (95% CI 0.34 to 0.54) and 0.78 (95% CI 0.68 to 0.86), respectively. A total of 11 studies reported data on the test performance of RBUS in detecting high-grade VUR; the summary sensitivity and specificity estimates were 0.59 (95% CI 0.45 to 0.72) and 0.79 (95% CI 0.65 to 0.87), respectively. A total of 19 studies reported data on the test performance of DMSA in detecting VUR; the summary sensitivity and specificity estimates were 0.75 (95% CI 0.67 to 0.81) and 0.48 (95% CI 0.38 to 0.57), respectively. A total of 10 studies reported data on the accuracy of DMSA in detecting high-grade VUR. The summary sensitivity and specificity estimates were 0.93 (95% CI 0.77 to 0.98) and 0.44 (95% CI 0.33 to 0.56), respectively. AUTHORS' CONCLUSIONS Neither the renal ultrasound nor the DMSA scan is accurate enough to detect VUR (of all grades). Although a child with a negative DMSA test has an < 1% probability of having high-grade VUR, performing a screening DMSA will result in a large number of children falsely labelled as being at risk for high-grade VUR. Accordingly, the usefulness of the DMSA as a screening test for high-grade VUR should be questioned.
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Affiliation(s)
- Nader Shaikh
- Children's Hospital of PittsburghGeneral Academic Pediatrics3414 Fifth Ave, Suite 301PittsburghPAUSA15213
| | - Russell B Spingarn
- University of Pittsburgh School of Medicine3550 Terrace StreetPittsburghPAUSA15261
| | - Stephanie W Hum
- Children's Hospital of PittsburghGeneral Academic Pediatrics3414 Fifth Ave, Suite 301PittsburghPAUSA15213
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Shaikh N, Shope TR, Hoberman A, Vigliotti A, Kurs-Lasky M, Martin JM. Association Between Uropathogen and Pyuria. Pediatrics 2016; 138:peds.2016-0087. [PMID: 27328921 DOI: 10.1542/peds.2016-0087] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/13/2016] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE We sought to determine factors associated with the absence of pyuria in symptomatic children whose urine culture was positive for a known uropathogen. METHODS We obtained data on children evaluated at the Children's Hospital of Pittsburgh emergency department between 2007 and 2013 with symptoms of urinary tract infection (UTI) who had paired urinalysis and urine cultures. We excluded children with an unknown or bag urine collection method, major genitourinary anomalies, immunocompromising conditions, or with multiple organisms on culture. We chose a single, randomly-selected urine specimen per child and limited the analysis to those with positive cultures. RESULTS There were 46 158 visits during the study period; 1181 children diagnosed with UTI met all inclusion criteria and had a microscopic urinalysis for pyuria. Pyuria (≥5 white blood cells per high-powered field or ≥10 white blood cells per cubic millimeter) was present in 1031 (87%) children and absent in 150 (13%). Children with Enterococcus species, Klebsiella species, and Pseudomonas aeruginosa were significantly less likely to exhibit pyuria than children with Escherichia coli (odds ratio of 0.14, 0.34, and 0.19, respectively). Children with these organisms were also less likely to have a positive leukocyte esterase on dipstick urinalysis. Results were similar when we restricted the analysis to children whose urine samples were collected by bladder catheterization. CONCLUSIONS We found that certain uropathogens are less likely to be associated with pyuria in symptomatic children. Identification of biomarkers more accurate than pyuria or leukocyte esterase may help reduce over- and undertreatment of UTIs.
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Affiliation(s)
- Nader Shaikh
- Division of General Academic Pediatrics, Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Timothy R Shope
- Division of General Academic Pediatrics, Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Alejandro Hoberman
- Division of General Academic Pediatrics, Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Alyssa Vigliotti
- Division of General Academic Pediatrics, Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Marcia Kurs-Lasky
- Division of General Academic Pediatrics, Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Judith M Martin
- Division of General Academic Pediatrics, Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Mathew JL, Sinha R. Can we predict antibiotic-resistance in urinary tract infection? Indian Pediatr 2016; 53:519-21. [DOI: 10.1007/s13312-016-0883-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Kim SH, Lyu SY, Kim HY, Park SE, Kim SY. Can absence of pyuria exclude urinary tract infection in febrile infants? About 2011 AAP guidelines on UTI. Pediatr Int 2016; 58:472-5. [PMID: 26607772 DOI: 10.1111/ped.12853] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Revised: 10/22/2015] [Accepted: 11/13/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND The aim of this study was to describe clinical and laboratory characteristics of urinary tract infection (UTI) without significant pyuria in young children aged 2-24 months. METHODS The subjects consisted of infants and young children with febrile UTI treated at Pusan National University Children's Hospital, Korea. Group A included 283 patients with definite UTI who fulfilled the revised American Academy of Pediatrics diagnostic criteria, and group B included 19 patients with presumed UTI who had significant culture of uropathogens without pyuria, bacteriuria or other focus of infection. RESULTS Duration of fever before hospital visit in group B was significantly shorter than in group A (17.7 ± 14.0 vs 34.5 ± 30.7 h). Most patients in group B (17/19, 89.5%) came to the hospital within 24 h of onset of fever. Acute scintigraphic lesions were found in 47.8% of patients in group A and 50% in group B. Underlying urological abnormalities such as vesicoureteral reflux and obstructive uropathy were found in 24.5% of patients in group A and in 33.3% of patients in group B (P = 0.74). CONCLUSIONS Clinicians cannot exclude UTI on the absence of pyuria in young children aged 2-24 months.
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Affiliation(s)
- Seong Heon Kim
- Department of Pediatrics, Pusan National University Children's Hospital, Yangsan, Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital
| | - Soo Young Lyu
- Department of Pediatrics, Pusan National University Children's Hospital, Yangsan, Korea
| | - Hye Young Kim
- Department of Pediatrics, Pusan National University Hospital, Busan, Korea
| | - Su Eun Park
- Department of Pediatrics, Pusan National University Children's Hospital, Yangsan, Korea
| | - Su Young Kim
- Department of Pediatrics, Pusan National University Children's Hospital, Yangsan, Korea
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Shaikh N, Hoberman A, Keren R, Ivanova A, Gotman N, Chesney RW, Carpenter MA, Moxey-Mims M, Wald ER. Predictors of Antimicrobial Resistance among Pathogens Causing Urinary Tract Infection in Children. J Pediatr 2016; 171:116-21. [PMID: 26794472 PMCID: PMC4808618 DOI: 10.1016/j.jpeds.2015.12.044] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Revised: 11/25/2015] [Accepted: 12/16/2015] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To determine which children with urinary tract infection are likely to have pathogens resistant to narrow-spectrum antimicrobials. STUDY DESIGN Children, 2-71 months of age (n = 769) enrolled in the Randomized Intervention for Children with Vesicoureteral Reflux or Careful Urinary Tract Infection Evaluation studies were included. We used logistic regression models to test the associations between demographic and clinical characteristics and resistance to narrow-spectrum antimicrobials. RESULTS Of the included patients, 91% were female and 76% had vesicoureteral reflux. The risk of resistance to narrow-spectrum antibiotics in uncircumcised males was approximately 3 times that of females (OR 3.1; 95% CI 1.4-6.7); in children with bladder bowel dysfunction, the risk was 2 times that of children with normal function (OR 2.2; 95% CI 1.2-4.1). Children who had received 1 course of antibiotics during the past 6 months also had higher odds of harboring resistant organisms (OR 1.6; 95% CI 1.1-2.3). Hispanic children had higher odds of harboring pathogens resistant to some narrow-spectrum antimicrobials. CONCLUSIONS Uncircumcised males, Hispanic children, children with bladder bowel dysfunction, and children who received 1 course of antibiotics in the past 6 months were more likely to have a urinary tract infection caused by pathogens resistant to 1 or more narrow-spectrum antimicrobials.
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Abstract
INTRODUCTION Delays in appropriate treatment and unnecessary antibiotic use for urinary tract infections (UTIs) increase the risk for serious adverse events and the potential for antibiotic resistance. The purposes of this quality improvement project were to decrease emergency department laboratory result follow-up time and increase the number of patients who are notified to stop taking an empiric antibiotic. METHOD Nine months of Plan-Do-Study-Act (PDSA) cycles were implemented in a pediatric emergency department and network of care sites. Three months of baseline data were compared with 3 months of postinvention data using t-tests and odds ratios. RESULTS Time to patient/family laboratory follow-up was reduced from 20.1 hours to 7.1 hours, demonstrating a 64.7% reduction in time to follow-up (p < .01). The percentage of patients who received follow-up notification of negative urine cultures and were told to discontinue antibiotic therapy increased from 8.8% to 74.4% (p < .001). DISCUSSION Implementation of a culture callback system, staffed by advanced practice providers, led to a significant reduction in the amount of time to follow-up and increased the number of follow-up calls to discontinue antibiotics when urine cultures were negative.
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Kitao T, Kimata T, Yamanouchi S, Kato S, Tsuji S, Kaneko K. Urinary Biomarkers for Screening for Renal Scarring in Children with Febrile Urinary Tract Infection: Pilot Study. J Urol 2015; 194:766-71. [PMID: 25934442 DOI: 10.1016/j.juro.2015.04.091] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/17/2015] [Indexed: 01/13/2023]
Abstract
PURPOSE Recurrent febrile urinary tract infections during infancy cause renal scarring, which is characterized by progressive focal interstitial fibrosis and may lead to renal failure. Renal scarring can be diagnosed through scintigraphy, although it seems impractical to perform renal scintigraphy for all infants with febrile urinary tract infections. Therefore, it is important to search for a biomarker to identify the presence of renal scarring. We hypothesized that urinary biomarkers of nephropathy may increase in infants with renal scarring following febrile urinary tract infections. MATERIALS AND METHODS A total of 49 infants who underwent renal scintigraphy for febrile urinary tract infections were enrolled in the study. Several measurements were performed using urine samples, including total proteins, beta2-microglobulins, N-acetyl-β-D-glucosaminidase, neutrophil gelatinase associated lipocalin, liver-type fatty acid binding protein and angiotensinogen. Values were corrected by creatinine and compared between patients with and without renal scarring. RESULTS Among urinary biomarkers only angiotensinogen in patients with scarring (median 14.6 μg/gm creatinine) demonstrated significantly higher levels than in patients without scarring (3.6 μg/gm creatinine, p <0.001). CONCLUSIONS Urinary angiotensinogen may be useful for diagnosing the presence of renal scarring.
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Affiliation(s)
- Tetsuya Kitao
- Department of Pediatrics, Kansai Medical University, Osaka, Japan
| | - Takahisa Kimata
- Department of Pediatrics, Kansai Medical University, Osaka, Japan
| | | | - Shogo Kato
- Department of Pediatrics, Kansai Medical University, Osaka, Japan
| | - Shoji Tsuji
- Department of Pediatrics, Kansai Medical University, Osaka, Japan
| | - Kazunari Kaneko
- Department of Pediatrics, Kansai Medical University, Osaka, Japan.
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Stein R, Dogan HS, Hoebeke P, Kočvara R, Nijman RJM, Radmayr C, Tekgül S. Urinary tract infections in children: EAU/ESPU guidelines. Eur Urol 2014; 67:546-58. [PMID: 25477258 DOI: 10.1016/j.eururo.2014.11.007] [Citation(s) in RCA: 217] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2014] [Accepted: 11/05/2014] [Indexed: 12/22/2022]
Abstract
CONTEXT In 30% of children with urinary tract anomalies, urinary tract infection (UTI) can be the first sign. Failure to identify patients at risk can result in damage to the upper urinary tract. OBJECTIVE To provide recommendations for the diagnosis, treatment, and imaging of children presenting with UTI. EVIDENCE ACQUISITION The recommendations were developed after a review of the literature and a search of PubMed and Embase. A consensus decision was adopted when evidence was low. EVIDENCE SYNTHESIS UTIs are classified according to site, episode, symptoms, and complicating factors. For acute treatment, site and severity are the most important. Urine sampling by suprapubic aspiration or catheterisation has a low contamination rate and confirms UTI. Using a plastic bag to collect urine, a UTI can only be excluded if the dipstick is negative for both leukocyte esterase and nitrite or microscopic analysis is negative for both pyuria and bacteriuria. A clean voided midstream urine sample after cleaning the external genitalia has good diagnostic accuracy in toilet-trained children. In children with febrile UTI, antibiotic treatment should be initiated as soon as possible to eradicate infection, prevent bacteraemia, improve outcome, and reduce the likelihood of renal involvement. Ultrasound of the urinary tract is advised to exclude obstructive uropathy. Depending on sex, age, and clinical presentation, vesicoureteral reflux should be excluded. Antibacterial prophylaxis is beneficial. In toilet-trained children, bladder and bowel dysfunction needs to be excluded. CONCLUSIONS The level of evidence is high for the diagnosis of UTI and treatment in children but not for imaging to identify patients at risk for upper urinary tract damage. PATIENT SUMMARY In these guidelines, we looked at the diagnosis, treatment, and imaging of children with urinary tract infection. There are strong recommendations on diagnosis and treatment; we also advise exclusion of obstructive uropathy within 24h and later vesicoureteral reflux, if indicated.
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Affiliation(s)
- Raimund Stein
- Division of Paediatric Urology, Department of Urology, Mainz University Medical Centre, Johannes Gutenberg University, Mainz, Germany.
| | - Hasan S Dogan
- Hacettepe University, Faculty of Medicine, Department of Urology, Division of Paediatric Urology, Ankara, Turkey
| | - Piet Hoebeke
- Department of Urology, Ghent University Hospital, Gent, Belgium
| | - Radim Kočvara
- Department of Urology, General Teaching Hospital in Praha, and Charles University 1st Faculty of Medicine, Praha, Czech Republic
| | - Rien J M Nijman
- Department of Urology, Division of Pediatric Urology, University of Groningen, Groningen, The Netherlands
| | - Christian Radmayr
- Department of Urology, Medical University of Innsbruck, Innsbruck, Austria
| | - Serdar Tekgül
- Hacettepe University, Faculty of Medicine, Department of Urology, Division of Paediatric Urology, Ankara, Turkey
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Could pyelonephritic scarring be prevented by anti-inflammatory treatment? An experimental model of acute pyelonephritis. BIOMED RESEARCH INTERNATIONAL 2014; 2014:134940. [PMID: 25105116 PMCID: PMC4106078 DOI: 10.1155/2014/134940] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Revised: 05/28/2014] [Accepted: 06/06/2014] [Indexed: 11/18/2022]
Abstract
Objectives. This study aimed to demonstrate if the addition of anti-inflammatory treatment to antibiotic therapy shows any superiority to the treatment with antibiotic only. Methods. Forty-nine Wistar rats were divided into 7 groups. Pyelonephritis was performed by E. coli injection to upper pole of kidneys except control group. Group 2 was not treated. Ceftriaxone, ketoprofen, “ceftriaxone + ketoprofen,” methylprednisolone, and “ceftriaxone + methylprednisolone” were given in the groups. The technetium-99m-dimercaptosuccinic acid scintigraphies were performed in 3rd day to detect pyelonephritis and 10th week to detect renal scarring. All kidneys were also histopathologically evaluated. Results. When 3rd day and 10th week scintigraphies were compared, initial 2.00 ± 0.30 point pyelonephritis score resulted in 0.71 ± 0.36 renal scar score in “ceftriaxone + ketoprofen” group (P = 0.039). Initial 2.00 ± 0.43 point pyelonephritis score resulted in 0.86 ± 0.26 renal scar score in “ceftriaxone + methylprednisolone” group (P = 0.041). Renal scar score was declined in “ceftriaxone + ketoprofen” group and “ceftriaxone + methylprednisolone” group compared with no-treatment group on 10th week of the study (P = 0.026, P = 0.044). On histopathological evaluation, it was seen that renal scar prevalence and expansion declined significantly in “ceftriaxone + ketoprofen and ceftriaxone + methylprednisolone” (P = 0.011, P = 0.023). Conclusion. It was evidenced that ceftriaxone treatment in combination with ketoprofen or methylprednisolone declined scar formation in scintigraphic and histopathologic examinations of the kidneys.
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Positioning irrigation of contrast cystography for diagnosis of occult vesicoureteric reflux: association with technetium-99m dimercaptosuccinic acid scans. J Pediatr Urol 2013; 9:846-50. [PMID: 23219319 DOI: 10.1016/j.jpurol.2012.11.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2012] [Accepted: 11/13/2012] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Positioning irrigation of contrast (PIC) cystography identifies occult or PIC vesicoureteral reflux (PIC-VUR) in children with recurrent febrile urinary tract infections (UTI) but no vesicoureteric reflux (VUR) on standard voiding cystourethrogram (VCUG). We sought to identify the relationship between PIC-VUR and renal scarring in technetium-99m dimercaptosuccinic acid (DMSA) scans. PATIENTS AND METHODS We retrospectively analysed PIC cystograms and DMSA scans for 154 kidneys in 81 children (65 girls; 16 boys; median age, 4.7 years; range, 0.9-15.2). Renal scarring was graded on a scale of 0-3. DMSA scans were pathologic in 66 patients (81%). Children had experienced mean 3.8 febrile UTI (range 1-25). Forty-seven (58%) children had a history of reflux, including 15 (19%) with previous anti-reflux operations. Indications for PIC cystography were recurrence of febrile UTI after either bilateral negative VCUG (66 children) or unilateral VUR (15 children) with contralateral/bilateral scarring or reflux that had changed sides in subsequent VCUGs. RESULTS PIC-VUR was bilateral in 63, unilateral in 12, and absent in 6 children. Statistically significant associations between PIC-VUR grade and severity of renal scarring were identified in inter-individual (n = 77, p = 0.017) and intra-individual (refluxing vs. nonrefluxing kidney; n = 12, p = 0.008) analyses. After excluding patients with history of VUR, statistical significance was maintained in inter-individual analysis (n = 49; p = 0.018). CONCLUSION The data suggest an association between PIC-VUR and severity of renal scarring, and legitimise the use of PIC cystography in children with renal scarring due to recurrent febrile UTI but negative findings on VCUG.
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Abstract
PURPOSE OF REVIEW To review recent changes in the diagnostic and therapeutic approach to pediatric urinary tract infection in the emergency department. RECENT FINDINGS Updated guidelines from the American Academy of Pediatrics have significantly changed the approach to UTI, risk-stratifying patients according to their likelihood of UTI, and re-defining criteria for diagnosis of UTI. New studies have delineated important risk factors for concomitant bacteremia and adverse events. Procalcitonin has emerged as the inflammatory marker most predictive of upper versus lower urinary tract infection and renal scarring. Delays in empiric antibiotic therapy are associated with increased rates of renal scarring. Corticosteroids are a potential adjunctive therapy to antibiotics. SUMMARY Timely diagnosis and therapy of UTI are essential. New guidelines may alter the traditional approach to evaluation and management. Future studies will likely focus on the impact of the new guidelines, further delineate the role of procalcitonin in predicting UTI, and explore the role of corticosteroids as an adjunct to antibiotic therapy.
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Bouguila J, Khalef I, Charfeddine B, Ben Rejeb M, Chatti K, Limam K, Essabbeh H, Essoussi AS, Boughammoura L. [Comparative study of C-reactive protein and procalcitonin in the severity diagnosis of pyelonephritis in children]. ACTA ACUST UNITED AC 2013; 61:93-8. [PMID: 23481452 DOI: 10.1016/j.patbio.2013.01.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2012] [Accepted: 01/11/2013] [Indexed: 10/27/2022]
Abstract
OBJECTIVE The aim of this study is to compare two biologic parameters; C-reactive protein (CRP) and procalcitonin (PCT) in the detection of acute renal lesions assessed by DMSA scintigraphy in the urinary tract infection in child. DESIGN In a prospective study, serum PCT, CRP and leukocyte counts were measured for children admitted, between January and December 2010, with a first episode of febrile urinary tract infection. RESULTS Seventy-five children were enrolled in the study. Thirty-three patients had renal lesions (group A) and 42 had a normal DMSA scintigraphy (group B). The mean PCT level was significantly higher in group A than in group B (8.81 ng/mL versus 1.7 ng/mL, P=0.01). In this study, using receiver operating characteristic (ROC) curve, we identified that the optimal cut-off value with ideal sensitivity and specificity for PCT in detection of renal lesions was 0.76 ng/mL and for CRP, it was 70 mg/L. The sensitivity, the negative predictive value and the indice of Youden of the cut-off value of PCT were significantly higher than CRP (82% versus 70%; 84% versus 70% and 0.58 versus 0.25). CONCLUSIONS This study confirmed that the serum PCT level was more sensitive and specific than the CRP in the detection of renal lesions in the first urinary tract infection in child.
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Affiliation(s)
- J Bouguila
- Service de pédiatrie, CHU Farhat Hached, avenue Ibn El Jazzar, 4000 Sousse, Tunisie.
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Newman DH, Shreves AE, Runde DP. Pediatric urinary tract infection: does the evidence support aggressively pursuing the diagnosis? Ann Emerg Med 2013; 61:559-65. [PMID: 23312370 DOI: 10.1016/j.annemergmed.2012.10.034] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2012] [Revised: 10/22/2012] [Accepted: 10/25/2012] [Indexed: 11/17/2022]
Abstract
The epidemiology of pediatric fever has changed considerably during the past 2 decades with the development of vaccines against the most common bacterial pathogens causing bacteremia and meningitis. The decreasing incidence of these 2 conditions among vaccinated children has led to an emphasis on urinary tract infection as a remaining source of potentially hidden infections in febrile children. Emerging literature, however, has led to questions about both the degree and nature of the danger posed by urinary tract infection in nonverbal children, whereas the aggressive pursuit of the diagnosis consumes resources and leads to patient discomfort, medical risks, and potential overdiagnosis. We review both early and emerging literature to examine the utility and efficacy of early identification and treatment of urinary tract infection in children younger than 24 months. We conclude that in well children of this age, it may be reasonable to withhold or delay testing for urinary tract infection if signs of other sources are apparent or if the fever has been present for fewer than 4 to 5 days.
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