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Alsaywid BS, Alyami FA, Alqarni N, Neel KF, Almaddah TO, Abdulhaq NM, Alajmani LB, Hindi MO, Alshayie MA, Alsufyani H, Alajlan SA, Albulushi BI, Labani SK. Urinary tract infection in children: A narrative review of clinical practice guidelines. Urol Ann 2023; 15:113-132. [PMID: 37304508 PMCID: PMC10252788 DOI: 10.4103/ua.ua_147_22] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 02/07/2023] [Accepted: 02/07/2023] [Indexed: 06/13/2023] Open
Abstract
Background Urinary tract infection (UTI) has been a major burden on the community and the health-care systems all over the globe. It is the most common cause of bacterial infection in the pediatric age group, with an annual incidence of 3%. The aim of this study is to review and summarize all available guidelines on the diagnosis and management of children with UTI. Materials and Methods This is a narrative review of the management of children with a UTI. All biomedical databases were searched, and any guidelines published from 2000 to 2022 were retrieved, reviewed, and evaluated to be included in the summary statements. The sections of the articles were formulated according to the availability of information in the included guidelines. Results UTI diagnoses are based on positive urine culture from a specimen of urine obtained through catheterization or suprapubic aspiration, and diagnoses cannot be established on the bases of urine collected from a bag. The criteria for diagnosing UTI are based on the presence of at least 50,000 colony-forming units per milliliter of a uropathogen. Upon confirmation of UTI, the clinician should instruct parents to seek rapid medical assessment (ideally within 48 h) of future febrile disease to ensure that frequent infections can be detected and treated immediately. The choice of therapy depends on several factors, including the age of the child, underlying medical problems, the severity of the disease, the ability to tolerate oral medications, and most importantly local patterns of uropathogens resistance. Initial antibiotic choice of treatment should be according to the sensitivity results or known pathogens patterns with comparable efficacy of oral and parenteral route, for 7 days to 14 days duration. Renal and bladder ultrasonography is the investigation of choice for febrile UTI, and voiding cystourethrography should not be performed routinely unless indicated. Conclusion This review summarizes all the recommendations related to UTIs in the pediatric population. Due to the lack of appropriate data, further high-quality studies are required to improve the level and strength of recommendations in the future.
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Affiliation(s)
- Basim S. Alsaywid
- Department of Urology, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
- Department of Education and Research Skills Directory, Saudi National Institute of Health, Riyadh, Saudi Arabia
| | - Fahad A. Alyami
- Department of Urology, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
- Division of Urology, King Khalid University Hospital, Riyadh, Saudi Arabia
- Department of Surgery, Division of Urology, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Naif Alqarni
- Department of Urology, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Khalid Fouda Neel
- Division of Urology, King Khalid University Hospital, Riyadh, Saudi Arabia
- Department of Surgery, Division of Urology, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Talah O. Almaddah
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
| | - Nada M. Abdulhaq
- Department of Pediatric, King Abdulaziz University, Rabigh, Saudi Arabia
| | - Lujin Bassam Alajmani
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
| | - Mawada O. Hindi
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
| | - Mohammed A. Alshayie
- Department of Urology, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Hazim Alsufyani
- Department of Surgery, Division of Urology, King Faisal Medical Complex, Taif, Saudi Arabia
| | - Sarah Abdulrahman Alajlan
- Department of Education and Research Skills Directory, Saudi National Institute of Health, Riyadh, Saudi Arabia
| | - Bashaer I. Albulushi
- Department of Urology, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Safiah K. Labani
- Research Unit, College of Dentistry, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Centre, Riyadh, Saudi Arabia
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Tanaka Y, Miyata I, Nakamura Y, Kondo E, Gotoh K, Oishi T, Nakano T, Ouchi K. Characteristics and etiology of infection in febrile infants aged ≤90 days. Pediatr Int 2022; 64:e15040. [PMID: 34704648 DOI: 10.1111/ped.15040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 09/25/2021] [Accepted: 10/24/2021] [Indexed: 01/06/2023]
Abstract
BACKGROUND Infants ≤90 days old can exhibit non-specific signs of infection, even in cases of serious bacterial infection (SBI). METHODS This prospective study included infants aged ≤90 days hospitalized for fever from June 2017 to August 2019. Nasopharyngeal swabs were tested using multiplex real-time polymerase chain reaction (PCR) tests and 16S ribosomal RNA analysis of whole blood to determine causative microorganisms. Data pertaining to inflammatory markers, maximum body temperature (BT), and respiratory symptoms of infants and their cohabiting families were collected at admission. RESULTS A total of 110 infants were enrolled (age range, 9-90 days), 17 (15.5%) of whom presented with SBIs. White blood cell (WBC) count and absolute neutrophil count (ANC) were significantly higher in patients with SBIs than in those without, although maximum BT did not significantly differ between the SBI and non-SBI groups (n = 93). One or more viruses were detected in 82 infants (74.5%). Viruses were detected more frequently in infants with respiratory symptoms than in those without respiratory symptoms (P = 0.038), and patients with SBIs experienced significantly less respiratory symptoms than those without SBIs (P = 0.049). Moreover, viruses were more often detected in infants from cohabiting families with respiratory symptoms than in those whose family members did not exhibit respiratory symptoms (P = 0.0018). CONCLUSION White blood cell count, and ANC were significantly higher, and respiratory symptoms were less in infants ≤90 days old with SBIs than in those without SBIs. Microorganisms from nasopharyngeal by multiplex real-time PCR swabs could not be judged as SBI or non-SBI.
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Affiliation(s)
- Yuhei Tanaka
- Department of Pediatrics and Child Health, Kurume University of Medicine, Kurume, Japan.,Department of Pediatrics, Kawasaki Medical School, Kurashiki, Japan
| | - Ippei Miyata
- Department of Pediatrics, Kawasaki Medical School, Kurashiki, Japan
| | | | - Eisuke Kondo
- Department of Pediatrics, Kawasaki Medical School, Kurashiki, Japan
| | - Kenji Gotoh
- Department of Pediatrics and Child Health, Kurume University of Medicine, Kurume, Japan
| | - Tomohiro Oishi
- Department of Pediatrics, Kawasaki Medical School, Kurashiki, Japan
| | - Takashi Nakano
- Department of Pediatrics, Kawasaki Medical School, Kurashiki, Japan
| | - Kazunobu Ouchi
- Department of Pediatrics, Kawasaki Medical School, Kurashiki, Japan
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Doyev R, Ben-Shalom E, Megged O. The predictive utility of prior positive urine culture in children with recurrent urinary tract infections. Eur J Pediatr 2020; 179:415-421. [PMID: 31768637 DOI: 10.1007/s00431-019-03522-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 10/31/2019] [Accepted: 11/03/2019] [Indexed: 11/25/2022]
Abstract
Urinary tract infections can cause renal damage if not treated promptly. The aim of this study was to examine if prior urine cultures can predict antibiotic susceptibility profile in a subsequent culture, in children with recurrent urinary tract infections. The medical records of all children with at least two episodes of urinary tract infection between 1999-2015 that occurred 2 weeks to 1 year apart were reviewed. Pathogen identity and antibiogram were compared between the two cultures for every patient. One hundred sixty-one cases of recurrent urinary tract infections were identified. Seventy-seven (48%) pairs of cultures grew the same pathogen. However, of these, 31 had an altered biogram. In 53% of the culture pairs, the pathogen in the second culture had a similar or better antibiotic susceptibility profile. We found no statistically significant correlation between the elapsed time between the two cultures and the probability of similar susceptibility profile between them. There was no correlation between antibiogram change and any of the demographic characteristics, including a history of renal transplantation and taking antibiotic prophylactic treatment.Conclusions: Antibiotic susceptibility profile of the pathogen in a prior urinary tract infection did not predict antibiotic susceptibility profile in a subsequent urinary tract infection in our study.What is Known:• Children with urinary tract infections often have recurrent infections.• Clinicians often use prior urine cultures to choose empirical antibiotic treatment in subsequent infections.What is New:• In only 50% of the cases, a subsequent urinary tract infection grows the same pathogen as the 1st urinary tract infection.• Even in cultures with the same pathogen growth, antibiogram is often different.
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Affiliation(s)
- Reut Doyev
- The Hebrew University Hadassah Medical School, Jerusalem, Israel
| | - Efrat Ben-Shalom
- Pediatric Department, Shaare Zedek Medical Center, P.O.B. 3235, Jerusalem, Israel.,Pediatric Nephrology Unit, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Orli Megged
- The Hebrew University Hadassah Medical School, Jerusalem, Israel. .,Pediatric Department, Shaare Zedek Medical Center, P.O.B. 3235, Jerusalem, Israel. .,Infectious Diseases Unit, Shaare Zedek Medical Center, Jerusalem, Israel.
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Abstract
Objective: To determine the risk with gynecological problems on the health of female university students. Methods: The study was conducted as a descriptive in university in Central Anatolia, Turkey. The research population was composed of 1305 female university students studying at a university in Central Anatolia. The study was conducted between January and March 2017. The data were collected through a questionnaire consisting of 23 questions prepared by the researchers to determine the socio-demographic characteristics of the participants and the risk with gynecological problems they encountered. Numerical and percentage statistics were used to analyze the data. Results: About 65.4 percent of the female students in this study previously had gynecological examination, and 38.8 percent of them were diagnosed with gynaecological problems. It was found that 87.6 percent of the female students had risk with gynecological disorders. the most common ones being dysmenorrhoea (63.2%), premenstrual syndrome (56.7%), urinary tract infection (22.4%), and polycystic ovarian syndrome (13%), respectively. Conclusions: It was found that nearly all the young girls had risk with gynecological problems and nearly half of them were diagnosed with different gynaecological disorders.
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Affiliation(s)
- Rukiye Hobek Akarsu
- Dr. Rukiye Hobek Akarsu, Department of Midwifery, Faculty of Health Sciences, Yozgat Bozok University, Yozgat, Turkey
| | - Selda Yuzer Alsac
- Dr. Selda Yuzer Alsac, Department of Nursing, Faculty of Health Sciences, Yozgat Bozok University, Yozgat, Turkey
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Korbel L, Howell M, Spencer JD. The clinical diagnosis and management of urinary tract infections in children and adolescents. Paediatr Int Child Health 2017; 37:273-279. [PMID: 28978286 DOI: 10.1080/20469047.2017.1382046] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Urinary tract infections (UTI) are one of the most common and serious bacterial infections encountered by paediatricians and primary care physicians. Although the diagnosis and management of UTI appear simplistic, they remain among the most contentious issues in paediatrics. In part, UTI controversies stem from the absence of classic clinical symptoms, inappropriate urine specimen collection, modified urinary tract imaging recommendations, and diverse treatment and prevention strategies. Recently published guidelines and large clinical trials have attempted to clarify UTI diagnostic and management strategies. In this manuscript, we review the diagnosis and management of acute and recurrent UTI in the paediatric and adolescent populations.
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Affiliation(s)
- Lindsey Korbel
- a Pediatrics Residency Program , Nationwide Children's Hospital , Columbus , OH , USA
| | - Marianella Howell
- b Department of Pediatrics, Division of Nephrology , Hospital Nacional de Niños , San Jose , Costa Rica
| | - John David Spencer
- c Department of Pediatrics, Division of Nephrology , Nationwide Children's Hospital , Columbus , OH , USA.,d Center for Clinical and Translational Research , The Research Institute at Nationwide Children's Hospital , Columbus , OH , USA
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Schröder A. [Vesicoureteral reflux : Watchful waiting, surgery or antibiotic prophylaxis?]. Urologe A 2017; 56:1158-1163. [PMID: 28710643 DOI: 10.1007/s00120-017-0453-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Primary vesicoureteral reflux (VUR) is a dynamic disease with several factors influencing its course. Therapeutic options range from watchful waiting to open surgery. Multiple risk factors for the development of pyelonephritis are identified, which then determine the decision for the appropriate treatment option. They include age, gender, history of pyelonephritis and renal scarring, bladder and bowel dysfunction (BBD), circumcision status and parental preference. The use of continuous antibiotic prophylaxis (CAP) is becoming increasingly controversial with antibiotic resistance being a major concern. Aggressive treatment of BBD and infant circumcision can greatly reduce the risk for pyelonephritis and should always be considered and discussed. This article is soley concerned with primary VUR.
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Affiliation(s)
- A Schröder
- Klinik und Poliklinik für Urologie und Kinderurologie, Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Langenbeckstraße 1, 55131, Mainz, Deutschland.
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Probiotics prophylaxis in pyelonephritis infants with normal urinary tracts. World J Pediatr 2016; 12:425-429. [PMID: 27059742 DOI: 10.1007/s12519-016-0013-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Accepted: 03/30/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Pyelonephritis in infants is considered as a major factor for the formation of renal scar. To prevent recurrent pyelonephritis and renal damage, prophylaxis is extremely important. The aim of this study was to compare the effectiveness of probiotic and antibiotic prophylaxis or no-prophylaxis in infants with pyelonephritis and normal urinary tract. METHODS Altogether 191 infants, who were diagnosed with acute pyelonephritis, proven to have normal urinary tracts and followed up for 6 months on prophylaxis, were retrospectively evaluated. According to the types of prophylaxis, the infants were divided into three groups [probiotics (Lactobacillus species), antibiotics (trimethoprim/sulfamethoxazole, TMP/SMX), and noprophylaxis]. The incidence of recurrent urinary tract infection (UTI) during 6 months after the development of pyelonephritis, main causative uropathogens, and its antimicrobial sensitivities were compared. RESULTS The incidence of recurrent UTI in the probiotic group was 8.2%, which was significantly lower than 20.6% in the no-prophylaxis group (P=0.035) and was not significantly different from 10.0% of the antibiotic group (P=0.532). The significant difference between the probiotic and no-prophylaxis groups was seen only in male infants (P=0.032). The main causative organism of recurrent UTI was Escherichia coli (E.coli), which was not different among the three groups (P=0.305). The resistance rate of E. coli to TMP/SMX was 100% in the antibiotic group, which was significantly higher than 25.0% in the probiotic group and 41.7% in the no-prophylaxis group (P=0.008). CONCLUSION Probiotic prophylaxis was more effective in infants with pyelonephritis and normal urinary tract than in those with no-prophylaxis. It could be used as a natural alternative to antibiotic prophylaxis.
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Azab S, Zakaria M, Raafat M, Seief H. The combination of urinary IL - 6 and renal biometry as useful diagnostic tools to differentiate acute pyelonephritis from lower urinary tract infection. Int Braz J Urol 2016; 42:810-6. [PMID: 27564295 PMCID: PMC5006780 DOI: 10.1590/s1677-5538.ibju.2016.0049] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Accepted: 03/13/2016] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE To evaluate the role of renal ultrasound (RUS) and urinary IL-6 in the differentiation between acute pyelonephritis (APN) and lower urinary tract infection (LUTI). PATIENTS AND METHODS This prospective study was carried out at the Pediatric and urology outpatient and inpatient departments of Cairo University Children's Hospital as well as October 6 University Hospital and it included 155 children between one month and fourteen years old with positive culture UTI. Patients were categorized into APN and LUTI based on their clinical features and laboratory parameters. Thirty healthy children, age and sex matched constituted the control group. Children with positive urine cultures were treated with appropriate antibiotics. Before treatment, urinary IL-6 was measured by enzyme immunoassay technique (ELISA), and renal ultrasound (RUS) was done. CRP (C-reactive protein), IL-6 and RUS were repeated on the 14th day of antibiotic treatment to evaluate the changes in their levels in response to treatment. RESULTS UIL-6 levels were more significantly higher in patients with APN than in patients with LUTI (24.3±19.3pg/mL for APN vs. 7.3±2.7pg/mL in LUTI (95% CI: 2.6-27.4; p< 0.01). Similarly, serum CRP was more significantly higher in patients with APN than in children with LUTI (19.7±9.1μg/mL vs. 5.5±2.3μg/mL (p< 0.01). IL-6 levels >20pg/mL and serum CRP >20μg/mL were highly reliable markers of APN. Mean renal volume and mean volume difference between the two kidneys in the APN group were more than that of the LUTI and control groups (P< 0.001). Renal volume between 120-130% of normal was the best for differentiating APN from LUTI. CONCLUSIONS RUS and urinary IL-6 levels have a highly dependable role in the differentiation between APN and LUTI especially in places where other investigations are not available and/ or affordable.
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Affiliation(s)
- Sherif Azab
- Department of Urology, Faculty of Medicine, October 6 University, Cairo, Egypt
| | | | - Mona Raafat
- Department of Clinical Pathology, National research Center, Cairo, Egypt
| | - Hadeel Seief
- Department of Radiology, University Cairo, Cairo, Egypt
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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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Thompson DB, Siref LE, Feloney MP, Hauke RJ, Agrawal DK. Immunological basis in the pathogenesis and treatment of bladder cancer. Expert Rev Clin Immunol 2015; 11:265-79. [PMID: 25391391 PMCID: PMC4637163 DOI: 10.1586/1744666x.2015.983082] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The pathogenesis and transition of normal urothelium into bladder carcinoma are multifactorial processes. Chronic inflammation causes initiation and progression of the underlying pathophysiology of invasive and metastatic cancer. A dichotomy is observed in the role of immune cells in bladder cancer. While the immune response defends the host by suppressing neoplastic growth, several immune cells, including neutrophils, macrophages and T-lymphocytes, promote tumor development and progression. The levels of human neutrophil peptide-1, -2 and -3, produced by neutrophils, increase in bladder cancer and might promote tumor angiogenesis and growth. The effect of macrophages is primarily mediated by pro-inflammatory cytokines, IL-6 and TNF-α. In addition, the underlying immunological mechanisms of two treatments, BCG and cytokine gene-modified tumor vaccines, and future directions are critically discussed.
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Affiliation(s)
- David B Thompson
- Center for Clinical and Translational Science, Creighton University School of Medicine, CRISS II Room 510, 2500 California Plaza, Omaha, NE 68178, USA
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Becknell B, Schober M, Korbel L, Spencer JD. The diagnosis, evaluation and treatment of acute and recurrent pediatric urinary tract infections. Expert Rev Anti Infect Ther 2014; 13:81-90. [PMID: 25421102 DOI: 10.1586/14787210.2015.986097] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Urinary tract infection (UTI) is one of the most common bacterial infections encountered by pediatricians. Currently, the diagnosis and management of acute UTI and recurrent UTI in children remain controversial. Recently published guidelines and large clinical trials have attempted to clarify UTI diagnostic and management strategies. In this manuscript, we review the diagnosis and management of acute and recurrent UTI in the pediatric population.
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Affiliation(s)
- Brian Becknell
- Department of Pediatrics, Division of Nephrology, Nationwide Children's Hospital, Columbus, OH, USA
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12
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Spencer JD, Schwaderer AL, Becknell B, Watson J, Hains DS. The innate immune response during urinary tract infection and pyelonephritis. Pediatr Nephrol 2014; 29:1139-49. [PMID: 23732397 PMCID: PMC3800267 DOI: 10.1007/s00467-013-2513-9] [Citation(s) in RCA: 96] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2013] [Revised: 04/16/2013] [Accepted: 05/08/2013] [Indexed: 11/27/2022]
Abstract
Despite its proximity to the fecal flora, the urinary tract is considered sterile. The precise mechanisms by which the urinary tract maintains sterility are not well understood. Host immune responses are critically important in the antimicrobial defense of the urinary tract. During recent years, considerable advances have been made in our understanding of the mechanisms underlying immune homeostasis of the kidney and urinary tract. Dysfunctions in these immune mechanisms may result in acute disease, tissue destruction and overwhelming infection. The objective of this review is to provide an overview of the innate immune response in the urinary tract in response to microbial assault. In doing so, we focus on the role of antimicrobial peptides-a ubiquitous component of the innate immune response.
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Affiliation(s)
- John David Spencer
- Department of Pediatrics, Division of Nephrology, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA,
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13
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Abstract
OBJECTIVES The objective of this study was (1) to determine the reliability of urinalysis (UA) for predicting urinary tract infection (UTI) in febrile children, (2) to determine whether UA findings can predict Escherichia coli versus non-E. coli urinary tract infection, and (3) to determine if empiric antibiotics should be selected based on E. coli versus non-E. coli infection predictions. METHODS This was a retrospective chart review of children from 2 months to 2 years of age who presented to the emergency department with fever (rectal temperature >100.4°F) and had a positive urine culture. This study was conducted between January 2004 and December 2007. Negative UA was defined as urine white blood cell count less than 5 per high-power field, negative leukocyte esterase, and negative nitrites. Urine cultures were classified into E. coli and non-E. coli groups. These groups were compared for sex, race, and UA findings. Multivariate forward logistic regression, using the Wald test, was performed to calculate the likelihood ratio (LR) of each variable (eg, sex, race, UA parameters) in predicting UTI. In addition, antibiotic sensitivities between both groups were compared. RESULTS Of 749 medical records reviewed, 608 were included; negative UA(-) was present in 183 cases, and positive UA(+) was observed in 425 cases. Furthermore, 424 cases were caused by E. coli, and 184 were due to non-E. coli organisms. Among 425 UA(+) cases, E. coli was identified in 349 (82.1%), whereas non-E. coli organisms were present in 76 (17.9%); in contrast, in 183 UA(-) cases, 108 (59%) were due to non-E. coli organisms versus 75 (41%), which were caused by E. coli. Urinalysis results were shown to be associated with organism group (P < 0.001). Positive leukocytes esterase had an LR of 2.5 (95% confidence interval [CI], 1.5-4.2), positive nitrites had an LR of 2.8 (95% CI, 1.4-5.5), and urine white blood cell count had an LR of 1.8 (95% CI, 1.3-2.4) in predicting E. coli versus non-E. coli infections. Antibiotic sensitivity compared between UA groups demonstrated equivalent superiority of cefazolin (94.7% sensitive in UA(+) vs 84.0% in UA(-) group; P < 0.0001), cefuroxime (98.2% vs 91.7%; P < 0.001), and nitrofurantoin (96.1% vs 82.2%; P < 0.0001) in the UA(+) group. In contrast, the UA(-) group showed significant sensitivity to trimethoprim-sulfamethoxazole (82.2% vs 71.3% in UA(+); P = 0.008). CONCLUSIONS Urinalysis is not an accurate predictor of UTI. A positive urine culture in the presence of negative UA most likely grew non-E. coli organisms, whereas most UA(+) results were associated with E. coli. This study also highlighted local patterns of antibiotic resistance between E. coli and non-E. coli groups. Negative UA results in the presence of strong suspicion of a UTI suggest a non-E. coli organism, which may be best treated with trimethoprim-sulfamethoxazole. Conversely, UA(+) results suggest E. coli, which calls for treatment with cefazolin or cefuroxime.
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Milošević D, Trkulja V, Turudić D, Batinić D, Spajić B, Tešović G. Ultrasound bladder wall thickness measurement in diagnosis of recurrent urinary tract infections and cystitis cystica in prepubertal girls. J Pediatr Urol 2013; 9:1170-7. [PMID: 23725853 DOI: 10.1016/j.jpurol.2013.04.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2012] [Accepted: 04/25/2013] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To evaluate urinary bladder wall thickness (BWT) assessed by ultrasound as a diagnostic tool for cystitis cystica. PATIENTS AND METHODS This was a 9-year prospective study comprising 120 prepubertal girls. Sixty subjects of whom half underwent cystoscopy represented cases while the other 60 (those with a single urinary tract infection and healthy subjects) represented controls. RESULTS Based on receiver operating characteristics (ROC) analysis, BWT discriminated very well between cases and controls with area under the ROC curve close to 1.0. At the optimum cut-off defined at 3.9 mm, negative predictive value (NPV) was 100% leaving no probability of cystic cystitis with BWT <3.9 mm. Positive predictive value (PPV) was also very high (95.2%), indicating only around 4.82% probability of no cystic cystitis in patients with BWT values ≥3.9 mm. BWT could also distinguish between healthy subjects and those with a cured single urinary tract infection, although discriminatory properties were moderate (area under ROC 86.7%, PPV 78.8%, NPV 85.2%). CONCLUSION Ultrasound mucosal bladder wall measurement is a non-invasive, simple and quite reliable method in diagnosis of cystitis cystica in prepubertal girls with recurrent urinary tract infections.
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Affiliation(s)
- Danko Milošević
- Department of Pediatrics, Zagreb University Hospital Centre, University of Zagreb, School of Medicine, Kišpatićeva 12, HR-10000 Zagreb, Croatia.
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Azap Ö, Togan T, Yesilkaya A, Arslan H, Haberal M. Antimicrobial susceptibilities of uropathogen Escherichia coli in renal transplant recipients: dramatic increase in ciprofloxacin resistance. Transplant Proc 2013; 45:956-7. [PMID: 23622597 DOI: 10.1016/j.transproceed.2013.03.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
The urinary tract is the most common site of bacterial infections in renal transplant recipients. The management of urinary tract infections (UTI) in renal transplant recipients is becoming more difficult because of drug-resistant bacteria. The antimicrobial susceptibilities of uropathogen bacteria isolated from 398 patients who underwent renal transplantation between 2007 and 2011 were obtained from medical records. At least 1 UTI episode was diagnosed in 172 (43.2%) patients. Among the 703 bacteria isolated from these patients, Exherichia coli the most common pathogen, was isolated from 407/703 episodes (57.8%). Ciprofloxacin, co-trimoxazole, ceftriaxone, and gentamicin resistance rates were 59.4%, 85.7%, 40.7%, and 36.6%, respectively. Ninty six of 407 E. coli isolates (23.5%) were ESBL positive. Analysis of resistance rates in our center demonstrated ciprofloxacin resistance rate in uropathogenic E. coli to have increased gradually from 30.4% in 2003, 41.3% in 2007, and 59.4% in 2012. Instutional data regarding the etiologic agents and antimicrobial susceptibility results are important for proper management of patients with UTI.
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Affiliation(s)
- Ö Azap
- Department of Infectious Diseases, Faculty of Medicine, Baskent University, Ankara, Turkey.
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Vachvanichsanong P, Dissaneewate P, McNeil E. Childhood recurrent urinary tract infection in southern Thailand. Ren Fail 2012; 35:66-71. [PMID: 23170976 DOI: 10.3109/0886022x.2012.741647] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Recurrent urinary tract infection (UTI) is one of the major health problems in children because of its high rate of occurrence. OBJECTIVE Our aim of the study was to evaluate the prevalence and determine risk factors of recurrent UTI in Thai children. PATIENTS AND METHODS The medical records of children aged less than 15 years diagnosed with UTI at the Department of Pediatrics, Songklanagarind Hospital were reviewed. RESULTS A total of 307 children (144 boys, 163 girls) were followed up for at least 1 year. Fifty-six children, 31 (19.0%) boys and 25 (17.4%) girls, developed at least one recurrence totaling 153 recurrent UTI episodes. The recurrence rate was not statistically different between the sexes (p = 0.8). On multivariate analysis, genitourinary system (GU) anomalies, particularly vesicoureteral reflux (VUR), were the most significant risk factors. Children aged greater than 5 years had a slightly higher risk of recurrence, irrespective of gender. Comparison of organisms associated with recurrent UTI with those associated with first UTI showed that the prevalence of Escherichia coli decreased from 76.9% to 56.2% but was still the major causative agent. In contrast, the prevalence of Klebsiella pneumoniae and unusual or mixed organisms significantly increased from 7.8% to 15.0% and 6.2% to 16.3%, respectively. CONCLUSION One-fifth of children who had UTI developed recurrence and the rates were similar for males and females. Independent risk factors for recurrent UTI were found to be at age of >5 years and underlying disease of either GU anomaly or VUR.
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Habib S. Highlights for management of a child with a urinary tract infection. Int J Pediatr 2012; 2012:943653. [PMID: 22888360 PMCID: PMC3408663 DOI: 10.1155/2012/943653] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2011] [Accepted: 05/26/2012] [Indexed: 11/18/2022] Open
Abstract
Urinary tract infections remain the most common bacterial infection in childhood. Escherichia coli is responsible for over 80% of Pediatric UTIs. Other common gram negative organisms include Kleibsiella, Proteus, Enterobacter and occasionally Pseudomonas. Signs and symptoms vary greatly by age of the patient becoming more specific as the child grows older. Even in the absence of specific signs a UTI should be included in the differential diagnosis of high grade fever. In younger children, presence of upper respiratory infections, otitis media or gastroenteritis does not eliminate the possibility of a UTI. Culture of the urine remains the gold standard for diagnosing UTIs. All males and females with well documented UTIs should be imaged for the presence of urological anomalies associated with UTI. Depending on patient's clinical symptoms and tolerance, therapy can be oral or parenteral as they have both been found equally efficacious. Healthcare professionals should ensure that when a child or young person has been identified as having a suspected UTI, they and their parents are given information about the need for treatment, the importance of completing any course of treatment and advice about prevention and possible long-term management.
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Affiliation(s)
- Sabeen Habib
- Department of Pediatrics, LSUHealth Shreveport, Shreveport, LA 71130, USA
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18
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Castagnetti M, Cimador M, Esposito C, Rigamonti W. Antibiotic prophylaxis in antenatal nonrefluxing hydronephrosis, megaureter and ureterocele. Nat Rev Urol 2012; 9:321-9. [DOI: 10.1038/nrurol.2012.89] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Development and Initial Validation of a Disease Specific Quality of Life Survey for Children With Vesicoureteral Reflux. J Urol 2012; 187:1828-33. [DOI: 10.1016/j.juro.2011.12.108] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2011] [Indexed: 12/26/2022]
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Spencer JD, Bates CM, Mahan JD, Niland ML, Staker SR, Hains DS, Schwaderer AL. The accuracy and health risks of a voiding cystourethrogram after a febrile urinary tract infection. J Pediatr Urol 2012; 8:72-6. [PMID: 21126919 PMCID: PMC3987123 DOI: 10.1016/j.jpurol.2010.10.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2010] [Accepted: 10/27/2010] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Physicians often defer obtaining a voiding cystourethrogram (VCUG) after the diagnosis of urinary tract infection (UTI) due to concerns regarding increased health risks and inflated rates of vesicoureteral reflux (VUR). This study examines the health risks and accuracy of VCUG testing after diagnosis of a febrile UTI. PATIENTS AND METHODS A retrospective review was conducted of children aged 0-18 years admitted to Nationwide Children's Hospital with a febrile UTI in 1995-2000. Children were divided into two cohorts - those who had a VCUG performed within 1 week of diagnosis (early VCUG cohort) and those who had a VCUG performed more than 1 week after diagnosis (late VCUG cohort). All children were followed for an additional 5 years after hospital discharge. RESULTS The incidence and severity of VUR were similar in patients that underwent early and late VCUG testing. Patients who underwent early VCUG testing showed no sign of worsening illness after the test was performed. During the 5-year follow up, these patients did not have higher rates of return emergency department visits or hospital readmission compared to those who received late VCUG testing. CONCLUSIONS The rate of VUR detection does not increase with early VCUG testing. Early VCUG testing does not lead to increased risk of bacterial dissemination or urosepsis.
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Affiliation(s)
- John David Spencer
- Nationwide Children's Hospital, Department of Pediatrics, Division of Nephrology, 700 Children's Drive, Columbus, OH 43205, USA.
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21
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Probability of urinary tract infection in infants with ureteropelvic junction obstruction: is antibacterial prophylaxis really needed? Pediatr Nephrol 2011; 26:1837-41. [PMID: 21520006 DOI: 10.1007/s00467-011-1889-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2010] [Revised: 03/31/2011] [Accepted: 03/31/2011] [Indexed: 10/18/2022]
Abstract
In infants with ureteropelvic junction obstruction (UPJO), the risk of urinary tract infection (UTI) is unknown, and there is a lack of prospective studies showing definitive evidence regarding the benefits and necessity of antibiotic prophylaxis. The aim of this study was to assess the risk of UTI in infants with UPJO and to determine whether the risk varies according to the degree of hydronephrosis. Infants with hydronephrosis detected prenatally or within the postnatal 28th day and who had no previous history of UTI were followed prospectively without antibacterial prophylaxis. Imaging studies were performed according to our Pediatric Uro-Nephrology Study Group protocol. Dimercaptosuccinate (DMSA) scintigraphy was performed in all infants at the end of 1 year of follow-up. Eighty-four infants (56 boys, 28 girls) were included in the study. The distribution of patients in each hydronephrosis grading group was incidentally similar. Within a median follow-up period of 18 (12-24) months, none of the patients had UTI. Furthermore, no pyelonephritic scar was found on DMSA scans in any patient. We conclude that prophylactic antibiotic usage is not indicated in infants with UPJO, regardless of the severity of hydronephrosis, as the risk of UTI is minimal in this population.
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Kaptein YE, Talving P, Konstantinidis A, Lam L, Inaba K, Plurad D, Demetriades D. Epidemiology of pediatric cardiac injuries: a National Trauma Data Bank analysis. J Pediatr Surg 2011; 46:1564-71. [PMID: 21843725 DOI: 10.1016/j.jpedsurg.2011.02.041] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2010] [Revised: 02/09/2011] [Accepted: 02/10/2011] [Indexed: 02/07/2023]
Abstract
BACKGROUND Few studies of pediatric cardiac injuries have been conducted in large cohorts. We, therefore, investigated the epidemiology of these injuries in the United States. METHODS We identified patients with traumatic cardiac injury from the National Trauma Data Bank, using the International Classification of Diseases, Ninth Revision, codes. Demographic data, clinical data, and inhospital outcomes were compared among 5 age groups. A logistic regression model was used to determine adjusted mortality among these groups. RESULTS Six hundred twenty-six patients met criteria. Fifty-nine percent sustained cardiac contusion; 36%, laceration. Penetrating injuries proved more severe than blunt, having lower average Glasgow Coma Scale (6.8 vs 8.7) and higher percentage of patients with Glasgow Coma Scale of 8 or lower (68% vs 53%). Associated injuries occurred in 484 (77%), most common being lung injuries (46%), hemopneumothorax (37%), and rib fractures (26%). Eleven percent underwent laparotomy; 9%, thoracotomy; 2%, craniotomy/craniectomy; and 0.2%, sternotomy. Complications occurred in 80 (13%), most common being cardiac arrest (4%). Firearm injuries result in the highest mortality rate (76%), compared with other mechanisms (26%-31%). Crude mortality in different age strata showed significant differences that were lost after adjustment for confounding variables. CONCLUSIONS The predominant cardiac injury was blunt (65%; 35% sustained penetrating insults), frequently paired with contusion. Pediatric cardiac injury is associated with excessive inhospital mortality (40%), with no age-related difference in adjusted mortality.
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Affiliation(s)
- Yvonne E Kaptein
- Department of Surgery, Division of Acute Care Surgery at Los Angeles County, University of Southern California Medical Center, Los Angeles, CA 90033, USA.
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Ilić T, Gračan S, Arapović A, Čapkun V, Šubat-Dežulović M, Saraga M. Changes in bacterial resistance patterns in children with urinary tract infections on antimicrobial prophylaxis at University Hospital in Split. Med Sci Monit 2011; 17:CR355-61. [PMID: 21709628 PMCID: PMC3539571 DOI: 10.12659/msm.881845] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2010] [Accepted: 02/17/2011] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND We assessed prevalence and resistance of uropathogens on antimicrobial agents (AA) from urine cultures (UC) in children hospitalized with urinary tract infections (UTI) at University Hospital in Split. MATERIAL/METHODS During the 7-year period, children hospitalized only once with UTI alone were compared to those repeatedly hospitalized, and who received long-term antimicrobial prophylaxis (LTAP), as well as those with associated anomalies of the urinary system (US). RESULTS E. coli was the most frequent isolate (67.7%) with resistance to ampicillin by 69.5%, amoxicillin/clavulonic acid by 3.5%, cephalexin by 6.6%, trimethoprim/sulfamethoxazole (TMP-SMX) by 27.5%, and nitrofurantoin by 0.4%. For other uropathogens, AA resistance rates were the following: 64.3%, 5.8%, 10.5%, 21.3%, and 7.9%. The high or increasing resistance to TMP-SMX is characterized by all uropathogens. Patients with anomalies of US showed a lower prevalence of E. coli and Enterococcus sp., but a higher prevalence of Pseudomonas sp., ESBL-producing E. coli and Klebsiella sp. than those without US anomalies. Repeatedly hospitalized patients showed a lower prevalence of E. coli, but a higher prevalence of Pseudomonas sp. and Klebsiella sp. than patients hospitalized only once. Both groups displayed significantly less resistance of Enterococcus sp. In patients receiving LTAP before hospitalization, E. coli was significantly more resistant to ampicillin, amoxicillin/clavulonic acid and TMP/SMX than in those without LTAP. CONCLUSIONS Based on our results, we recommend excluding ampicillin altogether, and reconsideration of further use of TMP-SMX, as well as use of nitrofurantoin, cephalexin and amoxicillin/clavulonic acid for LTAP in our region.
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Affiliation(s)
- Tanja Ilić
- School of Medicine, University of Split, Split, Croatia
| | - Sanda Gračan
- School of Medicine, University of Split, Split, Croatia
| | - Adela Arapović
- Department of Pediatrics, University Hospital in Split, Split, Croatia
| | - Vesna Čapkun
- Department of Nuclear Medicine, University Hospital in Split, Split, Croatia
| | - Mirna Šubat-Dežulović
- Department of Pediatric Nephrology, University Hospital Center Rijeka, Rijeka, Croatia
| | - Marijan Saraga
- School of Medicine, University of Split, Split, Croatia
- Department of Pediatrics, University Hospital in Split, Split, Croatia
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Pediatric urinary tract infections: an analysis of hospitalizations, charges, and costs in the USA. Pediatr Nephrol 2010; 25:2469-75. [PMID: 20711740 PMCID: PMC4741383 DOI: 10.1007/s00467-010-1625-8] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2010] [Revised: 07/15/2010] [Accepted: 07/19/2010] [Indexed: 10/19/2022]
Abstract
This study evaluates the impact of pediatric urinary tract infection (UTI)s on the economy and inpatient healthcare utilization in the USA. A retrospective analysis of patient demographics and hospital economics was performed on children less than 18 years of age admitted with a UTI between 2000 and 2006 using the Healthcare Cost and Utilization Project Kids' Inpatient Database. Our results were stratified as follows. Hospital admissions-nearly 50,000 children/year were admitted with a UTI. Pediatric UTIs represented 1.8% of all pediatric hospitalizations. Seventy-three percent of patients were female and 40% were under 1 year of age. Payer information-from 2000 to 2006, pediatric insurance coverage shifted from the private sector to the public sector. Hospital cost-in 2000, estimated hospital costs for UTIs were $2,858 per hospitalization and rose to $3,838 by 2006. Mean hospital charges increased from $6,279 to $10,489 per stay. By 2006, aggregate hospital charges exceeded $520 million. Our results indicate that UTIs are among the most common pediatric admission diagnoses. Hospitalization is more common in females and younger children. Since 2000, hospital charges for UTIs increased disproportionately to hospital costs. Over time, more children hospitalized with a UTI depend on public agencies to cover healthcare expense. More efforts are needed to evaluate cost-effective strategies for evaluation and treatment of UTIs.
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Mamì C, Palmara A, Paolata A, Marrone T, Marseglia L, Bertè LF, Arena F. Outcome and management of isolated severe renal pelvis dilatation detected at postnatal screening. Pediatr Nephrol 2010; 25:2093-7. [PMID: 20556430 DOI: 10.1007/s00467-010-1573-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2010] [Revised: 05/18/2010] [Accepted: 05/19/2010] [Indexed: 11/30/2022]
Abstract
The aim of this study was to evaluate the incidence and outcome of isolated severe renal pelvis dilatation (RPD; APD>15<or=20 mm) in an unselected population of 2-month-old infants prospectively followed up for 12-14 months of life. Isolated severe renal pelvis dilatation was detected in 46 of the 11,801 (0.39%) infants screened. Nephro-urological investigations were initiated if RPD persisted, or if urinary tract infection (UTI) occurred during follow-up, and antibiotic therapy was administered only when UTI occurred. At follow-up, RPD persisted in 24 infants. Of these, 8 infants presented with vesico-ureteral reflux (VUR) of grade>or=3 and 16 with ureteropelvic junction obstruction (UPJO). Incidence of UTI was significantly higher (p<0.001) in infants of the study group than in infants of the control group (13.9 vs 2.5%). Our data suggest that isolated severe RPD may be a self-limiting condition and that antibiotic prophylaxis (AP) for the prevention of UTI should not be performed. Considering RDP resolution and the incidence of UTI during follow-up, investigations for uropathy in infants with isolated, severe RPD are justified in persistent cases, or when UTI occurs during follow-up. Careful clinical monitoring for signs of UTI and treatment of each episode of UTI may be sufficient and safe.
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Affiliation(s)
- Carmelo Mamì
- Department of Paediatric and Surgery Sciences, University of Messina, 98124, Messina, Italy.
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Urinary tract infections: to prophylaxis or not to prophylaxis? Pediatr Nephrol 2009; 24:1605-9. [PMID: 19444477 DOI: 10.1007/s00467-009-1213-y] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2009] [Revised: 04/15/2009] [Accepted: 04/17/2009] [Indexed: 10/20/2022]
Abstract
Urinary tract infections, with or without reflux, are the most frequent reason for long-term antibacterial prophylaxis in infants and children. When one is considering the use of prophylaxis in these children, what is clear from existing published data? Up to 2006 there were a small number of poor quality studies, with no reliable evidence of the effectiveness of antibiotics in preventing recurrent symptomatic urinary tract infections (UTIs). Since then, four randomised controlled studies, to assess the benefits, or lack thereof, of antibiotic prophylaxis, have been published. None has demonstrated a clear benefit. The following conclusions can be drawn: antibiotic prophylaxis is not indicated for children following a first febrile UTI if no or mild grade I or II reflux is present; for higher grade reflux there is no definite conclusion.
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Lee MD, Lin CC, Huang FY, Tsai TC, Huang CT, Tsai JD. Screening young children with a first febrile urinary tract infection for high-grade vesicoureteral reflux with renal ultrasound scanning and technetium-99m-labeled dimercaptosuccinic acid scanning. J Pediatr 2009; 154:797-802. [PMID: 19230904 DOI: 10.1016/j.jpeds.2008.12.045] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2008] [Revised: 11/04/2008] [Accepted: 12/29/2008] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To evaluate the predictive value of renal ultrasound scanning and 99m-Technetium-dimercaptosuccinic acid (DMSA) scintigraphy for high-grade vesicoureteral reflux (VUR) in young children with a first urinary tract infection (UTI). STUDY DESIGN The medical records of children who had been examined with renal ultrasound scanning, DMSA scanning, and voiding cystourethrography (VCUG) were reviewed. The findings of renal ultrasound scanning, DMSA scanning, and their predictive values were evaluated. RESULTS Of 699 children, high-grade VUR (grades III-V) was diagnosed in 119 (17.0%). Signs of renal hypodysplasia (OR, 16.15), cyclic dilatation of pelvicaliceal system (OR, 11.73), hydroureter (OR, 4.00) with renal ultrasound scanning, and renal hypodysplasia (OR, 8.78), acute pyelonephritis (OR, 2.76) with DMSA scanning were associated with high-grade VUR. The sensitivities for high-grade VUR of ultrasound scanning alone (67.2%) or DMSA scanning alone (65.5%) were not as good as that of a both-test strategy, which had a sensitivity rate of 83.2%. The negative predictive value of the both-test strategy was 91.5%. CONCLUSION Renal ultrasound scanning and DMSA scanning both should be routinely performed in children with a first febrile UTI. VCUG is only indicated when abnormalities are apparent on either ultrasound scanning or DMSA scanning or both.
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Affiliation(s)
- Ming-Dar Lee
- Department of Pediatrics, Mackay Memorial Hospital, Taipei, Taiwan
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Ziessman HA, Majd M. Importance of methodology on (99m)technetium dimercapto-succinic acid scintigraphic image quality: imaging pilot study for RIVUR (Randomized Intervention for Children With Vesicoureteral Reflux) multicenter investigation. J Urol 2009; 182:272-9. [PMID: 19450818 DOI: 10.1016/j.juro.2009.02.144] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2008] [Indexed: 11/25/2022]
Abstract
PURPOSE We reviewed our experience with (99m)technetium dimercapto-succinic acid scintigraphy obtained during an imaging pilot study for a multicenter investigation (Randomized Intervention for Children With Vesicoureteral Reflux) of the effectiveness of daily antimicrobial prophylaxis for preventing recurrent urinary tract infection and renal scarring. We analyzed imaging methodology and its relation to diagnostic image quality. MATERIALS AND METHODS (99m)Technetium dimercapto-succinic acid imaging guidelines were provided to participating sites. High-resolution planar imaging with parallel hole or pinhole collimation was required. Two core reviewers evaluated all submitted images. Analysis included appropriate views, presence or lack of patient motion, adequate magnification, sufficient counts and diagnostic image quality. Inter-reader agreement was evaluated. RESULTS We evaluated 70, (99m)technetium dimercapto-succinic acid studies from 14 institutions. Variability was noted in methodology and image quality. Correlation (r value) between dose administered and patient age was 0.780. For parallel hole collimator imaging good correlation was noted between activity administered and counts (r = 0.800). For pinhole imaging the correlation was poor (r = 0.110). A total of 10 studies (17%) were rejected for quality issues of motion, kidney overlap, inadequate magnification, inadequate counts and poor quality images. The submitting institution was informed and provided with recommendations for improving quality, and resubmission of another study was required. Only 4 studies (6%) were judged differently by the 2 reviewers, and the differences were minor. CONCLUSIONS Methodology and image quality for (99m)technetium dimercapto-succinic acid scintigraphy varied more than expected between institutions. The most common reason for poor image quality was inadequate count acquisition with insufficient attention to the tradeoff between administered dose, length of image acquisition, start time of imaging and resulting image quality. Inter-observer core reader agreement was high. The pilot study ensured good diagnostic quality standardized images for the Randomized Intervention for Children With Vesicoureteral Reflux investigation.
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Affiliation(s)
- Harvey A Ziessman
- Division of Nuclear Medicine, Russell H. Morgan Department of Radiology and Radiological Sciences, The Johns Hopkins University, Baltimore, Maryland 21287, USA.
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Soylu A, Demir BK, Türkmen M, Bekem O, Saygi M, Cakmakçi H, Kavukçu S. Predictors of renal scar in children with urinary infection and vesicoureteral reflux. Pediatr Nephrol 2008; 23:2227-32. [PMID: 18612659 DOI: 10.1007/s00467-008-0907-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2007] [Revised: 04/23/2008] [Accepted: 05/13/2008] [Indexed: 02/05/2023]
Abstract
We evaluated the predictors of renal scar in children with urinary tract infections (UTIs) having primary vesicoureteral reflux (VUR). Data of patients who were examined by dimercaptosuccinic acid (DMSA) scintigraphy between 1995 and 2005 were evaluated retrospectively. Gender, age, reflux grade, presence/development of scarring, breakthrough UTIs, and resolution of reflux, were recorded. The relation of gender, age and VUR grade to preformed scarring and the relation of gender, age, VUR grade, presence of preformed scarring, number of breakthrough UTIs and reflux resolution to new scarring were assessed. There were 138 patients [male/female (M/F) 53/85]. Multivariate analysis showed that male gender [odds ratio (OR) 2.5], age > or = 27 months in girls (OR 4.2) and grades IV-V reflux (OR 12.4) were independent indicators of renal scarring. On the other hand, only the presence of previous renal scarring was found to be an independent indicator for the development of new renal scar (OR 13.4). In conclusion, while the most predictive variables for the presence of renal scarring among children presenting with a UTI were male gender, age > or = 27 months in girls, and grades IV-V reflux, the best predictor of new scar formation was presence of previous renal scarring.
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Affiliation(s)
- Alper Soylu
- Department of Pediatrics, Dokuz Eylül University Medical Faculty, Izmir, Turkey.
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Chesney RW, Carpenter MA, Moxey-Mims M, Nyberg L, Greenfield SP, Hoberman A, Keren R, Matthews R, Matoo TK. Randomized Intervention for Children With Vesicoureteral Reflux (RIVUR): background commentary of RIVUR investigators. Pediatrics 2008; 122 Suppl 5:S233-9. [PMID: 19018047 PMCID: PMC4336951 DOI: 10.1542/peds.2008-1285c] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Because of the frequency of urinary tract infections in children, off-label use of antimicrobial prophylaxis is often the usual treatment of children with vesicoureteral reflux, and such use is increasingly being called into question; hence, a definitive study to determine the value of antimicrobial prophylaxis with regard to the recurrence of urinary tract infection and the incidence of renal scarring is essential. The currently recommended follow-up procedures (repeated urine cultures, renal and genitourinary imaging, antimicrobial therapy and prophylaxis, as well as other factors including cleanliness, adequate bladder and bowel emptying, and compliance with protocols) are expensive (in terms of time, attention to detail, and cost) and cumbersome. Such recommendations should be evidence-based.
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Affiliation(s)
- Russell W. Chesney
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Myra A. Carpenter
- Department of Biostatistics, University of North Carolina, Chapel Hill, North Carolina
| | - Marva Moxey-Mims
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Leroy Nyberg
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | | | - Alejandro Hoberman
- Department of Pediatrics, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Ron Keren
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Ron Matthews
- Department of Urology, Johns Hopkins University, Baltimore, Maryland
| | - Tej K. Matoo
- Department of Pediatrics, Children's Hospital of Michigan, Detroit, Michigan
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The outcome of surgery versus medical management in the treatment of vesicoureteral reflux. Adv Urol 2008:437560. [PMID: 18670634 PMCID: PMC2479883 DOI: 10.1155/2008/437560] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2008] [Accepted: 06/12/2008] [Indexed: 11/18/2022] Open
Abstract
Evaluation of the relative merits of medical versus surgical management of vesicoureteral reflux (VUR) has been limited by the few prospective studies comparing these strategies. Among those trials that have been reported, the only consistent positive finding has been that incidence of febrile UTI is lower among children undergoing surgical treatment in comparison with medical treatment. Studies have not found significant differences in overall incidence of UTI, or in rates of new renal scarring or progression of existing scarring. It is likely that there is a subset of children with VUR who do benefit from aggressive treatment of their VUR, but we are not yet able to fully determine which children these are. It is hoped that future research will further clarify which treatments are useful in which children.
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de Kort EHM, Bambang Oetomo S, Zegers SHJ. The long-term outcome of antenatal hydronephrosis up to 15 millimetres justifies a noninvasive postnatal follow-up. Acta Paediatr 2008; 97:708-13. [PMID: 18410468 DOI: 10.1111/j.1651-2227.2008.00749.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIM To assess the incidence of urinary tract infections (UTIs) and surgery in infants with different grades of antenatal hydronephrosis (ANH) and to evaluate incidence, severity and course of underlying vesicoureteral reflux (VUR). METHODS Retrospective data of 125 infants with ANH were collected. The patients were divided into two groups according to the anterior-posterior pelvis diameter: group I, 5-14 mm and group II, > or =15 mm. RESULTS UTIs developed in 4 of 106 infants from group I and 5 of 19 infants from group II. Surgical interventions were performed on 1 of 106 patients of group I and 7 of 19 patients of group II. These differences were statistically significant (p-values 0.004 and <0.001, respectively). In group I, 6 of 106 patients had VUR; none of them required surgical intervention and only two developed a UTI (one of whom also had contralateral ureteropelvic junction obstruction). Five of 19 infants in group II had underlying VUR, four of them with associated anomalies, 1 infant required surgical correction and 4 developed UTIs. CONCLUSION Infants with ANH up to 15 mm have a low incidence of UTIs and surgery and a low incidence and benign course of underlying VUR. Therefore, noninvasive postnatal follow-up is justified and standard voiding cystourethrography should not be performed, but only in cases of ureteric dilatation.
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Affiliation(s)
- E H M de Kort
- Department of Pediatrics, Máxima Medical Centre, Veldhoven, The Netherlands
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Antibakterielle Prophylaxe beim primären vesikoureteralen Reflux. Monatsschr Kinderheilkd 2008. [DOI: 10.1007/s00112-008-1679-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Gargollo PC, Diamond DA. Therapy Insight: what nephrologists need to know about primary vesicoureteral reflux. ACTA ACUST UNITED AC 2007; 3:551-63. [PMID: 17895932 DOI: 10.1038/ncpneph0610] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2007] [Accepted: 04/20/2007] [Indexed: 12/11/2022]
Abstract
Vesicoureteral reflux (VUR) is the abnormal, retrograde flow of urine from the bladder to the upper urinary tract. This disease affects about 1% of otherwise normal children, 30-50% of those who present with urinary tract infections, and approximately 10% with prenatally diagnosed hydronephrosis. Over the past 50 years, tremendous progress has been made in the diagnosis, treatment and management of VUR. The realization that VUR is probably a component of generalized dysfunction of the lower urinary tract (i.e. dysfunctional elimination syndrome) has further enhanced understanding of the disease. This Review covers basic pathogenesis, diagnosis, management, clinical presentation, and current controversies surrounding VUR.
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Affiliation(s)
- Patricio C Gargollo
- Harvard Medical School, and Children's Hospital Boston, Boston, MA 02115, USA
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Abstract
In addition to conventional open surgery and endoscopic techniques, laparoscopic correction of vesicoureteric reflux, sometimes even robot-assisted, is becoming an alternative surgical treatment modality for this condition in a number of centres around the world. At least for a subgroup of patients laparoscopists are trying to develop new techniques in an effort to combine the best of both worlds: the minimal invasiveness of the STING and the same lasting effectiveness as in open surgery. The efficacy and potential advantages or disadvantages of these techniques are still under investigation. The different laparoscopic techniques and available data are presented.
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Affiliation(s)
- Piet R H Callewaert
- Department of Urology, University Hospital Maastricht, PB 5800, 6202 AZ Maastricht, The Netherlands.
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Soylu A, Kasap B, Demir K, Türkmen M, Kavukçu S. Predictive value of clinical and laboratory variables for vesicoureteral reflux in children. Pediatr Nephrol 2007; 22:844-8. [PMID: 17273861 DOI: 10.1007/s00467-006-0418-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2006] [Revised: 12/09/2006] [Accepted: 12/12/2006] [Indexed: 02/08/2023]
Abstract
We aimed to determine the predictability of clinical and laboratory variables for vesicoureteral reflux (VUR) in children with urinary tract infection (UTI). Data of children with febrile UTI who underwent voiding cystoureterography between 2002 and 2005 were evaluated retrospectively for clinical (age, gender, fever > or = 38.5 degrees C, recurrent UTI), laboratory [leukocytosis, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), pyuria, serum creatinine (S(Cr))] and imaging (renal ultrasonography) variables. Children with VUR (group 1) vs. no VUR (group 2) and children with high-grade (III-V) VUR (group 3) vs. no or low-grade (I-II) VUR (group 4) were compared. Among 88 patients (24 male), 38 had VUR and 21 high-grade VUR. Fever > or = 38.5 degrees C was associated with VUR [odds ratio (OR): 7.5]. CRP level of 50 mg/l was the best cut-off level for predicting high-grade VUR (OR 15.5; discriminative ability 0.89 +/- 0.05). Performing voiding cystourethrography based on this CRP level would result in failure to notice 9% of patients with high-grade VUR, whereas 69% of children with no/low-grade VUR would be spared from this invasive test. In conclusion, fever > or = 38 degrees C and CRP > 50 mg/l seem to be potentially useful clinical predictors of VUR and high-grade VUR, respectively, in pediatric patients with UTI. Further validation of these findings could limit unnecessary voiding cystourethrography.
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Affiliation(s)
- Alper Soylu
- Department of Pediatrics, Division of Nephrology, Dokuz Eylul University, Medical Faculty, Balcova, 35340, Izmir, Turkey.
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Falakaflak B, Fallah R, Jamshidi MR, Moezi F, Torabi Z. Comparison of Nitrofurantoin and Trimethoprim-Sulphamethoxazole for Long-Term Prophylaxis in Children with Recurrent Urinary Tract Infections. INT J PHARMACOL 2007. [DOI: 10.3923/ijp.2007.179.182] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Ismaili K, Avni FE, Piepsz A, Collier F, Schulman C, Hall M. Vesicoureteric Reflux in Children. ACTA ACUST UNITED AC 2006. [DOI: 10.1016/j.eeus.2006.05.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Bensman A, Ulinski T. International Vesicoureteral Reflux Study: unsolved questions remaining. Pediatr Nephrol 2006; 21:757-8. [PMID: 16703370 DOI: 10.1007/s00467-006-0105-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2006] [Accepted: 01/20/2006] [Indexed: 11/30/2022]
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