Timing of voiding cystourethrography in infants with first time urinary infection

Timing of voiding cystourethrography after febrile urinary tract infection in children: a systematic review

BACKGROUND

Despite a trend towards early voiding cystourethrography (VCUG) after febrile urinary tract infection (fUTI) in children, clinical guidelines do not comment on the optimal timing and current practice varies considerably.

OBJECTIVE

To assess whether the detection rate of vesicoureteric reflux (VUR) in children depends on the time period of VCUG procedure after onset of antibiotic therapy.

METHODS

MEDLINE, EMBASE and Cochrane Controlled Trials Register electronic databases were searched for eligible studies without language or time restriction (19 November 2018). Inclusion criteria were (1) patients <18 years of age; (2) VCUG performed in patients with fUTI after onset of antibiotic therapy either in the same patient population or in two or more different patient populations within one study at different time periods; and (3) with reported detection rate of VUR. The systematic review was carried out following the recommendations of the Cochrane Collaboration and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

RESULTS

Of 4175 records, nine studies were included (number of patients, n=1745) for the main outcome prevalence of VUR by VCUG <8 days compared with VCUG ≥8 days after onset of antibiotic therapy. Pooled overall prevalence of VUR was not significantly different between the early and the late VCUG groups (risk ratio 0.98, 95% CI 0.81 to 1.19). Prevalence of VUR stratified by grade was not significantly different between the two groups.

CONCLUSION

Early VCUG within 8 days after onset of antibiotic therapy does not affect the prevalence of VUR.

TRIAL REGISTRATION NUMBER

CRD42018117545.

Influence of Plasminogen Activator Inhibitor -1 Gene Polymorphism on Renal Scarring After First Febrile Urinary Tract Infection in Infants

Background

The pathogenesis of renal scarring (RS) after first febrile urinary tract infection (UTI) in children is multifactorial. In addition to well-known risk factors, a role for genetic predisposition has been suggested.

Aims

To determine whether deoxyribonucleic acid (DNA) polymorphisms at the plasminogen activator inhibitor -1 (PAI-1) gene were associated with evolution to RS following a febrile UTI in infants.

Materials and Methods

Our research included 100 infants, 84 girls and 16 boys, ages up to 1 year with a first febrile UTI, increased inflammatory parameters and positive urine culture treated at the Pediatric Clinic II of the University Clinical Center Sarajevo (UCCS). The diagnostic was based on the imaging studies: ultrasonography, voiding cystourethrography (VCUG) and initial and control static renal scintigraphy (DMSA renal scan), to assess the renal parenchymal damage (RPD). The polymorphisms of the PAI-1 were determined based on polymerase chain reaction technique. The distribution of PAI-1 genotypes and the allele frequencies were compared between different groups of patients with febrile UTI.

Results

Results presented that 66 infants had acute pyelonephritis (APN) and 22 had vesicoureteral reflux (VUR). On initial DMSA renal scan examination, we detected no RPD in any patient. After 6 months, the repeat DMSA renal scan revealed the presence of RPD in 18 (27%) out of 66 infants with APN. Distribution of PAI-1 genotypes was not different between various groups of patients with febrile UTI.

Conclusions

The results of our study have not shown that individual genetic variation in PAI-1 is an independent variable that predispose same of children for RS after first febrile UTI. Maybe that yet unknown gene polymorphisms together with geographical and /or socio-economic differences can influence on the development of RS.

[Imaging in urinary tract infections in childhood]

Diagnostic strategies for extended morphological and functional clarification after symptomatic urinary tract infections in children are changing. Improved knowledge of the causes for development of renal scarring and a changing view on the importance of vesicoureteral reflux have led to a change in paradigm in recent years. The purpose of this article is to present the ongoing discussions of the causes and outcome of childhood urinary tract infections, competing diagnostic imaging methods and different diagnostic algorithms.

Comparing between results and complications of doing voiding cystourethrogram in the first week following urinary tract infection and in 2-6 weeks after urinary tract infection in children referring to a teaching hospital

Introduction: Urinary tract infection is the most common genitourinary disease in children so about 40% of the children with urinary tract infection suffering from reflux that caused some consequences such as pyelonephritis and kidney parenchymal injury.

Objectives: This research was conducted to compare the timing of voiding cystourethrogram (VCUG) in children with urinary tract infection in first week and after the first week of urinary tract infection.

Patients and Methods: This research is a case-control study that both case and control groups include 208 children from 1 month to 12 years old with the complain of urinary tract infection. In case group, the VCUG was performed at the first week of infection and in control group, the VCUG was performed after the first week of infection.

Results: complication such as dysuria was observed in two-thirds of children who VCUG was performed during first week after urinary tract infection. Parents stress in case group was more than the other (P=0.015). For overall, the incidence of reflux in case and control groups was 49.5% and 50%, respectively. The mean of reflux grading in right kidney in case group was lower than control group resulting in significant differences between two groups.

Conclusion: According to higher grade of stress in parents and complications due to VCUG at the first week of urinary tract infection, it is suggested that VCUG be conducted on selective patients in the hospital at the first week of urinary tract infection and during hospitalization.

Approach to Pediatric Patients with UTI in the PICU

Urosepsis and UTI are common causes and comorbidities in children admitted to the pediatric intensive care unit (PICU). Risk factors for morbidity and mortality in pediatric patients include young age (< 2 years old), presence of congenital renal anomalies of the urinary tract, and immunosuppression from transplant (kidney, liver, heart, and bone marrow). Workup of urosepsis focuses on identification of renal anomalies of the urinary tract through ultrasound, X-ray cystourethrogram, urodynamic studies, and CT/MRI. Management consists of appropriate choice in antibiotics, hemodynamic instability, and prevention of acute kidney injury (AKI) with particular recognition that chronic renal failure can be present in all chronically ill children, which is not limited to pediatric patients with congenital anomalies of the kidney urinary tract. This review includes a review of the workup and management of pediatric patients with UTI and urosepsis in both healthy patients and patients with known anomalies of the urinary tract.

Urinary tract infections in children: EAU/ESPU guidelines

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.

2D/3D/4D contrast-enhanced voiding urosonography in the diagnosis and monitoring of treatment of vesicoureteral reflux in children - can it replace voiding cystourethrography?

Introduction

Vesicoureteral reflux appears in 20–50% of pediatric patients with recurrent urinary tract infections. The most common method of diagnosing this disease is voiding cystourethrography. However, contemporary pediatric radiology does not favor this method due to exposure to X-radiation.

Aim

The aim of this study was to assess the usefulness of 2D/3D/4D contrast-enhanced voiding urosonography in the diagnosis and treatment monitoring of vesicoureteral reflux in children and the possibility of using contrast-enhanced voiding urosonography to replace voiding cystourethrography.

Material and methods

Voiding cystourethrography and contrast-enhanced voiding urosonography were conducted in 80 pediatric patients in order to assess sensitivity, specificity, positive and negative predictive values as well as the number of vesicoureteral refluxes detected by each of the two methods. The second stage of the study involved performing voiding urosonography in an extended protocol in 58 children in order to determine the usefulness of three-dimensional (3D/4D) examinations in the assessment of vesicoureteral reflux and the ability to assess the urethra.

Results

The concordance between the two methods was 86.95%. The sensitivity of voiding urosonography was 84.51%, specificity – 90.99%, positive predictive value – 85.71% and negative predictive value – 90.17%. A 3D/4D assessment of the urinary bladder and transperineal 2D morphological assessment of the urethra were possible in all patients (100%). Assessment of the urethra during micturition with the use of 2D/3D/4D techniques was possible in all patients in whom voiding was elicited (95.83%), and 3D/4D assessment of vesicoureteral reflux was possible in all patients with reflux (100%). Although the application of 3D/4D techniques allowed accurate specification of the grade of reflux in all cases (100%), it appeared particularly useful in differentiating between grades II and III (70.97%).

Conclusions

Contrast-enhanced voiding urosonography allows the diagnosis and monitoring of treatment of vesicoureteral reflux in pediatric patients as well as assessment of the urethra in both girls and boys. The method is characterized by high sensitivity and specificity. Moreover, it is safe, relatively inexpensive and can replace voiding cystourethrography.

[Diagnostics and therapy of urinary tract infections]

In infants and young children, urinary tract infections (UTI) often present with unspecific symptoms. Appropriate techniques of urine sampling play an important role for accurate microbiological diagnosis. In infants urine sampling by bladder puncture or transurethral catheter is recommended. In young infants with suspected pyelonephritis, calculated antibiotic treatment should be initiated parenterally with a combination of a third generation cephalosporin or an aminoglycoside with ampicillin. After the age of 3-6 months group 3 oral cephalosporins can be used in uncomplicated pyelonephritis. With the first febrile UTI early sonography is recommended to provide information about renal parenchymal involvement and to exclude malformations of the kidneys and urinary tract. Strategies for the recognition of vesicoureteral reflux and renal damage are under discussion. Recently published guidelines by the American Academy of Pediatrics for the diagnosis and management of UTI in febrile children and infants aged 2-24 months will most likely influence the still pending German guidelines.

Febrile urinary tract infections in young children: recommendations for the diagnosis, treatment and follow-up

We report the recommendations for the diagnosis, treatment, imaging evaluation and use of antibiotic prophylaxis in children with the first febrile urinary tract infection, aged 2 months to 3 years. They were prepared by a working group of the Italian Society of Pediatric Nephrology after careful review of the available literature and a consensus decision, when clear evidence was not available.

CONCLUSION

These recommendations are endorsed by the Italian Society of Pediatric Nephrology. They can also be a tool of comparison with other existing guidelines in issues in which much controversy still exists.

Evaluation and management of urinary tract infections in the neonate

PURPOSE OF REVIEW

The prevalence of urinary tract infections (UTIs) among full-term neonates has been reported to be up to 1.1%, increasing up to 7% among those with fever. UTI in neonates may be the first indicator of underlying abnormalities of kidneys and the urinary tract.

RECENT FINDINGS

Early recognition and therapy of UTI and detection of risk factors offer chances for applying strategies to avoid renal damage and recurrences. However, established diagnostic strategies and prophylactic concepts today are under debate. Currently, the main focus has been on renal changes as indicators for underlying risk factors like vesicoureteral reflux, attaching much importance to dimercaptosuccinyl acid scans. Serum and urine markers will probably allow more restrictive diagnostic imaging. Prenatal and postnatal ultrasound screenings provide additional opportunities for prophylactic measures.

SUMMARY

Main objectives in the management of neonatal UTIs are the prevention of acute infection-related complications and renal damage. Neonates and very young infants with suspicious pyelonephritis should obligatorily be treated with a combination of parenterally administered antibiotics. As far as possible, diagnostic imaging should be risk-oriented and restricted to noninvasive, nonstressful procedures. The strategies of antibacterial prophylaxis for the prevention of recurrent UTIs are changing. In infants at risk, its benefits have not yet been proven by evident data.

Infantile urinary tract infection and timing of micturating cystourethrogram

OBJECTIVE

The investigation of infantile febrile urinary tract infection (UTI) is still a subject of debate and controversy. To evaluate for vesicoureteric reflux (VUR) most authorities recommend a micturating cystourethrogram (MCUG) to be performed at least 4 weeks after UTI to avoid false positive.

PATIENTS AND METHODS

At a tertiary centre for paediatric specialities, information on 427 infants who had undergone MCUG following a first febrile UTI was prospectively recorded and their case notes reviewed. The infants were divided into two groups: Group A (117) with MCUG performed less than 4 weeks from UTI diagnosis and Group B (310) with MCUG after at least 8 weeks from diagnosis.

RESULTS

Of the 427 children, VUR was detected in 33% of those for whom MCUG was performed less than 4 weeks after UTI diagnosis and in 24% of those for whom it was performed at least 8 weeks after diagnosis.

CONCLUSION

Neither the prevalence nor the grade of VUR in infants with a first episode of UTI is influenced by the timing of the MCUG following diagnosis. We therefore suggest that it is better to perform an MCUG as soon as possible, provided inflammation has subsided.