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Lindén M, Rosenblad T, Rosenborg K, Hansson S, Brandström P. Infant urinary tract infection in Sweden - A national study of current diagnostic procedures, imaging and treatment. Pediatr Nephrol 2024; 39:3251-3262. [PMID: 39008116 DOI: 10.1007/s00467-024-06415-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Revised: 04/29/2024] [Accepted: 05/15/2024] [Indexed: 07/16/2024]
Abstract
BACKGROUND Urinary tract infection (UTI) in infants is a common, potentially life-threatening bacterial infection, and must be managed carefully through the entire chain of care from diagnosis, choice of treatment, follow-up and risk stratification of future complications. This Swedish nationwide study of infant UTI was conducted to evaluate the current management of infant UTI, yield of investigations and the Swedish UTI guidelines' ability to detect abnormalities of importance in the urinary tract. METHODS Infants < 1 year with a first episode of UTI were included in a prospective multicenter study. Treatment and follow-up were provided by local pediatricians. Clinical and laboratory findings and imaging results were reported to the coordinating center. The current management and results were compared with a previous Swedish study. RESULTS One thousand three hundred six infants were included. Urine sampling was performed with clean catch technique in 93% of patients. Initial oral antibiotic treatment was used in 63%, predominantly third generation cephalosporines. Permanent kidney abnormalities were found in 10% and dilating vesicoureteral reflux (VUR) in 8%. Higher rates of male gender, non-E. coli infection and ultrasound dilatation were seen in infants < 1 month. UTI recurrences were reported in 18%. CONCLUSIONS Infant UTI is still generating a considerable amount of follow-up examinations. There is a significant shift towards clean catch as the main urine sampling method. Voiding cystourethrography is performed less frequently reducing the findings of low grade VUR. The incidence of renal scarring is comparable with earlier studies which suggests that the Swedish guidelines are able to identify individuals with risk for long-term complications.
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Affiliation(s)
- Magnus Lindén
- Department of Pediatrics, Halland Hospital, Halmstad, Sweden.
- Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Therese Rosenblad
- Department of Pediatrics, Lund Children's Hospital, Lund, Sweden
- Division of Microbiology, Immunology and Glycobiology, Institute of Laboratory Medicine, Lund University, Lund, Sweden
| | - Karin Rosenborg
- Sachs' Children and Youth Hospital, Södersjukhuset, Stockholm, Sweden
| | - Sverker Hansson
- Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Pediatric Uro-Nephrology Center, The Queen Silvia Children's Hospital, Gothenburg, Sweden
| | - Per Brandström
- Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Pediatric Uro-Nephrology Center, The Queen Silvia Children's Hospital, Gothenburg, Sweden
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Leahy C, Hanson KA, Desai J, Alvarez A, Rainey SC. Predictors of Abnormal Renal Ultrasonography in Children With Urinary Tract Infection. Hosp Pediatr 2024; 14:836-842. [PMID: 39238473 DOI: 10.1542/hpeds.2023-007557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 05/16/2024] [Accepted: 05/21/2024] [Indexed: 09/07/2024]
Abstract
BACKGROUND AND OBJECTIVES The 2011 American Academy of Pediatrics guidelines recommended a renal and bladder ultrasound (RBUS) after the first febrile urinary tract infection (UTI) in infants. Abnormal RBUS findings may be due to inflammation from the acute UTI or from vesicoureteral reflux (VUR), which may require a voiding cystourethrogram (VCUG) to diagnose, increasing health care costs. Our objective was to evaluate the effect of timing of imaging relative to the acute illness on abnormal dilation on RBUS and VCUG findings. METHODS Multicenter, retrospective study of patients aged 2 to 24 months presenting with first UTI and RBUS from January 1, 2015, to December 31, 2019. Demographics, isolated pathogen, and timing of RBUS and VCUG relative to urine culture date were recorded and compared. RESULTS A total of 227 patients were included. On multivariable logistic regression, increased time in days to RBUS was associated with decreased odds of abnormal dilation (adjusted odds ratio, 0.980; P = .018) in those patients meeting culture criteria for UTI (for each additional day of delay in obtaining RBUS, the adjusted odds of detecting dilation decreased by ∼2%). There was no significant association between timing of imaging and VUR on VCUG. Additionally, 32% of patients underwent RBUS who did not meet UTI culture criteria but had similar rates of abnormal dilation and VUR to those meeting UTI culture criteria. CONCLUSIONS Increased time to RBUS led to decreased odds of abnormal dilation, suggesting that delaying RBUS may lead to fewer false-positive results, which may limit unnecessary additional testing and reduce health care costs. Additionally, a significant number of patients who did not meet UTI culture criteria underwent RBUS but had similar results to those meeting criteria, suggesting that the previous colony-forming unit definition for UTI may be suboptimal.
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Affiliation(s)
- Catharine Leahy
- University of Illinois College of Medicine at Peoria, Peoria, Illinois
| | - Keith A Hanson
- Department of Pediatrics, University of Illinois College of Medicine at Peoria and OSF Healthcare Children's Hospital of Illinois, Peoria llinois
| | - Janki Desai
- Department of Medicine, University of Southern California, Los Angeles, California
| | | | - Shane C Rainey
- Department of Child Health, University of Arizona College of Medicine - Phoenix and Banner Children's at Desert Medical Center, Mesa, Arizona
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Conen P, Thiemann J, Stredele R, Clevert DA. Value of contrast-enhanced sonography in the diagnosis of vesicoureteral reflux. ROFO-FORTSCHR RONTG 2024; 196:1022-1028. [PMID: 38408474 DOI: 10.1055/a-2254-5490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
BACKGROUND Contrast-enhanced ultrasound of the urinary tract and bladder (ceVUS) is an alternative examination method to micturition cysturethrography (MCU/VCUG) for suspected vesicoureteral reflux (VUR) that is increasing in practice. The purpose of this review is to present the current value of ceVUS in the diagnosis. METHOD A systematic literature search was performed using the keywords "vesicoureteral reflux", "ceVUS", "VCUG" of the databases MEDLINE and Cochrane Library as well as a review of current German, European, and American guidelines on this topic. In addition, recommendations for action in clinical practice were developed. CONCLUSION ceVUS is a quick-to-learn examination method that is equivalent to VCUG for the diagnosis of vesicoureteral reflux and should be used as the diagnostic method of first choice when available given the absence of radiation exposure. KEY POINTS · Like VCUG, ceVUS is the diagnostic method of first choice in suspected vesicoureteral reflux and should be used preferentially given the absence of radiation exposure.. · Especially in comparison to the alternative VCUG, ceVUS is a quick-to-learn examination method.. · ceVUS can also be used to diagnose other pathologies of the lower urinary tract.. CITATION FORMAT · Conen P, Thiemann J, Stredele R et al. Value of contrast-enhanced sonography in the diagnosis of vesicoureteral reflux. Fortschr Röntgenstr 2024; 196: 1022 - 1028.
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Affiliation(s)
- Patrick Conen
- Department of Radiology, Ludwig Maximilians University Munich, München, Germany
- Interdisciplinary Ultrasound-Center, Ludwig Maximilians University Munich, München, Germany
| | - Janine Thiemann
- Department of Radiology, Ludwig Maximilians University Munich, München, Germany
- Interdisciplinary Ultrasound-Center, Ludwig Maximilians University Munich, München, Germany
| | - Regina Stredele
- Department of Urology, Ludwig Maximilians University Munich, München, Germany
| | - Dirk Andre Clevert
- Department of Radiology, Ludwig Maximilians University Munich, München, Germany
- Interdisciplinary Ultrasound-Center, Ludwig Maximilians University Munich, München, Germany
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Rosenblad T, Lindén M, Ambite I, Brandström P, Hansson S, Godaly G. Genetic determinants of renal scarring in children with febrile UTI. Pediatr Nephrol 2024; 39:2703-2715. [PMID: 38767678 PMCID: PMC11272715 DOI: 10.1007/s00467-024-06394-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Revised: 04/23/2024] [Accepted: 04/24/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND Febrile urinary tract infections (UTIs) are among the most severe bacterial infections in infants, in which a subset of patients develops complications. Identifying infants at risk of recurrent infections or kidney damage based on clinical signs is challenging. Previous observations suggest that genetic factors influence UTI outcomes and could serve as predictors of disease severity. In this study, we conducted a nationwide survey of infant genotypes to develop a strategy for infection management based on individual genetic risk. Our aims were to identify genetic susceptibility variants for renal scarring (RS) and genetic host factors predisposing to dilating vesicoureteral reflux (VUR) and recurrent UTIs. METHODS To assess genetic susceptibility, we collected and analyzed DNA from blood using exome genotyping. Disease-associated genetic variants were identified through bioinformatics analysis, including allelic frequency tests and odds ratio calculations. Kidney involvement was defined using dimercaptosuccinic acid (DMSA) scintigraphy. RESULTS In this investigation, a cohort comprising 1087 infants presenting with their first episode of febrile UTI was included. Among this cohort, a subset of 137 infants who underwent DMSA scanning was subjected to gene association analysis. Remarkable genetic distinctions were observed between patients with RS and those exhibiting resolved kidney involvement. Notably, the genetic signature indicative of renal scarring prominently featured mitochondrial genes. CONCLUSIONS In this nationwide study of genetic susceptibility to RS after febrile UTIs in infancy, we identified a profile dominated by mitochondrial polymorphisms. This profile can serve as a predictor of future complications, including RS and recurrent UTIs.
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Affiliation(s)
- Therese Rosenblad
- Section for Pediatric Nephrology, Skåne University Hospital, Lund, Sweden
| | - Magnus Lindén
- Department of Pediatrics, Halland Hospital, Halmstad, Sweden
| | - Ines Ambite
- Department of Laboratory Medicine, Lund University, Lund, Sweden
| | - Per Brandström
- Pediatric Uro-Nephrology Centre, Queen Silvia's Children's Hospital, Gothenburg, Sweden
| | - Sverker Hansson
- Pediatric Uro-Nephrology Centre, Queen Silvia's Children's Hospital, Gothenburg, Sweden
- Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Gabriela Godaly
- Department of Laboratory Medicine, Lund University, Lund, Sweden.
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Yang Z, Dai K, Sun X, Tian C, Yuan L, Liu J, Li B, Chung PHY, Wong KKY. Comparison and clinical analysis of antibiotics and endoscopic injection for vesicoureteral reflux in children. Pediatr Surg Int 2024; 40:184. [PMID: 38995440 PMCID: PMC11245421 DOI: 10.1007/s00383-024-05780-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/06/2024] [Indexed: 07/13/2024]
Abstract
PURPOSE This study evaluated the outcome of pediatric patients with primary vesicoureteral reflux (VUR) and compared of the treatments between continued antibiotic prophylaxis (CAP) and endoscopic injection. METHODS The clinical data of children diagnosed with primary vesicoureteral reflux from March 2015 to June 2020 who were treated with antibiotics or endoscopic injection were reviewed. Antibiotic was the first-chosen treatment after the diagnosis of VUR in children. Endoscopic treatment consisted of injection of dextran hyaluronic acid copolymer (DX/HA) into the ureteral opening under direct cystoscopy guidance. RESULTS Fifty-two children (35 males, 17 females) were included in this study, and for a total 90 ureters (14 unilateral, 38 bilateral) were diagnosed with vesicoureteral reflux by Voiding cystourethrography (VCUG). Twenty-two children were treated with antibiotics (8 unilateral, 14 bilateral), for a total of 36 ureters; thirty children were treated by endoscopic injection (6 unilateral, 24 bilateral), for a total of 54 ureters. The injection surgery took 36 ± 17 min including duration of general anesthesia and circumcision and the hospital stay was 2.3 ± 1.3 days. All male patients underwent circumcision simultaneously. There were no drug and allergic reactions in the antibiotic group, and no postoperative complications occurred in the injection group. With 23 months (13-63 months) of mean follow-up, the resolution rate, defined as radiological disappearance of VUR, was 36.1% (13/36) in the antibiotic group and 57.4% (31/54) in the injection group (P = 0.048).Two cases of bilateral reflux in the injection group required a second injection before resolution could be achieved. Thus, the overall success rate of injection was 64.8% (35/54). 9 cases (9/18, 50%) in the antibiotic group had renal scars on DMSA scans, while this was seen in 20 cases (20/23, 86.9%) in the injection group. There was a statistically significant difference between the two groups (P = 0.010).The positive rates of ultrasound between the antibiotic group and the injection group were 45.5% (10/22) and 80.0% (24/30), respectively. There was a statistically significant difference between the two groups in positive rates of ultrasound (P = 0.010). CONCLUSIONS Endoscopic injection is easy to operate with short surgical time and hospital stay, so it is a safe and feasible treatment. For the treatment of primary vesicoureteral reflux in children, the radiological resolution rate of endoscopic injection is better than antibiotic therapy. In this study, the presence of kidney scars on DMSA and the dilated of the collecting system on ultrasound are the indications for endoscopic injection.
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Affiliation(s)
- Zhen Yang
- Division of Pediatric Surgery, Department of Surgery, The University of Hong Kong Shenzhen Hospital, Shen Zhen, China
| | - Kanglin Dai
- Division of Pediatric Surgery, Department of Surgery, The University of Hong Kong Shenzhen Hospital, Shen Zhen, China
| | - Xianglun Sun
- Division of Pediatric Surgery, Department of Surgery, The University of Hong Kong Shenzhen Hospital, Shen Zhen, China
| | - Chen Tian
- Division of Pediatric Surgery, Department of Surgery, The University of Hong Kong Shenzhen Hospital, Shen Zhen, China
| | - Lihua Yuan
- Division of Pediatric Surgery, Department of Surgery, The University of Hong Kong Shenzhen Hospital, Shen Zhen, China
| | - Jingsi Liu
- Division of Pediatric Surgery, Department of Surgery, The University of Hong Kong Shenzhen Hospital, Shen Zhen, China
| | - Ban Li
- Division of Pediatric Surgery, Department of Surgery, The University of Hong Kong Shenzhen Hospital, Shen Zhen, China
| | - Patrick Ho Yu Chung
- Division of Pediatric Surgery, Department of Surgery, The University of Hong Kong Shenzhen Hospital, Shen Zhen, China
- Division of Pediatric Surgery, Department of Surgery, The University of Hong Kong, Queen Mary Hospital, Pokfulam Road, Hong Kong SAR, China
| | - Kenneth Kak Yuen Wong
- Division of Pediatric Surgery, Department of Surgery, The University of Hong Kong Shenzhen Hospital, Shen Zhen, China.
- Division of Pediatric Surgery, Department of Surgery, The University of Hong Kong, Queen Mary Hospital, Pokfulam Road, Hong Kong SAR, China.
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Nhungo CJ, Mwakalukwa KR, Wambura EP, Kibona HG, Mushi FA, Msangi NS, Maro IM, Kimu NM, Nyongole OV, Mkony CA. Surgical management of high-grade vesicoureteral reflux in an 18-month-old female with a solitary kidney: A case report from a resource-limited setting. Clin Case Rep 2024; 12:e9132. [PMID: 38966288 PMCID: PMC11222966 DOI: 10.1002/ccr3.9132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Revised: 05/23/2024] [Accepted: 06/13/2024] [Indexed: 07/06/2024] Open
Abstract
Key Clinical Message Conservative nonsurgical therapy ensures that the resolution is nearly 80% for vesicoureteral reflux grades I and II and 30%-50% for vesicoureteral reflux grades III and V within 4-5 years of follow-up. Open surgical reimplantation of ureters of grades IV and V is a highly successful procedure, with reported correction rates ranging from 95% to 99% regardless of the severity of vesicoureteral reflux. Abstract Patients with vesicoureteral reflux present with a wide range of severity. With an incidence of approximately 1%, vesicoureteral reflux is a relatively common urological abnormality in children. Postnatal diagnosis of vesicoureteral reflux is typically made following a diagnosis of a urinary tract infection and less frequently following family screening. Voiding cystourethrograms remain the gold standard for diagnosing vesicoureteral reflux. To preserve the kidney and prevent the need for potential renal replacement therapy, infants with a single kidney require significantly more assessments and prompt decision-making. Surgical correction is advised for patients with vesicoureteral reflux grades IV and V, while vesicoureteral reflux grades I, II, and III are managed conservatively.
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Affiliation(s)
- Charles John Nhungo
- Department of Surgery, School of MedicineMuhimbili University of Health and Allied SciencesDar es SalaamTanzania
| | - Kelvin Richard Mwakalukwa
- Department of Surgery, School of MedicineMuhimbili University of Health and Allied SciencesDar es SalaamTanzania
| | - Erasto Phares Wambura
- Department of Surgery, School of MedicineMuhimbili University of Health and Allied SciencesDar es SalaamTanzania
| | | | - Fransia Arda Mushi
- Department of Surgery, School of MedicineMuhimbili University of Health and Allied SciencesDar es SalaamTanzania
| | | | | | - Njiku Marko Kimu
- Department of UrologyMuhimbili National HospitalDar es salaamTanzania
| | - Obadia Venance Nyongole
- Department of Surgery, School of MedicineMuhimbili University of Health and Allied SciencesDar es SalaamTanzania
| | - Charles A. Mkony
- Department of Surgery, School of MedicineMuhimbili University of Health and Allied SciencesDar es SalaamTanzania
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Hughes K, Cannings-John R, Jones H, Lugg-Widger F, Lau TMM, Paranjothy S, Francis N, Hay AD, Butler CC, Angel L, Van der Voort J, Hood K. Long-term consequences of urinary tract infection in childhood: an electronic population-based cohort study in Welsh primary and secondary care. Br J Gen Pract 2024; 74:e371-e378. [PMID: 38806210 PMCID: PMC11147460 DOI: 10.3399/bjgp.2023.0174] [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: 05/04/2023] [Accepted: 08/10/2023] [Indexed: 05/30/2024] Open
Abstract
BACKGROUND Childhood urinary tract infection (UTI) can cause renal scarring, and possibly hypertension, chronic kidney disease (CKD), and end-stage renal failure (ESRF). Previous studies have focused on selected populations, with severe illness or underlying risk factors. The risk for most children with UTI is unclear. AIM To examine the association between childhood UTI and outcomes in an unselected population of children. DESIGN AND SETTING A retrospective population-based cohort study using linked GP, hospital, and microbiology records in Wales, UK. METHOD Participants were all children born in 2005-2009, with follow-up until 31 December 2017. The exposure was microbiologically confirmed UTI before the age of 5 years. The key outcome measures were renal scarring, hypertension, CKD, and ESRF. RESULTS In total, 159 201 children were included; 77 524 (48.7%) were female and 7% (n = 11 099) had UTI before the age of 5 years. A total of 0.16% (n = 245) were diagnosed with renal scarring by the age of 7 years. Odds of renal scarring were higher in children by age 7 years with UTI (1.24%; adjusted odds ratio 4.60 [95% confidence interval [CI] = 3.33 to 6.35]). Mean follow-up was 9.53 years. Adjusted hazard ratios were: 1.44 (95% CI = 0.84 to 2.46) for hypertension; 1.67 (95% CI = 0.85 to 3.31) for CKD; and 1.16 (95% CI = 0.56 to 2.37) for ESRF. CONCLUSION The prevalence of renal scarring in an unselected population of children with UTI is low. Without underlying risk factors, UTI is not associated with CKD, hypertension, or ESRF by the age of 10 years. Further research with systematic scanning of children's kidneys, including those with less severe UTI and without UTI, is needed to increase the certainty of these results, as most children are not scanned. Longer follow-up is needed to establish if UTI, without additional risk factors, is associated with hypertension, CKD, or ESRF later in life.
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Affiliation(s)
- Kathryn Hughes
- PRIME Centre Wales, School of Medicine, Cardiff University, Cardiff
| | | | - Hywel Jones
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff
| | - Fiona Lugg-Widger
- Centre of Research Trials, School of Medicine, Cardiff University, Cardiff
| | - Tin Man Mandy Lau
- Centre of Research Trials, School of Medicine, Cardiff University, Cardiff
| | | | - Nick Francis
- Primary Care Research Centre, University of Southampton; Aldermoor Health Centre, Southampton
| | - Alastair D Hay
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol
| | - Christopher C Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford
| | - Lianna Angel
- DECIPHer, School of Social Sciences, Cardiff University, Cardiff
| | | | - Kerenza Hood
- Centre for Trials Research, College of Biomedical and Life Sciences, Cardiff University, Cardiff
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Chandra T, Bajaj M, Iyer RS, Chan SS, Bardo DME, Chen J, Cooper ML, Kaplan SL, Levin TL, Moore MM, Peters CA, Saidinejad M, Schooler GR, Shet NS, Squires JH, Trout AT, Pruthi S. ACR Appropriateness Criteria® Urinary Tract Infection-Child: 2023 Update. J Am Coll Radiol 2024; 21:S326-S342. [PMID: 38823954 DOI: 10.1016/j.jacr.2024.02.025] [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: 02/20/2024] [Accepted: 02/28/2024] [Indexed: 06/03/2024]
Abstract
Urinary tract infection (UTI) is a frequent infection in childhood. The diagnosis is usually made by history and physical examination and confirmed by urine analysis. Cystitis is infection or inflammation confined to the bladder, whereas pyelonephritis is infection or inflammation of kidneys. Pyelonephritis can cause renal scarring, which is the most severe long-term sequela of UTI and can lead to accelerated nephrosclerosis, leading to hypertension and chronic renal failure. The role of imaging is to guide treatment by identifying patients who are at high risk to develop recurrent UTIs or renal scarring. This document provides initial imaging guidelines for children presenting with first febrile UTI with appropriate response to medical management, atypical or recurrent febrile UTI, and follow-up imaging for children with established vesicoureteral reflux. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Affiliation(s)
| | - Manish Bajaj
- Research Author, Children's Healthcare of Atlanta and Emory University, Atlanta, Georgia
| | - Ramesh S Iyer
- Panel Chair, Seattle Children's Hospital, Seattle, Washington
| | - Sherwin S Chan
- Panel Vice Chair, Children's Mercy Hospital, Kansas City, Missouri
| | - Dianna M E Bardo
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Jimmy Chen
- University of Florida College of Medicine Jacksonville, Jacksonville, Florida; American Academy of Pediatrics
| | | | - Summer L Kaplan
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Committee on Emergency Radiology-GSER
| | - Terry L Levin
- The Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York
| | | | - Craig A Peters
- University of Texas Southwestern Medical Center, Dallas, Texas; Society for Pediatric Urology
| | - Mohsen Saidinejad
- UCLA Medical Center, Los Angeles, California; American College of Emergency Physicians
| | - Gary R Schooler
- University of Texas Southwestern Medical Center, Dallas, Texas
| | - Narendra S Shet
- Children's National Hospital, Washington, District of Columbia
| | - Judy H Squires
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Andrew T Trout
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Commission on Nuclear Medicine and Molecular Imaging
| | - Sumit Pruthi
- Specialty Chair, Vanderbilt Children's Hospital, Nashville, Tennessee
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Marsh MC, Junquera GY, Stonebrook E, Spencer JD, Watson JR. Urinary Tract Infections in Children. Pediatr Rev 2024; 45:260-270. [PMID: 38689106 DOI: 10.1542/pir.2023-006017] [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: 05/02/2024]
Abstract
Despite the American Academy of Pediatrics guidelines for the evaluation, treatment, and management of urinary tract infections (UTIs), UTI diagnosis and management remains challenging for clinicians. Challenges with acute UTI management stem from vague presenting signs and symptoms, diagnostic uncertainty, limitations in laboratory testing, and selecting appropriate antibiotic therapy in an era with increasing rates of antibiotic-resistant uropathogens. Recurrent UTI management remains difficult due to an incomplete understanding of the factors contributing to UTI, when to assess a child with repeated infections for kidney and urinary tract anomalies, and limited prevention strategies. To help reduce these uncertainties, this review provides a comprehensive overview of UTI epidemiology, risk factors, diagnosis, treatment, and prevention strategies that may help pediatricians overcome the challenges associated with acute and recurrent UTI management.
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Affiliation(s)
- Melanie C Marsh
- Division of Hospital Medicine, Department of Pediatrics, Advocate Aurora Atrium Health Systems, Chicago, IL
| | - Guillermo Yepes Junquera
- Kidney and Urinary Tract Center, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH
- Division of Infectious Diseases
| | - Emily Stonebrook
- Kidney and Urinary Tract Center, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH
- Division of Nephrology and Hypertension, Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH
| | - John David Spencer
- Kidney and Urinary Tract Center, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH
- Division of Nephrology and Hypertension, Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH
| | - Joshua R Watson
- Center for Clinical Excellence, Nationwide Children's Hospital, Columbus, OH
- Division of Infectious Diseases
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Abda A, Panetta L, Blackburn J, Chevalier I, Lachance C, Ovetchkine P, Sicard M. Urinary tract infections in very premature neonates: the definition dilemma. J Perinatol 2024; 44:731-738. [PMID: 38553603 DOI: 10.1038/s41372-024-01951-1] [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] [Received: 05/29/2023] [Revised: 03/17/2024] [Accepted: 03/20/2024] [Indexed: 05/15/2024]
Abstract
BACKGROUND AND OBJECTIVES Data on urinary tract infections (UTIs) in very preterm neonates (VPTNs) are scarce. We aimed to (i) describe the characteristics of UTIs in VPTNs and (ii) compare the diagnostic practices of neonatal clinicians to established pediatric guidelines. METHODS All VPTNs (<29 weeks GA) with a suspected UTI at the CHU Sainte-Justine neonatal intensive care unit from January 1, 2014, and December 31, 2019, were included and divided into two definition categories: Possible UTI, and Definite UTI. RESULTS Most episodes were Possible UTI (87%). Symptoms of UTIs and pathogens varied based on the definition category. A positive urinalysis was obtained in 25%. Possible UTI episodes grew 2 organisms in 62% of cases and <50,000 CFU/mL in 62% of cases. CONCLUSION Characteristics of UTIs in VPTNs vary based on the definition category and case definitions used by clinicians differ from that of established pediatric guidelines.
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Affiliation(s)
- Assil Abda
- Department of Pediatrics, Division of Neonatology, CHU Sainte-Justine, University of Montreal, Montreal, QC, Canada.
| | - Luc Panetta
- Department of Pediatrics, Division of Infectious Diseases, CHU Sainte-Justine, University of Montreal, Montreal, QC, Canada
- Pediatric Emergency Department, Hospices Civils de Lyon, Hôpital Femme Mère Enfant, Lyon, France
| | - Julie Blackburn
- Department of Pediatrics, Division of Infectious Diseases, CHU Sainte-Justine, University of Montreal, Montreal, QC, Canada
- Research center, CHU Sainte-Justine, Montreal, QC, Canada
- Department of Microbiology, Infectious Diseases and Immunology, University of Montreal, Montreal, QC, Canada
| | - Isabelle Chevalier
- Department of Pediatrics, Division of General Pediatrics, CHU Sainte-Justine, University of Montreal, Montreal, QC, Canada
| | - Christian Lachance
- Department of Pediatrics, Division of Neonatology, CHU Sainte-Justine, University of Montreal, Montreal, QC, Canada
- Research center, CHU Sainte-Justine, Montreal, QC, Canada
| | - Philippe Ovetchkine
- Department of Pediatrics, Division of Infectious Diseases, CHU Sainte-Justine, University of Montreal, Montreal, QC, Canada
- Research center, CHU Sainte-Justine, Montreal, QC, Canada
| | - Melanie Sicard
- Department of Pediatrics, Division of Neonatology, CHU Sainte-Justine, University of Montreal, Montreal, QC, Canada
- Research center, CHU Sainte-Justine, Montreal, QC, Canada
- Department of Microbiology, Infectious Diseases and Immunology, University of Montreal, Montreal, QC, Canada
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11
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Mawad TN, Bin-Ali D, Daghistani G, Alshinawi A, Alsaywid B. Pattern of urinary tract infection in children with vesicoureteric reflux: Does breastfeeding reduce the occurrence of urinary tract infection? Urol Ann 2024; 16:160-168. [PMID: 38818430 PMCID: PMC11135348 DOI: 10.4103/ua.ua_51_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 01/15/2024] [Indexed: 06/01/2024] Open
Abstract
Introduction The protective factors against urinary tract infections (UTIs) in the setting of vesicoureteric reflux (VUR) remain poorly defined. Breastfeeding was suggested as a protective factor against UTI, but its role remains undetermined in this highly susceptible population. Objectives The objective of the study was to identify the pattern and risk factors of UTI and investigate the effect of breastfeeding on UTI occurrence in VUR children. Materials and Methods This was a mixed-method design, whereby the first part was a cross-sectional study that included children who were diagnosed with VUR and were assessed for their UTI pattern. The second part was a case-control study, which involved contacting the mothers of the children enrolled and questioning them about their breastfeeding pattern, and UTI development was assessed. Results Our study included 62 children with a median age of 4.4 (interquartile range = 21) months at diagnosis. Of those, 37 (60%) were male and 25 (40%) were female. Most UTIs occurred in the first 3 months of life, and the first episodes were more frequent in males. Constipation was significantly associated with the occurrence of UTI (relative risk [RR] =1.750 [95% confidence interval (CI): 1.231-2.489], P = 0.003). Children with breakthrough UTIs were more likely to have been breastfed for <9 months (odds ratio [OR] = 4.091 [95% CI: 1.287-13.002], P = 0.015) and to have been exclusively breastfed for <2 months (OR = 4.600 [95% CI: 1.337-15.823], P = 0.012). Conclusion Children with VUR are more susceptible to UTIs in their 1st year of life. Constipation is a major risk factor for UTI occurrence in VUR children and should be aggressively managed. Breastfeeding for longer durations showed promising protective features against breakthrough UTIs.
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Affiliation(s)
- Tala N. Mawad
- School of Medicine, The Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Dania Bin-Ali
- College of Applied Medical Science, Umm Al-Qura University, Makkah, Saudi Arabia
| | | | - Amani Alshinawi
- College of Applied Medical Science, Umm Al-Qura University, Makkah, Saudi Arabia
| | - Basim Alsaywid
- Department of Urology, Pediatric Urology Section, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
- Education and Research Skills Directory, Saudi National Institute of Health, Riyadh, Saudi Arabia
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12
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Chang CL, Yang SSD, Hsu CK, Chen CH, Chang SJ. Effectiveness of various treatment modalities in children with vesicoureteral reflux grades II-IV: a systematic review and network meta-analysis. BMJ Paediatr Open 2023; 7:e002096. [PMID: 37989356 PMCID: PMC10660918 DOI: 10.1136/bmjpo-2023-002096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 07/26/2023] [Indexed: 11/23/2023] Open
Abstract
BACKGROUND Vesicoureteral reflux (VUR) is one of the most common risk factors of urinary tract infection (UTI) among children. Various treatment modalities including antibiotic prophylaxis, surgical or endoscopic corrections and conservative treatment were used depending on the severity of VUR. The aim of this study is to compare the effectiveness of these treatment modalities in children with VUR grades II-IV by conducting a systematic review and network meta-analysis. METHODS A systematic search from different databases was performed from their earliest records to December 2022 without any language restriction. Only randomised controlled trials were included in this study. Effectiveness of treatment modalities was mainly compared by UTI. Other outcomes for renal scarring and resolution by renal units were also measured between treatments. RESULTS A total of 11 studies with 1447 children were included in this study. While comparing with antibiotic prophylaxis in network meta-analysis for UTI recurrence, surgical treatment probably lowers the rate of UTI recurrence (Log OR -0.26, 95% CI -0.54 to 0.02, high quality). However, endoscopic treatment (Log OR 0.2, 95% CI -1.41 to 1.81, high quality) and conservative treatment (Log OR 0.15, 95% CI -0.45 to 0.75, high quality) revealed probably inferior to antibiotic treatment. CONCLUSION Both pairwise and network meta-analytic results probably showed no difference between the treatments in terms of their impact on UTI recurrence, progression of previous renal scars, or formation of new renal scars in children with VUR grades II-IV. These findings may offer a better understanding of each treatment and evidence-based suggestions for the choice of treatment, which should be individualised and based on the patient's risk factors.
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Affiliation(s)
- Chia-Lun Chang
- Department of Urology, Taipei Tzu Chi General Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, Taiwan
| | - Stephen Shei-Dei Yang
- Department of Urology, Taipei Tzu Chi General Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, Taiwan
| | - Chun-Kai Hsu
- Department of Urology, Taipei Tzu Chi General Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, Taiwan
| | - Chun-Hua Chen
- Department of Neurology, Taipei Municipal Wanfang hospital, Taipei, Taiwan
| | - Shang-Jen Chang
- Department of Urology, Taipei Tzu Chi General Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei, Taiwan
- Department of Urology, National Taiwan University Hospital, Taipei, Taiwan
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13
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Yang S, Gill PJ, Anwar MR, Nurse K, Mahood Q, Borkhoff CM, Bijelić V, Parkin PC, Mahant S. Kidney Ultrasonography After First Febrile Urinary Tract Infection in Children: A Systematic Review and Meta-analysis. JAMA Pediatr 2023; 177:764-773. [PMID: 37252727 PMCID: PMC10230373 DOI: 10.1001/jamapediatrics.2023.1387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 04/02/2023] [Indexed: 05/31/2023]
Abstract
Importance Controversy exists on the clinical utility of kidney ultrasonography after first febrile urinary tract infection (UTI), and clinical practice guideline recommendations vary. Objective To determine the prevalence of urinary tract abnormalities detected on kidney ultrasonography after the first febrile UTI in children. Data Sources The MEDLINE, EMBASE, CINAHL, PsycINFO, and Cochrane Central Register of Controlled Trials databases were searched for articles published from January 1, 2000, to September 20, 2022. Study Selection Studies of children with first febrile UTI reporting kidney ultrasonography findings. Data Extraction and Synthesis Two reviewers independently screened titles, abstracts, and full texts for eligibility. Study characteristics and outcomes were extracted from each article. Data on the prevalence of kidney ultrasonography abnormalities were pooled using a random-effects model. Main Outcomes and Measures The primary outcome was prevalence of urinary tract abnormalities and clinically important abnormalities (those that changed clinical management) detected on kidney ultrasonography. Secondary outcomes included the urinary tract abnormalities detected, surgical intervention, health care utilization, and parent-reported outcomes. Results Twenty-nine studies were included, with a total of 9170 children. Of the 27 studies that reported participant sex, the median percentage of males was 60% (range, 11%-80%). The prevalence of abnormalities detected on renal ultrasonography was 22.1% (95% CI, 16.8-27.9; I2 = 98%; 29 studies, all ages) and 21.9% (95% CI, 14.7-30.1; I2 = 98%; 15 studies, age <24 months). The prevalence of clinically important abnormalities was 3.1% (95% CI, 0.3-8.1; I2 = 96%; 8 studies, all ages) and 4.5% (95% CI, 0.5-12.0; I2 = 97%; 5 studies, age <24 months). Study recruitment bias was associated with a higher prevalence of abnormalities. The most common findings detected were hydronephrosis, pelviectasis, and dilated ureter. Urinary tract obstruction was identified in 0.4% (95% CI, 0.1-0.8; I2 = 59%; 12 studies), and surgical intervention occurred in 1.4% (95% CI, 0.5-2.7; I2 = 85%; 13 studies). One study reported health care utilization. No study reported parent-reported outcomes. Conclusions and Relevance Results suggest that 1 in 4 to 5 children with first febrile UTI will have a urinary tract abnormality detected on kidney ultrasonography and 1 in 32 will have an abnormality that changes clinical management. Given the considerable study heterogeneity and lack of comprehensive outcome measurement, well-designed prospective longitudinal studies are needed to fully evaluate the clinical utility of kidney ultrasonography after first febrile UTI.
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Affiliation(s)
- Sarah Yang
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Peter J. Gill
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
- The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Mohammed Rashidul Anwar
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Kimberly Nurse
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Quenby Mahood
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Cornelia M. Borkhoff
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
- The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Vid Bijelić
- Children’s Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Patricia C. Parkin
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
- The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Sanjay Mahant
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada
- The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
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14
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Fang NW, Ou SH, Huang YS, Chiou YH. Urethral discharge as an early manifestation of urinary tract infection in children ≤24 months old. Front Pediatr 2023; 11:1149218. [PMID: 37404552 PMCID: PMC10315818 DOI: 10.3389/fped.2023.1149218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Accepted: 06/06/2023] [Indexed: 07/06/2023] Open
Abstract
Background Children with febrile urinary tract infections (UTIs) are prone to kidney scarring if they are not treated promptly; however, ambiguous symptoms before fever onset makes the early detection of UTIs difficult. Our study aimed to identify urethral discharge as an early manifestation in children with UTI. Methods This study enrolled 678 children younger than 24 months with paired urinalysis and culture performed between 2015 and 2021; 544 children were diagnosed with UTIs. Clinical symptoms, urinalysis, and paired urine culture results were compared. Results Urethral discharge was observed in 5.1% of children with UTI and yielded a specificity of 92.5% for diagnosing UTI. Children with urethral discharge had a less severe UTI course, furthermore, nine of them received antibiotics before fever occurred and seven of them were free of fever during UTI course. Urethral discharge was associated with alkalotic urine and Klebsiella pneumonia infection. Conclusions Urethral discharge is an early symptom in children with UTI; it may present before fever onset and help ensure prompt antibiotic intervention.
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Affiliation(s)
- Nai-Wen Fang
- Division of Pediatric Nephrology, Department of Pediatrics, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- Department of Pediatrics, Pingtung Veterans General Hospital, Pingtung, Taiwan
| | - Shih-Hsiang Ou
- Division of Nephrology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Yu-Shan Huang
- Department of Pediatrics, Pingtung Veterans General Hospital, Pingtung, Taiwan
| | - Yee-Hsuan Chiou
- Department of Pediatrics, Pingtung Veterans General Hospital, Pingtung, Taiwan
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15
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Zirngibl M, Buder K, Luithle T, Tönshoff B, Weitz M, Ariceta G, Awan A, Bakkaloglu SA, Baskin E, Bekassy Z, Bhimma R, Bitzan M, Bjerre AK, Bootsma‐Robroeks CM, Bouts A, Büscher A, Bulum B, Christian M, Cicek N, Clothier J, Cornelissen M, Dehoux L, Kılıç BD, Dinçel NT, Esfandiar N, Espinosa‐Román L, Fila M, Galiano M, Gander R, Gessner M, Grenda R, Henne T, Herthelius M, Goñi MH, Higueras W, Hooman N, Jahnukainen T, Jankauskiene A, de Jong H, Knops N, Konrad M, Levtchenko E, Madrid‐Aris A, Marks SD, Mattoo TK, Maxted A, Melgosa‐Hijosa M, Mincham CM, Mitsioni A, Montini G, Morgan H, Müller‐Sacherer T, Murer L, Özçakar ZB, Pape L, Parvex P, Printza N, Prytula A, Reynolds B, Roussinov D, Rubik J, Rumyantsev A, Rus R, Seeman T, Shenoy M, Silva ACSE, Sinha R, Stabouli S, Taşdemir M, Tasic V, Teixeira A, Thumfart J, Topaloğlu R, Torres D, Trnka P, Tschumi S, Tse Y, Aki FT, Verrina EE, Vidal E, Weber LT, Yalçınkaya FF, Yap Y, Yıldız N, Yüksel S, Zieg J. Diagnostic and therapeutic management of vesico-ureteral reflux in pediatric kidney transplantation-Results of an online survey on behalf of the European Society for Paediatric Nephrology. Pediatr Transplant 2023; 27:e14449. [PMID: 36478499 DOI: 10.1111/petr.14449] [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: 06/02/2022] [Revised: 09/27/2022] [Accepted: 11/16/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Vesico-ureteral reflux (VUR) is considered to be a risk factor for recurrent febrile urinary tract infections and impaired renal transplant survival. METHODS An online survey supported by the European Society for Paediatric Nephrology was designed to evaluate current management strategies of VUR in native and transplanted kidneys of recipients aged <18 years. RESULTS Seventy-three pediatric transplant centers from 32 countries contributed to the survey. All centers performed urological evaluation prior to pediatric kidney transplantation (KTx) with subsequent interdisciplinary discussion. Screening for VUR in native kidneys (30% in all, 70% in selected patients) led to surgical intervention in 78% (11% in all, 89% in selected patients) with a decided preference of endoscopic intervention over ureterocystoneostomy. Following KTx, continuous antibiotic prophylaxis was applied in 65% of the patients and screening for allograft VUR performed in 93% of selected patients. The main management strategies of symptomatic allograft VUR were continuous antibiotic prophylaxis (83%) and surgical treatment (74%) (endoscopic intervention 55%, redo ureterocystoneostomy 26%). CONCLUSIONS This survey demonstrates the high variability in the management of VUR in pediatric KTx recipients, points to knowledge gaps, and might serve as a starting point for improving the care for patients with VUR in native and transplanted kidneys.
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Affiliation(s)
- Matthias Zirngibl
- Department of General Pediatrics and Hematology/Oncology, University Children's Hospital, University Hospital Tübingen, Tübingen, Germany
| | - Kathrin Buder
- Department of General Pediatrics and Hematology/Oncology, University Children's Hospital, University Hospital Tübingen, Tübingen, Germany
| | - Tobias Luithle
- Department of Pediatric Surgery and Pediatric Urology, University Children's Hospital, University Hospital Tübingen, Tübingen, Germany
| | - Burkhard Tönshoff
- Department of Pediatrics I, University Children's Hospital Heidelberg, Heidelberg, Germany
| | - Marcus Weitz
- Department of General Pediatrics and Hematology/Oncology, University Children's Hospital, University Hospital Tübingen, Tübingen, Germany
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16
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Chimenz R, Chirico V, Cuppari C, Sallemi A, Cardile D, Baldari S, Ascenti G, Monardo P, Lacquaniti A. Febrile Urinary Tract Infections in Children: The Role of High Mobility Group Box-1. CHILDREN (BASEL, SWITZERLAND) 2022; 10:47. [PMID: 36670598 PMCID: PMC9856601 DOI: 10.3390/children10010047] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Revised: 12/16/2022] [Accepted: 12/19/2022] [Indexed: 12/28/2022]
Abstract
BACKGROUND Differentiating between febrile lower urinary tract infection (LUTI) and acute pyelonephritis (APN) is crucial for prompt clinical management. We investigated whether the high mobility group box-1 (HMGB1) could be a useful biomarker in differentiating between LUTI or APN. METHODS We enrolled seventy-four pediatric patients with suspected LUTI/APN, according to the positive or negative renal scintigraphy (DMSA) scan. If the first DMSA findings were abnormal, a second DMSA was performed after six months. Voiding cystourethrography ruled out vesicoureteral reflux (VUR). RESULTS Higher serum (s) HMGB1 levels characterized the APN group when compared to LUTI patients (13.3 (11.8-14.3) versus 5.9 (5.2-6.8) ng/mL, p: 0.02), whereas there were no differences according to urine (u) HMGB1 values. sHMGB1 correlated with C-reactive protein (CRP) levels (β = 0.47; p: 0.02). Receiver operating characteristic curves identified the best diagnostic profile for detecting APN. sHMGB1 area under the curve was different from CRP (p: 0.01) and white blood cells (p: 0.003). After multivariate analyses, VUR (HR:4.81) and sHMGB1 (HR 1.16; p: 0.006) were independently associated with the risk of renal scarring development. CONCLUSIONS sHMGB1 could represent a marker to differentiate APN from LUTI. Measurement of sHMGB1 could select children for early intervention or long-term follow-up.
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Affiliation(s)
- Roberto Chimenz
- Pediatric Nephrology and Dialysis Unit, University Hospital “G. Martino”, 98124 Messina, Italy
| | - Valeria Chirico
- Pediatric Nephrology and Dialysis Unit, University Hospital “G. Martino”, 98124 Messina, Italy
| | - Caterina Cuppari
- Pediatric Nephrology and Dialysis Unit, University Hospital “G. Martino”, 98124 Messina, Italy
| | - Alessia Sallemi
- Pediatric Nephrology and Dialysis Unit, University Hospital “G. Martino”, 98124 Messina, Italy
| | - Davide Cardile
- Nuclear Medicine Unit, University Hospital “G. Martino”, 98124 Messina, Italy
| | - Sergio Baldari
- Nuclear Medicine Unit, University Hospital “G. Martino”, 98124 Messina, Italy
| | - Giorgio Ascenti
- Section of Radiological Sciences, Department of Biomedical Sciences and Morphological and Functional Imaging, University Hospital “G. Martino”, 98124 Messina, Italy
| | - Paolo Monardo
- Nephrology and Dialysis Unit, Papardo Hospital, 98158 Messina, Italy
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Swartz S, Thakrar P, Kolinski J, Hadjiev J, Chou E, Zhang J, Yan K, Havens P. Imaging Practices and Implications in Young Infants With Urinary Tract Infection. Hosp Pediatr 2022; 12:922-932. [PMID: 36278285 DOI: 10.1542/hpeds.2021-006507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
OBJECTIVES Management of infants aged ≤60 days with urinary tract infections (UTI) is challenging. We examined renal imaging in infants aged ≤60 days with UTI at a tertiary care children's hospital to identify the impact of standardizing renal ultrasound (RUS) interpretation. METHODS We retrospectively studied infants aged ≤60 days hospitalized for UTI or fever with urine culture and renal imaging obtained and final diagnosis of UTI. RUS initially had noncriterion-based (NCB) interpretation by experienced pediatric radiologists. For this study, a single pediatric radiologist used a criterion-based (CB) hydronephrosis grading system to reinterpret films initially classified as "abnormal" on the NCB reading. We compared final renal imaging results between NCB and CB groups. RESULTS Of 193 infants, 180 (93%) had inpatient RUS with 114 (63%) abnormal NCB interpretation. Of those with initially abnormal NCB interpretation, 85 OF 114 (75%) had minor and 29 OF 114 (25%) had significant abnormality by CB reinterpretation. In follow-up, the CB "minor abnormality" group showed 25% abnormal renal imaging, whereas the "significant abnormality" group showed 77% abnormal renal imaging with 54% having high-grade reflux on a voiding cystourethrogram (VCUG). Patients with CB inpatient RUS minor abnormality showed 3% abnormal RUS at follow-up, but 13% showed high-grade reflux on VCUG. CONCLUSIONS Standardized RUS interpretation in young infants with UTI improved the accuracy of identification of abnormalities on follow-up renal imaging. In patients with CB minor abnormality on inpatient RUS, our results suggest limited utility of follow-up RUS; however, follow-up VCUG remained useful to identify high-grade reflux.
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Horsager TH, Hagstrøm S, Skals R, Winding L. Renal scars in children with febrile urinary tract infection - Looking for associated factors. J Pediatr Urol 2022; 18:682.e1-682.e9. [PMID: 36253233 DOI: 10.1016/j.jpurol.2022.09.012] [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: 01/12/2022] [Revised: 08/24/2022] [Accepted: 09/13/2022] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Febrile urinary tract infection (UTI) is a common childhood infection related to renal scarring and potentially long-term complications like chronic kidney disease. It would be of great benefit to find a correlation between easy-accessible factors in the acute phase of a febrile UTI and the development of renal scar formation and/or decreased renal function in order to identify children at risk of future complications. OBJECTIVE The aim of this study was to identify factors associated with the development of decreased split renal function (DSRF) and/or permanent renal scar formation in children with febrile UTI. STUDY DESIGN The medical records of 212 Children aged 0 months to 15 years with febrile UTI admitted to The Pediatric Department of Lillebaelt Hospital, Kolding from January 2011 to September 2014 were systematically reviewed. We analyzed clinical, laboratory, and radiologic findings. Statistical analysis was performed to identify factors associated with renal scar formation and DSRF on nuclear imaging at 6 months follow-up. RESULTS A total of 113 medical records were eligible for further analysis, 99 girls and 14 boys, 34 patients younger than 12 months. In total 30 patients (26.5%) had an abnormal follow-up imaging (DSRF less than 45% and/or renal scarring). Nine patients (8%) had renal scarring. Four patients (3.5%) had renal scarring only, 21 patients (18.6%) had DSRF only, and five patients (4.4%) had both renal scarring and DSRF. Patients with renal scar formation on follow-up imaging had significantly higher C-reactive protein (CRP) than patients with no scarring (p < 0.01). CRP and absolute neutrophil count (ANC) was significantly higher in patients with abnormal follow-up imaging (p < 0.01 and p = 0.010), and these patients more often had positive nitrite in urine dipstick compared to patients with normal kidneys on follow-up (p = 0.048). Temperature above 38.5 °C and CRP >50 mg/L in combination were also associated with a higher risk of abnormal follow-up imaging (p = 0.016). DISCUSSION This study contributes with further knowledge to the ongoing debate regarding renal scarring but also reveals the possibility of associated factors for the development of DSRF following a febrile UTI in children. However, due to the retrospective design as well as the small number of events in our study definite conclusions on whether the above-mentioned factors are indeed prognostic for the development of renal scarring or DSRF following a febrile UTI can not be drawn.
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Affiliation(s)
- Tanja Hübertz Horsager
- Department of Paediatrics and Adolescence Medicine, Lillebaelt Hospital Kolding, Kolding, Denmark.
| | - Søren Hagstrøm
- Department of Paediatrics, Aalborg University Hospital, Aalborg, Denmark
| | - Regitze Skals
- Unit of Epidemiology and Biostatistics, Aalborg University Hospital, Aalborg, Denmark
| | - Louise Winding
- Department of Paediatrics and Adolescence Medicine, Lillebaelt Hospital Kolding, Kolding, Denmark
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19
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Brady SS, Bavendam TG, Bradway CK, Conroy B, Dowling-Castronovo A, Epperson CN, Hijaz AK, Hsi RS, Huss K, Kim M, Lazar J, Lee RK, Liu CK, Loizou CN, Miran S, Mody L, Norton JM, Reynolds WS, Sutcliffe S, Zhang N, Hokanson JA. Noncancerous Genitourinary Conditions as a Public Health Priority: Conceptualizing the Hidden Burden. Urology 2022; 166:39-49. [PMID: 34536410 PMCID: PMC8924010 DOI: 10.1016/j.urology.2021.08.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 08/07/2021] [Accepted: 08/30/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To provide a conceptual framework to guide investigations into burdens of noncancerous genitourinary conditions (NCGUCs), which are extensive and poorly understood. METHODS The National Institute of Diabetes and Digestive and Kidney Diseases convened a workshop of diverse, interdisciplinary researchers and health professionals to identify known and hidden burdens of NCGUCs that must be measured to estimate the comprehensive burden. Following the meeting, a subgroup of attendees (authors of this article) continued to meet to conceptualize burden. RESULTS The Hidden Burden of Noncancerous Genitourinary Conditions Framework includes impacts across multiple levels of well-being and social ecology, including individual (ie, biologic factors, lived experience, behaviors), interpersonal (eg, romantic partners, family members), organizational/institutional (eg, schools, workplaces), community (eg, public restroom infrastructure), societal (eg, health care and insurance systems, national workforce/economic output), and ecosystem (eg, landfill waste) effects. The framework acknowledges that NCGUCs can be a manifestation of underlying biological dysfunction, while also leading to biological impacts (generation and exacerbation of health conditions, treatment side effects). CONCLUSION NCGUCs confer a large, poorly understood burden to individuals and society. An evidence-base to describe the comprehensive burden is needed. Measurement of NCGUC burdens should incorporate multiple levels of well-being and social ecology, a life course perspective, and potential interactions between NCGUCs and genetics, sex, race, and gender. This approach would elucidate accumulated impacts and potential health inequities in experienced burdens. Uncovering the hidden burden of NCGUCs may draw attention and resources (eg, new research and improved treatments) to this important domain of health.
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Affiliation(s)
- Sonya S Brady
- Division of Epidemiology and Community Health, University of Minnesota School of Public Health, Minneapolis, MN.
| | - Tamara G Bavendam
- Division of Kidney, Urologic, and Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD
| | - Christine K Bradway
- Department of Biobehavioral Health Sciences, University of Pennsylvania School of Nursing, Philadelphia, PA
| | - Britt Conroy
- Urology Institute, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH
| | | | - Cynthia Neill Epperson
- Department of Psychiatry, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO
| | - Adonis K Hijaz
- Urology Institute, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Ryan S Hsi
- Department of Urology, Vanderbilt University Medical Center, Nashville, TN
| | - Karen Huss
- Division of Extramural Science Programs, Symptom Science and Genetics, Self-Management Office, National Institute of Nursing Research, Bethesda, MD
| | - Michelle Kim
- Department of Urology, Massachusetts General Hospital, Boston, MA
| | - Jason Lazar
- Department of Medicine, SUNY Downstate Health Sciences University, New York, NY
| | - Richard K Lee
- Department of Urology, Weill Cornell Medical College, New York, NY
| | - Christine K Liu
- Section of Geriatrics, Division of Primary Care and Population Health, Stanford University School of Medicine, Stanford, CA; Geriatric Research and Education Clinical Center, Palo Alto VA Health Care System, Palo Alto, CA; Section of Geriatrics, Department of Medicine, Boston University, Boston, MA
| | | | - Saadia Miran
- Division of Kidney, Urologic, and Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD
| | - Lona Mody
- Division of Geriatric and Palliative Medicine, University of Michigan Medical School, Ann Arbor, MI and VA Ann Arbor Healthcare System, Ann Arbor, MI
| | - Jenna M Norton
- Division of Kidney, Urologic, and Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD
| | | | - Siobhan Sutcliffe
- Department of Surgery, Division of Public Health Sciences, Washington University School of Medicine, St. Louis, MO
| | - Nicole Zhang
- The Valley Foundation School of Nursing, College of Health and Human Sciences, San Jose State University, San Jose, CA
| | - James A Hokanson
- Department of Biomedical Engineering, Medical College of Wisconsin, Milwaukee, WI
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20
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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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21
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Ultrasonography Results in First Urinary Tract Infection During Childhood: Which Age Group Should Be Screened? Indian J Pediatr 2022:10.1007/s12098-022-04213-0. [PMID: 35771350 DOI: 10.1007/s12098-022-04213-0] [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: 07/05/2021] [Accepted: 03/02/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVES To determine the frequency of urinary system anomaly in children aged 0-18 y suffering from first urinary tract infection (UTI) and to establish which age group requires urinary ultrasonography (USG) screening. METHODS Age and gender, urine culture, urinary USG, and urological imaging results among 247 children in the 0-18 y age group with a first diagnosis of UTI were investigated retrospectively. RESULTS Anomaly was detected at USG in 68 (27.5%) of the 247 patients suffering from first UTI. The most common anomaly was hydronephrosis. Non-E. coli micro-organisms were the pathogenic agents in 61.8% of patients with anomalies detected at USG. Being in the 0-5 y age group (OR: 0.524, 95% CI 0.284-0.970, p = 0.040) and presence of atypical UTI (OR: 4.746, 95% CI: 1.675-13.450, p = 0.003) emerged as independent predictive markers of severe urinary system pathologies on multiple regression analysis. CONCLUSION Based on the data in the present study, routine USG screening is recommended for children suffering from first UTI under the age of 5 y and for the children suffering from atypical UTI at all ages.
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22
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Kavruk M, Soyaltın E, Erfidan G, Arslansoyu Çamlar S, Alaygut D, Mutlubaş F, Yılmaz N, Kasap Demir B. The Influence of Non-E. Coli or Extended-Spectrum β-Lactamase-Producing Bacterial Growth on the Follow-Up Procedure of Infants with the First Febrile Urinary Tract Infection. Indian J Pediatr 2022:10.1007/s12098-022-04183-3. [PMID: 35727527 DOI: 10.1007/s12098-022-04183-3] [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: 05/27/2021] [Accepted: 01/27/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To evaluate the effects of non-E. coli or extended-spectrum β-lactamase-positive (ESBL-positive) microorganism growth in the first febrile urinary tract infection (UTI) of infants on laboratory findings or renal parenchymal damage presenting the severity of inflammation, anatomic abnormalities defined by imaging studies, and recurrent UTIs in the follow-up period. METHODS The data of patients aged between 2 and 24 mo and followed up for at least 6 mo with febrile UTI guideline of the authors' pediatric-nephrology clinic, were retrospectively analyzed. Ultrasonography was performed in all the cases at the time of UTI and dimercaptosuccinic-acid (DMSA) at least 4 mo after the infection. Voiding cystourethrography (VCUG) was performed only if ultrasonography findings were abnormal, the uptake deformity was detected in DMSA scan, or the patients experienced recurrent UTIs. The patients were grouped concerning E. coli or non-E. coli and ESBL-PB or non-ESBL-BP growth in the urine cultures. RESULTS There were 277 infants followed up for 28.55 ± 15.24 (6-86) mo. The causative microorganisms were non-E. coli in 73 (26.4%) and ESBL-PB in 58 (20.9%) cases. CRP values, pyuria, and leukocyte-esterase positivity were significantly higher in UTIs caused by E. coli compared to non-E. coli bacteria. All clinical and laboratory findings were similar between the ESBL-PB and non-ESBL groups, but abnormal ultrasonography findings were more common in non-E. coli group. CONCLUSION E. coli causes more severe inflammation, but non-E. coli infections are more frequently associated with ultrasound abnormalities. However, ESBL production did not affect either laboratory or radiological findings in the present cohort.
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Affiliation(s)
- Mustafa Kavruk
- Department of Pediatrics, University of Health Sciences, Izmir Tepecik Training and Research Hospital, İzmir, Turkey
| | - Eren Soyaltın
- Department of Pediatrics, Division of Nephrology, University of Health Sciences, Izmir Tepecik Training and Research Hospital, İzmir, 35320, Turkey
| | - Gökçen Erfidan
- Department of Pediatrics, Division of Nephrology, University of Health Sciences, Izmir Tepecik Training and Research Hospital, İzmir, 35320, Turkey
| | - Seçil Arslansoyu Çamlar
- Department of Pediatrics, Division of Nephrology, University of Health Sciences, Izmir Tepecik Training and Research Hospital, İzmir, 35320, Turkey.
| | - Demet Alaygut
- Department of Pediatrics, Division of Nephrology, University of Health Sciences, Izmir Tepecik Training and Research Hospital, İzmir, 35320, Turkey
| | - Fatma Mutlubaş
- Department of Pediatrics, Division of Nephrology, University of Health Sciences, Izmir Tepecik Training and Research Hospital, İzmir, 35320, Turkey
| | - Nisel Yılmaz
- Department of Clinical Microbiology, University of Health Sciences, Izmir Tepecik Training and Research Hospital, İzmir, Turkey
| | - Belde Kasap Demir
- Department of Pediatrics, Division of Nephrology, University of Health Sciences, Izmir Tepecik Training and Research Hospital, İzmir, 35320, Turkey.,Department of Pediatrics, Division of Nephrology and Rheumatology, Izmir Katip Çelebi University Medical Faculty, İzmir, Turkey
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23
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Banno Y, Sugiyama T. Predicting factors of clinically significant urological anomalies after initial urinary tract infection among 2- to 24-month-old children. Acta Paediatr 2022; 111:1274-1281. [PMID: 35316554 DOI: 10.1111/apa.16341] [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: 01/01/2022] [Revised: 02/18/2022] [Accepted: 03/21/2022] [Indexed: 11/28/2022]
Abstract
AIM To find more effective criteria to identify clinically significant urological anomalies after initial urinary tract infection among children. METHODS Children aged 2-24 months with an initial urinary tract infection were consecutively recruited in a Japanese hospital from 2013 to 2019. Voiding cystourethrography, 99mTc dimercaptosuccinic acid scan and ultrasound were intended to perform for all cases. Clinically significant urological anomalies were defined as high-grade vesicoureteral reflux, obstructive and abnormal urinary tract lesions, need for surgical intervention, renal hypoplasia and scarring. Using classification and regression tree analysis, we sought the associated factors. We developed new criteria with these factors, retrospectively applied them to the original data, and calculated the sensitivity and specificity. RESULTS One hundred sixty-seven patients were eligible, and 39 had clinically significant urological anomalies. Classification and regression tree analysis showed that the associated factors were non-E. coli infections, serum creatinine levels and ultrasound abnormalities. When the gold standards were performed on children with non-E. coli infections or serum creatinine levels ≥0.21 mg/dl, sensitivity and specificity were 0.82 and 0.68, respectively. CONCLUSION The criteria including non-E. coli infections and high-normal or higher serum creatinine levels may efficiently predict clinically significant urological anomalies after initial urinary tract infections.
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Affiliation(s)
- Yoshinori Banno
- Department of Pediatrics Children’s Medical Center Matsudo City General Hospital Matsudo Chiba Japan
- Department of Pediatrics National Hospital Organization Saitama Hospital Wako Saitama Japan
| | - Takehiro Sugiyama
- Institute for Global Health Policy Research Bureau of International Health Cooperation National Center for Global Health and Medicine Tokyo Japan
- Diabetes and Metabolism Information Center Research Institute National Center for Global Health and Medicine Tokyo Japan
- Department of Health Services Research Faculty of Medicine University of Tsukuba Tsukuba Ibaraki Japan
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24
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Singhal N, Gopal M, Ali A, McGlade F, Ahmed I, Harkensee C, Gittins N, Senasi R, Peace R, Athiraman N, Tse Y. The prevalence of familial vesicoureteric reflux in infants with normal antenatal scans. Acta Paediatr 2022; 111:1808-1813. [PMID: 35642352 DOI: 10.1111/apa.16434] [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: 05/10/2022] [Revised: 05/23/2022] [Accepted: 05/30/2022] [Indexed: 11/26/2022]
Abstract
AIM To determine the prevalence of familial vesicoureteric reflux (VUR) by studying the outcomes of screening in a contemporary cohort of newborns with normal antenatal kidney scans. METHODS A review of screening outcomes in newborns with a first degree relative with VUR, normal antenatal scans and no prior urine infections between 2014-2019 at three maternity units in the North East of England was conducted. Imaging consisted of micturating cystourethrogram (MCUG) in all and renal tract ultrasound scan (RUS) routinely in two units and by clinician preference in one unit. RESULTS At a median age of 59 days, 265 infants underwent MCUG. High-grade VUR (Grades 3-5) was detected in 13 (4.9%) and low-grade VUR (Grades 1-2) in 24 (9.1%). In the 152 infants who had a RUS, abnormalities were detected in 21 (13.8%). An abnormal postnatal RUS has a low positive predictive value (14.3%) for high-grade VUR, but a normal RUS has a high negative predictive value (95.4%). CONCLUSION Compared to historical cohorts from two decades ago, the yield from familial VUR screening is low and unjustifiable in the setting of normal antenatal anomaly scans.
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Affiliation(s)
- Nidhi Singhal
- Department of Paediatric Nephrology Great North Children’s Hospital Newcastle Upon Tyne UK
| | - Milan Gopal
- Department of Paediatric Urology Great North Children’s Hospital Newcastle Upon Tyne UK
| | - Alaa Ali
- Department of Paediatric Nephrology Great North Children’s Hospital Newcastle Upon Tyne UK
| | - Fiona McGlade
- Department of Neonatology Sunderland Royal Hospital Sunderland UK
| | - Imran Ahmed
- Department of Neonatology Sunderland Royal Hospital Sunderland UK
| | | | - Nicola Gittins
- Department of Paediatrics Queen Elizabeth Hospital Gateshead UK
| | - Ramdas Senasi
- Department of Radiology Sunderland Royal Hospital Sunderland UK
| | - Richard Peace
- Department of Nuclear Medicine Royal Victoria Infirmary Newcastle Upon Tyne UK
| | - Naveen Athiraman
- Department of Neonatology Royal Victoria Infirmary Newcastle Upon Tyne UK
| | - Yincent Tse
- Department of Paediatric Nephrology Great North Children’s Hospital Newcastle Upon Tyne UK
- Faculty of Medical Sciences Newcastle University Newcastle Upon Tyne UK
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25
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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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Lombel RM, Brakeman PR, Sack BS, Butani L. Urologic Considerations in Pediatric Chronic Kidney Disease. Adv Chronic Kidney Dis 2022; 29:308-317. [PMID: 36084977 DOI: 10.1053/j.ackd.2022.02.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 02/20/2022] [Accepted: 02/23/2022] [Indexed: 11/11/2022]
Abstract
Common causes of pediatric ESRD are distinct from those seen in the adult population. In the pediatric population, the most common are congenital anomalies of the kidney and urinary tract (CAKUT), affecting approximately 30% of children with CKD. These structural anomalies often require coordinated care with the pediatric urology team to address voiding issues, bladder involvement, and the potential need for surgical intervention. For pediatric nephrologists and urologists, common CAKUT that are encountered include antenatal hydronephrosis, obstructive uropathies (eg, posterior urethral valves), and vesicoureteral reflux. As more pediatric patients with CAKUT, CKD, and ESRD transition to adult care, it is important for receiving adult nephrologists to understand the clinical presentation, natural history, and prognosis for these diagnoses. This review outlines the diagnosis and potential interventions for these conditions, including strategies to address bladder dysfunction that is often seen in children with CAKUT. A discussion of these management decisions (including surgical intervention) for CAKUT, which are quite common to pediatric nephrology and urology practices, may provide unique learning opportunities for adult nephrologists who lack familiarity with these pediatric conditions.
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Affiliation(s)
- Rebecca M Lombel
- Division of Pediatric Nephrology, University of Michigan, Ann Arbor, MI.
| | - Paul R Brakeman
- Division of Pediatric Nephrology, University of California, San Francisco, San Francisco, CA
| | - Bryan S Sack
- Division of Pediatric Urology, University of Michigan, Ann Arbor, MI
| | - Lavjay Butani
- Division of Pediatric Nephrology, University of California Davis Medical Center, Sacramento, CA
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27
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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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28
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Correlation of Renal Scarring to Urinary Tract Infections and Vesicoureteral Reflux in Children. Adv Urol 2022; 2022:9697931. [PMID: 35529476 PMCID: PMC9072046 DOI: 10.1155/2022/9697931] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 04/01/2022] [Indexed: 11/18/2022] Open
Abstract
Objective To study the association of the grade of vesicoureteral reflux (VUR) and urinary tract infections (UTI) with renal scarring at the first clinical presentation of patients who underwent antireflux surgery. Materials and methods. Between 2015 and 2020, 150 patients (194 units) who underwent antireflux surgery had dimercaptosuccinic acid (DMSA) renal scans preoperatively. Patients were classified into the nonscar and scar groups according to DMSA scan results. Moreover, cases were classified into afebrile UTI, febrile UTI, and antenatal hydronephrosis (ANH) according to the mode of presentation. We correlated the mode of presentation and the grade of VUR to the presence/absence of renal scars in both groups. Results The mean follow-up was 45 months preoperatively. The mode of presentation was afebrile, febrile UTIs, and antenatal hydronephrosis in (50, 14), (20, 46), and (10, 10) patients in the nonscar and scar groups, respectively. Of the 20 patients who presented ANH, 10 (50%) had scars. Clinical presentation was correlated to the presence of renal scarring and its degree. The scar group had significantly higher grades of VUR than the nonscar group (grades I–II (50 units versus 10 units), grade III (28 units versus 40 units), and grade IV–V (22 units versus 44 units) for the nonscar versus scar groups, respectively (pvalue <0.001). Conclusion Renal scarring is associated with higher grades of reflux and urinary tract infections. We advocate further research investigating infants who had UTIs with or without fever for early detection of reflux.
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Hum S, Liu H, Shaikh N. Risk Factors for the Development of Febrile Recurrences in Children with a History of Urinary Tract Infection. J Pediatr 2022; 243:152-157. [PMID: 34953817 PMCID: PMC8960327 DOI: 10.1016/j.jpeds.2021.12.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 12/01/2021] [Accepted: 12/17/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To identify risk factors for febrile recurrence of urinary tract infections (UTIs) in children with a history of UTI. STUDY DESIGN We included 500 children aged 2-72 months with a history of UTI who were followed prospectively for approximately 2 years in the context of 2 previously conducted studies (Randomized Intervention for Children with Vesicoureteral Reflux and Careful Urinary Tract Infection Evaluation). We identified significant risk factors for febrile recurrences among children not receiving antimicrobial prophylaxis using univariate and multivariate logistic regression. RESULT On univariate analysis, non-Black race, febrile index UTI, bowel-bladder dysfunction, grade IV vesicoureteral reflux, renal scarring at baseline, and renal-bladder ultrasound abnormalities were associated with febrile recurrence. On multivariate analysis, the following variables independently increased the odds of febrile recurrences (OR; 95% CI): non-Black race (7.1; 1.5-127.9), bowel-bladder dysfunction (2.6; 1.1-5.3), febrile index UTI (2.5; 1.1-6.9), abnormalities on renal-bladder ultrasound scan (2.6; 1.2-5.6), grade IV vesicoureteral reflux (3.9; 1.4-10.5), and renal scarring at baseline (4.7; 1.2-19.1). CONCLUSIONS Non-Black race and grade IV vesicoureteral reflux increased the odds of febrile recurrence of UTI. Although our findings should stimulate other studies to further explore the relationship between race and UTIs, given that the link between race and UTI recurrence is unclear, race should not be used to make decisions regarding management of children with a UTI.
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Affiliation(s)
- Stephanie Hum
- Department of Pediatrics, Children's Hospital Colorado, Aurora, CO
| | - Hui Liu
- Division of General Academic Pediatrics, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA
| | - Nader Shaikh
- Division of General Academic Pediatrics, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA.
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Lubell TR, Barasch JM, King B, Ochs J, Fan W, Duong J, Chitre M, Dayan P. Urinary tract infections in children: Testing a novel, noninvasive, point-of-care diagnostic marker. Acad Emerg Med 2022; 29:326-333. [PMID: 34665891 PMCID: PMC9199382 DOI: 10.1111/acem.14402] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 10/08/2021] [Accepted: 10/18/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Urinary neutrophil gelatinase-associated lipocalin (uNGAL) appears highly accurate to identify urinary tract infections (UTIs) when obtained via catheterization. Our primary aim was to determine the agreement in uNGAL levels between paired catheter and bag urine specimens. Our secondary aim was to compare the diagnostic test characteristics of quantitative uNGAL, dipstick uNGAL (a potential point-of-care test), and urinalysis (UA). METHODS This was a prospective study of febrile children < 24 months evaluated for UTIs. We evaluated quantitative uNGAL at a previously identified threshold of 39.1 ng/mL, dipstick uNGAL at its built-in threshold of >50 ng/mL, and UA at standard thresholds for leukocyte esterase (LE). A positive urine culture was defined as >100,000 CFUs/mL of a pathogen. RESULTS A total of 211 patients were included (10% with positive urine cultures); 116 had paired catheterized and bagged samples. The agreement between catheterized and bagged samples at a quantitative uNGAL cutoff of ≥39.1 ng/mL was 0.76 (95% confidence interval [CI] = 0.67 to 0.83) and 0.77 (95% CI = 0.68 to 0.84) at a uNGAL dipstick threshold of >50 ng/mL. The area under the receiver operating characteristic curve for uNGAL from a catheterized sample was 0.96 (95% CI = 0.89 to 1.00) compared to 0.93 (95% CI = 0.87 to -0.99) from a bagged sample. The sensitivities of catheterized sample quantitative and dipstick uNGAL (90.5%) were higher than UA at a LE threshold of ≥1+ (57.1%). Bagged-sample uNGAL had lower quantitative and dipstick specificities (both 73.8%) than from catheterized samples (94.3% and 95.3% respectively), similar to UA. CONCLUSIONS uNGAL from bagged and catheterized samples showed insufficient agreement to be used interchangeably. The low specificity of uNGAL from bagged samples suggests that sampling technique affects uNGAL levels.
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Affiliation(s)
- Tamar R. Lubell
- Department of Emergency Medicine Division of Pediatric Emergency Medicine Columbia University Vagelos College of Physicians and Surgeons New York New York USA
| | - Jonathan M. Barasch
- Departments of Medicine and Pathology and Cell Biology Division of Nephrology Columbia University Vagelos College of Physicians and Surgeons New York New York USA
| | - Benjamin King
- Department of Pediatrics Columbia University Vagelos College of Physicians and Surgeons New York New York USA
- Department of Primary Care Weill Cornell Medicine New York New York USA
| | - Julie B. Ochs
- Department of Emergency Medicine Division of Pediatric Emergency Medicine Columbia University Vagelos College of Physicians and Surgeons New York New York USA
- College of Osteopathic Medicine New York Institute of Technology Old Westbury New York USA
| | - Weijia Fan
- Department of Biostatistics Mailman School of Public Health Columbia University New York New York USA
| | - Jimmy Duong
- Department of Biostatistics Mailman School of Public Health Columbia University New York New York USA
| | - Manasi Chitre
- Department of Emergency Medicine Division of Pediatric Emergency Medicine Columbia University Vagelos College of Physicians and Surgeons New York New York USA
- Department of Pediatrics Division of Pediatric Emergency Medicine Albert Einstein College of Medicine Bronx New York USA
| | - Peter S. Dayan
- Department of Emergency Medicine Division of Pediatric Emergency Medicine Columbia University Vagelos College of Physicians and Surgeons New York New York USA
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Abstract
Urinary tract infection (UTI) is the most common type of urogenital disease. UTI affects the urethra, bladder, ureter, and kidney. A total of 13.3% of women, 2.3% of men, and 3.4% of children in the United States will require treatment for UTI. Traditionally, bladder (cystitis) and kidney (pyelonephritis) infections are considered independently. However, both infections induce host defenses that are either shared or coordinated across the urinary tract. Here, we review the chemical and biophysical mechanisms of bacteriostasis, which limit the duration and severity of the illness. Urinary bacteria attempt to overcome each of these defenses, complicating description of the natural history of UTI.
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Affiliation(s)
| | - Anne-Catrin Uhlemann
- Department of Medicine and Pathology and Urology, Columbia University, New York, NY, USA;
| | - Jonathan Barasch
- Department of Medicine and Pathology and Urology, Columbia University, New York, NY, USA;
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Hikmat S, Lawrence J, Gwee A. Short Intravenous Antibiotic Courses for Urinary Infections in Young Infants: A Systematic Review. Pediatrics 2022; 149:184548. [PMID: 35075480 DOI: 10.1542/peds.2021-052466] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/11/2021] [Indexed: 11/24/2022] Open
Abstract
CONTEXT Urinary tract infections (UTIs) are common in young infants, yet there is no guidance on the optimal duration of intravenous (IV) treatment. OBJECTIVE To determine if shorter IV antibiotic courses (≤7 days) are appropriate for managing UTIs in infants aged ≤90 days. METHODS PubMed, the Cochrane Library, Medline, and Embase (February 2021) were used as data sources. Included studies reported original data for infants aged ≤90 days with UTIs, studied short IV antibiotic durations (≤7 days), and described at least 1 treatment outcome. The Preferred Reporting Items for Systematic Reviews and Meta-analyses guideline was followed. Studies were screened by 2 investigators, and bias was assessed by using the Newcastle-Ottawa Scale and the Revised Cochrane Risk-of-Bias Tool. RESULTS Eighteen studies with 16 615 young infants were included. The largest 2 studies on bacteremic UTI found no difference in the rates of 30-day recurrence between those treated with ≤7 vs >7 days of IV antibiotics. For nonbacteremic UTI, there was no significant difference in the adjusted 30-day recurrence between those receiving ≤3 vs >3 days of IV antibiotics in the largest 2 studies identified. Three studies of infants aged ≥30 days used oral antibiotics alone and reported good outcomes, although only 85 infants were ≤90 days old. CONCLUSIONS Shorter IV antibiotic courses of ≤7 days and ≤3 days with early switch to oral antibiotics should be considered in infants aged ≤90 days with bacteremic and nonbacteremic UTI, respectively, after excluding meningitis. Further studies of treatment with oral antibiotics alone are needed in this age group.
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Affiliation(s)
- Samar Hikmat
- Faculty of Medicine, Dentistry, and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Jolie Lawrence
- Department of General Medicine, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Amanda Gwee
- Department of General Medicine, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia.,Infectious Diseases & Microbiology Research Group, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
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Sedighi I, Taheri-Moghadam G, Emad-Momtaz H, Vaseghi G, Eshraghi A, Asnaashari F, Mehrpooya M. Protective Effects of Omega-3 Fatty Acids Supplementation Against Renal Parenchymal Scarring in Children with Acute Pyelonephritis: Results of a Pilot Clinical Trial. Curr Pediatr Rev 2022; 18:72-81. [PMID: 34503428 DOI: 10.2174/1573396317666210909153643] [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: 01/13/2021] [Revised: 06/05/2021] [Accepted: 06/30/2021] [Indexed: 11/22/2022]
Abstract
AIM This trial aimed to determine if supplementation with omega-3 fatty acids as an adjunct therapy to antibiotic treatment can have protective effects against renal scar formation after acute pyelonephritis (APN) in pediatric patients. BACKGROUND Current evidence points out that besides antibiotic treatment, early administration of antioxidant and anti-inflammatory compounds may be effective in reducing the occurrence of renal damage following APN in children. OBJECTIVE The main endpoint of the trial was the comparison of the development of renal scarring formation after APN in an omega-3 fatty acids-treated group and in a control-treated group. METHODS This prospective randomized, controlled trial study was conducted from March 2016 to May 2018 on 60 children with a diagnosis APN in a tertiary hospital in Iran. After the diagnosis of APN based on the clinical signs and symptoms, urine analysis, urine culture, and dimercaptosuccinic acid renal scan (DMSA scan), the patients were randomly allocated into either the control group (n=30 patients: received standard antibiotic treatment only) or the intervention group (n=30 patients: received standard antibiotic-treatment in combination with oral omega-3 fatty acids based on the children's weight for three consecutive days). A second DMSA scan was performed for the patients at a minimum of six months after treatment. The development of renal scars was evaluated by comparing the baseline DMSA scan lesions with the follow-up DMSA scan lesions. RESULTS Fifty patients, including 26 and 24 individuals in the control and intervention groups, respectively, completed the entire course of the study. Renal parenchymal involvement based on the baseline DMSA scan was similar in the two groups (p-value =0.85, 0.90, and 0.53 regarding the right, left, and both kidney units together, respectively). Although comparison of the follow-up DMSA scan lesions to the baseline DMSA scan lesions considering the right and left kidneys as separate units between two groups did not reach the significant level, when considering both left and right kidney units together, results showed a statistically significant difference between groups in favor of the intervention group (p-value =0.04). CONCLUSION Although preliminary, the results of this study showed that administration of omega-3 fatty acids, a natural supplement with well-known anti-inflammatory and antioxidant properties, as an adjunct therapy to standard antibiotic treatment might significantly reduce the incidence of the occurrence renal scarring following APN in children. Confirmation of these results requires further studies.
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Affiliation(s)
- Iraj Sedighi
- Pediatrics Department, Faculty of Medicine, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Ghazal Taheri-Moghadam
- Department of Clinical Pharmacy, School of Pharmacy, Medicinal Plants and Natural Products Research Center, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Hossein Emad-Momtaz
- Division of Pediatric Nephrology, Besat Hospital, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Golnaz Vaseghi
- Applied Physiology Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Azadeh Eshraghi
- Department of Clinical Pharmacy, School of Pharmacy, Iran University of Medical Sciences, Tehran, Iran
| | - Farzaneh Asnaashari
- Department of Community and Preventive Medicine, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Maryam Mehrpooya
- Department of Clinical Pharmacy, School of Pharmacy, Medicinal Plants and Natural Products Research Center, Hamadan University of Medical Sciences, Hamadan, Iran
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Law ZW, Ong CCP, Yap TL, Loh AHP, Joseph U, Sim SW, Ong LY, Low Y, Jacobsen AS, Chen Y. Extravesical vs. intravesical ureteric reimplantation for primary vesicoureteral reflux: A systematic review and meta-analysis. Front Pediatr 2022; 10:935082. [PMID: 36340705 PMCID: PMC9633941 DOI: 10.3389/fped.2022.935082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 08/29/2022] [Indexed: 12/04/2022] Open
Abstract
PURPOSE This study aims to compare the outcomes of extravesical (EVUR) and intravesical (IVUR) ureteric reimplantation for primary vesicoureteral reflux (VUR) via systematic review and meta-analysis. METHODS Literature review from Medline, Embase, and Cochrane since inception to March 2022 was performed. Meta-analysis was conducted on eligible randomized controlled trials (RCT) and observational cohort studies (OCS) comparing outcomes between EVUR and IVUR. RESULTS Twelve studies were included, comprising 577 patients (778 ureters) operated by EVUR and 395 patients (635 ureters) by IVUR. Pre-operative VUR grade, postoperative VUR persistence and hydronephrosis was not statistically significant. EVUR had shorter operative time [mean differences (MD) -22.91 min; 95% confidence interval (CI), -44.53 to -1.30, P = 0.04] and hospital stay (MD -2.09 days; 95% CI, -2.82 to -1.36, P < 0.00001) compared to IVUR. Bilateral EVUR had higher risk of postoperative acute urinary retention (ARU) (8.1%) compared to bilateral IVUR (1.7%) (OR = 4.40; 95% CI, 1.33-14.58, P = 0.02). No patient undergoing unilateral EVUR or IVUR experienced ARU. CONCLUSION Both EVUR and IVUR are equally effective in correcting primary VUR. Operative time and hospital stay are shorter after EVUR compared to IVUR. However, bilateral EVUR is associated with higher risk of postoperative ARU.
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Affiliation(s)
- Zhi Wei Law
- Department of Urology, Singapore General Hospital, Singapore, Singapore
| | - Caroline C P Ong
- Department of Pediatric Surgery, KK Women's and Children's Hospital, Singapore, Singapore
| | - Te-Lu Yap
- Department of Pediatric Surgery, KK Women's and Children's Hospital, Singapore, Singapore
| | - Amos H P Loh
- Department of Pediatric Surgery, KK Women's and Children's Hospital, Singapore, Singapore
| | - Udayan Joseph
- Department of Pediatric Surgery, KK Women's and Children's Hospital, Singapore, Singapore
| | - Siam Wee Sim
- Department of Pediatric Surgery, KK Women's and Children's Hospital, Singapore, Singapore
| | - Lin Yin Ong
- Department of Pediatric Surgery, KK Women's and Children's Hospital, Singapore, Singapore
| | - Yee Low
- Department of Pediatric Surgery, KK Women's and Children's Hospital, Singapore, Singapore
| | - Anette S Jacobsen
- Department of Pediatric Surgery, KK Women's and Children's Hospital, Singapore, Singapore
| | - Yong Chen
- Department of Pediatric Surgery, KK Women's and Children's Hospital, Singapore, Singapore
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Moustafa BH, Rabie MM, El Hakim IZ, Badr A, El Balshy M, Kamal NM, Ali RM, Moustafa BH, Rabie MM, El Hakim IZ, Badr A, El Balshy M, Ali RM. Egyptian pediatric clinical practice guidelines for urinary tract infections in infants and children (evidence based). EGYPTIAN PEDIATRIC ASSOCIATION GAZETTE 2021. [DOI: 10.1186/s43054-021-00073-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
National evidence-based recommendations for diagnosis, treatment, imaging, and follow-up in urinary tract infection are crucial being a major health problem in pediatrics. Every region should follow international recommendations with respect to the disease local profile and available facilities for that area.
Methods
Based on AGREE II (the assessment tool of practice guidelines), Egyptian CGLs used *American Academy Pediatrics, *European Association Urology, European Society Pediatric Urology, and *Asian Association Urinary tract infections as its evidence-based references. Health questions were listed for evidence base answers adopted from selected CGLs after their permission. Key statements were approved by all members and further approved by the Egyptian Pediatric Guidelines Committee after local and international external peer reviewing.
Results
(1) Diagnosis recommendations: Urine culture with diagnostic colony counts is essential for diagnosis. Catheter samples are important for critical cases and non-toilet-trained cases especially when they show significant bacteriuria and pyuria. (2) Treatment plan included areas of debate as choice of antibiotic, oral versus intravenous, duration, antibiotic prophylaxis considering age, disease severity, recurrence, + risk factors, and imaging reports. (3) Imaging recommendations were tailored to suit our community. Renal bladder ultrasound is important for children with febrile UTI, due to the high prevalence of congenital anomalies of the kidney and urinary tract, paucity of prenatal ultrasound, and lack of medical documentation to reflect previously diagnosed UTI or US reports. We recommend renal isotopic scan and voiding cystography for serious presentation, high-risk factors, recurrence, and abnormal US. (4) Urological consultation is recommended: in urosepsis or obstruction, male infants < 6 months. Acute basal DMSA is recommended in congenital renal hypodysplasia. Six months post-infection, US and DMSA are recommended in severe pyelonephritis and vesico-ureteric reflux, where those with abnormal US or DMSA or both should have voiding cystography. (5) Follow-up recommendations include family orientation with hazards of noncompliance and monitoring at pregnancy.
Conclusion
Diagnosis and treatment show strong recommendations. Imaging depends on patient assessment. Referral to a pediatric nephrologist and urologist in complicated cases is crucial. Follow-up after the age of 16 years in adult clinics is important.
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Stultz JS, Francis N, Ketron S, Bagga B, Shelton CM, Lee KR, Arnold SR. Analysis of Community-Acquired Urinary Tract Infection Treatment in Pediatric Patients Requiring Hospitalization: Opportunity for Use of Narrower Spectrum Antibiotics. J Pharm Technol 2021; 37:79-88. [PMID: 34752558 DOI: 10.1177/8755122520964435] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background: The most narrow-spectrum antibiotic possible should be used for empiric and definitive treatment of pediatric urinary tract infections (UTIs). Objectives: The objectives of this study were to determine an appropriate narrow-spectrum antibiotic for empiric UTI treatment, factors differentiating empiric first-generation cephalosporin (FGC) versus third-generation cephalosporin (TGC) coverage, and factors associated with unnecessarily broad-spectrum definitive antibiotic treatment. Methods: This was a retrospective chart review of children admitted from 2013 to 2015 who were diagnosed with a UTI and received treatment. Multivariable logistic regression assessed independent factors associated with our outcomes. Results: Of 568 diagnosed UTIs, 88.6% received empiric TGC treatment. Empiric coverage among cultured organisms was only 5.4% lower in FGC versus TGC. Adolescent age group (odds ratio [OR] = 8.83, 95% confidence interval [CI] = 1.47-53.11), uncircumcised males (OR = 4.52, 95% CI = 1.27-16.08), Hispanic ethnicity (OR = 4.37, 95% CI = 1.14-16.82), and hospitalization within the preceding 3 months (OR = 4.73, 95% CI = 1.38-16.23) were associated with FGC nonsusceptibility among TGC susceptible Enterobacteriaceae pathogens. De-escalation occurred in 55.8% of diagnosed UTIs eligible for de-escalation at discharge. Urine white blood cell (WBC) count >5 (OR = 2.89, 95% CI = 1.14-7.21), serum WBC count (OR = 1.04, 95% CI = 1.01-1.07), and having only one narrow-spectrum treatment option (OR = 5.1, 95% CI = 2.43-10.66) were associated with unnecessarily broad-spectrum definitive treatment. Conclusion and Relevance: FGC would be an appropriate narrow-spectrum empiric agent for UTIs at our institution. The factors associated with FGC nonsusceptibility can further stratify empiric treatment decisions. The factors associated with unnecessarily broad-spectrum definitive treatment illustrate areas for educational efforts and future research regarding UTI treatment.
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Affiliation(s)
- Jeremy S Stultz
- The University of Tennessee Health Science Center, Memphis, TN, USA.,Le Bonheur Children's Hospital, Memphis, TN, USA
| | - Natalie Francis
- The University of Tennessee Health Science Center, Memphis, TN, USA.,Le Bonheur Children's Hospital, Memphis, TN, USA
| | | | - Bindiya Bagga
- The University of Tennessee Health Science Center, Memphis, TN, USA.,Le Bonheur Children's Hospital, Memphis, TN, USA
| | - Chasity M Shelton
- The University of Tennessee Health Science Center, Memphis, TN, USA.,Le Bonheur Children's Hospital, Memphis, TN, USA
| | - Kelley R Lee
- The University of Tennessee Health Science Center, Memphis, TN, USA.,Le Bonheur Children's Hospital, Memphis, TN, USA
| | - Sandra R Arnold
- The University of Tennessee Health Science Center, Memphis, TN, USA.,Le Bonheur Children's Hospital, Memphis, TN, USA
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Association between vesicoureteral reflux, urinary tract infection and antibiotics exposure in infancy and risk of childhood asthma. PLoS One 2021; 16:e0257531. [PMID: 34547047 PMCID: PMC8454937 DOI: 10.1371/journal.pone.0257531] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 09/06/2021] [Indexed: 11/19/2022] Open
Abstract
Background The use of antibiotics for treating infection in childhood and their association with increased risk of asthma remain controversial. Infants diagnosed with vesicoureteral reflux (VUR) belong to a unique population who are administered antibiotics for a long time and are susceptible to recurrent UTI. It is interesting to study the risk of asthma in these infants with or without VUR. Methods Taiwanese children born between 2000 and 2007 were enrolled in population-based birth cohort study. Participants diagnosed with VUR and UTI within first year were classified into four groups (VUR, UTI, VUR and UTI, and control). We calculated follow-up person-years for each participant from the index date until the asthma diagnosis, their withdrawal from the insurance system (because of death or loss to follow-up), or till the end of 2008. The risk of asthma was compared between the 4 cohorts by using Cox proportional hazards model analysis, adjusted hazard ratio (aHR), and 95% confidence interval (95% CI). Results Children diagnosed with VUR (n = 350), UTI (n = 15542), VUR and UTI (n = 1696), and randomly selected controls (n = 17588) were enrolled. The overall rate of incidence of asthma was found to be 1.64-fold, 1.45-fold, and 1.17-fold higher in the UTI, VUR/UTI, and VUR cohorts than in the controls (5.60, 5.07, and 4.10 vs. 3.17 per 100 person-years), respectively. After adjusting the potential factors, the overall risk of asthma remained the highest in UTI (aHR: 1.74, 95% CI : 1.65 to 1.80) followed by VUR/UTI (aHR: 1.56, 95% CI : 1.40 to 1.75) and VUR cohorts (aHR: 1.25, 95% CI: 0.96 to 1.62). The incidence of asthma was higher in boys than in girls. Conclusion The nationwide retrospective cohort study demonstrated that short-term therapeutic dose of antibiotics for UTI in infants with or without VUR has a positive correlation with the prevalence of childhood asthma. Significant risk of childhood asthma was not observed when VUR cohort was exposed to long-term low-dose of prophylactic antibiotics.
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Breinbjerg A, Jørgensen CS, Frøkiær J, Tullus K, Kamperis K, Rittig S. Risk factors for kidney scarring and vesicoureteral reflux in 421 children after their first acute pyelonephritis, and appraisal of international guidelines. Pediatr Nephrol 2021; 36:2777-2787. [PMID: 33754234 DOI: 10.1007/s00467-021-05042-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 02/05/2021] [Accepted: 03/03/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Acute pyelonephritis (AP) is a common bacterial infection in childhood. Follow-up guidelines on these children are controversial. This study aimed to identify risk factors for kidney scarring and vesicoureteral reflux (VUR). Furthermore, international follow-up guidelines were used for simulation to evaluate sensitivity and specificity. METHODS Urinary culture-confirmed first-time AP patients (aged 0-14 years) were enrolled (n = 421) from review of patient charts. All underwent kidney ultrasound (US) and a technetium-99m-dimercaptosuccinic acid (DMSA) scan or technetium-99m-mercaptoacetyltriglycine scinti-renography (MAG3) at 4-6 months of follow-up. The international guidelines used for simulation were from the National Institute of Health UK (NICE), the American Association of Paediatrics (AAP) and the Swedish Paediatric Society (SPS). RESULTS 17.8% presented with an abnormal DMSA/MAG3 at follow-up, 7.1% were diagnosed with VUR grades III-V and 4.7% were admitted for surgery. Non-Escherichia coli infections, abnormal kidney US, elevated creatinine and delayed response to treatment (>48 h) were risk factors for abnormal DMSA findings and VUR grades III-V. NICE and SPS guidelines showed best sensitivity in diagnosing VUR grades III-V (75%) compared with AAP (56%). CONCLUSIONS Risk factors are helpful in identifying the children in need of further investigations and minimizing invasive work-up for the rest. International guidelines on follow-up detect a varying number of children with kidney damage and/or significant VUR. Future work must focus on identifying more specific risk factors, better imaging, or specific biomarkers, to enhance sensitivity and specificity in detecting the children at high risk for developing recurrent infections and/or nephropathy.
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Affiliation(s)
- Anders Breinbjerg
- Department of Pediatric and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark.
| | | | - Jørgen Frøkiær
- Department of Clinical Medicine, Department of Nuclear Medicine and PET Centre, Aarhus University Hospital, Aarhus University, Aarhus, Denmark
| | - Kjell Tullus
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Konstantinos Kamperis
- Department of Pediatric and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Søren Rittig
- Department of Pediatric and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
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Yang SS, Tsai JD, Kanematsu A, Han CH. Asian guidelines for urinary tract infection in children. J Infect Chemother 2021; 27:1543-1554. [PMID: 34391623 DOI: 10.1016/j.jiac.2021.07.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 06/08/2021] [Accepted: 07/11/2021] [Indexed: 11/25/2022]
Abstract
The followings are the level of evidence (LE) and grade of recommendation (GR) on pediatric UTI in Asia. Classification according to the sites of infection (lower versus upper tract), the number of episode (first versus recurrent), the severity (simple versus severe), or the existence of complicating factor (uncomplicated versus complicated) is useful to differentiate children with UTI whether they are at risk of renal damage or not (LE: 2, GR: B). Diagnosis of UTI requires both urinalysis that suggests infection and positive urine culture (LE:3, GR B). For pre-toilet trained children, urine specimen for culture should be collected by urethral catheterization or suprapubic aspiration. For toilet trained children, midstream clean catch urine is reliable (LE: 3, GR: A). Urine culture is considered positive if it demonstrates growth of a single bacterium with the following colony counts: (1) any growth by suprapubic aspiration, (2) >5 × 104 CFU/ml by urethral catheterization, or (3) >105 CFU/ml by midstream clean catch (LE:3, GR: B). For children with febrile UTI, renal and bladder ultrasonography (RBUS) should be routinely performed as soon as possible (LE: 3, GR: C). RBUS should be followed up 6 months later in children with acute pyelonephritis and/or VUR (LE: 3, GR: C). Acute DMSA scan can be performed when severe acute pyelonephritis or congenital hypodysplasia is noted on RBUS or when the diagnosis of UTI is in doubt by the clinical presentation (LE: 3, GR: C). Late DMSA scan (>6 months after the febrile UTI) can be performed in children with severe acute pyelonephritis, high-grade VUR, recurrent febrile UTIs, or abnormal renal parenchyma on the follow-up RBUS (LE: 3, GR: C). Top-down or bottom-up approach for febrile UTI is suggested for the diagnosis of VUR. For top-down approach, VCUG should not be performed routinely for children after the first febrile UTI. VCUG is indicated when abnormalities are apparent on either RBUS or DMSA scan or both (LE: 2, GR: B). VCUG is also suggested after a repeat febrile UTI (LE:2, GR: B). Appropriate antibiotic should be given immediately after urine specimen for culture has been obtained (LE:2, GR: A). Initiating therapy with oral or parenteral antibiotics is equally efficacious for children (>3 months) with uncomplicated UTI (LE: 2: GR: A). The choice of empirical antibiotic agents is guided by the expected pathogen and the local resistance patterns (LE: 2, GR: A). For children with febrile UTI, the total course of antibiotic therapy should be 7-14 days (LE: 2, GR: B). Circumcision may, but not definitively, reduce the risk of febrile UTI in males and breakthrough febrile UTI in males with VUR. Circumcision should be offered to uncircumcised boys with febrile UTI and VUR in countries where circumcision is accepted by the general population (LE: 3, GR: B), while in countries where childhood circumcision is rarely performed, other measures for febrile UTI/VUR should be the preferred choice (LE: 4, GR: C). Bladder bowel dysfunction (BBD) is one of the key factors of progression of renal scarring (LE: 2). Early recognition and management of BBD are important in prevention of UTI recurrence (LE:2, GR: A). Antibiotic prophylaxis to prevent recurrent febrile UTI is indicated in children with moderate to high grade (III-V) VUR (LE: 1b, GR: A). Surgical intervention may be used to treat VUR in the setting of recurrent febrile UTI because it has been shown to decrease the incidence of recurrent pyelonephritis (LE: 2, GR: B).
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Affiliation(s)
- Stephen S Yang
- Division of Urology, Taipei Tzu Chi Hospital, Medical Foundation, New Taipei, Taiwan; Buddhist Tzu Chi University, Hualien, Taiwan.
| | - Jeng-Daw Tsai
- Department of Medicine, Mackay Medical College, Taiwan; Department of Pediatric Nephrology, MacKay Children's Hospital, Taiwan; Department of Pediatrics, Taipei Medical University Hospital, Taipei, Taiwan; Department of Pediatrics, School of Medicine, College of Medicine, Taipei Medical University, Taiwan
| | | | - Chang-Hee Han
- Department of Urology, Uijeongbu ST. Mary's Hospital, College of Medicine, The Catholic University of Korea, Uijeongbu, Republic of Korea
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Effectiveness and risks of endoscopic management compared to vesicoureteral reimplantation in patients with high-grade vesicoureteral reflux: systematic review and network meta-analysis. Eur J Pediatr 2021; 180:1383-1391. [PMID: 33474581 DOI: 10.1007/s00431-021-03948-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 01/11/2021] [Accepted: 01/14/2021] [Indexed: 10/22/2022]
Abstract
The purpose of this study is to determine the effectiveness and safety of endoscopic management compared to ureterovesical reimplantation in pediatric patients with high-grade vesicoureteral reflux in terms of urinary tract infection. We performed a network meta-analysis. We searched in MEDLINE, EMBASE, LILACS, and CENTRAL. We included clinical experiments, quasi-experiments, and cohorts studies. The population was men and women between 1 month and 15 years old. Patients had primary high-grade VUR diagnosed by voiding cystourethrography. The interventions were subureteric bulking agent endoscopic injection (polytetrafluoroethylene, hyaluronic acid, collagen, Dx/Ha, and PPC) vs vesicoureteral reimplantation (Cohen, Politano-Leadbetter, Glenn-Anderson, and Lich-Gregoir), and the primary outcome was urinary infections. Nine studies accomplished the inclusion criteria (seven observational and two clinical experiments). A total of 1448 renal units underwent surgical treatments for the correction of high-grade VUR. Regarding the primary outcome, we compared Dx/Ha with Cohen, Lich-Gregoir, and PPC, finding an RD of -0.02 (95%CI -0.09 to 0.06), RD of -0.02 (95%CI -0.10 to 0.07), and an RD of -0.03 (- 0.13 to 0.07), respectively.Conclusion: Our study showed that there were no differences in UTI episodes after VUR correction in patients undergoing endoscopic management compared with vesicoureteral reimplantation. What is Known: • Primary vesicoureteral reflux is one of the most common congenital anomalies of the urinary tract. • The clinical practice guidelines recommend the surgical management of patients with high-grade VUR. What is New: • There were no differences in UTI episodes after VUR correction in patients undergoing endoscopic management compared with vesicoureteral reimplantation.
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Akarken I, Tarhan H, Arslan FD, Sarıtas S, Yavascan O, Sahin H, Tekgul S. Is endothelial glycocalyx damage a cause of renal scarring in vesicoureteral reflux with febrile urinary tract infection? Nephrol Ther 2021; 17:175-179. [PMID: 33941491 DOI: 10.1016/j.nephro.2021.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 01/01/2021] [Accepted: 01/05/2021] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Endothelial glycocalyx is a luminal layer which can be damaged by inflammatory agents or pathogens. The endothelial glycocalyx damage is thought to have a role in the formation of renal scars in children who have febrile urinary tract infection and vesicoureteral reflux. This study aimed to compare the blood levels of endothelial glycocalyx components heparan sulfate and Syndecan-1 in children with and without renal scarring due to vesicoureteral reflux-associated febrile urinary tract infection. MATERIALS AND METHODS Data of the patients diagnosed with vesicoureteral reflux without renal scarring (Group 1), patients with vesicoureteral reflux and renal scarring (Group 2), and completely healthy children (Group 3) were retrospectively reviewed. Blood levels of heparan sulfate and Syndecan-1 were measured and the results were compared. RESULTS The entire cohort consisted of 90 patients; there were 30 patients in each group. Mean patient age was 49.7±18.0 months. Mean serum heparan sulfate (42.90±18.90 ng/mL) and Syndecan-1 (37.59±13.77 ng/mL) levels of Group 2 were significantly higher than those of other groups. The cut-off value for heparan sulfate was 35.17 ng/mL, with a 63% sensitivity and 86% specificity. The cut-off value for Syndecan-1 was 29.99 ng/mL with a 70% sensitivity and 80% specificity. CONCLUSION Our findings indicate that blood levels of heparan sulfate and Syndecan-1 could be related with renal scarring in patients with vesicoureteral reflux, especially in the setting of febrile urinary tract infection. However, due to their low sensitivity, these biomarkers should be used along with clinical data.
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Affiliation(s)
- Ilker Akarken
- Mugla Sıtkı Kocman University, School of medicine, Department of urology, Turkey
| | - Huseyin Tarhan
- Mugla Sıtkı Kocman University, School of medicine, Department of urology, Turkey.
| | - Fatma Demet Arslan
- Izmir Tepecik Education and Research Hospital, Department of biochemistry, Turkey
| | - Serdar Sarıtas
- Izmir Tepecik Education and Research Hospital, Department of pediatric nephrology, Turkey
| | - Onder Yavascan
- Medipol University, School of medicine, Department of pediatric nephrology, Turkey
| | - Hayrettin Sahin
- Mugla Sıtkı Kocman University, School of medicine, Department of urology, Turkey
| | - Serdar Tekgul
- Hacettepe University, School of medicine, Department of urology, Turkey
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Editorial: Urinary tract obstruction in children. Curr Opin Pediatr 2021; 33:217-219. [PMID: 33605626 DOI: 10.1097/mop.0000000000001002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Lertdumrongluk K, Lertdumrongluk P. Predictive score for vesicoureteral reflux in children with a first febrile urinary tract infection. Int J Urol 2021; 28:573-577. [PMID: 33745167 DOI: 10.1111/iju.14515] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Accepted: 01/05/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To develop a simple score for predicting vesicoureteral reflux after a first febrile urinary tract infection in children. METHODS A retrospective cohort study was conducted for a 12-year period (January 2008 to December 2019), including patients aged <72 months who underwent renal ultrasonography and voiding cystourethrography after a first febrile urinary tract infection. Patients with a history of antenatal hydronephrosis were excluded. The prediction model and score for vesicoureteral reflux were developed using multivariate logistic regression analysis. RESULTS Out of 260 patients in total (median age 4 months, 172 boys), 41 (16%) had vesicoureteral reflux. The score was based on four independent risk factors, including age >6 months (odds ratio 2.71, 95% confidence interval 1.27-5.76), presence of sepsis (odds ratio 3.44, 95% confidence interval 1.31-9.04), white blood cell count ≥15 000/mm3 (odds ratio 1.83, 95% confidence interval 0.88-3.8) and abnormal renal ultrasonography results (odds ratio 2.08, 95% confidence interval 1-4.31). A lower probability of vesicoureteral reflux (positive likelihood ratio = 0.66; P = 0.001) was found in the low-risk group (scores 0-2), whereas a higher probability of vesicoureteral reflux (positive likelihood ratio = 2.54; P = 0.001) was found in the high-risk group (scores 3-5). The predictive ability of the model was 70%. CONCLUSIONS The scores developed based on the patient characteristics and renal ultrasonography are useful in predicting presence of vesicoureteral reflux after a first febrile urinary tract infection in children and could guide clinicians' decisions to perform additional imaging studies.
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Affiliation(s)
- Kanita Lertdumrongluk
- Department of Paediatrics, Charoenkrung Pracharak Hospital, Bangkok Metropolitan Administration, Bangkok, Thailand
| | - Paungpaga Lertdumrongluk
- Panyananthaphikkhu Chonprathan Medical Center, Srinakharinwirot University, Nonthaburi, Thailand
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Sex Differences in Population Dynamics during Formation of Kidney Bacterial Communities by Uropathogenic Escherichia coli. Infect Immun 2021; 89:IAI.00716-20. [PMID: 33468577 DOI: 10.1128/iai.00716-20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 01/11/2021] [Indexed: 11/20/2022] Open
Abstract
Uropathogenic Escherichia coli (UPEC), the primary etiologic agent of urinary tract infections (UTIs), encounters a restrictive population bottleneck within the female mammalian bladder. Its genetic diversity is restricted during establishment of cystitis because successful UPEC must invade superficial bladder epithelial cells prior to forming clonal intracellular bacterial communities (IBCs). In this study, we aimed to understand UPEC population dynamics during ascending pyelonephritis, namely, formation of kidney bacterial communities (KBCs) in the renal tubular lumen and nucleation of renal abscesses. We inoculated the bladders of both male and female C3H/HeN mice, a background which features vesicoureteral reflux; we have previously shown that in this model, males develop severe, high-titer pyelonephritis and renal abscesses much more frequently than females. Mice were infected with 40 isogenic, PCR-tagged ("barcoded") UPEC strains, and tags remaining in bladder and kidneys were ascertained at intervals following infection. In contrast to females, males maintained a majority of strains within both the bladder and kidneys throughout the course of infection, indicating only a modest host-imposed bottleneck on overall population diversity during successful renal infection. Moreover, the diverse population in the infected male kidneys obscured any restrictive bottleneck in the male bladder. Finally, using RNA in situ hybridization following mixed infections with isogenic UPEC bearing distinct markers, we found that despite their extracellular location (in the urinary space), KBCs are clonal in origin. This finding indicates that even with bulk reflux of infected bladder urine into the renal pelvis, successful ascension of UPEC to establish the tubular niche is an uncommon event.
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Arapović A, Punda A, Brdar D, Čapkun V, Bajo D, Veljačić D, Punda H, Simičić-Majce A, Saraga-Babić M, Vukojević K, Saraga M. Types of Parenchymal Changes Diagnosed on DMSA Scans of Kidneys Affected by Different Grades of Vesicoureteral Reflux. Med Sci Monit 2021; 27:e929617. [PMID: 33647007 PMCID: PMC7934341 DOI: 10.12659/msm.929617] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background Renal parenchymal damage and scarring usually is associated with urinary tract infection (UTI), whereas the impact of vesicoureteral reflux (VUR) on the kidneys is unclear. We aimed to compare kidneys with all grades of VUR (grades Io-V) and those without VUR by using direct radionuclide cystography, voiding cystourethrography, and findings from 99mTc-DMSA scintigraphy (DMSA scan). Material/Methods The present analysis included 253 renal ureteral units (RUU) from 129 children with VUR and recurrent UTI and children with a single febrile UTI associated with abnormal ultrasonographic findings. The 6 grades of VUR (Io, I, II, III, IV, and V) and 35 RUUs without VUR were divided into 4 groups: 1. Non-dilated VUR (grades Io-II); 2. Mildly dilated VUR (grade III); 3. Dilated VUR (grades IV–V); and 4. The control group. Results DMSA scanning showed significant differences between the groups with non-dilated VUR, grade III VUR, grades IV–V VUR, and the control group in kidney width (χ2=30.5; P<0.001); position and shape (χ2=30.6; P<0.001); intensity of activity (χ2=38.1; P<0.001); distribution of activity (χ2=34.5; P<0.001); and existence of scars (χ2=16; P<0.001). The probability of abnormalities on DMSA scans increased with the VUR grade. However, inside the groups of dilated and non-dilated VUR we found no significant statistical differences between those characteristics. Conclusions Our results indicate that kidneys without VUR or with non-dilated lateral VUR and dilated VUR on the contralateral side represent 2 different categories of parenchymal changes.
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Affiliation(s)
- Adela Arapović
- Department of Pediatrics, University Hospital in Split, Split, Croatia
| | - Ante Punda
- School of Medicine, University of Split, Split, Croatia
| | - Dubravka Brdar
- Department of Nuclear Medicine, University Hospital in Split, Split, Croatia
| | - Vesna Čapkun
- Department of Nuclear Medicine, University Hospital in Split, Split, Croatia
| | - Diana Bajo
- Department of Rheumatology and Clinical Immunology, University Hospital in Split, Split, Croatia
| | - Daniela Veljačić
- Department of Pediatrics, University Hospital in Split, Split, Croatia
| | - Hrvoje Punda
- Department of Radiology, University Hospital in Split, Split, Croatia
| | - Ana Simičić-Majce
- Department of Pediatrics, University Hospital in Split, Split, Croatia
| | - Mirna Saraga-Babić
- Department of Anatomy, Histology and Embryology, School of Medicine, University of Split, Split, Croatia
| | - Katarina Vukojević
- Department of Anatomy, Histology and Embryology, School of Medicine, University of Split, Split, Croatia
| | - Marijan Saraga
- Department of Pediatrics, University Hospital in Split, Split, Croatia.,School of Medicine, University of Split, Split, Croatia
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Groen in 't Woud S, Westland R, Feitz WF, Roeleveld N, van Wijk JA, van der Zanden LF, Schreuder MF. Clinical Management of Children with a Congenital Solitary Functioning Kidney: Overview and Recommendations. EUR UROL SUPPL 2021; 25:11-20. [PMID: 34337499 PMCID: PMC8317823 DOI: 10.1016/j.euros.2021.01.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/05/2021] [Indexed: 11/25/2022] Open
Abstract
CONTEXT A congenital solitary functioning kidney (cSFK) is a common developmental defect that predisposes to hypertension and chronic kidney disease (CKD) as a consequence of hyperfiltration. Every urologist takes care of patients with a cSFK, since some will need lifelong urological care or will come with clinical problems or questions to an adult urologist later in life. OBJECTIVE We aim to provide clear recommendations for the initial clinical management and follow-up of children with a cSFK. EVIDENCE ACQUISITION PubMed and EMBASE were searched to identify relevant publications, which were combined with guidelines on related topics and expert opinion. EVIDENCE SYNTHESIS Initially, cSFK diagnosis should be confirmed and risk factors for kidney injury should be identified using ultrasound. Although more research into early predictors of kidney injury is needed, additional congenital anomalies of the kidney or urinary tract and absence of compensatory kidney hypertrophy have repeatedly been associated with a worse prognosis. The role of voiding cystourethrography and antibiotic prophylaxis remains controversial, and is complicated by the exclusion of children with a cSFK from studies. A yearly follow-up for signs of kidney injury is recommended for children with a cSFK. As masked hypertension is prevalent, annual ambulatory blood pressure measurement should be considered. During puberty, an increasing incidence of kidney injury is seen, indicating that long-term follow-up is necessary. If signs of kidney injury are present, angiotensin converting enzyme inhibitors are the first-line drugs of choice. CONCLUSIONS This overview points to the urological and medical clinical aspects and long-term care guidance for children with a cSFK, who are at risk of hypertension and CKD. Monitoring for signs of kidney injury is therefore recommended throughout life. Large, prospective studies with long-term follow-up of clearly defined cohorts are still needed to facilitate more risk-based and individualized clinical management. PATIENT SUMMARY Many children are born with only one functioning kidney, which could lead to kidney injury later in life. Therefore, a kidney ultrasound is made soon after birth, and other investigations may be needed as well. Urologists taking care of patients with a solitary functioning kidney should realize the long-term clinical aspects, which might need medical management.
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Affiliation(s)
- Sander Groen in 't Woud
- Department for Health Evidence, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
- Department of Pediatric Nephrology, Radboudumc Amalia Children’s Hospital, Radboud Institute for Molecular Life Sciences, Nijmegen, The Netherlands
| | - Rik Westland
- Department of Pediatric Nephrology, Amsterdam UMC, Amsterdam, The Netherlands
| | - Wout F.J. Feitz
- Division of Pediatric Urology, Department of Urology, Radboudumc Amalia Children’s Hospital, Radboud Institute for Molecular Life Sciences, Nijmegen, The Netherlands
| | - Nel Roeleveld
- Department for Health Evidence, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Joanna A.E. van Wijk
- Division of Pediatric Urology, Department of Urology, Radboudumc Amalia Children’s Hospital, Radboud Institute for Molecular Life Sciences, Nijmegen, The Netherlands
| | - Loes F.M. van der Zanden
- Department for Health Evidence, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Michiel F. Schreuder
- Department of Pediatric Nephrology, Radboudumc Amalia Children’s Hospital, Radboud Institute for Molecular Life Sciences, Nijmegen, The Netherlands
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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: 61] [Impact Index Per Article: 20.3] [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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Evaluation of the Diagnostic Value of Contrast-Enhanced Voiding Urosonography with Regard to the Further Therapy Regime and Patient Outcome-A Single-Center Experience in an Interdisciplinary Uroradiological Setting. ACTA ACUST UNITED AC 2021; 57:medicina57010056. [PMID: 33435420 PMCID: PMC7826578 DOI: 10.3390/medicina57010056] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 01/03/2021] [Accepted: 01/06/2021] [Indexed: 01/11/2023]
Abstract
Background and Objectives: Vesicoureteral reflux (VUR) describes a common pediatric anomaly in pediatric urology with a prevalence of 1-2%. In diagnostics, in addition to the gold standard of voiding cystourethrography (VCUG), contrast-enhanced urosonography (ceVUS) offers a radiation-free procedure, which, despite its advantages, is not yet widely used. In the present single-center study, subsequent therapeutic procedures and outcomes after ceVUS of 49 patients were investigated. The aim of the study is to investigate the efficacy of ceVUS with the intention of broader clinical implementation. Materials and Methods: Between 2016 and 2020, 49 patients were retrospectively included and received a ceVUS to evaluate VUR. With a distribution of 47:2 (95.9%), a clear female predominance was present. The age of the patients varied between 5 months and 60 years at the time of ceVUS. All examinations were all performed and subsequently interpreted by a single experienced radiologist (EFSUMB level 3). Results: Compared to intraoperative findings, ceVUS shows a sensitivity of 95.7% with a specificity of 100%. Allergic reactions to the contrast medium could not be observed. Conclusion: With its high sensitivity and intraoperative validation, ceVUS offers an excellent alternative to VCUG, the gold standard in the diagnosis of VUR. In addition, ceVUS is a radiation-free examination method with a low risk profile that offers an exceptional diagnostic tool in the diagnostic clarification of recurrent urinary tract infections with the suspected diagnosis of VUR and should also be included in the consideration of a diagnosis next to the established VCUG, especially in younger children.
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Vaseghi G, Eshraghi A, Rahimzadeh N, Amiri H, Jahed M. Evaluation of Serum Level of Carnitine in Children with Acute Pyelonephritis (APN) Compared to Healthy Children. Rev Recent Clin Trials 2021; 16:212-215. [PMID: 33148156 DOI: 10.2174/1574887115666201104154227] [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: 05/02/2020] [Revised: 10/06/2020] [Accepted: 10/07/2020] [Indexed: 06/11/2023]
Abstract
AIM This cross-sectional case-control study evaluated the serum carnitine level in children with urinary tract infection (UTI). BACKGROUND Acute pyelonephritis (APN) is a common bacterial infection of the upper urinary tract in children which may also lead to renal damage and tubular atrophy. Activation of inflammatory mediator bedside alterations in the cytokines and generation of reactive oxygen species (ROS) play a striking role in the development of tissue damage after pyelonephritis. L-carnitine as one of the most potent natural antioxidant agents by inhibition of lipid peroxidation may protect cells and tissues from damage. METHODS A total of 30 children with UTI (as a case group) and 30 healthy children (as a control group) which matched in terms of age and sex were enrolled in this study. All children were evaluated and compared with respect to age, sex, weight, body mass index (BMI) and serum carnitine level. Serum carnitine level was determined using serum carnitine ELISA kit. RESULTS Demographic and clinical data such as age, sex, weight and BMI were not statistically significant between the two groups. The serum carnitine levels were significantly lower in the case group with UTI than the control group. Mean serum carnitine concentration in the case group and in the control group was 36.56 ± 9.87 μmol/l and 62.8±21.35, respectively (P = 0.001). CONCLUSION According to our study, it could be concluded that low serum L-carnitine level is linked to UTI in children. Therefore, further studies are needed to confirm our results.
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Affiliation(s)
- Golnaz Vaseghi
- Applied Physiology Research Center, Isfahan Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Azadeh Eshraghi
- Department of Clinical Pharmacy, Iran University of Medical Sciences, Tehran, Iran
| | - Nahid Rahimzadeh
- Department of Pediatric Nephrology, Iran University of Medical Sciences, Tehran, Iran
| | - Hasan Amiri
- Department of Emergency Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Mohammadreza Jahed
- Department of Clinical Pharmacy, Iran University of Medical Sciences, Tehran, Iran
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Swiss consensus recommendations on urinary tract infections in children. Eur J Pediatr 2021; 180:663-674. [PMID: 32621135 PMCID: PMC7886823 DOI: 10.1007/s00431-020-03714-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Revised: 05/10/2020] [Accepted: 06/02/2020] [Indexed: 12/24/2022]
Abstract
The kidneys and the urinary tract are a common source of infection in children of all ages, especially infants and young children. The main risk factors for sequelae after urinary tract infections (UTI) are congenital anomalies of the kidney and urinary tract (CAKUT) and bladder-bowel dysfunction. UTI should be considered in every child with fever without a source. The differentiation between upper and lower UTI is crucial for appropriate management. Method of urine collection should be based on age and risk factors. The diagnosis of UTI requires urine analysis and significant growth of a pathogen in culture. Treatment of UTI should be based on practical considerations regarding age and presentation with adjustment of the initial antimicrobial treatment according to antimicrobial sensitivity testing. All children, regardless of age, should have an ultrasound of the urinary tract performed after pyelonephritis. In general, antibiotic prophylaxis is not recommended.Conclusion: Based on recent data and in line with international guidelines, multidisciplinary Swiss consensus recommendations were developed by members of Swiss pediatric infectious diseases, nephrology, and urology societies giving the clinician clear recommendations in regard to diagnosis, type and duration of therapy, antimicrobial treatment options, indication for imaging, and antibiotic prophylaxis. What is Known: • Urinary tract infections (UTI) are a common and important clinical problem in childhood. Although children with pyelonephritis tend to present with fever, it can be difficult on clinical grounds to distinguish cystitis from pyelonephritis, particularly in young children less than 2 years of age. • Method of urine collection is based on age and risk factors. The diagnosis of UTI requires urine analysis and significant growth of a pathogen in culture. What is New: • Vesicoureteric reflux (VUR) remains a risk factor for UTI but per se is neither necessary nor sufficient for the development of renal scars. Congenital anomalies of the kidney and urinary tract (CAKUT) and bladder-bowel dysfunction play a more important role as causes of long-term sequelae. In general, antibiotic prophylaxis is not recommended. • A switch to oral antibiotics should be considered already in young infants. Indications for invasive imaging are more restrictive and reserved for patients with abnormal renal ultrasound, complicated UTI, and infections with pathogens other than E. coli.
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