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Orfanos I. Decreased incidence of urinary tract infections in febrile infants aged ≤60 days during COVID-19 pandemic. Acta Paediatr 2024; 113:1934-1939. [PMID: 38676461 DOI: 10.1111/apa.17256] [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: 03/15/2024] [Revised: 04/16/2024] [Accepted: 04/19/2024] [Indexed: 04/29/2024]
Abstract
AIM To investigate the incidence rate of urinary tract infections (UTIs) among febrile infants aged ≤60 days before, during, and after the COVID-19 pandemic. METHODS We conducted a retrospective study in 2 Swedish paediatric emergency departments between 2014 and 2022. We included full-term infants aged ≤60 days with fever without source. We calculated the annual incidence rate of UTI per 1000 births. RESULTS We included 1589 full-term infants with fever without source. In 2020, 89 infants were evaluated in the emergency department versus 203-259 in 2017-2019. In 2020, the incidence rate of UTI was 1.43 per 1000 births/year versus 2.18-2.37 in 2017-2019. The median age, sex, fever duration, and urine testing were similar between the years 2017 and 2020. CONCLUSION The number of febrile infants who presented to the paediatric emergency department and the incidence rate of UTIs decreased in 2020. This decrease might imply a systematic misdiagnosis of UTIs in infants with febrile viral infections. A more selective urine testing approach for febrile, previously healthy, infants should be considered to mitigate UTI misdiagnosis and its potential harmful effects.
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Affiliation(s)
- Ioannis Orfanos
- Department of Clinical Sciences, Lund University, Lund, Sweden
- Department of Pediatrics, Skåne University Hospital, Lund University, Lund, Sweden
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van der Steeg HJJ, Luijten JCHBM, Fascetti-Leon F, Miserez M, Samuk I, Stenström P, de Wall LL, de Blaauw I, van Rooij IALM. High-grade Vesicoureteral Reflux in Patients With Anorectal Malformation From the ARM-Net Registry: Is Our Screening Sufficient? J Pediatr Surg 2024; 59:1470-1476. [PMID: 38355337 DOI: 10.1016/j.jpedsurg.2024.01.008] [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: 10/13/2023] [Revised: 12/24/2023] [Accepted: 01/09/2024] [Indexed: 02/16/2024]
Abstract
BACKGROUND Vesico-ureteral reflux (VUR) is a common associated urological anomaly in anorectal malformation (ARM)-patients. High-grade VUR requires antibiotic prophylaxis to prevent urinary tract infections (UTI's), renal scarring and -failure. The exact prevalence of high-grade VUR in ARM patients is unknown. Hence, the aim of this study was determining the incidence of high-grade VUR in ARM-patients, and its associated risk factors. METHODS A multicenter retrospective cohort study was performed using the ARM-Net registry, including data from 34 centers. Patient characteristics, screening for and presence of renal anomalies and VUR, sacral and spinal anomalies, and sacral ratio were registered. Phenotypes of ARM were grouped according to their complexity in complex and less complex. Multivariable analyses were performed to detect independent risk factors for high-grade (grade III-V) VUR. RESULTS This study included 2502 patients (50 % female). Renal screening was performed in 2250 patients (90 %), of whom 648 (29 %) had a renal anomaly documented. VUR-screening was performed in 789 patients (32 %), establishing high-grade VUR in 150 (19 %). In patients with a normal renal screening, high-grade VUR was still present in 10 % of patients. Independent risk factors for presence of high-grade VUR were a complex ARM (OR 2.6, 95 %CI 1.6-4.3), and any renal anomaly (OR 3.3, 95 %CI 2.1-5.3). CONCLUSIONS Although renal screening is performed in the vast majority of patients, only 32 % underwent VUR-screening. Complex ARM and any renal anomaly were independent risk factors for high-grade VUR. Remarkably, 10 % had high-grade VUR despite normal renal screening. Therefore, VUR-screening seems indicated in all ARM patients regardless of renal screening results, to prevent sequelae such as UTI's, renal scarring and ultimately renal failure. TYPE OF STUDY Observational Cohort-Study. LEVEL OF EVIDENCE III.
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Affiliation(s)
- H J J van der Steeg
- Department of Pediatric Surgery, Radboudumc Amalia Children's Hospital, Nijmegen, the Netherlands.
| | - J C H B M Luijten
- Department of Pediatric Surgery, Radboudumc Amalia Children's Hospital, Nijmegen, the Netherlands
| | - F Fascetti-Leon
- Department of Pediatric Surgery, University of Padua, Padua, Italy
| | - M Miserez
- Department of Abdominal Surgery, UZ Leuven, KU Leuven, Belgium
| | - I Samuk
- Department of Pediatric Surgery, Schneider Children's Medical Center, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - P Stenström
- Department of Pediatrics, Clinical Sciences Lund University, Skane University Hospital Lund, Sweden
| | - L L de Wall
- Department of Urology, Division of Pediatric Urology, Radboudumc Amalia Children's Hospital, Nijmegen, the Netherlands
| | - I de Blaauw
- Department of Pediatric Surgery, Radboudumc Amalia Children's Hospital, Nijmegen, the Netherlands
| | - I A L M van Rooij
- Department for Health Evidence, Radboud University Medical Center Nijmegen, the Netherlands
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Mathias S, Greenbaum LA, Shubha AM, Raj JAM, Das K, Pais P. Risk factors for renal scarring and clinical morbidity in children with high-grade and low-grade primary vesicoureteral reflux. J Pediatr Urol 2022; 18:225.e1-225.e8. [PMID: 35094942 DOI: 10.1016/j.jpurol.2021.12.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 12/29/2021] [Accepted: 12/30/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Primary vesicoureteral reflux (VUR) is associated with urinary tract infections (UTIs) and renal damage. However, the importance of early diagnosis of VUR has been questioned. Moreover, most studies have few patients with high-grade VUR. Hence, we retrospectively analyzed a large cohort of patients with primary high-grade and low-grade VUR and assessed risk factors for renal damage and clinical morbidity. MATERIAL AND METHODS We included patients (<18 years) at diagnosis with low-grade (1-3) or high-grade (4-5) primary VUR and noted their clinical history and presence of hypertension, low eGFR (<60ml/in/1.73 m2), renal scarring (focal or generalised) and reduced differential renal function (DRF; <45%). Risk factors were assessed (in patients and renal units) by logistic regression and generalised estimating equation. RESULTS Of 399 primary VUR patients, 255 (64%) had high-grade VUR. Indications for voiding cystourethrogram were recurrent UTI (38%), first UTI (28%) and antenatal hydronephrosis (17%). At diagnosis, 252 (65%) had renal scars (focal in 170 [44%], generalised in 82 [21%]), and 188 (47%) had reduced DRF. High-grade VUR patients were more likely than low-grade VUR patients to have renal scarring (75% vs. 49%, p < 0.01), low eGFR (23% vs. 13%, p = 0.04) and significant hypertension (26% vs. 13%, p = 0.02). High-grade VUR was associated with generalised scars (odds ratio [OR] 11, p < 0.001), focal scars (OR 3.1, p < 0.001) and reduced DRF (OR 2.3, p < 0.001) shown in the table. Male sex was a risk factor for generalised scars (OR 2.3, p = 0.005). Focal scars were associated with recurrent UTIs (OR = 1.8, p = 0.004) and reduced DRF (OR 1.4, p = 0.027). Patients with multiple focal scars were diagnosed at an older age (2 years [1,4] than those with single scars (1.5 years [1,4] or no scars (1 year [0, 3]), p = 0.04). DISCUSSION The prevalence of renal damage and clinical morbidity at VUR diagnosis was higher than other studies. High-grade VUR patients had a greater prevalence of renal damage, low eGFR and hypertension than low-grade VUR patients and was a risk factor for focal scars, generalised scars and reduced DRF. Focal scars were independently associated with recurrent UTI. Those with multiple scars were diagnosed later than those with single scars or no scars. CONCLUSIONS High-grade VUR was associated with renal damage and clinical morbidity. Our study highlights the importance of diagnosing VUR early to identify patients who may warrant long-term follow-up and intervention to minimize morbidity.
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Affiliation(s)
- Sitarah Mathias
- St John's Medical College, St John's National Academy of Health Sciences, Bangalore 560034, India
| | - Larry A Greenbaum
- Division of Pediatric Nephrology, Emory University and Children's Healthcare of Atlanta, 2015 Uppergate Drive, Atlanta, GA, 30322, USA
| | - A M Shubha
- Department of Pediatric Surgery, St Johns Medical College, St Johns National Academy of Health Sciences, Bangalore, 560034, India
| | - John A Michael Raj
- Department of Biostatistics, St John's Medical College, St John's National Academy of Health Sciences, Bangalore, 560034, India
| | - Kanishka Das
- Department of Pediatric Surgery, All India Institute of Medical Sciences, Bhubaneswar, 751019, India
| | - Priya Pais
- Department of Pediatric Nephrology, St John's Medical College, St John's National Academy of Health Sciences, Bangalore, 560034, India.
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YÜKSEL S, BECERİR T, SEYHAN B. The evaluation of the relationship of clinical and laboratory evidence with renal damage in the pediatric patients that had urinary tract infections. PAMUKKALE MEDICAL JOURNAL 2021:908-915. [DOI: 10.31362/patd.990677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2023]
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Doyev R, Ben-Shalom E, Megged O. The predictive utility of prior positive urine culture in children with recurrent urinary tract infections. Eur J Pediatr 2020; 179:415-421. [PMID: 31768637 DOI: 10.1007/s00431-019-03522-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 10/31/2019] [Accepted: 11/03/2019] [Indexed: 11/25/2022]
Abstract
Urinary tract infections can cause renal damage if not treated promptly. The aim of this study was to examine if prior urine cultures can predict antibiotic susceptibility profile in a subsequent culture, in children with recurrent urinary tract infections. The medical records of all children with at least two episodes of urinary tract infection between 1999-2015 that occurred 2 weeks to 1 year apart were reviewed. Pathogen identity and antibiogram were compared between the two cultures for every patient. One hundred sixty-one cases of recurrent urinary tract infections were identified. Seventy-seven (48%) pairs of cultures grew the same pathogen. However, of these, 31 had an altered biogram. In 53% of the culture pairs, the pathogen in the second culture had a similar or better antibiotic susceptibility profile. We found no statistically significant correlation between the elapsed time between the two cultures and the probability of similar susceptibility profile between them. There was no correlation between antibiogram change and any of the demographic characteristics, including a history of renal transplantation and taking antibiotic prophylactic treatment.Conclusions: Antibiotic susceptibility profile of the pathogen in a prior urinary tract infection did not predict antibiotic susceptibility profile in a subsequent urinary tract infection in our study.What is Known:• Children with urinary tract infections often have recurrent infections.• Clinicians often use prior urine cultures to choose empirical antibiotic treatment in subsequent infections.What is New:• In only 50% of the cases, a subsequent urinary tract infection grows the same pathogen as the 1st urinary tract infection.• Even in cultures with the same pathogen growth, antibiogram is often different.
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Affiliation(s)
- Reut Doyev
- The Hebrew University Hadassah Medical School, Jerusalem, Israel
| | - Efrat Ben-Shalom
- Pediatric Department, Shaare Zedek Medical Center, P.O.B. 3235, Jerusalem, Israel.,Pediatric Nephrology Unit, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Orli Megged
- The Hebrew University Hadassah Medical School, Jerusalem, Israel. .,Pediatric Department, Shaare Zedek Medical Center, P.O.B. 3235, Jerusalem, Israel. .,Infectious Diseases Unit, Shaare Zedek Medical Center, Jerusalem, Israel.
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Stephanos K, Bragg AF. Pediatric Genitourinary Infections and Other Considerations. Emerg Med Clin North Am 2019; 37:739-754. [PMID: 31563205 DOI: 10.1016/j.emc.2019.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Pediatric patients pose a unique host of challenges to the emergency provider across all complaints and ages, but this is particularly notable in the genitourinary (GU) system. The pediatric GU system is different from that of the adult in its etiology of symptoms, complications, and treatments. Based on age, there are variations in the anatomy. These differences result in symptoms and diagnoses that must be managed differently. Although in many respects management is similar to GU emergency conditions in adults, there are, occasionally subtle, differences between the care of children and adults, which can greatly impact outcomes.
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Affiliation(s)
- Kathleen Stephanos
- Department of Emergency Medicine, University of Rochester, 601 Elmwood Avenue Box 655, Rochester, NY 14642, USA.
| | - Andrew F Bragg
- Department of Pediatrics, University of Rochester, 601 Elmwood Avenue Box 655, Rochester, NY 14642, USA
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Increased community-acquired upper urinary tract infections caused by extended-spectrum beta-lactamase-producing Escherichia coli in children and the efficacy of flomoxef and cefmetazole. Clin Exp Nephrol 2019; 23:1306-1314. [PMID: 31428892 PMCID: PMC6797641 DOI: 10.1007/s10157-019-01775-w] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 08/06/2019] [Indexed: 11/24/2022]
Abstract
Background Urinary tract infections caused by extended-spectrum beta-lactamase-producing bacteria are increasing worldwide. At our hospital, the number of pediatric patients hospitalized because of an upper urinary tract infection has dramatically increased since 2016. In total, 60.5% of urinary tract infections are caused by extended-spectrum beta-lactamase-producing Escherichia coli. Such a high prevalence of extended-spectrum beta-lactamase-producing E. coli has not been detected previously in Japan. Therefore, we evaluated the clinical and bacteriologic characteristics and efficacy of antibiotics against upper urinary tract infections caused by E. coli in children. Methods This retrospective study surveyed 152 patients who were hospitalized in the pediatric department of Shimane Prefectural Central Hospital because of upper urinary tract infections caused by E. coli. Medical records were reviewed to examine patient characteristics. O antigens, antibiotic susceptibility, gene typing, and pulse-field gel electrophoresis were studied at the Shimane Prefectural Institute of Public Health and Environmental Science. Results Urine sample analyses showed extended-spectrum beta-lactamase types such as CTX-M-9 and plural virulence genes. We changed the primary antibiotic treatment to flomoxef or cefmetazole to treat upper urinary tract infections caused by Gram-negative bacilli. After changing treatment, the time to fever alleviation was significantly shortened. Conclusion Extended-spectrum beta-lactamase-producing E. coli should be suspected in community-acquired upper urinary tract infections. Therefore, when treating patients, it is necessary to focus on antibiotic susceptibility and the prevalence of extended-spectrum beta-lactamase-producing bacteria found in each area. Flomoxef and cefmetazole are useful primary treatments for upper urinary tract infections caused by extended-spectrum beta-lactamase-producing E. coli.
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Kim D, Yoon HJ, Woo SH, Lee WJ, Kim BS, Chung YA, Oh JK. Development of visual scoring system with Tc-99m DMSA renal scintigraphy to predict the risk of recurrence of symptomatic urinary tract infections in pediatric patients. Ann Nucl Med 2019; 33:708-715. [PMID: 31214960 DOI: 10.1007/s12149-019-01379-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 06/12/2019] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Vesicoureteral reflux (VUR) is a major risk factor for recurrent symptomatic urinary tract infection (UTI) in pediatric patients. In addition, dimercaptosuccinic acid renal scintigraphy (DMSA) is an important diagnostic modality of VUR. However, the value of DMSA for predicting recurrent pediatric UTI has not been studied. Therefore, we aimed to develop visual scoring system (VSS) with DMSA to predict the risk of recurrence of symptomatic urinary tract infection in pediatric patient under the age of 24 months. METHODS Pediatric UTI patients who visited our tertiary hospital emergency department and underwent DMSA for initial work-up from January 2006 to December 2014 were reviewed retrospectively. We developed a VSS with Tc-99m DMSA renal scintigraphy. We compared sensitivity and specificity between VSS with DMSA and other variables in predicting recurrent symptomatic UTI. Laboratory indices for systemic inflammation, abnormal finding on ultrasonography, VUR on voiding cystourethrogram (VCUG), and the VSS with DMSA were considered as variables. In addition, we used Kaplan-Meier estimator analyses and Cox proportional regression analyses to evaluate the predictive value of each variable for the recurrence of symptomatic UTI. RESULTS A total of 338 patients were enrolled. During the follow-up period, 42 patients (12.4%) had UTI recurrence. Visual scoring with DMSA resulted in 69.1% sensitivity and 79.4% specificity with an optimal cut-off value of score 2 (AUC = 0.790, p < 0.001). Significant predictive factors associated with recurrent symptomatic UTI were CRP ≥ 67.0 mg/L, VUR on VCUG and VSS with DMSA ≥ score 2. On multivariate analysis, the visual score with DMSA was the only independent prognostic factor for recurrent symptomatic UTI (p < 0.001; adjusted hazard ratio = 7.522; 95% CI = 2.799-20.224). CONCLUSION High scores in VSS with DMSA were associated with frequent recurrence and short recurrence periods in pediatric UTI patients. VSS with DMSA can stratify risk of recurrence in pediatric UTI patients.
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Affiliation(s)
- Daehee Kim
- Department Emergency Medicine, Incheon St. Mary's Hospital, The Catholic University of Korea, Incheon, South Korea
| | - Hai-Jeon Yoon
- Department of Nuclear Medicine, College of Medicine, Ewha Womans University, Seoul, South Korea.
| | - Seon Hee Woo
- Department Emergency Medicine, College of Medicine, The Catholic University of Korea, Seoul, South Korea.
| | - Woon Jeong Lee
- Department Emergency Medicine, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Bom Sahn Kim
- Department of Nuclear Medicine, College of Medicine, Ewha Womans University, Seoul, South Korea
| | - Yong An Chung
- Department of Radiology, Incheon St. Mary's Hospital, The Catholic University of Korea, Incheon, South Korea
| | - Jin Kyoung Oh
- Department of Radiology, Incheon St. Mary's Hospital, The Catholic University of Korea, Incheon, South Korea
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Maduemem KE, Rodriguez YD, Fraser B. How Sensitive are Dipstick Urinalysis and Microscopy in Making Diagnosis of Urinary Tract Infection in Children? Int J Prev Med 2019; 10:62. [PMID: 31198497 PMCID: PMC6547774 DOI: 10.4103/ijpvm.ijpvm_353_17] [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: 08/16/2017] [Accepted: 09/27/2017] [Indexed: 11/04/2022] Open
Abstract
Background Urinary tract infection (UTI) is a common reason for referral to the emergency department (ED) especially in unwell infants. Upper UTIs are particularly at risk of significant complications later in life. Rapid dipstick urinalysis and microscopy are often used in unwell children as a screening tool to guide early diagnosis and treatment. This study aims to evaluate the sensitivity of dipstick urinalysis and microscopy in the diagnosis of UTI. Methods A retrospective review of children aged 16 years and below with positive urine culture (UC) over a 3-year period was done. The results of urine dipstick and microscopy were compared with the positive UC and sensitivities calculated. Results Dipstick urinalysis and microscopy of 262 children were studied. Female-to -male ratio of 1.8:1. Median age was 0.79 (range: 0.02-15.95) years. The sensitivity of nitrite, blood, and leukocyte esterase (LE) were 0.54, 0.74, and 0.86 (95% confidence interval [CI] = 0.46-0.62, 0.68-0.80, and 0.82-0.91), respectively. The sensitivity of pyuria of ≥100 cells/mm3 was 0.92 (95% CI = 0.89-0.95). The presence of any of the 3 dipstick parameters increased the sensitivity to 0.97 (95% CI = 0.95-0.99). The lowest sensitivity 0.49 (95% CI = 0.40-0.58) was found with combined positive LE and nitrite. There was a significant comparison between positive LE dipstick test and pyuria (P = 0.000004). Conclusions Dipstick urinalysis may not be reliable in ruling out UTI in children. However, considering both positive dipstick and pyuria will be more useful in making the diagnosis.
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Affiliation(s)
| | | | - Brian Fraser
- Department of Paediatrics, Cork University Hospital, Cork, Ireland
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10
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Abstract
BACKGROUND Vesicoureteric reflux (VUR) results in urine passing retrograde up the ureter. Urinary tract infections (UTI) associated with VUR have been considered a cause of permanent renal parenchymal damage in children with VUR. Management has been directed at preventing UTI by antibiotic prophylaxis and/or surgical correction of VUR. This is an update of a review first published in 2004 and updated in 2007 and 2011. OBJECTIVES The aim of this review was to evaluate the available evidence for both benefits and harms of the currently available treatment options for primary VUR: operative, non-operative or no intervention. SEARCH METHODS We searched the Cochrane Kidney and Transplant Specialised Register to 3 May 2018 through contact with the Information Specialist using search terms relevant to this review. Studies contained in the Specialised Register are identified through search strategies specifically designed for CENTRAL, MEDLINE, and EMBASE; handsearching conference proceedings, and searching the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA RCTs in any language comparing any treatment of VUR and any combination of therapies. DATA COLLECTION AND ANALYSIS Two authors independently determined study eligibility, assessed quality and extracted data. Dichotomous outcomes were expressed as risk ratios (RR) with 95% confidence intervals (CI) and continuous data as mean differences (MD) with 95% CI. Data were pooled using the random effects model. MAIN RESULTS Thirty four studies involving 4001 children were included. Interventions included; long-term low-dose antibiotics, surgical reimplantation of ureters, endoscopic injection treatment, probiotics, cranberry products, circumcision, and oxybutynin. Interventions were used alone and in combinations. The quality of conduct and reporting of these studies was variable, with many studies omitting crucial methodological information used to assess the risk of bias. Only four of the 34 studies were considered at low risk of bias across all fields of study quality. The majority of studies had many areas of uncertainty in the risk of bias fields, reflecting missing detail rather than stated poor design.Low-dose antibiotic prophylaxis compared to no treatment/placebo may make little or no difference to the risk of repeat symptomatic UTI (9 studies, 1667 children: RR 0.77, 95% CI 0.54 to 1.09; low certainty evidence) and febrile UTI (RR 0.83, 95% CI 0.56 to 1.21; low certainty evidence) at one to two years. At one to three years, antibiotic prophylaxis made little or no difference to the risk of new or progressive renal damage on DMSA scan (8 studies, 1503 children: RR 0.73, 95% CI 0.33 to 1.61; low certainty evidence). Adverse events were reported in four studies with little or no difference between treatment groups (1056 children: RR 0.94, 95% CI 0.81 to 1.08; ), but antibiotics increased the likelihood of bacterial drug resistance threefold (187 UTIs: RR 2.97, 95% CI 1.54 to 5.74; moderate certainty evidence).Seven studies compared long-term antibiotic prophylaxis alone with surgical reimplantation of ureters plus antibiotics, but only two reported the outcome febrile UTI (429 children). Surgery plus antibiotic treatment may reduce the risk of repeat febrile UTI by 57% (RR 0.43, 95% CI 0.27 to 0.70; moderate certainty evidence). There was little or no difference in the risk of new kidney defects detected using intravenous pyelogram at 4 to 5 years (4 studies, 572 children, RR 1.09, 95% CI 0.79 to 1.49; moderate certainty evidence)Four studies compared endoscopic injection with antibiotics alone and three reported the outcome febrile UTI. This analysis showed little or no difference in the risk of febrile UTI with endoscopic injection compared to antibiotics (RR 0.74, 95% CI 0.31 to 1.78; low certainty evidence). Four studies involving 425 children compared two different materials for endoscopic injection under the ureters (polydimethylsiloxane (Macroplastique) versus dextranomer/hyaluronic acid polymer (Deflux), glutaraldehyde cross-linked (GAX) collagen (GAX) 35 versus GAX 65 and Deflux versus polyacrylate polyalcohol copolymer (VANTRIS)) but only one study (255 children, low certainty evidence) had the outcome of febrile UTI and it reported no difference between the materials. All four studies reported rates of resolution of VUR, and the two studies comparing Macroplastique with Deflux showed that Macroplastique was probably superior to dextranomer/hyaluronic acid polymer (3 months: RR 0.50, 95% CI 0.33 to 0.78; 12 months: RR 0.54 95% CI 0.35 to 0.83; low certainty evidence)Two studies compared probiotic treatment with antibiotics and showed little or no difference in risk of repeat symptomatic UTI (RR 0.82 95% CI 0.56 to 1.21; low certainty evidence)Single studies compared circumcision with antibiotics, cranberry products with no treatment, oxybutynin with placebo, two different surgical techniques and endoscopic injection with no treatment. AUTHORS' CONCLUSIONS Compared with no treatment, the use of long-term, low-dose antibiotics may make little or no difference to the number of repeat symptomatic and febrile UTIs in children with VUR (low certainty evidence). Considerable variation in the study designs and subsequent findings prevented drawing firm conclusions on efficacy of antibiotic treatment.The added benefit of surgical or endoscopic correction of VUR over antibiotic treatment alone remains unclear since few studies comparing the same treatment and with relevant clinical outcomes were available for analysis.
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Affiliation(s)
- Gabrielle Williams
- NSW Ministry of HealthAnalytics Assist73 Miller StNorth SydneyNSWAustralia2060
| | - Elisabeth M Hodson
- The University of SydneySydney School of Public HealthSydneyNSWAustralia2006
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchLocked Bag 4001WestmeadNSWAustralia2145
| | - Jonathan C Craig
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchLocked Bag 4001WestmeadNSWAustralia2145
- Flinders UniversityCollege of Medicine and Public HealthAdelaideSAAustralia5001
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Malone PS. Antenatal Diagnosis of Renal Tract Anomalies: Has it Increased the Sum of Human Happiness? J R Soc Med 2018; 89:155P-8P. [PMID: 8683521 PMCID: PMC1295702 DOI: 10.1177/014107689608900312] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
When used as a screening procedure, ultrasound examination of the fetal urinary tract seldom leads to beneficial interventions. There is also a cost in terms of parental anxiety and unnecessary investigation and treatment. A formal screening programme would therefore be unjustified. However, screening of women for obstetric purposes will continue to reveal fetal abnormalities, and a strategy for dealing with these is needed. Antenatal treatments remain experimental; for most of the common conditions postnatal treatment has no urgency; and, in cases of minor abnormality detected by ultrasound, the best course may be to do nothing.
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Affiliation(s)
- P S Malone
- Department of Paediatric Nephrourology, Southampton General Hospital, England
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12
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Hay AD, Birnie K, Busby J, Delaney B, Downing H, Dudley J, Durbaba S, Fletcher M, Harman K, Hollingworth W, Hood K, Howe R, Lawton M, Lisles C, Little P, MacGowan A, O'Brien K, Pickles T, Rumsby K, Sterne JA, Thomas-Jones E, van der Voort J, Waldron CA, Whiting P, Wootton M, Butler CC. The Diagnosis of Urinary Tract infection in Young children (DUTY): a diagnostic prospective observational study to derive and validate a clinical algorithm for the diagnosis of urinary tract infection in children presenting to primary care with an acute illness. Health Technol Assess 2018; 20:1-294. [PMID: 27401902 DOI: 10.3310/hta20510] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND It is not clear which young children presenting acutely unwell to primary care should be investigated for urinary tract infection (UTI) and whether or not dipstick testing should be used to inform antibiotic treatment. OBJECTIVES To develop algorithms to accurately identify pre-school children in whom urine should be obtained; assess whether or not dipstick urinalysis provides additional diagnostic information; and model algorithm cost-effectiveness. DESIGN Multicentre, prospective diagnostic cohort study. SETTING AND PARTICIPANTS Children < 5 years old presenting to primary care with an acute illness and/or new urinary symptoms. METHODS One hundred and seven clinical characteristics (index tests) were recorded from the child's past medical history, symptoms, physical examination signs and urine dipstick test. Prior to dipstick results clinician opinion of UTI likelihood ('clinical diagnosis') and urine sampling and treatment intentions ('clinical judgement') were recorded. All index tests were measured blind to the reference standard, defined as a pure or predominant uropathogen cultured at ≥ 10(5) colony-forming units (CFU)/ml in a single research laboratory. Urine was collected by clean catch (preferred) or nappy pad. Index tests were sequentially evaluated in two groups, stratified by urine collection method: parent-reported symptoms with clinician-reported signs, and urine dipstick results. Diagnostic accuracy was quantified using area under receiver operating characteristic curve (AUROC) with 95% confidence interval (CI) and bootstrap-validated AUROC, and compared with the 'clinician diagnosis' AUROC. Decision-analytic models were used to identify optimal urine sampling strategy compared with 'clinical judgement'. RESULTS A total of 7163 children were recruited, of whom 50% were female and 49% were < 2 years old. Culture results were available for 5017 (70%); 2740 children provided clean-catch samples, 94% of whom were ≥ 2 years old, with 2.2% meeting the UTI definition. Among these, 'clinical diagnosis' correctly identified 46.6% of positive cultures, with 94.7% specificity and an AUROC of 0.77 (95% CI 0.71 to 0.83). Four symptoms, three signs and three dipstick results were independently associated with UTI with an AUROC (95% CI; bootstrap-validated AUROC) of 0.89 (0.85 to 0.95; validated 0.88) for symptoms and signs, increasing to 0.93 (0.90 to 0.97; validated 0.90) with dipstick results. Nappy pad samples were provided from the other 2277 children, of whom 82% were < 2 years old and 1.3% met the UTI definition. 'Clinical diagnosis' correctly identified 13.3% positive cultures, with 98.5% specificity and an AUROC of 0.63 (95% CI 0.53 to 0.72). Four symptoms and two dipstick results were independently associated with UTI, with an AUROC of 0.81 (0.72 to 0.90; validated 0.78) for symptoms, increasing to 0.87 (0.80 to 0.94; validated 0.82) with the dipstick findings. A high specificity threshold for the clean-catch model was more accurate and less costly than, and as effective as, clinical judgement. The additional diagnostic utility of dipstick testing was offset by its costs. The cost-effectiveness of the nappy pad model was not clear-cut. CONCLUSIONS Clinicians should prioritise the use of clean-catch sampling as symptoms and signs can cost-effectively improve the identification of UTI in young children where clean catch is possible. Dipstick testing can improve targeting of antibiotic treatment, but at a higher cost than waiting for a laboratory result. Future research is needed to distinguish pathogens from contaminants, assess the impact of the clean-catch algorithm on patient outcomes, and the cost-effectiveness of presumptive versus dipstick versus laboratory-guided antibiotic treatment. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Alastair D Hay
- Centre for Academic Primary Care, National Institute for Health Research (NIHR) School of Primary Care Research, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Kate Birnie
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - John Busby
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Brendan Delaney
- Department of Primary Care and Public Health Sciences, National Institute for Health Research (NIHR) Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK
| | - Harriet Downing
- Centre for Academic Primary Care, National Institute for Health Research (NIHR) School of Primary Care Research, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Jan Dudley
- Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Stevo Durbaba
- Department of Primary Care and Public Health Sciences, Division of Health and Social Care Research, King's College London, London, UK
| | - Margaret Fletcher
- Centre for Health and Clinical Research, University of the West of England, Bristol, UK.,South West Medicines for Children Local Research Network, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Kim Harman
- Centre for Academic Primary Care, National Institute for Health Research (NIHR) School of Primary Care Research, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | | | - Kerenza Hood
- South East Wales Trials Unit (SEWTU), Institute for Translation, Innovation, Methodology and Engagement, School of Medicine, Cardiff University, Cardiff, UK
| | - Robin Howe
- Specialist Antimicrobial Chemotherapy Unit, Public Health Wales Microbiology Cardiff, University Hospital Wales, Cardiff, UK
| | - Michael Lawton
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Catherine Lisles
- South East Wales Trials Unit (SEWTU), Institute for Translation, Innovation, Methodology and Engagement, School of Medicine, Cardiff University, Cardiff, UK
| | - Paul Little
- Primary Care and Population Sciences Division, University of Southampton, Southampton, UK
| | | | - Kathryn O'Brien
- Cochrane Institute of Primary Care & Public Health, School of Medicine, Cardiff University, Cardiff, UK
| | - Timothy Pickles
- South East Wales Trials Unit (SEWTU), Institute for Translation, Innovation, Methodology and Engagement, School of Medicine, Cardiff University, Cardiff, UK
| | - Kate Rumsby
- Primary Care and Population Sciences Division, University of Southampton, Southampton, UK
| | - Jonathan Ac Sterne
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Emma Thomas-Jones
- South East Wales Trials Unit (SEWTU), Institute for Translation, Innovation, Methodology and Engagement, School of Medicine, Cardiff University, Cardiff, UK
| | - Judith van der Voort
- Department of Paediatrics and Child Health, University Hospital of Wales, Cardiff, UK
| | - Cherry-Ann Waldron
- South East Wales Trials Unit (SEWTU), Institute for Translation, Innovation, Methodology and Engagement, School of Medicine, Cardiff University, Cardiff, UK
| | - Penny Whiting
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Mandy Wootton
- Specialist Antimicrobial Chemotherapy Unit, Public Health Wales Microbiology Cardiff, University Hospital Wales, Cardiff, UK
| | - Christopher C Butler
- Cochrane Institute of Primary Care & Public Health, School of Medicine, Cardiff University, Cardiff, UK.,Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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13
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Adverse Events Following Diagnostic Urethral Catheterization in the Pediatric Emergency Department. CAN J EMERG MED 2017; 18:437-442. [PMID: 27780500 DOI: 10.1017/cem.2016.5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES The purpose of this study was to assess adverse events associated with diagnostic urethral catheterization (UC) in young children and to determine their impact on the patient and their family. METHODS This was a prospective cohort study conducted in the emergency department of a tertiary-care pediatric hospital. All 3- to 24-month-old children with fever who had a diagnostic UC were eligible. Parents who consented to participate were contacted by phone within 7 to 10 days after the UC to answer a standardized questionnaire inquiring about complications. The primary outcome was the occurrence of an unfavourable event in the seven days following UC, defined as painful urination, genital pain, urinary retention, hematuria or secondary urinary tract infection. Secondary outcomes included the need for further medical care and the need for parents to miss school or work. RESULTS Of the 199 patients who completed the study, 41 (21%) reported a complication: painful urination in 19 (10%) children, genital pain in 16 (8%), urinary retention in 11 (6%), gross hematuria in 9 (5%), and secondary urinary tract infection in 1 (0.5%). Three (1%) parents reported the need for further medical care and three (1%) missed work. Two independent variables (male sex and age 12-23 months) were associated with a higher risk of adverse events. CONCLUSIONS Urethral catheterization is associated with adverse events in 21% of young children in the week following the procedure. Accordingly, this procedure should be used judiciously in children, considering its potential to cause unfavourable events.
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14
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Abdelhalim A, Khoury AE. Critical appraisal of the top-down approach for vesicoureteral reflux. Investig Clin Urol 2017; 58:S14-S22. [PMID: 28612056 PMCID: PMC5468260 DOI: 10.4111/icu.2017.58.s1.s14] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Accepted: 03/14/2017] [Indexed: 11/18/2022] Open
Abstract
Vesicoureteral reflux (VUR) has been linked to recurrent urinary tract infections (UTIs), renal scarring, hypertension, renal insufficiency and end-stage kidney disease. Different imaging strategies have been proposed to approach children presenting with UTI to sort out patients with significant VUR while minimizing patient morbidity, radiation exposure and financial burden. None of these imaging strategies is universally accepted. The“top-down approach” (TDA) aims at restricting the number of voiding cystourethrograms (VCUGs) and its associated morbidity while identifying patients with clinically-significant reflux. In this approach, children presenting with febrile UTIs are acutely investigated with dimercapto-succinic acid (DMSA) renal scans to identify patients with renal parenchymal inflammation. Those with evidence of renal affection are offered VCUG and late DMSA scan to identify VUR and permanent renal scarring, respectively. Although TDA could identify clinically-significant VUR with high sensitivity, it is not without limitations. The approach segregates patients based on the presence of DMSA cortical lesions omitting the morbidity and the economic burden of UTI. Additionally, some of DMSA lesions are attributed to congenital dysplasia and unrelated to UTI. Ionizing radiation exposure, financial costs, limited availability of DMSA scans in the acute setting, variability in interpreting the results and low yield of actionable findings on DMSA scans are some other limitations. In this review, we tried to address the drawbacks of the TDA and reinforce the value of patient-centered approach for VUR.
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Affiliation(s)
- Ahmed Abdelhalim
- Department of Urology, University of California, Irvine, Children's Hospital of Orange County, Orange, CA, USA.,Department of Urology, Mansoura Urology and Nephrology Center, Mansoura University, Mansoura, Egypt
| | - Antoine E Khoury
- Department of Urology, University of California, Irvine, Children's Hospital of Orange County, Orange, CA, USA
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15
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Masika WG, O’Meara WP, Holland TL, Armstrong J. Contribution of urinary tract infection to the burden of febrile illnesses in young children in rural Kenya. PLoS One 2017; 12:e0174199. [PMID: 28323886 PMCID: PMC5360311 DOI: 10.1371/journal.pone.0174199] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Accepted: 03/06/2017] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION The clinical features of UTI in young children may not localize to the urinary tract and closely resemble other febrile illnesses. In malaria endemic areas, a child presenting with fever is often treated presumptively for malaria without investigation for UTI. Delayed or inadequate treatment of UTI increases the risk of bacteremia and renal scarring in young children and subsequently complications as hypertension and end stage renal disease in adulthood. METHODS A cross-sectional study was carried out in a hospital in western Kenya. Inpatients and outpatients 2 months to five years with axillary temperature ≥37.5°C and no antibiotic use in the previous week were enrolled between September 2012 and April 2013. Urine dipstick tests, microscopy, and cultures were done and susceptibility patterns to commonly prescribed antibiotics established. UTI was defined as presence of pyuria (a positive urine dipstick or microscopy test) plus a positive urine culture. RESULTS A total of 260 subjects were recruited; 45.8% were female and the median age was 25months (IQR: 13, 43.5). The overall prevalence of UTI was 11.9%. Inpatients had a higher prevalence compared to outpatients (17.9% v 7.8%, p = 0.027). UTI co-existed with malaria but the association was not significant (OR 0.80, p = 0.570). The most common organisms isolated were Escherichia coli (64.5%) and Staphylococcus aureus (12.9%) and were sensitive to ciproflaxin, cefuroxime, ceftriaxone, gentamycin and nitrofurantoin but largely resistant to more commonly used antibiotics such as ampicillin (0%), amoxicillin (16.7%), cotrimoxazole (16.7%) and amoxicillin-clavulinate (25%). CONCLUSION Our study demonstrates UTI contributes significantly to the burden of febrile illness in young children and often co-exists with other infections. Multi-drug resistant organisms are common therefore choice of antimicrobial therapy should be based on local sensitivity pattern.
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Affiliation(s)
- Wechuli Geoffrey Masika
- Department of Family Medicine, Webuye Sub-County Hospital, Webuye, Kenya
- Department of Family Medicine, Kabarak University, Kabarak, Kenya
| | - Wendy Prudhomme O’Meara
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, United States of America
- Duke Global Health Institute, Durham, North Carolina, United States of America
- School of Public Health, Moi University College of Health Sciences, Eldoret, Kenya
| | - Thomas L. Holland
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Janice Armstrong
- Department of Family Medicine, Webuye Sub-County Hospital, Webuye, Kenya
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16
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Bunting-Early TE, Shaikh N, Woo L, Cooper CS, Figueroa TE. The Need for Improved Detection of Urinary Tract Infections in Young Children. Front Pediatr 2017; 5:24. [PMID: 28271057 PMCID: PMC5319447 DOI: 10.3389/fped.2017.00024] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2016] [Accepted: 02/01/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND AND OBJECTIVES An estimated 400,000 urinary tract infections (UTIs) are diagnosed annually in children aged <3 years in the United States; yet >50% of febrile UTIs may be missed in this population. Here, we explored possible barriers to diagnosing febrile UTIs in very young children through social research of community pediatricians. METHODS Following qualitative interviews, a quantitative survey was developed that included a high-risk case for febrile UTI, presented before prompting for the topic of the survey, to gauge practice of delayed testing. Factors associated with delay were explored using univariate logistic regression. The final survey link was sent to three populations via email, with the largest response from a survey sent to pediatricians in Pennsylvania, which formed the basis of our primary results. RESULTS Of the 218 evaluable responses, 59.6% of physicians would initially test urine in the high-risk case patient, while 21.6% would choose to continue fever reducer and follow-up in 2 days. In the knowledge-based questions, 67.5, 34.0, and 35.6% of respondents identified the correct prevalences in total population, Caucasian girls, and uncircumcised boys, respectively. Many pediatricians (59.5%) believed that delays in detection are common in clinical practice. Physicians who chose to delay testing were more likely to be female, in practice for <25 years, to underestimate prevalence of febrile UTIs and have greater number of children seen per week (all P ≤ 0.02). CONCLUSION Our findings support the need for improved communication and education about prevalence in higher risk populations, outcomes associated with delayed diagnosis, and optimal skills for collection of urine in young patients.
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Affiliation(s)
| | - Nader Shaikh
- Children's Hospital of Pittsburgh , Pittsburgh, PA , USA
| | - Lynn Woo
- Rainbow Babies and Children's Hospital , Cleveland, OH , USA
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17
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Lee LC, Lorenzo AJ, Koyle MA. The role of voiding cystourethrography in the investigation of children with urinary tract infections. Can Urol Assoc J 2016; 10:210-214. [PMID: 27713802 DOI: 10.5489/cuaj.3610] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Urinary tract infections (UTIs) represent a common bacterial cause of febrile illness in children. Of children presenting with a febrile UTI, 25-40% are found to have vesicoureteral reflux (VUR). Historically, the concern regarding VUR was that it could lead to recurrent pyelonephritis, renal scarring, hypertension, and chronic kidney disease. As a result, many children underwent invasive surgical procedures to correct VUR. We now know that many cases of VUR are low-grade and have a high rate of spontaneous resolution. The roles of surveillance, antibiotic prophylaxis, endoscopic injection, and ureteral reimplantation surgery also continue to evolve. In turn, these factors have influenced the investigation of febrile UTIs. Voiding cystourethrography (VCUG) is the radiographic test of choice to diagnose VUR. Due to its invasive nature and questionable benefit in many cases, the American Academy of Pediatrics (AAP) no longer recommends VCUG routinely after an initial febrile UTI. Nevertheless, these guidelines pre-date the landmark Randomized Intervention of Children with Vesicoureteral Reflux (RIVUR) trial and there continues to be controversy regarding the diagnosis and management of VUR. This paper discusses the current literature regarding radiographic testing in children with febrile UTIs and presents a practical risk-based approach for deciding when to obtain a VCUG.
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Affiliation(s)
- Linda C Lee
- The Hospital for Sick Children, Toronto, ON, Canada
| | - Armando J Lorenzo
- The Hospital for Sick Children, Toronto, ON, Canada;; Division of Urology, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Martin A Koyle
- The Hospital for Sick Children, Toronto, ON, Canada;; Division of Urology, Department of Surgery, University of Toronto, Toronto, ON, Canada
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18
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Broadis E, Kronfli R, Flett ME, Cascio S, O'Toole SJ. 'Targeted top down' approach for the investigation of UTI: A 10-year follow-up study in a cohort of 1000 children. J Pediatr Urol 2016; 12:39.e1-6. [PMID: 26586296 DOI: 10.1016/j.jpurol.2015.07.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Accepted: 07/23/2015] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Investigations following urinary tract infection (UTI) aim to identify children who are prone to renal scarring, which may be preventable. In 2002, in an attempt to reduce unnecessary intervention, the present institution standardised the investigation of children with a confirmed UTI. OBJECTIVE This study aimed to identify the significance of urological abnormalities on investigations following a UTI in children, prior to the introduction of the National Institute for Health and Care Excellence (NICE) guidelines. METHODS Clinical information on the first 1000 patients was retrieved from a prospective UTI hospital database. The follow-up period was 10 years. RESULTS There were 180 males and 820 females (M:F = 1:4.5). The median age of presentation was 5 years (range 11 days-16 years). A renal ultrasound (US) was performed on all patients, and was normal in 93% of cases (n = 889) (see Figure). Of the 7% who had an abnormal US (n = 71), 54 were female and 17 male (M:F = 1:3). A total of 372 DMSA scans were requested and 350 attended their appointment. Of these, 278 cases (79%) were reported as normal, while 72 had an abnormality documented. Of these 72 patients with abnormalities on DMSA scan, 49 had a repeat DMSA scan: 30 demonstrated permanent scarring, while the DMSA scan became normal in 19. Sixteen of the 278 patients whose DMSA scan was initially normal had a repeat DMSA scan due to symptoms, and all scans were normal. Twelve (1.2%) patients required surgical intervention: three underwent circumcision for recurrent UTIs; three underwent endoscopic treatment of VUR; one had a PUV resection; one underwent a cystoscopy; three had a pyeloplasty for pelvi-ureteric junction obstruction; and one had a ureteric reimplantation for vesico-ureteric junction obstruction. After initial investigations and management, 936 patients were discharged from the UTI clinic: 47 of them re-presented - 40 with recurrent UTIs and seven with dysuria. Thirty-five of the 47 children who re-presented with urological symptoms underwent a DMSA scan, which showed scarring in three (6%). DISCUSSION Only 12% of children have a significant radiological abnormality picked up on investigation following a UTI. The present investigation approach differed from the NICE guidelines, where imaging is based on patient age and characteristics of the UTI. All children had a renal US, while DMSA scans were reserved for those children <1 year of age or those with upper tract symptoms. The present protocol recommended a renal US in all children presenting with a UTI. This promptly identified those with pelvi-ureteric junction obstruction and those with PUV, who all presented >6 months of age with a single UTI and, therefore, based on the NICE guidelines would not have undergone a renal US. Of the children who re-presented with further UTIs, a significant number were found to have dysfunctional voiding. As this link is well reported, it may be appropriate to screen for this in older children at initial presentation. Only three patients, who had a US at presentation, were subsequently found to have scarring on DMSA. After 10 years of follow-up, this could represent a false negative rate of 0.3% for the screening programme. None of the girls were found to have VUR or needed any surgical intervention, which suggested that early identification of the scarring might not have altered management. Few patients required surgical intervention, all of whom were identified early. No patient who re-presented required intervention. This would suggest that the present protocol is effective at picking up abnormalities that require surgical management. CONCLUSION This study suggested that after a childhood UTI, the liberal use of renal ultrasound and a focused 'top down' approach to investigation is likely to identify the vast majority of children who require intervention.
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Affiliation(s)
- E Broadis
- Department of Paediatric Surgery, The Royal Hospital for Children, 1345 Govan Road, G51 4TF, Glasgow, Scotland, UK.
| | - R Kronfli
- Department of Paediatric Surgery, The Royal Hospital for Children, 1345 Govan Road, G51 4TF, Glasgow, Scotland, UK
| | - M E Flett
- Department of Paediatric Surgery, The Royal Hospital for Children, 1345 Govan Road, G51 4TF, Glasgow, Scotland, UK
| | - S Cascio
- Department of Paediatric Surgery, The Royal Hospital for Children, 1345 Govan Road, G51 4TF, Glasgow, Scotland, UK
| | - S J O'Toole
- Department of Paediatric Surgery, The Royal Hospital for Children, 1345 Govan Road, G51 4TF, Glasgow, Scotland, UK
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Blais AS, Morin F, Cloutier J, Moore K, Bolduc S. Efficacy of dextranomer hyaluronic acid and polyacrylamide hydrogel in endoscopic treatment of vesicoureteral reflux: A comparative study. Can Urol Assoc J 2015. [PMID: 26225173 DOI: 10.5489/cuaj.2964] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Various bulking agents are available for vesicoureteral reflux (VUR) endoscopic treatment, but their inconsistent success rates and costs are concerns for urologists. Recently, polyacrylamide hydrogel (PAHG) has been shown to have a good overall success rate, which seems comparable to dextranomer hyaluronic acid (Dx/HA), currently the most popular bulking agent. Our objective was to compare the short-term success rate of PAHG and Dx/HA for VUR endoscopic treatment in children. METHODS We performed a prospective non-randomized study using PAHG and Dx/HA to treat VUR grades I to IV in pediatric patients. All patients underwent endoscopic sub-ureteric injection of PAHG or Dx/HA, using the double-HIT technique, followed by a 3-month postoperative renal ultrasound and voiding cystourethrogram. Treatment success was defined as the absence of de novo or worsening hydronephrosis and absence of VUR. RESULTS A total of 90 pediatric patients underwent an endoscopic injection: 45 patients (78 ureters) with PAHG and 45 patients (71 ureters) with Dx/HA. The mean injected volume of PAHG and Dx/HA was 1.1 mL and 1.0 mL, respectively. The overall success rate 3 months after a single treatment was 73.1% for PAHG and 77.5% for Dx/HA. Postoperatively, 1 patient in each group presented with acute pyelonephritis and 2 patients in the Dx/HA group developed symptomatic ureteral obstruction. CONCLUSION Success rates of PAGH and Dx/HA in endoscopic injections for VUR treatment were comparable. The rate of resolution obtained with Dx/HA was equivalent to those previously published. The lower cost of PAHG makes it an interesting option.
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Affiliation(s)
| | - Fannie Morin
- Department of Urology, CHU de Québec-Université Laval, Quebec, QC
| | | | - Katherine Moore
- Department of Urology, CHU de Québec-Université Laval, Quebec, QC
| | - Stéphane Bolduc
- Department of Urology, CHU de Québec-Université Laval, Quebec, QC
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Sakran W, Smolkin V, Odetalla A, Halevy R, Koren A. Community-acquired urinary tract infection in hospitalized children: etiology and antimicrobial resistance. A comparison between first episode and recurrent infection. Clin Pediatr (Phila) 2015; 54:479-83. [PMID: 25385933 DOI: 10.1177/0009922814555974] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Urinary tract infection (UTI) is common in infants and children, and Escherichia coli is the leading pathogen. The aims of this study were to compare first episode of UTI with recurrent infection, reveal organisms that cause UTI, uropathogen resistance, and presence of bacteria producing extended-spectrum β-lactamase (ESBL). The first-UTI group included 456 children. E coli was the leading pathogen (80.5%), and Pseudomonas aeruginosa was found in 1.5%. The uropathogens were resistant to gentamicin (3.41%) and cefuroxime (5.71%), and highly resistant to cefamezin (37.39%). The recurrent-infection group included 106 children. E coli was also the leading pathogen, but 7.5% of the isolates were P aeruginosa (P = .002 compared with first-episode group); 6.6% were ESBL-producing bacteria compared with 1.1% in the first-episode group (P = .002). E coli is the leading pathogen in both groups. P aeruginosa and ESBL-producing bacteria were more common in the recurrent infection group.
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Affiliation(s)
- Waheeb Sakran
- Emek Medical Center, Afula, Israel The Ruth and Baruch Rappaport School of Medicine, Technion, Haifa, Israel
| | - Vladislav Smolkin
- The Ruth and Baruch Rappaport School of Medicine, Technion, Haifa, Israel Pediatric Nephrology Unit, Emek Medical Center, Afula, Israel
| | | | - Raphael Halevy
- Emek Medical Center, Afula, Israel Pediatric Nephrology Unit, Emek Medical Center, Afula, Israel
| | - Ariel Koren
- Emek Medical Center, Afula, Israel The Ruth and Baruch Rappaport School of Medicine, Technion, Haifa, Israel
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21
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Wiles LK, Hooper TD, Hibbert PD, White L, Mealing N, Jaffe A, Cowell CT, Harris MF, Runciman WB, Goldstein S, Hallahan AR, Wakefield JG, Murphy E, Lau A, Wheaton G, Williams HM, Hughes C, Braithwaite J. CareTrack Kids-part 1. Assessing the appropriateness of healthcare delivered to Australian children: study protocol for clinical indicator development. BMJ Open 2015; 5:e007748. [PMID: 25854976 PMCID: PMC4390723 DOI: 10.1136/bmjopen-2015-007748] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Despite the widespread availability of clinical guidelines, considerable gaps remain between the care that is recommended (appropriate care) and the care provided. This protocol describes a research methodology to develop clinical indicators for appropriate care for common paediatric conditions. METHODS AND ANALYSIS We will identify conditions amenable to population-level appropriateness of care research and develop clinical indicators for each condition. Candidate conditions have been identified from published research; burden of disease, prevalence and frequency of presentation data; and quality of care priority lists. Clinical indicators will be developed through searches of national and international guidelines, and formatted with explicit criteria for inclusion, exclusion, time frame and setting. Experts will review the indicators using a wiki-based approach and modified Delphi process. A formative evaluation of the wiki process will be undertaken. ETHICS AND DISSEMINATION Human Research Ethics Committee approvals have been received from Sydney Children's Hospital Network, Children's Health Queensland Hospital and Health Service, and the Women's and Children's Health Network (South Australia). Applications are under review with Macquarie University and the Royal Australian College of General Practitioners. We will submit the results of the study to relevant journals and offer national and international presentations.
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Affiliation(s)
- Louise K Wiles
- Division of Education, Arts and Social Sciences, Centre for Sleep Research, School of Psychology, Social Work and Social Policy, University of South Australia, Adelaide, South Australia, Australia
- Faculty of Medicine and Health Sciences, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Tamara D Hooper
- Division of Education, Arts and Social Sciences, Centre for Sleep Research, School of Psychology, Social Work and Social Policy, University of South Australia, Adelaide, South Australia, Australia
- Faculty of Medicine and Health Sciences, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Peter D Hibbert
- Faculty of Medicine and Health Sciences, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Les White
- Discipline of Paediatrics, School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia
- Sydney Children's Hospital, Sydney Children's Hospitals Network, Randwick, New South Wales, Australia
- New South Wales Health, NSW Kids and Families, North Sydney, New South Wales, Australia
| | - Nicole Mealing
- Faculty of Medicine and Health Sciences, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Adam Jaffe
- Discipline of Paediatrics, School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia
- Department of Respiratory Medicine, Sydney Children's Hospital, Sydney Children's Hospitals Network, Randwick, New South Wales, Australia
| | - Christopher T Cowell
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
- Institute of Endocrinology and Diabetes, Children's Hospital at Westmead, Sydney Children's Hospitals Network, Westmead, New South Wales, Australia
| | - Mark F Harris
- Faculty of Medicine, Centre for Primary Health Care and Equity, University of New South Wales, Sydney, New South Wales, Australia
| | - William B Runciman
- Division of Education, Arts and Social Sciences, Centre for Sleep Research, School of Psychology, Social Work and Social Policy, University of South Australia, Adelaide, South Australia, Australia
- Faculty of Medicine and Health Sciences, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
- Australian Patient Safety Foundation, Adelaide, South Australia, Australia
| | - Stan Goldstein
- BUPA Health Foundation Australia, Sydney, New South Wales, Australia
| | - Andrew R Hallahan
- Patient Safety and Quality Unit, Children's Health Queensland Hospital and Health Service, Herston, Queensland, Australia
| | - John G Wakefield
- Patient Safety and Quality Unit, Children's Health Queensland Hospital and Health Service, Herston, Queensland, Australia
| | - Elisabeth Murphy
- New South Wales Health, NSW Kids and Families, North Sydney, New South Wales, Australia
| | - Annie Lau
- Faculty of Medicine and Health Sciences, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Gavin Wheaton
- Division of Paediatric Medicine, Women's and Children's Health Network, South Australia, Australia
| | | | - Clifford Hughes
- Clinical Excellence Commission, Sydney South, New South Wales, Australia
| | - Jeffrey Braithwaite
- Faculty of Medicine and Health Sciences, Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
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Telli O, Mermerkaya M, Hajiyev P, Aydogdu O, Afandiyev F, Suer E, Soygur T, Burgu B. Is top-down vs bottom-up radiological evaluation after febrile urinary tract infection really less stressful for the child and family? Challenging the dogma. J Urol 2014; 193:958-62. [PMID: 25444953 DOI: 10.1016/j.juro.2014.10.044] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/06/2014] [Indexed: 11/16/2022]
Abstract
PURPOSE We evaluated whether stress levels in children and parents during radiological evaluation after febrile urinary tract infection are really lower using the top-down approach, where (99m)technetium dimercaptosuccinic acid renal scintigraphy is used initially, than the bottom-up approach, where voiding cystourethrography is initially performed and repeated examinations are easier for all. MATERIALS AND METHODS We prospectively evaluated 120 children 3 to 8 years old. Pain ratings were obtained using the Faces Pain Scale-Revised, and conversation during the procedure was evaluated using the Child-Adult Medical Procedure Interaction Scale-Revised by 2 independent observers. To evaluate parental anxiety, the State-Trait Anxiety Inventory form was also completed. Following a documented febrile urinary tract infection children were randomized to the top-down or bottom-up group. A third group of 44 children undergoing repeat voiding cystourethrography and their parents were also evaluated. RESULTS Child ratings of pain using the Faces Pain Scale-Revised were not significantly different between the top-down group following (99m)technetium dimercaptosuccinic acid renal scintigraphy (2.99 on a scale of 10) and the bottom-up group following voiding cystourethrography (3.21). Also the Faces Pain Scale-Revised was not significantly different in the repeat voiding cystourethrography group (3.35). On the Child-Adult Medical Procedure Interaction Scale-Revised there was negative correlation between child coping and child distress, as well as rate of child distress and adult coping promoting behavior. Parental state anxiety scores were significantly less in the top-down and repeat voiding cystourethrography groups than in the bottom-up group. CONCLUSIONS Although the top-down approach and repeat voiding cystourethrography cause less anxiety for caregivers, these values do not correlate to pain scale in children. This finding might be due to lack of appropriate evaluation tools of pediatric pain and anxiety. However, the theory that the top-down approach is less invasive, and thus less stressful, requires further research. The Child-Adult Medical Procedure Interaction Scale-Revised data indicate that influences in adult-child interaction are bidirectional.
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Affiliation(s)
- Onur Telli
- Department of Pediatric Urology, Ankara University School of Medicine, Ankara, Turkey.
| | - Murat Mermerkaya
- Department of Urology, Ankara University School of Medicine, Ankara, Turkey
| | - Perviz Hajiyev
- Department of Urology, Ankara University School of Medicine, Ankara, Turkey
| | - Ozgu Aydogdu
- Urology Clinic, Bozyaka Training and Research Hospital, Izmir, Turkey
| | - Faraj Afandiyev
- Department of Urology, Ankara University School of Medicine, Ankara, Turkey
| | - Evren Suer
- Department of Urology, Ankara University School of Medicine, Ankara, Turkey
| | - Tarkan Soygur
- Department of Pediatric Urology, Ankara University School of Medicine, Ankara, Turkey
| | - Berk Burgu
- Department of Pediatric Urology, Ankara University School of Medicine, Ankara, Turkey
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Xu RY, Liu HW, Liu JL, Dong JH. Procalcitonin and C-reactive protein in urinary tract infection diagnosis. BMC Urol 2014; 14:45. [PMID: 24886302 PMCID: PMC4074860 DOI: 10.1186/1471-2490-14-45] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2013] [Accepted: 05/01/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Urinary infections are a common type of pediatric disease, and their treatment and prognosis are closely correlated with infection location. Common clinical manifestations and laboratory tests are insufficient to differentiate between acute pyelonephritis and lower urinary tract infection. This study was conducted to explore a diagnostic method for upper and lower urinary tract infection differentiation. METHODS The diagnostic values of procalcitonin (PCT) and C-reactive protein (CRP) were analyzed using the receiver operating characteristic curve method for upper and lower urinary tract infection differentiation. PCT was determined using chemiluminescent immunoassay. RESULTS The PCT and CRP values in children with acute pyelonephritis were significantly higher than those in children with lower urinary tract infection (3.90 ± 3.51 ng/ml and 68.17 ± 39.42 mg/l vs. 0.48 ± 0.39 ng/ml and 21.39 ± 14.92 mg/l). The PCT values were correlated with the degree of renal involvement, whereas the CRP values failed to show such a significant correlation. PCT had a sensitivity of 90.47% and a specificity of 88% in predicting nephropathia, whereas CRP had sensitivity of 85.71% and a specificity of 48%. CONCLUSIONS Both PCT and CRP can be used for upper and lower urinary tract infection differentiation, but PCT has higher sensitivity and specificity in predicting pyelonephritis than CRP. PCT showed better results than CRP. PCT values were also correlated with the degree of renal involvement.
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Affiliation(s)
- Rui-Ying Xu
- Department of Pediatrics, Qilu Hospital of Shan Dong University, Jinan 250012, China.
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24
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Newman DH, Shreves AE, Runde DP. Pediatric urinary tract infection: does the evidence support aggressively pursuing the diagnosis? Ann Emerg Med 2013; 61:559-65. [PMID: 23312370 DOI: 10.1016/j.annemergmed.2012.10.034] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2012] [Revised: 10/22/2012] [Accepted: 10/25/2012] [Indexed: 11/17/2022]
Abstract
The epidemiology of pediatric fever has changed considerably during the past 2 decades with the development of vaccines against the most common bacterial pathogens causing bacteremia and meningitis. The decreasing incidence of these 2 conditions among vaccinated children has led to an emphasis on urinary tract infection as a remaining source of potentially hidden infections in febrile children. Emerging literature, however, has led to questions about both the degree and nature of the danger posed by urinary tract infection in nonverbal children, whereas the aggressive pursuit of the diagnosis consumes resources and leads to patient discomfort, medical risks, and potential overdiagnosis. We review both early and emerging literature to examine the utility and efficacy of early identification and treatment of urinary tract infection in children younger than 24 months. We conclude that in well children of this age, it may be reasonable to withhold or delay testing for urinary tract infection if signs of other sources are apparent or if the fever has been present for fewer than 4 to 5 days.
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25
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Koyle MA, Kirsch AJ, Barone CJ, Elder JS, Shifrin D, Skoog SJ, Snodgrass WT, Weiss RA. Challenges in Childhood Urinary Tract Infection/Vesicoureteral Reflux Investigation and Management: Calming the Storm. Urology 2012; 80:503-8. [DOI: 10.1016/j.urology.2012.06.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2012] [Revised: 05/24/2012] [Accepted: 06/05/2012] [Indexed: 11/30/2022]
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Szymanski KM, Oliveira LM, Silva A, Retik AB, Nguyen HT. Analysis of indications for ureteral reimplantation in 3738 children with vesicoureteral reflux: a single institutional cohort. J Pediatr Urol 2011; 7:601-10. [PMID: 21741318 DOI: 10.1016/j.jpurol.2011.06.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2011] [Accepted: 06/01/2011] [Indexed: 01/13/2023]
Abstract
PURPOSE No method exists for predicting which child with vesicoureteral reflux (VUR) will have surgery. Our goals were to analyze practice patterns at a major pediatric center and to identify factors predisposing children to surgery for specific indications. MATERIALS AND METHODS We analyzed a cohort of 3738 children presenting with primary VUR (1996-2005). Surgical indications included: 1) breakthrough urinary tract infection (UTI), 2) non-resolution over 3 years, 3) renal scan abnormality and 4) parent/surgeon preference. Logistic regression was applied to a random 60% subset of children. Validation in the remaining 40% was done using receiver operating characteristic curve analysis and the Hosmer and Lemeshow goodness-of-fit test. RESULTS Independent predictors of surgery included higher age at presentation, antenatal hydronephrosis (ANH), bilateral VUR and VUR grade. Predictors of surgery for a breakthrough UTI included female gender, increasing age, and bilateral and high-grade VUR. Girls were less likely than boys to be operated for renal scan abnormality or parent/surgeon preference. ANH was a predictor of surgery for decreased function and parent/surgeon preference. The model had fair discrimination (c-statistic = 0.68-0.76) and high calibration (p ≥ 0.24). Probabilities of surgery were calculated. CONCLUSIONS Higher age at presentation, being followed for ANH, and bilateral and high-grade VUR are independent predictors of VUR-corrective surgery. Predictors of surgery vary with indication. Our methods allow comparison of urological practice patterns and outcomes between institutions by taking into account indications for surgery.
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Affiliation(s)
- Konrad M Szymanski
- Division of Urology, McGill University Health Center, Montreal, Quebec, Canada
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27
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Roberts KB. Urinary tract infection: clinical practice guideline for the diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months. Pediatrics 2011; 128:595-610. [PMID: 21873693 DOI: 10.1542/peds.2011-1330] [Citation(s) in RCA: 1013] [Impact Index Per Article: 77.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To revise the American Academy of Pediatrics practice parameter regarding the diagnosis and management of initial urinary tract infections (UTIs) in febrile infants and young children. METHODS Analysis of the medical literature published since the last version of the guideline was supplemented by analysis of data provided by authors of recent publications. The strength of evidence supporting each recommendation and the strength of the recommendation were assessed and graded. RESULTS Diagnosis is made on the basis of the presence of both pyuria and at least 50,000 colonies per mL of a single uropathogenic organism in an appropriately collected specimen of urine. After 7 to 14 days of antimicrobial treatment, close clinical follow-up monitoring should be maintained to permit prompt diagnosis and treatment of recurrent infections. Ultrasonography of the kidneys and bladder should be performed to detect anatomic abnormalities. Data from the most recent 6 studies do not support the use of antimicrobial prophylaxis to prevent febrile recurrent UTI in infants without vesicoureteral reflux (VUR) or with grade I to IV VUR. Therefore, a voiding cystourethrography (VCUG) is not recommended routinely after the first UTI; VCUG is indicated if renal and bladder ultrasonography reveals hydronephrosis, scarring, or other findings that would suggest either high-grade VUR or obstructive uropathy and in other atypical or complex clinical circumstances. VCUG should also be performed if there is a recurrence of a febrile UTI. The recommendations in this guideline do not indicate an exclusive course of treatment or serve as a standard of care; variations may be appropriate. Recommendations about antimicrobial prophylaxis and implications for performance of VCUG are based on currently available evidence. As with all American Academy of Pediatrics clinical guidelines, the recommendations will be reviewed routinely and incorporate new evidence, such as data from the Randomized Intervention for Children With Vesicoureteral Reflux (RIVUR) study. CONCLUSIONS Changes in this revision include criteria for the diagnosis of UTI and recommendations for imaging.
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28
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Mattoo TK. Vesicoureteral reflux and reflux nephropathy. Adv Chronic Kidney Dis 2011; 18:348-54. [PMID: 21896376 DOI: 10.1053/j.ackd.2011.07.006] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2011] [Accepted: 07/29/2011] [Indexed: 12/31/2022]
Abstract
Primary vesicoureteral reflux (VUR) is the commonest congenital urological abnormality in children, which has been associated with an increased risk of urinary tract infection (UTI) and renal scarring, also called reflux nephropathy (RN). In children, RN is diagnosed mostly after UTI (acquired RN) or during follow-up for antenatally diagnosed hydronephrosis with no prior UTI (congenital RN). The acquired RN is more common in female children, whereas the congenital RN is more common in male children. This observation in children might help explain the differences in the clinical presentation of RN in adults, with males presenting mostly with hypertension, proteinuria, and progressive renal failure as compared with females who present mostly with recurrent UTI and have a better outcome. Known risk factors for RN include the severity of VUR, recurrent UTI, and bladder-bowel dysfunction; younger age and delay in treatment of UTI are believed to be other risk factors. Management of VUR is controversial and includes antimicrobial prophylaxis, surgical intervention, or surveillance only. No evidence-based guidelines exist for appropriate follow-up of patients with RN.
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Abstract
BACKGROUND Vesicoureteric reflux (VUR) results in urine passing retrograde up the ureter. Urinary tract infections (UTI) associated with VUR have been considered a cause of permanent renal parenchymal damage in children with VUR. Management of these children has been directed at preventing UTI by antibiotic prophylaxis and/or surgical correction of VUR. The optimum strategy is not clear. OBJECTIVES To evaluate the benefits and harms of different treatment options for primary VUR. SEARCH STRATEGY In August 2010 we searched CENTRAL, MEDLINE and EMBASE and screened reference lists of papers and abstracts from conference proceedings. SELECTION CRITERIA RCTs in any language comparing any treatment of VUR including surgical or endoscopic correction, antibiotic prophylaxis, non-invasive non-pharmacological techniques and any combination of therapies. DATA COLLECTION AND ANALYSIS Two authors independently searched the literature, determined study eligibility, assessed quality, extracted and entered data. We expressed dichotomous outcomes as risk ratios (RR) and their 95% confidence intervals (CI) and continuous data as mean differences (MD) and their 95% CI's Data were pooled using the random effects model. MAIN RESULTS Twenty RCTs (2324 children) were included. Long-term low-dose antibiotic prophylaxis compared to no treatment/placebo did not significantly reduce repeat symptomatic UTI (846 children: RR 0.68, 95% CI 0.39 to 1.17) or febrile UTI (946 children: RR 0.77, 95% CI 0.47 to 1.24) at two years. There was considerable heterogeneity in the analyses and only one study was adequately blinded. At one to three years, antibiotic prophylaxis reduced the risk of new or progressive renal damage on DMSA scan (446 children: RR 0.35, 95% CI 0.15 to 0.80). Side effects were infrequent when reported, but antibiotics increased the likelihood of bacterial drug resistance threefold (132 UTIs: RR 2.94, 95% CI 1.39 to 6.25).When long-term antibiotic prophylaxis was compared with surgical or endoscopic correction of VUR plus antibiotics for one to 24 months (10 studies, 1141 children), the risk of symptomatic UTI was not significantly different at any time point. Combined surgical and antibiotic treatment caused a 57% reduction in febrile UTI by five years (2 studies, 449 children: RR 0.43, 95% CI 0.27 to 0.70) but did not decrease the risk of new or progressive renal damage at any time point. Postoperative obstruction was seen in 0% and 7% of children in two surgical studies and 0% in one endoscopic study. AUTHORS' CONCLUSIONS Compared with no treatment, use of long-term, low-dose antibiotics did not significantly reduce the number of repeat symptomatic and febrile UTIs in children with VUR. Considerable heterogeneity in the analyses and inclusion of only one adequately blinded study, made drawing firm conclusions challenging. Antibiotic prophylaxis significantly reduced the risk of developing new or progressive renal damage, but assuming an 8% baseline risk, 33 children would need long-term antibiotic prophylaxis to prevent one more child developing kidney damage over the course of two to three years.The added benefit of surgical or endoscopic correction of VUR over antibiotic treatment alone remains unclear. Eight children would require combined surgical and antibiotic treatment to prevent one additional child developing febrile UTI by five years, but it would not cause fewer children developing renal damage.
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Affiliation(s)
- Evi Vt Nagler
- Renal Division, Department of Internal Medicine, University Hospital Ghent, Ghent, Belgium
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30
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Impressive renal damage after acute pyelonephritis in a child. Pediatr Nephrol 2010; 25:1365-8. [PMID: 20157735 DOI: 10.1007/s00467-010-1461-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2009] [Revised: 12/18/2009] [Accepted: 12/29/2009] [Indexed: 10/19/2022]
Abstract
Urinary tract infection (UTI) is one of the most common bacterial infections in children, and its role in the pathogenesis of scarred kidney is debated. We report on a 7-year-old child who presented with severe UTI. The early (day 4) renal computed tomography (CT) scan showed normal-sized kidneys (110 mm on the left, 105 mm on the right), whereas the control CT scan and dimercaptosuccinic acid (DMSA) scan, performed 1 and 2 months later, respectively, showed a small scarred right kidney (60 mm) with a 12% residual function. An intermittent right vesicoureteral reflux (VUR) was diagnosed by direct isotopic cystography and then treated by Cohen vesicoureteral reimplantation. The patient remained free of infectious recurrence, hypertension, or renal function decrease. This report demonstrates that one episode of acute pyelonephritis can lead to severe renal scarring. Whereas antenatal lesions are thought to have a stronger role in the causal pathway for reflux nephropathy than is UTI in addition to VUR, this observation reminds us that UTI can truly play an important role in damaging kidneys.
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Nikfar R, Khotaee G, Ataee N, Shams S. Usefulness of procalcitonin rapid test for the diagnosis of acute pyelonephritis in children in the emergency department. Pediatr Int 2010; 52:196-8. [PMID: 20500474 DOI: 10.1111/j.1442-200x.2009.002917.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Urinary tract infection (UTI) is a common problem in children. The aim of this study was to determine the usefulness of the procalcitonin (PCT) rapid test in the diagnosis of renal involvement in children with urinary tract infection. METHODS Through a case series study, PCT and C-reactive protein rapid tests were measured in children with proven UTI at the Tehran Children's Medical Center, Iran. One-hundred patients aged 1 month-14 years old (19 boys and 81 girls) with documented UTI were enrolled in the study. RESULTS Of 100 children, 62 patients (62%) had renal involvement on the basis of abnormal Tc-dimercaptosuccinic acid scintigraphy and 38 patients (38%) had infection restricted to the lower urinary tract. There were no differences related to age or gender among the groups. The sensitivity and specificity of PCT were 77% and 89%, respectively, in prediction of renal involvement, whereas C-reactive protein had a sensitivity of 80% and a specificity of 65%. CONCLUSION We concluded that a rapid determination of PCT concentration could be useful for the management of children with febrile UTI in the emergency room.
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Affiliation(s)
- Roya Nikfar
- Department of Pediatric Infectious Diseases, Abuzar Children's Medical Center Hospital, Ahvaz Jondishapour University of Medical Sciences, Ahvaz, Iran.
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32
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Demirbag S, Atabek C, Caliskan B, Guven A, Sakarya MT, Surer I, Ozturk H. Bladder Dysfunction in Infants with Primary Vesicoureteric Reflux. J Int Med Res 2009; 37:1877-81. [DOI: 10.1177/147323000903700624] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
There is growing evidence that bladder dysfunction is a negative prognostic factor for spontaneous resolution of vesicoureteric reflux (VUR). This study evaluated the prevalence of urodynamic abnormalities in infants with primary VUR who were referred over a 4-year period. The urodynamic evaluations and medical records of 54 infants with primary VUR (79 ureters with reflux) were reviewed prospectively. Urodynamic dysfunction was observed in 46.3% ( n = 25) of infants with primary VUR; 35.2% ( n = 19) had a low bladder capacity and 11.1% ( n = 6) had a large bladder capacity. All infants with large bladder capacities also had high grade (IV-V) VUR. In conclusion, there was a close relationship between bladder dysfunction and primary VUR. For that reason, urodynamic testing of infants with primary VUR should be performed as part of routine clinical evaluations.
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Affiliation(s)
- S Demirbag
- Department of Paediatric Surgery, Gulhane Military Medical Academy, Ankara, Turkey
| | - C Atabek
- Department of Paediatric Surgery, Gulhane Military Medical Academy, Ankara, Turkey
| | - B Caliskan
- Department of Paediatric Surgery, Gulhane Military Medical Academy, Ankara, Turkey
| | - A Guven
- Department of Paediatric Surgery, Gulhane Military Medical Academy, Ankara, Turkey
| | - M T Sakarya
- Department of Paediatric Surgery, Gulhane Military Medical Academy, Ankara, Turkey
| | - I Surer
- Department of Paediatric Surgery, Gulhane Military Medical Academy, Ankara, Turkey
| | - H Ozturk
- Department of Paediatric Surgery, Gulhane Military Medical Academy, Ankara, Turkey
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Ziessman HA, Majd M. Importance of methodology on (99m)technetium dimercapto-succinic acid scintigraphic image quality: imaging pilot study for RIVUR (Randomized Intervention for Children With Vesicoureteral Reflux) multicenter investigation. J Urol 2009; 182:272-9. [PMID: 19450818 DOI: 10.1016/j.juro.2009.02.144] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2008] [Indexed: 11/25/2022]
Abstract
PURPOSE We reviewed our experience with (99m)technetium dimercapto-succinic acid scintigraphy obtained during an imaging pilot study for a multicenter investigation (Randomized Intervention for Children With Vesicoureteral Reflux) of the effectiveness of daily antimicrobial prophylaxis for preventing recurrent urinary tract infection and renal scarring. We analyzed imaging methodology and its relation to diagnostic image quality. MATERIALS AND METHODS (99m)Technetium dimercapto-succinic acid imaging guidelines were provided to participating sites. High-resolution planar imaging with parallel hole or pinhole collimation was required. Two core reviewers evaluated all submitted images. Analysis included appropriate views, presence or lack of patient motion, adequate magnification, sufficient counts and diagnostic image quality. Inter-reader agreement was evaluated. RESULTS We evaluated 70, (99m)technetium dimercapto-succinic acid studies from 14 institutions. Variability was noted in methodology and image quality. Correlation (r value) between dose administered and patient age was 0.780. For parallel hole collimator imaging good correlation was noted between activity administered and counts (r = 0.800). For pinhole imaging the correlation was poor (r = 0.110). A total of 10 studies (17%) were rejected for quality issues of motion, kidney overlap, inadequate magnification, inadequate counts and poor quality images. The submitting institution was informed and provided with recommendations for improving quality, and resubmission of another study was required. Only 4 studies (6%) were judged differently by the 2 reviewers, and the differences were minor. CONCLUSIONS Methodology and image quality for (99m)technetium dimercapto-succinic acid scintigraphy varied more than expected between institutions. The most common reason for poor image quality was inadequate count acquisition with insufficient attention to the tradeoff between administered dose, length of image acquisition, start time of imaging and resulting image quality. Inter-observer core reader agreement was high. The pilot study ensured good diagnostic quality standardized images for the Randomized Intervention for Children With Vesicoureteral Reflux investigation.
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Affiliation(s)
- Harvey A Ziessman
- Division of Nuclear Medicine, Russell H. Morgan Department of Radiology and Radiological Sciences, The Johns Hopkins University, Baltimore, Maryland 21287, USA.
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34
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Sahsi RS, Carpenter CR. Does This Child Have a Urinary Tract Infection? Ann Emerg Med 2009; 53:680-4. [DOI: 10.1016/j.annemergmed.2008.05.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2008] [Revised: 05/05/2008] [Accepted: 05/05/2008] [Indexed: 11/25/2022]
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35
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Jeon JH, Lee KH, Park JS. The Effect of Renal Scarring on Spontaneous Resolution and Breakthrough Infection in Children with Vesicoureteral Reflux. Korean J Urol 2009. [DOI: 10.4111/kju.2009.50.7.699] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Jong Ho Jeon
- Department of Urology, College of Medicine, Daegu Catholic University, Daegu, Korea
| | - Kyung Hun Lee
- Department of Pediatrics, College of Medicine, Daegu Catholic University, Daegu, Korea
| | - Jae Shin Park
- Department of Urology, College of Medicine, Daegu Catholic University, Daegu, Korea
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36
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Chesney RW, Carpenter MA, Moxey-Mims M, Nyberg L, Greenfield SP, Hoberman A, Keren R, Matthews R, Matoo TK. Randomized Intervention for Children With Vesicoureteral Reflux (RIVUR): background commentary of RIVUR investigators. Pediatrics 2008; 122 Suppl 5:S233-9. [PMID: 19018047 PMCID: PMC4336951 DOI: 10.1542/peds.2008-1285c] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Because of the frequency of urinary tract infections in children, off-label use of antimicrobial prophylaxis is often the usual treatment of children with vesicoureteral reflux, and such use is increasingly being called into question; hence, a definitive study to determine the value of antimicrobial prophylaxis with regard to the recurrence of urinary tract infection and the incidence of renal scarring is essential. The currently recommended follow-up procedures (repeated urine cultures, renal and genitourinary imaging, antimicrobial therapy and prophylaxis, as well as other factors including cleanliness, adequate bladder and bowel emptying, and compliance with protocols) are expensive (in terms of time, attention to detail, and cost) and cumbersome. Such recommendations should be evidence-based.
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Affiliation(s)
- Russell W. Chesney
- Department of Pediatrics, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Myra A. Carpenter
- Department of Biostatistics, University of North Carolina, Chapel Hill, North Carolina
| | - Marva Moxey-Mims
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Leroy Nyberg
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | | | - Alejandro Hoberman
- Department of Pediatrics, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Ron Keren
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Ron Matthews
- Department of Urology, Johns Hopkins University, Baltimore, Maryland
| | - Tej K. Matoo
- Department of Pediatrics, Children's Hospital of Michigan, Detroit, Michigan
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Hewitt IK, Zucchetta P, Rigon L, Maschio F, Molinari PP, Tomasi L, Toffolo A, Pavanello L, Crivellaro C, Bellato S, Montini G. Early treatment of acute pyelonephritis in children fails to reduce renal scarring: data from the Italian Renal Infection Study Trials. Pediatrics 2008; 122:486-90. [PMID: 18762516 DOI: 10.1542/peds.2007-2894] [Citation(s) in RCA: 103] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES The American Academy of Pediatrics recommendation for febrile infants and young children suspected of having a urinary tract infection is early antibiotic treatment, given parenterally if necessary. In support of this recommendation, data suggesting that delay in treatment of acute pyelonephritis increases the risk of kidney damage are cited. Because the risk was not well defined, we investigated renal scarring associated with delayed versus early treatment of acute pyelonephritis in children. METHODS The research findings are derived from 2 multicenter, prospective, randomized, controlled studies, Italian Renal Infection Study 1 and 2, whose primary outcomes dealt with initial antibiotic treatment and subsequent prophylaxis, respectively. From the 2 studies, we selected the 287 children with confirmed pyelonephritis on acute technetium-99m-dimercaptosuccinic acid scans who underwent repeat scanning to detect scarring 12 months later. The children were 1 month to <7 years of age when they presented with their first recognized episode of acute pyelonephritis in northeast Italy. RESULTS Progressive delay in antibiotic treatment of acute pyelonephritis from <1 to >/=5 days after the onset of fever was not associated with any significant increase in the risk of scarring on technetium-99m-dimercaptosuccinic acid scans obtained 1 year later. The risk of scarring remained relatively constant at 30.7 +/- 7%. Clinical and laboratory indices of inflammation were comparable in all groups, as was the incidence of vesicoureteric reflux. CONCLUSIONS Early treatment of acute pyelonephritis in infants and young children had no significant effect on the incidence of subsequent renal scarring. Furthermore, there was no significant difference in the rate of scarring after acute pyelonephritis when infants and young children were compared with older children.
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Affiliation(s)
- Ian K Hewitt
- Nephrology, Dialysis, and Transplant Unit, Pediatric Department, Azienda Ospedaliera di Padova, Via Giustiniani, 3, 35128 Padova, Italy
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The presence of urinary nitrites is a significant predictor of pediatric urinary tract infection susceptibility to first- and third-generation cephalosporins. J Emerg Med 2008; 39:6-12. [PMID: 18757159 DOI: 10.1016/j.jemermed.2008.01.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2007] [Revised: 12/05/2007] [Accepted: 01/08/2008] [Indexed: 11/20/2022]
Abstract
BACKGROUND Previous studies in adults have refuted the use of nitrites as a predictor of bacterial resistance to both trimethoprim-sulfamethoxazole and cephalosporins. Some centers now consider first-line outpatient therapy with an oral third-generation cephalosporin appropriate for young children. OBJECTIVE The objective of this study was to determine if nitrite-negative pediatric urinary tract infections (UTIs) were more likely than nitrite-positive UTIs to be resistant to cephalosporins. This may enable physicians to adjust antimicrobial therapy before patients leave the Emergency Department (ED) to avoid the complications of ineffectively treated pediatric UTIs. METHODS A retrospective chart review examined, over a 9-month period, 173 pediatric patients who were diagnosed with a clinical UTI in the ED and who also had a positive urine culture and a recorded dipstick at the time of visit. The chi-squared test and Fisher's exact test were used to compare nitrite-negative vs. nitrite-positive UTIs for resistance to third-generation cephalosporins and other empiric antimicrobials. RESULTS For third-generation cephalosporins, 1.4% of nitrite-positive UTIs were resistant, whereas 14.4% of nitrite-negative UTIs were resistant (95% confidence interval [CI] -0.22 to -0.05). For first-generation cephalosporins, 8.4% were resistant in the nitrite-positive group, compared to 22.2% in the nitrite-negative group (95% CI -0.24 to -0.03). CONCLUSION The absence of urinary nitrites is a significant indicator for potential resistance to cephalosporins in pediatric UTIs. Due to low levels of pediatric UTI resistance, cephalosporins continue to represent useful empiric therapy in the general pediatric population. However, in high-risk patients, physicians may opt to alter their empiric choice of antibiotic based on the presence of urinary nitrites.
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The outcome of surgery versus medical management in the treatment of vesicoureteral reflux. Adv Urol 2008:437560. [PMID: 18670634 PMCID: PMC2479883 DOI: 10.1155/2008/437560] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2008] [Accepted: 06/12/2008] [Indexed: 11/18/2022] Open
Abstract
Evaluation of the relative merits of medical versus surgical management of vesicoureteral reflux (VUR) has been limited by the few prospective studies comparing these strategies. Among those trials that have been reported, the only consistent positive finding has been that incidence of febrile UTI is lower among children undergoing surgical treatment in comparison with medical treatment. Studies have not found significant differences in overall incidence of UTI, or in rates of new renal scarring or progression of existing scarring. It is likely that there is a subset of children with VUR who do benefit from aggressive treatment of their VUR, but we are not yet able to fully determine which children these are. It is hoped that future research will further clarify which treatments are useful in which children.
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Roihuvuo-Leskinen HM, Koskimäki JE, Tammela TLJ, Lahdes-Vasama TT. Urine Flow Curve Shapes in Adults with Earlier Vesicoureteral Reflux. Eur Urol 2008; 54:188-94. [PMID: 17764825 DOI: 10.1016/j.eururo.2007.08.028] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2007] [Accepted: 08/16/2007] [Indexed: 10/22/2022]
Abstract
OBJECTIVES AND METHODS Voiding problems related to childhood vesicoureteral reflux (VUR) in a cohort of 120 patients (109 females, 11 males) were studied at early middle age (range, 33-50 yr). Forty-four patients had been operated on. The study included an interview by means of a symptom questionnaire, a urine flow measurement, a residual urine measurement, and a urine sample. RESULTS The flow curve shape was abnormal in 40% (tower-shaped in 7%, weak in 18%, interrupted in 8%, and big bladder in 8% of patients). Forty-five percent of operated patients and 70% of nonoperated patients had a normal flow curve shape. Almost half of the operated patients (45%) had either an interrupted or a weak flow. Figures for stress incontinence and urgency incontinence among the female patients were twice those in the controls, 35% versus 16% (p=0.05) and 20% versus 11%, respectively. Urinary tract infections (UTIs) were diagnosed in 76% of the adult female VUR patients and in 57% of their controls (p=0.041). Twenty-five percent of the female VUR patients (none of the controls) reported suffering from UTI more often than once a year. CONCLUSIONS Adult patients with childhood VUR have abnormal urine flow curve shapes and UTIs significantly more often than controls (p=0.00005 and p=0.04, respectively). Patients who were operated on for VUR especially seemed to have an interrupted or weak flow curve shape. A high percentage of these patients also suffered from urgency and stress incontinence and annual UTIs.
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Melican K, Boekel J, Månsson LE, Sandoval RM, Tanner GA, Källskog O, Palm F, Molitoris BA, Richter-Dahlfors A. Bacterial infection-mediated mucosal signalling induces local renal ischaemia as a defence against sepsis. Cell Microbiol 2008; 10:1987-98. [PMID: 18549455 DOI: 10.1111/j.1462-5822.2008.01182.x] [Citation(s) in RCA: 84] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Ascending urinary tract infections can cause extensive damage to kidney structure and function. We have used a number of advanced techniques including multiphoton microscopy to investigate the crucial early phases of uropathogenic Escherichia coli induced pyelonephritis within a living animal. Our results reveal a previously undescribed innate vascular response to mucosal infection, allowing isolation and eradication of the pathogen. The extremely rapid host response to mucosal infection was highlighted by the triggering of a cascade of events within 3-4 h. Epithelial signalling produced an increase in cellular O(2) consumption and affected microvascular flow by clotting, causing localized ischaemia. Subsequent ischaemic damage affected pathophysiology with actin re-arrangement and epithelial sloughing leading to paracellular bacterial movement. A denuded tubular basement membrane is shown to hinder immediate dissemination of bacteria, giving the host time to isolate the infection by clotting. Suppression of clotting by heparin treatment caused fatal urosepsis. Clinically these findings may be relevant in antibiotics delivery in pyelonephritis patients and to the use of anticoagulants in sepsis.
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Affiliation(s)
- Keira Melican
- Department of Neuroscience, Karolinska Institutet, Stockholm, Sweden
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Pyelonephritis, renal scarring, and reflux nephropathy: a pediatric urologist's perspective. Pediatr Radiol 2008; 38 Suppl 1:S76-82. [PMID: 18071695 DOI: 10.1007/s00247-007-0587-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2007] [Accepted: 07/10/2007] [Indexed: 10/22/2022]
Abstract
Imaging of children with a clinical diagnosis of pyelonephritis is performed to characterize the extent of the infection, to identify associated renal injury and to uncover risk factors for future infections and renal damage. Although there is general agreement regarding the need for parenchymal imaging and the need to exclude processes that are either functionally or anatomically obstructive, there is controversy regarding the need for routine cystography, especially when parenchymal involvement has not been documented. A protocol that limits the use of cystography for evaluation of urinary tract infections must assume that the diagnosis of reflux is at least of variable clinical significance. It is now clear that vesicoureteral reflux and reflux nephropathy represent a diverse population that includes both congenital and acquired processes. MR imaging will improve our understanding of vesicoureteral reflux, pyelonephritis and renal scarring and might help us to identify and manage those patients most at risk for recurrent infections and renal injury. To recognize the potential contributions of this newer imaging technique it is helpful to look at our understanding of the pathophysiology of pyelonephritis, reflux and reflux nephropathy.
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Abstract
PURPOSE OF REVIEW To highlight recent controversies regarding the rationale and effectiveness of imaging and treatment strategies for children who experience a first urinary tract infection. RECENT FINDINGS The yield of renal ultrasound for children who have had a first urinary tract infection is relatively low, and the most commonly identified abnormalities are of unclear clinical significance. If concerned about renal ultrasound abnormalities, clinicians should not be reassured by a normal late trimester prenatal ultrasound because its negative predictive value is not sufficiently high. Vesicoureteral reflux is neither necessary nor sufficient for developing renal scars. Some pyelonephritis and renal scarring may be related to vesicoureteral reflux that is missed by standard voiding cystourethrogram but detectable during positional instillation of contrast cystography. Dimercaptosuccinic acid scans provide important information about presence of pyelonephritis and renal scars, and have high negative predictive value for ruling out high-grade (III-V) vesicoureteral reflux. Antimicrobial prophylaxis may not be effective for preventing recurrent infections and may result in antimicrobial resistance. Endoscopic therapy (Deflux) has demonstrated moderate success in correcting vesicoureteral reflux, but little is known about its impact on recurrent infection and renal scarring. SUMMARY Debate continues about optimal imaging strategies after first urinary tract infection. More research is needed on the effectiveness of interventions designed to prevent recurrent infections and renal scarring.
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Abstract
BACKGROUND Urinary tract infection (UTI), worldwide, is a major source of disease in children and adults. As it may have long-term consequences such as kidney failure and hypertension, it is important to treat patients with UTI adequately. Although standard management of severe UTI usually means intravenous (IV) therapy, at least initially, there are studies showing that oral therapy may also be effective. OBJECTIVES To assess whether the mode of administration of antibiotic therapy for severe UTI has an effect on cure rate, reinfection rate and kidney scarring. SEARCH STRATEGY The Cochrane Renal Group's specialised register, the Cochrane Central Register of Controlled Trials (CENTRAL, in The Cochrane Library), MEDLINE and EMBASE were searched. No language restriction was applied. Reference lists of relevant articles and reviews were checked for additional studies and authors of relevant articles/abstracts were contacted for further information. Date of last search: July 2007. SELECTION CRITERIA All randomised controlled trials (RCTs) comparing different modes of antibiotic application for patients with severe UTI (children and adults) were considered. DATA COLLECTION AND ANALYSIS Study quality was assessed and data extracted. Statistical analyses were performed using the random effects model and the results expressed as relative risk (RR) for dichotomous outcomes or mean difference (WMD) for continuous data with 95% confidence intervals (CI). MAIN RESULTS Fifteen RCTs (1743 patients) were included. Studies compared oral versus parenteral treatment (1), oral versus switch treatment (initial intravenous (IV) or intramuscular (IM) therapy followed by oral therapy) (5), switch versus parenteral treatment (6) and single dose parenteral followed by oral therapy versus oral (1) or switch therapy (3). There was a variety of short-term and long-term outcomes, but no pooled outcomes showed significant differences. Most included studies were small though and there were few outcomes for combination in a meta-analysis. AUTHORS' CONCLUSIONS There is no evidence suggesting that oral antibiotic therapy is less effective for treatment of severe UTI than parenteral or initial parenteral therapy. The results of this review suggest that the mode of application does not determine therapeutic success.
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Affiliation(s)
- A Pohl
- University Clinic Freiburg, Center of Clincial Studies, Elsässerstr. 2, Freiburg, Germany, 79110.
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Gargollo PC, Diamond DA. Therapy Insight: what nephrologists need to know about primary vesicoureteral reflux. ACTA ACUST UNITED AC 2007; 3:551-63. [PMID: 17895932 DOI: 10.1038/ncpneph0610] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2007] [Accepted: 04/20/2007] [Indexed: 12/11/2022]
Abstract
Vesicoureteral reflux (VUR) is the abnormal, retrograde flow of urine from the bladder to the upper urinary tract. This disease affects about 1% of otherwise normal children, 30-50% of those who present with urinary tract infections, and approximately 10% with prenatally diagnosed hydronephrosis. Over the past 50 years, tremendous progress has been made in the diagnosis, treatment and management of VUR. The realization that VUR is probably a component of generalized dysfunction of the lower urinary tract (i.e. dysfunctional elimination syndrome) has further enhanced understanding of the disease. This Review covers basic pathogenesis, diagnosis, management, clinical presentation, and current controversies surrounding VUR.
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Affiliation(s)
- Patricio C Gargollo
- Harvard Medical School, and Children's Hospital Boston, Boston, MA 02115, USA
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47
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Doganis D, Siafas K, Mavrikou M, Issaris G, Martirosova A, Perperidis G, Konstantopoulos A, Sinaniotis K. Does early treatment of urinary tract infection prevent renal damage? Pediatrics 2007; 120:e922-8. [PMID: 17875650 DOI: 10.1542/peds.2006-2417] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Therapeutic delay has been suggested as the most important factor that is likely to have an effect on the development of scarring after acute pyelonephritis. However, this opinion has not been supported by prospective studies, so we tested it. METHODS In a prospective clinical study, we evaluated whether the time interval between the onset of the renal infection and the start of therapy correlates with the development of acute inflammatory changes and the subsequent development of renal scars, documented by dimercaptosuccinic acid scintigraphy. A total of 278 infants (153 male and 125 female) aged 0.5 to 12.0 months with their first urinary tract infection were enrolled in the study. RESULTS The median time between the onset of infection and the institution of therapy was 2 days (range: 1-8 days). Renal inflammatory changes were documented in 57% of the infants. Renal defects were recorded in 41% of the patients treated within the first 24 hours since the onset of fever versus 75% of those treated on day 4 and onward. Renal scarring was developed in 51% of the infants with an abnormal scan in the acute phase of infection. The frequency of scarring in infants treated early and in those whose treatment was delayed did not differ, suggesting that once acute pyelonephritis has occurred, ultimate renal scarring is independent of the timing of therapy. Acute inflammatory changes and subsequent scarring were more frequent in the presence of vesicoureteral reflux, especially that which is high grade. However, the difference was not significant, which suggests that renal damage may be independent of the presence of reflux. CONCLUSIONS Early and appropriate treatment of urinary tract infection, especially during the first 24 hours after the onset of symptoms, diminishes the likelihood of renal involvement during the acute phase of the infection but does not prevent scar formation.
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Affiliation(s)
- Dimitrios Doganis
- First Department of Pediatrics, P&A Kyriakou Children's Hospital, Athens, Greece.
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Hodson EM, Wheeler DM, Vimalchandra D, Smith GH, Craig JC. Interventions for primary vesicoureteric reflux. Cochrane Database Syst Rev 2007:CD001532. [PMID: 17636679 DOI: 10.1002/14651858.cd001532.pub3] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Vesicoureteric reflux (VUR) results in urine passing, in a retrograde manner, up the ureter. Urinary tract infections (UTIs) have been considered the main cause of permanent renal parenchymal damage in children with reflux. Management of these children has been directed at preventing infection by antibiotic prophylaxis and/or surgical correction of reflux. Controversy remains as to the optimum strategies. OBJECTIVES To evaluate the benefits and harms of different treatment options for primary VUR. SEARCH STRATEGY Randomised controlled trials (RCTs) were identified from the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, reference lists of articles and abstracts from conference proceedings. Date of last search: June 2006 SELECTION CRITERIA Any treatment of VUR including surgery, antibiotic prophylaxis of any duration, non-invasive techniques and any combination of therapies. DATA COLLECTION AND ANALYSIS Two authors independently searched the literature, determined study eligibility, assessed quality, extracted and entered data. For dichotomous outcomes, results were expressed as relative risk (RR) and 95% confidence intervals (CI). Data were pooled using the random effects model. MAIN RESULTS Eleven studies (1148 children) were identified. Seven compared correction of VUR (by surgery or endoscope) plus antibiotics for 1-24 months with antibiotics alone, two compared antibiotics with no treatment and two compared different materials for endoscopic correction of VUR. Risk of UTI by 2, 5 and 10 years was not significantly different between surgical and medical groups (2 years RR 1.07, 95% CI 0.32 to 2.09; 5 years RR 0.99, 95% CI 0.79 to 1.26; 10 years RR 1.06, 95% CI 0.78 to 1.44). Combined treatment resulted in a 50% reduction in febrile UTI by 10 years (RR 0.54, 95% CI 0.55 to 0.92) but no concomitant reduction in risk of new or progressive renal damage by 10 years (RR 1.03, 95% CI 0.53 to 2.00). In two small studies no significant differences in risk for UTI (RR 0.75, 95% CI 0.15 to 3.84) or renal damage (RR 1.70, 95% CI 0.36 to 8.07) were found between antibiotic prophylaxis and no treatment. AUTHORS' CONCLUSIONS It is uncertain whether the treatment of children with VUR confers clinically important benefit. The additional benefit of surgery over antibiotics alone is small at best. Assuming a UTI rate of 20% for children with VUR on antibiotics for five years, nine reimplantations would be required to prevent one febrile UTI, with no reduction in the number of children developing any UTI or renal damage.
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Affiliation(s)
- E M Hodson
- Children's Hospital at Westmead, Centre for Kidney Research, Locked Bag 4001, Westmead, NSW, Australia, 2145.
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Van Arendonk KJ, Madsen MT, Austin JC, Hawtrey CE, Graham MM, Cooper CS. Nuclear Cystometrogram-Determined Bladder Pressure at Onset of Vesicoureteral Reflux Predicts Spontaneous Resolution. Urology 2007; 69:767-70. [PMID: 17445668 DOI: 10.1016/j.urology.2007.01.048] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2006] [Revised: 10/30/2006] [Accepted: 01/21/2007] [Indexed: 11/18/2022]
Abstract
OBJECTIVES The bladder pressure at the onset of reflux may reflect the competence of the ureterovesical junction. The predictive value of the bladder pressure at the onset of vesicoureteral reflux, as measured by nuclear cystometrography, was assessed relative to subsequent reflux resolution. METHODS Nuclear cystometrograms of 67 children were reviewed to determine the presence of reflux, bladder pressure at the onset of reflux, and bladder volume at the onset of reflux. The data were analyzed for significant relationships between the nuclear cystometrogram results and patient outcomes using a Cox proportional hazards regression model, controlling for the duration of follow-up and for patients with bilateral reflux. RESULTS Data were gathered for reflux occurring in 85 ureters. As expected, reflux of a greater grade was less likely to resolve spontaneously (P = 0.005). The pressure at the onset of reflux was also highly predictive of spontaneous resolution (P = 0.0005). Reflux occurring at greater pressures was more likely to resolve spontaneously, independent of the reflux grade or bladder volume at the onset of reflux. Patient age (P = 0.45), normalized volume of urine refluxed (P = 0.97), and normalized bladder volume at the onset of reflux (P = 0.18) were not significant predictors of reflux resolution. CONCLUSIONS The findings of this report have demonstrated for the first time, to our knowledge, that the bladder pressure at the onset of vesicoureteral reflux, as determined by nuclear cystometrography, is a significant independent predictor of vesicoureteral reflux resolution in children.
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Affiliation(s)
- Kyle J Van Arendonk
- Division of Pediatric Urology, Department of Urology, University of Iowa, Iowa City, Iowa 52242-1089, USA
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Jung HJ, Aum JA, Jung SJ, Huh JW. Different characteristic between Escherichea coli and non-Escherichea coli urinary tract infection. KOREAN JOURNAL OF PEDIATRICS 2007. [DOI: 10.3345/kjp.2007.50.5.457] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Hee Jin Jung
- Department of pediatrics, IL Sin Christian Hospital, Pusan, Korea
| | - Ji A Aum
- Department of pediatrics, IL Sin Christian Hospital, Pusan, Korea
| | - Soo Jin Jung
- Department of pediatrics, IL Sin Christian Hospital, Pusan, Korea
| | - Jae Won Huh
- Department of pediatrics, IL Sin Christian Hospital, Pusan, Korea
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