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Mattoo TK, Spencer JD. Biomarkers for urinary tract infection: present and future perspectives. Pediatr Nephrol 2024; 39:2833-2844. [PMID: 38483594 DOI: 10.1007/s00467-024-06321-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 02/07/2024] [Accepted: 02/07/2024] [Indexed: 08/28/2024]
Abstract
A prompt diagnosis of urinary tract infection (UTI) is necessary to minimize its symptoms and limit sequelae. The current UTI screening by urine test strip analysis and microscopic examination has suboptimal diagnostic accuracy. A definitive diagnosis of UTI by urine culture takes two to three days for the results. These limitations necessitate a need for better biomarkers for the diagnosis and subsequent management of UTI in children. Here, we review the value of currently available UTI biomarkers and highlight the potential of emerging biomarkers that can facilitate a more rapid and accurate UTI diagnosis. Of the newer UTI biomarkers, the most promising are blood procalcitonin (PCT) and urinary neutrophil gelatinase-associated lipocalin (NGAL). PCT can provide diagnostic benefits and should be considered in patients who have a blood test for other reasons. NGAL, which is on the threshold of clinical care, needs more research to address its scope and utilization, including point-of-care application. Employment of these and other biomarkers may ultimately improve UTI diagnosis, guide UTI therapy, reduce antibiotic use, and mitigate UTI complications.
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Affiliation(s)
- Tej K Mattoo
- Pediatric Nephrologist, Wayne Pediatrics, Detroit, MI, USA.
- Department of Pediatrics, Wayne State University School of Medicine, Detroit, MI, USA.
- Department of Urology, Wayne State University School of Medicine, Detroit, MI, USA.
| | - John David Spencer
- The Kidney and Urinary Tract Center, Nationwide Children's Abigail Wexner Research Institute, Columbus, OH, USA
- The Ohio State University College of Medicine, Columbus, OH, USA
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Chandra T, Bajaj M, Iyer RS, Chan SS, Bardo DME, Chen J, Cooper ML, Kaplan SL, Levin TL, Moore MM, Peters CA, Saidinejad M, Schooler GR, Shet NS, Squires JH, Trout AT, Pruthi S. ACR Appropriateness Criteria® Urinary Tract Infection-Child: 2023 Update. J Am Coll Radiol 2024; 21:S326-S342. [PMID: 38823954 DOI: 10.1016/j.jacr.2024.02.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 02/28/2024] [Indexed: 06/03/2024]
Abstract
Urinary tract infection (UTI) is a frequent infection in childhood. The diagnosis is usually made by history and physical examination and confirmed by urine analysis. Cystitis is infection or inflammation confined to the bladder, whereas pyelonephritis is infection or inflammation of kidneys. Pyelonephritis can cause renal scarring, which is the most severe long-term sequela of UTI and can lead to accelerated nephrosclerosis, leading to hypertension and chronic renal failure. The role of imaging is to guide treatment by identifying patients who are at high risk to develop recurrent UTIs or renal scarring. This document provides initial imaging guidelines for children presenting with first febrile UTI with appropriate response to medical management, atypical or recurrent febrile UTI, and follow-up imaging for children with established vesicoureteral reflux. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Affiliation(s)
| | - Manish Bajaj
- Research Author, Children's Healthcare of Atlanta and Emory University, Atlanta, Georgia
| | - Ramesh S Iyer
- Panel Chair, Seattle Children's Hospital, Seattle, Washington
| | - Sherwin S Chan
- Panel Vice Chair, Children's Mercy Hospital, Kansas City, Missouri
| | - Dianna M E Bardo
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Jimmy Chen
- University of Florida College of Medicine Jacksonville, Jacksonville, Florida; American Academy of Pediatrics
| | | | - Summer L Kaplan
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Committee on Emergency Radiology-GSER
| | - Terry L Levin
- The Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York
| | | | - Craig A Peters
- University of Texas Southwestern Medical Center, Dallas, Texas; Society for Pediatric Urology
| | - Mohsen Saidinejad
- UCLA Medical Center, Los Angeles, California; American College of Emergency Physicians
| | - Gary R Schooler
- University of Texas Southwestern Medical Center, Dallas, Texas
| | - Narendra S Shet
- Children's National Hospital, Washington, District of Columbia
| | - Judy H Squires
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Andrew T Trout
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Commission on Nuclear Medicine and Molecular Imaging
| | - Sumit Pruthi
- Specialty Chair, Vanderbilt Children's Hospital, Nashville, Tennessee
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3
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Cajigas-Loyola SC, Chow JS, Hayatghaibi S, Iyer RS, Kwon J, Rubesova E, Sánchez-Jacob R, Wyers M, Otero HJ. Imaging of Vesicoureteral Reflux: AJR Expert Panel Narrative Review. AJR Am J Roentgenol 2024; 222:e2329741. [PMID: 37672329 DOI: 10.2214/ajr.23.29741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/07/2023]
Abstract
Vesicoureteral reflux (VUR) is a common congenital anomaly of the urinary tract that can present with collecting system dilation or as a febrile infection. VUR can lead to permanent renal sequelae requiring surgery but can also spontaneously resolve without complication. Therefore, recognizing patient populations who warrant imaging for screening, confirmation, or ongoing surveillance for VUR is important, as is avoiding overdiagnosis. In the appropriate patient populations, an accurate diagnosis of VUR allows early treatment and prevention of pyelonephritis and scarring. Various imaging modalities are available to diagnose and grade VUR, including voiding cystourethrography, radionucleotide cystography, and contrast-enhanced voiding urosonography (ceVUS). The objective of this article is to summarize the current understanding of VUR diagnosis and management and to discuss these imaging modalities' strengths and pitfalls. Considerations include indications for VUR imaging, patient preparation, conduct of the examination, issues related to radiologic reporting, and cost-effectiveness. An emphasis is placed on ceVUS, which is the most recently introduced of the three imaging modalities and is receiving growing support among pediatric radiologists.
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Affiliation(s)
- Stephanie C Cajigas-Loyola
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104
| | - Jeanne S Chow
- Department of Radiology, Boston Children's Hospital, Boston, MA
| | | | - Ramesh S Iyer
- Department of Radiology, Seattle Children's Hospital, Seattle, WA
| | - Jeannie Kwon
- Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Erika Rubesova
- Department of Radiology, Stanford Medicine Children's Health, Palo Alto, CA
| | | | - Mary Wyers
- Department of Radiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Hansel J Otero
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104
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Marsh MC, Junquera GY, Stonebrook E, Spencer JD, Watson JR. Urinary Tract Infections in Children. Pediatr Rev 2024; 45:260-270. [PMID: 38689106 DOI: 10.1542/pir.2023-006017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Abstract
Despite the American Academy of Pediatrics guidelines for the evaluation, treatment, and management of urinary tract infections (UTIs), UTI diagnosis and management remains challenging for clinicians. Challenges with acute UTI management stem from vague presenting signs and symptoms, diagnostic uncertainty, limitations in laboratory testing, and selecting appropriate antibiotic therapy in an era with increasing rates of antibiotic-resistant uropathogens. Recurrent UTI management remains difficult due to an incomplete understanding of the factors contributing to UTI, when to assess a child with repeated infections for kidney and urinary tract anomalies, and limited prevention strategies. To help reduce these uncertainties, this review provides a comprehensive overview of UTI epidemiology, risk factors, diagnosis, treatment, and prevention strategies that may help pediatricians overcome the challenges associated with acute and recurrent UTI management.
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Affiliation(s)
- Melanie C Marsh
- Division of Hospital Medicine, Department of Pediatrics, Advocate Aurora Atrium Health Systems, Chicago, IL
| | - Guillermo Yepes Junquera
- Kidney and Urinary Tract Center, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH
- Division of Infectious Diseases
| | - Emily Stonebrook
- Kidney and Urinary Tract Center, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH
- Division of Nephrology and Hypertension, Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH
| | - John David Spencer
- Kidney and Urinary Tract Center, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH
- Division of Nephrology and Hypertension, Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH
| | - Joshua R Watson
- Center for Clinical Excellence, Nationwide Children's Hospital, Columbus, OH
- Division of Infectious Diseases
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The value of interleukin levels in the diagnosis of febrile urinary tract infections in children and adolescents; a systematic review and meta-analysis. J Pediatr Urol 2022; 18:211-223. [PMID: 35184943 DOI: 10.1016/j.jpurol.2022.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 01/13/2022] [Accepted: 01/17/2022] [Indexed: 11/23/2022]
Abstract
INTRODUCTION In recent years, researchers have been looking for tools and biomarkers to identify urinary tract infections (UTI) in children. Since there exists no systematic reviews and meta-analyses on the matter, the present study intends to determine the diagnostic value of serum and urinary levels of interleukins (IL) in the diagnosis of febrile UTI in children and adolescents. METHODS Medline, Embase, Scopus, and Web of Science were searched until the end of 2020, using keywords related to UTI and serum and urinary ILs. Two independent researchers included relevant studies and summarized the data. Analyzed data were reported as standardized mean difference (SMD) with 95% confidence interval (CI). RESULTS Data from 23 articles were included in the present study. Analyses showed that IL-6, IL-8, IL 1 beta and IL-1 alpha urinary levels are significantly higher in children with UTI than that of other children. Moreover, serum levels of IL-6 and IL-8 in children with UTI were significantly higher than that of healthy children. However, IL-6 and IL-8 serum levels were not significantly different between children with UTI and non-UTI febrile group. Finally, the area under the curve of urinary IL-6 and IL-8 and serum IL-8 levels in the diagnosis of pediatric UTIs were 0.89 (95% CI: 0.86, 0.92), 0.95 (95% CI: 0.92, 0.96) and 0.80 (95% CI: 0.77, 0.84), respectively. CONCLUSION The findings of the present study showed that the diagnostic utility of ILs 8 and 6 urinary levels is most desirable in the detection of febrile UTIs from other febrile conditions in children and adolescents, in comparison with the diagnostic utility of other ILs' urinary and serum levels in the detection of febrile UTI. However, even after nearly 3 decades of research on these biomarkers, their optimal cut-off points in diagnosing pediatric UTIs are still to be determined in further studies.
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Clinical Epidemiology Characteristics and Antibiotic Resistance Associated with Urinary Tract Infections Caused by E. coli. Int J Nephrol 2022; 2022:2552990. [PMID: 35265377 PMCID: PMC8901359 DOI: 10.1155/2022/2552990] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Revised: 08/24/2021] [Accepted: 01/13/2022] [Indexed: 11/19/2022] Open
Abstract
Introduction In individuals with urinary tract infections, Escherichia coli (E. coli) is an ubiquitous causative agent and antibiotic resistance is on the rise throughout the world. Therefore, early diagnosis and appropriate choice of antimicrobials are essential. The purpose of our study is to describe some of the clinical and epidemiological characteristics and the laboratory test results of children treated in our hospital for urinary tract infections caused by E. coli. Methods The study included 128 patients from 2 months to 15 years of age with urinary tract infections caused by E. coli and treated at the Haiphong Children's Hospital during the periods of 2011–2013 and 2018–2020. Results During the two study periods, 57 and 71 cases, respectively, were included. The most common clinical symptom was fever in 40 and 46 cases, respectively. The proportion of E. coli's resistance to ampicillin increased from 85.3% in 2011–2013 to 97.1% in 2018–2020. In 2011–2013, 70.5% of E. coli isolates were resistant to cotrimoxazole, which increased to 81.4% during 2018–2020. During both periods, E. coli was highly sensitive to amikacin, at 87% and 95.5%, respectively. In 2018–2020, carbapenems (meropenem and imipenem) and piperacillin were also effective against E. coli. Conclusion Our study revealed that high fever was the most prevalent clinical characteristic in urinary tract infections caused by E. coli in children and E. coli was mostly resistant to ampicillin, nalidixic acid, and cotrimoxazole but was highly sensitive to ciprofloxacin, amikacin, piperacillin, meropenem, and imipenem.
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Sobowale K, Clayton A, Smith MV. Diaper Need Is Associated with Pediatric Care Use: An Analysis of a Nationally Representative Sample of Parents of Young Children. J Pediatr 2021; 230:146-151. [PMID: 33130154 PMCID: PMC9269865 DOI: 10.1016/j.jpeds.2020.10.061] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 10/21/2020] [Accepted: 10/26/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To examine the possible association between diaper need, difficulty affording an adequate amount of diapers, and pediatric care visits for urinary tract infections and diaper dermatitis. STUDY DESIGN This cross-sectional analysis using nationally representative survey data collected July-August 2017 using a web-based panel examined 981 parents of children between 0 and 3 years of age in the US (response rate, 94%). Survey weighting for differential probabilities of selection and nonresponse was used to estimate the prevalence of diaper need and to perform multivariable logistic regression of the association between parent reported diaper need and visits to the pediatrician for diaper rash or urinary tract infections within the past 12 months. RESULTS An estimated 36% of parents endorsed diaper need. Both diaper need (aOR 2.37; 95% CI 1.69-3.31) and visiting organizations to receive diapers (aOR 2.14; 95% CI 1.43-3.21) were associated with diaper dermatitis visits. Similar associations were found for diaper need (aOR 2.63; 95% CI 1.54-4.49) and visiting organizations to receive diapers (aOR 4.50; 95% CI 2.63-7.70) for urinary tract infection visits. CONCLUSIONS Diaper need is common and associated with increased pediatric care visits. These findings suggest pediatric provider and policy interventions decreasing diaper need could improve child health and reduce associated healthcare use.
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Affiliation(s)
- Kunmi Sobowale
- Department of Psychiatry, University of California Los Angeles, Los Angeles, California
| | | | - Megan V. Smith
- Department of Psychiatry, Yale School of Medicine,Child Study Center, Yale School of Medicine, New Haven, Connecticut,Social & Behavioral Sciences, Yale School of Public Health, New Haven, Connecticut
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8
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Downs SM. Interval Likelihood Ratios and the Diagnostic Process. Pediatrics 2021; 147:peds.2020-037721. [PMID: 33277352 DOI: 10.1542/peds.2020-037721] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/13/2020] [Indexed: 11/24/2022] Open
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Trends in Antimicrobial Susceptibility of Escherichia coli Isolates in a Taiwanese Child Cohort with Urinary Tract Infections between 2004 and 2018. Antibiotics (Basel) 2020; 9:antibiotics9080501. [PMID: 32785113 PMCID: PMC7460002 DOI: 10.3390/antibiotics9080501] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 08/05/2020] [Accepted: 08/08/2020] [Indexed: 11/28/2022] Open
Abstract
The aim of this study was to investigate the annual incidence of Escherichia coli isolates in urinary tract infections (UTIs) and the antimicrobial resistance of the third-generation cephalosporin (3GCs) to E. coli, including the factors associated with the resistance in hospitalized children in Taiwan. A large electronic database of medical records combining hospital admission and microbiological data during 2004–2018 was used to study childhood UTIs in Taiwan. Annual incidence rate ratios (IRR) of E. coli in children with UTIs and its resistant rate to the 3GCs and other antibiotics were estimated by linear Poisson regression. Factors associated with E. coli resistance to 3GCs were assessed through multivariable logistic regression analysis. E. coli UTIs occurred in 10,756 unique individuals among 41,879 hospitalized children, with 92.58% being community associated based on urine culture results reported within four days after the hospitalization. The overall IRR E. coli UTI was 1.01 (95% confidence interval (CI) 0.99–1.02) in community-associated (CA) and 0.96 (0.90–1.02) in healthcare-associated infections. The trend in 3GCs against E. coli increased (IRR 1.18, 95% CI 1.13–1.24) over time in CA-UTIs. Complex chronic disease (adjusted odds ratio (aOR), 2.04; 95% CI, 1.47–2.83) and antibiotics therapy ≤ 3 months prior (aOR, 1.49; 95% CI, 1.15–1.94) were associated with increased risk of 3GCs resistance to E. coli. The study results suggested little or no change in the trend of E. coli UTIs in Taiwanese youths over the past 15 years. Nevertheless, the increase in 3GCs-resistant E. coli was substantial. Interventions for children with complex chronic comorbidities and prior antibiotic treatment could be effective in reducing the incidence of 3GCs-resistant E. coli in CA-UTIs in this region and more generally.
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Kaufman J, Knight AJ, Bryant PA, Babl FE, Dalziel K. Liquid gold: the cost-effectiveness of urine sample collection methods for young precontinent children. Arch Dis Child 2020; 105:253-259. [PMID: 31444211 DOI: 10.1136/archdischild-2019-317561] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 08/03/2019] [Accepted: 08/08/2019] [Indexed: 11/03/2022]
Abstract
BACKGROUND Urinary tract infection (UTI) is a common childhood infection. Many febrile children require a urine sample to diagnose or exclude UTI. Collecting urine from young children can be time-consuming, unsuccessful or contaminated. Cost-effectiveness of each collection method in the emergency department is unknown. OBJECTIVE To determine the cost-effectiveness of urine collection methods for precontinent children. METHODS A cost-effectiveness analysis was conducted comparing non-invasive (urine bag, clean catch and 5 min voiding stimulation for clean catch) and invasive (catheterisation and suprapubic aspirate (SPA)) collection methods, for children aged 0-24 months in the emergency department. Costs included equipment, staff time and hospital bed occupancy. If initial collection attempts were unsuccessful subsequent collection using catheterisation was assumed. The final outcome was a definitive sample incorporating progressive dipstick, culture and contamination results. Average costs and outcomes were calculated for initial collection attempts and obtaining a definitive sample. One-way and probabilistic sensitivity analyses were performed. RESULTS For initial collection attempts, catheterisation had the lowest cost per successful collection (GBP£25.98) compared with SPA (£37.80), voiding stimulation (£41.32), clean catch (£52.84) and urine bag (£92.60). For definitive collection, catheterisation had the lowest cost per definitive sample (£49.39) compared with SPA (£51.84), voiding stimulation (£52.25), clean catch (£64.82) and urine bag (£112.28). Time occupying a hospital bed was the most significant determinant of cost. CONCLUSION Catheterisation is the most cost-effective urine collection method, and voiding stimulation is the most cost-effective non-invasive method. Urine bags are the most expensive method. Although clinical factors influence choice of method, considering cost-effectiveness for this common procedure has potential for significant aggregate savings.
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Affiliation(s)
- Jonathan Kaufman
- Royal Children's Hospital Melbourne, Parkville, Victoria, Australia .,Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia.,Murdoch Childrens Research Institute, Parkville, Victoria, Australia
| | - Andrew Joshua Knight
- Health Economics Unit, The University of Melbourne School of Population Health, Melbourne, Victoria, Australia
| | - Penelope A Bryant
- Royal Children's Hospital Melbourne, Parkville, Victoria, Australia.,Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia.,Murdoch Childrens Research Institute, Parkville, Victoria, Australia
| | - Franz E Babl
- Royal Children's Hospital Melbourne, Parkville, Victoria, Australia.,Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia.,Murdoch Childrens Research Institute, Parkville, Victoria, Australia
| | - Kim Dalziel
- Murdoch Childrens Research Institute, Parkville, Victoria, Australia.,Health Economics Unit, The University of Melbourne School of Population Health, Melbourne, Victoria, Australia
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12
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Simões E Silva AC, Oliveira EA, Mak RH. Urinary tract infection in pediatrics: an overview. J Pediatr (Rio J) 2020; 96 Suppl 1:65-79. [PMID: 31783012 PMCID: PMC9432043 DOI: 10.1016/j.jped.2019.10.006] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 09/12/2019] [Accepted: 10/16/2019] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE This review aimed to provide a critical overview on the pathogenesis, clinical findings, diagnosis, imaging investigation, treatment, chemoprophylaxis, and complications of urinary tract infection in pediatric patients. SOURCE OF DATA Data were obtained independently by two authors, who carried out a comprehensive and non-systematic search in public databases. SUMMARY OF FINDINGS Urinary tract infection is the most common bacterial infection in children. Urinary tract infection in pediatric patients can be the early clinical manifestation of congenital anomalies of the kidney and urinary tract (CAKUT) or be related to bladder dysfunctions. E. coli is responsible for 80-90% of community-acquired acute pyelonephritis episodes, especially in children. Bacterial virulence factors and the innate host immune systems may contribute to the occurrence and severity of urinary tract infection. The clinical presentation of urinary tract infections in children is highly heterogeneous, with symptoms that can be quite obscure. Urine culture is still the gold standard for diagnosing urinary tract infection and methods of urine collection in individual centers should be determined based on the accuracy of voided specimens. The debate on the ideal imaging protocol is still ongoing and there is tendency of less use of prophylaxis. Alternative measures and management of risk factors for recurrent urinary tract infection should be emphasized. However, in selected patients, prophylaxis can protect from recurrent urinary tract infection and long-term consequences. According to population-based studies, hypertension and chronic kidney disease are rarely associated with urinary tract infection. CONCLUSION Many aspects regarding urinary tract infection in children are still matters of debate, especially imaging investigation and indication of antibiotic prophylaxis. Further longitudinal studies are needed to establish tailored approach of urinary tract infection in childhood.
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Affiliation(s)
- Ana Cristina Simões E Silva
- Universidade Federal de Minas Gerais (UFMG), Faculdade de Medicina, Laboratório Interdisciplinar de Investigação Médica, Departamento de Pediatria, Unidade de Nefrologia Pediátrica, Belo Horizonte, MG, Brazil.
| | - Eduardo A Oliveira
- Universidade Federal de Minas Gerais (UFMG), Faculdade de Medicina, Laboratório Interdisciplinar de Investigação Médica, Departamento de Pediatria, Unidade de Nefrologia Pediátrica, Belo Horizonte, MG, Brazil
| | - Robert H Mak
- University of California, Rady Children's Hospital San Diego, Division of Pediatric Nephrology, San Diego, United States
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Evaluation of bladder stimulation as a non-invasive technique for urine collection to diagnose urinary tract infection in infants under 6 months: a randomized multicenter study ("EE-Sti.Ve.N"). Trials 2019; 20:783. [PMID: 31881992 PMCID: PMC6935056 DOI: 10.1186/s13063-019-3914-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 11/18/2019] [Indexed: 12/03/2022] Open
Abstract
Background Febrile urinary tract infection (UTI) is common in infants and needs to be diagnosed quickly. However, the symptoms are non-specific, and diagnosis can only be confirmed after high quality urinalysis. The American Academy of Pediatrics recommends suprapubic aspiration (1–9% contamination) and urinary catheterization (8–14% contamination) for urine collection but both these procedures are invasive. Recent studies have shown a new non-invasive method of collecting urine, bladder stimulation, to be quick and safe. However, few data about bacterial contamination rates have been published for this technique. We hypothesize that the contamination rate of urine collection by bladder stimulation to diagnose febrile UTI in infants under 6 months is equivalent to that of urinary catheterization. Methods/design This trial aims to assess equivalence in terms of bacterial contamination of urinary samples collected by urinary catheterization and bladder stimulation to diagnose UTI. Seven hundred seventy infants under 6 months presenting with unexplained fever in one of four Pediatric Emergency Departments in France will be enrolled. Each child will be randomized into a bladder stimulation or urinary catheterization group. The primary endpoints will be the validity of the urine sample assessed by the presence of contamination on bacterial culture. Conclusion A high recruitment rate is achievable due to the high prevalence of suspected UTIs in infants. The medical risk is the same as that for routine clinical care as we analyze patients with isolated fever. If our hypothesis holds true and the rate of urine contamination collected by bladder stimulation is acceptable, the infants included in the study will have benefited from a non-invasive and reliable means of collecting urine. Trial registration ClinicalTrials.gov, NCT03801213. Registered on 11 January 2019.
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Mushi MF, Alex VG, Seugendo M, Silago V, Mshana SE. C - reactive protein and urinary tract infection due to Gram-negative bacteria in a pediatric population at a tertiary hospital, Mwanza, Tanzania. Afr Health Sci 2019; 19:3217-3224. [PMID: 32127899 PMCID: PMC7040338 DOI: 10.4314/ahs.v19i4.45] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Introduction Gram-negative bacteria are the major cause of urinary tract infections (UTI) in children. There is limited data on UTI systemic response as measured using C-reactive protein (CRP). Here, we report the association of CRP and UTI among children attending the Bugando Medical Centre, Mwanza, Tanzania. Methods A cross-sectional study was conducted between May and July 2017. Urine and blood were collected and processed within an hour of collection. Data were analyzed using STATA version 13. Results Of 250 enrolled children, 76(30.4%) had significant bacteriuria with 56(22.4%, 95%CI; 11.5–33.3) having gram-negative bacteria infection. There was dual growth of gram-negative bacteria in 3 patients. Escherichia coli (32.2%, 19/59) was the most frequently pathogen detected. A total of 88/250(35.2%) children had positive CRP on qualitative assay. By multinomial logistic regression, positive CRP (RRR=4.02, 95%CI: 2.1–7.7, P<0.001) and age ≤ 2years (RRR=2.4, 95%CI: 1.23–4.73, P<0.01) significantly predicted the presence of significant bacteriuria due to gram-negative enteric bacteria. Conclusion C-reactive protein was significantly positive among children with UTI due to gram-negative bacteria and those with fever. In children with age ≤ 2 years, positive CRP indicates UTI due to gram-negative enteric bacteria.
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Affiliation(s)
- Martha F Mushi
- Department of Microbiology/Immunology, Weill Bugando School of Medicine, Catholic University of Health and Allied Science
| | - Vaileth G Alex
- Department of Microbiology/Immunology, Weill Bugando School of Medicine, Catholic University of Health and Allied Science
| | - Mwanaisha Seugendo
- Department of Pediatric and Child Health, Weill Bugando School of Medicine, Catholic University of Health and child health
| | - Vitus Silago
- Department of Microbiology/Immunology, Weill Bugando School of Medicine, Catholic University of Health and Allied Science
| | - Stephen E Mshana
- Department of Microbiology/Immunology, Weill Bugando School of Medicine, Catholic University of Health and Allied Science
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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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16
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Targeted Workup after Initial Febrile Urinary Tract Infection: Using a Novel Machine Learning Model to Identify Children Most Likely to Benefit from Voiding Cystourethrogram. J Urol 2019; 202:144-152. [PMID: 30810465 DOI: 10.1097/ju.0000000000000186] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE Significant debate persists regarding the appropriate workup in children with an initial urinary tract infection. Greatly preferable to all or none approaches in the current guideline would be a model to identify children at highest risk for a recurrent urinary tract infection plus vesicoureteral reflux to allow for targeted voiding cystourethrogram while children at low risk could be observed. We sought to develop a model to predict the probability of recurrent urinary tract infection associated vesicoureteral reflux in children after an initial urinary tract infection. MATERIALS AND METHODS We included subjects from the RIVUR (Randomized Intervention for Children with Vesico-Ureteral Reflux) and CUTIE (Careful Urinary Tract Infection Evaluation) trials in our study, excluding the prophylaxis treatment arm of the RIVUR. The main outcome was defined as recurrent urinary tract infection associated vesicoureteral reflux. Missing data were imputed using optimal tree imputation. Data were split into training, validation and testing sets. Machine learning algorithm hyperparameters were tuned by the validation set with fivefold cross-validation. RESULTS A total of 500 subjects, including 305 from the RIVUR and 195 from the CUTIE trials, were included in study. Of the subjects 90% were female and mean ± SD age was 21 ± 19 months. A recurrent urinary tract infection developed in 72 patients, of whom 53 also had vesicoureteral reflux (10.6% of the total). The final model included age, sex, race, weight, the systolic blood pressure percentile, dysuria, the urine albumin-to-creatinine ratio, prior antibiotic exposure and current medication. The model predicted recurrent urinary tract infection associated vesicoureteral reflux with an AUC of 0.761 (95% CI 0.714-0.808) in the testing set. CONCLUSIONS Our predictive model using a novel machine learning algorithm provided promising performance to facilitate individualized treatment of children with an initial urinary tract infection and identify those most likely to benefit from voiding cystourethrogram after the initial urinary tract infection. This would allow for more selective application of this test, increasing the yield while also minimizing overuse.
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Affiliation(s)
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- Department of Urology, Boston Children's Hospital , Boston , Massachusetts.,Operations Research Center, Massachusetts Institute of Technology , Cambridge , Massachusetts
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17
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Erol S. Urinary Tract Infections in Neonatal Intensive Care Unit: 4-Year Experience. ANKARA MEDICAL JOURNAL 2019. [DOI: 10.17098/amj.542422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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18
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Abstract
Urinary tract infection (UTI) is the second most common bacterial infection in children and is considered a public health threat given the mounting rates of antibiotic-resistance among uropathogens. This article highlights recent encouraging developments in UTI research. Further work is necessary to translate the discoveries into accessible, cost-effective technologies that will aid clinicians in real-time decision-making.
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Affiliation(s)
- Rachel Millner
- UAMS Division of Pediatric Nephrology, Arkansas Children's Hospital, 1 Children's Way, Little Rock, AR 72212, USA
| | - Brian Becknell
- Nephrology Section, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA; Department of Pediatrics, Ohio State University School of Medicine, 700 Children's Drive, Columbus, OH 43210, USA; Center for Clinical and Translational Research, The Research Institute at Nationwide Children's Hospital, 700 Children's Drive, W308, Columbus, OH 43205, USA.
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19
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Sabzehei MK, Basiri B, Shokouhi M, Eghbalian F. Urinary tract infection profile among a hospitalized newborn: a single center study in Iran, 2006-2015. MEDICAL JOURNAL OF INDONESIA 2018. [DOI: 10.13181/mji.v27i2.2677] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
Background: Urinary tract infection in infants is associated with septicemia and genitourinary anomalies. This study was aimed at investigating the frequency, clinical signs, and anomalies in infants hospitalized for urinary tract infection.Methods: This cross-sectional study was conducted on all infants with urinary infection who were hospitalized in the neonatal ward of Be’sat Hospital from 2006 to 2015.Results: Of 79 infants with urinary infection, 62% were male and 87.3% were term infants. The mean age at admission was 16.62±7.17 days, and the mean weight was 3276±478.23 grams. The most frequent clinical sign and the most common pathogen reported were prolonged jaundice (62%) and Escherichia coli (69.6%), respectively. Of the samples, 93.7% were obtained by suprapubic aspiration, 23% had leukocytosis, and 2.5% had urosepsis. In urinalysis examination, 81% had pyuria and 19% had positive nitrate. Among 25.3% infants who had abnormal ultrasound findings, the most abnormal finding was mild bilateral hydronephrosis and 6.3% of the infants had abnormal voiding cystourethrogram (VCUG) in which vesicoureteral reflux was the most frequent finding.Conclusion: It showed that a prolonged jaundice in infants should be considered as a strong factor predicting urinary tract infection.
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20
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Selekman RE, Shapiro DJ, Boscardin J, Williams G, Craig JC, Brandström P, Pennesi M, Roussey-Kesler G, Hari P, Copp HL. Uropathogen Resistance and Antibiotic Prophylaxis: A Meta-analysis. Pediatrics 2018; 142:peds.2018-0119. [PMID: 29954832 PMCID: PMC6317567 DOI: 10.1542/peds.2018-0119] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/20/2018] [Indexed: 11/24/2022] Open
Abstract
CONTEXT Limited data exist regarding uropathogen resistance in randomized controlled trials of urinary tract infection (UTI) prevention and antibiotic prophylaxis. OBJECTIVE To assess the effect of prophylaxis on developing a multidrug-resistant first recurrent UTI among children with vesicoureteral reflux. DATA SOURCES Cochrane Kidney and Transplant Specialized Register through May 25, 2017. STUDY SELECTION Randomized controlled trials of patients ≤18 years of age with a history of vesicoureteral reflux being treated with continuous antibiotic prophylaxis compared with no treatment or placebo with available antibiotic sensitivity profiles. DATA EXTRACTION Two independent observers abstracted data and assessed quality and validity per Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Adjusted meta-analyses were performed by using a mixed-effects logistic regression model. RESULTS One thousand two hundred and ninety-nine patients contributed 224 UTIs. Patients treated with prophylaxis were more likely to have a multidrug-resistant infection (33% vs 6%, P < .001) and were more likely to receive broad-spectrum antibiotics (68% vs 49%, P = .004). Those receiving prophylaxis had 6.4 times the odds (95% confidence interval: 2.7-15.6) of developing a multidrug-resistant infection. One multidrug-resistant infection would develop for every 21 reflux patients treated with prophylaxis. LIMITATIONS Variables that may contribute to resistance such as medication adherence and antibiotic exposure for other illnesses could not be evaluated. CONCLUSIONS Prophylaxis increases the risk of multidrug resistance among recurrent infections. This has important implications in the risk-benefit assessment of prophylaxis as a management strategy and in the selection of empirical treatment of breakthrough infections in prophylaxis patients.
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Affiliation(s)
| | - Daniel J. Shapiro
- Boston Combined Residency Program, Boston Children’s Hospital and Boston Medical Center, Boston, Massachusetts
| | - John Boscardin
- Medicine, and Biostatistics, University of California, San Francisco, San Francisco, California
| | - Gabrielle Williams
- School of Public Health, University of Sydney, Camperdown, New South Wales, Australia
| | - Jonathan C. Craig
- School of Public Health, University of Sydney, Camperdown, New South Wales, Australia
| | - Per Brandström
- Pediatric Uro-Nephrologic Center, Sahlgrenska Academy, University of Gothenburg and Queen Slivias Children’s Hospital, Gothenburg, Sweden
| | - Marco Pennesi
- Department of Pediatrics, Institute for Child and Maternal Health, University of Trieste, Trieste, Italy
| | | | - Pankaj Hari
- Department of Pediatrics, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
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21
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Anigilaje EA. A Putative Role of Apolipoprotein L1 Polymorphism in Renal Parenchymal Scarring Following Febrile Urinary Tract Infection in Nigerian Under-Five Children: Proposal for a Case-Control Association Study. JMIR Res Protoc 2018; 7:e156. [PMID: 29903699 PMCID: PMC6024104 DOI: 10.2196/resprot.9514] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 03/23/2018] [Accepted: 04/10/2018] [Indexed: 01/13/2023] Open
Abstract
Background Although urinary tract infection (UTI) resolves with prompt treatment in a majority of children, some children, especially those aged less than 5 years, also develop renal parenchymal scarring (RPS). RPS causes high blood pressure that may lead to severe chronic kidney disease and end-stage renal disease (ESRD). Although the risk of UTI is higher in white children than in black children, it is unknown whether RPS is more common in white children than in black children as data are scarce in this regard. A common genetic predisposition to kidney disease in African Americans and the sub-Saharan African blacks is the possession of apolipoprotein L1 (APOL1). APOL1 risk variants regulate the production of APOL1. APOL1 circulates in the blood, and it is also found in the kidney tissue. While circulating, APOL1 kills the trypanosome parasites; an increased APOL1 in kidney tissues, under the right environmental conditions, can also result in the death of kidney tissue (vascular endothelium, the podocytes, proximal tubules, and arterial cells), which, ultimately, is replaced by fibrous tissue. APOL1 may influence the development of RPS, as evidence affirms that its expression is increased in kidney tissue following UTI caused by bacteria. Thus, UTI may be a putative environmental risk factor responsible for APOL1-induced kidney injury. Objective The aim of this proposal was to outline a study that seeks to determine if the possession of two copies of either G1 or G2 APOL1 variant increases the risk of having RPS, 6 months following a febrile UTI among Nigerian under-five children. Methods This case-control association study seeks to determine whether the risk of RPS from febrile UTI is conditional on having 2 APOL1 risk alleles (either G1 or G2). Cases will be children with a confirmed RPS following a febrile UTI. Controls will be age-, gender-, and ethnic-matched children with a febrile UTI but without RPS. Children with vesicoureteral reflux and other congenital anomalies of the urinary tract are to be excluded. Association between predictor variables (ethnicity, APOL1 G1 or G2, and others) and RPS will be tested at bivariate logistic regression analyses. Predictors that attained significance at a P value of ˂.05 will be considered for multiple logistic regressions. Likelihood-based tests will be used for hypothesis testing. Estimation will be done for the effect size for each of the APOL1 haplotypes using a generalized linear model. Results The study is expected to last for 3 years. Conclusions The study is contingent on having a platform for undergoing a research-based PhD program in any willing university in Europe or elsewhere. The findings of this study will be used to improve the care of African children who may develop RPS following febrile UTI. Registered Report Identifier RR1-10.2196/9514
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Affiliation(s)
- Emmanuel Ademola Anigilaje
- Nephrology Unit, Department of Paediatrics, College of Health Sciences, University of Abuja, Abuja, Nigeria
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22
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Karmazyn BK, Alazraki AL, Anupindi SA, Dempsey ME, Dillman JR, Dorfman SR, Garber MD, Moore SG, Peters CA, Rice HE, Rigsby CK, Safdar NM, Simoneaux SF, Trout AT, Westra SJ, Wootton-Gorges SL, Coley BD. ACR Appropriateness Criteria ® Urinary Tract Infection-Child. J Am Coll Radiol 2018; 14:S362-S371. [PMID: 28473093 DOI: 10.1016/j.jacr.2017.02.028] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 02/20/2017] [Accepted: 02/21/2017] [Indexed: 11/15/2022]
Abstract
Urinary tract infection (UTI) is common in young children and may cause pyelonephritis and renal scarring. Long-term complications from renal scarring are low. The role of imaging is to evaluate for underlying urologic abnormalities and guide treatment. In neonates there is increased risk for underlying urologic abnormalities. Evaluation for vesicoureteral reflux (VUR) may be appropriate especially in boys because of higher prevalence of VUR and to exclude posterior urethral valve. In children older than 2 months with first episode of uncomplicated UTI, there is no clear benefit of prophylactic antibiotic. Ultrasound is the only study that is usually appropriate. After the age of 6 years, UTIs are infrequent. There is no need for routine imaging as VUR is less common. In children with recurrent or complicated UTI, in addition to ultrasound, imaging of VUR is usually appropriate. Renal cortical scintigraphy may be appropriate in children with VUR, as renal scarring may support surgical intervention. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
- Boaz K Karmazyn
- Principal Author and Panel Chair, Riley Hospital for Children, Indiana University, Indianapolis, Indiana.
| | | | | | | | | | | | - Matthew D Garber
- Wolfson Children's Hospital, Jacksonville, Florida; American Academy of Pediatrics
| | | | - Craig A Peters
- UT Southwestern Medical Center, Dallas, Texas; Society for Pediatric Urology
| | - Henry E Rice
- Duke University Medical Center, Durham, North Carolina; American Pediatric Surgical Association
| | - Cynthia K Rigsby
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Nabile M Safdar
- Children's National Medical Center, Washington, District of Columbia
| | | | - Andrew T Trout
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | | | - Brian D Coley
- Specialty Chair, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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23
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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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24
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Jung N, Byun HJ, Park JH, Kim JS, Kim HW, Ha JY. Diagnostic accuracy of urinary biomarkers in infants younger than 3 months with urinary tract infection. KOREAN JOURNAL OF PEDIATRICS 2018; 61:24-29. [PMID: 29441109 PMCID: PMC5807987 DOI: 10.3345/kjp.2018.61.1.24] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 09/25/2017] [Accepted: 09/26/2017] [Indexed: 01/11/2023]
Abstract
Purpose The aim of this study was to evaluate the diagnostic accuracy of urinary biomarkers, such as neutrophil gelatinase-associated lipocalin (uNGAL) and β-2 microglobulin (uB2MG), in early detection of urinary tract infection (UTI) in infants aged <3 months with fever. Methods A total of 422 infants aged <3 months (male:female=267:155; mean age, 56.4 days), who were admitted for fever, were retrospectively included in this study. We compared uNGAL and uB2MG between the UTI and non-UTI groups at the time of admission. The sensitivity, specificity, accuracy, and area under the curve (AUC) of uNGAL and uB2MG for use in diagnosing UTI were assessed. Results Among 422 patients, 102 (24.2%) were diagnosed with UTI. Levels of uNGAL were higher in the UTI group than in the non-UTI group (366.6 ng/mL vs. 26.9 ng/mL, P<0.001). Levels of uB2MG were not different between the 2 groups. Multivariate analysis revealed that uNGAL was an independent predictive factor for UTI (P=0.033). The sensitivity, specificity, and accuracy were 90.2%, 92.5%, and 91.9% for uNGAL, and 48.0%, 43.8%, and 44.8% for uB2MG, respectively. AUC of uNGAL was 0.942 and that of uB2MG was 0.407. Conclusion Accuracy of uNGAL in the diagnosis of UTI is high in febrile infants aged <3 months. uNGAL can help in the early diagnosis and treatment of UTI in infants.
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Affiliation(s)
- Nani Jung
- Department of Pediatrics, Keimyung University School of Medicine, Daegu, Korea
| | - Hye Jin Byun
- Department of Urology, Keimyung University School of Medicine, Daegu, Korea
| | - Jae Hyun Park
- Department of Pediatrics, Keimyung University School of Medicine, Daegu, Korea
| | - Joon Sik Kim
- Department of Pediatrics, Keimyung University School of Medicine, Daegu, Korea
| | - Hae Won Kim
- Department of Nuclear Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Ji Yong Ha
- Department of Urology, Keimyung University School of Medicine, Daegu, Korea
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25
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Haid B, Roesch J, Strasser C, Oswald J. The method of urine sampling is not a valid predictor for vesicoureteral reflux in children after febrile urinary tract infections. J Pediatr Urol 2017; 13:500.e1-500.e5. [PMID: 28412102 DOI: 10.1016/j.jpurol.2017.01.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2016] [Accepted: 01/29/2017] [Indexed: 10/19/2022]
Abstract
INTRODUCTION The likelihood of detecting vesicoureteral reflux (VUR) after febrile urinary tract infections (UTI) in children logically should correlate with the correct diagnosis of the UTI. Beneath the unspecific symptoms of fever urine analysis is the main diagnostic criterion for the exact diagnosis of febrile UTIs in children. Use of inadequate urine sampling techniques during diagnosis may lead to impaired accuracy in UTI diagnosis. This could lead to the assumption that children, having diagnosed their UTI by the use of possibly inadequate urine sampling techniques should not be evaluated as consequently compared to those, where the diagnosis relied on sterile urine sampling techniques. We hypothesized that children with possibly contaminated urine samples during the initial diagnosis may show a lower rate of VUR in subsequent VCUGs because of a wrong diagnosis initially compared to children, where accurate urine sampling techniques were used. PATIENTS Between 2009 and 2014, a total of 555 patients underwent a primary VCUG at our department indicated because of febrile UTIs. Patients with urine collection methods other than bag urine and catheter/suprapubic aspiration (SPA) were excluded from this study (mid-stream urine, potty urine, n = 149). We evaluated 402 patients (male/female 131/271, mean age 1.91 years), VUR rates and grades were compared between patients where urine was sampled by the use of a urine bag only at the time of diagnosis (n = 296, 73.6%) and those where sterile urine sampling (catheter, suprapubic puncture) was performed (n = 106, 26.3%). 4 patients were excluded due to equivocal data on urine sampling. RESULTS VUR rate in children after sterile urine sampling using a catheter or SPA accounted to 31.1%. In those where urine samples acquired by the use of urine bags were used, 33.7% showed VUR on subsequent VCUG (p = 0.718). There were no significant differences as to VUR grades or gender, although VUR was much more commonly diagnosed in female patients (37.0% vs 28.2%, p = 0.227) (Figure). CONCLUSION Children diagnosed with their UTI by use of bag urine in our experience carried the same risk of showing a VUR in a subsequent VCUG compared to those, where the initial diagnosis relied - beneath clinical criteria - on urine samples acquired by suprapubic puncture or catheterization. Consequently urine-sampling technique during initial UTI diagnosis alone should not be used as predictor for the reliability of UTI diagnosis and should not influence the further management after UTI.
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Affiliation(s)
- Bernhard Haid
- Department of Pediatric Urology, Hospital of the Sisters of Charity, Linz, Austria.
| | - Judith Roesch
- Department of Pediatric Urology, Hospital of the Sisters of Charity, Linz, Austria
| | - Christa Strasser
- Department of Pediatric Urology, Hospital of the Sisters of Charity, Linz, Austria
| | - Josef Oswald
- Department of Pediatric Urology, Hospital of the Sisters of Charity, Linz, Austria
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Felt JR, Yurkovich C, Garshott DM, Kamat D, Farooqi A, Fribley AM, Callaghan MU, Hebert K. The Utility of Real-Time Quantitative Polymerase Chain Reaction Genotype Detection in the Diagnosis of Urinary Tract Infections in Children. Clin Pediatr (Phila) 2017; 56:912-919. [PMID: 28436231 DOI: 10.1177/0009922817706144] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Urinary tract infections (UTIs) are the most common serious bacterial infection in children with significant morbidity with delayed diagnosis. Polymerase chain reaction (PCR) is very accurate in detecting bacteria and widely available, but has never been evaluated to detect UTIs in children. To assess the utility of PCR as a rapid diagnostic tool, we conducted a prospective cohort study of 193 urine samples from children younger than 36 months undergoing evaluation for UTI in the emergency department over a 10-month period. A quantification cycle (Cq) threshold of 26.15 identified all Escherichia coli positive samples with sensitivity and specificity of 100% and 99.5%, respectively (95% CI = 71.5%-100% and 97.9%-99.5%, respectively). A Cq threshold of 19.03 identified E coli infections >100 000 colony forming units/mL with sensitivity and specificity of 100% (95% CI = 72.2%-100% and 98.6%-100%, respectively). PCR is very accurate in diagnosing E coli UTIs in young children and could be useful as a rapid diagnostic tool.
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Affiliation(s)
- Jon R Felt
- 1 Children's Hospital of Michigan, Wayne State University, Detroit, MI, USA
| | - Chelsey Yurkovich
- 1 Children's Hospital of Michigan, Wayne State University, Detroit, MI, USA
| | | | - Deepak Kamat
- 1 Children's Hospital of Michigan, Wayne State University, Detroit, MI, USA
| | - Ahmad Farooqi
- 1 Children's Hospital of Michigan, Wayne State University, Detroit, MI, USA
| | - Andrew M Fribley
- 1 Children's Hospital of Michigan, Wayne State University, Detroit, MI, USA
| | | | - Katherine Hebert
- 1 Children's Hospital of Michigan, Wayne State University, Detroit, MI, USA
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Yamasaki Y, Uemura O, Nagai T, Yamakawa S, Hibi Y, Yamamoto M, Nakano M, Kasahara K, Bo Z. Pitfalls of diagnosing urinary tract infection in infants and young children. Pediatr Int 2017; 59:786-792. [PMID: 28390079 DOI: 10.1111/ped.13292] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Revised: 03/28/2017] [Accepted: 04/04/2017] [Indexed: 11/27/2022]
Abstract
BACKGROUND The aim of this study was to examine the sensitivity and specificity of pyuria-based diagnosis of urinary tract infection (UTI) in urine collected by transurethral catheterization, and the reliability of diagnosis of pyuria in urine collected in a perineal bag. The gold standard for UTI diagnosis is significant colony counts of a single organism in urine obtained in a sterile manner. METHODS We enrolled 301 patients who underwent medical examination at the present hospital for possible UTI between January 2005 and December 2009. We collected 438 urine samples by transurethral catheterization. We investigated the accuracy of pyuria-based diagnosis of UTI using transurethral catheterization urine specimens, and the reliability of diagnosis of pyuria using bag-collected urine specimens. RESULTS The false-negative rate of UTI diagnosis based on pyuria in transurethral catheterization urine sediments was 9.0%; there was no significant difference in the false-negative rate of UTI diagnosis between boys and girls. Approximately 28% of pyuria-positive bag-collected urine specimens were pyuria negative on transurethral catheterization; this rate was significantly higher in girls than in boys (56.7% vs. 8.9%, P < 0.0001). CONCLUSIONS The absence of pyuria in transurethral catheterization urine sediments does not rule out UTI. Pyuria in bag-collected urine specimens frequently consists of urine leukocytes from external genitalia as well as from the urinary tract.
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Affiliation(s)
- Yasuhito Yamasaki
- Department of Pediatric Nephrology, Aichi Children's Health and Medical Center, Obu, Aichi, Japan
| | - Osamu Uemura
- Department of Pediatric Nephrology, Aichi Children's Health and Medical Center, Obu, Aichi, Japan
| | - Takuhito Nagai
- Department of Pediatric Nephrology, Aichi Children's Health and Medical Center, Obu, Aichi, Japan
| | - Satoshi Yamakawa
- Department of Pediatric Nephrology, Aichi Children's Health and Medical Center, Obu, Aichi, Japan
| | - Yoshiko Hibi
- Department of Pediatric Nephrology, Aichi Children's Health and Medical Center, Obu, Aichi, Japan
| | - Masaki Yamamoto
- Department of Pediatric Nephrology, Aichi Children's Health and Medical Center, Obu, Aichi, Japan
| | - Masaru Nakano
- Department of Pediatric Nephrology, Aichi Children's Health and Medical Center, Obu, Aichi, Japan
| | - Katsuaki Kasahara
- Department of Pediatric Nephrology, Aichi Children's Health and Medical Center, Obu, Aichi, Japan
| | - Zhang Bo
- Department of Biochemistry, Fukuoka University School of Medicine, Jonanku, Fukuoka, Japan
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González MJ, Robino L, Iribarnegaray V, Zunino P, Scavone P. Effect of different antibiotics on biofilm produced by uropathogenic Escherichia coli isolated from children with urinary tract infection. Pathog Dis 2017; 75:3821168. [PMID: 28505288 DOI: 10.1093/femspd/ftx053] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Accepted: 05/08/2017] [Indexed: 11/14/2022] Open
Affiliation(s)
- María José González
- Departamento de Microbiología, Instituto de Investigaciones Biológicas Clemente Estable, 11600 Montevideo, Uruguay
| | - Luciana Robino
- Departamento de Bacteriología y Virología, Instituto de Higiene, Facultad de Medicina, Universidad de la República, 11600 Montevideo, Uruguay
| | - Victoria Iribarnegaray
- Departamento de Microbiología, Instituto de Investigaciones Biológicas Clemente Estable, 11600 Montevideo, Uruguay
| | - Pablo Zunino
- Departamento de Microbiología, Instituto de Investigaciones Biológicas Clemente Estable, 11600 Montevideo, Uruguay
| | - Paola Scavone
- Departamento de Microbiología, Instituto de Investigaciones Biológicas Clemente Estable, 11600 Montevideo, Uruguay
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Saha D, Patel J, Buckingham D, Thornton D, Barber T, Watson JR. Urine Culture Follow-up and Antimicrobial Stewardship in a Pediatric Urgent Care Network. Pediatrics 2017; 139:peds.2016-2103. [PMID: 28302674 DOI: 10.1542/peds.2016-2103] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/19/2016] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Empiric antibiotic therapy for presumed urinary tract infection (UTI) leads to unnecessary antibiotic exposure in many children whose urine culture results fail to confirm the diagnosis. The objective of this quality improvement study was to improve follow-up management of negative urine culture results in the off-campus urgent care network of Nationwide Children's Hospital to reduce inappropriate antibiotic exposure in children. METHODS A multidisciplinary task force developed and implemented a protocol for routine nurse and clinician follow-up of urine culture results, discontinuation of unnecessary antibiotics, and documentation in the electronic medical record. Monthly antibiotic discontinuation rates were tracked in empirically treated patients with negative urine culture results from July 2013 through December 2015. Statistical process control methods were used to track improvement over time. Fourteen-day return visits for UTIs were monitored as a balancing measure. RESULTS During the study period, 910 patients received empiric antibiotic therapy for UTIs but had a negative urine culture result. The antibiotic discontinuation rate increased from 4% to 84%, avoiding 3429 (40%) of 8648 antibiotic days prescribed. Among patients with discontinued antibiotics, none was diagnosed with a UTI within 14 days of the initial urgent care encounter. CONCLUSIONS Implementation of a standard protocol for urine culture follow-up and discontinuation of unnecessary antibiotics was both effective and safe in a high-volume pediatric urgent care network. Urine culture follow-up management is an essential opportunity for improved antimicrobial stewardship in the outpatient setting that will affect many patients by avoiding a substantial number of antibiotic days.
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Affiliation(s)
| | | | | | - David Thornton
- Department of Pathology and Laboratory Medicine, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio
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Hollingworth W, Busby J, Butler CC, O'Brien K, Sterne JAC, Hood K, Little P, Lawton M, Birnie K, Thomas-Jones E, Harman K, Hay AD. The Diagnosis of Urinary Tract Infection in Young Children (DUTY) Study Clinical Rule: Economic Evaluation. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2017; 20:556-566. [PMID: 28407997 PMCID: PMC5406157 DOI: 10.1016/j.jval.2017.01.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 01/06/2017] [Accepted: 01/13/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE To estimate the cost-effectiveness of a two-step clinical rule using symptoms, signs and dipstick testing to guide the diagnosis and antibiotic treatment of urinary tract infection (UTI) in acutely unwell young children presenting to primary care. METHODS Decision analytic model synthesising data from a multicentre, prospective cohort study (DUTY) and the wider literature to estimate the short-term and lifetime costs and healthcare outcomes (symptomatic days, recurrent UTI, quality adjusted life years) of eight diagnostic strategies. We compared GP clinical judgement with three strategies based on a 'coefficient score' combining seven symptoms and signs independently associated with UTI and four strategies based on weighted scores according to the presence/absence of five symptoms and signs. We compared dipstick testing versus laboratory culture in children at intermediate risk of UTI. RESULTS Sampling, culture and antibiotic costs were lowest in high-specificity DUTY strategies (£1.22 and £1.08) compared to clinical judgement (£1.99). These strategies also approximately halved urine sampling (4.8% versus 9.1% in clinical judgement) without reducing sensitivity (58.2% versus 56.4%). Outcomes were very similar across all diagnostic strategies. High-specificity DUTY strategies were more cost-effective than clinical judgement in the short- (iNMB = £0.78 and £0.84) and long-term (iNMB =£2.31 and £2.50). Dipstick tests had poorer cost-effectiveness than laboratory culture in children at intermediate risk of UTI (iNMB = £-1.41). CONCLUSIONS Compared to GPs' clinical judgement, high specificity clinical rules from the DUTY study could substantially reduce urine sampling, achieving lower costs and equivalent patient outcomes. Dipstick testing children for UTI is not cost-effective.
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Affiliation(s)
| | - John Busby
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Christopher C Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Kathryn O'Brien
- Division of Population Medicine, Cardiff University, Cardiff, UK
| | | | - Kerenza Hood
- South East Wales Trials Unit (SEWTU Centre for Trials Research), Cardiff University, Cardiff, UK
| | - Paul Little
- Primary Care and Population Sciences Division, University of Southampton, Southampton, UK
| | - Michael Lawton
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Kate Birnie
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Emma Thomas-Jones
- South East Wales Trials Unit (SEWTU Centre for Trials Research), Cardiff University, Cardiff, UK
| | - Kim Harman
- Primary Care and Population Sciences Division, University of Southampton, Southampton, UK
| | - Alastair D Hay
- Centre for Academic Primary Care, NIHR School of Primary Care Research, School of Social and Community Medicine, University of Bristol, Bristol, UK
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Qureshi AH, Ajayi O, Schwaderer AL, Hains DS. Decreased Identification of Vesicoureteral Reflux: A Cautionary Tale. Front Pediatr 2017; 5:175. [PMID: 28848728 PMCID: PMC5554494 DOI: 10.3389/fped.2017.00175] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Accepted: 07/31/2017] [Indexed: 11/20/2022] Open
Abstract
AIM To find the trend in patient's visits to our centers for vesicoureteral reflux (VUR). We hypothesize that VUR diagnosis and hence possible nephropathy recognition may be diminishing because of changing practice patterns. METHODS Data were extracted from electronic medical records for new and follow-up patients aged 0-18 years with ICD-9/10 codes to correspond with VUR, VUR unilateral, VUR bilateral, and VUR with reflux nephropathy, as well as new patients with diagnoses of urinary tract infections (UTI) and pyelonephritis at two major pediatric centers from 2012 to 2015. Figures and statistics to reflect absolute clinic visits and annual trends were created with SPSS 2010. Linear regression was applied. RESULTS Annually, Le Bonheur Children's Hospital and Nationwide Children's Hospital experienced an average decrease of 13 and 17% in total VUR visits, and an average decrease of 22 and 27% in VUR nephropathy visits, respectively, for each institution. Patient visits for UTIs were reduced an average of 16% annually in both centers. Linear regression demonstrated that number of patients (patients/year ± SE) decreased annually 69 ± 19 (P = 0.02), 7 ± 2 (P = 0.02), and 67 ± 25 (P = 0.04) for VUR, VUR nephropathy, and UTI, respectively. CONCLUSION We conclude that the decreased number of VUR and VUR nephropathy cases identified in subspecialty clinics (Nephrology/Urology) at two major children's hospitals reflect a possible decreased identification of VUR. This trend may also be due to decreased referral of low grade cases of VUR. We cannot conclude that "undifferentiated UTI" referrals increased concomitantly to account for the decreased VUR as our data reflects a decreased trend in those visits as well. We suggest that clinicians following the American Academy of Pediatrics guidelines ensure that all UTI are accounted for and surveillance is appropriately escalated for recurrent UTI or abnormal imaging results.
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Affiliation(s)
- Aslam Hyder Qureshi
- Innate Immunity Translational Research Center, Children Foundation Research Institute, Le Bonheur Children's Hospital, Memphis, TN, United States.,Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, United States
| | - Oluwaseun Ajayi
- Biomedical Informatics Core, Children's Foundation Research Institute, Le Bonheur Children's Hospital, Memphis, TN, United States
| | | | - David S Hains
- Innate Immunity Translational Research Center, Children Foundation Research Institute, Le Bonheur Children's Hospital, Memphis, TN, United States.,Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, United States
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Labrosse M, Levy A, Autmizguine J, Gravel J. Evaluation of a New Strategy for Clean-Catch Urine in Infants. Pediatrics 2016; 138:peds.2016-0573. [PMID: 27542848 DOI: 10.1542/peds.2016-0573] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/16/2016] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES A new noninvasive bladder stimulation technique has been described to obtain clean-catch urine (CCU) in infants aged <30 days. Objectives were (1) to determine proportion and predictive factors for successful CCU collections using a stimulation maneuver technique among infants <6 months and (2) to determine the proportion of bacterial contamination with this method. METHODS A prospective cohort study was conducted in a tertiary pediatric emergency department among infants <6 months needing a urine sample. CCU samples were collected using a standardized stimulation technique. Invasive technique was performed after CCU for three specific conditions. Primary outcomes were proportions of successful CCU specimens and bacterial contamination. We determined associations between successful urine samples and 4 predictive factors (age, sex, low oral intake, and recent voiding). RESULTS A total of 126 infants were included (64 boys, median age: 55 days). The CCU procedure was effective in 62 infants (49%; median time: 45 seconds). Infants 0 to 29 days; 30 to 59 days, and 60 to 89 days had more successful procedures, compared with infants >89 days (odds ratios [95% confidence interval (CI)]: 4.3 [1.4 to 13.4]; 3.2 [1.2 to 8.4]; and 4.44 [1.5 to 13.3], respectively). The contamination proportion was 16% (95% CI: 8% to 27%) in the CCU group. This proportion was not statistically different compared with the invasive method group (6%, 95% CI: 3% to 15%). CONCLUSIONS The CCU procedure is a quick and effective noninvasive method in children aged <90 days. Contamination proportions were similar to those reported in the literature for urethral catheterization. Circumstances for which the CCU procedure could be performed are proposed.
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Affiliation(s)
| | | | - Julie Autmizguine
- Departments of Pediatrics, and Pharmacology, University of Montreal, Montreal, Canada
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Cheng MF, Chen WL, Huang IF, Chen JR, Chiou YH, Chen YS, Lee SSJ, Hung WY, Hung CH, Wang JL. Urinary tract infection in infants caused by extended-spectrum beta-lactamase-producing Escherichia coli: comparison between urban and rural hospitals. Pediatr Nephrol 2016; 31:1305-12. [PMID: 26975387 DOI: 10.1007/s00467-016-3338-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Revised: 01/24/2016] [Accepted: 01/26/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND Community-acquired urinary tract infection (UTI) caused by extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli is an emerging problem. Compared with urban infants, rural infants may encounter different distributions of community-acquired resistant strains and various barriers to efficient management. METHODS A retrospective survey and comparison was conducted for infants with UTI caused by ESBL-producing E. coli admitted to an urban hospital (n = 111) and a rural hospital (n = 48) in southern Taiwan from 2009 to 2012. RESULTS Compared with 2009 and 2010, the total number of cases at both hospitals significantly increased in 2011 and 2012 (p < 0.001). Compared with the rural patients, the urban patients were significantly younger, and they had fewer days of fever before and after admission, fewer presentations of poor activity and poor appetite, and a lower serum creatinine level. Most of the patients had no prior history of illness, and we could not identify any significant different risk factors for acquiring ESBL-producing E. coli, such as past antimicrobial use, hospitalization, UTI, and underlying renal diseases, between the urban and rural populations. CONCLUSIONS The increase in community-acquired UTI in infants caused by ESBL-producing E. coli was similar between the urban and rural populations. Our preliminary data suggest that the rural-urban disparities were probably related to easy access to health care by the urban population. ESBL complicates disease management, and the increase in the prevalence of ESBL producers is a major health concern and requires further healthy carrier and environmental surveillance.
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Affiliation(s)
- Ming-Fang Cheng
- Department of Pediatrics, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Fooyin University, Kaohsiung, Taiwan
| | - Wan-Ling Chen
- Department of Pediatrics, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Department of Pediatrics, Pingtung Branch of Veterans General Hospital-Kaohsiung, Pingtung, Taiwan
| | - I-Fei Huang
- Department of Pediatrics, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Jung-Ren Chen
- Department of Biological Science and Technology, College of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Yee-Hsuan Chiou
- Department of Pediatrics, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Fooyin University, Kaohsiung, Taiwan
| | - Yao-Shen Chen
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Susan Shin-Jung Lee
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Wan-Yu Hung
- Department of Chemical Engineering and Institute of Biotechnology and Chemical Engineering, I-Shou University, No. 1, Sec. 1, Syuecheng Rd., Dashu District, Kaohsiung City, 84001, Taiwan (R.O.C)
| | - Chih-Hsin Hung
- Department of Chemical Engineering and Institute of Biotechnology and Chemical Engineering, I-Shou University, No. 1, Sec. 1, Syuecheng Rd., Dashu District, Kaohsiung City, 84001, Taiwan (R.O.C).
| | - Jiun-Ling Wang
- Department of Internal Medicine, National Cheng Kung University Hospital, No.1, University Road, Tainan City, 701, Taiwan (R.O.C).
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Personal History and Physical Examination in Judgment of Urinary Tract Infection in Children Aged 3 Months to 2 Years. Pediatr Neonatol 2016; 57:274-9. [PMID: 26934828 DOI: 10.1016/j.pedneo.2015.09.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Revised: 06/06/2015] [Accepted: 09/25/2015] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Pediatricians ubiquitously rely on urine analysis for diagnosing urinary tract infection (UTI) in young febrile children due to discrepancies in symptom presentation. This study aimed to identify the determinants of physical examination and personal history for diagnosing UTI. METHODS Four hundred and ten patients aged between 3 months and 2 years presenting with a tympanic temperature of >38°C for >24 hours were requested to undergo urinary tests. Pediatricians completed patient record charts before the test results were generated, examined the final results of the tests, and compared the results with those reported in the medical records. Multivariate logistic regression analysis was performed to detect potential confounding factors. RESULTS An age of <1 year [odds ratio (OR): 5.05; p < 0.01], female sex (OR: 2.117; p < 0.05), and the absence of throat redness (OR: 1.907; p < 0.05) were risk factors for UTI. Patients defecating ≤3 times/day (OR: 8.80; p < 0.05) were more likely to have pyuria than those who defecated >3 times/day. CONCLUSION For febrile patients in the age group examined, the absence of throat redness and female sex were independent predictors of UTI. Moreover, the risk of UTI was higher in younger patients.
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Abstract
BACKGROUND Pediatricians frequently use urinalysis to diagnose urinary tract infection (UTI) while awaiting urine culture results, but sensitivity and specificity of urinalysis are limited. This study evaluated the diagnostic accuracy of the antimicrobial peptides (AMPs) human α-defensin 5 (HD5) and human neutrophil peptides (HNP) 1-3 as novel UTI biomarkers in children. METHODS We prospectively enrolled 199 pediatric Emergency Department or Urgent Care patients evaluated for a UTI. Urine concentrations of HD5 and HNP1-3 were measured by enzyme-linked immunosorbent assay. Urine culture was the reference standard. Sensitivities and specificities of leukocyte esterase (LE), HD5, HNP1-3, and test combinations were compared. RESULTS For predicting positive urine culture, the areas under the receiver-operating characteristic curves for HD5 and HNP1-3 were 0.86 (95% confidence interval (CI): 0.81-0.92) and 0.88 (95% CI: 0.82-0.93), respectively. Compared to LE ≥ trace, the combination test "LE and HD5" increased specificity by 6% (95% CI: 3-10%) without decreasing sensitivity. In the subgroup whose urine was collected by a clean-catch method, combination tests "LE and HD5" and "HD5 and HNP1-3" increased specificity by > 10% compared to LE alone. CONCLUSION Urine AMP profiles are a promising novel strategy as an adjunct to urinalysis to aid UTI diagnosis in children.
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Rambaud-Althaus C, Shao AF, Kahama-Maro J, Genton B, d’Acremont V. Managing the Sick Child in the Era of Declining Malaria Transmission: Development of ALMANACH, an Electronic Algorithm for Appropriate Use of Antimicrobials. PLoS One 2015; 10:e0127674. [PMID: 26161753 PMCID: PMC4498609 DOI: 10.1371/journal.pone.0127674] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2014] [Accepted: 04/17/2015] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To review the available knowledge on epidemiology and diagnoses of acute infections in children aged 2 to 59 months in primary care setting and develop an electronic algorithm for the Integrated Management of Childhood Illness to reach optimal clinical outcome and rational use of medicines. METHODS A structured literature review in Medline, Embase and the Cochrane Database of Systematic Review (CDRS) looked for available estimations of diseases prevalence in outpatients aged 2-59 months, and for available evidence on i) accuracy of clinical predictors, and ii) performance of point-of-care tests for targeted diseases. A new algorithm for the management of childhood illness (ALMANACH) was designed based on evidence retrieved and results of a study on etiologies of fever in Tanzanian children outpatients. FINDINGS The major changes in ALMANACH compared to IMCI (2008 version) are the following: i) assessment of 10 danger signs, ii) classification of non-severe children into febrile and non-febrile illness, the latter receiving no antibiotics, iii) classification of pneumonia based on a respiratory rate threshold of 50 assessed twice for febrile children 12-59 months; iv) malaria rapid diagnostic test performed for all febrile children. In the absence of identified source of fever at the end of the assessment, v) urine dipstick performed for febrile children <2 years to consider urinary tract infection, vi) classification of 'possible typhoid' for febrile children >2 years with abdominal tenderness; and lastly vii) classification of 'likely viral infection' in case of negative results. CONCLUSION This smartphone-run algorithm based on new evidence and two point-of-care tests should improve the quality of care of <5 year children and lead to more rational use of antimicrobials.
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Affiliation(s)
- Clotilde Rambaud-Althaus
- Epidemiology and Public Health department, Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Amani Flexson Shao
- Epidemiology and Public Health department, Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
- National Institute for Medical Research, Tukuyu Medical Research Center, Tukuyu, Tanzania
| | - Judith Kahama-Maro
- City Medical Office of Health, Dar es Salaam City Council, Dar es Salaam, Tanzania
| | - Blaise Genton
- Epidemiology and Public Health department, Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
- Infectious Disease Service, University Hospital, Lausanne, Switzerland
- Department of Ambulatory Care and Community Medicine, University Hospital, Lausanne, Switzerland
| | - Valérie d’Acremont
- Epidemiology and Public Health department, Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
- Infectious Disease Service, University Hospital, Lausanne, Switzerland
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Utsch B, Klaus G. Urinalysis in children and adolescents. DEUTSCHES ARZTEBLATT INTERNATIONAL 2015; 111:617-25; quiz 626. [PMID: 25283761 DOI: 10.3238/arztebl.2014.0617] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Revised: 07/08/2014] [Accepted: 07/08/2014] [Indexed: 11/27/2022]
Abstract
BACKGROUND Urinalysis is the most commonly performed biochemical test in infancy and early childhood. The urine sample should be correctly obtained, age-specific aspects should be considered, and age-dependent reference values should be used. METHOD This review is based on a selective literature search in electronic databases, textbooks, and guidelines from Germany and abroad on the acquisition of urine samples and the performance of urinalysis in infancy and early childhood. RESULTS The timing and mode of acquisition of the urine sample affect the assessment of hematuria, proteinuria, leukocyturia, nitrituria, and the uropathogenic bacterial colony count in the urine culture. Dipstick tests can be used for targeted screening for these features. The test results should be interpreted together with the findings of urine microscopy, the medical history, and the physical examination. Proteinuria should be quantified and differentiated; both of these things can be done either from collected urine or (especially in infants and young children) from a spontaneously voided urine sample, by determination of the protein/creatinine quotient. Orthostatic proteinuria in an adolescent requires no further evaluation or treatment. Hematuria should be characterized as either glomerular or non-glomerular erythrocyturia. Asymptomatic, isolated microhematuria in childhood is not uncommon and often transient; in the absence of a family history, it usually does not require an extensive work-up. Proteinuria combined with hematuria should arouse the suspicion of glomerulonephritis. CONCLUSION Urinalysis in infancy and early childhood is a simple and informative diagnostic test as long as the urine sample has been obtained properly and the results are interpreted appropriately for this age group.
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Affiliation(s)
- Boris Utsch
- Center for Pediatric and Adolescent Medicine, Justus Liebig University, Gießen, KfH Pediatric Kidney Center, Marburg
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Keren R, Shaikh N, Pohl H, Gravens-Mueller L, Ivanova A, Zaoutis L, Patel M, deBerardinis R, Parker A, Bhatnagar S, Haralam MA, Pope M, Kearney D, Sprague B, Barrera R, Viteri B, Egigueron M, Shah N, Hoberman A. Risk Factors for Recurrent Urinary Tract Infection and Renal Scarring. Pediatrics 2015; 136:e13-21. [PMID: 26055855 PMCID: PMC4485012 DOI: 10.1542/peds.2015-0409] [Citation(s) in RCA: 147] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/15/2015] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To identify risk factors for recurrent urinary tract infection (UTI) and renal scarring in children who have had 1 or 2 febrile or symptomatic UTIs and received no antimicrobial prophylaxis. METHODS This 2-year, multisite prospective cohort study included 305 children aged 2 to 71 months with vesicoureteral reflux (VUR) receiving placebo in the RIVUR (Randomized Intervention for Vesicoureteral Reflux) study and 195 children with no VUR observed in the CUTIE (Careful Urinary Tract Infection Evaluation) study. Primary exposure was presence of VUR; secondary exposures included bladder and bowel dysfunction (BBD), age, and race. Outcomes were recurrent febrile or symptomatic urinary tract infection (F/SUTI) and renal scarring. RESULTS Children with VUR had higher 2-year rates of recurrent F/SUTI (Kaplan-Meier estimate 25.4% compared with 17.3% for VUR and no VUR, respectively). Other factors associated with recurrent F/SUTI included presence of BBD at baseline (adjusted hazard ratio: 2.07 [95% confidence interval (CI): 1.09-3.93]) and presence of renal scarring on the baseline (99m)Tc-labeled dimercaptosuccinic acid scan (adjusted hazard ratio: 2.88 [95% CI: 1.22-6.80]). Children with BBD and any degree of VUR had the highest risk of recurrent F/SUTI (56%). At the end of the 2-year follow-up period, 8 (5.6%) children in the no VUR group and 24 (10.2%) in the VUR group had renal scars, but the difference was not statistically significant (adjusted odds ratio: 2.05 [95% CI: 0.86-4.87]). CONCLUSIONS VUR and BBD are risk factors for recurrent UTI, especially when they appear in combination. Strategies for preventing recurrent UTI include antimicrobial prophylaxis and treatment of BBD.
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Affiliation(s)
- Ron Keren
- Division of General Pediatrics, Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Departments of Pediatrics and Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania;
| | - Nader Shaikh
- University of Pittsburgh School of Medicine and Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania
| | - Hans Pohl
- Division of Urology, Children’s National Health System, Washington, DC; and
| | | | - Anastasia Ivanova
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Lisa Zaoutis
- Division of General Pediatrics, Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Melissa Patel
- Division of General Pediatrics, Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Rachel deBerardinis
- Division of General Pediatrics, Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Allison Parker
- Division of General Pediatrics, Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Sonika Bhatnagar
- University of Pittsburgh School of Medicine and Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania
| | - Mary Ann Haralam
- University of Pittsburgh School of Medicine and Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania
| | - Marcia Pope
- University of Pittsburgh School of Medicine and Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania
| | - Diana Kearney
- University of Pittsburgh School of Medicine and Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania
| | - Bruce Sprague
- Division of Urology, Children’s National Health System, Washington, DC; and
| | - Raquel Barrera
- Division of Urology, Children’s National Health System, Washington, DC; and
| | - Bernarda Viteri
- Division of Urology, Children’s National Health System, Washington, DC; and
| | - Martina Egigueron
- Division of Urology, Children’s National Health System, Washington, DC; and
| | - Neha Shah
- Division of Urology, Children’s National Health System, Washington, DC; and
| | - Alejandro Hoberman
- University of Pittsburgh School of Medicine and Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania
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Spence J, Ross J. Diagnosing urinary tract infections in febrile infants and children: when evidence-based medicine and clinical practice collide. CAN J EMERG MED 2015; 2:197-200. [PMID: 17621398 DOI: 10.1017/s1481803500004929] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
ABSTRACTThe management of febrile pediatric patients is challenging, and the literature is replete with articles describing diverse diagnostic and therapeutic strategies. As many as 5% of infants and young children presenting with fever will be diagnosed with urinary tract infection. Many controversies exist concerning the management of these infections, the most important being: how to make the diagnosis. The financial and time costs of emergency department management must be balanced against the potential future costs of investigations and complications.
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Affiliation(s)
- J Spence
- Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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Emergence of extended spectrum-β-lactamase-producing Escherichia coli O25b-ST131: a major community-acquired uropathogen in infants. Pediatr Infect Dis J 2015; 34:469-75. [PMID: 25879646 DOI: 10.1097/inf.0000000000000623] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Escherichia coli sero-group O25b-sequence type 131 (O25b-ST131), a multidrug-resistant clonal group, is a significant pathogen in adults and children. This study investigated the genotyping and role of extended spectrum β-lactamase (ESBL)-producing E. coli O25b-ST131 and non-O25b-ST131 in urinary tract infections in infants. METHODS Clinical and laboratory data from 111 infants less than 1 year of age, who were hospitalized for urinary tract infections caused by ESBL-producing E. coli between 2009 and 2012 were collected. Polymerase chain reactions and multi-locus sequence typing were used to identify E. coli O25-ST131 clones. The gene blaCTX-M groups 1, 2 and 9, a specific polymerase chain reaction of CTX-M 14 and 15, were also determined in ESBL-producing E. coli isolates. RESULTS O25b-ST131 accounted for 65% of the 111 isolates, although 92 isolates belonged to the blaCTX-M group 9, of which most were CTX-M-14. Those with O25b-ST131 clones had similar risk factors, clinical features and outcomes as those with non-O25b-ST131. The E. coli O25b-ST131 isolates were more resistant to ciprofloxacin and gentamicin, but more susceptible to cefoxitin, minocycline and trimethoprim/sulfamethoxazole than the non-O25b-ST131 isolates. Most of the infants (78%) were previously healthy with no apparent risk factors. CONCLUSIONS E. coli O25b-ST131 is a major community-acquired uropathogen in the infant population. Regardless of O25b-ST131 or non-O25b-ST131 clones, CTX-M-14 accounts for majority of the ESBL genotype. The O25b-ST131 clone is not associated with more severe clinical disease, but it may make the diagnosis and selection of antimicrobials for treatment more challenging.
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Frumkin K. Bacteriology of Urinary Tract Infections in Emergency Patients Aged 0–36 Months. J Emerg Med 2015; 48:405-15. [DOI: 10.1016/j.jemermed.2014.11.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Revised: 10/10/2014] [Accepted: 11/16/2014] [Indexed: 11/28/2022]
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Burgers LT, Redekop WK, Severens JL. Challenges in modelling the cost effectiveness of various interventions for cardiovascular disease. PHARMACOECONOMICS 2014; 32:627-637. [PMID: 24748448 DOI: 10.1007/s40273-014-0155-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
OBJECTIVES Decision analytic modelling is essential in performing cost-effectiveness analyses (CEAs) of interventions in cardiovascular disease (CVD). However, modelling inherently poses challenges that need to be dealt with since models always represent a simplification of reality. The aim of this study was to identify and explore the challenges in modelling CVD interventions. METHODS A document analysis was performed of 40 model-based CEAs of CVD interventions published in high-impact journals. We analysed the systematically selected papers to identify challenges per type of intervention (test, non-drug, drug, disease management programme, and public health intervention), and a questionnaire was sent to the corresponding authors to obtain a more thorough overview. Ideas for possible solutions for the challenges were based on the papers, responses, modelling guidelines, and other sources. RESULTS The systematic literature search identified 1,720 potentially relevant articles. Forty authors were identified after screening the most recent 294 papers. Besides the challenge of lack of data, the challenges encountered in the review suggest that it was difficult to obtain a sufficiently valid and accurate cost-effectiveness estimate, mainly due to lack of data or extrapolating from intermediate outcomes. Despite the low response rate of the questionnaire, it confirmed our results. CONCLUSIONS This combination of a review and a survey showed examples of CVD modelling challenges found in studies published in high-impact journals. Modelling guidelines do not provide sufficient guidance in resolving all challenges. Some of the reported challenges are specific to the type of intervention and disease, while some are independent of intervention and disease.
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Affiliation(s)
- Laura T Burgers
- Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands,
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Abstract
Early-onset sepsis remains a common and serious problem for neonates, especially preterm infants. Group B streptococcus (GBS) is the most common etiologic agent, while Escherichia coli is the most common cause of mortality. Current efforts toward maternal intrapartum antimicrobial prophylaxis have significantly reduced the rates of GBS disease but have been associated with increased rates of Gram-negative infections, especially among very-low-birth-weight infants. The diagnosis of neonatal sepsis is based on a combination of clinical presentation; the use of nonspecific markers, including C-reactive protein and procalcitonin (where available); blood cultures; and the use of molecular methods, including PCR. Cytokines, including interleukin 6 (IL-6), interleukin 8 (IL-8), gamma interferon (IFN-γ), and tumor necrosis factor alpha (TNF-α), and cell surface antigens, including soluble intercellular adhesion molecule (sICAM) and CD64, are also being increasingly examined for use as nonspecific screening measures for neonatal sepsis. Viruses, in particular enteroviruses, parechoviruses, and herpes simplex virus (HSV), should be considered in the differential diagnosis. Empirical treatment should be based on local patterns of antimicrobial resistance but typically consists of the use of ampicillin and gentamicin, or ampicillin and cefotaxime if meningitis is suspected, until the etiologic agent has been identified. Current research is focused primarily on development of vaccines against GBS.
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Urinary tract infection in outpatient febrile infants younger than 30 days of age: a 10-year evaluation. Pediatr Infect Dis J 2014; 33:342-4. [PMID: 24104957 DOI: 10.1097/inf.0000000000000110] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND To determine the prevalence of outpatient-diagnosed urinary tract infection (UTI) in consecutive febrile neonates ≤ 30 days of age and correlate demographic, laboratory and radiographic imaging results with infectious etiology. METHODS Review of medical records of consecutive febrile infants ≤ 30 days of age presenting to an urban pediatric emergency department during a 10-year period, whose policy is to perform a sepsis evaluation (urine culture obtained by bladder catheterization) and hospitalize for parenteral antibiotic therapy pending culture results. RESULTS Of 670 febrile neonates ≤ 30 days of age evaluated for sepsis, urine culture was obtained in 651 cases (97%). Of 100 patients with UTI (15.4%), 73% were male; the most common uropathogens were Escherichia coli (71%), Enterococcus (10%) and Klebsiella sp. (10%). In all, 39% had a maximum documented fever ≥ 102 °F, and 40% had CBC total white blood cells count ≥ 15,000/mm(3). Urine dipstick test was positive for leukocyte esterase or nitrite in 79%. Renal ultrasound performed in 95 patients (95%) showed anatomic abnormalities in 47%; 5/26 (24%) with hydronephrosis had vesicoureteral reflux on voiding cystourethrogram. Four patients had urosepsis; none had bacterial meningitis and no patients died. CONCLUSIONS UTI affects approximately 1 in 6 febrile neonates ≤ 30 days of age. Males are affected 2.5-times greater than females. E. coli continues to be the predominant uropathogen. Clinical parameters like height of fever, CBC total white blood cell count and urine dipstick test lack sensitivity in identifying UTI risk in the outpatient setting. Only 4 infants had urosepsis (4%). Nearly half of neonates with UTI have a radiographically identified anatomic abnormality. All febrile young infants should receive performance of a urine culture; those with UTI require imaging.
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The comparison of pain caused by suprapubic aspiration and transurethral catheterization methods for sterile urine collection in neonates: a randomized controlled study. ScientificWorldJournal 2014; 2014:946924. [PMID: 24587764 PMCID: PMC3920630 DOI: 10.1155/2014/946924] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2013] [Accepted: 10/22/2013] [Indexed: 11/29/2022] Open
Abstract
This study was performed to compare the levels of pain experienced by young infants undergoing either suprapubic aspiration (SPA) or transurethral catheterization (TUC) for the collection of sterile urine samples. This prospective randomized clinical trial was conducted in hospitalized neonates in a university-affiliated hospital. Patients who required urine cultures were randomly assigned into one of two groups, the SPA or TUC group. The infants' faces were videotaped, and the changes in the facial expression and physiological parameters during the procedure were scored using the Premature Infant Pain Profile (PIPP) in a blind manner. The primary outcome was the severity of the pain experienced during each procedure, and the secondary outcomes were the success rate, the duration, and the complications of each procedure. Ninety-four percent of male infants in the TUC group and 77.3% in the SPA group were uncircumcised (P = 0.1). The mean (SD) of the PIPP pain scores did not differ between groups (9.95 ± 3.7 in SPA and 9.64 ± 3.2 in TUC, P = 0.6). The duration of TUC was longer. Both methods can be used to collect urine from neonates, but the difficulty of performing TUC on females and uncircumcised males should be considered.
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Bitsori M, Galanakis E. Pediatric urinary tract infections: diagnosis and treatment. Expert Rev Anti Infect Ther 2014. [DOI: 10.1586/eri.12.99] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Leroy S, Fernandez-Lopez A, Nikfar R, Romanello C, Bouissou F, Gervaix A, Gurgoze MK, Bressan S, Smolkin V, Tuerlinckx D, Stefanidis CJ, Vaos G, Leblond P, Gungor F, Gendrel D, Chalumeau M. Association of procalcitonin with acute pyelonephritis and renal scars in pediatric UTI. Pediatrics 2013; 131:870-9. [PMID: 23629615 DOI: 10.1542/peds.2012-2408] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Urinary tract infections (UTIs) are common childhood bacterial infections that may involve renal parenchymal infection (acute pyelonephritis [APN]) followed by late scarring. Prompt, high-quality diagnosis of APN and later identification of children with scarring are important for preventing future complications. Examination via dimercaptosuccinic acid scanning is the current clinical gold standard but is not routinely performed. A more accessible assay could therefore prove useful. Our goal was to study procalcitonin as a predictor for both APN and scarring in children with UTI. METHODS A systematic review and meta-analysis of individual patient data were performed; all data were gathered from children with UTIs who had undergone both procalcitonin measurement and dimercaptosuccinic acid scanning. RESULTS A total of 1011 patients (APN in 60.6%, late scarring in 25.7%) were included from 18 studies. Procalcitonin as a continuous, class, and binary variable was associated with APN and scarring (P < .001) and demonstrated a significantly higher (P < .05) area under the receiver operating characteristic curve than either C-reactive protein or white blood cell count for both pathologies. Procalcitonin ≥0.5 ng/mL yielded an adjusted odds ratio of 7.9 (95% confidence interval [CI]: 5.8-10.9) with 71% sensitivity (95% CI: 67-74) and 72% specificity (95% CI: 67-76) for APN. Procalcitonin ≥0.5 ng/mL was significantly associated with late scarring (adjusted odds ratio: 3.4 [95% CI: 2.1-5.7]) with 79% sensitivity (95% CI: 71-85) and 50% specificity (95% CI: 45-54). CONCLUSIONS Procalcitonin was a more robust predictor compared with C-reactive protein or white blood cell count for selectively identifying children who had APN during the early stages of UTI, as well as those with late scarring.
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Affiliation(s)
- Sandrine Leroy
- Centre for Statistics in Medicine, University of Oxford, Oxford, UK.
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Caillaud C, Abély M, Pons A, Brunel D, Viprey M, Pietrement C. Évaluation d’un protocole de limitation des indications de cystographie dans les infections urinaires fébriles. Arch Pediatr 2013; 20:476-83. [DOI: 10.1016/j.arcped.2013.02.069] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2012] [Revised: 01/14/2013] [Accepted: 02/10/2013] [Indexed: 11/29/2022]
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Abstract
Urinary tract infections (UTIs) are one of the most common sources of bacterial infections among young febrile children. Accurate diagnosis of acute pyelonephritis (APN) and vesico-ureteral reflux (VUR) are important because of their association with renal scarring, sometimes leading to long-term complications. However, the gold standard examinations are either a DMSA scan for APN and scarring, or cystography for VUR, but both present limitations (feasibility, pain, cost, etc.). Procalcitonin, a reliable marker of bacterial infections, was demonstrated to be a good predictor of renal parenchymal involvement in the acute phase and in late renal scars, as well as of high-grade VUR. These findings need further broad validations and impact studies before being implemented into daily practice. However, procalcitonin may play a role in the complex and still debated picture of which examination should be performed after UTI in children.
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Affiliation(s)
- S Leroy
- Unité d'épidémiologie des maladies émergentes, Institut Pasteur, Paris, France.
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