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DR. MUHAMMAD IMRAN ASSOCIATE PROFESSOR DEPARTMENT OF PEDIATRIC NEPHROLOGY

APPAROCH TO A CHILD WITH URINARY TRACT INFECTION AND VESICOURETERAL REFLUX ACCORDING TO THE CURRENT GUIDLINES. DR. MUHAMMAD IMRAN ASSOCIATE PROFESSOR DEPARTMENT OF PEDIATRIC NEPHROLOGY THE CHILDREN’S HOSPITAL & THE INSTITUTE OF CHILD HEALTH, MULTAN. AIMS. INTRODUCTION.

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DR. MUHAMMAD IMRAN ASSOCIATE PROFESSOR DEPARTMENT OF PEDIATRIC NEPHROLOGY

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  1. APPAROCH TO A CHILD WITH URINARY TRACT INFECTION AND VESICOURETERAL REFLUX ACCORDING TO THE CURRENT GUIDLINES DR. MUHAMMAD IMRAN ASSOCIATE PROFESSOR DEPARTMENT OF PEDIATRIC NEPHROLOGY THE CHILDREN’S HOSPITAL & THE INSTITUTE OF CHILD HEALTH, MULTAN

  2. AIMS

  3. INTRODUCTION

  4. Current Guidelines For UTI in Children

  5. When to suspect UTI • NEWBORNS

  6. When to suspect… • CHILDREN 2-24 MONTHS

  7. When to suspect… • OLDER CHILDREN

  8. Also Suspect UTI when

  9. Bowel Bladder Dysfunction (BBD) An important risk factor for UTI in older children ( who are not toilet trained )

  10. Urine collection methods

  11. URINALYSIS • Dipstick : • Leukocyte Estrase (sensitivity 83%, specificity 78%) • Nitrites (sensitivity 53%, specificity 98%) • Microscopy : • Pus cells (sensitivity 73%, specificity 81%) • Bacteria (sensitivity 81%, specificity 83%)

  12. How to confirm • URINE CULTURE

  13. IMAGING IN UTI ?? • US KUB To detect anatomic abnormalities • MicturitingCystourethrogram (MCUG) To find Vesicoureteral Reflux (VUR) • Dimercaptosuccinic Acid Scan (DMSA) To look for Acute Pyelonephrtis/Renal Scarring

  14. PRIMARY VUR Retrograde flow of urine from the bladder up into the upper urinary tract VUR increases the risk of UTI and renal scarring Prevalence in children with UTIs 15-70% depending upon the age Siblings have about 35% risk of having VUR

  15. VOIDING CYSTOURETHROGRAM (VCUG) • Dilating VUR may be missed by US in 24-33% cases • VCUG is the gold standard to diagnose VUR & to determine its severity • However, it’s an invasive procedure & distressing to the child and the family • NO ROUTINE VCUG AFTER FIRST FEBRLIE UTI

  16. DMSA RENAL SCAN • DMSA has greater sensitivity for detecting acute pyelonephritis and, later, scarring than US or VCUG • However, findings rarely affect acute clinical management • No routine DMSA in first febrile UTI

  17. AAP GUIDELINES • Action statements 1 – 7 • 2 - 24 months age group

  18. ACTION STATEMENT 1Presumptive therapy for all ill-appearing children • Obtain a urine specimen by catheterization both for urinalysis & culture before starting antibiotic

  19. ACTION STATEMENT 2DETERMINING THE LIKELIHOOD OF INFECTION • 2a : If UTI less likely : clinical follow up without testing • 2b :If UTI likely : • 1.Obtain catheterized urine sample for urinalysis & culture or • 2. Obtain convenient urinalysis : • If indicative of infection : take a catheterized sample for culture • If urinalysis normal , no antibiotics with close follow up

  20. INDIVIDUAL RISK FACTORS - GIRLS

  21. INDIVIDUAL RISK FACTORS - BOYS

  22. Guide Lines for Obtaining Urine Specimens in Febrile Girls Is the child ill enough to warrant immediate antimicrobial therapy based on initial clinical assessment Obtain urine specimen And treat Yes No What is the clinicians’s threshold for evaluation? Lower threshold: Risk of UTI needs to be greater than 1 % for evaluation (Leads to more urine specimens) Higher threshold: Risk of UTI needs to be greater than 2 % for evaluation (Leads to fewer urine specimens) How many UTI risk factors * are present? How many UTI risk factors * are present? Three or more None to two Three or more None to two No Specimen Obtain Specimen No Specimen Obtain Specimen

  23. Guide Lines for Obtaining Urine Specimens in Febrile Boys Is the child ill enough to warrant immediate antimicrobial therapy based on initial clinical assessment? Yes No Obtain urine specimen And treat Is the child cicumcised? No Is the child cicumcised? yes What is the clinicians’s threshold for evaluation? Lower threshold: Risk of UTI needs to be greater than 1 % for evaluation (Leads to more urine specimens) Higher threshold: Risk of UTI needs to be greater than 2 % for evaluation (Leads to fewer urine specimens) How many UTI risk factors * are present? How many UTI risk factors * are present? None to two Three or more None to two Three or more No Specimen Obtain Specimen No Specimen Obtain Specimen

  24. ACTION STATEMENT 3CITERIA FOR DIAGNOSIS OF UTI • DIAGNOSIS REQUIRES BOTH • Positive urinalysis (Nitrite +/LE + or Pyuria/Bacteriuria) • Positive urine culture (at least 50,000 cfu/ml)

  25. ACTION STATEMENT 4 ANTIMICROBIAL THERAPY • 4a : Choose antibiotic according to local sensitivity patterns • Oral/parenteral equally effective • Change to appropriate antibiotic according to culture sensitivity report • 4b : Duration: 7-14 days

  26. ACTION STATEMENT 5NEED FOR UROLOGIC IMAGING ? • Allfebrile infants and children should undergo USKUB at the earliest (within 24 hours)

  27. ACTION STATEMENT 6VCUG • NO ROUTINE VCUG AFTER FIRST FEBRLIE UTI • 6a: VCUGindicatedIf US reveals • Hydronephrosis, renal scarring, or findings suggestive of vesicoureteral reflux (VUR) or obstructive uropathy • Other atypical/complex situations • 6b:If Recurrence of UTI

  28. ACTION STATEMENT 7PARENTAL EDUCATION & FOLLOW UP • Seek prompt medical evaluation for further febrile illnessto ensure that recurrent infection can be quickly detected and treated • No periodic follow up cultures now recommended. Do detect & treat febrile recurrences

  29. 1.Diagnosis and management of UTI in febrile infants and young children 2.Is the patient judged to require immediate antimicrobial therapy? 4.Is the likelihood of UTI<1%? 6.Obtain urine for urinalysis only by Catheter or SPA or bag 3.Obtain urine by catheterization or SPA 5.Perform urinalysis 7.Coduct enhanced urinalysis by microscope and counting chamber 8.Conduct dipstick urinalysis ; considered positive if LE and /or nitrite is positive 9.Urinalysis positive? 10.culture urine obtained by catheterization or SPA 15.Follow clinical course, re evaluate if fever persist 11.Treat with antimicrobial effective against common uropathogens according to local sensitivity patterns;oral and parenteral stop

  30. 12.Urinalysis or culture positive? 13.Adjust antimicrobial therapy according to sensitivities. Treat for 7 to 14 days 16.Discontinue antimicrobials 14.Obtain USKUB any time after UTI is confirmed STOP 17.SECOND OR HHIGHER PROVEN UTI OR VCUG INDICATED BY USKUB 17.Obtain VCUG to evaluate for grade IV –V VUR 20.UROLOGIC MANAGEMENT AS INDICATED BY IMAGING 19.INSTRUCT FAMILY TO SEEK MEDICAL CARE FOR FUTURE FEVER TO ENSURE TIMELY TREATMENT OF UTI

  31. NEED FOR PROPHYLAXIS ?

  32. NEED FOR PROPHLAXIS – THE RIVUR STUDY

  33. RIVUR - CONCLUSION

  34. AAP Guidelines VS RIVUR

  35. CUTIE STUDY • Ancillary to RIVUR Study • Had a comparator group with no VUR • Aimed to find which children who are at greatest risk of developing renal scarring following a UTI • Two months to 6 years age children followed for 2 years

  36. THE CUTIESTUDY

  37. CUTIE - CONCLUSION • VUR & BBD are risk factors for recurrent UTI • Strategies to prevent UTI include antimicrobial prophylaxis and treatment of BBD

  38. TAKE HOME MESSAGE • High index of suspicion of UTI • Diagnosis requires both an abnormal urinalysis and a positive culture (at least 50,000 CFU/ml) • Catheterized urine sample. • Mid-stream clean-catch fairly acceptable method in toilet trained older children • Oral antibiotics are as effective as parenteral – for 7-14 days

  39. TAKE HOME MESSAGE • US KUB in all • NoRoutine VCUG/DMSA after first febrile UTI • However, it seems prudent to diagnose VUR in selected children after first febrile UTI • Prophylaxisfor UTI with or without VUR should be selective and not a routine • No routine regular follow up urine cultures • Treat BBD in older children to prevent UTI

  40. TAKE HOME MESSAGE As clinicians we bear the responsibility to share EvidenceBasedresults with parents who have the right to make a choice about what’s best for their children

  41. REFERENCES • Roberts KB. Subcommittee on Urinary Tract Infection. Steering Committee on Quality Improvement and Management. Urinary tract infection: clinical practice guidelines for the diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months. Pediatrics 201;128:595-610 • Stein R et al. Urinary Tract Infections in Children: EAU/ESPU Guidelines; Euro Urol 67(2015); 546-558 • National Institute for Health and Clinical excellence. Urinary tract infection in children: diagnosis, treatment, and long-term management. Clinical guidelines 54 London: NICE, August 2007

  42. REFERENCES • Mattoo TK et al.PediatrNephrol. 2015 May;30(5):707-712. doi:10.1007/s00467-014-3022-1 • Craig JC, Simpson JM, Williams GJ, et al. Prevention of Recurrent Urinary Tract Infection in Children with Vesicoureteral Reflux and Normal renal Tracts (PRIVENT) investigators. Antibiotic prophylxis and recurrent urinary tract infection in children. N Engl J Med. 2009;361(18):1748-1759 • The RIVUR Trial: Profile and Baseline Clinical Associations of Children with Vesicoureteral Reflux. Pediatrics 2013;132:e34-e45 • The CUTIE study

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