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Pediatric UTI: Making Sense of Local Data and the New AAP Guidelines

Pediatric UTI: Making Sense of Local Data and the New AAP Guidelines. Heidi Román, MD and Alan Schroeder, MD SCVMC Pediatric Grand Rounds March 13, 2013. Objectives. To review diagnosis and management of UTI in infants and young children

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Pediatric UTI: Making Sense of Local Data and the New AAP Guidelines

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  1. Pediatric UTI: Making Sense of Local Data and the New AAP Guidelines Heidi Román, MD and Alan Schroeder, MD SCVMC Pediatric Grand Rounds March 13, 2013

  2. Objectives • To review diagnosis and management of UTI in infants and young children • To be aware of changes in management suggested by 2011 AAP CPG • To review recent clinical research projects at VMC examining: • imaging protocols • diagnosis and management of bacteremic UTIs

  3. Why Do We Care About UTI? Freedman, J. Urology, 2005 UTI now most common site for SBI in infants More than 1 million office visits per year $180M/year for hospitalization alone

  4. When should urine be tested? Consider UTI in all infants < 24 mos with FWS Not ill and “low risk”  monitor Ill enough to require abx  obtain urine for UA/culture prior to initiation “Not low risk”  urine for UA/culture and act based on results AAP CPG, Pediatrics, 2011

  5. What constitutes “not low risk”? • 2011 AAP CPG: “low risk” = febrile infant with < 3% risk of UTI • Factors known to change risk • Age • Gender • Circumcision status • Duration of fever • Lack of other source

  6. Factors Modifying Risk for UTI From Marmor “Updates in Management of UTI in Febrile Infants/Children < 24 mo of Age” 2012

  7. How should urine be tested? • SPA • Catheterization • Bag • Clean Catch

  8. What defines a “UTI”? • 2011 AAP CPG: • At least 50K CFU/ml of uropathogen via cath or SPA • AND UA suggesting infection (pyuria and/or bacteruria)

  9. How can UA help you? AAP CPG, Pediatrics, 2011

  10. Urine Culture • When to send • Definitely “positive”? • UA + and Cath Ucx + if > 50k CFU/mL • UA + and Bag Ucx + if > 100K CFU/ml single org • Possibly +: • high clinical suspicion and • UA + and > 10K org OR • UA – and > 50K single org

  11. UTI Management • When/how long to hospitalize? • Abx: what, how and how long? • Prophylaxis? • Imaging?

  12. Inpatient vs outpatient • Hoberman cefixime study (Pediatrics, 1999) • 306 children 1-36 months • PO Cefixime x 14 d vs IV cefotax x 3 d + PO Cefixime x 11 d • No difference in readmission, scarring

  13. Duration of IV Abx • PHIS study on UTI practice variation (Brady, Pediatrics, 2010) • 12,333 infants < 6 months • Treatment failure: • ≤3 days = 1.6% • ≥4 days = 2.2% • 1000 kids (~30%) < 1 month got short course!

  14. AAP recs • “Initiating treatment orally or parenterally is equally efficacious” • “Adjust choice according to sensitivity testing” • 7-14 days total • “Outcomes of short courses (1-3 days) are inferior to those of 7-14 day courses” • No reference!!

  15. Our recs (if well) • > 1 month: outpatient, IM/PO • < 1 month: inpatient, IV x 48 hours • 5-7 day course total (sooner if side effects) E coli susceptibilities 2011, VMC 5th floor

  16. Prophylactic Abx • Mid-2000’s  Practice questioned by handful of RCTs

  17. PRIVENT trial[Craig, NEJM, 2009] • 576 Children age 0-18 years with first febrile UTI • Renal US, VCUG, DMSA in most patients • DMSA again at 1 year • Daily TMP/SMX

  18. 600 children 2 months – 6 years Grades I-IV VUR TMP/SMX vs placebo Still Pending

  19. Our recs • No prophylaxis unless high-grade, persistent VUR

  20. Imaging

  21. Imaging makes sense if… • Abnormalities are common • Abnormalities lead to recurrent UTIs and/or long-term damage • Detection of the abnormalities improves outcomes Andrea Marmor, MD http://www.ucsfcme.com/2012/slides/MFC13003/3a%20-%20Marmor,%20Andrea%20REF.pdf

  22. 1.) Abnormalities are common • VUR same prevalence (~35%) in patients with true UTIs and false UTIs [Hanula, Pediatr Nephrol 2010]

  23. Abnormalities lead to recurrent UTIs and/or long-term damage • Literature review: 0/1576 reviewed CKD cases had UTI as primary cause • Own institution: 13/366 had h/o childhood UTI – all 13 had abnl kidney anatomy • Recurrent UTI  CKD 1/366

  24. Crunching the #’s Craig, Pediatrics 2011

  25. 3. Detection of the abnormalities improves outcomes • Prophylactic Abx? • VUR surgery? • Other anatomic abnormalities?

  26. 2008: Initiation of new guidelines at SCVMC • Grand Rounds • Meeting of inter-disciplinary group • Discussed at faculty meeting • Radiologist reminders

  27. New AAP recs • US on everyone, VCUG if abnormal or if recurrence

  28. Take Home Points • Diminishing urgency to detect/treat UTIs in healthy children • Knowledge of risk factors can help stratify risk • Management of UTI • Selective imaging OK • Cost/benefit of prophylaxis too high

  29. Questions?

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