Management of uti (1)

for pediatric postgradutes

1. Management of first episode and recurrent Urinary tract infection Presented by Dr Janani D Dr Sheela Aglecha

2. REFERENCES: Nelson textbook of pediatrics 21 st South Asia edition Ghai textbook of pediatrics Pediatric Nephrology 6 th edition Bagga & Shrivastava Revised statement on Management of UTI guidelines by Indian Soceity of Pediatric Nephrology- 2011 NICE guidelines on UTI

3. INTRODUCTION Urinary tract infections (UTI) imply invasion of urinary tract by pathogens, which may involve the upper or lower tract depending on the infection in the kidney, or bladder and urethra. C ommon cause of morbidity that in association with abnormalities of the urinary tract, contribute to long-term complications, including hypertension and chronic renal failure

4. PREVALENCE :- UTI occur in 1% of boys and 1-3% of girls During the first yr of life, the male female ratio is 2.8-5.4:1 Beyond 1-2 yrs male female ratio is 1:10

5. Simple UTI –UTI with low grade fever, dysuria , frequency, urgency. Complicated UTI - fever>39ºc, systemic toxicity, persistent vomiting, renal angle tenderness and raised creatinine . Atypical UTI - UTI assoc. With sepsis, failure to respond to antibiotics in 48hrs, impaired RFT, infection with non E. coli infection. Recurrent UTI - two or more episode of febrile UTI, one episode of pyelonephritis and one episode of cystitis, 3 or more episodes of cystitis.

6. Significant pyuria : > 10 leukocytes/mm 3 in a fresh uncentrifuged sample (OR) > 5 leukocytes/mm 3 in a centrifuged sample Significant bacteriuria : Colony count of >10 5 /ml of a single species in a midstream clean catch sample Asymptomatic bacteriuria : Significant bacteriuria in the absence of symptoms of Urinary tract infection Detection of leukocyturia in the absence of significant bacteriuria is not sufficient to diagnose UTI.

7. ETIOLOGY: - female – E. coli (75-90%), Klebsiella , proteus , male – E . Coli (most common), Proteus, Other organisms- staphylococcus saprophyticus enterococcus adenovirus.

8. classification The 3 basic forms of UTI Clinical pyelonephritis Cystitis Asymptomatic bacteriuria Focal pyelonephritis and renal abscesses are less common

9. Clinical pyelonephritis :- C haracterized by any or all of the following: abdominal pain or flank pain, fever, malaise, nausea vomiting and occasionally diarrhea. Newborns can show nonspecific symptoms such as poor feeding, irritability, jaundice and weight loss. Pyelonephritis is the most common serious bacterial infection in infants younger than 24 months of age.

10. Cystitis :- Indicates that there is bladder involvement ; symptom include dysuria, urgency, frequency, suprapubic pain incontinence and malodorous urine. Acute hemorrhagic cystitis - it is caused by E coli. Self limiting and associated w ith hematuria, lasting approximately 4 days. Eosinophilic cystitis – rare form of cystitis of obscure origin Interstitial cystitis - it is irritative voiding symptoms such as urgency, frequency, dysuria and pelvic pain relieved by voiding with negative urine culture.

11. Asymtomatic bacteriuria : it is a condition in which there is a positive urine culture without manifestations of infection. It is most common in girls. Incidence is <1% in preschool and school age girls. It becomes symptomatic if left untreated.

12. Pathogenesis 3 routes of bacterial entry to urinary tract. Ascending infection Blood borne spread Direct extension from other organs In the neonatal period renal parenchymal infection is due to hematogenous spread. Beyond this period, most UTI are caused by ascending infection

13. RISK FACTORS FEMALE GENDER Uncircumcised male Vesicourethral reflux Toilet training Voiding dysfunction Obstructive uropathy Urethral instrumentation Wiping from back to front in girls Tight clothing Pinworm infestation Constipation Bacteria with p fimbriae Anatomic abnormality (labial adhesion) Neuropathic bladder Sexual activity pregnancy

14. Clinical features AGE group MORE COMMON SYMPTOMS LESS COMMON SYMPTOMS INFANTS <3 MONTHS OLD NON VERBAL Fever, vomiting, lethargy, irritability, poor feeding, failure to thrive jaundice, hematuria INFANTS > 3 MONTHS OLD PRE VERBAL Fever, abdominal pain, loin tenderness, vomiting Lethargy, hematuria , failure to thrive OLDER CHILDREN VERBAL Frequency, dysuria , dysfunctional voiding, incontinence Fever, malaise, vomiting, hematuria Adapted from NICE guidelines: UTI in children; RCOG press LONDON 2007

15. DIAGNOSIS history based on symptoms findings on urinalysis culture is necessary for confirmation and appropriate therapy The correct diagnosis of UTI depends on having the proper sample of urine 18

16. A urine culture is necessary for diagnosis and appropriate therapy . .Mid stream urine collection . -In children 2-24 months a catherized or suprapubic sample should be collected.. Alternate method is sterile plastic bag collection which has negative predictive value of 100%. If child is symptomtic a UTI is possible even if urianalysis result is negative .

17. Sensitivity and Specificity of Components of urinanalysis ,Alone and In combination Test Sensitivity Specificity Leukocyte Esterase Test 83(67-94) 78%(64-92) Nitrite Test 53%(15-82) 98%(90%100) Leukocyte Esterase or Nitrite Test positive 93%(90-100) 72%(58-91) Microscopy (WBC) 73(32-100) 81(45-98) Microscopy (BACTERIA) 81%(16-99) 83%(11-100) Leukocyte Esterase Test, Nitrite Test OR Microscopy positive 99.8(99-100) 70%(60-72)

18. Criteria for diagnosis of UTI

19. IMAGING STUDIES The goals of imaging studies in children with a UTI are 1.To identify anatomic abnormalities that predispose to infection. 2.To determine whether there is active renal involvement. 3.To asses whether renal function is normal or at risk.

20. Ultrasound scan It provides information on kidney size, number and location, presence of hydronephrosis , urinary bladder anomalies and post-void residual urine. Renal sonography also is sensitive for detecting lobar nephronia and pyonephrosis , a condition that may require prompt drainage of the collecting system by percutaneous nephrostomy .

21. VCUG (voiding cystourethrogram ) It detects VUR and provides anatomical details regarding the bladder and the urethra. The MCU is recommended 2-3 weeks later, diagnosis of UTI.  Patients showing hydronephrosis in the absence of VUR should be evaluated by diuretic renography using 99mTc-labeled diethylenetriamine-pentaacetic acid (DTPA) or mercaptoacetylglycine (MAG-3). Follow-up studies in patients with VUR can be performed using direct radionuclide cystography .

22. VCUG

23. Radionucleotide cystography

24. DMSA SCAN ( Dimercaptosuccinic acid)  It is a sensitive technique for detecting renal parenchymal infection and cortical scarring. It is carried out 2-3 months after treatment of UTI.

25. Photopenic kidney Normal kidney Renal scan DMSA SCAN

26. IAP Guidelines on imaging in first Febrile UTI

27. Recommended imaging schedule for children with UTI (NICE) Age and test Responds to treatment within 48 hours Atypical infection Recurrent infection USG during acute infection Children <6 months No Yes Yes USG within 6 weeks Yes No No DMSA scan 4-6 month after acute infection No Yes Yes MCU Yes if USG abnormal Yes yes

28. Age and test Responds to treatment within 48 hours Atypical infection Recurrent infection USG during acute infection Children 6 months-3yrs Yes no no USG within 6 weeks no No yes DMSA scan 4-6 month after acute infection No Yes Yes MCU no Not routine if dilatation on USG, poor urine flow, non E-coli inf n , family H/o VUR

29. Age and test Responds to treatment within 48 hours Atypical infection Recurrent infection USG during acute infection Children >3 years Yes no no USG within 6 weeks no No yes DMSA scan 4-6 month after acute infection No Yes Yes MCU no no no

30. TREATMENT Acute cystitis should be treated promptly to prevent possible progression to pyelonephritis . If the symptoms are severe, a specimen of bladder urine is obtained for culture, and presumptive treatment is started immediately.

31. Acute cystitis 1.Trimethorphin sulphmethoxazole (6-12mgTMP/kg/24hrs in 2 divided dose) is effective against many strains of E.COLI. 2.Nitrofuratoin ( 5-7mg/kg/24hrs in 3-4 divided dose) is also effective and is active against klebseilla and enterobacter . 3 .Amoxicillin ( 50mg/kg/24hrs in 2 divided dose) Course of therapy 3-5 days .

32. Acute febrile UTI Both iv and oral route are equally efficacious. For hospitalized child options are Ceftriaxone (50mg/kg/24Hrs) Cefepime ( 100mg/kg/24hrs) Cefotaxime (100-150mg/kg/24hrs) Oral antibiotics 3 rd generation cephalosporin like cefixime , cephalexin . 2 oral fluoroquinolone like levofloxacin (safer), ciprofloxacin

33. Acute febrile UTI course of antibiotic therapy 7-14 days. Change in antibiotic as per culture sensitivity.

34. Acute lobar Nephronia , Renal Abscess , and Perinephric Abscess Abscess more than 3cm requires surgical drainage. Course of antibiotic 14-21 days. A 48 hrs trial of iv antibiotic trial may be warranted in otherwise stable child.

35. Supportive Therapy Adequate hydration. A sick, febrile child with inadequate oral intake or dehydration may require parenteral fluids. Routine alkalization of the urine is not necessary. Paracetamol is used to relieve fever; therapy with non steroidal anti- inflammatory agents should be avoided. A repeat urine culture is not necessary, unless there is persistence of fever and toxicity despite 72 hours of adequate antibiotic therapy.

36. with recurrent UTIs, identification of predisposing factors is beneficial. Many school-aged girls have voiding dysfunction; treatment of this condition often reduces the likelihood of recurrent UTI. Prophylaxis against reinfection sulfamethoxazole-trimethoprim , trimethoprim , or nitrofurantoin at⅓of the normal therapeutic dose once a day.

37. Prophylaxis with amoxicillin or cephalexin also may be effective, but the risk of breakthrough UTI may be higher. Other indications for long-term prophylaxis (e.g., neurogenic bladder, urinary tract stasis and obstruction, reflux, calculi etc. The main consequences of chronic renal damage caused by pyelonephritis are arterial hypertension and renal insufficiency.

38. Indications of Prophylaxis The indications of prophylaxis depends on patient age and presence or absence of VUR. Antibiotic prophylaxis is recommended for patients with:- UTI below 1-yr of age, while awaiting imaging studies VUR (iii) frequent febrile UTI even if the urinary tract is normal. Antibiotic prophylaxis is not advised in patients with urinary tract obstruction (e.g., posterior urethral valves), urolithiasis and neurogenic bladder, and in patients on clean intermittent catheterization.

39. PREVENTION OF RECURRENT UTI General management Adequate fluid intake frequent voiding is advised constipation should be avoided. In children with VUR who are toilet trained, regular and volitional low pressure voiding with complete bladder emptying is encouraged. Double voiding:- emptying of the bladder of post void residual urine. Circumcision:- have benefits in patients with high grade reflux .

40. Take home message UTI should be suspected in any patient with fever >39 ◦c without another source lasting for more than 24hr for male and more than 48hr for female. Febrile UTI should be managed with proper antibiotics(dose and duration) and imaging modalities . USG should be done in all cases of febrile UTI. Risk factors for recurrent UTI should be identifed and management should be done accordingly in order to prevent renal damage.