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Management and
treatment of urinary tract
infection in children
Pr A. Gervaix
Objectives

Prevalence, risk groups

Diagnosis

Treatment, prophylaxis

Follow-up investigations
Objectives

Prevalence, risk groups

Diagnosis

Treatment, prophylaxis

Follow-up investigations
Prevalence of UTI:
Demographic and Clinical
Characteristics

Higher in females than males (relative risk 2.27)

Higher when temperature ≥39o C

Higher in white infants than African American infants

Higher in infants with no identified source of fever
than among those with a possible source

Highest in white females with fever ≥390C (17%)
Hoberman et al Pediatrics 1993;123
Another risk factor in boys:
“uncircumcision”
Message 1
 The presence of UTI should be considered in all
infants and young children 2 months to 2 years
of age with unexplained fever
 In boys, circumcision is a protective factor
against
UTI
 In older children, dysuria, frequency, altered
voiding pattern may be signs of
UTI
Objectives

Prevalence, risk groups

Diagnosis

Treatment, prophylaxis

Follow-up investigations
Diagnosis:
Cystitis vs. pyelonephritis
60 - 65 % of children with a febrile UTI
have a renal parenchymal
involvement (pyelonephritis)
DMSA
10 – 20% of children with a
pyelonephritis will have a renal scar
J Pediatr 1994;124:17
Pediatrics 1999;104:79
Diagnosis of UTI in children

Collection of the urine
Severely ill child
1) Transurethral bladder catheterization
2) Suprapubic aspiration (SPA)
If the prevalence of UTI is 5%
85% of positive cultures will be
false-positive
resultsill child
Not severely
3) Bag collection
+
Direct examination
Culture
4) Mid-stream clean catch
-
Clinical
follow-up
Diagnosis of UTI in children
• Direct examination:
Centrifuged urine
 5 WBC/hpf
 any bacteria/hpf
Uncentrifuged urine
 Neubauer hemocytometer
 10 WBC
 any bacteria)
Diagnosis of UTI in children
• Dipstick:
Message 2
 The urinanalysis cannot substitute for a urine
culture to document the presence of UTI

Suggestive but not diagnostic of UTI
Leucocyte esterase +
Nitrite test ++
> 5 WBC /hpf on a spun specimen
Bacteria present on gram-stained specimen

Diagnosis of UTI requires a culture of the urine
(> 50’000 CFU/ml SPA or bladder catheterization
)
Diagnosis:
Cystitis vs. pyelonephritis
Pyelonephritis =
Febrile UTI !
www.nice.org.uk 2007
whereas 35-40% of these children only have cystitis
!
J Pediatr 1994;124:17
Pediatrics 1999;104:79
•
Is pyelonephritis predictable by a
biological marker ?
Diagnosis:
Cystitis vs. pyelonephritis
(N=54)
Inflammatory markers: Usefulness of PCT
0.1
99
0.2
1000
0.5
95
DMSA +
90
1
500
2
5
10
20
200
80
100
50
70
20
10
60
5
40
2
30
50
DMSA -
1
30
20
0.5
40
0.2
10
60
0.1
0.05
5
70
0.02
80
0.01
0.005
2
0.002
1
50
90
0.5
95
0.001
0.2
99
0.1
Pretest
ptobability
LR
Posttest
probability
Pyelonephritis and
renal scars
Severity of DMSA renal lesions
N=80
Benador et al. Pediatrics, 1998; 102:1422
Message 3

Importance to distinguish cystitis from pyelonephritis

Procalcitonin is a good marker of pyelonephritis

Procalcitonin is a good predictor of severity of renal
lesions in pyelonephritis
Objectives

Prevalence, risk groups

Diagnosis

Treatment, prophylaxis

Follow-up investigations
Treatment iv vs. oral
Hoberman et al
Pediatrics 1999
Montini et al
BMJ 2007
Neuhaus et al.
Eur J Ped 2009
N = 306
Age: 1 mo to 24 mo
N = 502
Age: 1 mo to 7 y
N = 152
Age: 6 mo to 16 y
Treatment
Treatment
Treatment
Cefixime 14 d po
Co-amoxi 10d po
Ceftibuten 14 d po
Ceftriaxone 3d iv +
cefixime 11d po
Ceftriaxone 3d iv +
Co-amoxi 7d po
Ceftriaxone 3d iv +
Ceftibuten 11d po
Outcome:
Outcome:
Outcome:
Scars at 6 months
9.8% / 7.2%
Scars at 12 months
13.7% / 17.7%
Scars at 6 months
26% / 46%
NA
NA
Recurrence
4.6% / 7.2%
Treatment iv vs. oral
Message 4
o When initiating treatment, the clinician should base the choice
of route of administration on practical considerations.
o Initiating treatment orally or parenterally is equally efficacious.
o The clinician should base the choice of agent on local
antimicrobial sensitivity patterns (if available) and should
adjust the choice according to sensitivity testing of the
isolated
uropathogen
Prophylaxis
o The aim is to prevent the recurrence of febrile UTI
o The recurrence of febrile UTI is increased in
children with vesico-ureteral reflux (VUR)
Prophylaxis
6 RCT studies, 1091 patients, compilation of data
Message 5
o
A formal meta-analysis did not detect a
statistically significant benefit of prophylaxis
in preventing recurrence of febrile UTI/
pyelonephritis in infants without reflux or those with
grades I, II, III, or IV VUR (grade V ??)
o The clinician should instruct parents or
guardians to seek prompt medical evaluation
(ideally within 48 hours) for future febrile illnesses,
to ensure that recurrent infections can be
detected and treated promptly
Objectives

Prevalence, risk groups

Diagnosis

Treatment, prophylaxis

Follow-up investigations
Follow-up investigations
To look for severe malformations of the urinary tract
RBUS
(renal and
bladder
ultrasonography)
VCUG
(voiding
cystourethrography)
Follow-up investigations
RB ultrasonography: Anatomy, rapid, non invasive
Follow-up investigations
VCUG: invasive, irradiation
o Recurrent febrile UTI can
occur in absence of VUR
o Prophylaxis in infants with
VUR (I-IV) does not prevent
recurrence
o VCUG is no more
recommended in all infants
Follow-up investigations
VUR is risk factor
for pyelonephritis
Can severe VUR
be predicted by
PCT
PCT is a marker of
pyelonephritis
VUR and procalcitonin
Procalcitonin to Reduce the Number of Unnecessary Cystographies
in Children with a Urinary Tract Infection: A European Validation
Study
o Conclusions High PCT is a
strong, independent and now
validated predictor of VUR
that can be used to identify
low-risk patients and thus
avoid one third of the
unnecessary
cystourethrographies in
children with a first febrile UTI.
(J Pediatr 2007;150:89-95)
Message 6
o Febrile infants with UTIs should undergo renal and
bladder ultrasonography (RBUS)
o VCUG should not be performed routinely after
the first febrile UTI; VCUG is indicated if RBUS
reveals hydronephrosis, scarring, or other findings
that would suggest either high-grade VUR such
as elevated procalcitonin value or obstructive
uropathy
Summary
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