Transcript Imaging After Febrile UTI in Children: Time for Less

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
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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
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Why Do We Care About UTI?
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UTI now most common site for SBI in
infants
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More than 1 million office visits per year
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$180M/year for hospitalization alone
Freedman, J. Urology, 2005
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
What constitutes “not low risk”?
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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
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Factors Modifying Risk for UTI
From Marmor “Updates in Management of UTI in Febrile Infants/Children < 24 mo
of Age” 2012
How should urine be tested?
•SPA
•Catheterization
•Bag
•Clean Catch
What defines a “UTI”?
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2011 AAP CPG:
 At least 50K CFU/ml of uropathogen via
cath or SPA
 AND UA suggesting infection (pyuria and/or
bacteruria)
How can UA help you?
AAP CPG, Pediatrics, 2011
Urine Culture
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When to send
Definitely “positive”?
UA + and Cath Ucx + if > 50k CFU/mL
 UA + and Bag Ucx + if > 100K CFU/ml single org
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Possibly +:
high clinical suspicion and
 UA + and > 10K org OR
 UA – and > 50K single org
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UTI Management
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When/how long to hospitalize?
Abx: what, how and how long?
Prophylaxis?
Imaging?
Inpatient vs outpatient
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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
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Duration of IV Abx
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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!
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AAP recs
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“Initiating treatment orally or parenterally is
equally efficacious”
“Adjust choice according to sensitivity testing”
7-14 days total
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“Outcomes of short courses (1-3 days) are inferior
to those of 7-14 day courses”
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No reference!!
Our recs (if well)
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> 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
Ampicillin 41%
Cefazolin 88%
CTX
94%
Gent
91%
SXT
66%
Prophylactic Abx
• Mid-2000’s  Practice questioned by handful of RCTs
PRIVENT trial
[Craig, NEJM, 2009]
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576 Children age 0-18 years with first febrile
UTI
Renal US, VCUG, DMSA in most patients
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DMSA again at 1 year
Daily TMP/SMX
Still Pending
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600 children 2 months – 6 years
Grades I-IV VUR
TMP/SMX vs placebo
Our recs
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No prophylaxis unless high-grade, persistent
VUR
Imaging
Imaging makes sense if…
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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
1.) Abnormalities are common
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VUR same prevalence (~35%) in patients with
true UTIs and false UTIs [Hanula, Pediatr Nephrol 2010]
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
Crunching the #’s
UTI incidence
50,000 per million
Incidence of ESRD
from VUR
5 per million
UTI  ESRD
1/10,000
Craig, Pediatrics 2011
3. Detection of the abnormalities
improves outcomes
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Prophylactic Abx?
VUR surgery?
Other anatomic abnormalities?
2008: Initiation of new guidelines at
SCVMC
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Grand Rounds
Meeting of inter-disciplinary group
Discussed at faculty meeting
Radiologist reminders
New AAP recs
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US on everyone, VCUG if abnormal or if
recurrence
Take Home Points
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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
Questions?