CESDI Audit

download report

Transcript CESDI Audit

Urinary Infection in
Children &
Vesico Ureteric Reflux
Dr. Ramesh Babu Srinivasan
M.S., M.Ch.(Paed Surg), FRCS Glas, FRCS Edin, FRCS (Paed)
Paediatric Urologist
Sri Ramachandra Medical Centre, Porur, Chennai,
India
Why is UTI important
in children ?
Childhood UTI

30-50% have underlying problems

Symptoms can be vague & diagnosis can
be missed

Failure to treat  scarring; hypertension;
loss of function & renal failure
What is the Incidence ?

5% of girls and 2% of boys will have
UTI during childhood

Before 3m: Boys more susceptible

After 3m: Boys = Girls
What is the pathogenesis?
Host
Bacteria
What are the symptoms ?

Often non specific in neonates &infants

Suspect in any infant with unexplained fever > 3 days

Any neonate with fever, lethargy, seizures

Children: fever, diarrhea, abdominal pain

Older Children: burning, urgency, frequency, flank
pain, wetting, turbid or foul smelling urine.
What is the essential
history in a child with
UTI?
History - underlying factors
Constipation (pain, consistency / frequency)
Bladder Instability (frequency, urgency)
Dysfunctional voiding
(holding, straining, Vincent’s Curtsey Sign)
Toileting habits (position, wiping post void)
Drinking history: quantity + quality; bladder stimulants
(caffeine, black currant)
Bathing habits: bubble baths, shampoo bath
Family history/social history
How to diagnose a UTI?

How to collect specimen?

Rapid tests?

Confirmation?
Definition

Significant Bacteriuria: presence of a pure
growth of > 105 colony forming units of
bacteria/ml

Lower counts may be important, in specimens
obtained by urinary catheter

Any growth clinically important if obtained by
suprapubic aspiration
Definitions

Simple UTI: low grade fever, dysuria,
frequency, urgency

Complicated UTI; fever >38.5, vomiting,
dehydration, renal angle tenderness

Recurrent UTI: Second attack of UTI

Relapsing UTI: UTI with same strain

Breakthrough UTI: UTI while on prophylaxis
Initial Management

Send FBC, BU, S Cr, Electrolytes; Urine

Children with complicated UTI, infants < 3m and those
with systemic signs are admitted for IV antibiotics

Adequate hydration is essential during acute phase

USG and repeat urine culture are necessary if there is
no improvement < 48hrs

If there is obstruction it needs to be relieved
(catheter in PUV; nephrostomy in pyonephrosis)
Initial Management

Infants > 3m and those with simple UTI – oral
antibiotics: amoxycillin; co trimoxazole or
cephalosporin

Usual duration of treatment is 10-14 days for
complicated and 7-10 days for simple UTI

After this course, start prophylactic antibiotic
until further evaluation in all children < 2yrs
Investigations after First UTI
USG (KUB)
Abnormal
Normal
<2yr
MCU, DMSA
2-5 yr
>5yr
DMSA
MCU
no further test
(if scar + or DMSA not available)
MCU, DMSA
Role & timing of Investigations

USG: helps to detect PC dilatation, ureter dilatation,
bladder thickening, ureterocele, post void residual
(useful in acute phase when obstruction suspected)

DMSA: ideally after 3m to detect scarring

MCU: provides anatomical information of urethra /
ureters; grading of reflux possible

Nuclear Cystogram: Less invasive; less radiation; Older
cooperative children required; poor anatomical
information; grading difficult; not ideal as first
investigation; useful for F/U of reflux
Recurrent UTI
Children with recurrent UTI irrespective of
age require USG, DMSA & MCU
Antibiotic Prophylaxis

Following First UTI in all children < 2yrs

Following complicated UTI in children > 5 yrs
while waiting for imaging

Children with VUR (up to 5 yrs)

Scars on DMSA even if there is no VUR (stop if
repeat MCU or RNCU is normal)

Children with frequent febrile UTI (? Even if
imaging is normal)
Antibiotic Prophylaxis
Age of Pt
Duration
First UTI
Reflux
No reflux/ scar +
No reflux; no scar
Recurrent UTI
(no reflux or scar)
All
up to 5 yrs
All
6m, re evaluate
< 2 yrs
6m, re evaluate
> 2 yrs
no prophylaxis
All
six months
Antibiotic Prophylaxis

Ideal: effective, non toxic with few side effects;
does not alter natural flora; does not promote
resistance

Cephalexin 10 mg/kg nocte (ideal for < 3m)

Cotrimoxazole 2 mg/kg nocte (avoid <3m)

Nitrofurantoin 1 mg/kg nocte (avoid in < 3m,
renal impairment, GI upset)
Measures to reduce recurrent UTI

Avoid tight undergarments

Plenty of fluids; avoid bladder irritants

Regular voiding; double voiding

Perineal hygiene; avoid shampoo/ soap

Control constipation

Circumcision in select group
Breakthrough UTI

Resistant flora

Poor compliance

Inadequate dosing

Poor bladder emptying

Host immunity

Address above issues

double prophylaxis
Asymptomatic Bacteriuria

1% in girls; 0.05% in boys

Good history and examination

USG to exclude abnormalities

Benign condition

Does not lead to scar

Often non virulent strain

Don’t treat: may get UTI with
virulent strain
What are the principles in the
management of VUR?

In the absence of UTI, isolated low pressure
VUR does not lead to scar formation

Uncomplicated primary reflux resolves
spontaneously
UTI
VUR
Scarring
What is the medical
management?

Treat acute episode of UTI

Start prophylactic antibiotics

Investigations to exclude anatomical causes
of secondary VUR

Treat factors like constipation, dysfunctional
voiding and bladder instability

follow-up, parental commitment and patient
compliance are essential for success
How long to continue prophylaxis?

resolution rate:


The duration to resolution since diagnosis:


Grade I: 2.5 yrs, II: 5 years and Grade III and IV: 8 years
risk factors for new scarring:


Grade I: 80%; II: 60%; III: 40%; IV: 10%; V 0%
younger age, high-grade reflux, and previous scarring
scarring rate with different grades:

Grade I: 10%, II: 17% and III and above 60%.
Indications for Surgery

Anatomical factors – duplex, para uret diverticulum

Obstructed refluxing megaureter

Secondary VUR – treat underlying cause

Primary VUR – failure of conservative treatment

Break through infection; worsening function; new scars

Poor follow up; non compliance

High grade (IV or V) reflux; bilateral reflux; multiple scars
Surgical options

Circumcision

STING


Teflon, macroplastique, deflux, chondrocytes
Ureteric reimplantation

Cohen, Leadbetter, Lich Gregoir, laparoscopic

Transureteroureterostomy

Heminephrectomy, common channel reimplant

Nephrectomy
Scenario

A ten-year-old girl, who was initially managed medically for grade III
VUR (on MCUG), was referred to the urologist because she
developed two episodes of UTI

A DMSA scan revealed unscarred kidneys with normal function

A repeat MCU confirmed persistent right-sided grade III reflux

On history symptoms of bladder instability

Treat bladder instability; still has symptoms

Urodynamics examination revealed normal compliance with no
instability; still gets recurrent UTIs

Extravesical reimplantation
Thank You!