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!