Presented by Alex Henri MD
Presented by Alex Henri MD
Brandström P, Hansson S. Long-term, low-dose prophylaxis against urinary tract infections in young children. Pediatr Nephrol. 2015 Mar;30(3):425-32.
Urinary tract infection (UTI) affects about 2 % of boys and 8 % of girls during the first 6 years of life with Escherichia coli as the predominant pathogen. Symptomatic UTI causes discomfort and distress, and carries a risk of inducing renal damage. The strong correlation between febrile UTI, dilating vesicoureteral reflux (VUR), and renal scarring led to the introduction of antibiotic prophylaxis for children with VUR to reduce the rate of UTI recurrence. It became common practice to use prophylaxis for children with VUR and other urinary tract abnormalities. This policy has been challenged because of a lack of scientific support. Now, randomized controlled studies are available that compare prophylaxis to no treatment or placebo. They show that children with normal urinary tracts or non-dilating VUR do not benefit from prophylaxis. Dilating VUR may still be an indication for prophylaxis in young children. After the first year of life, boys have very few recurrences and do not benefit from prophylaxis. Girls with dilating VUR, on the other hand, are more prone to recurrences and benefit from prophylaxis. There has been a decline in the use of prophylaxis due to questioning of its efficacy, increasing bacterial resistance, and a propensity to low adherence to medication. Alternative measures to reduce UTI recurrences should be emphasized. However, in selected patients carefully followed, prophylaxis can protect from recurrent UTI and long-term sequelae. 1. There is a strong correlation between UTI, VUR, and renal scarring. 2. Children with normal urinary tracts or non-dilating VUR do not benefit from prophylaxis. 3. Young children, mainly girls, with dilating VUR are at risk of recurrent UTI and acquired renal scarring and seem to gain from antibiotic prophylaxis. 4. Increasing bacterial resistance and low adherence with prescribed medication is a major obstacle to successful antibiotic prophylaxis.
Paquette K, Cheng MP, McGillivray D, Lam C, Quach C. Is a lumbar puncture necessary when evaluating febrile infants (30 to 90 days of age) with an abnormal urinalysis? Pediatr Emerg Care. 2011 Nov;27(11):1057-61.
Routine LPs are not required in infants (30-90 days) presenting to the ED with a fever and a positive urinalysis if they are considered at low risk for serious bacterial infection based on clinical and laboratory criteria. However, we recommend that judicious clinical judgment be used; in doubt, an LP should be performed before empiric antibiotic therapy is begun.
Tebruegge M, et al.The age-related risk of co-existing meningitis in children with urinary tract infection. PLoS One. 2011;6(11):e26576.
Identification of co-existing meningitis in children presenting with UTI is critically important, as failure to detect CNS infection can result in partial treatment of meningitis with potentially severe long-term consequences , , . Our findings suggest that the risk of co-existing meningitis in infants with UTI under the age of one month is not insignificant. In contrast, outside the neonatal period this risk is small, indicating that a selective, rather than universal, approach to lumbar puncture is warranted.
Presented by Caitlin Nichols, MD PGY-1
Given a history of recurrent UTIs, is renal ultrasound and/or VCUG indicated to assess for underlying anatomic abnormalities in older children?
Schroeder AR, Chang PW, Shen MW, Biondi EA, Greenhow TL. Diagnostic accuracy
of the urinalysis for urinary tract infection in infants < 3 months of age. Pediatrics. 2015 May 25. [Epub ahead of print]
This study sheds new light on the diagnostic characteristics of the UA in young infants. A definition of a positive UA that includes pyuria and/or positive LE was highly sensitive and specific. All but 1 of 203 infants with bacteremic UTI and recorded UA results for both LE and WBC/HPF were positive for 1 or both of these tests, and the one infant with negative results for these components was infected with an organism (GBS) not commonly described as a uropathogen. A negative LE and the absence of pyuria were also fairly specific (87.8%) in infants with negative urine cultures. UA bacteria, however, demonstrated poor specificity, suggesting that this component of the UA is not as useful as LE or pyuria for ruling in a UTI.
Presented by Lajja Desai, MD