Urinary tract infections and vesicoureteral reflux in children

Август 24, 2022

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Urinary tract infections and vesicoureteral reflux in children

Содержание

2. Urinary Tract Infections UTI: Growth of significant number of organisms of a single species in the
3. Signs & Symptoms of UTIs Features of UTI in infants are nonspecific: thus a high degree
4. Urine Sample Collection & Diagnostic Testing Methods Prevent contamination!!!!! Send urine within 1 hour for accurate
5. Who needs X-Ray evaluation? Any child with febrile UTI or recurrent UTIs. ALL females “Non-febrile” UTIs
6. Vesicoureteral Reflux “Backwash” or retrograde flow of urine from the bladder into the ureters, and usually
7. Primary: (Congenital) defect of UVJ (ureterovesical junction) – Most common –deficient tunnel / laterally displaced orifices
8. Anatomy and Grading System
9. Management Trends / Rx A person can NEVER be cured of UTIs A person CAN BE
10. TREATMENT of VUR Daily prophylactic antibiotic until reflux self-resolves or is surgically repaired. Surgery (laparoscopic, open
11. Complications of VUR Infection Renal Scarring Greatest risk of scarring: Birth to 5 years of age.
12. Referral Criteria and Follow Up Referral Abnormal “antenatal ultrasounds” = hydronephrosis Recurrent UTI Febrile UTIs VUR
13. Prophylactic Medications Bactrim/Septra/TMP-SMX Macrodantin, Furadantin, Nitrofurantoin (1-2 mg/kg/per day) Capsules are the best. Keflex Amoxicillin: (for
14. Evolution in VUR management Changes Minimally invasive surgery Observation off RX Aggressive management DES Prenatal detection
15. The END!
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Слайд 2

Urinary Tract Infections
UTI: Growth of significant number of organisms of a

single species in the urine, in the presence of symptoms.
> 50,000 CFU/ml from an accurately collected specimen
TWO TYPES OF UTIs
Distinction between “upper (pyelo) and lower tract (cystitis)” UTI is not always possible - or even necessary.
“Clinical severity” determines management course.
ALL FEBRILE UTIs: considered to involve the upper tract with the greatest potential for renal scarring.

Слайд 3

Signs & Symptoms of UTIs
Features of UTI in infants are

nonspecific: thus a high degree of suspicion is necessary.
Infant or child with “unexplained fever” beyond 3 days.
Fever generally will not break with conservative measures.
Neonates – usually part of septicemia and presents with fever, vomiting, lethargy, jaundice and seizures.
Infants & young children – may present with fever, diarrhea, vomiting, abd. pain, and poor weight gain.
Older child – dysuria, hematuria, urgency, frequency, flank pain, foul smelling urine, or onset of wetting.

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Urine Sample Collection & Diagnostic Testing Methods
Prevent contamination!!!!!
Send urine within 1

hour for accurate culture results.
Can refrigerate for up to 24 hrs if delay.
Significant UTIs: >100,000 CFU/HPF

“Bagged” = BAD highly unreliable!
Voided “clean catch (80-90% accurate if perineum well cleaned & caught midstream)
Catheterized Most accurate and reliable
Supra pubic aspiration very rare / very accurate

Слайд 5

Who needs X-Ray evaluation?
Any child with febrile UTI or recurrent UTIs.
ALL

females < 5 yo with UTI
“Non-febrile” UTIs (male at any age, neonate, toilet training children)
STANDARD WORK UP includes
VCUG (voiding cystourethrogram)
Allows for grading (NCG can not grade VUR)
RUS (complete renal ultrasound)
Optional: Nuclear Renal Scans
DTPA (GFR) / Glucoheptonate-DMSA (Cortical Binding)

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Vesicoureteral Reflux
“Backwash” or retrograde flow of urine from the bladder

into the ureters, and usually up to the kidneys.
VUR is a risk factor for upper tract infection=Pyelonephritis.
VUR found in 50% of children with UTI.
Affects 1% of all children.
Boys typically dx with higher grades than girls.
Female to Male ratio is 6:1
10 times more common in whites vs blacks
Hereditary components / Family history !
parent: 50% / sibling 33-45%

Слайд 7

Primary: (Congenital) defect of UVJ (ureterovesical junction) – Most common –deficient

tunnel / laterally displaced orifices
Secondary (Acquired) increased intravesical pressure secondary to neurogenic problems or DES, bladder instability, bladder outlet obstruction (PUVs)
UTIs (problem #1) do not cause reflux!!
Reflux (problem #2) does not cause UTIs!!

Etiology / Pathophysiology

Слайд 8

Anatomy and Grading System

Слайд 9

Management Trends / Rx
A person can NEVER be cured of UTIs
A

person CAN BE cured of reflux.
Must address UTI risk factors FIRST !
Poor voiding habits
Constipation
Hygiene
Poor bladder immunity
Gender
Structural anomalies

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TREATMENT of VUR
Daily prophylactic antibiotic until reflux self-resolves or is surgically

repaired.
Surgery (laparoscopic, open ,DEFLUX)
Aggressive tx of dysfunctional elimination.
ABSOLUTE indication to repair =
Catheterized culture documented breakthrough UTI.
Several other relative indications to repair

Слайд 11

Complications of VUR Infection
Renal Scarring
Greatest risk of scarring: Birth to

5 years of age.
Impaired renal growth and function
Hypertension (occurs in 10% cases with scarring)
End stage renal disease
Pregnancy complications (pre-eclampsia)

Слайд 12

Referral Criteria and Follow Up
Referral
Abnormal “antenatal ultrasounds” = hydronephrosis
Recurrent UTI

Febrile UTIs
VUR lasting 5 years or longer.

Follow-up
VCUGs/NCGs/RUS are done yearly.
NRS as indicated if concerns of scarring and function loss.
DES patients need close f/u as indicated.

Слайд 13

Prophylactic Medications
Bactrim/Septra/TMP-SMX
Macrodantin, Furadantin, Nitrofurantoin (1-2 mg/kg/per day) Capsules are the best.
Keflex
Amoxicillin:

(for infants less than 2 months or allergy to Bactrim)
Generally dose prophylactics at 1/3 – 1/ 4 the therapeutic treatment dose.

Bactrim
5 kg = ¼ tsp
10 kg = ½ tsp
15 kg = ¾ tsp
20 kg = 1 tsp

Слайд 14

Evolution in VUR management
Changes
Minimally invasive surgery
Observation off RX
Aggressive management DES
Prenatal

detection

Improvements
Early detection
Decreased surgical morbidity
Pain management
Early hospital discharge
Reduced post-op X-Ray evaluations.

Слайд 15

Urinary tract infections and vesicoureteral reflux in children

Содержание

Urinary Tract InfectionsUTI: Growth of significant number of organisms of a

Signs & Symptoms of UTIs Features of UTI in infants are

Urine Sample Collection & Diagnostic Testing MethodsPrevent contamination!!!!!Send urine within 1

Who needs X-Ray evaluation?Any child with febrile UTI or recurrent UTIs.ALL

Vesicoureteral Reflux “Backwash” or retrograde flow of urine from the bladder

Primary: (Congenital) defect of UVJ (ureterovesical junction) – Most common –deficient

Anatomy and Grading System

Management Trends / RxA person can NEVER be cured of UTIsA

TREATMENT of VURDaily prophylactic antibiotic until reflux self-resolves or is surgically

Complications of VUR InfectionRenal ScarringGreatest risk of scarring: Birth to

Referral Criteria and Follow UpReferralAbnormal “antenatal ultrasounds” = hydronephrosisRecurrent UTI

Prophylactic MedicationsBactrim/Septra/TMP-SMXMacrodantin, Furadantin, Nitrofurantoin (1-2 mg/kg/per day) Capsules are the best.KeflexAmoxicillin:

Evolution in VUR managementChangesMinimally invasive surgery Observation off RXAggressive management DESPrenatal

The END!

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