Medical Management of

childhood UTI and VUR

Dr Patrina HY Caldwell

Paediatric Continence Education, CFA

15th November 2013

Terminology

• According to the current ICCS terminology guidelines – Bladder and bowel dysfunction = combined

bladder and bowel disturbance that encompasses lower urinary tract and bowel function.

– Dysfunctional voiding = habitually contracts

the urethral sphincter during voiding

– UTI = urinary tract infection

– VUR = vesicoureteric reflux

UTIs Background • UTIs are common in children

• 1/10 girls and 1/30 boys will have a UTI by 16

• More common in boys in first year

• More common in girls after the first year

• Commonly caused by E coli (80%)

• Other organisms –urinary tract anomalies,

younger age, previous antibiotics

Risk for UTI

• Females (2-4X) Shaikh 2008

• Ethnicity (white 2-4x) Shaikh 2008

• Genetic factors

• Anatomical obstruction (70% present

with UTI in first 2 months of life) Ring 1988

• Functional obstruction (bladder and

bowel dysfunction, neurogenic bladder)

Risk for Recurrent UTIs

• 10-30% will develop a further UTI

• Risk factors: • <6/12 at first UTI

• Bladder and bowel dysfunction

• Renal damage at first UTI (DMSA defect)

• VUR

• Previous UTIs

• Female

• Bacterial virulence and host susceptibility Panaretto 1999

Typical UTIs

• Pyelonephritis/upper tract infection:

– Bacteriuria + fever >38°C

– Bacteriuria + any fever + loin pain – 14% acute pyelonephritis had urinary tract abnormalities vs

3% with lower tract or asymptomatic bacteriuria (Pylkkanen 1981)

• Cystitis/ lower tract infection

– Bacteriuria + urgency, frequency, incontinence, dysuria

• Asymptomatic bacteriuria

– Bacteriuria + no symptoms

Atypical UTIs

• Seriously ill

• Poor urine flow

• Abdominal or bladder mass

• Raised creatinine

• Septicaemia

• Poor treatment response within 48/24

• Non- E Coli infection Nice Guidelines on UTI in children

Recommended Tests

• Urine microscopy and culture

• Urinalysis

• (CRP, procalcitonin)

• Ultrasound infants < 6 months and those with atypical or recurrent UTIs

• DMSA – atypical or recurrent UTI

• (Do not need MCUG) Nice Guidelines on UTI in children

Urine collection

• Clean catch urine

• Urine collection

pads

• Suprapubic aspirate

• Catheter urine

• (Bag urine – 50%

contaminated Al-Orifi 2000)

Urinalysis

• leukocyte esterase

and nitrites helpful

• Combination more

helpful

• Less reliable in

children 2 years

Acute management

• Antibiotics

– Parenteral AB for those <3 months

– Pyelonephritis – oral AB for 7-10 days (or

IV followed by oral AB)

– Cystitis – oral AB for 3 days

• Do NOT treat asymptomatic bacteriuria

• If on prophylactic AB, use different AB Nice Guidelines on UTI in children

Long term management

• Recurrent pyelonephritis associated with renal scarring (5%) Wennerstrom 2000

• Aim of long term management – reduce risk for further UTI and renal damage – Address inappropriate voiding patterns, dysfunctional voiding

– bowel management

– Encourage adequate fluid intake

– Access clean toilet, don’t delay voiding

– (Antibiotic prophylaxis not routinely recommended) Nice Guidelines on UTI in children

• For recurrent UTI antibiotic prophylaxis may reduce risk – (need to treat 14 children to prevent 1 UTI)

Craig 2009

• Circumcision also reduce risk – (need 111 circumcisions to prevent 1 UTI) Singh-Grewal 2005

VUR: abnormal movement of urine from the bladder into the

ureters or kidneys

Background

• VUR may be: – primary (congenital)

– secondary (caused by UTI, obstruction, bladder and bowel dysfunction)

• Can be familial – in 43% of infants of mothers with VUR

– 1/3 children with VUR have sibling with VUR North 2000

• Found in 17-37% of prenatal U/S

• 11% boys and 8% girls have dilating VUR

• About ½ had bilateral VUR

Grades of VUR

• 5 grades of VUR (III to V = dilating)

• Spontaneous resolution or improvement in 31-84%, particularly for unilateral or low grade VUR

Treatment for VUR

• Usually not necessary

• Surgery vs Surgery + long term antibiotics vs Long term antibiotics alone vs Endoscope (deflux) (Hodson et al Cochrane 2007)

Risk of UTI no different between medical and surgical group

Combined Rx resulted in 50% reduction in febrile UTI, but no reduction in risk of renal damage

2 studies no difference between AB and no Rx

Relationship between VUR

and UTI • VUR most common abnormality in children with

UTI (in 30% under 2 years)

• Associated with recurrent UTI (41% recurrent UTI vs 27% first time UTI)

Panaretto 1999

• Risk highest with bilateral VUR and high grades VUR

• Children with VUR and UTI more likely to have febrile UTI Smellie 1981

• Parenchymal damage more common bilateral, dilating VUR

Dysfunctional voiding, UTI and

VUR • Does dysfunction voiding cause secondary

VUR which may result in UTI?

• Of girls with dysfunctional voiding 67% developed UTI and 20% had VUR

• In those with dysfunctional voiding and VUR, ½ had constipation, ½ had bladder instability or infrequent voiding

• Dysfunctional voiding associated with increased time to resolution or non-resolution of VUR Koff 1998, Snodgrass 1991

Conclusion • Bladder and bowel dysfunction can cause

secondary VUR which increase the risk of UTI in children

• Recurrent pyelonephritis predispose children to permanent renal scarring, hypertension, impaired renal function and end stage renal disease

• This risk can be reduced by: • Appropriate diagnosis and management of UTIs • Treat dysfunctional voiding by addressing

constipation, voiding posture and encourage regular timed voiding

References • Craig JC, Simpson JM, Williams GJ, Lowe A, Reynolds GJ, McTaggart SJ, Hodson EM, Carapetis JR, Cranswick NE, Smith G,

Irwig LM, Caldwell PH, Hamilton S, Roy LP, Prevention of Recurrent Urinary Tract Infection in Children with Vesicoureteric Reflux and Normal Renal Tracts (PRIVENT) Investigators. Antibiotic prophylaxis and recurrent urinary tract infection in children. N Engl J Med. 2009;361(18):1748

• Koff SA, Wagner TT and Jayanthi VR. The relationship among dysfunctional elimination syndromes, primary vesicoureteral reflux

• and urinary tract infections in children. Journal of Urology 1998;160(3 Pt 2):1019–22.

• National Collaborating Centre for Women's and Children's Health. Urinary Tract Infection in Children: Diagnosis, Treatment and Long-term Management. National Institute for Health and Clinical Excellence Clinical Guideline. London, United Kingdom: RCOG Press; 2007

• North RA, Taylor RS and Gunn TR. Pregnancy outcome in women with reflux nephropathy and the inheritance of vesico-ureteric reflux. Australian & New Zealand Journal of Obstetrics & Gynaecology. 2000;40(3):280–5

• Panaretto KS, Craig JC, Knight JF, et al. Risk factors for recurrent urinary tract infection in preschool children. Journal of Paediatrics and Child Health 1999;35(5):454–9.

• Pylkkanen J, Vilska J and Koskimies O. The value of level diagnosis of childhood urinary tract infection in predicting renal injury. Acta Paediatrica Scandinavica 1981;70(6):879–83.

• Ring E and Zobel G. Urinary infection and malformations of urinary tract in infancy. Archives of Disease in Childhood.1988;63(7):818–20.

• Shaikh N, Morone NE, Bost JE, Farrell MH. Prevalence of urinary tract infection in childhood: a meta-analysis.Pediatr Infect Dis J. 2008;27(4):302.

• Smellie JM, Normand IC and Katz G. Children with urinary infection: a comparison of those with and those without vesicoureteric

• reflux. Kidney International 1981;20(6):717–22.

• Snodgrass W. Relationship of voiding dysfunction to urinary tract infection and vesicoureteral reflux in children. Urology

• 1991;38(4):341–4.

• Wennerström M, Hansson S, Jodal U, Stokland E. Primary and acquired renal scarring in boys and girls with urinary tract infection. J Pediatr. 2000;136(1):30.