Transcript Definition of acute pyelonephritis

URINARY TRACT
INFECTION
MOHAMMED ALMAGHRABI,MD
PEDIATRIC NEPHROLOGIST
KING FAHAD SPECIALIST HOSPITAL ,
DAMMAM, SAUDI ARABIA
introduction
In the past 30–50 years, the natural history of urinary
tract infection (UTI) in children has changed as a result of
the introduction of antibiotics and improvements in
healthcare.
This change has contributed to uncertainty about the
most appropriate and effective way to manage UTI in
children, and whether or not investigations and follow-up
are justified.
introduction
• UTI is a common bacterial infection causing
illness in infants and children.
• It may be difficult to recognise UTI in children
because the presenting symptoms and signs are
non-specific, particularly in infants and children
younger than 3 years.
• Collecting urine and interpreting results are not
easy in this age group, so it may not always be
possible to unequivocally confirm the diagnosis.
prevalence
• varied by age, gender, race, and
circumcision status.
• Uncircumcised male infants less than 3
months of age and females less than 12
months of age had the highest baseline
prevalence of UTI.
• Prevalence in our area is not known yet .
prevalence
• overall prevalence of UTI was 7.0% .
• The pooled prevalence rates of febrile UTIs in females aged 0–3
months, 3–6 months, 6–12 months, and >12 months was 7.5%,
5.7%, 8.3%, and 2.1% respectively.
•
Among febrile male infants less than 3 months of age, 2.4% of
circumcised males and 20.1% of uncircumcised males had a UTI.
• UTI rates were higher among white infants 8.0% than among black
infants 4.7% .
•
Among older children (<19 years) with urinary symptoms, the
pooled prevalence of UTI (both febrile and afebrile) was 7.8%
•
Nader , etal Pediatr Infect Dis J 2008;27: 302–308)
Introduction
Introduction
definitions
Definition of acute pyelonephritis:
• All studies required a positive urine culture.
•
The additional criteria required for diagnosis of acute pyelonephritis in
childrenwithUTI varied between studies:
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Two studies required fever > 38°C (Baker 2001;Hoberman 1999),
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six required fever and at least one additional clinical feature (Bakkaloglu 1996;
Carapetis 2001; Chong 2003; Grimwood 1988; Noorbakhsh 2004; Repetto 1984; Schaad 1998; Toporovski 1992).
•
Seven studies required fever, clinical features and/or laboratory
abnormalities (C-reactive protein, erythrocyte sedimentation rate, white
blood count)
(Fischbach 1989; Francois 1997; Kafetzis 2000; Levtchenko 2001; Montini 2003; Pylkkänen 1981; Vigano 1992).
definitions
• Definition of acute pyelonephritis
• Seven studies required fever, clinical features and/or laboratory
abnormalities (C-reactive protein, erythrocyte sedimentation rate,
white blood count) (Fischbach 1989; Francois 1997; Kafetzis 2000; Levtchenko
2001; Montini 2003; Pylkkänen 1981; Vigano 1992).
• Three studies required fever, clinical features and acuterenal
parenchymal injury on DMSA scan (Benador 2001; Neuhaus 2006; Vilaichone 2001).
•
One study required fever withCTscan evidence of acute lobular
nephronia (Cheng 2006)
defintions
•
Cystitis and lower urinary tract infection :
Cystitis is inflammation of the urinary bladder, usually caused by
infection, which can occur alone or in conjunction with pyelonephritis
• Uncomplicated cystitis :
lower urinary tract and occurs in older children (older than 2 years)
or adolescents with no underlying medical problems or anatomic or
physiologic abnormalities.
• Complicated cystitis : Complicated cystitis is associated with upper
tract disease, multiple-resistant uropathogens, or hosts with special
considerations such as malignancy, diabetes, anatomic or
physiologic abnormalities, or an indwelling bladder catheter.
defintions
Asymptomatic bactiuria :
• The term asymptomatic bacteriuria (ASB) refers to the presence of
two consecutive clear-voided urine specimens both yielding positive
cultures (≥105 cfu/ml) of the same uropathogen, in a patient without
urinary symptoms
• The prevalence of ASB in full-term infants is less than 1% and in
premature infants 3% .
• Male infants are more affected than female infants
• The prevalence of ASB in school-age girls is approximately 2% and
about 5% of them have bacteriuria of some type by the age of 15
Clinical symptoms
RISK FACTORS
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poor urine flow
history suggesting previous UTI or confirmed previous UTI
recurrent fever of uncertain origin
antenatally-diagnosed renal abnormality
family history of vesicoureteric reflux (VUR) or renal disease
constipation
dysfunctional voiding
enlarged bladder
abdominal mass
evidence of spinal lesion
poor growth
high blood pressure.
Diagnostic workup
• Urine testing:
- nitrate
- Leukocyte estrase
- Urine bacteria
- Urine WBC
- Urine culture
Diagnostic workup
• Dipstick negative for both LE and nitrite or microscopic
analysis negative for both pyuria and bacteriuria of a
clean voided urine, bag, or nappy/pad specimen may
reasonably be used to rule out UTI.
• These patients can then reasonably be excluded from
further investigation, without the need for confirmatory
culture. Similarly, combinations of positive tests could be
used to rule in UTI, and trigger further investigation.
• Correlation with clinical presentation is essential .
•
Whiting P etal BMC Pediatr. 2005 Apr 5;5(1):4
Diagnostic workup
Diagnostic workup
Indication for culture :
• infants and children who have a diagnosis of acute
pyelonephritis/upper urinary tract infection
• in infants and children with a high to intermediate risk of serious
illness
• infants and children under 3 years
• infants and children with a single positive result for leukocyte
esterase or nitrite
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infants and children with recurrent UTI
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infants and children with an infection that does not respond to
treatment within 24–48 hours, if no sample has already been sent
• when clinical symptoms and dipstick tests do not correlate.
Diagnostic workup
Procalcitonin and pyelonephritis
•PCT is a polypeptide identical to the prohormone of calcitonin that
has been described as a potential marker for biologic disease .
• PCT is a 116- amino acid propeptide of calcitonin that lacks
hormonal activity.
• Plasma concentrations in healthy subjects, chronic inflammatory
states, viral infections, and autoimmune disease are below 0.5
ng/mL.
•In moderate localized bacterial infection PCT ranges from 0.5 to 2,
and in severe gram-negative bacterial infections with sepsis and
multiorgan failure the level is found to be above 2 ng/mL
Diagnostic workup
• Benador N, Siegrist CA, Gendrel D, et al Pediatrics 1998; 102:1422– 1425.
• Smolkin V, Koren A, Raz R, et al. Pediatr Nephrol 2002; 17:409– 412.
•Pecile P, Miorin E, Romanello C, et al.Pediatrics 2004; 114:e249– e254.
•Gurgoze MK, Akarsu S, Yilmaz E, et alPediatr Nephrol 2005; 20:1445–1448.
•15 Bigot S, Leblond P, Foucher C, et al.Arch Pediatr 2005; 12:1075– 1080;
Imaging studies
Imaging studies
Imaging of the urinary tract following infection has several
aims:
(1) to localize infection,
(2) to identify the presence of reflux,
(3) to detect renal scarring,
(4) to identify structural anomalies.
Imaging studies
• The previous guidelines for the investigation and
management of childhood UTI in the UK, published by
the Royal College of Physicians in 1991 recommended
that:
• all children should undergo renal tract imaging after a
first episode of confirmed UTI and gave age-related
recommendations.
• However, these guidelines have been superseded by
those published by the Royal College of Pediatrics and
Child Health , based on the USA practice guidelines of
the American Academy of Pediatrics
Imaging studies
• The USA guidelines recommend investigation of febrile
children aged between 2 months and 2 years with initial
UTI with urgent renal ultrasound and either micturating
cysto-urethrography (MCUG) if there is no clinical
response within 48 h of antimicrobial therapy.
• If there is good clinical response, then these
investigations should be performed at the earliest
convenient time.
Imaging studies
• Ultrasound :
Hoberman etal nengl j med 348;3 nejm.january 16, 2003
Imaging studies
• Prenatal-RUS have been performed in most children 5
years old hospitalized with a first simple UTI.
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Concordance with post-infection tests is very high with
positive predictive value of more than 96% Findings
which appear only in post-infectious
• RUS usually have negligible effects on children’s
management.
• Thus, in such children with normal antenatal RUS
omitting post-UTI RUS could be considered
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Dan Miron etal Arch Dis Child 2007;92:502–504
• Is this type of antenatal care existing
in our community ….?
Imaging studies
Hoberman etal nengl j med 348;3 nejm.january 16, 2003
Is it necessary to do VCUG as
screening ?:
Imaging studies
• Preda prospectively studied 290 children younger than 1 year of age
with a documented UTI using DMSA scintigraphy and VCUG to
detect VUR.
Only 1 child of 141 with a normal DMSA scan had VUR grade III or
higher. The positive and negative predictive values for DMSA
scintigraphy to detect higher grade VUR were 17% and 99%
respectively.
Thus, a negative DMSA scan may help to rule out VUR but is not
diagnostic if positive.
Preda I, et al. J Pediatric. 2007;151:581–584, e1.
Imaging studies
So, what happens if we miss vesicouretric •
reflux (VUR) ??......
Imaging studies
• The natural history for lower grades of VUR (grades I,II, and III) is
spontaneous resolution at a rate of 13% per year
• There are recent data to support the notion that mild and moderate
VUR do not increase the incidence of UTI pyelonephritis or renal
scarring after acute pyelonephritis
• VUR, even if dilated, does not seem to cause renal scarring in the
postnatal period.
• VUR is related to congenital renal damage and to the development
of upper tract UTI but has not been shown to cause postnatal kidney
damage without infection
Imaging studies
DMSA :
• A DMSA scan performed during an episode of suspected acute
pyelonephritis is the gold standard to localize the site of infection.
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As clinical symptoms are often nonspecific, imaging tests can be
useful in confirming or excluding the diagnosis.
• Several authors have shown that one in three patients with a
clinically suspected acute pyelonephritis have a normal DMSA
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Jacobsson B ETAL Arch Dis Child 67:1338-1342, 1992
18. Levtchenko et al Pediatr Nephrol 16: 878-884, 2001
Imaging studies
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The DMSA scan performed during the acute pyelonephritis appears
to have prognostic value.
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It has been shown that a normal DMSA during an acute
pyelonephritis with or without reflux is associated with a 0% risk of
renal scarring.
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Mild renal inflammatory involvement with or without reflux and
extensive renal involvement without reflux are likely to be associated
with an intermediate risk of developing renal scars after the UTI.
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Extensive renal inflammatory involvement with reflux is associated
with a high risk of developing renal scars.20
Biggi A,et al: Pediatr Nephrol 16:733-738, 2001
Imaging studies
• Incidence of scarring :
• Among 23 references the overall rates of renal scarring in terms of
patients and renal units were 41.6% and 37.0%, respectively.
• In terms of patients the incidence of renal scarring following acute
pyelonephritis varied by region, from 26.5% (Australia) to 49.0%
(Asia).
• In terms of renal units the incidence of acquired renal cortical
scarring varied by region, from 16.7% (Middle East) to 58.4% (Asia).
• When combined by vesicoureteral reflux status children and renal
units with refluxing ureters exhibited an increased risk of renal
scarring (odds ratios 2.8 and 3.7,
William C.etal Journal of urology Vol. 181, 290-298, January 2009
Traditional Imaging
Strategies in Children With UTI
Approach: The Focus on Reflux
• This strategy is focused on VUR as the main risk
factor in children with UTI.
• Children with VUR are considered at high risk of
developing renal damage and therefore they
should be identified with a cystogram and
commenced on prophylactic antibiotics until the
VUR resolves.
Traditional Imaging
Strategies in Children With UTI
• this approach selects a number of children who
are not at risk of renal scarring and fails to
identify other children, with no demonstrable
VUR, who nevertheless do develop renal
scarring.
• Moreover, the MCUG is perceived as traumatic
and invasive test, especially in older children,
with an additional associated risk of infection.
• Aggressive intervention to avoid
presumed serious complications
Coasty procedures
Extra burden on healthy children and their
families
Questionable chronic complications
• the compliance of practitioners with the AAP guidelines
is startlingly low. In the state of Washington, a large
survey of children who experienced UTI in the first year
of life showed that only 35% received imaging according
to the AAP guidelines, while 51% received
recommended antimicrobial prophylaxis.
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Cohen AL, et al. Pediatrics. 2005;115:1474 –1478.
New Imaging
Strategies in Children With UTI
A New Approach: The Focus on Acute Renal •
Inflammatory Involvement
This is focused on detecting renal inflammatory •
involvement during the clinical episode of acute
pyelonephritis and uses the acute DMSA,
performed during the episode of infection, as its
cornerstone.
Hansson S, et al:J Urol 172:1071-1073, 2004
•
National institute for health and clinical excellence
National institute for health and clinical
excellence
National institute for health and clinical
excellence
Acute management
Acute management
• Questions to be addressed :
• Inpatient vs outpatient?
• Oral vs intravenous ?
• First line therapy ?
• Therapy duration?
Acute management
• Decision to hospitalize:
• Age <2 months
• Clinical urosepsis or potential bacteremia
• Immunocompromised patient
• Vomiting or inability to tolerate oral medication
• Lack of adequate outpatient follow-up (eg, no telephone, live far
from hospital, etc.)
• Failure to respond to outpatient therapy
Acute management
Acute management
• The following implications for practice in the treatment of children
with acute pyelonephritis have been identified:
• There are no significant differences in efficacy between treatment with
oral cefixime, ceftibuten or amoxicillin/ clavulanic acid given for 10 to
14 days and IV therapy given for three days followed by oral therapy
for a total duration of 10 to 14 days suggesting that children with acute
pyelonephritis can be treated effectivelywith oral antibiotics.
• There are no significant differences in efficacy between IVantibiotic
therapy given for two to four days followed by oral therapy with total
therapy duration of 10 to 21 days and IV antibiotic therapy given for 7
to 10 days with total duration of therapy of 10 to 21 days.
Acute management
• The optimal duration of initial IV antibiotic therapy is
unknown.
• Studies using comparing oral with IV then oral
antibioticsor IV then oral with IV therapy were no
stratified according to the grade of vesicoureteric reflux
so it remains unclear whether results apply to children
with dilating vesicoureteric reflux.
Acute management
• Single daily dosing of aminoglycosides is safe and
effective compared with eight-hourly dosing.
• No data are available as to whether aminoglycosides
alone or in combination are as effective as other
medications including third generation cephalosporins in
initial parenteral treatment.
Acute management
Implications for research IN treatment of pyelonephritis:
• Further RCTs are required to determine the benefits and harms in
children of different ages with acute pyelonephritis of:
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Treatment for shorter periods (seven days or less)
with 10 to 14 days.
• Initial treatment with oral antibiotics compared with
parenteral therapy or IV then oral therapy compared
with IV therapy in children with dilating VUR or other
major urinary tract malformation.
compared
•
Acute management
• Management of cystitis :
- complicated cystitis
-uncomplicated cystitis
Prevention
Antibiotics prophylaxis
The recommendation of prophylactic antimicrobial therapy is
based on the following premises:
• coexisting vesicoureteral reflux predisposes children with urinary
tract infections to the development of acute pyelonephritis; reflux
nephropathy, which leads to renal scarring, is a consequence of
infection plus reflux;
•
continuous prophylactic antimicrobial herapy successfully prevents
infection until reflux resolves spontaneously or is corrected
surgically;
•
the initiation of treatment after the diagnosis of intercurrent
episodes of urinary tract infection in such children will be insufficient
to prevent scarring.
Antibiotics prophylaxis
Antibiotic prophylaxis
Antibiotics prophylaxis
Antibiotics prophylaxis
Antibiotics prophylaxis
CONCLUSIONS.
After 1 year of follow-up monitoring, mild/moderate VUR does
not increase the incidence of UTI, pyelonephritis, or renal
scarring after acute pyelonephritis.
Moreover, a role for urinary antibiotic prophylaxis in preventing
the recurrence of infection and the development of renal
scars is not supported by this study.
•
Garin EH, et al.Pediatrics. 2006;117:626–632.
Antibiotics prophylaxis
Interventions for primary vesicoureteric reflux (Review)
Hodson EM, Wheeler DM, Smith GH, Craig JC,
Vimalachandra D
2009, Issue 1
Antibiotics prophylaxis
• Eleven studies (1148 children) were identified.
• Seven compared correction of VUR (by surgery
or endoscope) plus antibiotics for 1-24 months
with antibiotics alone,
• two compared antibiotics with no treatment and
two compared different materials for endoscopic
correction of VUR.
Antibiotics prophylaxis
• Risk of UTI by 2, 5 and 10 years was not significantly different
between surgical and medical groups
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Combined treatment resulted in a 50% reduction in febrile UTI by
10 years ,but no concomitant reduction in risk of new or progressive
renal damage by 10 years
Authors’ conclusions:
• It is uncertain whether the treatment of children with
VUR confers clinically important benefit.
• The additional benefit of surgery over antibiotics alone is
small at best
THERE ARE NO EXISTING STUDIES
TESTING FOR EFFICACY OF
ANTIBIOTICS PROPHYLAXIS IN HIGH
GRADE REFLUX
Other preventive measures
• CULTURE SURVILLANCE
• AVOIDANCE BUBBLE PATH
• CRANBERRY JUICE
• CRCUCISSION
Summary of new advances
• Imaging studies shifted toward more
targeted objective
• DMSA has 99%-ve predictive value for VUR
• Scarring related mainly to both inflammation
and reflux
• Accumilating evidence of no rule of
antibiotics prophylaxis in grade I, II,III reflux
• No evidence in high grade reflux
• WHERE IS OUR GUIDELINES
DIRECTION ?
OUR PROBLEMS
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Antenatal care problems
Weak intact health system
Antibiotics abuse
Underestimation of problems
Lacking of epidimiological studies
Urinary symptoms
without four
+ test without symptoms
Febrile Child
Non specific symptoms
Urinary symptoms
Do tests
Do culture
+ test
-Ve test
Presume UTI
No UTI
Do Culture
Start Antibiotic
Consider Imagine
Prophylaxes
TAKE HOME MESSAGE
• UTI is high index of suspicion in all febrile
children less than 3 years
• Identifying risk group is an essential part of
management
• Urine culture still is the gold standard of
diagnosis and should be considered before any
antibiotics therapy
• U.S is needed for all definite UTI patient in our
population
• Antibiotic prophylaxis is considered for high risk
group only
THANK YOU
urinary symptoms without fever
- either no or low grade fever
- if positive tests …..consider cystitis
- treat with oral antibiotics for 3 to 5 days
Back
Positive tests without symptoms
- Consider asymptomatic bactiuria
- No antibiotic treatment
- Consider conservative treatment
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Antibiotic therapy
• I.V therapy for :
- less than 3 months
- atypical UTI
• Therapy duration ;
- pyelonephritis n 7-10 days
complicated infections :at least 2 weeks
- cystitis : 3 to 5 days
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Imaging evaluation
• U.S kidney and urinary tract for all treated
patient
• VCUG for those with abnormal U.S and
those with atypical UTI
• DMSA for every difinite UTI after 4
months
• DMSA in acute episode for complicated
UTI and if diagnosis is uncertin
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Antibiotic prophylaxis
• It is considered for every abnormal VCUG
with grade III ,IV , V VUR
• It may be considered in atypical UTI
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