Article

Management and investigation of urinary tract infection in young children are always evolving and controversial. Our College President, Dr. Wong Sik Nin has recently reviewed the current guidelines from different countries and written up the updates to fellows through a brief communication. I would like to summarize the important issues discussed for your consideration on your current management in UTI in paediatric patients.

Previous concepts on UTI

• It was believed that UTI often signals an underlying urologic abnormality, especially vesicoureteral reflux (VUR) or obstructive uropathy,
• The urologic abnormality would cause UTI recurrence and renal scarring, leading to long term complications such as chronic kidney disease, hypertension, or complications during pregnancy
• Guidelines focused on universal imaging with ultrasound and voiding cystourethrogram, and antibiotic prophylaxis for VUR.1;2

VUR and Renal Scar

• It was realized recently most "renal scars" were in fact congenital dysplasia associated with gross VUR as part of the Congenital Anomalies of the Kidneys and Urinary Tract spectrum which probably not related to recurrent UTI
• Randomized controlled trials on antibiotic prophylaxis in children with VUR have reported conflicting results on its efficacy in preventing UTI and renal damage.3-9

Diagnosis

• Most centres recommended using clean void urine samples for urinalysis and culture
• Confirmation of diagnosis depended on presence of symptoms, evidence of inflammation (mostly as pyuria), and significant colony counts on culture
• 10^5 CFU/ml was taken as significant growth in clean void urine sample

Management

• Guidelines recommend giving antibiotics according to local sensitivity pattern of possible uropathogens.
• Cephalosporins or amoxicillin-clavulinic acid could be given for 7-14 days.
• Randomized controlled trials reported no differences between oral versus full intravenous treatment

Investigation

• Different Authorities had major variations in recommendations occur in the imaging strategy and prophylactic treatment after a febrile UTI.Imaging
• AAP recommended only USG and follow up, and doing VCUG when USG is abnormal or UTI recurs
• NICE, Italian and Australian guidelines recommended, in addition to above, doing VCUG and DMSA scan if a patient had high risk of renal damage

Prophylactic treatment

• AAP does not recommend routine antibiotic prophylaxis
• NICE guidelines recommend to "consider" antibiotic prophylaxis for recurrent UTI
• the Italian and Australian guidelines also recommend prophylaxis in dilating VUR or recurrent UTI

The local UTI guideline in Hospital Authority 10

• No routine VCUG or antibiotic prophylaxis
• VCUG if USG was abnormal or UTI recurred and “considered” VCUG if risk factors presented
• Antibiotic prophylaxis would be “considered” in patients with grade III VUR, and “recommended” if such patients had UTI recurrence (second episode).
• DMSA would be ordered for VUR of grade III or above.
• The option of surgical intervention such asDeflux injection after the second UTI for severerenal scarring on DMSA scan would be offered
• Surgical intervention (e.g reimplantation of ureters)should be recommended to patients with gross VUR has a second recurrence (third episode) despite antibiotic prophylaxis,.

References:

1. American Academy of Pediatrics Committee on Quality Improvement Subcommittee on Urinary Tract Infection. Practice Parameter: The Diagnosis, Treatment, and Evaluation of the Initial Urinary Tract Infection in Febrile Infants and Young Children. Pediatrics 1999; 103(4):843 852
2. Jodal U, Lindberg U. Guidelines for management of children with urinary tract infection and vesico-ureteric reflux. Recommendations from a Swedish state-of-the-art conference. Acta Paediatr 1999; 88(Suppl.431):87-89.
3. Garin EH, Olavarria F, Nieto VG, Valenciano B, Campos A, Young L. Clinical significance of primary vesicoureteral reflux and urinary antibiotic prophylaxis after acute pyelonephritis: a multicenter, randomized, controlled study. Pediatrics 2006; 117(3):626-632.
4. Roussey-Kesler G, Gadjos V, Idres N, Horen B, Ichay L, Leclair MD et al. Antibiotic prophylaxis for the prevention of recurrent urinary tract infection in children with low grade vesicoureteral reflux: results from a prospective randomized study. J Urol 2008; 179:674-679.
5. Pennesi M, Travan L, Peratoner L, Bordugo A, Cattaneo A, Ronfani L et al. Is antibiotic prophylaxis in children with vesicoureteral reflux effective in preventing pyelonephritis and renal scars? A randomized, controlled trial. Pediatrics 2008; 121(6):e1489-e1494.
6. Montini G, Rigon L, Zucchetta P, Fregonese F, Toffolo A, Gobber D et al. Prophylaxis after first febrile urinary tract infection in children? A multicenter, randomized, controlled, noninferiority trial. Pediatrics 2008; 122(11):1064-1071. 4
7. Craig JC, Simpson JM, Williams GJ, Lowe A, Reynolds GJ, McTaggart SJ et al. Antibiotic Prophylaxis and Recurrent Urinary Tract Infection in Children. N Engl J Med 2009; 361(18):1748-1759.
8. Brandstrom P, Jodal U, Sillen U, Hansson S. The Swedish reflux trial: review of a randomized, controlled trial in children with dilating vesicoureteral reflux. Journal of Pediatric Urology 2011; 7:594-600.
9. The RIVUR Trial Investigators. Antimicrobial prophylaxis for children with vesicoureteral reflux. N Engl J Med 2014; 370:2367-2376.
10. UTI Guideline Development Panel. Clinical Guideline on The Diagnosis and Initial Management of Urinary Tract Infections in Infants and Children aged 2 to 24 months. Hospital Authority, Hong Kong.