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Management & Long term follow up

FAYROUZ
Management

 Eliminate infection & prevent bacteremia.


 Relief of acute symptoms (fever, dysuria, frequency)
 Prevent recurrence & long term complications (renal scarring)
 Identify patients at high risk of developing recurrence
Hospitalization

 Less 3 months of age


 With complicated UTI
 Immunocompromised children
 Clinical urosepsis
 Vomiting &inability to tolerate oral medication
 Failure to respond to OP treatment.
Medication Dose, mg/kg/day
Parenteral
Ceftriaxone 75-100, in 1-2 divided doses IV
Cefotaxime 100-150, in 2-3 divided doses IV
Amikacin 10-15, single dose IV or IM
Gentamicin 5-6, single dose IV or IM
Coamoxiclav 30-35 of amoxicillin, in 2 divided doses IV
Oral
Cefixime 8-10, in 2 divided doses
Coamoxiclav 30-35 of amoxicillin, in 2 divided doses
Ciprofloxacin 10-20, in 2 divided doses
Ofloxacin 15-20, in 2 divided doses
Cephalexin 50-70, in 2-3 divided doses
Fluroquinolones

 AAP – limit to - Pseudomonas aeruginosa


• multidrug-resistant,
• gram-negative bacteria.

 Ciprofloxacin - complicated UTIs and pyelonephritis - E. coli :1 to 17 years of age.23


 Fluoroquinolones - sustained injury to developing joints,

Committee on Infectious Diseases. The use of systemic fluoroquinolones. Pediatrics. 2006;118(3):1287–


1292.
 Cephalexin : P. Vulgaris
Pseudomonas

 Norfloxacin & ciprofloxacin E coli,


 K pneumonia,
 P. Mirabilis ,
 Pseudomonas Aeroginosa
 Nalidixic acid , nitrofurantoin – excreted in urine
Not used in Febrile children
Oral Antibiotics

 Simple UTI
 above 3 months of age

 reduction of symptoms by 48-72


hours.

 If not suspect
resistant pathogens,
complicating factors
noncompliance
Duration of Treatment

 10-14 days - infants & children with complicated UTI,


 7-10 days - uncomplicated UTI.

 Prophylactic antibiotic therapy - children below 1 year of age,


Supportive Therapy

Routine alkalization of the urine is


not necessary

Adequate hydration Paracetamol- fever


Acute lobar nephronia

 IV – 2 weeks
 Followed up oral -1 week
 Follow up image in 2nd week:
 Surgery : if renal abscess formed
Fungal UTI

 Bladder irrigation with Amphotericin B


 Oral fluconazole : Candida cystitis
 IV Amphotericin B/ Fluconazole – 3-4 weeks
EVALUATION AFTER THE FIRST UTI

Aim
 Identify patients at high risk of renal damage,
 Below one year age
 Those with VUR or urinary tract obstruction or anomalies.
USG
MCU
Anatomy of kidney and urinary
VUR DMSA
tract
Anatomical details of
Kidney size, number and location,
bladder & urethra. renal parenchymal infection
hydronephrosis,
cortical scarring
urinary bladder anomalies
Postvoid residual urine.
IAP Guidelines
NICE GUIDELINES

LESS THAN 6 MONTHS 6 months- 3 years More than 3 years


USG WITHIN 6 WEEKS( IF USG during acute infection USG during acute infection
RESPONDING) (atypical ) (atypical )

USG DURING ACUTE USG WITHIN 6 WEEKS USG WITHIN 6 WEEKS


INFECTION (If atypical or (Recurrent) (Recurrent)
recurrent)
DMSA (if atypical / recurrent) DMSA (Atypical / recurrent) DMSA (recurrent)

MCUG (if atypical / recurrent) MCUG ( no need) MCUG ( no need)


 With significant advancement of antenatal scan .

Reconsider routine imaging

ISPN –All children 1st UTI to undergo evaluation.


 Ultrasonography -soon after diagnosis of UTI.
 MCU : 2-3 weeks later.
 DMSA scan : 2-3 months after treatment.
PREVENTION OF RECURRENT UTI

Hydration

Frequent voiding
Avoid Constipation

Anterior to posterior washing


technique
Circumcision
VUR
 Toilet train
 Regular & volitional low pressure voiding with complete bladder emptying
 Double voiding -emptying of the bladder of post void residual urine.
ANTIBIOTIC PROPHYLAXIS

 Long-term, low dose


ISPN GUIDELINES 2011

VUR grade Management


Grades I and II
Antibiotic prophylaxis until 1 yr old. Restart antibiotic prophylaxis if
breakthrough febrile UTI.

Grades III to V
Antibiotic prophylaxis up to 5 yr of age. Consider surgery if breakthrough
febrile UTI.

Beyond 5 yr: Prophylaxis continued if there is bowel bladder dysfunction.


 UTI below 1-yr of age, while awaiting imaging studies,
 VUR
 frequent febrile UTI (3 or more episodes in a year)even if the urinary tract is
normal.
 DMSA shows renal scar(even if VUR absnt)
 If hydronephrosis in absence of VUR - (DTPA)
(MAG-3).
 Quantitative assessment of renal function & drainage of the dilated collecting system.
Treatment and follow up- VUR

Grades Treatment
1-3 Mostly resolves Follow up
3-5 If not resolved by 5 years Surgery
3-5 Renal scarring + Surgery
Any grade Breakthrough UTI Surgery
recurrent even with
prophylaxis
Any grade Deterioration of renal Surgery
function
Any grade Paraureteric Surgery
diverticulum+, duplex
system +
Surgical management

1)Sub ureteric injection of Deflux / macroplastique

2)Extra vesical ureteric reimplant technique


Screening siblings

 Autosomal dominant with incomplete penetrance.


 Usg in siblings.
Long term follow up

 Physical growth and BP – 6-12 months


 Urine Analaysis : proteinuria , Sr creatinine
 Annual USG: monitor renal growth
 Cochrane review : short-duration (2-4 days) Vs standard-duration (7-14 days) oral antibiotics.
 In 652 children- Lower UTIs no significant difference in positive urine cultures between the
therapies immediately after treatment
 No significant difference between short &standard-duration therapies in the development of
resistant organisms at the end of treatment.

 Michael M, Hodson EM, Craig JC, Martin S, Moyer VA. Short versus standard
duration oral antibiotic therapy for acute urinary tract infection in
children. Cochrane Database Syst Rev. 2003;(1):CD003966.
STUDIES AGAINST PROHYLAXIS

 Conway PH, Cnaan A, Zaoutis T, Henry BV, Grundmeier RW, Keren R. Recurrent
urinary tract infections in children: risk factors and association with prophylactic
antimicrobials. JAMA. 2007;298(2):179–186.
 Montini G, Rigon L, Zucchetta P, et al.; IRIS Group. Prophylaxis after first febrile
urinary tract infection in children? A multicenter, randomized, controlled, noninferiority
trial. Pediatrics. 2008;122(5):1064–1071.