6
 


 Background
 Epidemiology
 Etiology
 Clinical features
 Diagnosis
 Treatment
 Follow up
 Prevention
 Imaging
 Vesico--ureteral reflux (VUR
Vesico (VUR))
 Summary
 S

 Urinary tract infection (UTI) is common in infants and children
 UTI is difficult to recognise
 Collecting urine and interpreting laboratory results is not easy
 Diagnosis is not always confirmed
 UTI in infants and children may have long term sequelae
 UTI due to ESBL produces ranging uncomplicated infection to
life threatening sepsis emerging very fast.
 Management of it differ altogether.
 d
 
d


  d
 
VUR (30-40%)
obstructive uropathy (5%)

Reflux nephropathy

Hypertension & ESRD

 

×
- Infection of urinary tract identified by
growth of a significant number of organism of a single
species in urine in the presence of symptoms.
 




 ± Midstream urine
sample showing colony count >105/ ml of a single
organism.
Any bacterial growth in specimen by SPA



×
-- significant bacteriuria
with symptoms like dysuria frequency & urgency with or
without fever & renal or flank pain.
 
 
Ú 


S


 £significant bacteriuria
on 2 or > specimen in a child without symptoms
(Incidence 1-2 % preschool age girls ,0.03% boys)
No treatment except in pregnent women & following
instrumentation



×
£UTI with presence of fever
>38.50c ,toxic look, vomiting, dehydration & renal angle
tenderness

×
±UTI with low grade fever, dysuria,
frequency,urgency but none of the symptoms of toxemia
 
 
Ú

×

 seriously ill, poor urine flow, abdominal or bladder mass,
raised creatinine, septicaemia, failure to respond to treatment
with suitable antibiotics within 48 hours or infection with
non-E. Coli organisms.

î



×

 two or more episodes of UTI with acute pyelonephritis/upper UTI,
or one episode of UTI with acute pyelonephritis/upper UTI plus
one or more episodes of UTI with cystitis/lower UTI, or three or
more episodes of UTI with cystitis/lower urinary tract infection.

NICE 2007
"

M



 ×

 -irls 3-5%, first UTI by 5 years
(peak -infancy, toilet training)

-In 60-80% 2nd UTI within 18 months

-In Boys-mostly during 1st year of life.
-Much more common uncircimcised males
 Boys 1%, most UTIs during the first year of life
 During infancy
Male : female :: 2.8-5.4 : 1
 Beyond 1-2 years of age
Male : female :: 1: 10
 ll rst in¶s P
Clin. North Am 1995;42 ;1437-1457
IPNG INDIAN P
iatrics 2001;38:1106-1115
IJP-2009.76(8):809-814.
 ×rinary Tract Inf ction
Epi
miology (N=990)
Ú
  


 
  
 


   

 
 !     

"
  ! !


    

Christian MT t. al. Arch Dis. Chil
. 2000;82:376






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 Population based study in Sweden

- 9.3/ lac with ratio girls : boys- 2 : 1
-0.18% girls & .11% boys in population ±Renal
Parenchymal defect.
 Systemic review 4 prospective studies
-5-15% children have Renal parenchymal defects
(Dick PT t al . Journal of pa
. 1996;128 (1) :15-22)
 "

Mainly by colonic bacteria
E.coli( 75- 90 %)
Klebsiella spp.
Proteus spp
Proteus =E.coli < 1yrs boys
-rm.+ve organism ± males
Staph. Saprophyticus & Enterococci in both
Viral infection ±sp. Adenovirus£cystitis
Proteus & pseudomonas£Recurrent UTI, instrumentation &
Nosocomial infection.
Fungi£ immunocompromised
Candida albicans£common in preterms
immunocompromised & prolonged antibiotic therapy.
 î 

  ×

 Female gender Tight clothing
 Uncircumcised male Pinworm infestation
 VUR Constipation
 Toilet training Bacteria with p.fimbriae
Anatomic abnormality
 Voiding dysfunction (labial adhesion)
 Obstructive uropathy Wiping from back to front in female
 Urethral Neuropathic bladder
instrumentation Sexual activity
 Bubble bath Pregnancy
Broad spectrum antibiotics for minor
infections
N lson t t book of pa
iatrics
î
 
 


† Age
† Frequent episodes of APN
† Therapeutic delay
† Anatomical obstruction
† High grade VUR
† Bacterial virulence factors
† Host response
† Low birth weight
† Prenatal dysplasia
† Dysfunctional voiding
 M



Usually ascending infection

Haematogenous ±Endocarditis & some neonates

×
 



 

  

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"   




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Infants younger than Fever Poor feeding Abdominal pain

3 months Vomiting Failure to thrive Jaundice
Lethargy Haematuria
Irritability Offensive urine

Infants Preverbal Fever Abdominal pain Lethargy

and Loin tenderness Irritability
children, Vomiting Haematuria
3 months Poor feeding Offensive urine
or Failure to thrive
Older
Verbal Frequency Dysfunctional Fever
Dysuria voiding Malaise
Changes to Vomiting
continence Haematuria
Abdominal pain Offensive urine
Loin tenderness Cloudy urine
 ×

×

a
×



 ×
×
 

%
-urgency, dysuria -Fever ,vomiting,toxemia ,flank
frequency, pain (occasionally diarrhoea)
suprapubic pain, -In new borns poor feeding,
incontinence & malodorous irritability & wt loss.
urine
-fever is not common -usually associated with urinary
-common in females tract malformations
-less chance of associated
anomalies.



  % 

 d " & d  

 "
% '( 
(M hta KR Ali ×. (un
r IAP subsp. S ri s on Pa
.inf ctious
is as (un
rIAP action Plan 2006) 1st
n
2006; 178-183.
   

Classical signs and symptoms ± urgency, frequency

and dysuria may not be present
Symptoms are non-specific ± irritability, anorexia,
failure to gain weight, vomiting, diarrhea, fever
Thus delay in diagnosis of acute pyelonephritis likely
High index of suspicion of UTI essential as:

UTI is the commonest bacterial infection in febrile infants and

young children without an obvious cause.

Younger child is at greatest risk for renal damage if treatment

is delayed
 
 
 

±Poor urine flow or dysfunctional voiding
±Previously suggested or confirmed UTI
±Recurrent fever of uncertain origin
±Antenatally diagnosed renal abnormality
±Family history of vesico-ureteric reflux or renal disease
±Constipation
±Dysfunctional voiding
±Enlarged bladder
±Abdominal mass
±Evidence of spinal lesion
±Poor growth
±High blood pressure
 





 
 

--old standard for obtaining urine in infant
-Invasive (should be avoided -NICE 2007)
-Risk of contamination is very low
-2cm. above syphysis gentle negative Pressure while
advancing the needle.
-Complications rare if US- guided
-Any growth ± diagnostic

 





 



-In toilet trained children
-Most widely used
-Can be easily performed
-Ramag t al. demonstrated strong correlation with sample
from SPA
-Recommended method by NICE 2007
 



 



Temporary catheterisation or from indwelling catheter
Urine aspirated from catheter by using sterile needle & syringe
Very reliable method, fewer contamination


 




ÚÚM

Adhesively attached to perineal area
High contamination rate
False positivity very high
Unneccessary testing & hospitalisation
No role in diagnosis of childhood UTI
If negative rules out UTI
 ×  







 Mild proteinuria
 leukocytouria (leukocytosis>5/hpf(spun) or
>10/mm3(unspun)
¬
 

10 ml, spun @5000 rpm for 5 min
 Bacteriuria
 UTI can occur in absence of pyuria..
 Pyuria can be present without UTI.
 Normal urinalysis in asymptomatic child
excludes UTI.
 Symptomatic child ±UA negative -UTI possible.
 a



"



 LE is produced from the breakdown of
leukocytes. Not always indicative of infection
Vaginitis/vulvitis can lead to inflammation without
infection + LE
 Has to accumulate in urine
 Insufficient accumulation possible in small
infants who void frequently
 Infants <3 months old may not have mature
enough immune system to induce leukocytes
in urine
 è



 

 Nitrites are produced by bacteria that metabolize

nitrates: E. coli, Klebsiella, Proteus (-NRs)
 Much more predictive of UTI
 -PCs do not produce nitrites
 By products of E. coli and other lactose fermenters
 Insufficient accumulation possible in small infants
who void frequently
 Insufficient accumulation possible in older child
during the day and in older patient who has
significant frequency
 If positive, highly suggestive of UTI (high
specificity)
 
 
 
 

 




 

×Ú
# ) 

 )
  

Leukocyte esterase 83 (67.94) 78 (64-92)

Nitrite 53 (15-82) 98 (90-100)

Leukocyte esterase or nitrite positive 93 (90-100) 72 (58-91)

Microscopy: white blood cells 73 (32-100) 81 (45-98)

Microscopy: bacteria 81 (16-99) 83 (11-100)

Leukocyte esterase, nitrite , 99.8 (99.100) 70 (60-92)

Microscopy positive
AAP 1999
 ×



 


 

 
 



 
¬

 



  


 







 



 












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 ll rst in S. R curr nt urinary tract inf ctions in chil
r n. P
iatr Inf ct Dis 1982;1:271-81.
 6



 CBC£leukocytosis,Neutrophilia

 ESR raised
CRP increased
 Blood culture (neonates & infants)
(Garin t al, p
iatrics N phr . 2007;22;1002-1006)
 Specific gravity-- renal concentrating capcity decreased in
Pyelonephritis
(Winsb rg S. t al P a
.1959;48;577-589)
 Antibody coated bacteria in urine detected by fluorescin
-labelled antiimmunoglobin diagnostic of pyelonephritis in
adolescents & young adults
(Bensman et al, Arch fr. Pediatrics 1978;35:242-252)
 Unreliable in children
(hellerstein et al, j.paediatrics 1978;92:188-193)
 High procalcitonin in serum -ac.pyelonephritis in febrile
UTI.
( Smolkin t al. pediatric Nephr 2002;17:409-412)

 
î
 ×

 Detects structural malformations

 Hydronephrosis
 Pyonephrosis & perinephric abscess
 Pyelonephritis-focal or diffuse enlargement
 Renal scars-hypoechoic
 Helpful in detecting the ureteral dilatation of
advanced stage reflux (-rades III-IV)
 Can be done immediately
" 

 



  
 {×
Bladder is fully filled via catheter with radiopaque liquid
Child is asked to void
During voiding, look under fluoroscopy for reflux
Can be done after 48 hrs of receiving antibiotics
Can be done 4 ± 6 weeks after UTI
Two techniques
± One involves fluoroscopic contrast ± more
radiation but better delineation of anatomy for
grading VUR
± The other uses a radionuclide ± less radiation
and more sensitive than contrast
è {×
{




 
{×î

 M


×  






  
AJR 2009; 192:1253±1260
* $¬ * + $¬

Sensitivity % 29.1 74.5 76.4

Specificity % 95.6 82.2 79.4

PPV % 41.0 30.4 27.8

NPV % 92.8 96.9 97.0

 î
 




  

ÚÚè
Difficult to distinguish between new acute inflammatory
changes and stablished renal scars
Metaanalysis of animal studies ±sensitivity -86% &
specificity ± 91%.
(CRAIG JC t al, J.nucl.m
.2000;41:986-993)
Only recmmonded by NICE clinical guidelines 2007
Only where to confirm or exclude ac. Pyelonephritis &
power doppler US- is not available.
   %

 




% %
,
  

Contrast enhancement d/t renal ischemia.
Normal perenchyma brighter.
#!significant radiation exposer.
Hypersensitivity to iodinated contrast
Sedation
Rarely used

î

 Darkening of normal renal parenchyma.
 Brighter areas of pyelonephritis.
 D/A- cost, need for sedation
 IV gadolinium in renal insufficiency.
(st an  t al. pa
N phr.2007;22:1239-1242)
Lack of ionising ra
iation is app aling in p
iatric ag
 Ú
 



 

An l-ray of the spine± spinal abnormalities if clinically

suspected.
l-ray KUB region --- calculi.
IVP may be performed to examine for renal scarring if
facilities for renal scintigraphy are not available.
î"Ú
"è
 



S





¬
 


Age <3 months Older children
Septicemia Not toxic
Upper UTI Accepting orally
Toxic, vomiting

IV, later oral Oral agents

  






Infants < 2-3 months with febrile UTI
Older infants and children with
complicated UTI
High fever and clinically ill or µtoxic¶
Persistent vomiting
Moderate to severe dehydration
Poor compliance anticipated
Renal angle tenderness.
 






 The efficacy of oral regimens is as
effective as parenteral regimens
 If the child is not responding the empiric
treatment within two days while awaiting
culture results, repeat the urine culture
and perform a renal ultrasound.

Hoberman A, Wald ER, Hickey RW, Baskin M, Charron M, Majd M, et al. Oral versus initial
intravenous therapy for urinary tract infections in young febrile children. Pediatrics
1999;104:79-86.

Baker PC, Nelson DS, Schunk JE. The addition of ceftriaxone to oral therapy does not
improve outcome in febrile children with urinary tract infections. Arch Pediatr Adolesc Med
2001;155:135-9.
 Ú

    



 ×

 6

$ -,- - $ -,- -

Ampicillin 100 3 Amoxicillin 30-35 3

6-10
-entamicin 5-6 2 2
Cotriomoxazole (trimethoprim)

Amikacin 15-20 2 Cephalexin 50-70 3

30-35
Cefotaxime 100-150 3 Co-amoxiclav 2-3
(amoxicillin)

Ceftriaxone 75-100 1-2 Cefaclor 40 3

Ciprofloxacin 10-20 2

Cefixime 8-10 IPNG 2001

 
  

 

¬
 d 10-14 d


 d 7-10 d

%  3-4 d

lower tract infection [Cochrane 2003]
 ×


"Sa
  

Klebsiella pneumoniae, E.coli, Proteus mirabilis, enterobacter

Widespread use of 3rd generation cephalosporins is the major
cause
In a study in JNMC Hospital Aligarh India, 42% isolates were
ESBL producers in the community acquired UTI
Poor response to 3rd generation cephalosporin and also
resistant to Aminoglycosides & Fluoroquinolones
Confirm ESBL producing status on culture & sensitivity pattern
Ú



Piperaacillin-tazobactum, Cefoperzone-sulbactum,
Imipenem, Meropenem, Ertapenem, Faropenem,
Cefepime
 ×


 

 Urine cultures need not be routinely repeated at

cessation of antibiotic therapy.
 A culture should however be obtained in patients
-Who fail to show the expected response to the treatment
-Recurrence of symptoms suggestive of a UTI
-Initial culture contaminated
Ú


  



  



  
  M  
Antibiotic prophylaxis is recommended under the following
circumstances:
1. Following treatment of:
(i) First UTI in all children below 2 years of age, and
(ii) complicated UTI in children below 5 years old, while awaiting
imaging studies.
2. Children with VUR.
3. Patients showing renal scars following a UTI even if reflux is not
demonstrated. Prophylaxis may be stopped if a radionuclide
cystogram or MCU repeated 6 months later is normal.
4. Children with frequent febrile UTI (3 or more episodes in a year)
even if the urinary tract is normal
Not recommended in patients with urinary tract obstruction
( .g., PUV), urolithiasis or neurogenic bladder.
chance of colonization with resistant organisms.
IPNG 2001
 
   
 Evidence is not conclusive, it appears the risk of
scarring diminishes with age.
 Some experts recommend cessation of
prophylaxis after age 5 to 7 years, even if low-
grade VUR persists.
 In one study of 51 low-risk (no voiding
abnormalities or renal scarring) older children
(mean age 8.6 years) with grades I to IV VUR,
cessation of prophylactic antibiotics resulted in
no new renal scarring on annual DMSA

Coop r CS, t al. Th outcom of stopping prophylactic antibiotics in ol
r

chil
r n with v sicour t ral r flu. J ×rol 2000 Jan;163(1):269-72;
iscussion
272-3.



  
 Ú

 
M  
  

 

6irst ×TI

Reflux Next Table

No reflux but renal scar All Six months and re-evaluate*

No reflux, no renal scar <2 years Six months and re-evaluate*

>2 Years No prophylaxis

R curr nt ×TI
All Six months
(Without reflux or scar)

* DRC-/MCU to look for reflux, which might have been missed on initial evaluation.
Prophylaxis is stopped if reflux is not detected.
IPNG 2001
 



 M {





î

* 

 d # .& 

Antibiotic prophylaxis till 5

-rade I and II
years of age

Antibiotic prophylaxis Surgery beyond 5 years if

-rade III and unilateral
below 5 years reflux persists at same
-rade IV
Surgery above 5 years grade

Antibiotic prophylaxis
-rade IV (bilateral) and Surgery if reflux persists at
below 1 year, Surgery
-rade V same grade
above 1 year

IPNG 2001
 Ú

   M    ×

 -,-  ,

Avoid in infants <3 months age and --6 PD

Cotrimoxazole 1-2 (trimethoprim)
deficiency.

-I upset; avoid in infants <3

Nitrofurantoin 1-2 months age, --6 PD deficiency and renal
insufficiency. Resistance rare

Cephalexin 10 Drug of choice in first 3-6 mo

Cefadroxil 3-5

Used in young infants where NFT &

Cefaclor 5-10
cotrimoxazole is restricted

Cefixime 2
 Ú


  
ABP should not be routinely recommended in
infants and children following first UTI.
ABP may be considered in infants and children
with recurrent UTI.
Asymptomatic bacteriuria in infants and children
should not be treated with prophylactic
antibiotics.

è
"





 Ú


  
d % d ¬
Antibiotic prophylaxis following UTI does not
appear to prevent recurrence of infection and/or
renal scarring in children with or without VUR,
considered separately.
 Antibiotic prophylaxis could result in increased
risk of recurrence with resistant organisms.
 
% .&   d
  ¬%/ Ú




î

 î 


  

0
%  $%&
A
vanc
P
iatrics C ntr , PGIMER, Chan
igarh
In
ian P
iatr 2010;47: 599-605
  ¬  # d

 Bacteria colonize urethral meatus

   1!23-2444
 ¬  2!5-2444
 Relative risk: 4-10 fold
 S
   
 

 6  
   
Baby boys with severe VUR or other renal
anomalies at risk of UTI
Ú
   544(784/9(:!9(9
 

 
Baby boys with severe VUR or other renal
anomalies at risk of UTI
± Boys with recurrent UTI +/- balanitis
± Any boy with balanitis xerotica obliterans

Ú
   544(784/9(:!9(9

 $    d

 Circumcision is not recommended routinely but may be

considered for infants with recurrent UTI
 Attention to under-garments and perineal hygiene, including
the foreskin in boys, is explained to the parents.
 Plenty of fluid intake and frequent voiding ensures flushing out
of the uropathogens.
 Constipation predisposes to recurrent UTI and improvement in
bowel habits reduces the incidence of UTI
 In children with VUR who are toilet trained, regular and
volitional low pressure voiding with complete bladder emptying
is encouraged
 Double voiding is recommended in order to empty the bladder
of post void residual urine


Ú
è
AAP (PEDIATRICS Vol.103 No.4 April 1999)
<2Years with UTI

Antimicrobial therapy

Response
48 hrs 48 hrs

No Yes

US-
US- &
VCU- or RNC VCU- or RNC
 " 
  




×

First UTI

Ultrasound examination

Normal Abnormal

<2 years 2-5 years >5 years All ages

MCU DMSA scan MCU and

and MCU if: No further DMSA
DMSA Scar on scan evaluation scan
scan or scan -nt
Recurrent UTI , any age, US- & MCU, Renal scan for scar IAP 2001
 î



 



è
 





   




 &  
 d  d
  &%
39 %

<6 6 >3 <6 6 >3 <6 6 >3

 Mths Mths- Yrs Mths Mths- Yrs Mth Mths Yrs
3 yrs 3 yrs s -3
yrs
Ultrasound during No No No Yesb Yesb Yesb,d Yes No No
the acute infection

Ultrasound within Yesa No No No No No No Yes Yesd

6 weeks

DMSA 4±6 months No No No Yes Yes No Yes Yes Yes

following the acute
infection
MCU- No No No Yes Noc No Yes Noc No

 

In atypical UTI, US- of the urinary tract during the acute infection to
identify structural abnormalities of the urinary tract e.g. obstruction
For infants < 6 months with first-time UTI that responds to treatment,
US- should be carried out within 6 weeks of the UTI
For 6 months or older with first-time UTI that responds to treatment,
routine US- is not recommended except atypical UTI
Infants and children with a lower UTI should undergo US- (within 6
weeks) only if they are < 6 months or have had recurrent infections.
A DMSA scan 4±6 months following the acute infection should be used
to detect renal parenchymal defects
In subsequent UTI while awaiting DMSA, the timing of the DMSA
should be reviewed and consideration given to doing it sooner.
 î



 



† a-If abnormal consider MCU-.
† b-In an infant or child with a non-E. coli ×TI, r spon
ing
w ll to antibiotics an
with no oth r f atur s of atypical
infection, the ultrasound can be requested on a non-
urgent basis to take place within 6 weeks.
† c-While MCU- should not be performed routinely it
should be considered if the following features are
present:
† dilatation on ultrasound
† poor urine flow
† non-E. coli inf ction
† family history of VUR.
† d-Ultrasound in toilet-trained children should be performed with
a full bladder with an estimate of bladder volume before and
after micturition.

 M

 
×

Ultrasound MCU DMSA

National Institute Of Health &

Clinical Excellence (2007)
Indian Pediatric Nephrology All 2 yr <5 yr
-roup (2001)
American Academy of <2 yr <2 yr No guideline
Pediatrics (1999)
Royal College of Physicians All <1 yr 1-7 yr
London (1991)

IPN-: US, VCU- & DMSA if any abnormality

AAP: Recommendations for <2 yr-old only
 è




 255 children < 5 years old admitted with

their first uncomplicated febrile UTI
 Renal ultrasound did not change
management

ö
  
        
     ! "# $ %&&'()*'++,)
 è




 150 children 2 ± 10 years old with first UTI were

randomized to routine imaging (U/S and VCU-) or
to selective imaging (for recurrent UTI or persistent
problems)
 21 % (1 in 5) in the selective group had imaging
performed
 Routine imaging increased the use of prophylactic
antibiotics (28% vs 5%)
 No change in rate of recurrent UTIs (26% vs 21%)
 No change in rate of renal scarring (9% vs 9%)

-.   !$  - / 0%,0+%&&%- 1%&&%(%+2%340&5

{






{×î
 {




 î
{×î
 Retrograde passage of urine from bladder to
upper urinary tract
 VUR = most common urologic abnormality in
children
1% newborns
30 - 45% of children with UTI
 {




 î

 Approximately 40% of children with febrile UTIs
have VUR.
 Approximately 8% of children with febrile UTIs
demonstrate renal scarring when studied.
 Treatment recommendations are made to stop
the progression of VUR with
medications/antibiotics and/or surgery.
 No data demonstrate that treatment of VUR
prevents renal scarring, hypertension and CKD
1   6    ,"      
!0 - 1" %&&0(0++*,3%
   

 {




 î

TYPE CAUSE
Primary Congenital incompetence of the valvular
mechanism of the vesicoureteral junction

Primary associated with other Ureteral duplication

malformations of the ureterovesical Ureterocele with duplication
junction Ureteral ectopia
Paraureteral diverticula
Secondary to increased intravesical Neuropathic bladder
pressure Non-neuropathic bladder dysfunction

Bladder outlet obstruction

Secondary to inflammatory Severe bacterial cystitis
processes Foreign bodies
Vesical calculi
Clinical cystitis
Secondary to surgical procedures Surgery
involving the ureterovesical junction
N lson t t book of p
iatrics
{





î
 
 î
 

>Antenatally diagnosed hydroureteronephrosis
with postnatal conformation of
Dilatoing VUR often shows renal scarring on
DMSA before any UTI has occurred.
This is renal dysplasia and accounts for a
significant proportion of the renal damage
seen in dilating VUR´

IJP 2009; 76(10):1031-1035

  
Dysembryogenesis vs. Infection

¬ 
 ; 

 -lobal damage  Small scars
 Hypertension, renal  Limited long term
failure morbidity
 Boys with VUR IV-V
 -irls: recurrent UTI
 Not amenable to
therapy  May be prevented
 {×î

The management of VUR is

evolving and the final word is yet to
be said

(Dav s t al. In
ian j urology 2007: 23:403-413)

 M

   



 VUR can cause upper UTI by bringing

bacteria to the kidneys
 Results: renal scarring, loss of
parenchyma reflux nephropathy:
Potential for hypertension, decreased renal
function, proteinuria, renal failure/ end stage
renal disease
 Management: based on -
Identification of children with VUR
Prevention of renal damage due to reflux
 



î



  {




 î

 
 ×  






INITIAL
-RADE A-E (YR) SCARRIN- TREATMENT FOLLOW-UP
I±II Any Yes/No Antibiotic No consensus
prophylaxis
III±IV 0±5 Yes/No Antibiotic Surgery
prophylaxis
III±IV 6±10 Yes/No Unilateral:antibiotic Surgery
prophylaxis
Bilateral:surgery
V <1 Yes/No Antibiotic Surgery
prophylaxis
V 1±5 No Unilateral:antibiotic Surgery
prophylaxis
V 1±5 No Bilateral:surgery
V 1±5 Yes Surgery
V 6±10 Yes/No Surgery

Summary of gui
lin s
v lop
by Am rican ×rological Association;ag r f rs to ag

at
iagnosis
 {×î 




Ú×Ú


 Children <1 year of age, regardless of grade of reflux, should
be treated medically, as they have a high likelihood of
spontaneous resolution. Surgery is a reasonable option if they
have grade V reflux and renal scarring.
 All patients with grade I or II reflux, either with unilateral or
bilateral disease, should be treated medically, as they have
high likelihood of spontaneous resolution.
 Children between 1 and 5 years of age with grade III or IV
reflux, either unilateral or bilateral disease, should be treated
medically. Surgery is a reasonable option if there is bilateral
reflux and renal scarring.
 Children between 1 and 5 years of age with grade V, either
unilateral or bilateral disease, without renal scarring, can be
treated medically. If there is renal scarring, surgery is
recommended for both unilateral and bilateral disease.
 {×î 




 Children 6 years or older with unilateral grade III to IV

reflux without renal scarring can be treated medically. If
the reflux is bilateral and/or there is renal scarring,
surgical treatment is recommended.
 Children 6 years or older with grade V reflux should be
treated surgically with or without evidence of renal
scarring, as their reflux is unlikely to resolve
spontaneously.
 Surgery also should be considered if medical therapy
fails either because of poor compliance, breakthrough
infections on account of antibiotic resistance, or
significant antibiotic side effects. Finally, consideration of
patient and parent preference is important in the final
decision.
El
r JS, t al. P
iatric V×R Gui
lin s Pan l summary r port on th manag m nt of
primary V×R in chil
r n, J ×rol 1997 May;157(5):1846-51.
 

  




 
 Long-term antibiotics may complications:
 minor to severe - including bone marrow
suppression, Stevens-Johnson syndrome
 Adherence (compliance)
 Breakthrough infection
 Urine-analysis and cultures whenever UTI
possible
 Surveillance cultures at 3-4 months
 Need to monitor reflux with either VCU- or
radionuclide cystography (RNC), both with
discomfort and radiation
 {×î î"Ú
"è
 Medical vs surgical therapy
 Not clear
 Meta±analysis





  Ú
  
  
 7 randomized, controlled studies,
 ABP vs surgery, n = 859
4 studies: no difference after 5 years
2 studies: less febrile UTI, at 5 years, surgery
(10%) vs ABP (22%)
But no difference in scarring!



   



4 studies: no differences in scarring after 5
years
5% overall risk of new scars by DMSA
4 studies: no differences in renal growth
2 studies: no difference in hypertension or
end-stage renal disease
No information about surgical vs medical
adverse events



   




 9 reimplantations required to prevent 1 febrile UTI
 No reduction in rate of renal scarring!
 Hardly seems wise to prefer surgical therapy
 {

 





 Aim of treatment is to prevent further scarring
 No difference in outcome between surgical and
Medical intervention
(Int rnational R flu Stu
y in Chil
r n, Europ an Branch. J ×rol
1992;148:1666
Birmingham R flu Stu
y Group. BMJ 1987;295:237-241)
 Surgical correction
 STIN- (Macroplastique,defflux)
 Ureteric reimplantaion
 {×î

   


Parental preference, poor compliance,

intolerance to medical treatment
 
 Breakthrough UTI
 New scarring
 Persistent grade V reflux beyond infancy
 Reflux with nephropathy, reduced -FR
>It is not clear whether any intervention for
children with primary VUR does more good
than harm. Well designed and adequately
powered placebo controlled randomized
trials of antibiotics alone in children with
VUR are now required.´

(Wh l r t al, Antibiotics an
surg ry for V×R: a m ta-analysis of RCTs, ADC, 2003)
 
  
No. (%) with Recurrent UTI
% 0 <  6   8() ¬d
Savage, Lancet, 1975 7/29 (24%) 4/32 (13%) 1.9 (0.6-5.9)

-arin, Pediatrics, 2006 13/55 (24%) 12/58 (21%) 1.1 (0.6-2.3)

Roussey, JU, 2008 18/103 (17%) 32/122 (26%) 0.7 (0.4-1.1)

-arin: Up to age 18 years, febrile UTI, grades 1-3 VUR, unblinded

Roussey: 1 mo ± 3 years, febrile UTI, grades 1-3 VUR, unblinded
In -arin study, recurrent acute pyelo seen in 7/55 (abx) v. 1/58 (placebo)
(p=0.03) raising specter of INCREASED risk of APN with prophylactic antibiotics.
 



î



>The evidence to support the widespread

use of antibiotics to prevent recurrent
symptomatic UTI is weak. Large
randomized, double blinded studies are
needed«´

Williams et al, Long-term antibiotics for preventing recurrent UTIs in children.

Cochrane Database of Systematic Reviews 2006, Issue 3.
 M    è
 {×î
 No difference in risk of UTI, scarring
(Reddy. Pediatrics Suppl 1997; RCT; 43 children; followed for 1 yr)

   d  &%-&%

%

(-eorgaki-Angelaki. Scand J Infect Dis 2005)

 Multicenter RCT; no difference in UTI rates, scars

(-arin. Pediatrics 2006; 236 patients with/without VUR followed 1 yr)

 More UTI with prophylaxis; no difference in scars

(Peratoner. Ped Nephr ¶06 ; 90 pts; followed 2 yr with/without
prophylaxis)
  
 Urine culture: standard for diagnosis
 All patients with UTI need evaluation
 No need for surveillance cultures
 Current management of VUR might not result in reduction in
ESRD
 VUR: prophylaxis, surgery or nothing?