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7/28/2019 AAP Webinar UTI Roberts Final
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AAP Guideline for theDiagnosis and Management
of UTIs in Febrile InfantsUnanswered Questions and
Unquestioned Answers
Kenneth B. Roberts, MD, FAAPProfessor of Pediatrics (Emeritus)
University of North Carolina
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Prepared for your next patient.
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Disclaimers
Statements and opinions expressed are those of the authors and notnecessarily those of the American Academy of Pediatrics.
Mead Johnson sponsors programs such as this to give healthcare
professionals access to scientific and educational information provided by
experts. The presenter has complete and independent control over theplanning and content of the presentation, and is not receiving any
compensation from Mead Johnson for this presentation. The presenter’s
comments and opinions are not necessarily those of Mead Johnson. In the
event that the presentation contains statements about uses of drugs that
are not within the drugs' approved indications, Mead Johnson does notpromote the use of any drug for indications outside the FDA-approved
product label.
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Diagnosis and Management of the Initial UTI in Febrile
Infants and Children, 2 to 24 Months*
*Guideline: Pediatrics. 2011;128(3):595 –610
Technical report: Pediatrics. 2011;128(3):e749 –e770
AAP 2011 Clinical Practice Guideline
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Revision of 1999 Guideline•
Routine for American Academy of Pediatrics (AAP) to reviseguidelines
• New evidence since 1999
• New explicit reporting format
– “Recommendations” now “Action Statements”
– Aggregate evidence quality
• Benefits
• Harms/risks/costs
• Benefit-harms assessment
• Value judgments
• Role of patient preferences
• Exclusions
• Intentional vagueness
– Policy level (strength of recommendation)
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Evidence Quality Preponderance of Benefit or Harm
Balance of Benefit and Harm
A. Well-designed RCTs or diagnostic
studies on relevant population
Strong
Recommendation
B. RCTs or diagnostic studies withminor limitations; overwhelmingly
consistent evidence from
observational studies
C. Observational studies (case-control
and cohort design)Recommendation
D. Expert opinion, case reports,
reasoning from first principlesOption
No
Recommendation
Option
Abbreviation: RCTs, randomized controlled trials.
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Evidence QualityPreponderance of
Benefit or Harm
X. Exceptional situations
where validating studies
cannot be performed and
there is a clear
preponderance of benefit
or harm
Strong
Recommendation
Recommendation
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AAP Subcommittee on
Urinary Tract Infection (UTI)• Stephen M. Downs, MD, MS: Epidemiology/informatics
• S. Maria E. Finnell, MD, MS: Epidemiology/informatics
•
Stanley Hellerstein, MD: Pediatric nephrology• Kenneth B. Roberts, MD, Chair: General pediatrics
• Linda D. Shortliffe, MD: Pediatric urology
• Ellen R. Wald, MD: Pediatric infectious diseases
• J. Michael Zerin, MD: Pediatric radiology• Caryn Davidson, MA: AAP staff
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Driving Force from the 1960s
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Used with permission, ScienceCartoonsPlus.com
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What’s New in This Revision
1. Diagnosis
– Abnormal urinalysis as well as positive culture
– Positive culture = ≥50,000 colony-forming units (cfu)/mL
– Assessment of likelihood of UTI2. Treatment: Oral as effective as parenteral
3. Imaging: Voiding cystourethrography (VCUG) not
recommended routinely after first febrile UTI
4. Follow-up: Emphasis on urine testing with subsequent
febrile illnesses
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Population Addressed
• Infants and young children, 2 –24 months of age, with
unexplained fever
– Rate of UTI: ~5%
– Rate of scarring: Higher than in older children
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Population Addressed
• Infants and young children, 2 –24 months of age, with
unexplained fever
– Rate of UTI: ~5%
– Rate of scarring: Higher than in older children• Excludes: <2 months of age
• Excludes: >24 months of age
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Content
• Action Statements: 7
– Diagnosis: 3
– Treatment: 1
– Imaging: 2
– Follow-up: 1
• Areas for Research: 8
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Action Statement 1
If a clinician decides that a febrile infant with no
apparent source for the fever requires antimicrobial
therapy because of ill appearance or another pressing
reason, a urine specimen should be obtained bycatheterization for both culture and urinalysis before
an antimicrobial is given.
Evidence quality: A Strong recommendation
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Methods of Collecting Specimen
• Suprapubic aspiration: “Gold standard,” but
– Variable success rates: 23 –90% (higher with
ultrasound guidance)
–
Requires technical expertise and experience – Often viewed as invasive
– More painful than catheterization
– May be no alternative in boys with severe
phimosis or girls with tight labial adhesions
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Methods of Collecting Specimen
• Bag urine
– Can’t avoid getting “vaginal wash” in girl or contamination
in uncircumcised boy.
– Not suitable for culture.
Negative culture rules out UTI, but
Positive culture likely to be false-positive
o 88% false-positive overall
o 95% in boys
o 99% in circumcised boys
– Positive culture requires confirmation, which is not
possible once antibiotic is started.
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Methods of Collecting Specimen
• Catheterization
– Compared to suprapubic aspiration:
Sensitivity = 95%
Specificity = 99%
– Requires some skill, particularly in small infant girls.
(Tip: If unsuccessful, leave catheter in.)
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Action Statement 2
If a febrile infant is assessed as not requiring immediate
antimicrobial therapy, then the likelihood of UTI should
be assessed.
•
If likelihood is low (<1%, <2%), it is reasonable to followthe child clinically.
• If the likelihood is not low, there are two options:
– Obtain specimen by catheter for culture and urinary
analysis (UA). – Obtain specimen by any means for UA and only culture
those with positive UA.
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Probability of UTI: Infant GIRLS
Individual FactorsProbability of
UTI
# of Factors
Present
• Race: White
• Age: <12 months
• Temperature: ≥39⁰C
• Fever: ≥2 days
• Absence of anothersource of infection
≤1% No morethan 1
≤2%
No more
than 2
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Probability of UTI: Infant BOYS
Individual FactorsProbability
of UTI
# of Factors Present
• Race: Nonblack
• Temperature: ≥39⁰C
• Fever: >24 hours
• Absence of another
source of infection
Circumcised
No Yes
≤1% *No more
than 2
≤2% None No morethan 3
*Probability of UTI exceeds 1% even with no risk factors other than being uncircumcised.
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Action Statement 3
Diagnosis of UTI requires both:
• Positive culture
– ≥50,000 cfu/mL of uropathogen cultured from catheter
specimen, AND• Positive urinalysis
Evidence quality: C
Recommendation
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Where Did 100,000 Come From?
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Asymptomatic women in medicalOPD
Asymptomatic women withdiabetes
Asymptomatic women with
cystocelePts with diagnosis of pyelonephritis
0 100-1 101-2 102-3 103-4 104-5 105-6 >106
Kass E. Asymptomatic infections of the urinary tract. Trans Assoc Am Phys. 1956;69:56 –64
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Urinalysis
• Positive urinalysis required for diagnosis
– Positive culture with “negative” urinalysis
• Contamination
•
Asymptomatic bacteriuria• Urinalysis not sensitive enough
• Positive
– Dipstick: +LE (leukocyte esterase) and/or +nitrite
– Microscopy: White blood cells ± bacteria
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Action Statement 4
Choice of route: Initiating treatment orally or parenterally
is equally efficacious, so choice is based on practical
considerations.
Evidence quality: A Strong recommendation
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Action Statement 4
Choice of route: Initiating treatment orally or parenterally
is equally efficacious, so choice is based on practical
considerations.
Evidence quality: A
Strong recommendation
Choice of drug: Based on local sensitivity patterns,
adjusted according to sensitivity of particular uropathogen
Evidence quality: A
Strong recommendation
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Action Statement 4
Choice of route: Initiating treatment orally or parenterally is equallyefficacious, so choice is based on practical considerations.
Evidence quality: A
Strong recommendation
Choice of drug: Based on local sensitivity patterns, adjusted
according to sensitivity of particular uropathogen
Evidence quality: A
Strong recommendation
Duration of treatment: 7 –14 days
Evidence quality: B
Recommendation
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Action Statement 5
Febrile infants with UTIs should undergo renal andbladder ultrasonography (RBUS),
Evidence quality: C
Recommendation
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Action Statement 5
Febrile infants with UTIs should undergo RBUS.
Evidence quality: C Recommendation
Why:• Yield of abnormal findings: 12 –16%• Permanent renal damage (1 year later)
–Sensitivity: 41% – Specificity: 81%
• Actionable findings sufficient to warrant?
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Action Statement 5
Febrile infants with UTIs should undergo RBUS.
Evidence quality: C Recommendation
When:
• Decide clinically: Within 48 hours if not responding totreatment as expected, unusually ill, or extenuating
circumstances; otherwise, when convenient.
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Action Statement 6
VCUG is not recommended to be performed routinelyafter the first febrile UTI if RBUS is normal.
Evidence quality: B
Recommendation
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Action Statement 6
1. Garin EH, Olavarrio F, Garcia Nieto V, et al. Clinical significance of primary vesicoureteralreflux and urinary antibiotic prophylaxis after acute pyelonephritis: a multicenter,
randomized controlled study. Pediatrics. 2006;117(3):626 –632
2. Pennesi M, Travan L, Peratoner L, et al. Is antibiotic prophylaxis in childrfen with
vesicoureteral reflux effective in preventing pyelonephritis and renal scars? A randomized
controlled trial. Pediatrics. 2008;121(6):e1489 –e1494
3. Montini G, Rigon L, Zuccheta P, et al. Prophylaxis after first febrile urinary tract infection inchildren? A multicenter, randomized, controlled, noninferiority trial. Pediatrics.
2008;122(5):1064 –1071
4. Roussey-Kesler G, Gadjos V, Idres N, 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(2):674 –679
5. Craig JC, Simpson JM, Williams GJ, et al. Antibiotic prophylaxis and recurrent urinary tractinfection in children. N Engl J Med . 2009;361(18):1748 –1759
6. Brandström P, Esbjörner E, Herthelius M, et al. The Swedish reflux trial in children: III.
Urinary tract infection pattern. J Urol . 2010;184(1):286 –291
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Action Statement 6
Reflux
GradeN
ProphylaxisNo
Prophylaxis P
# of Recurrences / Total N # of Recurrences / Total N
None 373 7 / 210 11 / 163 0.15
Grade I 72 2 / 37 2 / 35 1.00
Grade II 257 11 / 133 10 / 124 0.95
Grade III 285 31 / 140 40 / 145 0.29
Grade IV 104 16 / 55 21 / 49 0.14
1,091
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Recurrence Rate of Febrile UTIBy Reflux Grade, 1,091 Infants 2 –24 Months
0
50
100
150
200
250
None Grade I Grade II Grade III Grade IV
Prophylaxis
No Prophylaxis
Grade of Vesico-Ureteral Reflux (VUR)
NS
NS
NS
NS
NS
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Recurrence Rate of Febrile UTIBy Reflux Grade, 1,091 Infants 2 –24 Months
0%
20%
40%
60%
80%
100%
None Grade I Grade II Grade III Grade IV
Prophylaxis
No Prophylaxis
Grade of VUR
(N=373) (N=100) (N=257) (N=285) (N=104)
Recurrence
NSNS NS
NS
NS
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Action Statement 6
If RBUS is abnormal, VCUG may be part of additionalimaging required to evaluate the abnormality.
Evidence quality: B
Recommendation
Further evaluation should be conducted if there is a
recurrence of febrile UTI.
Evidence quality: X
Recommendation
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Action Statement 6
After First UTI
(N=100)
After Recurrence
(N=10)
No VUR 65 (65%) 2.6 (26%)
Grade I –III VUR 29 (29%) 5.6 (56%)
Grade IV VUR 5 (5%) 1.2 (12%)
Grade V VUR 1 (1%) 0.6 (6%)
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Action Statement 6
Risk of Renal Scarring by Number of UTIs
0%
20%
40%
60%
80%
100%
1 2 3 4 5
Adapted from Jodul U. The natural history of bacteriuria in childhood. Infect Dis Clin North Am. 1987;1(4):713 –729
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• N=103
• “By restricting urinary tract imaging after an initial febrileUTI [based on NICE guidelines, 2007 ] , rates of voiding
cystourethrography and prophylactic antibiotic use
decreased substantially without increasing the risk of UTI
recurrence within 6 months and without an apparent
decrease in detection of high-grade VUR.”
Schroeder AR, Abidari JM, Kirpekar R, et al. Impact of a more restrictive approach to urinary tract imaging after febrile urinary tract
infection. Arch Pediatr Adolesc Med . 2011;165(11):1027 –1032
Impact of a More Restrictive Approach to Urinary
Tract Imaging After Febrile Urinary Tract Infection
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• N=1,576
•
“VUR with UTI without structural abnormalities inthe kidneys seems not to cause CKD.”
• “Active treatment of VUR seems not to reduce the
occurrence of CKD and, in large prospective follow-
up studies, the renal function of patients with VURhas been well preserved.”
Salo J, Ikäheimo R, Tapiainen T, et al. Childhood urinary tract infections as a cause of chronic kidney disease. Pediatrics.
2011;128(5):840 –847
Childhood Urinary Tract Infections as aCause of Chronic Kidney Disease
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Action Statement 7
Following confirmation of UTI, parents or guardiansshould be instructed to seek prompt medical evaluation
for future febrile illnesses to ensure that recurrent
infections can be detected and treated promptly.
Evidence quality: C
Recommendation
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Summary: What’s New . . .
1. Diagnosis – Abnormal urinalysis, as well as positive culture
– Positive culture = ≥50,000 cfu/mL
– Assessment of likelihood of UTI2. Treatment: Oral as effective as parenteral
3. Imaging: VCUG not recommended routinely after first
febrile UTI
4. Follow-up: Emphasis on urine testing with subsequent
febrile illnesses
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