AAP Webinar UTI Roberts Final

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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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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• 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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• 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




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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


Choice of drug: Based on local sensitivity patterns, adjusted

according to sensitivity of particular uropathogen

Evidence quality: A


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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AAP Webinar UTI Roberts Final