Pediatric UTI: Pediatric UTI: Making Sense of Making Sense of

Local Data and the Local Data and the New AAP GuidelinesNew AAP Guidelines

Heidi Román, MD and Alan Heidi Román, MD and Alan Schroeder, MDSchroeder, MD

SCVMCSCVMCPediatric Grand RoundsPediatric Grand Rounds

March 13, 2013March 13, 2013

ObjectivesObjectives

To review diagnosis and management of To review diagnosis and management of UTI in infants and young children UTI in infants and young children

To be aware of changes in management To be aware of changes in management suggested by 2011 AAP CPGsuggested by 2011 AAP CPG

To review recent clinical research To review recent clinical research projects at VMC examining:projects at VMC examining: imaging protocols imaging protocols diagnosis and management of bacteremic diagnosis and management of bacteremic

UTIsUTIs

Why Do We Care About Why Do We Care About UTI?UTI?

UTI now most common site for SBI UTI now most common site for SBI in infantsin infants

More than 1 million office visits More than 1 million office visits per yearper year

$180M/year for hospitalization $180M/year for hospitalization alonealone

Freedman, J. Urology, 2005

When should urine be When should urine be tested?tested?

Consider UTI in all infants < 24 mos with FWS

Consider UTI in all infants < 24 mos with FWS

Not ill and “low risk” monitorNot ill and “low risk” monitor

Ill enough to require abx obtain urine for UA/culture prior

to initiation

Ill enough to require abx obtain urine for UA/culture prior

to initiation

“Not low risk” urine for UA/culture

and act based on results

“Not low risk” urine for UA/culture

and act based on results

AAP CPG, Pediatrics, 2011

What constitutes “not What constitutes “not low risk”?low risk”?

2011 AAP CPG: “low risk” = febrile 2011 AAP CPG: “low risk” = febrile infant with < 3% risk of UTIinfant with < 3% risk of UTI

Factors known to change riskFactors known to change risk AgeAge GenderGender Circumcision statusCircumcision status Duration of feverDuration of fever Lack of other sourceLack of other source

Factors Modifying Risk Factors Modifying Risk for UTIfor UTI

From Marmor “Updates in Management of UTI in Febrile Infants/Children < 24 mo of Age” 2012

How should urine be How should urine be tested?tested?

•SPA

•Catheterization

•Bag

•Clean Catch

What defines a “UTI”?What defines a “UTI”?

2011 AAP CPG:2011 AAP CPG: At least 50K CFU/ml of At least 50K CFU/ml of

uropathogen via cath or SPAuropathogen via cath or SPA ANDAND UA suggesting infection UA suggesting infection

(pyuria and/or bacteruria)(pyuria and/or bacteruria)

How can UA help you?How can UA help you?

AAP CPG, Pediatrics, 2011

Urine CultureUrine Culture

When to sendWhen to send Definitely “positive”?Definitely “positive”?

UA + and Cath Ucx + if > 50k CFU/mLUA + and Cath Ucx + if > 50k CFU/mL UA + and Bag Ucx + if > 100K CFU/ml UA + and Bag Ucx + if > 100K CFU/ml

single orgsingle org Possibly +:Possibly +:

high clinical suspicion andhigh clinical suspicion and UA + and > 10K org ORUA + and > 10K org OR UA – and > 50K single orgUA – and > 50K single org

UTI ManagementUTI Management

When/how long to hospitalize?When/how long to hospitalize? Abx: what, how and how long?Abx: what, how and how long? Prophylaxis?Prophylaxis? Imaging?Imaging?

Inpatient vs outpatientInpatient vs outpatient

Hoberman cefixime study Hoberman cefixime study (Pediatrics, 1999)(Pediatrics, 1999) 306 children 1-36 months306 children 1-36 months PO Cefixime x 14 d vs IV cefotax x 3 d + PO Cefixime x 14 d vs IV cefotax x 3 d +

PO Cefixime x 11 dPO Cefixime x 11 d No difference in readmission, scarringNo difference in readmission, scarring

Duration of IV AbxDuration of IV Abx

PHIS study on UTI practice variation PHIS study on UTI practice variation (Brady, Pediatrics, 2010)(Brady, Pediatrics, 2010)

12,333 infants < 6 months 12,333 infants < 6 months Treatment failure:Treatment failure:

≤≤3 days = 1.6%3 days = 1.6% ≥≥4 days = 2.2%4 days = 2.2% 1000 kids (~30%) < 1 month got short 1000 kids (~30%) < 1 month got short

course!course!

AAP recsAAP recs

““Initiating treatment orally or Initiating treatment orally or parenterally is equally efficacious”parenterally is equally efficacious”

““Adjust choice according to Adjust choice according to sensitivity testing”sensitivity testing”

7-14 days total7-14 days total ““Outcomes of short courses (1-3 days) Outcomes of short courses (1-3 days)

are inferior to those of 7-14 day are inferior to those of 7-14 day courses”courses” No reference!!No reference!!

Our recs (if well)Our recs (if well)

> 1 month: outpatient, IM/PO> 1 month: outpatient, IM/PO < 1 month: inpatient, IV x 48 hours< 1 month: inpatient, IV x 48 hours 5-7 day course total (sooner if side 5-7 day course total (sooner if side

effects)effects)

AmpicilAmpicillinlin

41%41%

CefazoliCefazolinn

88%88%

CTXCTX 94%94%

GentGent 91%91%

SXTSXT 66%66%

E coli susceptibilities 2011, VMC 5th floor

Prophylactic AbxProphylactic Abx

• Mid-2000’s Practice questioned by handful of RCTs

PRIVENT trialPRIVENT trial[Craig, NEJM, 2009][Craig, NEJM, 2009]

576 Children age 0-18 years with 576 Children age 0-18 years with first febrile UTIfirst febrile UTI

Renal US, VCUG, DMSA in most Renal US, VCUG, DMSA in most patientspatients DMSA again at 1 yearDMSA again at 1 year

Daily TMP/SMXDaily TMP/SMX

Still PendingStill Pending

600 children 2 months – 6 years600 children 2 months – 6 years Grades I-IV VURGrades I-IV VUR TMP/SMX vs placeboTMP/SMX vs placebo

Our recsOur recs

No prophylaxis unless high-grade, No prophylaxis unless high-grade, persistent VURpersistent VUR

ImagingImaging

Imaging makes sense Imaging makes sense if…if…

Abnormalities are commonAbnormalities are common Abnormalities lead to recurrent UTIs Abnormalities lead to recurrent UTIs

and/or long-term damageand/or long-term damage Detection of the abnormalities Detection of the abnormalities

improves outcomesimproves outcomes

Andrea Marmor, MDhttp://www.ucsfcme.com/2012/slides/MFC13003/3a%20-%20Marmor,%20Andrea%20REF.pdf

1.) Abnormalities are 1.) Abnormalities are commoncommon

VUR same prevalence (~35%) in VUR same prevalence (~35%) in patients with true UTIs and false patients with true UTIs and false UTIs UTIs [Hanula, Pediatr Nephrol 2010][Hanula, Pediatr Nephrol 2010]

Abnormalities lead to Abnormalities lead to recurrent UTIs and/or long-recurrent UTIs and/or long-

term damageterm damage

• Literature review: 0/1576 reviewed CKD Literature review: 0/1576 reviewed CKD cases had UTI as primary causecases had UTI as primary cause• Own institution: 13/366 had h/o childhood Own institution: 13/366 had h/o childhood UTI – all 13 had abnl kidney anatomyUTI – all 13 had abnl kidney anatomy

• Recurrent UTI Recurrent UTI CKD 1/366 CKD 1/366

Crunching the #’sCrunching the #’s

Craig, Pediatrics 2011

UTI incidenceUTI incidence 50,000 per 50,000 per millionmillion

Incidence of Incidence of ESRD from VURESRD from VUR

5 per million5 per million

UTI UTI ESRD ESRD 1/10,0001/10,000

Prophylactic Abx?Prophylactic Abx? VUR surgery?VUR surgery? Other anatomic abnormalities?Other anatomic abnormalities?

3. Detection of the 3. Detection of the abnormalities improves abnormalities improves

outcomesoutcomes

2008: Initiation of new 2008: Initiation of new guidelines at SCVMCguidelines at SCVMC

Grand RoundsGrand Rounds Meeting of inter-disciplinary groupMeeting of inter-disciplinary group Discussed at faculty meetingDiscussed at faculty meeting Radiologist remindersRadiologist reminders

New AAP recsNew AAP recs

US on everyone, VCUG if abnormal US on everyone, VCUG if abnormal or if recurrenceor if recurrence

Take Home PointsTake Home Points

Diminishing urgency to detect/treat Diminishing urgency to detect/treat UTIs in healthy childrenUTIs in healthy children

Knowledge of risk factors can help Knowledge of risk factors can help stratify riskstratify risk

Management of UTIManagement of UTI Selective imaging OKSelective imaging OK Cost/benefit of prophylaxis too highCost/benefit of prophylaxis too high

Questions?Questions?