Pediatric UTI Controversies

20 December, 2012 by: colinparker

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So, you thought it was straightforward: suspect UTI, diagnose UTI, treat UTI
And let someone else worry about the follow-up.
Unfortunately, we work in a fragmented system, where we need to kick-start the correct follow-up for our patients, who may otherwise miss out if we don’t get them on the right track before they leave the Emergency Department.

We used to be paranoid about investigating Urinary Tract Infection in children.  Some of us still are, some of us are less worried, while some of us have not yet realised that kids are different, and are unaware that the Pediatricians out there have been aggressively investigating UTIs in kids for decades.  Maybe we can stop trying to educate and inform these laggards now?

Although the evidence is far from complete, the landscape of pediatric UTI is definitely changing, and the discussion is driving a less aggressive approach to investigating and following up UTI in children.  But are we swinging too far in the other direction?

Join us on a tour of the literature, and decide for yourself…


UTI Controversies PEMcast – Outline

[cp] Hello, disclaimer, introduction

[cp] Background

Common clinical problem, significant consequences if missed – some debate about this more recently.
Not clear what pre-requisites are for renal scarring – whether genetic predisposition, related to timing of infection and treatment, severity of infection.
Not clear whether renal scarring is preventable by a strategy of aggressive treatment and investigation.
Both the treatments and investigations come with associated risks, discomfort, and costs.

[AH] Controversies include:

  • When to treat with IV ABs
  • How long to treat
  • When to give prophylactic antimicrobials
  • Utility of proof-of-cure urine test
  • Who to investigate
  • How to investigate
  • Treatment of VUR

…because of a relative lack of RCT evidence.

[cp] Ideally we need to balance risks and costs of any tests/interventions against the likelihood of benefit to the patient, aiming to achieve ‘greatest good for the greatest number’ with our resources (or: spend more money to prevent any adverse outcomes).

We will not be able to definitively answer these questions, but aim to give a representative cross-section of opinion and a small amount of science to inform the debate…

Papers

[AH] NICE CG 54 (2007) (& RCH Melbourne interpretation)

http://www.nice.org.uk/CG54

http://www.rch.org.au/clinicalguide/cpg.cfm?doc_id=5241
http://www.rch.org.au/clinicalguide/cpg.cfm?doc_id=15338

[SF] Coulthard 2008 (scarring)
http://www.ncbi.nlm.nih.gov/pubmed/19015216

[SF] Montini 2008 (Italian mob – prophylaxis RCT)
http://www.ncbi.nlm.nih.gov/pubmed/18977988

[AH] Craig 2009 NEJM (prophylaxis)
http://www.ncbi.nlm.nih.gov/pubmed/19864673

[cp] Mathews 2009 (VUR controversies)
http://www.ncbi.nlm.nih.gov/pubmed/19570724

[cp] Schroeder 2011 (validation of NICE)
http://www.ncbi.nlm.nih.gov/pubmed/22065183

[cp] Finnell 2011 (AAP Guideline, incorporating info from Montini & Craig):
Background:
http://www.ncbi.nlm.nih.gov/pubmed/21873694
Guideline:
http://pediatrics.aappublications.org/content/early/2011/08/24/peds.2011-1330.full.pdf+html

[SF] Tullus 2012 (Editorial, AAP vs NICE)
http://www.ncbi.nlm.nih.gov/pubmed/22203365

[all] Summary & best-guess recommendations

References

National Institute for Health and Clinical Excellence
Clinical Guideline CG 54: Urinary Tract Infection in Children
August 2007 http://www.nice.org.uk/CG54

Coulthard MG, Lambert HJ, Keir MJ.
Do systemic symptoms predict the risk of kidney scarring after urinary tract infection?
Arch Dis Child. 2009 Apr;94(4):278-81. doi: 10.1136/adc.2007.132290. Epub 2008 Nov 17. PubMed PMID: 19015216.

Montini G, Rigon L, Zucchetta P, Fregonese F, Toffolo A, Gobber D, Cecchin D, Pavanello L, Molinari PP, Maschio F, Zanchetta S, Cassar W, Casadio L, Crivellaro C, Fortunati P, Corsini A, Calderan A, Comacchio S, Tommasi L, Hewitt IK, Da Dalt L, Zacchello G, Dall’Amico R; IRIS Group.
Prophylaxis after first febrile urinary tract infection in children? A multicenter, randomized, controlled, noninferiority trial.
Pediatrics. 2008 Nov;122(5):1064-71. doi: 10.1542/peds.2007-3770. PubMed PMID: 18977988.

Craig JC, Simpson JM, Williams GJ, Lowe A, Reynolds GJ, McTaggart SJ, Hodson EM, Carapetis JR, Cranswick NE, Smith G, Irwig LM, Caldwell PH, Hamilton S, Roy LP; Prevention of Recurrent Urinary Tract Infection in Children with Vesicoureteric Reflux and Normal Renal Tracts (PRIVENT) Investigators.
Antibiotic prophylaxis and recurrent urinary tract infection in children.
N Engl J Med. 2009 Oct 29;361(18):1748-59. doi: 10.1056/NEJMoa0902295.
Erratum in: N Engl J Med. 2010 Apr 1;362(13):1250. PubMed PMID: 19864673.

Mathews R, Carpenter M, Chesney R, Hoberman A, Keren R, Mattoo T, Moxey-Mims M, Nyberg L, Greenfield S. Controversies in the management of vesicoureteral reflux: the rationale for the RIVUR study.
J Pediatr Urol. 2009 Oct;5(5):336-41. doi: 10.1016/j.jpurol.2009.05.010. Epub 2009 Jul 1. Review. PubMed PMID:
19570724; PubMed Central PMCID: PMC3163089.

Schroeder AR, Abidari JM, Kirpekar R, Hamilton JR, Kang YS, Tran V, Harris SJ.
Impact of a more restrictive approach to urinary tract imaging after febrile urinary tract infection.
Arch Pediatr Adolesc Med. 2011 Nov;165(11):1027-32. doi: 10.1001/archpediatrics.2011.178. PubMed PMID: 22065183.

Finnell SM, Carroll AE, Downs SM; Subcommittee on Urinary Tract Infection.
Technical report—Diagnosis and management of an initial UTI in febrile infants and young children.
Pediatrics. 2011 Sep;128(3):e749-70. doi: 10.1542/peds.2011-1332. Epub 2011 Aug 28. PubMed PMID: 21873694.

Subcommittee on Urinary Tract Infection and Steering Committee on Quality Improvement and Management.
Urinary Tract Infection: Clinical Practice Guideline for the Diagnosis and Management of the Initial UTI in Febrile Infants and Children 2 to 24 Months.
Pediatrics peds.2011-1330; published ahead of print August 28, 2011, doi:10.1542/peds.2011-1330
http://pediatrics.aappublications.org/content/early/2011/08/24/peds.2011-1330.full.pdf+html

Tullus K.
What do the latest guidelines tell us about UTIs in children under 2 years of age.
Pediatr Nephrol. 2012 Apr;27(4):509-11. doi: 10.1007/s00467-011-2077-5. Epub 2011 Dec 28. PubMed PMID: 22203365.

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