Beruflich Dokumente
Kultur Dokumente
i n C h i l d re n : W h e n
t o Wo r r y
Curtis J. Clark, MDa, William A. Kennedy II MDa,b,
Linda D. Shortliffe, MDa,b,*
KEYWORDS
Urinary tract infection Pediatric Cystitis
Pyelonephritis Treatment
urologic.theclinics.com
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Clark et al
tend to be less specific in nature and parents
commonly report their symptoms as fever, irritability, lethargy, poor feeding, incontinence, and
pungent urine odor. Children presenting with these
symptoms, or with unexplained fever, should have
UTI eliminated as a diagnosis. On performing
a genitourinary examination, no specific abnormalities are consistently present. Definitive diagnosis
of a UTI requires a properly obtained urine culture.
Perineally bagged urine is useful only for
excluding UTI, as there is a high chance that any
growth is the result of skin colonization. Clean
catch urine specimens also have a higher falsepositive rate in young children, likely due to periurethral colonization. This collection technique
can be more useful in older children.
The 2 most reliable sources of urine for culture
are a catheterized urine specimen or a suprapubic
aspirate. The drawbacks of catheterized urine
include the potential for (a) introduction of
bacteria, which may lead to an iatrogenic infection,
and (b) psychological trauma to the patient. Suprapubic aspirates avoid introduction of pathogens
into the urinary tract and give a reliable specimen;
however, the use of this technique is limited by
physician comfort. A suprapubic aspirate is obtained by blind passage of a small-gauge (21F or
22F) needle through the abdominal wall approximately 1 to 2 cm cephalad to the pubic symphysis
into a bladder that is palpably full.4 The use of
bedside ultrasonography enhances the ability to
safely perform this technique by ensuring an
adequately full bladder and allowing assessment
of structures between the abdominal wall and
bladder, while topical anesthesia can decrease
patient discomfort.
Imaging for UTI is a subject of ongoing debate
beyond the scope of this article. Prior teaching
deferred imaging for a nonfebrile UTI, while recommending renal/bladder ultrasonography and voiding cystourethrography (VCUG) for a febrile UTI.
More recently, the top-down approach has been
advocated as a method of avoiding VCUG and
concentrating effort on those at greatest risk of
renal scarring.5 This approach, which will be discussed in detail elsewhere in this issue, focuses
on using a dimercaptosuccinic acid (DMSA) scan
to document pyelonephritis and/or renal scarring.
Additional lower tract imaging with a VCUG is performed on patients with documented renal
involvement. DMSA scans are considered the
gold standard for detection of acute pyelonephritis
and renal scarring (Fig. 1), with 92% sensitivity
when compared with histology in an animal
model.6 As always, limitation of radiation exposure
is a goal in pediatrics, and use of imaging modalities that limit radiation exposure while providing
TREATMENT OF UTI
Treatment of UTI focuses on the site of infection,
presence of fever, and the pathogen causing the
infection. Ampicillin and gentamicin continue to
be the mainstay of empirical treatment of pyelonephritis. The use of a third-generation cephalosporin may be considered with the knowledge
that its coverage will not include Enterococcus
and that there is emerging extended-spectrum blactam resistance. When a patient has recently
been on antibiotics, it is worthwhile to consider
using alternative choices due to the possibility of
resistant bacteria. Once afebrile for 24 to 48 hours,
consideration can be given to transitioning to oral
(PO) antibiotics. Improvement in serum markers
such as the white blood cell count or C-reactive
protein is also encouraging when considering transition to oral antibiotics. The use of longer duration
of intravenous (IV) antibiotics has not been shown
to be superior to an early transition to PO therapy
in preventing scarring based on DMSA scans at 9
months.10 In all cases, the combination of IV and
oral therapy should include 10 to 14 days of appropriate antibiotics, with neonates and more severe
infections favoring the longer duration.
Although traditional teaching has been that
febrile UTI should be treated promptly with IV antibiotics in an inpatient setting to avoid renal scarring, recent data have brought this teaching into
question. In a study by Hewitt and colleagues11
from Italy, the frequency of renal scarring on
DMSA scan at 1 year was similar (approximately
30%) in those treated early in a comparison with
treatment by a delayed fashion. Nonetheless,
treatment should be started as soon as possible
to relieve symptoms and with the hope of avoiding
renal scarring. Even with upper tract involvement,
outpatient treatment of UTI has been shown to
be safe and effective, particularly in older children
who are tolerating oral intake and are clinically
stable.12,13 In these cases, outpatient treatment
with trimethoprim/sulfamethoxazole (TMP/SMX),
cephalosporins, or fluoroquinolones are viable
options. Nitrofurantoin is inadequate when renal
involvement is suspected as a result of poor tissue
levels. In addition, daily intramuscular (IM) injection
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staphylococci, and Corynebacterium species are
not considered pathogens in otherwise healthy children of 2 months to 2 years old, and treatment is
unnecessary.19
During the period of toilet-training, children are
at an increased risk of lower UTI because of
changes in voiding and stooling habits. Less than
optimal hygiene, in combination with the newly
developed ability to hold ones urine, can lead to
UTIs. While still warranting treatment, these infections may be more related to functional changes.
In the case of an isolated UTI during toilet-training,
establishing good voiding and stooling habits is
the primary goal after initial treatment of the UTI.
The presence of a UTI in the setting of corrected
or spontaneously resolved reflux can cause significant anxiety for parents and primary care physicians, while not posing as great a risk as
perceived. After the initial diagnosis of vesicoureteral reflux (VUR), parents often become conditioned to associate UTI and the risk of damage
to the kidneys. The correction of VUR does not
decrease the risk of a child developing a lower
UTI but only eliminates the reflux of infected urine
into the kidney, thereby preventing or delaying the
development of upper UTI. It is important to ensure
that parents understand the purpose of VUR
correction, are informed that VUR correction
does not alter host susceptibility to UTI, and are
counseled to seek appropriate treatment for UTI.
Finally, a clinical scenario that is challenging to
understand is asymptomatic bacteriuria. Clinical
situations exist in which colonization of the urinary
tract is inevitable. In these situations, the presence
of bacteria is normal and does not require treatment despite a positive urine culture. Examples
of scenarios in which the urinary tract can be expected to be colonized are patients with longterm indwelling tubes, patients performing clean
intermittent catheterization (CIC), patients with
intestinal neobladders or augmented bladders,
and patients in whom the urinary tract is opened
to the skin (vesicostomy, ureterostomy, and so
forth). In these cases, routine bacteria cultured
from the urinary tract and not causing significant
clinical symptoms (dysuria, incontinence, fever,
and so forth) should not be treated. One should
also favor observation for bacteria noted on
a screening urinalysis performed in an asymptomatic patient without complicating factors. Treatment of these asymptomatic bacteria will only
allow recolonization with different, potentially
more pathogenic bacteria and increase the risk
of antibiotic resistance. Fever in a setting of
asymptomatic bacteriuria should be worked up
as a fever of unknown origin, including urine
culture and blood cultures, with treatment as
WHEN TO WORRY
The authors now focus attention on situations in
which UTI is more complicated, often requiring
a high index of clinical suspicion and a low
threshold to proceed to admission, broad-spectrum antibiotics, further investigation, and pediatric urology consultation. Attempts have been
made to sort these infrequent scenarios into
more generalized groups; however, many pathologic processes could be placed under multiple
headings. The rare nature of very complicated
UTI makes research comparing different
approaches to treatment difficult. Prospective
placebo-controlled studies do not exist. In these
complex cases, there are undoubtedly multiple
effective ways to approach treatment. When the
literature does not provide clear evidence supporting one approach, information is provided on the
clinical pathway followed by the authors for
managing these difficult situations.
Some general principles apply in these complex
clinical scenarios. The presence of abnormal
anatomy, particularly abnormal drainage, should
always prompt additional workup in the presence
of UTI. The presence of prior renal scarring should
also prompt additional concern, as these patients
are starting with fewer functioning nephrons and
have established they are susceptible to renal
injury. Failure of a patient to respond to conventional treatment of a UTI should also prompt
concern. Additional workup should be performed
to confirm that culture-specific antibiotics are
being used, that adequate drainage exists, and
that the antibiotics reach all sites of bacterial
infection.
Bad Pathology
While a single febrile UTI is a cause for concern,
the presence of repeated febrile infections should
alert all physicians to the need for a more extensive evaluation. One must be concerned about
the presence of a physiologic or anatomic patient
factor as the origin. While most renal scarring is felt
Fig. 2. Renal abscess. (A) Note heterogeneous appearing abscess (asterisk) in the left kidney on this CT scan with
contrast. (B) Gross pathology of the left kidney, including the necrotic area of kidney as a result of the abscess
(asterisk).
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bacterial pyelonephritis and obstruction. XGP is
named after the xanthoma cell, a foamy lipid-laden
histiocyte that is seen on histology in this infection.
Although primarily a condition that affects adults,
XGP is occasionally seen in children, most often
males younger than 8 years. It is most often unilateral, causing significant destruction to a kidney.
XGP may lead to a total loss of renal function on
the affected side, although it is often focal within
the kidney in children.23 The most common causative organisms are Proteus mirabilis and E coli.
Radiographic imaging is notable for the presence
of obstruction, most often due to a calculus. The
XGP kidney classically has been described as
having an appearance on CT scan similar to
a bear paw as a result of dilated calyces and
abscesses. Pediatric patients with XGP have clinical symptoms ranging from vague complaints to
hemodynamic instability and sepsis. In a stable
patient with evidence of XGP, drainage of the collecting system, via stent or nephrostomy tube,
may allow for true assessment of residual renal
function. Placement of additional drains may be
needed if nonoperative management is considered safe and desirable. Unfortunately, surgical
intervention is required in the majority of cases,
often with the need for total nephrectomy. In rare
circumstances a partial nephrectomy may be
effective.
Bad Anatomy
The presence of anatomically or functionally
abnormal segments of the urinary tract can lead
to rapid clinical deterioration when a patient
develops a UTI. Renal insufficiency is one example
of a functional issue. Impairment in renal function,
as indicated by an elevated serum creatinine,
limits the bioavailability of the antibiotics, making
careful monitoring of serum levels necessary. For
example, the potentially nephrotoxic antibiotics
gentamicin and vancomycin require close
management to minimize the risk of renal injury.
Imaging options in patients with compromised
renal function may also be impacted. IV contrast
for CT scans and fluoroscopic examinations can
be nephrotoxic, particularly for those with renal
insufficiency. Gadolinium, which is used as
contrast for MRI, may cause nephrogenic
systemic fibrosis when used in patients with an
estimated glomerular filtration rate less than 30
mL/min/1.73 m2.24 These limitations may cause
difficulties in diagnosing more complicated urinary
pathology in this patient population. Another situation in which renal function should prompt heightened concern is the solitary kidney. When a patient
with a known solitary kidney presents with a febrile
Bad Drainage
Those patients in whom segmental urine drainage
is persistently compromised are also at risk for
increased severity of infection. Causes of obstruction can be similar to those seen frequently in
adults (stones, strictures, ureteropelvic junction
[UPJ] obstruction, and mass effect) or those
diagnosed infrequently in adults (ectopic ureter,
ureterovesical junction obstruction, megaureter,
ureterocele). Symptoms may be difficult to discern
in younger children. Fever is often the first sign.
Failure to defervesce or improve with appropriate
antibiotics should prompt further investigation.
This evaluation may lead to the initial diagnosis
of segmental obstruction. In children with known
Fig. 3. Utricle. (A) Note bladder and urethra with a dilated, fluid-filled structure posteriorly on this bladder ultrasonograph. Cystoscopy at the time of hypospadias repair confirmed the presence of a large utricle, which complicated catheterization. (B) Note the presence of a utricle during VCUG in a patient who is extremely difficult to
catheterize.
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Fig. 4. Prune belly syndrome
(PBS). (A) Note the lax abdominal wall musculature on physical examination in this patient
with PBS. (B) VCUG displaying
anterior displacement of the
bladder and presence of small
utricle, which may combine to
make catheterization difficult.
Also note vesicoureteral reflux
with dilated, tortuous ureters.
Fig. 5. Ureteral stone. (A) Note the impacted ureteral stone obstructing the entire lumen of the ureter as seen
during ureteroscopy. (B) The stone has been removed endoscopically and the ureter is now patent.
Fig. 6. UPJ obstruction. (A) Note the presence of a massively dilated renal pelvis in this patient with UPJ obstruction. This patient presented with a febrile UTI and was found to have significant sediment (asterisk) within the
kidney. (B) When free of infection, the massively dilated pelvis shows no evidence of sediment on
ultrasonograph.
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Fig. 8. (A) Note the appearance of a ureterocele on VCUG (arrow), seen early as the bladder was being filled with
contrast. (B) Note the appearance of another ureterocele as seen on ultrasonograph of the bladder.
Bad/Rare Bugs
The infecting organism in any UTI plays a large role
in how severe an infection becomes, through
possession of virulence factors, resistance to antibiotics, and other mechanisms. The classic
example of a mechanism through which bacteria
possess greater virulence is fimbriae, specifically
P-fimbriae. Fimbriae (or pili) are surface structures
involved in adherence. P-piliated E coli possess
fimbriae that bind the human red cell P-group
antigen, leading to an increased risk of pyelonephritis. Another factor favoring more virulent
bacteria is the presence of mannose-resistant
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increasing, the complications of this disease,
including UTI, can be expected to increase as well.
Nosocomial Infection
A final situation that warrants brief discussion is
nosocomial infections. Nosocomial UTI is an infection acquired while in a hospital. A whole article
could be written about the epidemiology,
pathology, treatment, and implications of nosocomial UTI. These infections can be significant
because they occur in a population that is already
ill and often involve resistant bacteria. Financial
challenges also exist, as Medicare has eliminated
payment for nosocomial UTI treatment and any
additional care that occurs as a result of these
infections.43 Basic principles underlie prevention
of nosocomial UTI: appropriate hand washing
and cleaning, appropriate care for indwelling tubes
(including removal at the earliest medically appropriate time), and antibiotics when deemed
necessary.
SUMMARY
UTI in children is a frequent cause of worry for
parents and physicians. While many infections
will not be severe in nature, one should always
consider potential complicating factors that may
exist in the pediatric population. When a UTI
does not resolve routinely or when more complicated scenarios present, knowledge of these
complicating factors can allow accurate diagnosis. Consideration should be given to the many
approaches to treatment in developing a treatment
plan for each individual patient.
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