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Urinary Tract Infections in Children: Diagnostic Imaging Based On Clinical Practice Guidelines
Urinary Tract Infections in Children: Diagnostic Imaging Based On Clinical Practice Guidelines
Learning Objectives
State prevalence, associations, and consequences of febrile UTIs in children Discuss imaging options and timing of procedures Discuss classification systems used in radiologic reports Review variations of Clinical Practice Guidelines from reputable institutions- will discuss CMH guidelines and include others in handout.
Febrile UTIs
Most common serious bacterial infection occurring in infancy and childhood Affects at least 3.6% of boys, 11% of girls 10-30% of children with febrile UTIs will develop renal scarring
Diagnosis of UTI
Combination of clinical features and presence of bacteria in urine > 10 cfu/ml Acute pyelonephritis = UTI + fever > 38 (100.4) - most common in infants Cystitis = symptoms of dysuria, frequency, suprapubic pain in toilet-trained child
Escherichia coli - Most common organism; causative agent in > 80% of 1st UTI Klebsiella species - 2nd most common organism. Seen more in young infants Proteus species - May be more common in males Enterobacter species - cause < 2% of UTIs Pseudomonas species - cause < 2% or UTIs Enterococci species- Uncommon > 30 days of age Coagulase-negative staphylococcus - Uncommon in childhood Staphylococcus aureus - Uncommon > 30 days of age Group B streptococci - Uncommon in childhood
Female
< 1 yr non-African American race fever > 39 (102.2)
Atypical UTIs
Seriously ill Poor urine flow Abdominal or bladder mass Raised creatinine Septicemia Failure to respond to treatment within 48 hrs Infection with non- E. coli organisms
Seriously Ill
Recurrent UTIs
2 or more episodes of acute pyelonephritis / upper urinary tract infection
or
Recurrent UTIs
Girls are more prone to recurrences with age Children who present early in life with UTI are more prone to recurrences
of children presenting < 1 year will have recurrences > 1 year of age ~ 40% of girls, 30% of boys Overall incidence of UTI recurrences after pyelonephritis is 20.1%
Asymptomatic Bacteriuria
Most common in boys in early infancy 1.6% boys < 2 months affects 0.2% in school age boys Girls have lower rates until 8-14 months 1.5 - 2% in school age girls; peak prevalence 7-11 years of age
A 6 month old female has had 3 UTIs. Which of the following is the best approach?
A. No imaging needed B. US + VCUG C. MRI D. DMSA scan
63%
25% 13% 0%
A. B. C. D.
Imaging Procedures
Ultrasound - detect renal anomalies, dilatation, renal sizes, bladder abnormalities, ureteral dilatation VCUG - Voiding Cystourethrogram- assess for vesicoureteral reflux, bladder volumes, bladder abnormalities, urethral anatomy DMSA Scintigraphy- assess for pyelonephritis and renal scarring Radionuclide Cystogram - assess for VUR; used infrequently at CMH
Normal
Hydronephrotic MCDK
Duplication of renal pelvis and ureter is one of the most common anomalies of the urinary tract Partial - range from bifid renal pelvis to 2 ureters joining anywhere proximal to uterovesical junction Complete - 2 separate ureters with the upper pole ureter draining more caudal and medial than the lower pole ureter = ectopia (Weigert-Meyer rule) Ureteral duplication is of no clinical significance unless it is complicated with ectopia, VUR, UTI, or obstruction
Voiding Cystourethrogram
Requires bladder catheterization: 8 Fr feeding tube (No balloon) Lidocaine gel used on majority of patients Local analgesia Dilates meatal opening Radiation: Decreased dose with pulse and digital techniques 1-3% risk of UTI
Vesicoureteral Reflux
International Reflux Grading System of VUR
Bilateral Grade 2
Grade 1
Grade 3
Vesicoureteral Reflux
Incidence 20-40 % of children presenting with UTI Girls 17-34% Boys 18-45% Increased incidence if family history of VUR Parent to Child: up to 66% Siblings: up to 34% Overall prevalence in general population 1-3%
Prevalence of VUR
Girls: 0 - 18 yrs
Grade I - 7% Grade II - 22% Grade III - 6 % Grade IV - 1% Grade V - < 1%
DMSA Scintigraphy
Intravenous injection of a radiopharmaceutical labelled with TC-99m DMSA is concentrated in the proximal renal tubules. Identifies functioning renal tissue Images obtained between 2-6 hours after injection Usually requires sedation in children < 3 years of age
Timing of DMSA
Acute imaging: Within 5-7 days of acute infection
90% sensitivity for pyelonephritis Cannot differentiate pyelonephritis from renal scarring
DMSA
Normal Renal Scarring
Renal Damage
Of children with acute pyelonephritis diagnosed by DMSA, 38-57% will develop permanent renal scarring Seen in 78% of infants with dilating reflux(grades III-V), obstruction, clinically relevant anomalies (renal aplasia, ectopic kidney, complete duplication) Seen in 15% of infants without the above diagnoses
A 5 year old female has recurrent febrile UTIs. What imaging study would be useful to detect renal scarring?
38% 38%
A. B. C. D.
13%
13%
A.
B.
C.
D.
Utility of Diagnostic Imaging Procedures Identifying pathologic malformations and risk factors Changing management approaches Affecting follow-up monitoring
Outside of Guidelines
Infants and children:
known pre-existent uropathy or underlying renal disease hydronephrosis or obstruction neurogenic bladder with urinary catheters in situ immunosuppressed
CMH Guidelines
Boys- All Girls < 36 months Girls 3-7 years of age with fever > 38.5 ( 101.3 ) Ultrasound VCUG If identification of pyelonephritis or renal scarring DMSA
CMH Guidelines
Girls > 3 years with fever < 38.5 (101.3) All Girls > 7 years Observation without imaging If subsequent UTI Ultrasound VCUG If pyelonephritis or renal scarring DMSA
An uncircumcized 2 month old male was admitted with a febrile UTI that has not responded to antibiotic therapy after 48 hours. When is the best time to perform a VCUG?
50%
A. On the day of admission B. After 24 hours C. After 24 hours without a fever D. No need to do VCUG
25%
13%
13%
A.
B.
C.
D.
Vesicoureteral Reflux
Classification per CMH Clinical Practice Guidelines
Mild: grade I and II, unilateral grade III in a child < 2 years old Moderate-Severe: all other grade IIIs, IV, V
Conclusions
Better understanding of the impact of febrile UTIs on children Better understanding of some of the radiologic procedures and findings Understanding of CMH Clinical Practice Guidelines and ability to compare with other Clinical Practice Guidelines from reputable institutions Effects on diagnostic imaging and timing of imaging procedures
AAP Guidelines
Every febrile infant or young child, 2 months-2 years of age, should be imaged with ultrasound and a study to detect for VUR Those who do not demonstrate the expected clinical response within 2 days of antibiotics, should have ultrasound promptly and reflux study at earliest convenience
NICE Guidelines
Not recommend antibiotic prophylaxis following 1st UTI, even in child with VUR Not routinely evaluate for VUR with imaging Infants < 6 months with 1st UTI that responds to treatment - US within 4-6 weeks of UTI Infants > 6 months- US not recommended unless atypical UTI
NICE Guidelines
Infants < 6 months
Ultrasound during acute infection Ultrasound within 6 weeks DMSA within 4-6 months following infection VCUG
Atypical UTI
Yes*
Recurrent UTI
Yes
Yes No
No Yes
No Yes
No
Yes
Yes
*In a child with non-E. coli UTI, responding well to antibiotics and no other features of atypical infection, ultrasound can be requested on a non-urgent basis
If Ultrasound abnormal, consider VCUG
NICE Guidelines
Children Responds well to Atypical UTI 6 months - < 3 yrs Tx within 48 hours Ultrasound during infection Ultrasound within 6 weeks DMSA 4-6 months following acute infection VCUG No No No Yes* No Yes Recurrent UTI No Yes Yes
No
No
No
*In a child with non-E. coli UTI, responding well to antibiotics and no other features of atypical infection, ultrasound can be requested on a non-urgent basis Consider VCUG if dilatation on ultrasound, poor urine flow, non-E. coli infection, family history of VUR
NICE Guidelines
Children > 3 yrs Ultrasound during acute infection Ultrasound within 6 weeks DMSA 4-6 months following acute infection VCUG Responds well to Tx within 48 hours No No No Atypical UTI Yes* No No Recurrent UTI No Yes Yes
No
No
No
*In a child with non-E. coli UTI, responding well to antibiotics and no other features of atypical infection, ultrasound can be requested on a non-urgent basis