Occurrence of renal scars in children after their first referral for urinary tract infection

Paediatric Escherichia coli urinary tract infection: susceptibility trends and clinical management-a retrospective analysis of a 10-year period

BACKGROUND

Escherichia coli is the predominant urinary pathogen in children. Irish and international studies have demonstrated increasing antimicrobial resistance (AMR) to antibiotics such as co-amoxiclav.

AIMS

We aimed to (1) examine the AMR patterns of paediatric urinary E. coli isolates, from both hospital and community sources, over a 10-year period; (2) assess the effectiveness of Children's Health Ireland (CHI) antimicrobial guidance given local susceptibility data; and (3) review the clinical management of an admitted patient sub-set over a 6-year period.

METHODS

Pure growth of urinary E. coli from patients aged ≤ 14 from 2012 to 2021 were analysed for AMR. Differences in susceptibility rates were assessed. A retrospective chart review conducted on inpatients aged ≥ 2 months to ≤ 14 years, 2016-2021.

RESULTS

E. coli accounted for 70.8% of likely significant positive pure growth cultures (9314 isolates). Susceptibility to co-amoxiclav significantly increased over time, from 66.7% to 80.4% (2016-2021, p < 0.001). Nitrofurantoin and cefalexin had significantly higher susceptibility rates than trimethoprim (< 70% annually). 85.1% of isolates were susceptible to the combination of co-amoxiclav and gentamicin, recommended for those > 2months and systemically unwell. The additional gain in empiric susceptibility provided by gentamicin above that provided by co-amoxiclav alone has fallen from 16.4% to 6.7% (2016-2021). The 222 clinical cases reviewed showed improved antimicrobial guideline compliance over time.

CONCLUSIONS

This study provides important regional AMR data. Co-amoxiclav susceptibility increased significantly over time, contrasting with previous studies. This was temporally associated with stewardship measures reducing co-amoxiclav prescribing. Decreasing utility of gentamicin supports recent CHI guideline updates reducing gentamicin use.

Prevalence of Urinary Tract Infection in Children With Severe Acute Malnutrition Aged Between Six Months and Five Years and Their Antibiotic Sensitivity Pattern

Objective This study was conducted to determine the prevalence of urinary tract infection in children with severe acute malnutrition (SAM) aged between six months and five years and to identify the causative organisms and their antibiotic sensitivity pattern. Study design This study was an observational cross-sectional study. Setting and participants The study was conducted in the Department of Paediatrics in a tertiary care hospital in India over a period of 18 months. A total of 140 children aged between six months and five years according to the World Health Organisation's criteria of severe acute malnutrition were included upon fulfillment of inclusion and exclusion criteria. Ultrasound of kidney, ureter, and bladder (USG-KUB) was also done to exclude children with any underlying anatomical anomaly. Intervention Detailed clinical examination was performed on each of the participants with emphasis on anthropometry. Relevant blood investigations were sent along with urine routine microscopy and culture sensitivity in all patients. Results The prevalence of urinary tract infection (UTI) in our study was 23.57%. The most common organism isolated was Escherichia coli found in 54.54% of cases, followed by Klebsiella in 24.24%. Other organisms isolated were Enterococcus in 12.12%, Pseudomonas aeruginosa 6.06% and Citrobacter in 3.03%. E. coli showed high sensitivity to imipenem (88.87%), meropenem (83.84%), nitrofurantoin (77.76%) and amikacin (72.23%). Overall these organisms showed good sensitivity to amikacin (60.06%), imipenem (66.6%), meropenem (63.63%) and nitrofurantoin (72.72%). Resistance to common antibiotics like ciprofloxacin, cefotaxime and cefuroxime was seen. Conclusion Children with malnutrition are at risk of UTI. Urine routine examination and urine culture should be performed in all these children before starting antibiotics. Selection of an antibiotic should be according to the local drug sensitivity data. These antibiotics should have good efficacy against gram-negative organisms.

Urinary tract infections in children from the Gulf Cooperation Council countries: a literature review (2011-2022)

Urinary tract infections (UTIs) are common healthcare-associated and community-acquired bacterial infections in children. Data on pediatric UTIs in the Gulf Cooperation Council (GCC) region (Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and the United Arab Emirates) have not been collated. Our aim is to review the published literature on the risk factors, etiology, antimicrobial susceptibility, and treatment of pediatric (aged <18 years) UTIs from healthcare and community settings in the GCC countries.

Evidence-based circumcision policy for Australia

The aim was (1) to perform an up-to-date systematic review of the male circumcision (MC) literature and (2) to determine the number of adverse medical conditions prevented by early MC in Australia. Searches of PubMed using "circumcision" with 39 keywords and bibliography searches yielded 278 publications meeting our inclusion criteria. Early MC provides immediate and lifetime benefits, including protection against: urinary tract infections, phimosis, inflammatory skin conditions, inferior penile hygiene, candidiasis, various STIs, and penile and prostate cancer. In female partners MC reduces risk of STIs and cervical cancer. A risk-benefit analysis found benefits exceeded procedural risks, which are predominantly minor, by approximately 200 to 1. It was estimated that more than 1 in 2 uncircumcised males will experience an adverse foreskin-related medical condition over their lifetime. An increase in early MC in Australia to mid-1950s prevalence of 85% from the current level of 18.75% would avoid 77,000 cases of infections and other adverse medical conditions over the lifetime for each annual birth cohort. Survey data, physiological measurements, and the anatomical location of penile sensory receptors responsible for sexual sensation indicate that MC has no detrimental effect on sexual function, sensitivity or pleasure. US studies found that early infant MC is cost saving. Evidence-based reviews by the AAP and CDC support early MC as a desirable public health measure. Although MC can be performed at any age, early MC maximizes benefits and minimises procedural risks. Parents should routinely be provided with accurate, up-to-date evidence-based information in an unbiased manner early in a pregnancy so that they have time to weigh benefits and risks of early MC and make an informed decision should they have a son. Parental choice should be respected. A well-trained competent practitioner is essential and local anaesthesia should be routinely used. Third party coverage of costs is advocated.

Febrile Urinary Tract Infections in Children with Primary Non-Refluxing Megaureter: A Systematic Review and Meta-Analysis

BACKGROUND

Knowledge of the baseline risk of febrile urinary tract infections in patients with primary non-refluxing megaureter can help clinicians to make informed decisions for offering continuous antibiotic prophylaxis.

OBJECTIVE

The primary objective of this systematic review was to determine the pooled prevalence of febrile urinary tract infections in patients with primary non-refluxing megaureter selected for primary non-surgical management independent of associated attributed risk factors at initial presentation in order to assess the value of continuous antibiotic prophylaxis.

METHODS

MEDLINE, EMBASE, and Cochrane Controlled Trials Register electronic databases were searched for eligible studies without language and time restriction. The systematic review was carried out following the recommendations of the Cochrane Collaboration and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. (PROSPERO registration number CRD42018104752).

RESULTS

Of 25 871 records, 16 studies (n=749 patients) were eligible for inclusion. The overall pooled prevalence of febrile urinary tract infections in patients with primary non-refluxing megaureter was 14.35% (95% confidence interval: 8.8-22.6). The calculated number needed to treat for patients on continuous antibiotic prophylaxis to prevent one single febrile urinary tract infection over the course of 1-2 years would be 4.3.

CONCLUSION

Based on the current available evidence the use of continuous antibiotic prophylaxis for children with PM selected for primary non-surgical treatment should be taken into consideration, at least in patients with urinary outflow impairment, higher grade of ureteral dilatation, and for children in the first months of life.

Long-term outcomes of urinary tract infection (UTI) in Childhood (LUCI): protocol for an electronic record-linked cohort study

INTRODUCTION

Current guidelines advise the prompt diagnosis and treatment of urinary tract infection (UTI) in children to improve both short and longer term outcomes. However, the risk of long-term complications following childhood UTI is unclear.UTI is relatively common but difficult to diagnose in children as symptoms are non-specific. Diagnosis requires a urine sample, but sampling is difficult and infrequent, and it is not clear if sampling should be given greater priority in primary care. The LUCI study will assess the short, medium and longer term outcomes of childhood UTI associated with routine and systematic sampling practices.

METHODS AND ANALYSIS

Two data sets will be established. The first will consist of routinely collected data (hospital, general practice (GP), microbiology) from children born and resident in Wales, linked via the Secure Anonymised Information Linkage (SAIL) Databank (an 'e-cohort'). Urine sampling in this data set reflects normal practice 'routine sampling'. Outcomes (including renal scarring, hypertension, end-stage renal failure, hospital admissions, GP consultations, antibiotic prescriptions) for children with at least one UTI confirmed with microbiological culture (mcUTI) or no mcUTI before the age of 5 will be compared.The second will combine data from two prospective observational studies ('DUTY' and 'EURICA') employing systematic urine sampling for children presenting to primary care with acute, undifferentiated illness, linked to routine data via SAIL (Wales) and NHS Digital (England). Outcomes (as above, plus features of mcUTI) for children with an mcUTI in this data set, identified through systematic urine sampling, will be compared with those with an mcUTI identified through routine urine sampling (data set 1).

ETHICS AND DISSEMINATION

The study protocol has been approved by NHS Wales Research Ethics Committee and the Health Research Authority's Confidentiality Advisory Group. Methods of innovative study design and findings will be disseminated through peer-review journals and conferences. Results will be of interest to clinical and policy stakeholders in the UK.

Long-term antibiotics for preventing recurrent urinary tract infection in children

BACKGROUND

Urinary tract infection (UTI) is common in children. Symptoms include fever, lethargy, anorexia, and vomiting. UTI is caused by Escherichia coli in over 80% of cases and treatment is a course of antibiotics. Due to acute illness caused by UTI and the risk of pyelonephritis-induced permanent kidney damage, many children are given long-term (several months to 2 years) antibiotics aimed at preventing recurrence. This is the third update of a review first published in 2001 and updated in 2006, and 2011.

OBJECTIVES

To assess whether long-term antibiotic prophylaxis was more effective than placebo/no treatment in preventing recurrence of UTI in children, and if so which antibiotic in clinical use was the most effective. We also assessed the harms of long-term antibiotic treatment.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Register of Studies up to 30 July 2018 through contact with the Cochrane Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal, and ClinicalTrials.gov.

SELECTION CRITERIA

Randomised comparisons of antibiotics with other antibiotics, placebo or no treatment to prevent recurrent UTI in children.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed and extracted information for the initial and previous updates. A random-effects model was used to estimate risk ratio (RR) and risk difference (RD) for recurrent UTI with 95% confidence intervals (CI).

MAIN RESULTS

In this update sixteen studies (2036 children randomised, 1977 analysed) were included. Seven studies (612 children) compared two or more types of antibiotics, six (1088 children) compared antibiotics with placebo or no treatment, one four-armed study compared circumcision with and without antibiotic treatment, one study compared dose of antibiotic, and one three-armed study compared two different antibiotics as well as no treatment. Of the sixteen included studies only one study was judged to be at low risk of bias for all domains, with the majority judged to be at unclear risk of bias due to very poorly reported methodology. The number of studies judged to be a low risk of bias was: selection bias (7); performance bias (4); detection bias (1); attrition bias (6); reporting bias (7); and other bias (2). The number of studies judged to be at high risk of bias was: selection bias (0); performance bias (5); detection bias (1); attrition bias (4); reporting bias (6); and other bias (1).Compared to placebo/no treatment, antibiotics lead to a modest decrease in the number of repeat symptomatic UTI in children; however the estimate from combining all studies was not certain and the confidence interval indicates low precision indicating that antibiotics may make little or no difference to risk of repeat infection (RR 0.75, 95% CI 0.28 to 1.98). When we combined only the data from studies with concealed treatment allocation, there was a similar reduction in risk of repeat symptomatic UTI in children taking antibiotics (RR 0.68) and we have greater certainty in this estimate because of the more robust study designs, the confidence interval is smaller and it does not include the point of no effect (95% CI 0.48 to 0.95). The estimated reduction in risk of repeat symptomatic UTI for children taking antibiotics was similar in children with vesicoureteric reflux (VUR) (RR 0.65, 95% CI 0.39 to 1.07) compared to those without VUR (RR 0.56, 95% CI 0.15 to 2.12) however there was considerable uncertainty due to imprecision from fewer events in the smaller group of children with VUR. There was no consistency in occurrence of adverse events, with one study having more events in the placebo group and a second study having more events in the antibiotics group. Three studies reported data for antibiotic resistance with the analysis estimating the risk of a UTI caused by a bacteria resistant to the prophylactic antibiotic being almost 2.5 times greater in children on antibiotics than for children on placebo or no treatment (RR 2.40, 95% CI 0.62 to 9.26). However the confidence interval is wide, showing imprecision and there may be little or no difference between the two groups.Eight studies involving 659 children compared one antibiotic with another but few studies compared the same combination for the same outcome so little data could be pooled. Two studies reported microbial resistance data and analysis showed that treatment with nitrofurantoin may lead to a lower risk of a UTI caused by a bacteria resistant to the treatment drug compared to children given trimethoprim-sulphamethoxazole as their prophylactic treatment (RR 0.54, 95% CI 0.31 to 0.92).

AUTHORS' CONCLUSIONS

Long-term antibiotics may reduce the risk of repeat symptomatic UTI in children who have had one or more previous UTIs but the benefit may be small and must be considered together with the increased risk of microbial resistance.

A systematic review of parents' experiences and information needs related to their child's urinary tract infection

OBJECTIVE

As a first step toward the development of an animated video and infographic to increase parents' knowledge of pediatric urinary tract infections (UTIs), we conducted a systematic review of their experiences and information needs.

METHODS

We searched Ovid Medline, Ovid PsycINFO, CINAHL, and ProQuest Dissertations and Theses Global for studies published in 2000 or thereafter. We appraised quality using the Mixed Methods Appraisal Tool. We summarised the quantitative data narratively and the qualitative data thematically.

RESULTS

We identified 1493 records and included four. Sample size ranged from 20 to 2726 parents. The children ranged from <1 to 12 years old and had experienced one to >10 UTIs. Parents were not always aware of UTI symptoms and generally received little information. Parents sought information online, and desired it via other means. Some parents were not confident in healthcare providers' (HCPs') knowledge of UTIs. Inadequate information about diagnostic tests sometimes resulted in fear and non-compliance.

CONCLUSIONS

From the limited literature, it appears that parents would like information about prevention, diagnosis, treatment, and prognosis, but do not always consider HCPs good information sources.

PRACTICE IMPLICATIONS

Care providers should communicate information in ways that suit parents' self-identified needs.

Prevalence and antimicrobial sensitivity pattern of urinary tract infection among children with cerebral palsy, Moshi, Tanzania

Background

Urinary tract infection (UTI) in children with cerebral palsy (CP) is a challenging yet common clinical condition. Children with CP bare the greatest risk of contracting UTI because of their difficulties in neuromotor control which lead to delay of bladder control, causing incomplete bladder emptying and urine retention.

Method

This was an analytical cross-sectional study that was conducted from September 2016 to March 2017 at Comprehensive Community Based Rehabilitation in Tanzania – Moshi and Kilimanjaro Christian Medical Centre Neurological Pediatrics Outpatient Clinic. All children who met the inclusion criteria were studied. Urine samples were collected at one point by catheterization, and urine dipstick and urine culture were done. Data were analyzed using SPSS version 20.

Results

A total of 99 children were enrolled in the study. The median age was 4 years (3–8 years); 53.5% were aged between 2 and 4 years. More than half were male. UTI was detected in 13.1% (n=13) of the children. Five causative agents of UTI were isolated, namely Escherichia coli, Proteus mirabilis, Klebsiella pneumonia, Staphylococcus aureus, and Enterococcus faecalis. The two most common organisms, E. coli and P. mirabilis, both had low sensitivity to ampicillin and co-trimoxazole while they were sensitive to ciprofloxacin and ceftriaxone.

Conclusion

UTI is a common finding among children with CP. E. coli and P. mirabilis are the commonest causative agents and are sensitive to ciprofloxacin and ceftriaxone but have low sensitivity to ampicillin and co-trimoxazole.

The Diagnosis of Urinary Tract infection in Young children (DUTY): a diagnostic prospective observational study to derive and validate a clinical algorithm for the diagnosis of urinary tract infection in children presenting to primary care with an acute illness

BACKGROUND

It is not clear which young children presenting acutely unwell to primary care should be investigated for urinary tract infection (UTI) and whether or not dipstick testing should be used to inform antibiotic treatment.

OBJECTIVES

To develop algorithms to accurately identify pre-school children in whom urine should be obtained; assess whether or not dipstick urinalysis provides additional diagnostic information; and model algorithm cost-effectiveness.

DESIGN

Multicentre, prospective diagnostic cohort study.

SETTING AND PARTICIPANTS

Children < 5 years old presenting to primary care with an acute illness and/or new urinary symptoms.

METHODS

One hundred and seven clinical characteristics (index tests) were recorded from the child's past medical history, symptoms, physical examination signs and urine dipstick test. Prior to dipstick results clinician opinion of UTI likelihood ('clinical diagnosis') and urine sampling and treatment intentions ('clinical judgement') were recorded. All index tests were measured blind to the reference standard, defined as a pure or predominant uropathogen cultured at ≥ 10(5) colony-forming units (CFU)/ml in a single research laboratory. Urine was collected by clean catch (preferred) or nappy pad. Index tests were sequentially evaluated in two groups, stratified by urine collection method: parent-reported symptoms with clinician-reported signs, and urine dipstick results. Diagnostic accuracy was quantified using area under receiver operating characteristic curve (AUROC) with 95% confidence interval (CI) and bootstrap-validated AUROC, and compared with the 'clinician diagnosis' AUROC. Decision-analytic models were used to identify optimal urine sampling strategy compared with 'clinical judgement'.

RESULTS

A total of 7163 children were recruited, of whom 50% were female and 49% were < 2 years old. Culture results were available for 5017 (70%); 2740 children provided clean-catch samples, 94% of whom were ≥ 2 years old, with 2.2% meeting the UTI definition. Among these, 'clinical diagnosis' correctly identified 46.6% of positive cultures, with 94.7% specificity and an AUROC of 0.77 (95% CI 0.71 to 0.83). Four symptoms, three signs and three dipstick results were independently associated with UTI with an AUROC (95% CI; bootstrap-validated AUROC) of 0.89 (0.85 to 0.95; validated 0.88) for symptoms and signs, increasing to 0.93 (0.90 to 0.97; validated 0.90) with dipstick results. Nappy pad samples were provided from the other 2277 children, of whom 82% were < 2 years old and 1.3% met the UTI definition. 'Clinical diagnosis' correctly identified 13.3% positive cultures, with 98.5% specificity and an AUROC of 0.63 (95% CI 0.53 to 0.72). Four symptoms and two dipstick results were independently associated with UTI, with an AUROC of 0.81 (0.72 to 0.90; validated 0.78) for symptoms, increasing to 0.87 (0.80 to 0.94; validated 0.82) with the dipstick findings. A high specificity threshold for the clean-catch model was more accurate and less costly than, and as effective as, clinical judgement. The additional diagnostic utility of dipstick testing was offset by its costs. The cost-effectiveness of the nappy pad model was not clear-cut.

CONCLUSIONS

Clinicians should prioritise the use of clean-catch sampling as symptoms and signs can cost-effectively improve the identification of UTI in young children where clean catch is possible. Dipstick testing can improve targeting of antibiotic treatment, but at a higher cost than waiting for a laboratory result. Future research is needed to distinguish pathogens from contaminants, assess the impact of the clean-catch algorithm on patient outcomes, and the cost-effectiveness of presumptive versus dipstick versus laboratory-guided antibiotic treatment.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

An update on new antibiotic prophylaxis and treatment for urinary tract infections in children

INTRODUCTION

This review focuses on the treatment of urinary tract infections (UTI) in children and in particular its recent changes. Areas covered: Acute pyelonephritis, acute cystitis and asymptomatic bacteriuria or asymptomatic infections have to be clearly distinguished. Prompt treatment is required in pyelonephritis and cystitis, but not in asymptomatic bacteriuria or infection, in order to avoid selection of more virulent strains. This concept should be considered even in immunocompromised or bedridden children. In case of pyelonephritis, there should be no delay in beginning the antibiotic treatment in order to decrease the risk of long term complication, such as renal scars. Predisposing conditions for UTI, such as voiding anomalies and urinary tract malformation should be carefully evaluated. Expert opinion: One major concern is the increasing resistance to 3^rd generation cephalosporins. Therefore overconsumption in low-risk settings should be absolutely avoided. The prevalence of infections with E. coli producing extended spectrum ß-lactamase (ESBL) is increasing and pediatricians should be aware about the specific treatment options. Any recommendation about (initial) antibiotic treatment should be regularly updated and adapted to local resistance profiles and to economic factors in different health systems.

Resistance to oral antibiotics in 4569 Gram-negative rods isolated from urinary tract infection in children

To investigate antibiotic resistance among pathogens isolated from urines in a tertiary care children's hospital in Italy. Retrospective analysis of prospectively collected data on antibiotic susceptibility of Gram-negatives isolated from urines at the Istituto Giannina Gaslini, Genoa - Italy from 2007 to 2014. Antibiotic susceptibility was evaluated. By means of CLSI criteria from 2007 to 2010, while from 2011 EUCAST criteria were adopted. Data on susceptibility to amoxicillin-clavulanate, co-trimoxazole, cefuroxime, nitrofurantoin, fosfomycin and ciprofloxacin were evaluated for Escherichia coli, while for other Enterobacteriaceae data were collected for amoxicillin-clavulanate, co-trimoxazole and ciprofloxacin and for ciprofloxacin against Pseudomonas aeruginosa. Univariate and multivariable analyses were performed for risk factors associated with resistance. A total of 4596 Gram-negative strains were observed in 3364 patients. A significant increase in the proportion of resistant strains was observed for E.coli against amoxicillin-clavulanate, cefuroxime and ciprofloxacin and for others Enterobacteriaceae against co-trimoxazole and ciprofloxacin. Resistance to nitrofurantoin and fosfomycin was very infrequent in E.coli. Logistic regression analysis showed that repeated episode of urinary tract infections was a risk factor for E.coli resistance to amoxicillin-clavulanate, co-trimoxazole and cefuroxime, while admission in one of the Units usually managing children with urinary tract malformations was significantly associated to resistance to amoxicillin-clavulanate and cefuroxime.

CONCLUSION

In conclusion the present study shows an increase in antibiotic resistance in pediatric bacteria isolated from urines in children, especially in presence of repeated episodes and/or urinary tract malformations. This resistance is worrisome for beta-lactams and cotrimoxazole, and start to increase also for fluoroquinolones while nitrofurantoin and fosfomycin still could represent useful drugs for oral treatment of these infections.

WHAT IS KNOWN

• Infections are frequent in patients with urinary tract malformations • Antibiotic prophylaxis can select for resistant pathogens What is New: • The increase in the resistance to β-lactams, co-trimoxazole or fluoroquinolones in pathogens causing urinary tract infections cause a reduction of drugs with oral formulations available for therapy • Old drugs like nitrofurantoin and fosfomycin can represent attractive compounds for oral treatment of urinary tract infections in children presence of resistance to other drug classes.

Urinary tract infection in the setting of vesicoureteral reflux

Vesicoureteral reflux (VUR) is the most common underlying etiology responsible for febrile urinary tract infections (UTIs) or pyelonephritis in children. Along with the morbidity of pyelonephritis, long-term sequelae of recurrent renal infections include renal scarring, proteinuria, and hypertension. Treatment is directed toward the prevention of recurrent infection through use of continuous antibiotic prophylaxis during a period of observation for spontaneous resolution or by surgical correction. In children, bowel and bladder dysfunction (BBD) plays a significant role in the occurrence of UTI and the rate of VUR resolution. Effective treatment of BBD leads to higher rates of spontaneous resolution and decreased risk of UTI.

The effect of vitamin A on renal damage following acute pyelonephritis in children: a meta-analysis of randomized controlled trials

BACKGROUND

Renal scarring after acute pyelonephritis (APN) in children is of concern and in the worst cases leads to long-term cardiovascular morbidity. There are reports that vitamin A may alleviate renal damage following APN. We conducted a meta-analysis to investigate the role of vitamin A in the alleviation of renal damage.

METHODS

We searched PubMed, EMBASE, the Cochrane Central Register of Controlled trials (CENTRAL, the Cochrane Library) and the Wang Fang database (Chinese) from their inception to February 3, 2015 for randomized controlled trials (RCTs) investigating vitamin A and renal damage. Primary outcome was number of patients/kidneys with renal damage, defined as persistence of photopenic lesions based on technetium-99m dimercaptosuccinic acid renal scintigraphy. We calculated pooled relative risks for renal damage in the vitamin A group.

RESULTS

Four RCTs, involving a total of 248 patients aged 1-144 months (120 in experimental group, 128 in control group), were included in the meta-analysis. Vitamin A was inversely associated with renal damage (relative risk 0.53, 95 % confidence interval 0.43, 0.67) when compared with placebo group after an average follow-up of 5 months.

CONCLUSIONS

Current evidence indicates that vitamin A may exert a preventive effect on renal damage in children with APN. However, this finding largely relies on a few studies of low methodological quality, i.e., high risk of selection bias, performance bias and attrition bias. Hence, high-quality and adequately powered RCTs are warranted.

Low urinary bacterial counts: do they count?

In their article which appears in this issue of Pediatric Nephrology, Dr. S. Swerkersson and co-workers claim that as many as one in every five infants with a true episode of urinary tract infection (UTI) will be missed with the commonly used cut-off level of ≥10(5) colony forming units (CFU)/mL. This controversial finding is supported by the results of seven previous studies including a total of 1587 children. Dr. E.H. Kass, who in the 1950s suggested the presently used cut-off level, knew at the time that it excluded a number of patients with a true infection. Later studies in adult patients also showed that up to 46–49% of women with a likely diagnosis of cystitis had low bacterial counts. These findings can, if true, improve our understanding of cases of unexplained postinfectious renal scarring. Children with low bacterial counts during an acute infectious episode have a significant risk of receiving delayed or even no antimicrobial treatment. The results of scientific studies are also confounded if 20 % of the subjects with a true infection are wrongly included in a control group diagnosed as having no UTI due to low bacterial counts. This problem cannot be easily solved by lowering the cut-off level and generally accepting that any bacterial count signifies a Btrue^ infection as this approach will drastically reduce the specificity of the culture result. Instead, as many as possible urine samples for culture should be collected from babies, infants and small children with a suprapubic bladder puncture, or a catheterised sample. In such samples bacterial counts as low as 103 CFU/mL are generally regarded as significant. In many cases, however, the only possibility is a Bclean catch^ or bag sample. In these situations, the treating physician needs to take all relevant clinical and laboratory parameters into account and if clinically important data support the diagnosis of a UTI not disregard this diagnosis based only on low bacterial counts. C-reactive protein or procalcitonin can, in a febrile child, help the physician differentiate between a febrile bacterial UTI and a viral infection. A positive nitrite test provides, albeit with a low sensitivity, strong support for a UTI diagnosis.

Efficacy of Fluoroquinolone/Probiotic Combination Therapy for Recurrent Urinary Tract Infection in Children: A Retrospective Analysis

PURPOSE

Children with normal urinary tract anatomy and function and highly recurrent urinary tract infection (rUTI) may have a lack of alternatives when antibiotic prophylaxis and "watchful waiting" approaches fail. This retrospective review reports the outcomes in children who received a fluoroquinolone/probiotic combination in an attempt to quantify a reduction in rUTI that was perceived by both clinicians and patients' families.

METHODS

Data from all children with rUTIs previously managed with a fluoroquinolone/probiotic combination at the Pediatric Infectious Diseases Clinic at Duke University Medical Center (Durham, North Carolina) were identified and analyzed.

FINDINGS

Data from 10 children were eligible for inclusion. Compared with before therapy initiation, total UTI episodes were significantly fewer after therapy initiation (57 vs 4; P = 0.0001). Seven (70%) were free of rUTIs during the follow-up period. Of the 8 patients with known compliance, 7 (88%) were free of rUTIs.

IMPLICATIONS

Given the chronic nature of these patients' symptoms, the significant decrease in UTI after the initiation of therapy, and the increase in the interval without an infection and/or its symptoms, this treatment regimen has the potential to improve overall quality of life, decrease antibiotic courses, and decrease health care costs in children with rUTI. These results will be validated with a larger cohort of patients in a prospective, randomized trial.

Urinary tract infection in children: recurrent infections

INTRODUCTION

Up to 11% of girls and 7% of boys will have had a urinary tract infection (UTI) by the age of 16 years, and recurrence of infection is common. Vesicoureteric reflux (VUR) is identified in up to 40% of children being investigated for a first UTI, and is a risk factor for, but weak predictor of, renal parenchymal defects.

METHODS AND OUTCOMES

We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of prophylactic antibiotics to prevent recurrent urinary tract infection in children? We searched: Medline, Embase, The Cochrane Library, and other important databases up to December 2013 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review).

RESULTS

We found three studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.

CONCLUSIONS

In this systematic review we present information relating to the effectiveness and safety of the following intervention: prophylactic antibiotics.

Implementation of NICE guidance on urinary tract infections in children in primary and secondary care

AIM

To audit compliance with the 2007 National Institute of Clinical Excellence guidelines on the management of urinary tract infection in children under the age of 16 years across primary and secondary care services in England.

METHODS

A retrospective multisite audit of 10 general practice, 3 paediatric, 2 paediatric emergency and 2 emergency general units. Four distinct geographical areas were represented. Data were collected between 1 January 2010 and 31 December 2010. Six criteria were audited, which focused on the following: improving the rate of diagnosis, management of the very young child with UTI and selection of children for imaging.

RESULTS

A total of 1149 children were audited (682 from primary care and 467 from secondary care). Overall compliance was as follows: criterion 1: 28%; criterion 2: 68%; criterion 3: 89%; criterion 4: 43%; criterion 5 (comprising 12 subcriteria): 13% and for criterion 6: 45%.

CONCLUSION

The results indicate significant shortcomings in the implementation of NICE guidance on childhood UTI in England. The guidance is complex and this makes its implementation challenging. It was difficult to identify children presenting with nonspecific fever from clinical data systems. Adequate IT systems throughout the NHS are a key step to improving implementation of this and other NICE guidance.

Antibiotic resistance in pediatric urology

Antibiotics are a mainstay in the treatment of bacterial infections, though their use is a primary risk factor for the development of antibiotic resistance. Antibiotic resistance is a growing problem in pediatric urology as demonstrated by increased uropathogen resistance. Lack of urine testing, nonselective use of prophylaxis, and poor empiric prescribing practices exacerbate this problem. This article reviews antibiotic utilization in pediatric urology with emphasis on modifiable practice patterns to potentially help mitigate the growing rates of antibiotic resistance. This includes urine testing to only treat when indicated and tailor broad-spectrum therapy as able; selective application of antibiotic prophylaxis to patients with high-grade vesicoureteral reflux and hydronephrosis with counseling regarding the importance of compliance; and using local antiobiograms, particularly pediatric-specific antiobiograms, with inpatient versus outpatient data.

Does prompt treatment of urinary tract infection in preschool children prevent renal scarring: mixed retrospective and prospective audits

OBJECTIVE

To test whether active management of urinary tract infections (UTI) in young children by general practitioners can reduce kidney scarring rates.

DESIGN

A comparison of two audits in Newcastle, of children aged <8 years, presenting with UTIs ; a retrospective audit of conventional management during 1992-1995 (1990s) versus a prospective audit of direct access management during 2004-2011 (2000s).

MAIN OUTCOME MEASURES

Kidney scarring rates, and their relationship with time-to-treat.

RESULTS

Children with a first UTI in the 2000s compared to those in the 1990s, were referred younger, were half as likely to have a renal scar (girls OR 0.47, 95% CI 0.29 to 0.76; boys 0.35, 0.16 to 0.81), and were about 12 times more likely to have vesicoureteric reflux without scarring (girls 11.9, 4.3 to 33.5; boys 14.4, 4.3 to 47.6). In the 2000s, general practitioners treated about half the children at first consultation. Children who were treated within 3 days of their symptoms starting were one-third as likely to scar as those whose symptoms lasted longer (0.33, 0.12 to 0.72).

INTERPRETATION

Most kidney defects seen in children after UTIs, are acquired scars, and in Newcastle, active management in primary care has halved this rate.

Alarm signs and antibiotic prescription in febrile children in primary care: an observational cohort study

BACKGROUND

Although fever in children is often self-limiting, antibiotics are frequently prescribed for febrile illnesses. GPs may consider treating serious infections by prescribing antibiotics.

AIM

To examine whether alarm signs and/or symptoms for serious infections are related to antibiotic prescription in febrile children in primary care.

DESIGN AND SETTING

Observational cohort study involving five GP out-of-hours services.

METHOD

Clinical information was registered and manually recoded. Children (<16 years) with fever having a face-to-face contact with a GP were included. Children who were already using antibiotics or referred to secondary care were excluded. The relation between alarm signs and/or symptoms for serious infections and antibiotic prescription was tested using multivariate logistic regression.

RESULTS

Of the 8676 included patients (median age 2.4 years), antibiotics were prescribed in 3167 contacts (36.5%). Patient characteristics and alarm signs and/or symptoms positively related to antibiotic prescription were: increasing age (odds ratio [OR] = 1.03; 95% confidence interval [95% CI] = 1.02 to 1.05), temperature measured by GP (OR = 1.72; 95% CI = 1.59 to 1.86), ill appearance (OR = 3.93; 95% CI = 2.85 to 5.42), being inconsolable (OR = 2.27; 95% CI = 1.58 to 3.22), shortness of breath (OR = 2.58; 95% CI = 1.88 to 3.56), duration of fever (OR = 1.31; 95% CI = 1.26 to 1.35). Negative associations were found for neurological signs (OR = 0.45; 95% CI = 0.27 to 0.76), signs of urinary tract infection (OR = 0.63; 95% CI = 0.49 to 0.82), and vomiting and diarrhoea (OR = 0.65; 95% CI = 0.57 to 0.74). These variables explained 19% of the antibiotic prescriptions.

CONCLUSION

Antibiotics are often prescribed for febrile children. These data suggest that treatment of a supposed serious bacterial infection is a consideration of GPs. However, the relatively low explained variation indicates that other considerations are also involved.

Urinary concentration of cytokines in children with acute pyelonephritis

Urinary tract infection (UTI) is a common bacterial infection among infants and children. Predicting which children with upper UTI will develop long-term sequelae remains difficult. We aimed at evaluating the predictive value of urine concentrations of interleukin-6 (UIL-6) and interleukin-8 (UIL-8) in subsequent renal scarring. In the current observational prospective study, urine samples for UIL-6 and UIL-8 were obtained from two groups: 31 children with first episode of febrile UTI and 22 febrile children of other origin. UIL-6 and UIL-8 were increased in children with febrile UTI, compared to children with fever of other origin [median and range (picograms per milliliter): (1) UIL-6, 74.46 (0-168) vs. 10.51 (0-47.50), respectively, p = 0.0001; (2) UIL-8, 2,660.38 (0-13,801) vs. 0, respectively, p = 0.0001]. Renal scarring was found in 5/31 (16 %) children with acute pyelonephritis. Initial median UIL-8 values were significantly higher in children with later renal scarring than in those without renal scarring [median and range (picograms per milliliter): 6,163 (2,021-13,801) vs. 1,490.5 (0-5,737), respectively, p = 0.018]. In conclusion, UIL-8 might serve as a predictive biomarker for renal scarring after an acute episode of pyelonephritis. Since UIL-8 emerges as a renal-specific diagnostic and prognostic marker, it may be suitable as a selective screening tool for children with febrile UTI.

The effect of vitamin E or vitamin A on the prevention of renal scarring in children with acute pyelonephritis

BACKGROUND

Numerous factors may contribute to renal tissue injury after urinary tract infection. We have evaluated the effects of vitamins A or E supplementation in combination with antibiotics for the prevention of renal scarring in acute pyelonephritis.

METHODS

A simple non-blind randomized clinical trial was conducted on 61 children aged 1 month to 10 years between 2004 and 2006. The inclusion criteria were positive urine culture, clinical findings, and 99mTc-dimercaptosuccinic acid (DMSA) scintigraphy-based evidence in favor of acute pyelonephritis. The children were randomized into three treatment groups: 10-day treatment with only antibiotics (control group; n = 25) and 10-day treatment with supplements of vitamin A (n = 17) or vitamin E (n = 18) in addition to antibiotics during the acute phase of infection. The final analysis was performed after excluding male patients. Each patient was evaluated twice by 99mTc-DMSA scintigraphy performed at least 6 months apart. P < 0.05 was considered to be statistically significant.

RESULTS

The analysis included 108 kidney units. The frequency of inflammation at the beginning of therapy was not significantly different in the three groups (63.3 % in vitamin A, 61 % in vitamin E, and 76.2 % in the control group). A worsening of lesions, based on the second 99mTc-DMSA scan, was observed in 42.5, 0, and 23.3 % of the control, vitamin E, and vitamin A patients, respectively (LR = 26.3, P < 0.001).

CONCLUSION

Vitamins A or E supplements were effective in reducing renal scarring secondary to acute pyelonephritis.

Antibiotics for treating lower urinary tract infection in children

BACKGROUND

Urinary tract infection (UTI) is one of the most common bacterial infections in infants and children. Lower UTI is the most commonly presenting and in the majority of cases can be easily treated with a course of antibiotic therapy with no further complications. A number of antimicrobials have been used to treat children with lower UTIs; however is it unclear what are the specific benefits and harms of such treatments.

OBJECTIVES

This review aims to summarise the benefits and harms of antibiotics for treating lower UTI in children.

SEARCH METHODS

We searched the Renal Group's Specialised Register (April 2012), CENTRAL (The Cochrane Library 2012, Issue 5), MEDLINE OVID SP (from 1966), and EMBASE OVID SP (from 1988) without language restriction. Date of last search: May 2012.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-RCTs in which antibiotic therapy was used to treat bacteriologically proven, symptomatic, lower UTI in children aged zero to 18 years in primary and community healthcare settings were included.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed study quality and extracted data. Statistical analyses were performed using the random effects model and the results expressed as risk ratios (RR) with 95% confidence intervals (CI).

MAIN RESULTS

Sixteen RCTs, analysing 1,116 children were included. Conventional 10-day antibiotic treatment significantly increased the number of children free of persistent bacteriuria compared to single-dose therapy (6 studies, 228 children: RR 2.01, 95%CI 1.06 to 3.80). No heterogeneity was observed. Persistent bacteriuria at the end of treatment was reported in 24% of children receiving single-dose therapy compared to 10% of children who were randomised to 10-day therapy. There were no significant differences between groups for persistent symptoms, recurrence following treatment, or re-infection following treatment. There was insufficient data to analyse the effect of antibiotics on renal parenchymal damage, compliance, development of resistant organisms or adverse events. Despite the inclusion of 16 RCTs, methodological weakness and small sample sizes made it difficult to conclude if any of the included antibiotics or regimens were superior to another.

AUTHORS' CONCLUSIONS

Although antibiotic treatment is effective for children with UTI, there are insufficient data to answer the question of which type of antibiotic or which duration is most effective to treat symptomatic lower UTI. This review found that 10-day antibiotic treatment is more likely to eliminate bacteria from the urine than single-dose treatments. No differences were observed for persistent bacteriuria, recurrence or re-infection between short and long-course antibiotics where the antibiotic differed between groups. This data adds to an existing Cochrane review comparing short and long-course treatment of the same antibiotic who also reported no evidence of difference between short and long-course antibiotics.

Issues in febrile urinary tract infection management

Urinary tract infections are common occurrences in the pediatric age group and are a cause of significant morbidity and expense. The understanding of the consequences and sequelae of febrile urinary tract infections led to revision of standard protocols initiated by the American Academy of Pediatrics (AAP) in 1999. A less invasive protocol of radiologic evaluation has been the major outcome of the revised AAP guidelines. Emphasis on prevention of recurrent febrile urinary tract infections has also led to therapeutic programs that are centered less around the use of prophylactic antibiotics than has previously been the practice.

Urinary tract infections in children and the risk of ESRF

AIMS

Paediatric guidance on diagnosis and treatment of urinary tract infections (UTIs) has in the past largely focused on identifying children with vesicoureteral reflux, thought to be at greatest risk of renal scarring. This practice has been questioned, specifically the accepted association between UTI and end-stage renal failure (ESRF) through renal scarring. The aim of this article is to ascertain whether we can predict with confidence the true level of risk that a child with a first-time UTI will subsequently develop ESRF attributable to UTI.

METHODS

Using data available from renal registries, an analytical approach based on previous estimates of risk is used to demonstrate the range of plausible estimates of risk that can be generated and levels of uncertainty that surrounds those estimates.

RESULTS

Estimates of the perceived risk of developing ESRF following UTI range from 1/154 to 1/199,900 and are heavily dependent on the assumptions made and the source of data.

CONCLUSION

There is considerable uncertainty in the relationship between childhood UTI and risk of ESRF based on the data currently available. Until further evidence is available, clinicians will continue to debate the risk of UTI and ESRF and consensus opinion will continue to guide management.

Genetic variations of interleukin-8, CXCR1 and CXCR2 genes and risk of acute pyelonephritis in children

Acute pyelonephritis (APN) is the most severe form of urinary tract infection, the etiopathogenesis of which is still not well understood. Previous studies demonstrated that chemotaxis of neutrophils into the tissue and across the infected epithelial layer is a key step in rapid bacterial clearance. Variations within genes encoding the major chemokine interleukin-8 and its receptors CXCR1 and CXCR2 are therefore attractive candidates for participation in genetic predisposition to APN. The aim of our study was to evaluate the association of single nucleotide polymorphisms (SNPs) -251 T/A, +781 C/T, +1633 C/T and +2767 A/T in the IL-8 gene, +2608 G/C in the CXCR1 gene and +1208 C/T in the CXCR2 gene with susceptibility to APN in the Slovak population. PCR-SSP and PCR-RFLP were used to genotype SNPs in 147 children with APN (62 with recurrent and 85 with episodic form) and 215 healthy individuals. Statistical analysis revealed significantly increased frequency of CXCR1 +2608 C allele (P = 0.0238, OR = 2.452, 95% CI = 1.147-5.243) and GC genotype (P = 0.0201, OR = 2.627, 95% CI = 1.188-5.810) and lower frequency of CXCR2 +1208 T allele (P = 0.0408, OR = 0.645, 95% CI = 0.429-0.972) and TT+TC genotypes (P = 0.0497, OR = 0.5273, 95% CI = 0.288-0.964) in patients with recurrent APN compared with healthy controls. Furthermore, the A allele of IL-8 -251 T/A SNP was also significantly overrepresented in patients with recurrent APN when compared with those with only single episode of APN (P = 0.0439, OR = 1.627, 95% CI = 1.019-2.599). Our results indicate that the minor CXCR1 +2608 C allele is associated with significantly increased susceptibility to APN in childhood, while the CXCR2 +1208 T allele confers protection from recurrent APN. Moreover, allele A of the IL-8 -251 T/A may also increase the risk of developing recurrent attacks after the first-time APN.

In vitro analysis of the bactericidal activity of Escherichia coli Nissle 1917 against pediatric uropathogens

PURPOSE

The usefulness of prophylactic antibiotics to prevent recurrent urinary tract infections in children was recently questioned. Some groups have attempted to use probiotics, most commonly lactobacillus, to prevent recurrent infections by altering the intestinal bacterial reservoir with variable results. Mutaflor® is a possible alternative probiotic in which the active agent is Nissle 1917. Nissle 1917 is a commensal Escherichia coli strain that eradicates pathogenic bacteria from the gastrointestinal tract. Due to its ability to alter the intestinal biome we hypothesized that Mutaflor may have the potential to prevent recurrent urinary tract infections. Thus, we used an in vitro assay to analyze the effectiveness of Nissle 1917 for eradicating pediatric uropathogens.

MATERIALS AND METHODS

We established a collection of 43 bacterial pediatric uropathogens. With each isolate a microcin-type assay was performed to determine the effectiveness of Nissle 1917 on bacterial growth inhibition and competitive overgrowth.

RESULTS

Nissle 1917 adversely affected the growth of 34 of the 43 isolates (79%) isolates. It inhibited the growth of 21 isolates and overgrew 13. The percent of species adversely affected by Nissle 1917 was 40% for Pseudomonas, 50% for E. coli, Enterococcus and Staphylococcus, 100% for Klebsiella and Enterobacter, and 0% for Citrobacter and Serratia.

CONCLUSIONS

Nissle 1917, the active agent in Mutaflor, inhibited or out competed most bacterial isolates. These mechanisms could be used in vivo to eradicate uropathogens from the gastrointestinal tract. Further study is needed to determine whether Mutaflor can prevent recurrent urinary tract infections in children.

Primary, nonsyndromic vesicoureteric reflux and nephropathy in sibling pairs: a United Kingdom cohort for a DNA bank

BACKGROUND AND OBJECTIVES

Primary vesicoureteric reflux (VUR) can coexist with reflux nephropathy (RN) and impaired renal function. VUR appears to be an inherited condition and is reported in approximately one third of siblings of index cases. The objective was to establish a DNA collection and clinical database from U.K. families containing affected sibling pairs for future VUR genetics studies. The cohort's clinical characteristics have been described.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Most patients were identified from tertiary pediatric nephrology centers; each family had an index case with cystography-proven primary, nonsyndromic VUR. Affected siblings had radiologically proven VUR and/or radiographically proven RN.

RESULTS

One hundred eighty-nine index cases identified families with an additional 218 affected siblings. More than 90% were <20 years at the study's end. Blood was collected and leukocyte DNA extracted from all 407 patients and from 189 mothers and 183 fathers. Clinical presentation was established in 122; 92 had urinary tract infections and 16 had abnormal antenatal renal scans. RN was radiologically proven in 223 patients. Four patients had been transplanted; none were on dialysis. In 174 others aged >1 year, estimated GFR (eGFR) was calculated. Five had eGFR 15 to 59 and 48 had eGFR 60 to 89 ml/min per 1.73 m(2). Values were lower in bilateral RN patients than in those with either unilateral or absent RN.

CONCLUSIONS

The large DNA collection from families with VUR and associated RN constitutes a resource for researchers exploring the most likely complex, genetic components predisposing to VUR and RN.

Long-term antibiotics for preventing recurrent urinary tract infection in children

BACKGROUND

Urinary tract infection (UTI) is common in children. Symptoms include fever, lethargy, anorexia, and vomiting. UTI is caused by Escherichia coli in over 80% of cases and treatment is a course of antibiotics. Due to acute illness caused by UTI and the risk of pyelonephritis-induced permanent kidney damage, many children are given long-term antibiotics aimed at preventing recurrence.

OBJECTIVES

To determine the efficacy and harms of long-term antibiotics to prevent recurrent UTI in children.

SEARCH STRATEGY

In November 2010 we searched without language restriction MEDLINE, EMBASE, CENTRAL (in the Cochrane Library), the Cochrane Renal Group's Specialised Register, reference lists of review articles and contacted content experts.

SELECTION CRITERIA

Randomised comparisons of antibiotics with other antibiotics, placebo or no treatment to prevent recurrent UTI.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed and extracted information. A random-effects model was used to estimate risk ratio (RR) and risk difference (RD) for recurrent UTI with 95% confidence intervals (CI).

MAIN RESULTS

Twelve studies (1557 children) were identified with six (five analysed, 1069 children) comparing antibiotics with placebo/no treatment. Duration of antibiotic prophylaxis varied from 10 weeks to 12 months. Compared to placebo/no treatment, when all studies were included, antibiotics did not appear to reduce the risk of symptomatic UTI (RR 0.75, 95% CI 0.36 to 1.53) however when we evaluated the effects of antibiotics in studies with low risk of bias, there was a statistically significant reduction (RR 0.68, 95% CI 0.48 to 0.95). The effect was similar in children with vesicoureteric reflux (VUR) (RR 0.65, 95% CI 0.39 to 1.07) compared to those without VUR (RR 0.56, 95% CI 0.15 to 2.12). There was no consistency in occurrence of adverse events. Three studies reported antibiotic resistance, showing a non-significant increased risk for resistance to the antibiotic in the active treatment groups (RR 2.4, 95% CI 0.62 to 9.26).Five studies (4 analysed, 367 children) compared one antibiotic with another but all compared different combinations or different outcomes and studies were not pooled. Two studies reported microbial resistance, nitrofurantoin having a significantly lower risk of resistance than cotrimoxazole (RR 0.54, 95% CI 0.31 to 0.92).One study compared alternate with every day cefadroxil treatment.

AUTHORS' CONCLUSIONS

Long-term antibiotics appear to reduce the risk of repeat symptomatic UTI in susceptible children but the benefit is small and must be considered together with the increased risk of microbial resistance.

Urinary tract infection in children

INTRODUCTION

Up to 11.3% of girls and 3.6% of boys will have had a urinary tract infection (UTI) by the age of 16 years, and recurrence of infection is common. Vesicoureteric reflux is identified in up to 40% of children being investigated for a first UTI, and is a risk factor for, but weak predictor of, renal parenchymal defects.

METHODS AND OUTCOMES

We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of treatment of acute urinary tract infection in children? What are the effects of interventions to prevent recurrence? We searched: Medline, Embase, The Cochrane Library, and other important databases up to July 2009 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).

RESULTS

We found 25 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.

CONCLUSIONS

In this systematic review we present information relating to the effectiveness and safety of the following interventions: antibiotics (short initial intravenous antibiotics, long initial intravenous antibiotics, initial oral antibiotics, single-dose or single-day courses of oral antibiotics, short courses of oral antibiotics, long courses of oral antibiotics, immediate empirical antibiotics, delayed antibiotics, prolonged delay of antibiotics, prophylactic antibiotics); immunotherapy; surgical correction of minor functional abnormalities; and surgical correction of moderate to severe vesicoureteric reflux.

A survey of the management of urinary tract infection in children in primary care and comparison with the NICE guidelines

BACKGROUND

The aim of this study was to establish current practices amongst general practitioners in the West of Ireland with regard to the investigation, diagnosis and management of urinary tract infection (UTI) in children and to evaluate these practices against recently published guidelines from the National Institute for Health and Clinical Excellence (NICE).

METHODS

A postal survey was performed using a questionnaire that included short clinical scenarios. All general practices in a single health region were sent a questionnaire, cover letter and SAE. Systematic postal and telephone contact was made with non-responders. The data was analysed using SPSS version 15.

RESULTS

Sixty-nine general practitioners were included in the study and 50 (72%) responded to the questionnaire. All respondents agreed that it is important to consider diagnosis of UTI in all children with unexplained fever. Doctors accurately identified relevant risk factors for UTI in the majority (87%) of cases. In collecting urine samples from a one year old child, 80% of respondents recommended the use of a urine collection bag and the remaining 20% recommended collection of a clean catch sample. Respondents differed greatly in their practice with regard to detailed investigation and specialist referral after a first episode of UTI. Co-amoxiclav was the most frequently used antibiotic for the treatment of cystitis, with most doctors prescribing a five day course.

CONCLUSIONS

In general, this study reveals a high level of clinical knowledge amongst doctors treating children with UTI in primary care in the catchment area of County Mayo. However, it also demonstrates wide variation in practice with regard to detailed investigation and specialist referral. The common practice of prescribing long courses of antibiotics when treating lower urinary tract infection is at variance with NICE's recommendation of a three day course of antibiotics for cystitis in children over three months of age when there are no atypical features.

Antibiotic prophylaxis and recurrent urinary tract infection in children

BACKGROUND

Antibiotics are widely administered to children with the intention of preventing urinary tract infection, but adequately powered, placebo-controlled trials regarding efficacy are lacking. This study from four Australian centers examined whether low-dose, continuous oral antibiotic therapy prevents urinary tract infection in predisposed children.

METHODS

We randomly assigned children under the age of 18 years who had had one or more microbiologically proven urinary tract infections to receive either daily trimethoprim-sulfamethoxazole suspension (as 2 mg of trimethoprim plus 10 mg of sulfamethoxazole per kilogram of body weight) or placebo for 12 months. The primary outcome was microbiologically confirmed symptomatic urinary tract infection. Intention-to-treat analyses were performed with the use of time-to-event data.

RESULTS

From December 1998 to March 2007, a total of 576 children (of 780 planned) underwent randomization. The median age at entry was 14 months; 64% of the patients were girls, 42% had known vesicoureteral reflux (at least grade III in 53% of these patients), and 71% were enrolled after the first diagnosis of urinary tract infection. During the study, urinary tract infection developed in 36 of 288 patients (13%) in the group receiving trimethoprim-sulfamethoxazole (antibiotic group) and in 55 of 288 patients (19%) in the placebo group (hazard ratio in the antibiotic group, 0.61; 95% confidence interval, 0.40 to 0.93; P = 0.02 by the log-rank test). In the antibiotic group, the reduction in the absolute risk of urinary tract infection (6 percentage points) appeared to be consistent across all subgroups of patients (P > or = 0.20 for all interactions).

CONCLUSIONS

Long-term, low-dose trimethoprim-sulfamethoxazole was associated with a decreased number of urinary tract infections in predisposed children. The treatment effect appeared to be consistent but modest across subgroups. (Australian New Zealand Clinical Trials Registry number, ACTRN12608000470392.)

Can prompt treatment of childhood UTI prevent kidney scarring?

The aim of the study reported here was to determine whether kidney scarring after urinary tract infections (UTI) in children can be prevented and to identify the risk factors for developing scars. We identified children in the Northern health region of the UK who had been seen to develop scars, identified as new defects on dimercapto-succinic acid (DMSA) scanning. Risk factors were sought by reviewing case-notes and interviews with parents. Twenty girls were identified whose new scarring was strongly associated with having both vesicoureteric reflux (VUR) and a UTI (p = 0.0001); 19/23 (83%) of kidneys exposed to both of these factors developed scars. Children were much more likely to be febrile (94 vs. 30%, p < 0.0001) or unwell (82 vs. 10%, p < 0.0001) during their earlier UTIs when they were of median age 2.8 years (range 0.3-5.0 years) and did not scar, compared to their later UTIs at age 7.3 years (1.2-12.5 years), when they did scar. However, most patients were treated within 1 day of their symptoms for their early UTIs, compared to a wait >or=7 days for later UTIs (p = 0.001). Being febrile or unwell during a UTI does not predict the development of scars, but prompt treatment appears to prevent scarring in children with VUR.

Vesicoureteric reflux is not a benign condition

Renal parenchymal defects may be congenital, usually associated with dilated vesicoureteric reflux (VUR), or they may appear in previously normal kidneys and be caused by reflux nephropathy due to VUR combined with urinary tract infection (UTI). A piglet model defined that the 70% of children with VUR and vulnerable pyramids would scar rapidly with their first UTI. Because most defects are present at first imaging after a UTI, and from the lack of benefit from apparently reasonable clinical interventions, many now believe that most defects are congenital, their association with VUR being a shared dysplasia rather than causal. Consequently, guidelines now argue for less assiduous management. These conclusions ignore adult human transplant evidence, adult pig studies, and clinical anecdotes, which indicate that scars may develop in infant kidneys quicker than urine culture can confirm the diagnosis, and that reflux nephropathy has no age limit. Its rarity over 4 years suggests that most vulnerable children develop scars before then, despite all medical efforts. I argue that preventing such scarring will require better diagnosis of infant UTI, quicker treatment, reliable imaging of scars and VUR, and subsequent protection until VUR resolves. To make a difference, we need more assiduous management, not less, and cannot afford to consider VUR to be a benign condition.

The role of dexamethasone on decreasing urinary cytokines in children with acute pyelonephritis

Cytokines play a major role in renal scar formation following febrile urinary tract infection (UTI). We investigated the role of dexamethasone combined with antibiotics in diminishing urinary interleukin-6 (UIL-6) and UIL-8 concentrations during the acute phase of pyelonephritis compared with standard antibiotic therapy. UIL-6 and UIL-8 concentrations were determined by enzyme immunoassay in 34 children with pyelonephritis who were treated with ceftriaxone plus dexamethasone (case group) and in 20 patients with the same diagnosis treated with ceftriaxone alone (control group). Urine samples were obtained at the time of presentation prior to drug administration and at follow-up 72 h after initiation of medication. Creatinine concentrations were also determined, and cytokine/creatinine ratios were calculated to standardize samples. Differences between cytokine/creatinine ratios in initial and follow-up urine samples were significant in the case group (P < 0.001) but not for controls. In addition, combined antibiotic and dexamethasone significantly decreased UIL-6 and UIL-8 concentrations compared with antibiotic alone (P < 0.05). We conclude that dexamethasone combined with antibiotics significantly decreases UIL-6 and UIL-8 levels in patients with acute pyelonephritis. This suggests that the clinical use of corticosteroids may prevent scar formation following febrile UTI.

Therapy Insight: what nephrologists need to know about primary vesicoureteral reflux

Vesicoureteral reflux (VUR) is the abnormal, retrograde flow of urine from the bladder to the upper urinary tract. This disease affects about 1% of otherwise normal children, 30-50% of those who present with urinary tract infections, and approximately 10% with prenatally diagnosed hydronephrosis. Over the past 50 years, tremendous progress has been made in the diagnosis, treatment and management of VUR. The realization that VUR is probably a component of generalized dysfunction of the lower urinary tract (i.e. dysfunctional elimination syndrome) has further enhanced understanding of the disease. This Review covers basic pathogenesis, diagnosis, management, clinical presentation, and current controversies surrounding VUR.

Management of children's urinary tract infections in Dutch family practice: a cohort study

BACKGROUND

Optimal clinical management of childhood urinary tract infections (UTI) potentiates long-term positive health effects. Insight into the quality of care in Dutch family practices for UTIs was limited, particularly regarding observation periods of more than a year. Our aim was to describe the clinical management of young children's UTIs in Dutch primary care and to compare this to the national guideline recommendations.

METHODS

In this cohort study, all 0 to 6-year-old children with a diagnosed UTI in 2001 were identified within the Netherlands Information Network of General Practitioners (LINH), which comprises 120 practices. From the Dutch guideline on urinary tract infections, seven indicators were derived, on prescription, follow-up, and referral.

RESULTS

Of the 284 children with UTI who could be followed for three years, 183 (64%) were registered to have had one cystitis episode, 52 (18%) had two episodes, and 43 (15%) had three or more episodes. Another six children were registered to have had one or two episodes of acute pyelonephritis. Overall, antibiotics were prescribed for 66% of the children having had < or = 3 cystitis episodes, two-thirds of whom received the antibiotics of first choice. About 30% of all episodes were followed up in general practice. Thirty-eight children were referred (14%), mostly to a paediatrician (76%). Less than one-third of the children who should have been referred was actually referred.

CONCLUSION

Treatment of childhood UTIs in Dutch family practice should be improved with respect to prescription, follow-up, and referral. Quality improvement should address the low incidence of urinary tract infections in children in family practice.

Infections and vesicoureteral reflux

Vesicoureteral reflux (VUR) is a common condition in children. It may cause and maintain urinary tract infections, eventually leading to progressive renal damage and end-stage renal disease. Ideally, VUR should be detected and treated before renal scarring occurs. Although fetal hydronephrosis on antenatal ultrasound may be the first indicator, the role of further diagnostic investigations in these newborns is still controversial. Because VUR is an inherited condition, offspring of women with a family history of VUR and urinary tract infection should be screened closely for early detection of VUR. Once diagnosed, however, the optimal management of VUR (i.e. medical or surgical treatment) remains controversial. Evidence-based treatment recommendations, like the American Urological Association guidelines, may aid physicians in their therapeutic decision making, but cannot replace personal experience or surgical skill.

Long-term antibiotics for preventing recurrent urinary tract infection in children

BACKGROUND

Acute urinary tract infection (UTI) is common in children. By the age of seven 8.4% of girls and 1.7% of boys will have suffered at least one episode. Symptoms include fever, lethargy, anorexia, and vomiting. UTI is caused by Escherichia coli in over 80% of cases and treatment consists of a course of antibiotics. Due to acute illness caused by UTI and the risk of pyelonephritis-induced permanent kidney damage, many children are given long-term antibiotics aimed at preventing recurrence.

OBJECTIVES

To determine the efficacy and harms of long-term antibiotics to prevent recurrent UTI in children.

SEARCH STRATEGY

We searched without language restriction MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, the Cochrane Renal Group's Specialised Register, reference lists of review articles and contacted content experts. Date of most recent search: January 2006

SELECTION CRITERIA

Randomised comparisons of antibiotics with other antibiotics, placebo or no treatment to prevent recurrent UTI.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed and extracted information. A random-effects model was used to estimate relative risk (RR) and risk difference (RD) for recurrent UTI with 95% confidence intervals (CI).

MAIN RESULTS

Eight studies (618 children) were identified, five (406) comparing antibiotics with placebo/no treatment. The duration of antibiotic prophylaxis treatment varied from 10 weeks to 12 months. Compared to placebo/no treatment, antibiotics reduced the risk of repeat positive urine culture (RR 0.44, 95% CI 0.19 to 1.00; RD -30%, 95% CI -56% to -4%) No side effects were reported. One study reported that nitrofurantoin was more effective than trimethoprim in preventing recurrent UTI over a six month period (RR 0.48, 95% CI 0.25 to 0.92; RD -18%, 95% CI -34% to -3%). However, patients receiving nitrofurantoin were more likely to discontinue the antibiotic due to side effects (mainly gastrointestinal) (RR 3.17, 95% CI 1.36 to 7.37; RD 22%, 95% CI 8% to 36%). The other study found cefixime was more effective in preventing recurrent UTI than nitrofurantoin (RR 0.74, 95% CI 0.13 to 4.10; RD -3%, 95% CI -17% to -12%). However, 62% of patients receiving cefixime experienced an adverse reaction during the first six months of treatment (18/29) while only 26% (8/31) of patients receiving nitrofurantoin reported an adverse reaction.

AUTHORS' CONCLUSIONS

Large, properly randomised, double blinded studies are needed to determine the efficacy of long-term antibiotics for the prevention of UTI in susceptible children.

A nurse led education and direct access service for the management of urinary tract infections in children: prospective controlled trial

OBJECTIVES

To determine whether a nurse led education and direct access service improves the care of children with urinary tract infections.

DESIGN

Prospective cluster randomised trial.

SETTING

General practitioners in the catchment area of a UK paediatric nephrology department.

PARTICIPANTS

88 general practices (346 general practitioners, 107 000 children).

MAIN OUTCOME MEASURES

Rate and quality of diagnosis of urinary tract infection, use of prophylactic antibiotics, convenience for families, and the number of infants with vesicoureteric reflux in whom renal scarring may have been prevented.

RESULTS

The study practices diagnosed twice as many urinary tract infections as the control practices (6.42 v 3.45/1000 children/year; ratio 1.86, 95% confidence interval 1.42 to 2.44); nearly four times more in infants (age < 1 year) and six times more in children without specific symptoms. Diagnoses were made more robustly by study practices than by control practices; 99% v 89% of referred patients had their urine cultured and 79% v 60% had bacteriologically proved urinary tract infections (P < 0.001 for both). Overall, 294 of 312 (94%) children aged under 4 years were prescribed antibiotic prophylaxis by study doctors compared with 61 of 147 (41%) by control doctors (P < 0.001). Study families visited hospital half as much as the control families. Twice as many renal scars were identified in patients attending the study practices. Twelve study infants but no control infants had reflux without scarring.

CONCLUSION

A nurse led intervention improved the management of urinary tract infections in children, was valued by doctors and parents, and may have prevented some renal scarring.

Antibiotics for the prevention of urinary tract infection in children: A systematic review of randomized controlled trials

OBJECTIVE

The objective was to evaluate the effectiveness of low-dose, long-term antibiotics for the prevention of symptomatic urinary tract infection (UTI) in children.

DESIGN

This was a systematic review of randomized controlled trials with a random effects model meta-analysis.

PARTICIPANTS

Five trials involving 463 children were performed.

RESULTS

Three trials (n = 392) evaluated the effectiveness of long treatment courses of antibiotics (2 to 6 months) for children with acute UTI to prevent subsequent, off-treatment infection. Only 2 trials (n = 71) evaluated the effectiveness of long-term, low-dose antibiotics to prevent on-treatment UTI. Very few of the children enrolled in the trials were boys, had abnormal renal tracts, or were infants. The trial quality was poor, with a lack of blinding, and unstated UTI definitions were almost universal. Long-term antibiotic administration reduced the risk of UTI with treatment (relative risk 0.31, 95% confidence limits 0.10 to 1.00), but there was significant heterogeneity (Q = 13.45, P <.01), and there was no sustained benefit once antibiotics had ceased (relative risk 0.79, 0.61 to 1.02).

CONCLUSIONS

Methodologic and applicability problems with published trials mean that there is considerable uncertainty about whether long-term, low-dose antibiotic administration prevents UTI in children. Well-designed, randomized, placebo-controlled trials are still required to evaluate this commonly used intervention.

Long-term antibiotics for preventing recurrent urinary tract infection in children

BACKGROUND

Acute urinary tract infection (UTI) is common in children. By the age of seven years, 8.4% of girls and 1.7% of boys will have suffered at least one episode. Symptoms are systemic rather than localised in early childhood and consist of fever, lethargy, anorexia, and vomiting. UTI is caused by E. coli in over 80% of cases and treatment consists of a course of antibiotics. Due to the unpleasant acute illness caused by UTI and the risk of pyelonephritis-induced permanent kidney damage, many children are given long-term antibiotics aimed at preventing recurrence. However these medications may cause side effects and promote the development of resistant bacteria.

OBJECTIVES

To determine the efficacy and side effects of long-term antibiotics given to prevent recurrent UTI in children.

SEARCH STRATEGY

A search of MEDLINE (1966 to Jan 2001), EMBASE (1988 to Jan 2001) and the Cochrane Controlled Trials Register for relevant randomised controlled trials without language restriction; reference lists of review articles; contact with content experts.

SELECTION CRITERIA

Randomised comparisons of two or more antibiotics and placebo with one or more antibiotics to prevent recurrent UTI.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed and extracted information. For each trial, information was collected on the methods of the trial, participants, interventions and outcomes. A random-effects model was used to estimate a summary relative risk (RR) and a summary risk difference (RD) for recurrent UTI. Heterogeneity tests and subgroup analyses were carried out based on a priori hypothesis of plausible effect modification.

MAIN RESULTS

There were three trials (n = 151) comparing antibiotics with placebo/no treatment. The duration of antibiotic prophylaxis treatment varied among the studies (10 weeks to 12 months). The method of allocation concealment in the three trials was inadequate, unclear and adequate. The overall rate of recurrent UTI in the placebo/no treatment group was 63% (48/76). Compared to placebo/no treatment, antibiotics reduced the risk of recurrent UTI (RR 0.36, 95% CI 0.16 to 0.77; RD -46%, 95% CI -59% to -33%). No side effects were described in any of these three trials. There was one double-blinded trial (n = 120) with unclear allocation concealment that compared two different types of antibiotics to prevent recurrent UTI. Nitrofurantoin was more effective than trimethoprim in preventing recurrent UTI over a six month period (RR 0.48, 95% CI 0.25 to 0.92; RD -18%, 95% CI -34% to -3%). However, patients receiving nitrofurantoin were more likely to discontinue the antibiotic due to side effects (mainly gastrointestinal) than patients receiving trimethoprim (RR 3.17, 95% CI 1.36 to 7.37; RD 22%, 95% CI 8% to 36%).

REVIEWER'S CONCLUSIONS

Most published studies to date have been poorly designed with biases known to overestimate the true treatment effect. Large, properly randomised, double blinded trials are needed to determine the efficacy of long-term antibiotics for the prevention of UTI in susceptible children.