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      A guideline for the inpatient care of children with pyelonephritis

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          Abstract

          BACKGROUND AND OBJECTIVES:

          Febrile urinary tract infections and pyelonephritis are common in children and frequently lead to hospitalization for management, especially in the child who appears toxic. The American Academy of Pediatrics (AAP) practice parameter on the diagnosis, treatment and evaluation of the initial urinary tract infection in febrile infants and young children provides experience and evidence-based guidelines for the practitioner caring for children between the ages of 2 months to 2 years. No established guideline exists for older children and the AAP guideline does not specifically focus on inpatient care.

          METHODS:

          We conducted a comprehensive review of recently published literature and practice guidelines to develop a consensus on the inpatient diagnosis and management of children with pyelonephritis.

          RESULTS:

          Eight recommendations are proposed for the diagnosis and management, including revised guidelines for the imaging studies postpyelonephritis on the basis of current best evidence.

          CONCLUSION:

          Proper diagnosis of pyelonephritis, timely initiation of appropriate therapy and identification of children at risk for renal injury will help to reduce immediate as well as long-term complications due to chronic kidney disease.

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          Prevalence of urinary tract infection in childhood: a meta-analysis.

          Max H Farrell, James E. Bost, Nader Shaikh … (2008)
          Knowledge of baseline risk of urinary tract infection can help clinicians make informed diagnostic and therapeutic decisions. We conducted a meta-analysis to determine the pooled prevalence of urinary tract infection (UTI) in children by age, gender, race, and circumcision status. MEDLINE and EMBASE databases were searched for articles about pediatric urinary tract infection. Search terms included urinary tract infection, cystitis, pyelonephritis, prevalence and incidence. We included articles in our review if they contained data on the prevalence of UTI in children 0-19 years of age presenting with symptoms of UTI. Of the 51 articles with data on UTI prevalence, 18 met all inclusion criteria. Two evaluators independently reviewed, rated, and abstracted data from each article. Among infants presenting with fever, the overall prevalence (and 95% confidence interval) of UTI was 7.0% (CI: 5.5-8.4). The pooled prevalence rates of febrile UTIs in females aged 0-3 months, 3-6 months, 6-12 months, and >12 months was 7.5%, 5.7%, 8.3%, and 2.1% respectively. Among febrile male infants less than 3 months of age, 2.4% (CI: 1.4-3.5) of circumcised males and 20.1% (CI: 16.8-23.4) of uncircumcised males had a UTI. For the 4 studies that reported UTI prevalence by race, UTI rates were higher among white infants 8.0% (CI: 5.1-11.0) than among black infants 4.7% (CI: 2.1-7.3). Among older children (<19 years) with urinary symptoms, the pooled prevalence of UTI (both febrile and afebrile) was 7.8% (CI: 6.6-8.9). Prevalence rates of UTI varied by age, gender, race, and circumcision status. Uncircumcised male infants less than 3 months of age and females less than 12 months of age had the highest baseline prevalence of UTI. Prevalence estimates can help clinicians make informed decisions regarding diagnostic testing in children presenting with signs and symptoms of urinary tract infection.
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            Imaging studies after a first febrile urinary tract infection in young children.

            Jerry M. Baskin, R Wald, Kimberly Hickey … (2003)
            Guidelines from the American Academy of Pediatrics recommend obtaining a voiding cystourethrogram and a renal ultrasonogram for young children after a first urinary tract infection; renal scanning with technetium-99m-labeled dimercaptosuccinic acid has also been endorsed by other authorities. We investigated whether imaging studies altered management or improved outcomes in young children with a first febrile urinary tract infection. In a prospective trial involving 309 children (1 to 24 months old), an ultrasonogram and an initial renal scan were obtained within 72 hours after diagnosis, contrast voiding cystourethrography was performed one month later, and renal scanning was repeated six months later. The ultrasonographic results were normal in 88 percent of the children (272 of 309); the identified abnormalities did not modify management. Acute pyelonephritis was diagnosed in 61 percent of the children (190 of 309). Thirty-nine percent of the children who underwent cystourethrography (117 of 302) had vesicoureteral reflux; 96 percent of these children (112 of 117) had grade I, II, or III vesicoureteral reflux. Repeated scans were obtained for 89 percent of the children (275 of 309); renal scarring was noted in 9.5 percent of these children (26 of 275). An ultrasonogram performed at the time of acute illness is of limited value. A voiding cystourethrogram for the identification of reflux is useful only if antimicrobial prophylaxis is effective in reducing reinfections and renal scarring. Renal scans obtained at presentation identify children with acute pyelonephritis, and scans obtained six months later identify those with renal scarring. The routine performance of urinalysis, urine culture, or both during subsequent febrile illnesses in all children with a previous febrile urinary tract infection will probably obviate the need to obtain either early or late scans. Copyright 2003 Massachusetts Medical Society
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              Recurrent urinary tract infections in children: risk factors and association with prophylactic antimicrobials.

              Theoklis Zaoutis, Amy B Henry, Ron Keren … (2007)
              The evidence regarding risk factors for recurrent urinary tract infection (UTI) and the risks and benefits of antimicrobial prophylaxis in children is scant. To identify risk factors for recurrent UTI in a pediatric primary care cohort, to determine the association between antimicrobial prophylaxis and recurrent UTI, and to identify the risk factors for resistance among recurrent UTIs. From a network of 27 primary care pediatric practices in urban, suburban, and semirural areas spanning 3 states, a cohort of children aged 6 years or younger who were diagnosed with first UTI between July 1, 2001, and May 31, 2006, was assembled. Time-to-event analysis was used to determine risk factors for recurrent UTI and the association between antimicrobial prophylaxis and recurrent UTI, and a nested case-control study was performed among children with recurrent UTI to identify risk factors for resistant infections. Time to recurrent UTI and antimicrobial resistance of recurrent UTI pathogens. Among 74 974 children in the network, 611 (0.007 per person-year) had a first UTI and 83 (0.12 per person-year after first UTI) had a recurrent UTI. In multivariable Cox time-to-event models, factors associated with increased risk of recurrent UTI included white race (0.17 per person-year; hazard ratio [HR], 1.97; 95% confidence interval [CI], 1.22-3.16), age 3 to 4 years (0.22 per person-year; HR, 2.75; 95% CI, 1.37-5.51), age 4 to 5 years (0.19 per person-year; HR, 2.47; 95% CI, 1.19-5.12), and grade 4 to 5 vesicoureteral reflux (0.60 per person-year; HR, 4.38; 95% CI, 1.26-15.29). Sex and grade 1 to 3 vesicoureteral reflux were not associated with risk of recurrence. Antimicrobial prophylaxis was not associated with decreased risk of recurrent UTI (HR, 1.01; 95% CI, 0.50-2.02), even after adjusting for propensity to receive prophylaxis, but was a risk factor for antibimicrobial resistance among children with recurrent UTI (HR, 7.50; 95% CI, 1.60-35.17). Among the children in this study, antimicrobial prophylaxis was not associated with decreased risk of recurrent UTI, but was associated with increased risk of resistant infections.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Ann Saudi Med
                Journal ID (publisher-id): ASM
                Title: Annals of Saudi Medicine
                Publisher: Medknow Publications (India )
                ISSN (Print): 0256-4947
                ISSN (Electronic): 0975-4466
                Publication date (Print): Sep-Oct 2010
                Volume: 30
                Issue: 5
                Pages: 341-349
                Affiliations
                [a ]From the Department of Pediatrics, Division of Nephrology, University of Kentucky, Lexington, Kentucky, USA
                [b ]From the Section of Inpatient Pediatrics, Division of General Academic Pediatrics, University of Kentucky, Lexington, Kentucky, USA
                [c ]From the Division of Infectious Disease, University of Kentucky, Lexington, Kentucky, USA
                Author notes
                Correspondence: Aftab S. Chishti, MD · Department of Pediatrics, Division of Nephrology Hypertension and Renal Transplantation, University of Kentucky, Kentucky Children’s Hospital, William R. Wallard Medical Science Bldg, Rm # MN 115, 800 Rose Street, Lexington KY 40536-0298 USA · T: +1-859-257-1552 F: +1-859-257-7799 · aftab.chishti@ 123456uky.edu
                Article
                Publisher ID: ASM-30-341
                DOI: 10.4103/0256-4947.68549
                PMC ID: 2941245
                PubMed ID: 20716830
                SO-VID: b3be7457-aaf5-417d-9494-84764bd93a33
                Copyright © © Annals of Saudi Medicine
                License:

                This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date accepted : September 2009
                Categories
                Subject: Review

                ScienceOpen disciplines: Medicine
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                ScienceOpen disciplines: Medicine

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