AimOur aim was to update the recommendations for the diagnosis, treatment and follow‐up of the first febrile urinary tract infection in young children, which were endorsed in 2012 by the Italian Society of Pediatric Nephrology.MethodsThe Italian recommendations were revised on the basis of a review of the literature published from 2012 to October 2018. We also carried out an ad hoc evaluation of the risk factors to identify children with high‐grade vesicoureteral reflux or renal scarring, which were published in the previous recommendations. When evidence was not available, the working group held extensive discussions, during various meetings and through email exchanges.ResultsFour major modifications have been introduced. The method for collecting urine for culture and its interpretation has been re‐evaluated. We have reformulated the algorithm that guides clinical decisions to proceed with voiding cystourethrography. The suggested antibiotics have been revised, and we have recommended further restrictions of the use of antibiotic prophylaxis.ConclusionThese updated recommendations have now been endorsed by the Italian Society of Pediatric Nephrology and the Italian Society for Pediatric Infectivology. They can also be used to compare other recommendations that are available, as a worldwide consensus in this area is still lacking.
Acute pyelonephritis is one of the most serious bacterial illnesses during childhood. Escherichia coli is responsible in most cases, however other organisms including Klebsiella, Enterococcus, Enterobacter, Proteus, and Pseudomonas species are being more frequently isolated. In infants, who are at major risk of complications such as sepsis and meningitis, symptoms are ambiguous and fever is not always useful in identifying those at high risk. A diagnosis of acute pyelonephritis is initially made on the basis of urinalysis; dipstick tests for nitrites and/or leukocyte esterase are the most accurate indicators of infection. Collecting a viable urine sample for urine culture using clean voided methods is feasible, even in young children. No gold standard antibiotic treatment exists. In children appearing well, oral therapy and outpatient care is possible. New guidelines suggest less aggressive imaging strategies after a first infection, reducing radiation exposure and costs. The efficacy of antibiotic prophylaxis in preventing recurrence is still a matter of debate and the risk of antibiotic resistance is a warning against its widespread use. Well-performed randomized controlled trials are required in order to better define both the imaging strategies and medical options aimed at preserving long-term renal function.
E. coli is the most common organism causing UTIs in infants; however, other bacterial strains are frequently isolated. As a result, antibiotic prophylaxis should be more elastic and adaptable over time in order to guarantee maximum efficacy.
Patients on dialysis are exposed to a series of factors that are known to be associated with risk of acute pancreatitis (AP), including medications, hyperparathyroidism, hypercalcemia, and hypertriglyceridemia; the role of the dialysis modality itself is still debated. Data regarding AP in children on chronic dialysis are scarce. Data from the Italian Registry of Pediatric Chronic Dialysis (IRPCD) confirm that children on dialysis have a significant increased relative risk (RR) for AP as compared with the general pediatric population (RR 60.4; 95% CI 3.2-214). Diagnosis of AP in patients on dialysis may be troublesome, because it can mimic other acute intraabdominal conditions and the role of serum pancreatic enzyme assays may be confounding. In this setting, instrumental imaging is mandatory. Conservative management such as fluid, bowel rest, and antibiotics is the mainstay of AP management, as necrotizing forms are rare. Mortality in the series of 12 patients from the IRPCD was high (25%), but deaths were not directly related to AP. Adult case series confirm that mortality among patients on dialysis who develop AP is highly variable (8-58%), but higher as compared to 10% mortality from AP in non-renal failure patients.
Among the risk factors proposed by the Italian guidelines, only the presence of a pathogen other than E. coli significantly predicted reflux. Cystography can be postponed in children with no risk factors.
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