Swiss consensus recommendations on urinary tract infections in children

Abstract

The kidneys and the urinary tract are a common source of infection in children of all ages, especially infants and young children. The main risk factors for sequelae after urinary tract infections (UTI) are congenital anomalies of the kidney and urinary tract (CAKUT) and bladder-bowel dysfunction. UTI should be considered in every child with fever without a source. The differentiation between upper and lower UTI is crucial for appropriate management. Method of urine collection should be based on age and risk factors. The diagnosis of UTI requires urine analysis and significant growth of a pathogen in culture. Treatment of UTI should be based on practical considerations regarding age and presentation with adjustment of the initial antimicrobial treatment according to antimicrobial sensitivity testing. All children, regardless of age, should have an ultrasound of the urinary tract performed after pyelonephritis. In general, antibiotic prophylaxis is not recommended. Conclusion: Based on recent data and in line with international guidelines, multidisciplinary Swiss consensus recommendations were developed by members of Swiss pediatric infectious diseases, nephrology, and urology societies giving the clinician clear recommendations in regard to diagnosis, type and duration of therapy, antimicrobial treatment options, indication for imaging, and antibiotic prophylaxis. What is Known:• Urinary tract infections (UTI) are a common and important clinical problem in childhood. Although children with pyelonephritis tend to present with fever, it can be difficult on clinical grounds to distinguish cystitis from pyelonephritis, particularly in young children less than 2 years of age.• Method of urine collection is based on age and risk factors. The diagnosis of UTI requires urine analysis and significant growth of a pathogen in culture. What is New:• Vesicoureteric reflux (VUR) remains a risk factor for UTI but per se is neither necessary nor sufficient for the development of renal scars. Congenital anomalies of the kidney and urinary tract (CAKUT) and bladder-bowel dysfunction play a more important role as causes of long-term sequelae. In general, antibiotic prophylaxis is not recommended.• A switch to oral antibiotics should be considered already in young infants. Indications for invasive imaging are more restrictive and reserved for patients with abnormal renal ultrasound, complicated UTI, and infections with pathogens other than E. coli.

Antibiotic Resistance Patterns of Uropathogens Causing Urinary Tract Infections in Children with Congenital Anomalies of Kidney and Urinary Tract

“…Only four patients had more than 10 episodes of UTI. High-grade bilateral VUR, PUV, or urogenital sinus, in absence of effective surgical treatment, remain challenging cases in terms of antibiotic treatment options [ 24 ]. Multiple hospitalizations for UTIs led to increased antibiotic resistance of uropathogens and multidrug-resistant opportunistic strain selection ( Stenotrophomonas maltophilia , Proteus spp., Serratia marcescens , Enterobacter spp.).…”

What’s the catch? Urine sample collection from young pre-continent children: a qualitative study in primary care.

“… 23 , 24 Several recent guidelines recommend voiding stimulation techniques, such as the Quick-Wee method, to improve the speed and success of clean catch collection. 7 , 28 – 30 …”

Vesicoureteral reflux: we have yet to complete our learning

“…Since the application of continuous antibiotic prophylaxis (CAP) for the management of vesicoureteral reflux (VUR), the adage "less is more" has been a guiding principle [1]. The diagnosis of VUR during the prenatal period or following recurrent febrile urinary tract infections and associated with acquired renal cortical scarring is relatively not very common.…”

“…The diagnosis of VUR during the prenatal period or following recurrent febrile urinary tract infections and associated with acquired renal cortical scarring is relatively not very common. VUR increasingly became a disease that children lived with, rather than suffered from, notably once it was recognized that VUR spontaneously resolved and CAP prevented UTIs during observation, in most [1]. However, not all children fare well on CAP, and the rising incidence of bacterial resistance requires that we challenge the current paradigm.…”

“…However, not all children fare well on CAP, and the rising incidence of bacterial resistance requires that we challenge the current paradigm. Studies have called into question CAP's wholesale application, identifying children at the most significant risk for recurrent UTIs and its consequences as those who benefit most from CAP [1]. Variables increasing one's risk for recurrent UTI include age < 6 months, presence of foreskin, female gender, dilating VUR (i.e., grades 3-5), renal cortical scarring, and bladderbowel dysfunction (BBD) [2].…”