Consider entire patient when diagnosing, treating UTI

Issue: December 2010

NEW YORK CITY – Pediatricians should expect some updated guidelines on managing urinary tract infections early in 2011, according to a speaker here at the 23^rd Annual Infectious Diseases in Children New York Symposium.

Russell W. Chesney, MD, from The University of Tennessee Health Science Center in Memphis, TN, said that UTIs are sometimes missed and diagnosed instead as “undifferentiated febrile illness of childhood.” It is important to consider that 3% to 7% of girls and 2% of boys will have a UTI before age 5; and most of these are caused by Escherichia coli. Vesicoureteral reflux (VUR) is found in 25% to 40% of patients after febrile UTI, and renal scarring develops in 30%, regardless of VUR.

Chesney said treatment of acute UTI is important to prevent recurrence, fever, fungal infections and other issues.

Children with Grade 5 reflux and obstruction are currently indicated to receive prophylaxis. Trimethoprim-sulfamethazole, nitrofurantoin and mandelic acid can all be used as prophylaxis.

Controversy exists, however, over those patients that should be administered prophylaxis, according to Chesney. He cited the RIVUR study, which he and colleagues are currently using to explore whether children with VUR need to be treated using antimicrobial prophylaxis, and whether treatment prevents recurring UTIs and renal scarring. As of July, the trial had enrolled 500 participants, and enrollment is expected to be completed by early 2011.

The controversy took center stage last year as investigators with another trial showed that a “one-size-fits-all approach” for children with this condition might not be appropriate. The trial showed an overall reduction of about 6 percentage points in the absolute risk of symptomatic and febrile UTIs; time-to-event-analysis showed that antimicrobial prophylaxis benefit was not sustained, and about 14 children would need to be treated to prevent one infection.

However, early findings from RIVUR indicate that the lack of rigorous radiographic standardization in all studies of VUR may have affected those study outcomes, Chesney said.

In the meantime, Chesney stressed the importance of assessing the risk of renal injury and scarring for individual patients based upon clinical factors known to be associated with VUR and renal injury. These include: age, grade of reflux, scarring, abnormal bladder function and UTI history and tailoring therapies appropriate to the risk profile.

“VUR may be a wolf in sheep’s clothing. It continues to evolve and there will be no cookbook solution,” Chesney said.

Honing in on those children who would benefit most from prophylaxis would go a long way to reduce overuse of antimicrobials, Chesney said.

For more information:

Chesney RW. Recurrent UTIs and reflux. Presented at: the 23rd Annual Infectious Diseases in Children Symposium; Nov. 20-21, 2010; New York City.

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