(From the May 2015 Issue of PediatricsOnline)
Urinary tract infection (UTI) is a common but serious bacterial infection in children. To avoid complications including chronic medical problems or fatal urosepsis, a wide range of factors must be considered in determining the best diagnosis, treatment and management protocols.
In a review published in Expert Review of Anti-Infective Therapy, researchers at Nationwide Children’s Hospital and The Ohio State University summarize current understandings regarding diagnosis, evaluation and management of pediatric UTIs.
“UTI diagnosis and treatment is nuanced, particularly in children with structural and functional disorders of the urinary tract. Prompt recognition of UTI is critical,” says Brian Becknell, MD, a practicing nephrologist and principal investigator at the Center for Clinical and Translational Research at Nationwide Children’s and lead author on the paper. “UTIs associated with fever signify kidney infections, or pyelonephritis, placing children at risk for irreversible kidney damage.”
One of the barriers to rapid diagnosis and prompt therapy is urine sample collection from infants or children who are not toilet trained. Common noninvasive methods are problematic due to high rates of cross contamination and false positives.
The American Academy of Pediatrics’ current recommendation is transurethral bladder catheterization or suprapubic aspirate in children who are not toilet trained, because of low contamination risk. “However, these methods are invasive, stressful and not always feasible in a primary care setting,” Dr. Becknell says.
To date, most UTIs are unable to be appropriately treated with targeted antibiotics until the uropathogen is cultured, identified and subjected to antibiotic susceptibility testing. This typically results in a two- to three-day delay in targeted treatment. Broad-spectrum antibiotics can be administered in the meantime, but their overuse and misuse have contributed to the emergence of multi-drug-resistant uropathogens. More than 30 percent of UTI are caused by E. coli resistant to trimethoprim-sulfamethoxazole (TMP-SMX).
“To prevent resistance, it is important to not over-prescribe antibiotics and to discontinue empiric antibiotics if urine cultures are negative,” Dr. Becknell says. “Additionally, although antibiotic prophylaxis may prevent pyelonephritis episodes, it comes at the expense of increased rates of antibiotic resistance.”
Antibiotic prophylaxis for recurrent UTI has been debated heavily. Evidence for the use of continuous antibiotic prophylaxis has been obtained mostly in patients with vesicoureteral reflux (VUR), and it remains largely inconclusive. However, a recent randomized trial cited in Dr. Becknell’s review showed a benefit, particularly for females with febrile UTI and those with bladder and bowel dysfunction.
“While it is exhilarating to see results of randomized, placebo-controlled trials on antibiotic prophylaxis, care and judgment must be exercised when applying these studies to children with abnormal urinary tract anatomy and function,” Dr. Becknell cautions. “We encourage clinicians to collaborate with their nephrology and urology colleagues in such cases.”
Finding new strategies to reduce the use of broad-spectrum antibiotics is critical as the rate of antibiotic resistance continues to rise, Dr. Becknell says. Rapid antibiotic susceptibility tests would speed early UTI treatment with targeted and effective drugs. Identification of new UTI biomarkers would also help improve accuracy of diagnosis, determine infection severity and identify renal scarring risks. Currently, children whose urinary tracts are colonized with harmless bacteria are particularly difficult to diagnose.
“I collaborate with a large group of physician-scientists at Nationwide Children’s and around the country in an effort to develop antimicrobial peptides for diagnostic, prognostic and therapeutic applications in children with UTI,” Dr. Becknell says. “While this work is in the discovery phase, we feel it has the potential to significantly impact child health.”
In the paper, Dr. Becknell and his team also discuss another tactic for reducing the use of broad-spectrum antibiotics: complementary and alternative medicine. The use of cranberry juice and probiotics to treat or prevent UTI are popular alternative therapies. However, placebo-controlled studies are needed before these alternative and complementary therapies can be fully integrated into treatment regimens.
Becknell B, Schober M, Korbel L, Spencer JD. The diagnosis, evaluation and treatment of acute and recurrent pediatric urinary tract infections. Expert Review in Anti-Infective Therapy. 2015, 13(1):81-90.