How to Manage UTI in Children and Pregnancy

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How to Manage UTI in Children and
Pregnancy

• SANG DON LEE
• PUSAN NATIONAL UNIVERSTIY

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Contents

• Management of UTI in Children
• Based on Pathophysiology
• Management of UTI in Pregnancy

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Pathophysiology
Finer G, et al. Lancet Infect Dis 20044631-5
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UTI vs VUR and Renal scar

• VUR the most common, 21-57
• Renal scar 40-73 in UTI with VUR

Pediatrics, 1999 Hodson CJ, BMJ 1965
Rushinton J Urol 2002
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VD, Constipation vs UTI
Scand J Urol Nephrol 200236260-7
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Constipation, OAB vs UTI

• Close relationship between recurrent UTI and
  constipation
• Neumann et al, Pediatrics 197352241-5
• ORegan et al, Clin Nephrol 198523152-4
• Close relationship between recurrent UTI,
  constipation and OAB
• Hellstein S et al, Clin Pediatr 20034243-9

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Voiding dysfunction
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VD, Constipation, OAB vs UTI
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Relationship between VUR, VD constipation, OAB
and UTI
OAB
Constipation
Milk back of infected urine Effects on local
defence mechanism Increased post-void rediduals
VUR
Change in bladder sensation
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Why does UTI in children needs to manage ?
Shortliffe LMD, Campbells Urology 2002
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J Urol 2006175989-93
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General Principles of Treatment
VUR
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Principle of voiding dysfunction
Breakage of Vicious Cycle
Pharmacotherapy Posture Correction Tx for
Constipation
Pharmacotherapy Voiding drinking
chart Intravesical Biofeedback
Relaxation Biofeedback Uroflow Biofeedback Pharmac
otherapy
Scand J Urol Nephrol 200236260-7
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Management of Constipation

• Relief of Pain on defecation
• ?Breakage of Vicious cycle
• Fiber diet
• Encourage Fluid Intake
• Go to stool whenever feel sense of defecation
• Posture correction
• Pelvic floor relaxation
• Mineral oil, Sorbitol, Mg, Laxatives
• Enema
• Suppositories

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Major Treatment Modalities for OAB

• Behavioral therapy
• Pharmacotherapy
• Oral
• Intravesical
• Neuromodulation
• Electrical
• Magnetic
• Surgical therapy
• Noninvasive
• Invasive

• Anticholinergics
• Antimuscarinics
• Alpha antagnoists
• UTI control
• Constipation control

Campbells Urology 9th ed BJU Int 00187723-31
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Treatment algorithm by the AAP (1999)
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Conclusions Pediatric UTI (1)

• UTIs in children often go undiagnosed since the
  signs symptoms are usually non specific and
  overlap with other common childhood illnesses.
• We need to understand the pathogenesis of UTIs
  and the relationship between UTIs, VUR,
• voiding dysfunction OAB.
• Prompt management of UTIs its underlying
  causes in children is required to reduce
  morbidity, long-term complications improve
  outcomes.

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Conclusions Pediatric UTI (2)

• Voiding dysfunction UTI OAB in children may
  be treated without accurate evaluation of
  bladder, urethral, bowel function. However it
  would require a longer treatment than necessary
  with the possibility of trial and error.
• Evidence based proper Tx can promise to
  prevention of the disease progression into
  adulthood.
• To accomplish high success rate of treatment,
  multidisciplinary comprehensive Tx is
  mandatory.

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Contents

• Management of UTI in Children
• Based on Pathophysiology
• Management of UTI in Pregnancy

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Pathogenesis and UT changes

• Although the incidence of bacteriuria in
  pregnant women is similar to that in their
  nonpregnant counterparts, the incidence of acute
  pyelonephritis in pregnant women with bacteriuria
  is significantly increased, compared with
  non-pregnant women.
• Anatomic and physiologic urinary tract changes in
  pregnancy may cause pregnant women with
  bacteriuria to have an increased susceptibility
  to pyelonephritis.

Obstet Gynecol Clin North Am 20012858191 Infect
Dis Clin North Am 1997111326
J Urol 1981125(3)2716
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Significance of ASB

• If untreated, as many as 20-40 of pregnant women
  with ASB will develop PN.
• Treatment of bacteriuria early in pregnancy has
  been shown to decrease the incidence of PN by
  90.
• In various studies, untreated bacteriuria has
  been linked with prematurity, low birth weight,
  intrauterine growth retardation, and neonatal
  death.

Urol Clin N Am 200734 35, Infect Dis Clin North
Am 199711593, Infect Dis Clin North Am
19971113, Am J Public Health 199484405
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Treatment of ASB

• Screening and Tx for ASB significantly decreases
  the risk of symptomatic UTI and its
  complications.
• Tx of ASB decreases the incidence of PN during
  pregnancy from 13.5-65 down to 5.3-0.
• The Tx duration varies from a single dose to one
  week.
• Cure rates of single dose 3-day Tx 50-60
  70-80.
• Cure rates do not improve with longer courses of
  therapy and thus, 3-day therapy is recommended.
• A follow-up culture 1 week following Tx should be
  obtained.
• In 20-30 of patients, short-course Tx will fail.
  
• a repeat 7-10 day culture-specific Tx is
  appropriate .

Urol Clin N Am 200734 35, Infect Dis Clin North
Am 9971113, Br J Obstet Gynaecol 1983901054,
Urol Clin North Am 19752485, N Engl J Med
19933291328, Semin Perinatol 1977125,
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Prevention of ASB

• After a negative culture is obtained, daily
  antimicrobial suppression should be considered.
• Without prophylaxis, as many as one third of
  women will experience recurrent infections during
  pregnancy .
• If suppression is not used following Tx of ASB,
  women should have frequent urine cultures
  throughout the remainder of pregnancy to identify
  recurrent bacteriuria.
• In women with recurrent or persistent
  bacteriuria,
• follow-up cultures should also be obtained
  after delivery. Additionally, a urologic
  evaluation 3 to 6 months postpartum is
  appropriate .

Obstet Gynecol Clin North Am 200128581, Infect
Dis Clin North Am 9971113, Infect Dis Clin
North Am 200317367, Clin Infect Dis
199214810, J Reprod Med 19863123
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Treatment of cystitis in pregnancy

• Treatment of cystitis is the same as treatment
  for ASB.
• Follow-up is important because up to one third of
  women may experience recurrent UTI during
  pregnancy.

Urol Clin N Am 200734 35
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Significance of PN Complications

• Fetal complications
• Preterm labor, prematurity, low birth weight
• Intrauterine growth retardation, neonatal death
• Maternal complications
• Anemia, hypertension, transient renal failure
• Acute respiratory distress syndrome, sepsis

Obstet Gynecol Clin North Am 200128581, Clin
Obstet Gynecol 199336855, Am J Obstet Gynecol
1981141709, Urol Clin N Am 20073435
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Treatment of PN (1)

• All patients who have PN during pregnancy should
  be admitted and treated with parenteral agents.
• Initial AB Tx is typically ampicillin plus
  gentamicin or cephalosporins.
• 2nd or 3rd generation cephalosporins may also be
  considered for single-agent Tx.
• With these Tx regimens, more than 95 of women
  will respond within 72 hours.
• Resistant organisms must be considered in women
  who do not respond appropriately to Tx, and
  antimicrobials should be changed according to
  culture results.

Obstet Gynecol Clin North Am 200128581, Obstet
Gynecol 197342112, Am J Obstet Gynecol
1995172129, Campbells Urology.8th ed 2002,516,
Urol Clin North Am 199926779
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Treatment of PN (2)

• If Tx response is suboptimal despite
  culture-specific Tx,
• an ultrasound should be obtained to rule out
  nephrolithiasis, structural abnormality, or renal
  abscess.
• Once afebrile, women may be switched to a 2-week
  outpatient course of an oral antimicrobial.
• This course should be followed by suppressive Tx
  until delivery.
• As with ASB and cystitis, follow-up after Tx is
  important.
• Women should be monitored closely throughout
  their pregnancy because there is an increased
  risk of recurrent PN.

South Med J 198477455, Scand J Infect Dis
199123221 Am J Obstet Gynecol 1981141709,
Urol Clin N Am 200734 35
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Antimicrobials in pregnancy
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Summaries Pregnancy UTI

• Urine culture is the gold standard for screening
  for bacteriuria in pregnancy.
• All pregnant women should be screened for
  bacteriuria in the first trimester.
• Women with a history of recurrent UTI or urinary
  tract anomalies should have repeat bacteriuria
  screening throughout pregnancy.
• All bacteriuria should be treated during
  pregnancy.
• Treatment should be effective, and nontoxic to
  the fetus.
• Antimicrobial prophylaxis or close follow-up
  after treatment of ASB and symptomatic UTI is
  necessary throughout the remainder of pregnancy.

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Conclusions Pregnancy UTI

• UTIs are common complications of pregnancy and
  may lead to significant morbidity for both mother
  and fetus.
• During pregnancy, ASB is the major risk factor
  for developing a symptomatic UTI.
• Screening and Tx of pregnant women for ASB may
  prevent morbidity associated with symptomatic
  UTIs.
• Bacteriuria should be treated with short-course
  Tx with appropriate antimicrobials.
• Women should be followed closely after Tx of
  bacteriuria because recurrence may occur in up
  to one third of patients.

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