Paediatric Urinary Tract Infection: Microbiologic Profile and Antibiotics Sensitivity in Children Presenting with UTI

Background: This study was designed to determine the microbiologic profile and Antibiotics Sensitivity in Children presenting with UTI. Materials & Methods: This hospital based prospective study was conducted in 28 patients Patients from 2 months to 12 years were admitted to the pediatric ward and visited in outpatient department (OPD) with diagnosis of UTI based on history with routine and microscopic examination of urine were considered for this study. The UTI investigation protocol recommended ultrasound, voiding cystourethrography (VCUG), and DMSA scan. Clinical and laboratory parameters at the index infection, including highest measured temperature, highest C-reactive protein (CRP), bacterial findings, and the number of febrile recurrences, were recorded. Results: Fever was the most common symptom accounting for 76.4% of patients with nausea and vomiting (42.8%), dysuria (53.6%), abdominal pain (57.1%) and anorexia (46.4%). Urine analysis was done in all suspected cases of UTI. Among all urine samples 60.7% had WBC >10/hpf, followed by 87 (28.6%) which had WBC between 6-10/hpf. Only 6 (10.7%) had WBC 5 or less. Among all urine analyses 68 (57.1%) Conclusion: E. coli (82%) was the most common organism found followed by Klebsiella pneumonia (12%), Proteus mirabilis (5%)and 1% were other pathogens like Enterococcus species (Table 4, Fig 1). All isolated E. coli was sensitive to Imipenem, Nalidixic acid, Netilmicin and Vancomycin. E. coli were 80-90% sensitive to Amikacin, Ceftriaxone, Cefuroxime, Ofloxacin, Gentamicin and Nitrofurantoin.

Clinical features and renal morphological changes of the patients with urinary tract infection associated ureteral stent / 中华泌尿外科杂志

Objective To evaluate the clinical features and renal morphological changes of the patients with urinary tract infection associated ureteral stent.Methods From Oct.2012 to May.2013,21 patients were divided into three groups depending on the different conditions:Group A (n=7):patients who had febrile urinary tract infections associated with ureteral stents; Group B (n =7):patients with ureteral stents but no fever; Group C (n=7):patients who had febrile urinary tract infections but no ureteral stent.The clinical data,laboratory data and 99Tcm-dimercaptosuccinic acid (DMSA) renal scintigraphy results were recorded prospectively and analyzed.Results In Group A,there were two patients had flank pain and positive costovertebral angle percussion tcnderness.The mean value of white blood cells and Hs-CRP of Group A and Group C were obviously higher than Group B (P＜0.05).The ratios of pyuria were 100.0％,71.4％ and 100.0％ in Group A,B and C.The ratios of positive urine bacteuria culture were 100.0％,42.9％ and 100.0％ in Group A,B and C.The results of 99Tcm-DMSA renal scintigraphy demonstrated the decreased uptake in the different portion of the kidneys on the sides of ureteral stents inserted in all the patients in Group A but no such changes in Group B and Group C.Conclusions 99Tcm-DMSA renal scintigraphy can be used to judge the status of urinary tract infection associated ureteral stent.The febrile urinary tract infection associated with ureteral stents always means pyelonephritis occurs and prompt treatment must be given.

Differences in the Clinical Characteristics of Children with Urinary Tract Infections Based on the Results of 99mTc-Dimercaptosuccinic Acid Renal Scanning

PURPOSE: The 99mTc-Dimercaptosuccinic acid (DMSA) renal scan is used primarily for the diagnosis of renal scarring and acute pyelonephritis in children with urinary tract infections (UTI). This study aimed to evaluate clinical differences based on the positive or negative results of DMSA scans and kidney ultrasonography (US) in pediatric UTI. METHODS: We retrospectively reviewed 142 pediatric patients with UTI who were admitted to Myongji Hospital from January 2004 to December 2012. We performed a comparative analysis of clinical parameters such as age, sex, white blood cell (WBC) count, neutrophil count, blood urea nitrogen (BUN) level, creatinine (Cr) level, C-reactive protein (CRP) level, and durations of hospitalization and fever, grouped by the results of the DMSA scans and kidney US. RESULTS: The mean age of the patients was 33.8+/-48.3 months, and 78 (55%) were male. Fifty-two patients had abnormal DMSA findings, and 71 patients had abormal kidney US findings (test positive groups). In the DMSA scan positive group, there were significant differences in age, WBC counts, neutrophil counts, CRP level, BUN level, Cr level, hospitalization duration, number of abnormal findings on kidney US, and incidence of vesicoureteral reflux (VUR) compared with the scan negative group. The kidney US positive group had significant differences in age, neutrophil count, CRP level, BUN level, Cr level, hospitalization duration, number of abnormal findings on the DMSA scans, and more frequent VUR compared with the US negative group. CONCLUSION: Our data suggest that there were no major differences in clinical parameters based on the results of the DMSA scans compared with kidney US in pediatric UTI. However, as kidney US and DMSA scan were performed to predict VUR, the sensitivity and negative predictive value was increased.

Prevalence of Vesicoureteral Reflux According to the Timing of Voiding Cystourethrography in Infantile Urinary Tract Infection

PURPOSE: To evaluate the prevalence of vesicoureteral reflux (VUR) according to the timing of voiding cystourethrography (VCUG) in infantile urinary tract infection (UTI). METHODS: The data of 134 infants (1-12 months) with renal cortical defect in 99mTc-2, 3-dimercaptosuccinic acid (99mTc-DMSA) scan with a diagnosis of UTI in two hospitals from 2000 to 2010 were retrospectively analyzed. The VCUG was performed after 2 weeks from the diagnosis of UTI in Group I (n=68), and the VCUG was performed within 2 weeks from the diagnosis of UTI in Group II (n=66). RESULTS: There were no significant differences between the two groups in the duration of fever, white blood cell count, C-reactive protein levels, and abnormalities in ultrasonography (P>0.05). There was no significant difference between the two groups in the prevelence of VUR, bilateral VUR, and severe VUR. VCUG-induced UTI was detected 16 (23.5%) of patients in whom the procedure was performed 2 weeks after the diagnosis, and none of VCUG-induced UTI occurred in those in whom the procedure was performed 2 weeks within the diagnosis. CONCLUSION: We conclude that the prevalence of VUR according to the timing of VCUG did not differ between the two groups in infantile UTI with renal cortical defect in DMSA scan. We also found that performing VCUG with antibiotics can decrease risk of VCUG-induced UTI.

Clinical Significance of Hydronephrosis in Febrile Urinary Tract Infection

PURPOSE: Hydronephrosis is found about 30% of children with urinary tract infection (UTI). It can be caused by various conditions, although most childhood hydronephrosis is congenital. This study was performed to investigate the relationship between febrile UTI and hydronephrosis. METHODS: We retrospectively reviewed the medical charts of 183 patients diagnosed as UTI between January 2007 and May 2009 at Korea University Guro Hospital. Inclusion criteria were as followings; 1) fever more than 37.5degrees C measured in the axilla , 2) positive urine culture, 3) no history of urinary tract anomaly on antenatal sonography and urinary tract infection. We classified the enrolled children into two groups of patients with hydronephrosis (HN) and those without hydronephrosis (NHN). RESULTS: The 80 patients were HN and 103 patients NHN. Hydronephrosis was found in 58 patients with left kidney, 8 right and 14 both kidneys. Most of hydronephrosis were of low grade. Compared with NHN group, initial renal cortical defects on DMSA scan significantly increased in HN group (HN 37.5%, NHN 16.5%, P < 0.05). The incidence of VUR was not different between the two groups (HN 22%, NHN 12.1%). White blood cell counts and C-reactive protein were not different between the two groups. Follow-up DMSA scan (about 6 months later after UTI) showed no difference of renal scarring in both two groups. CONCLUSION: Our data suggests that hydronephrosis in febrile UTI patients is clinically useful for detecting renal cortical defects, but is not associated with follow-up renal scar.

Clinical Signif icance of Intrarenal Reflux in Children with Urinary Tract Infection

PURPOSE: Intrarenal reflux(IRR) is backflow of urine from the renal pelvis into the collecting ducts. IRR is the main cause of renal injury in children with vesicoureteral reflux (VUR) which leads to renal scars, hypertension, proteinuria, and chronic renal failure. The purpose of our study was to investigate the characteristics of intrarenal reflux. METHODS: We retrospectively reviewed the medical records of 80 patients who were diagnosed as having grades of III-V VUR from Jan. 2004 to Dec. 2006 in the department of pediatrics in Ajou University Hospital. The patients were divided into two groups according to the presence of IRR on voiding cystoureterogram and compared to each other for the possible factors associated with intrarenal reflux. RESULTS: Among 80 VUR patients, IRR(+) group comprised 17(21.3%) patients and 27 renal units(23.2%) and revealed younger age, higher grade of VUR, and more proteinuria compared to IRR(-) group. There were no significant difference in gender, laboratory findings and the rate of resolution in VUR or defects on renal scan between two groups. Also, intrarenal reflux mostly corresponded to the same site of photon defects on DMSA scan. CONCLUSION: We suggest that intrarenal reflux tends to be associated with younger age, higher grade of reflux, more proteinuria with no difference in resolution rate of VUR when compared to the VUR patients without IRR. From this study, we were able to understand the characteristics of intrarenal reflux in children with urinary tract infection.

The Significance of Renal Imaging Studies in the Diagnosis of Acute Pyelonephritis

PURPOSE: It is difficult to diagnose acute pyelonephritis(APN) in young children, because of their nonspecific symptoms. The younger the age, the higher the risk of renal scars after APN, which can be prevented by early diagnosis and treatment. We compare the significance of renal imaging studies by age for diagnosis of APN in febrile urinary tract infection(UTI) in children. METHODS: Fifty-three hospitalized children(34 patients under age 2 and 19 patients over age 2) with febrile UTI and who had undergone dimercaptosuccinic acid(DMSA) scan, renal ultrasonography(RUS) and voiding cystourethrography(VCUG) during the acute stage were reviewed. We compared the renal imaging studies between the different age groups. RESULTS: The DMSA scan showed cortical defects in 23.5% of patients under age 2, which was significantly lower than 63.2% of patents over age 2(P<0.05). The renal cortical defects on DMSA scan were associated only with a high peripheral leukocyte count, but not with fever duration, erythrocyte sedimentation rate(ESR), and C-reactive protein(CRP). And there was no correlation between the DMSA scan, VCUG or RUS findings. CONCLUSIONS: The DMSA scan is not sensitive for diagnosis of APN in children less than 2 years of age and the findings cannot predict the presence of vesicoureteral reflux(VUR). VCUG may be necessary for proper management in this age group.

The Significance of (99m)Technetium Dimercaptosuccinic Acid(DMSA) Scan as a Substitute for Voiding Cystourethrography(VCUG) in Evaluating Children with first Febrile Urinary Tract Infection

PURPOSE: We studied the value of clinical signs, laboratory findings and (99m)technetium dimercaptosuccinic acid(DMSA) scan in predicting the presence of vesicoureteral reflux(VUR) in children with first febrile urinary tract infection(UTI). METHODS: A retrospective analysis of 84 hospitalized children with first febrile UTI was performed. They underwent DMSA scan and voiding cystourethrography(VCUG) during the acute phase, and were divided into three groups according to the results of the VCUG: absence of VUR, mild(grade I-II) and severe VUR(grade III-V). We studied the relation of VUR to age, gender, fever duration, causative organism, white blood cell count, serum C-reactive protein and result of DMSA scan. RESULTS: Among 84 patients, 6 had mild and 17 had severe VUR. Thirty-eight had abnormal DMSA scan. results Patients with VUR were older than those without VUR(P<0.01). There was a lower probability of infection with Escherichia coli in patients with severe VUR than in those with mild and absent VUR(P<0.01). An abnormal DMSA scan correlated with the presence and severity of VUR(P<0.05). Severe VUR was present in 10.9% of patients with normal DMSA scan. The sensitivity, specificity, positive and negative predictive values of the DMSA scan in predicting the presence of VUR were 69.6%, 63.9%, 42.1%, and 84.8%, respectively. CONCLUSION: An abnormal DMSA scan correlated to the presence and severity of VUR, but the sensitivity, specificity and positive predictive value of the DMSA scan were low. Therefore, patient with an abnormal DMSA scan requires a VCUG. In order to prevent missing the 10.9% of patients with severe VUR but normal DMSA scans, a VCUG should be performed in patient with normal DMSA scan.

Necessity of (99m)Tc-dimercaptosuccinic acid scan in infants with low grade vesicoureteral feflux / 소아과

OBJECTIVE: (99m)Tc-dimercaptosuccinic acid(DMSA) scan is considered to be the most sensitive examination for detection of renal scars. However, because of its high radiation exposure to the kidney and its limited usefulness for patients with low grade vesicoureteral reflux(VUR), some authors have suggested that DMSA scans should be reserved primarily for children with VUR grade 3 and above. The aim of this study was to reevaluate the necessity of DMSA scans as a screening test in infants without reflux or with low grade reflux. METHODS: In this retrospective study, 189 infants(mean age:6.2 months) diagnosed as UTI were enrolled. Voiding cystourethrogram(VCUG), DMSA scan and renal ultrasonography were performed within 1 month of UTI. VUR grade was classified into three subgroups; low grade(grade 1-2), moderate grade(grade 3), and high grade(grade 4-5), respectively. RESULTS: Renal defects were present in 67 of 189 infants, and 82 of the 378 renal units. The incidence of renal defects was significantly correlated with VUR grade(P<0.01); 28 percent without reflux, 38 percent with low grade, 53 percent with moderate grade, 100 percent with high grade, respectively. However, there was no significant differences in incidence of renal defects between the low grade and moderate grade group. CONCLUSION: In this study, renal defects were found in quite high percentages; 28 percent patients without reflux and 38 percent patients with low grade VUR, respectively. Moreover, there was no significant difference in the incidence of renal defects between the low grade and moderate grade groups. Therefore, DMSA scan should be performed for infants with UTI as a screening test regardless of the presence of VUR.

Vesicoureteral Reflux and Renal Scar

PURPOSE: Vesicoureteral reflux(VUR) is the major risk factor of urinary tract infection(UTI) in children and may result in serious complications such as renal scarring and chronic renal failure. The purpose of this study was to evaluate the relationship between VUR and renal scar formation, the usefulness and correlation of various imaging studies in reflux nephropathy, and the spontaneous resolution of VUR. METHODS: We retrospectively reviewed 106 patients with VUR with no accompanying urogenital anomalies in the Department of Pediatrics, Bundang CHA Hospital during the period from Jan. 1996 to Mar. 2005. Ultrasonography and 99mTc-dimercaptosuccinic acid(DMSA) scan were performed in the acute period of UTI. Voiding cystourethrography(VCUG) was performed 1 to 3 weeks after treatment with UTI. Follow-up DMSA scan was performed 4 to 6 months after treatment and a follow-up VCUG was performed every 12 months. RESULTS: The mean age at detection of VUR was 13.8+/-22.2 months and the male to female ratio was 2:1. The incidence of renal scarring showed a tendency of direct correlation between severity of VUR(P<0.001) and abnormal findings of renal ultrasonography(P<0.01). 63.2%(24 of 38 renal units) of renal parenchymal defects present in the first DMSA scan disappeared on follow-up DMSA scans. Follow-up DMSA scans detected renal scars in 7(14%) of 50 renal units with ultrasonographically normal kidneys. Meanwhile, ultrasonography did not show parenchymal defects in 7(36.8%) of 19 renal units where renal scarring was demonstrated on a follow-up DMSA scan. The spontaneous resolution rate of VUR was higher(75%) in cases with low grade(I to III) VUR(P<0.01). CONCLUSIONS: The presence and severity of VUR and abnormal findings of renal ultrasonography significantly correlated with renal scar formation. DMSA scan was useful in the diagnosis of renal defects. Meanwhile renal ultrasonography was an inadequate method for evaluating renal parenchymal damage. Therefore, follow-up DMSA scans should be performed to detect renal scars even in children with low-grade VUR and normal renal ultrasonography.

Changes in the Findings of 99mTc-dimercaptosuccinic Acid(DMSA) Scan after Acute Pyelonephritis in Childhood and Renal Scar

PURPOSE: We evaluated the change in the findings of DMSA scan after acute pyelonephritis (APN), and the relationship between renal scar formation and risk factors such as vesicoureteral reflux (VUR), organism and inflammatory reaction. METHODS: We examined 200 patients under the age of 5 years with first APN. DMSA scan, voiding cystourethrography (VCUG), erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were performed initially. If the initial DMSA scan was abnormal, it was repeated after 6 months. RESULTS: Median age was 1.1 years. Initial renal defects existed in 136 (68%) of 200 cases. At 6 months after initial infection, follow up DMSA scan was checked in 61 children with initial renal defects for evaluation of scar. Initial renal defects disappeared in 19 (31%)children. Initial renal defects were present in 60 (64%) of 94 kidneys with the VUR, however, they were present in 94 (31.0%) of 306 kidneys without VUR(P0.05). CRP was 11.0+/-7.0mg/dL in 127 patients with initial renal defects and 4.4 5.5mg/dL in 53 patients without initial renal defects (P<0.05) and CRP was 13.0+/-4.7mg/dL in 39 patients with scar and 8.7+/-4.6 mg/dL in 19 patients without scar in follow up DMSA scan (P<0.05). CONCLUSION: The presence of VUR and higher CRP level are risk factors for initial renal defects but renal scarring occured higher in the higher level of CRP, irrespective of VUR.

99mTc-DMSA Renal Scan after Anti-reflux Surgery in Children with Primary Vesicoureteral Reflux / 대한비뇨기과학회지

PURPOSE: 99mTc-dimercaptosuccinic acid(DMSA) renal scintigraphy is recognized as the most effective imaging modality for demonstrating renal scarring In children with vesicoureteral reflux. We determined if significant numbers of new scar develop and progression of scarring occur after antireflux surgery. MATERIALS AND METHODS: Retrospective study was undertaken In a series of 102 reflux renal units out of 60 children(male 35, female 25) with vesicoureteral reflux as documented by voiding cystourethrography, whose age was 28(median, range:1-150) months. We carefully examined DMSA renal scans taken in 2(median, range:0.3-58) months before operation and 18(median, range:3-62) months after operation in each patients. Twenty two children(37 renal units) were further followed up by additional scans up to 50(median, range:25-120) months postoperatively. Each scan was blindly reviewed twice in terms of the size, number and zonal location of the cortical defects based on morphology. The Interval changes were categorized into 3 patterns(improved, no change, progressed) based on the review findings RESULTS: There were no patients with postoperative pyelonephritis but asymptomatic bacteriuria were found in 19 patients(31.5%). Most(57 patients, 109 renal units) of the antireflux operation were done by Cohen method and refluxes were still found in 8 renal units(7.8%) in immediately postoperative periods and were ultimately disappeared. No postoperative urethral obstruction was found on intravenous pyelogram. On follow-up renal scintigraphy most of renal units(89, 87.3%) showed no change while 11(10.7%) showed improvement and progression was observed In 2(2.0%). No correlation was established between scintigraphic change and several clinical factors such as sex, age of first pyelonephritis presentation, presence or frequency of pyelonephritis before initial renal scan , nor postoperative episodes of urinary tract infection. CONCLUSIONS: Our results show that on the contrary to the most of the previous reports, no further development of renal scar was found after successful surgery. There was no significant morphologic change in the postoperative follow-up renal scan in most of reflux and if any, most were disappearance or diminution of renal scars.

Conservative Treatment of Major Renal Injury: Morphological and Functional Recovery / 대한비뇨기과학회지

PURPOSE: To re-evaluate the morphological and functional recovery of conservative treatment of major renal injuries. MATERIALS AND METHODS: We reviewed 68 patients admitted at our hospital due to major renal injury from Jan. 1991 to Dec. 1996. 33 of the 68 patients(48.5 percent) could be managed conservatively without surgery, All patients underwent follow-up abdominal CT and 12 of the 33 patients underwent DMSA renal scan at more than 3 months after injury. RESULTS: The mean function of the injured kidneys in comparison with contralateral kidney was 88.3 percent in case of normal finding in follow-up abdominal CT scan. CONCLUSIONS: We concluded that DMSA renal scan would be the valuable study for evaluation of the functional recovery of major renal injury.

Clinical Significance of Multiple Defects on DMSA scan in Recurrent Acute Pyelonephritis / 대한내과학회지

OBJECTIVES: This study was undertaken to evaluate associated underlying disease and follow-up changes of multiple cortical defects(MCD) in recurrent acute pyelonephritis(APN) patients with MCD on DMSA scan. METHODS: DMSA scan was performed in 128patients who visited Asan Medical Center with recurrent APN and 80patients showed MCD. Intravenous pyelography(IVP), ultrasound of the kidney(US), voiding cystourethrography(VCUG) were performed to search associated underlying diseases and changes of MCD were studied with follow-up DMSA scan at least 6 months after initial DMSA scan. RESULTS: 1) Underlying diseases were detected in 34patients, including vesicoureteral reflux in 21, renal stone in 4, renal tuberculosis in 3, ureteral stenosis in 3, renal infarction in 1, megaureter in 1, neurogenic bladder in 1, 2) Follow up DMSA scan revealed no changes in 14patients, improvement in 2. CONCLUSION: The patients with multiple defects on DMSa scan have underlying abnormalities in 42%, so they need more radiologic studies such as VCUG, IVP, US. Multiple defects indicate irreversible damage in most patients.

Renal scarring in relation to visicoureternal reflux in urinary tract infection

The vesicoureteral reflux (VUR) is frequently found among the patients with urinary tract infection (UIT) and some patients with VUR progress to reflux nephropathy. The presence of scarring at UIT is an important determinant in the selection of those at risk of progressive damage. 99m Technetium dimercaptosuccinic acid (99m Tc-DMSA) is a renal scanning agent provides a good quality of renal image as a result of preferential cortical accumulation. 99m Tc-DMSA scan and VCUG were performed in 133 patients diagnosed UTI at pediatric department of Kyung Hee University, College of Medicine from May, 1990 to May, 1992 The results were as follows: 1) VUR was seen in 27 children among 133 patients with UTI. The incidence was 20.3%. Under 1 year of age, male to female ratio was higher incidence of VUR. 2) Incidence of renal scarring was higher in patients with VUR than those of without VUR. 3) Grading of VUR in relation to age, the older the age, the lower the grade. 4) There is no correlation between renal scarring and grades of VUR. 5) In distribution of renal scarring, it was found to have tendency to develop at upper polar area, there was diffuse and multiple in patients with VUR. In conclusion the incidence of renal scarring was related to the age of onset, duration of UTI and the severity of the VUR and 99mTc-DMSA scan is mandatory in patient with UTI even without VUR in order to detect early phase of renal scarring.

Comparison of DMSA scan and DTPA scan for evaluation of relative renal function in pediatric hydronephrosis / 대한비뇨기과학회지

The previous reports have indicated that both the DMSA scan and the DTPA scan were significantly related with the relative renal function ( RRF) and there was a close relationship between the DMSA scan and the DTPA scan in the evaluation of the RRF We reviewed our experience with 24 cases, in which the DMSA scan and the DTPA scan were performed within 2 weeks from January 1987 to April 1991. The DMSA scan was more reliable than the DTPA scan and the difference of the RRF between right and left side by the DMSA scan was more apparent than that by the DTPA scan. However, in infants, both scans showed the reversed results. Our study suggests that DMSA scan is more reliable than the DTPA scan in the evaluation of the RRF, but both renal scans are inappropriate in infants, especially under the age of 1 months.