Urinary tract infection (UTI) in newborns: risk factors, identification and prevention of consequences.

The aim of the study is identification of urinary tract infections (UTI) and urinary tract anomalies (UTA) already in the perinatal period. The authors attempted to prevent serious consequences of the above conditions in the examined children. Family history data, certain conditions in pregnancy and appertaining symptoms in children were elaborated to specify selective distinctive criteria for children at risk. Newborns (1200) were selected for potential existence of a UTI. All the examined newborns underwent a urinalysis. Those with significant bacteriuria were taken urine specimens, C-reactive protein (RVP), Complete Blood Count (CBC) and bilirubin. The newborns with a UTI and a suspected UTA were sent to ultrasound examination, direct radio nuclide cystography and Tc99m MAG3 dynamic scanning. The frequency of a UTI in the perinatal period amounted to 4.5%. A UTA was found in 29.6% of the examinees. The infection was more likely to appear among newborns with a UTA in their families, a UTI, pre-eclampsia and a febrile infection in mother, intrauterine growth retardation, premature rupture of membranes (RVP), umbilical cord strangulation, jaundice, cyanosis, breathing difficulties, seizures and asphyxia.

[A retrospective study to evaluate a protocol aimed at reducing the number of unnecessary voiding cystourethrographies performed after a first episode of febrile urinary tract infection]. / Évaluation d'un protocole de limitation des indications de cystographie dans les infections urinaires fébriles.

AIM: Whether or not voiding cystourethrography (VCUG) should be performed after a first episode of urinary tract infection (UTI) remains a matter of debate. The role of VCUG is primarily to diagnose high-grade vesicoureteral reflux (≥grade III) (VUR) and hence prevent the development of renal scars and poor long-term outcome. We designed a protocol designed to reduce the indications for performing unnecessary VCUGs after a first episode of febrile UTI. In order to evaluate the efficacy of our protocol, we designed a retrospective study to verify whether high-grade VUR was subsequently being underdiagnosed. METHODS: This study compared the number of cases of VUR diagnosed over 2 1-year periods in children aged 1 month to 18 years. Data were collected from records held in the pediatric emergency department of the University Hospital of Reims. All cases included had presented to the department with a first episode of febrile UTI. During the first 1-year collection period, all patients underwent a VCUG. During the second collection period, the protocol was in place and VCUG was only performed in children with a serum procalcitonin level greater than 1 ng/L and/or an abnormal renal ultrasound scan. RESULTS: During the first year, 100 patients underwent routine VCUG and 7 cases of high-grade VUR were diagnosed. During the following year, VCUG was limited according to the new protocol: 102 patients were enrolled, 52 VCUGs were performed and 8 cases of high-grade VUR were diagnosed. Cases of low-grade VUR (I and II) were less frequently detected, without significant consequences for the patients. CONCLUSION: The protocol led to a 40% decrease in the number of VCUGs performed. No cases of high-grade VUR were missed; however, the number of VCUGs performed with a normal outcome remained significant.

Acute focal bacterial nephritis in 25 children.

Acute focal bacterial nephritis (AFBN), formerly known as lobar nephronia, is a rare form of interstitial bacterial nephritis. Most often described in adults with diabetes, there is only limited knowledge of AFBN in children. Ultrasound shows circular hypoechogenic, hypoperfused parenchyma lesions, which may be misdiagnosed as a renal abscess or tumor. From 1984 to 2005, AFBN was diagnosed in 30 children at the University Hospital Münster and the General Hospital Celle, Germany. Data of 25 cases (14 girls, 11 boys) were available for retrospective evaluation. Twenty-five children with AFBN, mean age 4.5 years (range: 0.25-17.5 years), were followed up on average 4.2 years (range: 0.5-11 years). All children were admitted to hospital due to fever and rapid deterioration of clinical condition, initially suspected of having meningitis (four patients), urinary tract infections (five patients), renal tumor (three patients), pneumonia (two patients), appendicitis (one patient), or with only unspecific symptoms (ten patients). AFBN was diagnosed by ultrasound on average 3 days (range: 1-10 days) after onset of symptoms. Pyuria was found in 18/25 children, bacteriuria in 20/25 children, and hematuria in one patient. Blood cultures were negative in all but one patient. Urinary tract abnormalities were found in 12 children, including vesicoureteral reflux (8), megaureter (1), urethral valves (1), unilateral renal hypoplasia (1), and one patient with megacystis, megaureter, caudal dystopic left kidney combined with hypoplasia and dysplasia of the right kidney. High-resolution ultrasound showed AFBN lesions to have resolved completely within 12 weeks after onset of intravenous antibiotic therapy in 20/25 children. Renal parenchymal cysts remained in three cases and focal scarring in two. Blood pressure and renal function was normal in 24/25 cases. AFBN should be suspected in children with fever and rapid deterioration of clinical condition. Residual lesions such as cysts or scarring of renal parenchyma could remain.

Multiphasic helical CT diagnosis of early medullary and papillary necrosis.

PURPOSE: The feasibility of identifying early manifestations of renal papillary necrosis (RPN) and medullary necrosis (RMN) on multiphasic helical CT, leading to prompt treatment for the causative conditions, and its impact on reducing the incidence of late-stage RML and RPN, was investigated. PATIENTS AND METHODS: Sixty-eight patients (35 male, 33 female) aged 19 to 88 years were examined by multiphasic helical CT for complaints of microscopic hematuria (N=49), macroscopic hematuria (N=2), bacteriuria (N=45), pyuria (N=10), fever (N=15), and flank pain (N=27). Preenhancement, arterial corticomedullary, parenchymal, and excretory phase scans generated 1.25 to 7-mm-thick slices. Follow-up CTs were performed at 1 month (N=62) and 3 months (N=58). RESULTS: While the attenuation coefficients of areas suspect for RMN and RPN were similar on preenhancement CT, they differed substantially on the arterial corticomedullary phase (lesions 55 HU mean; normal medulla 120 HU mean) and parenchymal phase (lesions 58 HU mean, normal medulla 210 HU mean). Investigation for predisposing conditions identified diabetes in 18 patients, upper urinary-tract infections in 48, sickle-cell disease or trait in 17, urinary obstruction in 7, and cirrhosis of the liver in 1. On follow-up examinations, enhancement had normalized in 26 compromised areas of 14 patients at 1 month, and 47 areas (23 patients) at 3 months, remained stationary in 28 patients at 1 month and 9 at 3 months, and progressed in 20 at 1 and 26 at 3 months (P<0.001; Fisher's exact test). Patients (N=35) treated for underlying conditions causing ischemia showed reperfusion in 12 cases at 1 month and 20 at 3 months, while of the untreated patients (N=10), none showed reperfusion, and all lesions increased in size. CONCLUSIONS: Multiphasic helical CT is recommended for identification of RMN and RPN at a stage when effective treatment of underlying causative conditions can arrest or reverse the process of devascularization and prevent loss of medullary tissue.

Relationship of asymptomatic bacteriuria and renal scarring in children with neuropathic bladders who are practicing clean intermittent catheterization.

OBJECTIVE: To determine whether untreated asymptomatic bacteriuria is associated with renal scarring in children with neuropathic bladders managed with clean intermittent catheterization (CIC). DESIGN: Retrospective study of 207 patients aged 1 to 30 years (mean 11.9 +/- 5.5 years) treated with CIC for a mean duration of 6.6 +/- 3.9 years by the spina bifida program at Children's National Medical Center. All patients were examined for renal scarring with dimercaptosuccinic acid (DMSA) renal scans. Catheterized urine cultures were obtained annually, but bacteriuria ( > 10,000 colony-forming units of a single organism per milliliter) was treated only if the patients had symptoms or if vesicoureteral reflux (VUR) was present. RESULTS: Of 207 children, 176 (85%) had one or more episodes of untreated asymptomatic bacteriuria and 72 (35%) had one or more febrile episodes associated with positive urine culture results. Biannual DMSA scans detected 54 new scarring episodes in 42 patients. Of newly recognized scars, 55% were preceded within 1 year by a febrile infection, 26% were detected in patients with VUR and asymptomatic bacteriuria, and 19% were detected in new patients during their initial examination. Univariate analysis revealed that new scarring was present in 35 of 176 patients with asymptomatic bacteriuria compared with 7 of 31 patients without (p = 809). Logistic regression analysis revealed that factors associated with scarring were febrile infections (adjusted odds ratio [OR] = 30.6, 95% confidence interval [CI] = 9.8 to 95.8), age more than 20 years (OR = 4.3, CI = 1.01 to 18.5), the presence of bladder trabeculation (OR = 2.7, CI = 1.0 to 7.6), and VUR (OR = 58.8, CI = 6.3 to 547.3), but asymptomatic bacteriuria was not associated with scarring. CONCLUSION: In the absence of VUR, asymptomatic bacteriuria in patients undergoing CIC is not a significant risk factor for scarring and does not require antibiotic therapy.

A five-year prospective follow-up of women with non-obstructive pyelonephritic renal scarring.

Fifty women with pyelonephritic renal scarring were prospectively followed for five years and the changes in renal function were related to blood pressure control, plasma renin activity, urinary albumin excretion and the incidence of urinary tract infections (UTI). Five patients (10%) developed end stage renal disease. All these patients had bilateral disease, proteinuria and anti-hypertensive treatment at presentation. The mean +/- SD glomerular filtration rate (GFR) of all patients with renal scarring was 74 +/- 27 ml/min x 1.73 m2 at presentation which was significantly lower than the GFR in 55 patients with a recent episode of acute pyelonephritis (p less than 0.001) and 10 healthy controls (p less than 0.001). GFR and age corrected GFR decreased significantly during follow-up (p less than 0.001) and p less than 0.02 respectively). The decrease in GFR was significantly higher in patients with bilateral scarring, in patients on blood pressure treatment and in patients with an episode of symptomatic UTI during follow-up. Eight patients (16%) had antihypertensive treatment at presentation and another 11 patients (26%), of whom 10 had bilateral scarring, developed hypertension (greater than 140/90 mmHg) during follow-up. Seventy-five per cent of all patients had symptomatic UTI and 40% had an episode of acute pyelonephritis during follow-up. In conclusion, patients with pyelonephritic scarring have a high incidence of UTI and are at high risk of developing renal failure and hypertension. It is essential that recurrent episodes of symptomatic UTI are treated promptly and that blood pressure is monitored carefully in these patients.

[Nephrosonography--findings in acute pyelonephritis gravidarum]. / Nephrosonographie--Ergebnisse bei akuter Pyelonephritis gravidarum.

Nephrosonographic checks were made on 25 women during pregnancy (prior to and after treatment) and after childbirth, in order to obtain morphological information on dynamics of upper urinary tract in cases of acute pyelonephritis gravidarum. Pyelectasia was recorded from 19 patients (76 per cent) on the right side, one patient (four per cent) on the left, two patients (eight per cent) on either side, and was not recorded at all from three women (twelve per cent). Moderate to severe dilatations had been more often recordable from patients with high temperature, but not as often from mild cases. Recurrence rates went up along with severity of ectasia. Physical treatment (lateral positioning and heat) yielded subjectively perceived improvement but failed to result in nephrosonographically recordable decline in dilatation. Pregnancies ended in premature births in 20 per cent of these cases. No dilatation of upper urinary tract was any detectable three months after parturition. While nephrosonography for routine still is disputed in the context of normal pregnancy, it should be used on all cases of acute pyelonephritis gravidarum.

Ureteral dilatation in children with febrile urinary tract infection or bacteriuria.

Little information is available on the relationship between urinary infection in children and infants, with or without vesicoureteral reflux, and dilatation of the urinary tract. The purpose of this study was to determine the effects of infection and reflux on the diameter of the ureter at excretory urography in children with acute, febrile urinary tract infections and in infants with bacteriuria found at screening. Standardized measurements of ureteral diameter were obtained for 79 children (2 months to 6 years old) with urinary tract infections and for 45 infants with bacteriuria. Patients with urinary tract obstruction or malformations were excluded. Seventy-one children with febrile urinary tract infection had ureteral visualization that allowed measurements. Ureteral diameter in this group was significantly wider than in a reference group, and 42 children (59%) had ureteral diameters that were more than 2 standard deviations above the normal mean. Ureteral diameter at excretory urography increased with increasing grades of reflux, but dilatation occurred also in the absence of reflux. Twenty-two of the 45 infants in the group with bacteriuria had sufficient ureteral visualization for measurements. The ureters in this group were wider than in the reference group, and eight infants had ureteral diameters that were more than 2 standard deviations above the normal mean. We conclude that ureteral dilatation is a common effect of acute urinary tract infection and bacteriuria in children.

Hemorrhagic focal bacterial nephritis: findings on gray-scale sonography and CT.

Five patients with acute focal bacterial nephritis and hematuria had sonographic and CT findings atypical for renal infection. Sonographically, each presented with an echogenic focus in the renal parenchyma. Noncontrast CT images showed an area of increased density in the corresponding segment of the kidney in three patients, mixed high and low density in one patient, and low density alone in the remaining patient. It is proposed that these appearances result from the presence of hemorrhage at different stages, associated with focal infection. Venous compromise is suggested as the etiology.

Urologic evaluation of urinary tract infection in pregnancy.

Thirty-three antepartum patients with urinary tract infections underwent urologic evaluation as soon as the infection had been successfully treated. The evaluation included history of voiding habits, cystometry, urethral calibration and cystourethroscopy. A second phase of the urologic evaluation included an excretory urogram and repeat cystometry 10-12 weeks postpartum. Sixty percent had a history of infrequent voiding, and 90% of them had a bladder capacity greater than 450 mL. Forty-one percent of the patients had a normal bladder capacity (less than 450 mL), and 85% of this group did not have any history of infrequent voiding. The radiographic evaluation postpartum in 18 of 33 patients revealed major abnormalities in 50%. These abnormalities were seen as often and were as significant in women with asymptomatic bacteriuria as in those who presented with acute pyelonephritis. The results suggest that the large bladder seen in pregnant women may be secondary to the chronic, unphysiologic habit of infrequent voiding. Furthermore, this study reinforced the fact that most pregnant women with urinary tract infection have preexisting chronic bladder or renal abnormalities that predispose them to infection. Those at risk should be identified early through a careful history and urinalysis to determine which ones need urinary prophylaxis during pregnancy. Postpartum urologic investigation should be carried out to identify any structural or functional problems; understanding them is helpful in present and future management.

Upper urinary tract changes in patients with spinal cord injury.

Two hundred and six intravenous urograms on 119 patients with spinal cord injury were reviewed and the findings correlated with the clinical data. Fifty (42%) of 119 patients had pathological changes in their upper urinary tracts. The most common feature was impaired renal emptying. Patients with normal and pathological upper tracts had similar findings according to the number of positive urine cultures during the first post-injury year, but in the follow-up those with pathological urograms showed bacteriuria significantly more often. Febrile urinary tract infections at least once a year were encountered in the follow-up of 40% of the patients with pathological urograms, as compared with 8% with normal urograms. All patients with severe renal changes had impaired emptying from the kidneys. This supports the view that the basic patho-physiological mechanism leading to upper tract deterioration in patients with spinal cord injury is a functional or mechanical obstruction of the lower urinary tract. This should be treated actively before irreversible renal changes develop.

[Septicemia associated with urinary infection in infants. Apropos of 36 cases]. / Les septicémies associées à une infection urinaire du nourrisson. A propos de 36 cas.

While studying 213 cases of septicemia among children less than one year of age, we found 36 cases of septicemia with bacteriuria. Among these 213 septicemic children, urinary tract infection (UTI) was second only to meningitis as an associated focus of infection. A radiological investigation was done in 27 cases; the pyelography or the cystography was abnormal in 14 instances, and 6 of these 14 patients needed to be surgically corrected.

A four-year follow-up of schoolgirls with untreated covert bacteriuria: bacteriological aspects.

In 75 schoolgirls aged 5-11 with untreated covert coliform bacteriuria who were followed up to 4 years, infection cleared in 16 (21%), cleared and recurred in 37 (50%) and persisted in 22 (29%). Clearance of bacteriuria was significantly (P less than .05) more frequent in girls with normal radiological findings than in those with abnormal findings. In 31 (59%) of the 53 girls in whom bacteriuria cleared spontaneously, the urine became sterile within the first year after the discovery of the bacteriuria. Spontaneous clearance of bacteriuria was preceded by an increase of the sensitivity of the urinary pathogens to the cidal effect of human serum. Seven (10%) of the 75 untreated bacteriuric girls had shown progression of kidney damage (progression of scarring in 4 and failure of kidney growth in 3). In all of these 7 girls vesico-ureteric reflux (VUR) was present and bacteriuria was persistent, but in 6 of them from one to three changes in the serotype of Esch. coli or bacterial species were noted during follow-up. These observations suggest that changes in bacterial flora may be a risk factor in the progression of kidney damage in girls with urinary tract infection and VUR.

[Early experience with repeated determinations of 131-I-hipuran clearance-equivalent during pregnancy ]. / Erste Erfahrungen mit der wiederholten Bestimmung der 131J-Hippurat-Clearanceäquivalente während der Gravidität.

Serial observations of ureteric and renal function during pregnancy were carried out by using isotope clearances; renal scintigraphy was performed for the first examination and isotope nephrography subsequently. The results of both types of examination are tabulated. It is shown that these procedures provide the necessary information on renal and ureteric function, given the indications which we have listed. The information concerns both kidneys or can be confined to a single kidney.

Kidney size compared with vertebral height. Importance of possible variations in normal values.

Results are presented showing that the normal values derived in one research centre, for the relationship between kidney length and the heights of the first 3 lumbar vertebrae, are not applicable to children in another one. The girls who are the subject of this investigation are those taking part in the survey on asymptomatic bacteriuria in Newcastle upon Tyne.

Observer variation in assessing renal scarring.

To examine the extent of variation between experienced observers in recognizing renal scarring, 60 intravenous urograms from schoolgirls with bacteriuria were presented separately to three radiologists with a major interest in the radiology of the urinary tract. Observers were asked to state whether scarring was "absent", "doubtful" or "present" at each of three sites in each kidney: the poles and the midportion. The proportion of overall agreement, i.e. the proportion of coincident opinions, was 86% to 89%. Results were also analysed by using the kappa statistic, which corrects for agreement due to chance. Kappa values ranged from 0.67 to 0.73. These values indicate higher levels of inter-observer agreement than those recorded for many other radiological examinations and are much greater than those noted by others for inter-observer variation in the recognition of renal scarring in urograms in adults. The likely explanations for these high levels of agreement are discussed. Observers disagreed about the extent of scarring in one-third of cases. Studies of the prevalence of scarring should take account of observer variation and should be based on judgments by more than one experienced observer.

Asymptomatic bacteriuria in schoolgirls. VII. A follow-up study of the urinary tract in treated and untreated schoolgirls with asymptomatic bacteriuria.

The urinary tracts of 116 schoolgirls with asymptomatic bacteriuria detected at screening were investigated by excretory urography and micturition cystourethrography. Three years later the studies were repeated in 11 patients with scarred kidneys, 11 patients with unscarred kidneys plus reflux, and 14 untreated patients with radiologically normal urinary tracts. Exceptionally small scarred kidneys showed little growth. Unscarred kidneys with vesico-ureteral reflux exhibited normal growth, as did unscarred kidneys in untreated patients. The risk of kidney damage developing as a result of asymptomatic bacteriuria in a schoolgirl with a radiologically normal urinary tract seems to be small.