Highlights in this issue

To identify the clinical and urodynamic risk factors associated with the development of recurrent febrile urinary tract infections (FUTIs) in children with neurogenic bladder (NB) who perform clean intermittent catheterization(CIC). Children with NB receiving CIC were prospectively enrolled from January to December 2019 and followed up prospectively for 2 years. All data were compared between occasional (0-1 FUTI) and recurrent FUTIs (≥2 FUTI) groups. In addition, the risk factors for recurrent FUTIs in children were evaluated. Complete data from 321 children were analyzed. Occasional FUTIs occurred in 223 patients, and 98 patients experienced recurrent FUTIs. Univariate and multivariate analyses, showed late-initiation and low-frequency CIC, vesicoureteral reflux (VUR), small bladder capacity and low compliance, and detrusor overactivity were associated with an increased risk of recurrent FUTIs. Children with high-grade VUR (grades IV-V) had a higher risk of recurrent FUTIs than those with low-grade VUR (grades I-III) (odds ratio [OR]: 26.95 vs.OR: 4.78, p < 0.001). Our study suggests that late-initiation and low-frequency CIC, VUR, small bladder capacity and low compliance, and detrusor overactivity were associated with recurrent FUTIs in patients with NB. In addition, high-grade VUR is a crucial risk factor for recurrent FUTIs.

Upper tract dilation is an independent risk factor for febrile UTI in children with primary vesicoureteral reflux

BACKGROUND AND OBJECTIVES:Febrile urinary tract infections and pyelonephritis are common in children and frequently lead to hospitalization for management, especially in the child who appears toxic. The American Academy of Pediatrics (AAP) practice parameter on the diagnosis, treatment and evaluation of the initial urinary tract infection in febrile infants and young children provides experience and evidence-based guidelines for the practitioner caring for children between the ages of 2 months to 2 years. No established guideline exists for older children and the AAP guideline does not specifically focus on inpatient care.METHODS:We conducted a comprehensive review of recently published literature and practice guidelines to develop a consensus on the inpatient diagnosis and management of children with pyelonephritis.RESULTS:Eight recommendations are proposed for the diagnosis and management, including revised guidelines for the imaging studies postpyelonephritis on the basis of current best evidence.CONCLUSION:Proper diagnosis of pyelonephritis, timely initiation of appropriate therapy and identification of children at risk for renal injury will help to reduce immediate as well as long-term complications due to chronic kidney disease.

Vitamin D has emerged as a key factor in innate immunity. Its involvement in the pathogenesis of urinary tract infections (UTIs) has gained a lot of attention recently. The objective of this study is to investigate the association between serum 25-hydroxyvitamin D (25(OH)D) levels and first-time or recurrent UTIs in children. A prospective, case-control study was conducted on 101 pediatric patients, who were divided into two groups: 59 patients with UTIs and 42 age-matched healthy controls. Serum 25(OH)D was determined in each child and expressed in ng/mL. Vitamin D presented significantly lower values in study group subjects than in healthy controls (p < 0.01). Moreover, a significantly higher prevalence of vitamin D insufficiency and deficiency was found in children with UTIs (p < 0.01). Patients with recurrent UTIs presented significantly lower levels of vitamin D than those with first-time UTIs (p = 0.04). Urinary tract abnormalities did not seem to exercise an additional effect upon vitamin D levels within the study group. In conclusion, first-time and recurrent UTIs are associated with lower vitamin D levels. Further studies are necessary to validate our findings, as well as future longitudinal research regarding efficacy of vitamin D supplementation in children with UTIs.

Periodic breathing can be converted to regular breathing by the administration of high inspired oxygen mixtures /FIO2/. The amount of FIO2 required depends on a/ maturity, b/ postnatal age. The new method of transcutaneous oxygen tension /tc O2/ measurements provided a simple, non-invasive to test whether the previously found negative correlation between FIO2 and maturity ie also present with tc O2. Each infant was tested at laest twice, usually three or four times. Results demonstrate the same general pattern as that previously found with FIO2: generally a high tc O2 /< 200 mm Hg/ is necessary for the conversion of periodic into regular breathing in small preterm infants /< 1800 g/. At 2500 g most infants only need a tc O2 of 100–150 mm Hg in ordre to convert periodic into regular breathing.

Purpose: Fever serves as the most frequent cause of visits to emergency/outpatient pediatric departments among children under the age of five. Very frequently, the youngster is given antibiotics on an arbitrary basis without receiving the proper examination for a urinary tract infection (UTI). This study’s goals were to assess the prevalence of UTIs in febrile children between 6 months and 5 years of age. To study the proportion of UTIs in children between 6 months and 5 years presenting with fever. To study the association of various risk factors with UTI. Methodology: This Cross-sectional Descriptive observational research was done in the Pediatric department of tertiary care hospital from August 2020 to December 2022, in febrile kids between 6 months and 5 years age group using different variables. Association between two qualitative variables was seen by using Chi-square/Fischer’s exact test. A P &lt; 0.05 was considered statistically significant whereas a P &lt; 0.001 was considered highly significant. Results: Among the total study population, it was found that 5.58% of the patients with fever without focus had a UTI, while the majority of patients, 94.42% did not have a UTI but had fever without a specific focus. In UTI cases, urine culture growth patterns showed the presence of different isolates, including Escherichia coli (30.43%), Klebsiella (56.52%), Pseudomonas aeruginosa (8.7%), and Candida (4.34%). Conclusion: In the present research, the overall occurrence of UTI in children &lt;5 years with fever without focus was 5.58%. Patients with significant pyuria and positive urine culture (UTI) were 43.75% and with significant pyuria but the sterile culture was 56.25%. So, it is concluded that significant pyuria can be sterile pyuria and cannot be labeled as UTI without confirmation on the urine culture report.

Early predictive biomarkers for the diagnosis and management of febrile urinary tract infections (UTIs) can be valuable diagnostic tools in children. The study cohort comprised 73 pediatric patients with febrile UTIs [46 with acute pyelonephritis (APN) and 27 with lower UTIs] and 56 healthy children. Urine neutrophil gelatinase-associated lipocalin (uNGAL) and kidney injury molecule-1 (uKIM-1) levels and serum cystatin C (sCysC) levels were measured. The uNGAL/creatinine (Cr) and uKIM-1/Cr levels were higher in the UTI group than in the controls (P < 0.05). uNGAL/Cr and sCysC levels were higher in patients with APN than in those with lower UTIs (P < 0.05). uNGAL/Cr levels in both the APN and UTI groups decreased following the administration of antibiotics compared to those before treatment (P < 0.05). The uNGAL/Cr level was correlated with serum levels of white blood cells, C-reactive protein, CysC and with uKIM-1/Cr (P < 0.05). uKIM-1/Cr was also correlated with sCysC (P < 0.05). Receiver operating curve analyses showed good diagnostic profiles of uNGAL/Cr and uKIM-1/Cr for identifying UTIs [area under the curve (AUC) 0.9 and 0.66, respectively) and of uNGAL/Cr and sCysC for predicting APN (AUC 0.78 and 0.72, respectively). Our results suggest that uNGAL, uKIM-1 and sCysC levels may be useful for predicting and managing febrile UTIs in children.

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Risk Factors for Febrile Urinary Tract Infection in Children with Prenatal Hydronephrosis: A Prospective Study

In children with urinary tract anomalies, febrile urinary tract infections (UTIs) are associated with increased risks of sepsis, hospitalization, and kidney injury. However, the best treatment strategies are unknown. We aimed to describe antibiotic treatment practices and outcomes for UTIs in children with urinary tract anomalies and evaluate whether variability in UTI treatment exists between hospitals. We conducted a multicenter retrospective cohort study of children seen in emergency departments (EDs) in 6free-standing US children's hospitals from January 1, 2017, through December 31, 2018. We included children aged 0-17years with an anatomic or functional urinary tract anomaly and a physician diagnosis of febrile or hypothermic UTI. Outcomes included intravenous (IV) antibiotic administration practices, hospitalization rates, length of stay, and return ED visits. Multivariable logistic and linear regression were performed, adjusting for differences in patient and illness characteristics. Among the 510children included, anomaly types, presence of home catheterization regimens, and baseline glomerular filtration rates varied between sites. In the adjusted analyses, sites differed in several treatment practices: IV antibiotic administration before ED discharge (P = .007), IV antibiotic spectrum (P = .003), IV antibiotic duration (P < .001), and hospital length of stay (P < .001). No statistically significant differences existed with bacteremia (P = .24) or intensive care stays (P = .08). Returns to the ED within 30days did not significantly differ by site (P = .68). Children's hospitals vary in their treatment of UTIs in children with urinary tract anomalies, yet ED revisits are similar across sites, highlighting the opportunity to promote high-value care in treatment of UTIs in this population.

Background: Urinary tract infection ( UTI) is a common bacterial infection in children. Even a single confirmed UTI is serious, due to the potential for recurrent UTI, parenchymal damage, hypertension and renal failure . Objective : To find the risk factors associated with febrile UTI in children aged 1 month to 14 years. Method: All children from 1 month to 14 years of age with culture proven febrile (≥101 0 F) UTI were included in the study. Further evaluation was done based on Indian Society of Paediatric Nephrology guidelines. Demographic data, clinical features and underlying risk factors of UTI were studied and analysed. Results: Out of 79 cases of febrile UTI, majority were boys aged more than 5 years. Escherichia coli was the predominant cause of febrile UTI in 73.4% cases. Among risk factors, improper toilet training practice was present in 73%, recurrent UTI in 23% and a history of catheterization /instrumentation in 14% children. Structural anomalies were found only in 6.3% cases. Conclusion : Improper toilet training practices was commonest risk factor associated with febrile UTI in children aged 1 month to 14 years in our study. Sri Lanka Journal of Child Health, 2015; 44(3): 143-146

To develop a simple score for predicting vesicoureteral reflux after a first febrile urinary tract infection in children. A retrospective cohort study was conducted for a 12-year period (January 2008 to December 2019), including patients aged <72months who underwent renal ultrasonography and voiding cystourethrography after a first febrile urinary tract infection. Patients with a history of antenatal hydronephrosis were excluded. The prediction model and score for vesicoureteral reflux were developed using multivariate logistic regression analysis. Out of 260 patients in total (median age 4months, 172 boys), 41 (16%) had vesicoureteral reflux. The score was based on four independent risk factors, including age >6months (odds ratio 2.71, 95% confidence interval 1.27-5.76), presence of sepsis (odds ratio 3.44, 95% confidence interval 1.31-9.04), white blood cell count ≥15000/mm3 (odds ratio1.83, 95% confidence interval 0.88-3.8) and abnormal renal ultrasonography results (odds ratio2.08, 95% confidence interval 1-4.31). A lower probability of vesicoureteral reflux (positive likelihood ratio=0.66; P=0.001) was found in the low-risk group (scores 0-2), whereas a higher probability of vesicoureteral reflux (positive likelihood ratio=2.54; P=0.001) was found in the high-risk group (scores 3-5). The predictive ability of the model was 70%. The scores developed based on the patient characteristics and renal ultrasonography are useful in predicting presence of vesicoureteral reflux after a first febrile urinary tract infection in children and could guide clinicians' decisions to perform additional imaging studies.

Urinary tract infections (UTIs) due to MDR organisms are increasingly common. The lack of paediatric data on efficacious antibiotics makes UTI treatment particularly challenging. Data on the efficacy of fosfomycin use for UTI in children are variable. We conducted a retrospective audit of children aged 0-18 years who were treated with fosfomycin for UTI at seven tertiary paediatric hospitals in Australia over a 7 year period, from 2014 to 2020. Ninety-one children with a median age of 5 years (range 2 months to 18 years) received oral fosfomycin for UTI. The majority (57/91, 63%) had one or more comorbidity, with the most common being renal tract anomalies (24/91, 26%). Fifty-nine (65%) had febrile UTI, 14/91 (15%) had pyelonephritis and 1/91 (1%) was bacteraemic. A majority (80/91, 88%) of urinary cultures had an ESBL-producing Gram-negative pathogen isolated. Fosfomycin susceptibility was evident in all 80 isolates tested. For uncomplicated UTI, the most common dose in children aged <1, 1-12 and >12 years was 1, 2 and 3 g, respectively. For complicated UTI, doses of 2 and 3 g were most common. The median duration of fosfomycin administration was 5 days (range 1-82). Clinical cure was achieved in 84/90 (93%); the six with treatment failure had underlying comorbidities. Overall, 2/91 (2%) children experienced drug-related adverse effects comprising gastrointestinal symptoms in both, which resolved after treatment discontinuation. Fosfomycin is well tolerated and associated with favourable treatment outcomes in children with UTI. Further research on the optimal dosing strategy is required.

Background: Urinary tract infection (UTI) is a term applied to a variety of clinical conditions ranging from asymptomatic presence of bacteria in the urine to severe infection of the kidney with resultant sepsis. According to The National Institute for Health and Clinical Excellence (NICE) guidelines, urinary tract infection is defined by a combination of clinical features and the presence of bacteria in urine. The risk factors of UTI are age, gender, constipation, lack of circumcision, not taking anthelmintic and lack of toilet training. Methods: This was across sectional study conducted on febrile preschool children, aged 3 to 6 years, who attended the outpatient department of Sri Siddhartha Medical College, Tumkur. Children with symptoms suggestive of UTI were enrolled, and a written informed consent was obtained from the parents. They were then interviewed using structured questionnaire for UTI. Results: Out of 194 febrile preschool children, 21 cases were diagnosed to have UTI. Of the 194 cases, 102 (52.6%) were females and 92 (47.42%) were male. Out of 21 urine culture positive cases 14 (66.6%) were females and 7 (33.33%) were males. Occurrence of UTI was 7.6% in febrile males, 13.72% in febrile females and had the estimated overall occurrence is 10.8%. Fever was present in all the cases. Besides fever, 47.62% children had increased frequency, 42.86% had excessive crying while micturition and 38.10% had chills and rigors. Foul smelling urine was present in 33.33% of children while 23.81% had abdominal pain. Out of 92 male children studied 16 (17.39%) males had phimosis, of which 2 (12.5%) developed urinary tract infections. Constipation was seen in 3 (14.29%) children with UTI. Worm infestation was seen in 5 (23.81%) children with UTI. Conclusions: Children with urinary tract infections usually present with nonspecific symptoms and signs and hence a urine analysis and culture should always be part of an initial diagnostic evaluation of urinary tract infections. Female sex, constipation, not taking anthelmintic, lack of toilet training and phimosis are significant risk factors for febrile urinary tract infection in children.

Endoscopic Therapy for Vesicoureteral Reflux: A Meta-Analysis. I. Reflux Resolution and Urinary Tract Infection