Reading Between the (Guide)lines to Manage Pediatric UTI and Vesicoureteral Reflux

By Halima Janjua, MD

Diagnostic and treatment guidelines for urinary tract infection (UTI) issued by the American Academy of Pediatrics fall short of providing all the answers a pediatrician may need. The same goes for guidelines on primary vesicoureteral reflux (VUR) issued by the American Urological Association.

Both sets of guidelines fail to address frequent clinical challenges — or at least fail to do so with the specificity that real-world practice can demand. To fill this void, I and my colleagues in Cleveland Clinic Children’s Centers for Pediatric Nephrology and Urology generally rely on the principles outlined below to handle UTI and VUR challenges for which guideline recommendations are lacking .

I invite perspectives on these principles — and additional recommendations for addressing neglected challenges in UTI/VUR management — from colleagues across the nation.

Diagnosis

• Persistent high fever is not a reliable differentiator between upper and lower UTI. The risk of renal scarring is comparable in children with and without persistent high fever. Therefore, we recommend meticulous treatment and prevention of both nonfebrile and febrile UTI.
• Evaluation for VUR is required when children younger than 2 years of age have an abnormal renal ultrasound or more than one febrile UTI, as recommended by the American Academy of Pediatrics. We do not routinely perform voiding cystourethrography (VCUG) in children older than 2 who have symptoms of lower urinary tract dysfunction.
• Assessment for renal scarring with a dimercaptosuccinic acid (DMSA) renal scan is also recommended when renal and bladder ultrasonography is abnormal, when there is grade III-V VUR, or in the presence of hypertension, proteinuria or elevated serum creatinine.

Antibiotic therapy

• Initial uncomplicated cystitis should be treated with five to seven days of oral antibiotics.
• Febrile UTI and complicated or recurrent cystitis merit 10 to 14 days of oral antibiotics.
• Intravenous therapy is needed for infants younger than 1 month or for children who have high-grade fever for more than 48 hours after initiating antibiotics, who present with nausea and vomiting, or who require rehydration.
• Broader antibiotic coverage for Enterococcus and/or Pseudomonas and a renal ultrasound are required when febrile UTI fails to defervesce in 48 hours despite adequate treatment.

Test of cure

• Repeat urine cultures are not recommended to prove eradication of UTI except in cases of recurrent infections, infections with drug-resistant organisms, immunosuppression or urological abnormalities.

Antibiotic prophylaxis

• Infants younger than 1 year with febrile UTI and any grade VUR, or with grade III-V VUR, require prophylaxis.
• Children of any age with bladder/bowel dysfunction and VUR require prophylaxis due to increased risk of UTI while the bladder/bowel dysfunction is being treated. Symptoms include urinary incontinence, dysuria, urinary frequency or infrequent voiding, constipation and encopresis. Children with VUR and bladder/bowel dysfunction may be at increased risk for renal damage.
• Bladder/bowel dysfunction tends to increase the risk of breakthrough UTI in children on antibiotic prophylaxis.

Bladder/bowel dysfunction: Beyond antibiotics

• Treatments for bladder/bowel dysfunction may include constipation management, behavioral therapy, anticholinergic medications, alpha-blockers, biofeedback or pelvic floor muscle retraining.
• Electromyography-based biofeedback therapy can be used to retrain pelvic muscles and strengthen and coordinate bladder contractions. Use of animated biofeedback encourages interest and helps attain results more quickly.

Dr. Janjua is a pediatric nephrologist in Cleveland Clinic Children’s Center for Pediatric Nephrology.