# S08-1 (O)
INVESTIGATING FEBRILE UTI'S IN INFANTS- IS A CYSTOGRAM NECESSARY?
Giampierro SOCORRSO, Prasad GODBOLE, Jane WAGSTAFF, Kathryn BLAKEY, Ewen MACKINNON, Julian ROBERTS, Penny BROADLEY* and Gail MOSS† Sheffield Children's NHS Foundation Trust, Paediatric Urology and Surgery, Sheffield, UNITED KINGDOM - * Sheffield Children's NHS Foundation trust, Radiology, Sheffield, UNITED KINGDOM - † Sheffield Children's NHS Foundation trust, Paediatric Nephrology, Sheffield, UNITED KINGDOM
Background
Guidelines from the Royal College of Physicians
and the American Academy of Pediatrics recommend that all cases of bacteriologically
proven febrile urinary tract infection (UTI) under 1 year of age should
be investigated with a renal ultrasound scan (US) followed by a micturating
cystogram (MCUG) to identify vesicoureteral reflux (VUR) or other structural
abnormalities. A dimercaptosuccinic acid (DMSA) scan is also recommended
to document renal scarring with the aim of preventing renal insufficiency
and hypertension in the long term. Several authors have raised doubts
over the benefit of MCUG in the investigation of a first UTI in children
aged under 1 year of age.
Aims
We investigated the role of MCUG following a first infantile UTI.
Methods
A retrospective review of 427 children (854 renal units) aged 0 -12 months who were investigated after a first febrile UTI was performed. Only infants with a febrile culture proven (pure growth of a single organism > 100,000cfu/hpf) UTI were included. All infants underwent both MCUG and DMSA scan after initial investigation with US as per the local paediatric guidelines. The children were divided in two groups: one with normal renal US ( Group A = 708 ) and one with abnormal USS ( Group B = 146 ). For both groups DMSA findings were correlated with findings on MCUG. A normal USS was defined as one with no or minimal upper tract dilatation (< 8mm for AP renal pelvis), no calyceal dilatation, no ureteric dilatation and a structurally normal bladder.
Results
In Group A (n=708) the DMSA scan revealed scarring in 44 renal units (6.2%). Of these 44 renal units, 26 demonstrated VUR (59%) on MCUG. Of the renal units with a normal DMSA scan, 75 demonstrated low grade VUR (11%). Overall VUR was present in 101 of 708 (14%) and was of low grade. Only 26/708 renal units with a normal USS had both scarring on DMSA and VUR (3%). In Group B ( n=146) a DMSA scan revealed scarring in 86 renal units (59%). Of these 86 renal units, 23 demonstrated VUR on MCUG (27%). Of the renal units with a normal DMSA scan, VUR was present in 43 units (37%). Overall VUR was present in 66/146 renal units (45%) and was predominantly Grade III-V. Therefore 23/146 units with an abnormal USS had scarring on DMSA and VUR on MCUG (16%). The majority of the children of both groups were successfully treated conservatively with chemoprophylaxis. Only 5 children in Group B (3.4%) required surgical intervention.
Conclusion
An abnormal DMSA scan in the presence of a normal USS following
a febrile UTI in infants < 1 year of age is associated with a high incidence of VUR
as compared to a normal USS and normal DMSA scan. An abnormal
USS is associated with a high incidence of VUR irrespective
of a normal or abnormal DMSA
scan. We therefore recommend an USS and DMSA in all infants < 1 year of
age following a febrile UTI. Where the USS is normal, an MCUG
should be reserved for those cases where there is scarring
on DMSA or if surgical
intervention is contemplated. Where the USS is abnormal, an
MCUG should be performed in all infants irrespective of findings
of the DMSA scan.
A randomised prospective study is necessary to evaluate this
further.
# S08-2 (PP)
PROTECTIVE EFFECTS OF CRANBERRY ON INFECTION-INDUCED OXIDATIVE RENAL DAMAGE IN VESICOURETERAL REFLUX RABBIT MODEL
Chang Hee HAN, Soo Hwan KIM, Sung Hak KANG and Yong Hyun CHO
The Catholic University of Korea, Urology, Uijongbu, KOREA (REPUBLIC OF)
PURPOSE
We evaluated the protective effects of cranberry, which is known as
fruit with anti-oxidative function, on infection-induced oxidative
renal damage in rabbits with experimental VUR.
MATERIAL AND METHODS
A total of 36 New Zealand male rabbits were divided into 5 groups. VUR was created by incising the roof of the left intravesical ureter and confirmed at 2 weeks after operation. Infection was induced by intravesical instillation of 2 ml of E. coli suspension (105 E. coli in 1 ml). Cranberry powder (1 g/kg/day) was supplied with feed during the experimental period. Melatonin was injected into the peritoneal cavity immediately after operation and every week. 3 weeks after operation the rabbits were sacrificed and the kidneys were obtained. Oxidative renal damage was evaluated by measuring malondialdehyde in the renal tissue.
|
Group |
procedure |
| control (n=4) | Shamp operation |
| sterile (n=8) | VUR + sterile urine |
| E.coli (n=8) | VUR + infected urine |
| cranberry (n=8) | VUR + infected urine + cranberry |
| melatonin (n=8) | VUR + infected urine + melatonin |
RESULTS
The kidneys from E. coli group showed apparent periglomerular mononuclear cell infiltration, tubular dilatation and atrophy, and interstitial fibrosis. The kidneys from reflux, cranberry and melatonin group showed mild mononuclear cell infiltration without interstitial fibrosis. The level of malondialdehyde in E. coli group was significantly higher than that in control, cranberry and melatonin group (p<0.05). The malondialdehyde level in cranberry and melatonin group did not differ significantly from that in reflux group.
| group | Mean MDA ± SD (μM/gm) |
| control |
3.01±1.41 |
| sterile |
3.97±1.52 |
| E. coli |
5.12±1.54* |
| cranberry |
3.47±1.34 |
| melatonin |
2.69±0.97 |
CONCLUSIONS
This study demonstrates that cranberry has an anti-inflammatory effect
by anti-oxidative function and may prevent infection-induced oxidative
renal damage. Thus, clinically cranberry may be used for a beneficial
adjuvant treatment to prevent renal damage due to pyelonephritis
in children with VUR.
# S08-3 (PP)
TRIMETHOPRIM RESISTANCE IN THE 21st CENTURY: IT IS COMMONER THAN PERCEIVED
Devesh MISRA, Kati HAJIBAGHERI*, Max PRIESEMANN*, Ian MORRISON*, Nick LESSOF* and Liz PRICE*
Royal London Hospital, Paed-Surgery, London, UNITED KINGDOM - * Royal London Hospital, Paeds, London, UNITED KINGDOM
Click
here to open the presentation PURPOSE
This study aims at documenting the incidence and clinical course of trimethoprim
resistant urinary tract infections (UTI) in children. It also compares the present
local incidence of trimethoprim resistance with previous years.
MATERIAL AND METHODS
In 2003 over a 3 month period, data was analysed on all children who had
presented to our Paediatric A&E and had a positive urine culture. After
3 days of trimethoprim treatment, symptoms were recorded and sensitivities reviewed.
The same data was recorded over a 12 month period in 2005.
RESULTS
In 2003, trimethoprim resistant organisms were detected in 23 out of 50 Gram
negative infections, predominantly with E.coli. After 3 days of trimethoprim,
19 (83%) patients with trimethoprim resistant infections were still symptomatic.
Only 1 patient with a sensitive organism was symptomatic In 2005, the incidence
of trimethoprim resistance was 41%, In 1999, this figure was only 30%. In 2005,
incidence of nitrofurantoin and cefalexin resistance was 10 % and 15 %.
CONCLUSIONS
Trimethoprim resistance was found in over 40% of paediatric UTIs. Several
of these were first time infections. In trimethoprim resistant infections, over
80% of patients have persistent symptoms. We believe that such widespread resistance
results from overusage of Trimethoprim as opposed to other agents in the treatment
of paediatric UTIs. It is also possible that putting children on long term prophylaxis,
sometimes unnecessarily, contributes to this problem. Antibiotic protocols,
both for treatment and prophylaxis, need to be revised and cephalosporins and
nitrofurantoin may need to be used more often.
# S08-4 (PP)
ANTIOXIDANT ADMINISTRATION WITH INITIATION OF FEVER PREVENTS RENAL SCARRING IN THE RAT MODEL OF ACUTE PYELONEPHRITIS
Zhina SADEGHI, Abdol-mohammad KAJBAFZADEH*, Parvin TAJIK†, Maryam MONAJEMZADEH‡, Azadeh ELMI, Seyed Mehdi PAYABVASH and Amirali HASSANZADEH SALMASI
Pediatric Urology Research Center, Section of Human Cell Culture and Tissue Engineering, Department of Urology, Children’s Hospital Medical Center, Tehran University of Medical Sciences, Tehran, IRAN (ISLAMIC REPUBLIC OF) - * Director of Pediatric Urology Research Center, Department of Urology, Children’s Hospital Medical Center, Tehran University of Medical Sciences, Tehran, IRAN (ISLAMIC REPUBLIC OF) - † Tehran University of Medical Sciences, Students' Scientific Research Center, Tehran, IRAN (ISLAMIC REPUBLIC OF) - ‡ Children’s Hospital Medical Center, Department of Pathology, Tehran University of Medical Sciences, Tehran, IRAN (ISLAMIC REPUBLIC OF)
Click
here to open the presentationPURPOSE
To
evaluate the efficacy of antioxidant administration starting at the
onset of fever detection in reducing renal scars in animal model
of acute pyelonephritis (APN), and comparing the effectiveness of
Allopurinol and vitamin E in prevention of renal scaring.
MATERIAL AND METHODS
Twenty male Wister rats divided to 4 groups. Group 1 to 3 underwent direct inoculation of 0.1 ml of E-coli suspension into the parenchyma of the right kidney. Group 4 received 0.1 ml of saline. Group I treated with ceftriaxone only for 5 days, starting 3 days after bacterial inoculation; group II & III received Allopurinol and vitamin E as soon as animal's body temperature raised over 37˚C; followed by administration of daily ceftriaxone 3 says after inoculation for five days. Six weeks later all rats were scarified; both kidneys examined histopathologically for scarring. Renal cell apoptosis index was determined in paraffin embedded kidneys (using TUNEL assay).
RESULTS
The
fever started 4.6±1.3 hours (measured by continues digital rectal
thermometer) after inoculation in all rats. Histopathologically,
subsequent scar formation was occurred in all rats of the group 1 which
didn’t receive antioxidant agents. The inflammation and fibrosis was
mildest in group 2 and 3 (Allopurinol and Vitamin E); whereas it was
significantly lower in group 3 than in group 2 (p<0.05). Renal cell
apoptosis index was significantly decreased in group 2 and 3 compared
to group 1 (p<0.05).
CONCLUSIONS
Initiation
of the antioxidant agents following detection of fever can be effective
in reducing the severity of scarring in APN. Comparing the total scar
scores in experimental groups, vitamin E has more protective effect
against renal damage due to APN than Allopurinol.
# S08-5 (O)
ANTIBIOPROPHYLAXIS INTEREST IN PREVENTING URINARY TRACT INFECTION IN CHILDREN WITH LOW GRADE VESICOURETERAL REFLUX: RESULTS FROM A PROSPECTIVE RANDOMIZED STUDY
Gwenaelle ROUSSEY-KESLER, Vincent GADJOS*, François BOUISSOU†, Jean-michel N'GUYEN‡ and Claude GUYOT
Hopital Mère-Enfant, Pediatric Department, Nantes, FRANCE - * Hopital Antoine Beclère, Pediatric Department, Clamart, FRANCE - † Hopital des Enfants, nephrologic pediatric department, Toulouse, FRANCE - ‡ CHU Nantes, Statistical Department, Nantes, FRANCE
Click here to open the presentation PURPOSE
Antibioprophylaxis is administered in children at risk of urinary tract
infection (UTI). However, its effectiveness in children with low grade
vesicoureteral reflux (VUR) is lacking. The objective was to determine
whether antibioprophylaxis reduced or not the incidence of UTI .
MATERIAL AND METHODS
Children, 1-month to 3-years-old, with a low grade VUR, were assigned
randomly to receive daily cotrimoxazole or not, and then followed up
during 18 months. Clinical examination and renal ultrasound were
controlled at 9 and 18 months, and voiding cystourethrogram at 18
months. An UTI constituted an exit criteria. Survival curves without
infection were compared with a log-rank test.
RESULTS
223 children were enrolled, 102 in the cotrimoxazole group and 121 in
the control group. Sex repartition, age at inclusion and grade reflux
repartition were similar in the two groups. There was no significant
difference for the occurrence of UTI or pyelonephritis between the two
groups. Considering pyelonephritis, there was no significant difference
for girls, whatever was the grade of VUR. However, prophylaxis tended
to reduce pyelonephritis only for boys with a grade III VUR.
CONCLUSIONS
These data suggested that antibioprophylaxis did not reduce the
incidence of UTI in young children with low grade VUR. However, it may
prevent further pyelonephritis in boys with a grade III VUR.