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Early Antibiotic Treatment for Pediatric Febrile Urinary Tract Infection and Renal Scarring.

Published on Sep 1, 2016in JAMA Pediatrics12.004
· DOI :10.1001/jamapediatrics.2016.1181
Nader Shaikh24
Estimated H-index: 24
(University of Pittsburgh),
Tej K. Mattoo26
Estimated H-index: 26
(WSU: Wayne State University)
+ 6 AuthorsAlejandro Hoberman37
Estimated H-index: 37
(University of Pittsburgh)
Sources
Abstract
Importance Existing data regarding the association between delayed initiation of antimicrobial therapy and the development of renal scarring are inconsistent. Objective To determine whether delay in the initiation of antimicrobial therapy for febrile urinary tract infections (UTIs) is associated with the occurrence and severity of renal scarring. Design, Setting, and Participants Retrospective cohort study that combined data from 2 previously conducted longitudinal studies (the Randomized Intervention for Children With Vesicoureteral Reflux trial and the Careful Urinary Tract Infection Evaluation Study). Children younger than 6 years with a first or second UTI were followed up for 2 years. Exposure Duration of the child’s fever prior to initiation of antimicrobial therapy for the index UTI. Main Outcomes and Measures New renal scarring defined as the presence of photopenia plus contour change on a late dimercaptosuccinic acid renal scan (obtained at study exit) that was not present on the baseline scan. Results Of the 482 children included in the analysis, 434 were female (90%), 375 were white (78%), and 375 had vesicoureteral reflux (78%). The median age was 11 months. A total of 35 children (7.2%) developed new renal scarring. Delay in the initiation of antimicrobial therapy was associated with renal scarring; the median (25th, 75th percentiles) duration of fever prior to initiation of antibiotic therapy in those with and without renal scarring was 72 (30, 120) and 48 (24, 72) hours, respectively ( P  = .003). Older age (OR, 1.03; 95% CI, 1.01-1.05), Hispanic ethnicity (OR, 5.24; 95% CI, 2.15-12.77), recurrent urinary tract infections (OR, 0.97; 95% CI, 0.27-3.45), and bladder and bowel dysfunction (OR, 6.44; 95% CI, 2.89-14.38) were also associated with new renal scarring. Delay in the initiation of antimicrobial therapy remained significantly associated with renal scarring even after adjusting for these variables. Conclusions and Relevance Delay in treatment of febrile UTIs and permanent renal scarring are associated. In febrile children, clinicians should not delay testing for UTI.
  • References (16)
  • Citations (41)
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References16
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#1Ron Keren (UPenn: University of Pennsylvania)H-Index: 41
#2Nader Shaikh (Boston Children's Hospital)H-Index: 24
Last. Alejandro Hoberman (Boston Children's Hospital)H-Index: 37
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#1Alejandro Hoberman (University of Pittsburgh)H-Index: 37
#2Saul P. Greenfield (Women & Children's Hospital of Buffalo)H-Index: 28
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#1Malcolm G. Coulthard (Boston Children's Hospital)H-Index: 32
#2Heather J Lambert (Boston Children's Hospital)H-Index: 16
Last. John N. S. Matthews (Newcastle University)H-Index: 35
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Objective To test whether active management of urinary tract infections (UTI) in young children by general practitioners can reduce kidney scarring rates. Design A comparison of two audits in Newcastle, of children aged Main outcome measures Kidney scarring rates, and their relationship with time-to-treat. Results Children with a first UTI in the 2000s compared to those in the 1990s, were referred younger, were half as likely to have a renal scar (girls OR 0.47, 95% CI 0.29 to 0.76; boys 0.35, 0...
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#1David Newman (ISMMS: Icahn School of Medicine at Mount Sinai)H-Index: 19
#2Ashley E. Shreves (ISMMS: Icahn School of Medicine at Mount Sinai)H-Index: 4
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The epidemiology of pediatric fever has changed considerably during the past 2 decades with the development of vaccines against the most common bacterial pathogens causing bacteremia and meningitis. The decreasing incidence of these 2 conditions among vaccinated children has led to an emphasis on urinary tract infection as a remaining source of potentially hidden infections in febrile children. Emerging literature, however, has led to questions about both the degree and nature of the danger pose...
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#1Mi Mi Oh (KU: Korea University)H-Index: 13
#2Jin Wook Kim (KU: Korea University)H-Index: 9
Last. Du Geon Moon (Inje University)H-Index: 23
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We assessed the role of therapeutic delay time (TDT) in acute renal cortical scintigraphic lesion (ASL) and ultimate scar formation (USF) in children with first febrile UTI and whether it is affected by the presence of vesico-ureteral reflux (VUR). 230 children, 90 girls and 140 boys with first febrile UTI were included. Radiologic (USG, DMSA, and VCUG), clinical (age, gender, peak fever, therapeutic delay time) and laboratory (CBC with differential count, ANC (absolute neutrophil count), BUN, C...
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#1Ron Keren (UPenn: University of Pennsylvania)H-Index: 41
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Objective Our goal is to determine if antimicrobial prophylaxis with trimethoprim/sulfamethoxazole prevents recurrent urinary tract infections and renal scarring in children who are found to have vesicoureteral reflux after a first or second urinary tract infection. Design, Participants, and Methods The Randomized Intervention for Children With Vesi-coureteral Reflux (RIVUR) study is a double-blind, randomized, placebo-controlled trial. Six hundred children aged 2 to 72 months will be recruited ...
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#1Ian K. HewittH-Index: 9
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OBJECTIVES. The American Academy of Pediatrics recommendation for febrile infants and young children suspected of having a urinary tract infection is early antibiotic treatment, given parenterally if necessary. In support of this recommendation, data suggesting that delay in treatment of acute pyelonephritis increases the risk of kidney damage are cited. Because the risk was not well defined, we investigated renal scarring associated with delayed versus early treatment of acute pyelonephritis in...
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#1Nader Shaikh (Boston Children's Hospital)H-Index: 24
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ContextUrinary tract infection (UTI) is a frequently occurring pediatric illness that, if left untreated, can lead to permanent renal injury. Accordingly, accurate diagnosis of UTI is important.ObjectiveTo review the diagnostic accuracy of symptoms and signs for the diagnosis of UTI in infants and children.Data SourcesA search of MEDLINE and EMBASE databases was conducted for articles published between 1966 and October 2007, as well as a manual review of bibliographies of all articles meeting in...
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Urinary tract infections (UTIs) are a common reason for referral to pediatric specialists and the risk profile of these children is influenced by age, sex, and underlying urinary tract abnormalities. UTIs in toilet-trained children represent a different entity than confirmed, febrile UTIs that occur in infants, impacted by suboptimal bladder habits, bladder dysfunction, constipation, or a combination of these factors. A comprehensive literature search was conducted using PubMed and MEDLINE and s...
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#1Nader Shaikh (University of Pittsburgh)H-Index: 24
#2Timothy R. Shope (University of Pittsburgh)H-Index: 11
Last. Howard E. Rockette (University of Pittsburgh)H-Index: 53
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BACKGROUND To evaluate the efficacy of adjuvant systemic corticosteroids in reducing kidney scarring. A previous study suggested that use of adjuvant systemic corticosteroids reduces kidney scarring in children radiologically confirmed to have extensive pyelonephritis. Efficacy of corticosteroids for children with febrile urinary tract infection (UTI) has not been studied. METHODS Children aged 2 months to 6 years with their first febrile UTI were randomized to corticosteroids or placebo for 3 d...
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#1Kjell Tullus (GOSH: Great Ormond Street Hospital)H-Index: 37
#2Nader Shaikh (Boston Children's Hospital)H-Index: 24
Summary Urinary tract infections (UTIs) in children are among the most common bacterial infections in childhood. They are equally common in boys and girls during the first year of life and become more common in girls after the first year of life. Dividing UTIs into three categories; febrile upper UTI (acute pyelonephritis), lower UTI (cystitis), and asymptomatic bacteriuria, is useful for numerous reasons, mainly because it helps to understand the pathophysiology of the infection. A single episo...
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Urinary tract infections can cause renal damage if not treated promptly. The aim of this study was to examine if prior urine cultures can predict antibiotic susceptibility profile in a subsequent culture, in children with recurrent urinary tract infections. The medical records of all children with at least two episodes of urinary tract infection between 1999–2015 that occurred 2 weeks to 1 year apart were reviewed. Pathogen identity and antibiogram were compared between the two cultures for ever...
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#2Christina A. Collins (WashU: Washington University in St. Louis)H-Index: 2
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Abstract Objective This review aimed to provide a critical overview on the pathogenesis, clinical findings, diagnosis, imaging investigation, treatment, chemoprophylaxis, and complications of urinary tract infection in pediatric patients. Source of data Data were obtained independently by two authors, who carried out a comprehensive and non-systematic search in public databases. Summary of findings Urinary tract infection is the most common bacterial infection in children. Urinary tract infectio...
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Urinary tract infections (UTIs) are generally considered a disease of women. However, UTIs affect females throughout the lifespan, and certain male populations (including infants and elderly men) are also susceptible. Epidemiologically, pyelonephritis is more common in women but carries increased morbidity when it does occur in men. Among children, high-grade vesicoureteral reflux is a primary risk factor for upper-tract UTI in both sexes. However, among young infants with UTI, girls are outnumb...
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