Controversies in childhood urinary tract infections

Abstract

Management of childhood urinary tract infections is conceptually straightforward, but controversies persist. Specimens must be collected carefully or culture results can be difficult to interpret. Urine culture remains the diagnostic standard but does not substitute for careful urinalysis. Radiography studies are designed to define abnormalities predisposing patients to pyelonephritis and to assess the extent of renal involvement during infection, but there is no agreement on the most appropriate combination of studies. Circumcision reduces the incidence of urinary infections in male infants. Vaginal reflux may have an impact on recurrent infections, especially after courses of antibiotics. The importance of vesicoureteral reflux remains controversial because renal scarring appears to be related more to infection than to reflux itself. A strong argument can be made for the avoidance of prophylactic antibiotic therapy, even in patients with reflux. Increased attention to early diagnosis and treatment may be responsible for a decreasing incidence in renal failure from reflux nephropathy in children.

Predictors of renal scar in children with urinary infection and vesicoureteral reflux

“…Significant association of renal scarring detected by DMSA scan at presentation with reflux grade both in girls and boys in this study is compatible with the traditional dogma that patients with VUR are more prone to renal scarring [6]. New/progressive scar development, on the other hand, was not affected by gender, age, VUR grade or resolution of VUR spontaneously or surgically.…”

“…Follow-up cystograms were performed as direct radionuclide cystography. Renal parenchymal involvement was assessed by DMSA scan [6]. All children with impaired differential uptake (>10% uptake difference between renal units) or hypoactive foci in the first DMSA scan underwent a second imaging 4-6 months later for determination of the persistence of globally low uptake or hypoactive foci compatible with hypoplasia or scarring, respectively.…”

“…Furthermore, neither the incidence of recurrent UTIs nor the progression of existing scars or development of new scars was affected by spontaneous resolution or surgical correction of reflux [3][4][5]. These findings caused VUR to lose its image as a main factor for susceptibility to UTIs, to the point that, in the presence of normal findings on ultrasonography (USG) and DMSA scan, voiding cystourethrography (VCUG) has been considered to be unnecessary unless there is an abnormal voiding pattern [1,6,7].…”

Diagnostic significance of clinical and laboratory findings to localize site of urinary infection

“…The photopenic defect observed on DMSA scan is the result of a decrease in DMSA uptake by proximal tubular cells and decreased perfusion of the infected area. Because most UTIs are ascending in origin and involve the renal medulla prior to the cortex, it has been argued that some patients with early acute pyelonephritis may have no defects on DMSA scan (false negative results) because the lesions are only present in the renal medulla [13,24]. There are no data that assess the false negative result rate using DMSA scan in children for the diagnosis of acute pyelonephritis.…”

Neonatal Genital Herpes Simplex Virus Type 1 Infection After Jewish Ritual Circumcision: Modern Medicine and Religious Tradition

“…The medically beneficial versus harmful consequences have long been debated. 3 Circumcision has been reported to reduce the incidence of urinary tract infections in infants, 4 young boys under the age of 2 years, 5 and preschool boys. 6 Pathologic phimosis and paraphimosis is precluded by the absence of a foreskin, and balanitis and posthitis (inflammation of the prepuce) primarily affect uncircumcised male individuals.…”