Management of Urinary Tract Infections and Vesicoureteric Reflux: Key Updates from Revised Indian Society of Pediatric Nephrology Guidelines 2023

Introduction

Urinary tract infection (UTI) is a common bacterial infection in childhood affecting 1.7% of boys and 8.4% of girls before the age of 7 years.¹ UTI may be associated with acute discomfort, fever, and long-term complications such as hypertension and kidney scarring.² The diagnosis of UTI in infants and young children is difficult. Primary vesicoureteric reflux (VUR) and bladder-bowel dysfunction (BBD) are the two most common risk factors for the recurrence of UTI. Almost 20%-30% of children with the first episode of febrile UTI may have an underlying congenital anomaly. Therefore, prompt evaluation and treatment are important for managing acute and long-term complications associated with UTI. The last guidelines by the Indian Society of Pediatric Nephrology (ISPN) on this topic were published in 2011.³ Because of significant new evidence that has emerged in the last decade, the Indian Society of Pediatric Nephrology (ISPN) has recently revised and published evidence-based guidelines with a robust methodology.⁴ This article highlights the key updates in the recent guidelines [Table 1 and Figure 1]. Box 1 describes the various definitions used in this review.

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Figure 1:

Approach to a child with suspected urinary tract infection (UTI). 1. Fever (>48 h) without focus in children less than 24 months or with specific urinary symptoms in older children; 2. If feasible to perform urine microscopy (leukocyturia and bacteriuria) can be used as an alternative to the dipstick; 3. Risk factors: bladder-bowel dysfunction, primary vesicoureteric reflux, previous history of UTI; 4. Oral route is preferred over IV except in infants less than 2 months, sepsis, and inability to take oral medications; 5. In adolescents where it is feasible to make the diagnosis of cystitis oral antibiotic therapy of 3–7 days is sufficient; 6. MCU study can also be considered in children with UTI due to non-E.coli uropathogens.¹¹ LE: Leukocyte esterase, DMSA: Dimarcapto succinic acid scintigraphy, VUR: vesicoureteric reflux, BBD: bladder bowel dysfunction.

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Materials and Methods

These guidelines were developed using international standards for developing good-quality clinical practice guidelines. Initially, six working groups and an evidence review group were formed, following which questions were developed in PICOM (population, intervention, control, outcome, methods) format, a detailed systematic literature search was performed, and used the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach⁵ to assess the quality of evidence and strength of recommendations. While recommendations are based on evidence generated through systematic review and meta-analysis, clinical practice points are drafted chiefly based on limited literature or expert opinions. For detailed methodology, one may refer to the original manuscript.⁴

Diagnosis

Management of primary VUR

Antibiotic prophylaxis is the first line of management and surgical reimplantation only in patients with recurrent breakthrough febrile UTIs.

In patients with primary VUR, neither antibiotic prophylaxis nor surgical reimplantation is effective in reducing the risk of kidney scarring, although the latter is more effective in preventing febrile UTIs.⁹ The revised guidelines suggest that surgical reimplantation should be reserved for patients with recurrent febrile UTIs despite antibiotic prophylaxis and optimal management of BBD. Endoscopic injection of bulking agents has a lower success rate as compared to surgical reimplantation and hence, should be used after careful discussion with the caregivers.¹⁰

Children with primary VUR may have associated kidney damage termed as reflux nephropathy. Kidney damage in these patients is chiefly caused by congenital hypodysplasia but may also be due to kidney scars caused by febrile UTI. Patients with reflux nephropathy may develop proteinuria, hypertension, and rarely impaired kidney function in the long term. Hence, these patients require long-term follow-up and monitoring. An ultrasound scan can be used to assess the growth of kidneys. DMSA scan may be repeated in patients with a recurrence of febrile UTI. The median time to resolution is variable depending on the grade of VUR therefore, if felt necessary, repeat imaging for resolution of VUR may be done 4 to 8 years after initial diagnosis. Primary VUR is reported to be common in siblings, however, considering limited intervention to alter the long-term outcome, the guidelines suggest that screening should be done using an ultrasound scan only in siblings below 3 years of age. If the ultrasound scan is abnormal or the sibling develops febrile UTI, clinicians may consider MCU to confirm the diagnosis of VUR.

Conclusion

Timely diagnosis of UTI can be sometimes challenging but is necessary to reduce acute discomfort and long-term consequences. BBD and primary VUR, are two important risk factors for recurrence. These updated guidelines present evidence-based systematic and algorithmic guidance for optimal management of these disorders. Updated guidelines emphasize less aggressive approaches while evaluating shorter courses of treatment and briefer duration of antimicrobial prophylaxis to reduce the burden of antimicrobial resistance.