Pediatric INSIGHTS - Fall 12Children's Hospital of Pittsburgh of UPMC

Decoding a Common Childhood Infection

New, Comprehensive UTI Treatment Center is Locus of Research and Information

Tori Gilliland preparing for her DMSA scan

Urinary tract infections (UTIs) are one of the most common serious infections among infants, toddlers, and young children. According to the National Institutes of Health, 3 percent of children in the United States are affected each year and account for more than a million visits to pediatricians.

“Next to ear infections, UTI is the most frequently occurring bacterial infection in children,” says Alejandro Hoberman, MD, chief, General Academic Pediatrics, “and its symptoms and consequences can be severe.” UTIs can result in kidney scarring, with symptoms like high fever and febrile seizures sometimes seen in the emergency room.

Now, taking advantage of decades of work investigating the prevalence and treatment of UTIs, Children’s Hospital of Pittsburgh of UPMC is establishing its UTI Center to serve as the locus of research, information, and support for community practitioners and parents. Its multidisciplinary approach combines capabilities and expertise of the divisions of General Academic Pediatrics, Urology, and Nephrology, as well as the Department of Pediatric Radiology.

Mary Ann Haralam, CRNP, examines a patient.

Enrolling in a UTI Center Research Study

Early and accurate diagnosis is essential with UTI, especially for children to be enrolled in the research studies that may offer comparative treatments.

Children’s recommends that when infants present with a fever, practitioners should collect a urine specimen because UTI is often the cause. “Don’t wait for a child to have a fever for three days before checking the urine. The longer you wait, the more the kidney scars,” Dr. Hoberman says.

Proper urine sample collection is critical. Research has revealed that UTIs are sometimes misdiagnosed or children inappropriately treated because of improperly collected samples, says Mary Ann Haralam, clinical director of the UTI Center.

Children’s recommends collecting samples via catheter to avoid contamination, followed by a quick “dipstick” method of checking urine before sending it to a lab for full analysis.

“With some of our current studies, we need to enroll children right at the time of the UTI diagnosis,” Ms. Haralam says. When a pediatrician identifies a potential study candidate, he or she should call the UTI Center at 412-692-UTIS (8847). Research nurses can generally be dispatched to the practitioner’s office to meet with the family and present options for study participation.

There is no charge, and some allowances are made to families for meals and travel. Transportation assistance also is available. Review summaries of current UTI Center clinical studies.

“Our goal is to create a more careful and comprehensive approach to the care of children with UTIs,” Dr. Hoberman says.

The UTI Center is “virtual” in the sense that it is a clearinghouse for data and research programs related to UTI. Its intent is to support practitioners and promote early diagnosis and evidence-based care for children with UTIs. Much of that information, including links to relevant clinical studies, will be accessible via the new UTI Center website, www.chp.edu/UTIS.

The unique team of experts involved in the center creates a support base for pediatricians and families throughout western Pennsylvania and beyond. In Pediatric Nephrology, researchers are investigating genetic reasons for children having vesicoureteral reflux (VUR) and urinary tract obstructions. Urology provides management of problems, including surgical corrections when needed, and voiding dysfunction (a common cause of UTI) through its Healthy Elimination Learning Program (HELP). HELP provides evaluation and treatment of children with a history of UTIs, day and nighttime urinary incontinence, and voiding symptoms such as urgency, frequency, and incomplete bladder emptying. The UTI Center’s urology experts also provide evaluation of children with VUR III or IV or with recurrent UTI.

A research-based foundation

To say Dr. Hoberman knows a few things about UTI would be an understatement. He’s co-authored numerous papers and conducted ongoing research programs on the condition since joining Children’s 22 years ago as a pediatric fellow. Working with Robert Hickey, MD, in Pediatric Emergency Medicine, that first study of about 1,000 babies under 1 year of age who presented with fever to the ED determined that UTI was present in about 5 percent of cases. The study showed that girls, particularly Caucasians, were far more likely to have UTI, at rates upwards of 16 percent.

More studies, working with still larger patient populations, followed. Insights gained by Children’s researchers have been used to help establish the American Academy of Pediatrics’ (AAP) guidelines for UTI diagnosis and treatment, the latest of which were published in Pediatrics in September 2011. Methodologies developed at Children’s on how to properly collect a urine specimen and conduct urinalysis, as well as the standards for defining UTI in children, are today considered the gold standard.

The growing portfolio of research projects and the support that went along with it provided the idea behind creating the UTI Center. “We have never had a portfolio of research as comprehensive as we have now,” Dr. Hoberman says, citing five NIH clinical research programs that are currently under way at Children’s. “This isn’t happening anywhere else in the country.”

  • RIVUR (Randomized Intervention for Vesicoureteral Reflux) is a randomized, placebo-controlled follow-up study of children with VUR, trying to determine whether prophylaxis with antibiotics is beneficial.
  • CUTIE (Careful UTI Evaluation) looks at the risk factors resulting in renal scars from UTI for children who do not have VUR.

Two new studies have just begun.

  • Biomarkers, led by Nader Shaikh, MD, MPH, looks at biomarkers to distinguish between kidney and bladder infections among children with febrile UTI.
  • STARRS, also led by Dr. Shaikh, will determine whether an intervention with corticosteroids can reduce the likelihood of kidney scars among children with acute febrile UTIs.

SCOUT will evaluate a five-day course of treatment vs. the standard 10 to 14 days of treatment. SCOUT is funded but not yet open for enrollment.

Family-focused team

Alejandro Hoberman, MD

The UTI Center director is Dr. Hoberman. Mary Ann Haralam, CRNP, is the clinical director and Diana Kearney, RN, CCRC, is the research manager. Support faculty includes Dr. Shaikh, Sonika Bhatnagar, MD, and Timothy Shope, MD, MPH, from General Academic Pediatrics; Carlton Bates, MD, and Michal Moritz, MD, from Nephrology; Steven Docimo, MD, Glenn Cannon, MD, and Mary Ellen Cook, CRNP, from Urology.

In a sense, the UTI Center simply puts an umbrella over something special that Children’s has had all along: a comprehensive research initiative, exceptionally dedicated clinicians, and an uncommon level of personal attentiveness around the issue of UTI.

“What the families love is the dedicated, personalized care,” Dr. Hoberman says. “At 7 in the morning a mother involved in a research project calls, and I answer the phone. She’s telling me her child is having accidents overnight and complaining that something’s wrong ‘down there.’ She wants to know, Should she see the pediatrician? Should she go to the emergency room? Should she send her daughter to day care?”

A little parent education goes a long way, says Ms. Haralam. “Even though UTI is a very common condition, it frightens parents. Parents have said to us, ‘We’re so happy we’re involved in this study because now we feel like we’re on top of this.’”

“Sometimes when families finish the study, we have a hard time disengaging. I always tell them, ‘If we can be helpful in any way, just call us.’”

Now, with the UTI Center, that’s easier than ever.

Referrals

Physicians who wish to refer a patient to the UTI Center or seek a consultation should call 412-692-UTIS (8847) or send an email to UTIS@chp.edu.

For Further Reading

“Urinary Tract Infection: Clinical Practice Guideline for the Diagnosis and Management of the Initial UTI in Febrile Infants and Children 2 to 24 Months,” The Subcommittee on Urinary Tract Infection, Steering Committee on Quality Improvement and Management, Pediatrics, September 2011, 595-607.

“Acute management, imaging, and prognosis of urinary tract infections in children,” Nader Shaikh, MD and Alejandro Hoberman, MD, UpToDate® clinical information service on the web and mobile devices, Oct. 19, 2011.

“Clinical features and diagnosis of urinary tract infections in children,” Nader Shaikh, MD and Alejandro Hoberman, MD, UpToDate® clinical information service on the web and mobile devices, Oct. 19, 2011.

A Kinder, Gentler Approach to Kidney Scans

DMSA scan showing UTI-related scarring of the right kidney.

Tori watches "My Little Pony" during a DMSA renal scan.

Imaging children poses unique challenges. It can be difficult for children to hold still for an X-ray, or they may be frightened by the noise of a DMSA scan. Children’s pediatric radiologists, working with child life specialists, make their young patients’ experience as safe and pleasant as possible, while obtaining the high-quality images needed to rule out or diagnose vesicoureteral reflux, pyelonephritis, or other renal conditions.

When it comes to urinary matters, three types of imaging techniques are typically applied:

•   Ultrasound can reveal obstructions of the urinary tract from the ureters between the kidneys and bladder, down to the urethra leading from the bladder. The latest AAP guideline suggests that for children up to 24 months, an ultrasound be done at the first febrile UTI.

•   The voiding cystourethrogram (VCUG), an X-ray of the bladder and urinary tract at work, can be used to identify cases of reflux. This procedure requires catheterization, filling the bladder with a contrast substance, and then putting pressure on the abdomen so the child will void. The latest AAP guideline suggests that for infants and toddlers up to 24 months, a VCUG be done at the second febrile UTI, but not the first.

•   DMSA scans are used in several of the studies at Children’s to determine the potential and extent of UTI-related kidney scarring, as well as the possible prevention of scarring, given treatment with steroids during UTI therapy.

In a DMSA scan, the radioisotope dimercaptosuccinic acid is injected intravenously, and the child must lie still for four images, each of which takes about four minutes to complete, a challenge when dealing with babies and energetic toddlers.

“In many places throughout the country children are being sedated in order to do this,” says Dr. Hoberman. Children’s Molecular Imaging team specializes in performing DMSA kidney scans without sedation. “Here, 95 percent of the kidney scans are done without sedation. We employ distraction therapy instead: We wrap them with a sheet and have a child life specialist play a movie or music."