Revised Indian Society of Pediatric Nephrology Guidelines 2023 on UTIs and Vesicoureteric Reflux Management

Diagnosing urinary tract infections (UTIs) in children is challenging due to the non-specific symptoms and difficulty collecting urine specimens. However, early diagnosis and treatment are crucial to avoid complications. Children with recurrent UTIs need thorough evaluation and follow-up for effective management. 

The following are updates on the 2023 guidelines from the Indian Society of Pediatric Nephrology on UTIs and primary vesicoureteric reflux (VUR):

Diagnosis:

• For urine collection, the clean-catch method is recommended for toilet-trained children. In non-toilet-trained stable children, attempt clean catch first, then catheterization or suprapubic aspiration if unsuccessful. For sick infants, catheterization and suprapubic aspiration are preferred.
• Urine dipstick (leukocyte esterase and nitrite combination) is suggested as a first-line screening test. Urine microscopy can also be used.
• A UTI diagnosis should be based on positive urine culture in symptomatic children, with specific colony-forming unit (CFU) thresholds for different urine collection methods.

Treatment:

• Initiate antibiotic therapy within 48-72 hours of fever onset. Third-generation cephalosporins or amoxicillin-clavulanic acid are recommended for febrile UTI, while first-generation cephalosporins or amoxicillin-clavulanic acid are suggested for adolescent cystitis.
• Oral antibiotics are preferred over intravenous administration, except in infants under 2 months, severely ill patients, or those unable to take oral antibiotics.
• Therapy should last 7-10 days for acute symptomatic UTIs and 3-7 days for cystitis. Avoid antibiotics for asymptomatic bacteriuria and urine cultures in asymptomatic children.

Imaging:

• An ultrasound of the urinary tract is recommended after a UTI episode. Micturating cystourethrography is suggested for specific cases such as non-E. coli uropathogens, abnormal ultrasound, or recurrent UTI history.
• Avoid acute-phase DMSA scans for febrile UTI, but consider late-phase DMSA scans for assessing kidney scarring in recurrent UTI or high-grade VUR cases.
• Prevention:
• Antibiotic prophylaxis is advised for recurrent febrile UTIs in patients with high-grade VUR but not for those with normal urinary tracts and no bladder-bowel dysfunction (BBD). Cotrimoxazole or nitrofurantoin is recommended for children over 3 months.
• Discontinue prophylaxis in toilet-trained children over 2 years old who have no BBD and no febrile UTI in the past year.
• Consider circumcision and cranberry products for preventing UTI in at-risk children. Evaluate all toilet-trained children with UTI for BBD and manage BBD with urotherapy to prevent recurrence.

Primary VUR Management:

• Surgical reimplantation is suggested for high-grade VUR with recurrent febrile UTI on prophylaxis. Endoscopic injection of a bulking agent can be an alternative, though it has a lower success rate than ureteric reimplantation.
• Periodic follow-up for children with high-grade VUR and reflux nephropathy includes monitoring growth, blood pressure, proteinuria, and kidney function. Ultrasound is recommended for ongoing kidney growth assessment.

General Recommendations:

• Screening siblings under 3 years of children with primary VUR, using an ultrasound scan is advised.
• Emphasis is on less aggressive evaluation, shorter treatment courses, and reduced antimicrobial prophylaxis duration to mitigate antimicrobial resistance.

These guidelines provide evidence-based strategies for managing pediatric UTIs and primary VUR, focusing on minimizing treatment duration and preventing antibiotic resistance.

Source: Meena J, Bagga A, Hari P. Indian Pediatrics. 2024 Feb 26:S097475591600597-.