Claudio La Scola (Bologna)

Dall’esame delle urine
Le urine torbide: IVU
Dott. Claudio La Scola
Nefrologia Pediatrica di Bologna
[email protected]
Palermo 12/06/2014
Urine Normali
Le urine normali sono chiare di color giallo paglierino e
sono composte da:
95% Acqua
3% Urea
2% Soluti in eccesso (sali)
Urine torbide
Maria 3 anni e 1/2
APR
Nella norma
Motivo invio
Disuria da un paio di giorni
Richiedete urinocoltura….ma nell’attesa del
risultato?
A) Stick urine?
B) Esame microscopico del sedimento?
C) Entrambi?
enated RBC can resemble WBC
RBC Correlation
• Correlate microscopic evaluation with
– Physical exam
• Color
• Clarity
– Chemical exam
• Positive reagent strip
• Ascorbic acid: causes false negative result
• Myoglobin: causes false positive result
31
leukocytes
32
WBC: leukocytes
n urine: leukocyturia
• Spherical
es infection ((bacterial, non-bacterial))
• Contain nucleus,
granules etc
granules,
l: 0-8 WBC/hpf
phil predominant type of WBC found
e
• Approximately
2x larger
than RBC
33
34
Batteri
ytes
Globuli bianchi
m
granules
is
ed (lobed)
ound
in clumps
WBC clump
35
36
Absolute and relative accuracy of rapid urine tests for urinary tract
infection in children: a meta-analysis
pH 8
cristalli amorfi di
fosfato
Esterasi
Leucocitaria e
nitriti positivi
Piuria e
batteri
Stick urine
proteinuria
Chiluria
Cause di urine torbide
– IVU
– Piuria
– Batteriuria
– Fosfati amorfi:urine alcaline
– Urati amorfi: urine acide
– Cristalli, Cellule epiteliali e muco
– Chiluria e lipiduria
TAKE HOME MESSAGE
DI FRONTE AD UN BAMBINO CON URINE TORBIDE:
Anamnesi e clinica
+
DIPSTIK URINE ed ESAME
MICROSCOPICO DEL SEDIMENTO
Can Urine Clarity Exclude the Diagnosis of Urinary Tract I nfection?
Blake Bulloch, Judith C. Bausher, Wendy J. Pomerantz, J. Michael Connors, Melinda
Mahabee-Gittens and M. Denise Dowd
Pediatrics 2000;106;e60
The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/106/5/e60.full.html
PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly
publication, it has been published continuously since 1948. PEDIATRICS is owned,
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
LE IVU…
• Come raccogliere campione urine per urinocoltura in un
bambino che non ha raggiunto controllo sfinteri?
• Antiobioticoterapia per una IVU febbrile: parenterale o
orale?
• Batteriuria asintomatica ricercarla e trattarla?
• Quale imaging dopo IVU?
• Profilassi o non profilassi?
Marco 3 mesi
APR
Nella norma
Motivo invio
Febbre TC >39° >24 h
EO
Nella norma, non circonciso
When to suspect a UTI?
Unexplained
TC
>39°
Urinary Tract I nfection: Clinical Practice Guideline for the Diagno
Management of the I nitial UTI in Febrile I nfants and Children 2 to 24
Subcommittee on Urinary Tract Infection, Steering Committee on Qu
Improvement and Management
Pediatrics 2011;128;595 ; originally published online August 28, 20
DOI: 10.1542/peds.2011-1330
Unexplained
>39°
The online version of this article, along with updated information and ser
located on the World Wide Web at:
Guidelines
Fever
AAP
ISPN
Uncircumcised
Yes
Yes
http://pediatrics.aappublications.org/content/128/3/595.full.html
PEDIATRICS is the official journal of the American Academy of Pediatrics. A month
publication, it has been published continuously since 1948. PEDIATRICS is owned,
published, and trademarked by the American Academy of Pediatrics, 141 Northwest P
Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2011 by the American Ac
of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.
Urinary Tract Infection: Clinical Practice Guideline
Management of the Initial UTI in Febrile Infants and C
Subcommittee on Urinary Tract Infection, Steering C
Improvement and Management
Pediatrics 2011;128;595 ; originally published onlin
DOI: 10.1542/peds.2011-1330
Downloaded from pediatrics.aappublications.org by guest on November 16, 2013
The online version of this article, along with updated info
Marco 3 mesi
APR
Nella norma
Motivo invio
Febbre TC >39° >24 h
EO
Nella norma, non circonciso
Eseguo stick urine
Esterasi leucocitaria +++, Nitriti +
Subcommittee on Urinary Tract Infection, Steering Committee o
Improvement and Management
Pediatrics 2011;128;595 ; originally published online August 2
DOI: 10.1542/peds.2011-1330
DIAGNOSI OF UTI?
The online version of this article, along with updated information an
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/128/3/595.full.h
Guidelines
AAP
I SPN
POSI TI VE URI NE ANALYSI S AND/OR DI PSTI CK
+
URI NE CULTURE WI TH SI GNI FI CATI VE GROWTH
of UROPATHOGEN
PEDIATRICS is the official journal of the American Academy of Pediatrics. A
publication, it has been published continuously since 1948. PEDIATRICS is ow
published, and trademarked by the American Academy of Pediatrics, 141 North
Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2011 by the Americ
of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-42
Urinary Tract Infection: Clinical Practice
Management of the Initial UTI in Febrile Inf
Subcommittee on Urinary Tract Infection,
Improvement and Ma
Pediatrics 2011;128;595 ; originally publ
DOI: 10.1542/peds.2
Downloaded from pediatrics.aappublications.org by guest on November 16, 2
Come ottengo il campione di urine per l’urinocoltura?
I problemi iniziano con le cose più semplici
Come ottengo il campione di urine per
l’urinocoltura per Marco 3 mesi?
Puntura sovrapubica
Cateterismo vescicale
Mitto intermedio
Sacchetto perineale
La Scola et al. in press
Current primary care management of children 1-36 months
of age with urinary tract infections in Europe.
Large scale survey: 1,129 paediatricians
EAPRASnet: European Academy of Paediatrics
Research in Ambulatory Setting Network in press
Guidelines
AAP
ISPN
SPA
U-CATH
First choice
Not considered
In severely ill
children
Clean Catch
Not considered
First choice
Sterile
bag
Under no
circumstances
Second option*
* If febrile children are in good clinical condition
La Scola et al. in press (modified)
A TAPPING THE
SUPRAPUBIC AEREA
B STIMULATION
OF THE LOWER
BACK
C MIDSTREAM
URINE
PER MARCO 3 MESI INIZIATE ANTIBIOTICO
TERAPIA SU BASE EMPIRICA COME ?
A) ANTIBIOTICO PER VIA PARENTERALE FINO
ALLO SFEBBRAMENTO E POI PER VIA ORALE
B) ANTIBIOTICO PER VIA ORALE
Current primary care management of children 1-36 months of age with
urinary tract infections in Europe. Large scale survey.
1,129 paediatricians
EAPRASnet: European Academy of Paediatrics Research
in Ambulatory Setting Network in press
Primary and Secondary outcomes in
the 502 randomised children
ORALE
Montini, G. et al. BMJ 2007;335:386
PARENTERALE
+ORALE
Urinary Tract I nfection: Clinical Practice Guideline for the Diagnosis and
Management of the I nitial UTI in Febrile I nfants and Children 2 to 24 Months
Subcommittee on Urinary Tract Infection, Steering Committee on Quality
Improvement and Management
Pediatrics 2011;128;595 ; originally published online August 28, 2011;
DOI: 10.1542/peds.2011-1330
The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/128/3/595.full.html
PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly
publication, it has been published continuously since 1948. PEDIATRICS is owned,
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2011 by the American Academy
of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.
Urinary Tract Infection: Clinical Practice Guideline for the Diagnosis and
Management of the Initial UTI in Febrile Infants and Children 2 to 24 Months
Subcommittee on Urinary Tract Infection, Steering Committee on Quality
Improvement and Management
Pediatrics 2011;128;595 ; originally published online August 28, 2011;
DOI: 10.1542/peds.2011-1330
BAMBINO CON FEBBRE SENZA FOCOLAIO
o SINTOMI DI IVU
STICK
URINE
-
+
ESAME URINE ED URINOCOLTURA
(MITTO INTERMEDIO o CATERISMO)
+
ANTIBIOTICOTERAPIA EMPIRICA
VIGILE ATTESA
MARGHERITA 2 anni ½
IVU febbrile a 3 mesi, RVU II grado
Da allora esegue esame delle urine e urinocoltura mensili
Un giorno
La madre è preoccupata perché!
Urinocoltura da mitto intermedio positiva per E. Coli >100.000 UFC/ml……….
ma l’esame urine è nella norma
Interventions for covert bacteriuria in children (Review)
Analysis 1.5. Comparison 1 Antibiotics
treatment,
Fitzgerald A,versus
Mori R,no
Lakhanpaul
M O utcome 5 Pyelonephritis.
Review: Interventionsfor covert bacteriuria in children
Comparison: 1 Antibioticsversus no treatment
Thisisareprint of aCochranereview, prepared and maintained by TheCochraneCollaboration and published in TheCochraneLibrary
2012, Issue 2
http://www.thecochranelibrary.com
Comparison Antibiotics versus no treatment, Outcome Pyelonephritis
Outcome: 5 Pyelonephritis
Study or subgroup
NCBRG 1981
Savage 1975
Total (95% CI)
Antibiotics
No treatment
Risk Ratio
MH,Random,95%
CI
Weight
Risk Ratio
MH,Random,95%
CI
Interventions for covert bacteriuria in children (Review)
Copyright © 2012 T he Cochrane Collaboration. Published by John W iley & Sons, Ltd.
n/N
n/N
3/105
5/100
83.4 %
0.57 [ 0.14, 2.33 ]
0/18
1/24
16.6 %
0.44 [ 0.02, 10.18 ]
123
124
100.0 %
0.55 [ 0.15, 1.97 ]
Total events: 3 (Antibiotics), 6 (No treatment)
Heterogeneity: Tau2 = 0.0; Chi2 = 0.02, df = 1 (P = 0.88); I2 =0.0%
Test for overall effect: Z = 0.92 (P = 0.36)
Test for subgroup differences: Not applicable
0.01
0.1
Favours antibiotics
Review:
1
10
100
Favours no treatment
Authors’ conclusions
The included studies do not provide sufficient detail about the
Thisisareprint of aCochranereview, prepared and maintained by TheCochraneCollaboration and published in TheCochraneLibrary
2012, Issue
2
harms
and
benefits of treating covert bacteriuria to enable
http://www.thecochranelibrary.com
formation of reliable conclusions. It appears that antibiotic
Analysis
1.6. Comparison
1 Antibiotics
versus no is
treatment,
O utcome
6 Renal growth.
treatment
for covert
bacteriuria
unlikely
to benefit
children
Interventionsfor
covert
bacteriuria
in children
in the
long
term.
Comparison: 1 Antibioticsversus no treatment
Outcome: 6 Renal growth
DITE ALLA MADRE DI MARGHERITA DI NON
PREOCCUPARSI E DI:
ESEGUIRE ESAME DELLE URINE
ED URINOCOLTURA SOLO IN CASO DI
SINTOMI SUGGESTIVI DI IVU
UTI
The old concept
DMSA scan
Ultrasonography
CUM
Different Guidelines for Imaging After First Febrile UTI in Infants
La Scola C et al. Pediatrics 2013;131;e665
Different Guidelines for Imaging After First Febrile UTI in Infants
La Scola C et al. Pediatrics 2013;131;e665
Different Guidelines for Imaging After First Febrile UTI in Infants
La Scola C et al. Pediatrics 2013;131;e665
Different Guidelines for Imaging After First UTI in Febrile Infants
La Scola C et al. Pediatrics 2013;131;e665
Summary of modifiable risk factors relating to
recurrence of urinary tract infections
Study
Risk Factors
Panaretto
Shaikh
Stauffer
Bratslavsky
Bakker
Conway
Constipation
NE
++
++
NS
NE
NE
Dysfunctional
voiding/Inadeq
uate toilet
habits
NE
++
++
NE
++
NE
Poor fluid
intake
NE
NE
++
NE
NE
NE
VUR
++
++
NE
NE
NE
++
La Scola et al. in press (modified)
Pediatr Nephrol (2009) 24:1605–1609
Current primary care management of children 1-36 months of age with
urinary tract infections in Europe.
Large scale survey.
1,129 paediatricians
EAPRASnet: European Academy of Paediatrics Research in
Ambulatory Setting Network in press
Metanalisi: profilassi vs no profilassi in bambini con reflusso
NNT 17 CI:
9 to 62
Journal of Paediatrics and Child Health 49 (2013) 876–879
Guidelines
Antibiotic prophylaxis
NICE
Not for routine use
AAP
ISPN
Others interventions
Treat dysfunctional elimination
syndromes and constipation
Drink an adequate amount of fluid
Do not delay voiding
Not for routine use
Not considered
For reflux III-V
Recurrent febrile UTI*
Not considered
* ≥3 febrile UTIs within 12 months
La Scola et al. in press
May 4, 2014
RESULTS: primary endpoint
Interval between enrollment – 10% incidence of recurrence:
336 days (TMP-SMX) vs 106 days (Placebo)
RESULTS
p. NS
p < 0,001
NB: 2 anni di profilassi per 300 bambini = 600 anni di profilassi senza un effetto
significativo sulla formazione di scar e con un rischio significativo di antibiotico
resistenza!!!
Take Home Message
• Come raccogliere campione urine per urinocoltura in un
bambino che non ha raggiunto controllo sfinteri? MITTO
INTERMEDIO
• Antiobioticoterapia per una IVU febbrile: parenterale o
orale? ORALE se le condizioni cliniche lo permettono
• Batteriuria asintomatica ricercarla e trattarla? NO
• Quale imaging dopo IVU? ECOGRAFIA
• Profilassi o non profilassi?
THE PREDICT TRIAL
Antibiotic Prophylaxis and REnal Damage In Congenital
abnormalities of the kidney and urinary Tract
PREDICT: Trial Design
Prospectic, Controlled, Randomized, Open-label, Multicentric Trial
PURPOSE: To study the role of antibiotic prophilaxis in children with VUR
grade III-V
Grazie per l’attenzione