Q: My 2-year-old granddaughter was recently treated for a kidney infection. I have several questions about how she was managed:
1) To diagnose the infection, a tube was placed into her bladder, causing pain and terror in the poor child. Why did they not use the plastic bag method of collecting the urine, which is much less traumatic?
2) She had a high fever and looked sick to us, but she was treated at home with an antibiotic given by mouth. Why was she not hospitalized, and why did she not need antibiotics given by vein?
3) After the infection was treated, apparently successfully, she had tests to see if there was a reason for the infection.
Her parents, my daughter and son-in-law, were told she had reflux. What is that, and how should it be treated to avoid more problems?
A: These are all good questions on a very confusing topic. One would think that we would have all the answers, because infections in the bladder and kidney (doctors call them urinary tract infections, or UTIs) are very common. Unfortunately, answers to many important questions regarding UTIs, especially in young children, are still controversial.
Your first question regards initial diagnosis of a UTI. Fevers are very frequent in young children, and a small number of them are serious and need treatment. UTIs are the most common serious bacterial infection.
Once upon a time, we used special little plastic bags that we stuck on around a small child’s genitals to catch urine. Little or no pain was involved, and most children eventually peed, though they and their parents often sat for hours before the bag was filled. The problem (aside from those idle clinic hours) was that the bags collected specimens from the skin and the girls’ vaginas or the boys’ foreskins in addition to the urine coming out of the bladder; interpretation of the results was difficult or impossible.
There is general agreement among doctors that in non-potty-trained small children, a catheter specimen is necessary, even though it is a little traumatic — a little, I say, because the catheters are small, and those placing the catheter have lots of skill at doing it quickly and easily. And clean, uncontaminated urine is absolutely essential to making the diagnosis of a UTI.
Deciding the location of the infection may be difficult as well, especially in small children and infants. It’s hard to ask a 2-year-old if it hurts when she urinates (that often indicates a bladder infection in older people) or if there’s pain on one side of the back (a symptom of a kidney infection, pyelonephritis). We assume that most UTIs with fever involve the kidney, but the term “febrile UTI” is probably more honest than making that assumption.
Most physicians subject the urine obtained by catheter to two tests, a urinalysis and a urine culture. Usually, the urinalysis — dipping a test strip with multiple chemical indicators on it — will accurately tell us whether a urinary tract infection is present or not, but the culture is necessary for being sure bacteria are present and finding out which antibiotics will work against it.
There’s no hurrying the culture — it takes at least 24 hours — but if the patient’s symptoms and the urinalysis strongly suggest infection, many times we’ll start an antibiotic, knowing we may have to change it if we find the germ is not sensitive to our first choice.
In the past, children with fever and UTI were usually hospitalized and given antibiotics through their veins. Recently, though, studies have shown that most children will do just as well with oral antibiotics, avoiding the trouble, terror and expense of being in a hospital.
To your third question: reflux is urine going the wrong way on a one-way street — up (from the bladder toward or to the kidney). Going the wrong way on a one-way street causes problems, both in traffic and in the ureter, the tube between the kidney and the bladder.
Reflux is detected by some combination of X-ray, ultrasound and radioactive chemical testing, all of which have advantages and disadvantages. If these tests detect reflux, experts will grade it from Grade I to V, with increasing Roman numerals indicating worse reflux. Grades I and II are usually considered relatively trivial, while Grade V reflux demands treatment, usually with surgery. But there is endless debate about what to do with children with Grade III and IV reflux.
Recently, the prestigious New England Journal of Medicine asked three UTI experts what they would do with a 6-year-old with long-documented Grade III reflux. Watchful waiting (checking the urine frequently, especially with fever), prophylactic antibiotics (giving a small daily dose of an antibiotic when no infection is present), and surgical treatment were each supported by one expert, each of whom could quote chapter and verse from the literature of medicine.
Each held out hope that a “new and better” study currently in progress will give us a clear answer as to what’s best. I hope so. But don’t hold your breath.
Lance Chilton, M.D., is a pediatrician at the Young Children’s Health Center in Albuquerque, associated with the University of New Mexico. He is happy to take questions at 272-9242 or firstname.lastname@example.org.