Society For Pediatric Urology

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Gram Positive Urinary Tract Infections are Associated with Higher Incidence of Abnormal Imaging Findings in Pediatric Males
Sarah A. Holzman, MD1, Campbell Grant, MD2, Rebecca Zee, MD3, Md Sohel Rana, MBBS3, Bruce M. Sprague, BS3, H. Gil Rushton, MD3.
1Medstar Georgetown, Washginton, DC, USA, 2George Washington University, Washginton, DC, USA, 3Children's National Medical Center, Washginton, DC, USA.

Title:  Gram Positive Urinary Tract Infections are Associated with Higher Incidence of Abnormal Imaging Findings in Pediatric Males
Introduction and Objective: The 2011 AAP Guideline recommends against VCUG until the second febrile urinary tract infection (UTI). We hypothesized that UTI speciation might be predictive of abnormal findings on ultrasound and/or VCUG. We sought to identify if Staphylococcal and Streptococcal UTIs were more likely than those with other bacterial species to be associated with anatomic anomalies in males diagnosed with UTI after presentation to the emergency department.  
We retrospectively reviewed a cohort of male patients under 18 years of age who presented to our emergency department and had positive urine cultures from 2011-2015. Males under 18 years of age with >50,000 CFU/mL Staphylococcal, Streptococcal, Proteus or Escherichia UTIs on clean catch or catheterized specimens were included. Both febrile and afebrile UTIs were included if culture inclusion criteria were met. Patients on intermittent catheterization or with augmented bladders were excluded. Ultrasound and cystogram images were reviewed when available. Abnormal cystogram was defined as the presence of any grade VUR or bladder diverticulum. Circumcision status was determined from emergency department and urology notes when available. Chi squared and Fisher’s exact tests were performed using Stata software, version 14.0 SE (Stata Corporation, College Station, Texas, USA).
A total of 703 males with urine culture results from the emergency department were evaluated and 357 met inclusion criteria. Median age was 7.7 months (2.5- 46.8 months IQR). Forty-two Proteus, 16 Staphylococcus, 7 Streptococcus and 292 Escherichia UTIs were included.  When documented, the incidence of circumcision was significantly higher in Staphylococcus (78.57%, 11/14) and Streptococcus (66.67%, 4/6) infections when compared with Escherichia (16.37%, 37/226) and Proteus (2.70%, 1/36) infections (Fisher’s Exact test p<0.001). Of the patients who underwent cystogram, 71% (5/7) of Staphylococcus patients had abnormal cystograms compared to 50% (1/2) of Streptococcus, 16% (18/111) of Escherichia and 15% (2/13) of Proteus (Fisher’s Exact test 0.004). High grade hydronephrosis (SFU grades 3 and 4) was seen in 27% of Staphylococcus compared to 17% of Streptococcus, 4% Escherichia and 0% of Proteus UTIs (Fisher’s Exact test p<0.012).
Staphylococcal and Streptococcal UTIs are more commonly seen in circumcised boys and are associated with higher rates of abnormal imaging findings. Pediatric-age males who present with first UTI with gram-positive organisms should be considered for additional imaging prior to developing a second UTI.

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