PYELONEPHRITIS in CHILDREN an Interim Review of Recent Literature MALCOLM MACGREGOR, M.D., F.R.C.P

Postgrad Med J: first published as 10.1136/pgmj.41.478.485 on 1 August 1965. Downloaded from POSTGRAD. MED. J. (1965), 41, 485 Clinical Review PYELONEPHRITIS IN CHILDREN An Interim Review of Recent Literature MALCOLM MACGREGOR, M.D., F.R.C.P. From the South Warwickshire Hospital Group PYELONEPHRITIS is now a fast-changing subject, But in infancy the diagnosis is often missed: with which the general reader may keep abreast in one autopsy series it had been missed clinic- only if frequent attempts are made to bring ally in 8.3% (Pryle and Neumann, 1962). T-he together published work from different sources. initial urinary infection often occurs in the This survey aims to provide a balanced account newborn period; in one series 0.3%/, of hospital of recent concepts, but is in no sense exhaustive. births (Smellie and others, 1964) and in another 1.5% (James, 1959) were considered to be in- Incidence of the Disease fected. In fact, the incidence among the new- Among childhood infections those of the born may be higher than in other age groups; urinary tract are second in frequency only to congenital defects in the kidney may pre- respiratory infections, and are the commonest dispose (Porter and Giles, 1956). Postmortem bacterial infections under two years of age studies suggest that the prevalence of urinary in- Protected by copyright. (Pryles, 1960; Deluca, Fisher and Swenson, fection is still underestimated (Kleeman, Hewitt 1963). The incidence of overt urinary infections and Gaze, 1960); about 2%/, of routine autopsies in the general population is estimated at 8 per on American children disclose evidence of 1,000 per annum (Percival, Brumfitt and pyelonephritis (Pryles and Neumann, 1962; Louvois, 1964), and in American schoolgirls Spark, Travis, Dodge, Dalschmer and Hopps, at 1.4% of the school population per annum 1962; Macaulay, 1964), but the difficulties in (Kunin, Deutscher and Paquin, 1964). Between diagnosis of this infection from postmortem I and 4%/, of hospital admissions of children material must be borne in mind. An increased are for this disease (Stansfeld, 1954); 3 to 4%/ incidence of pyelonephritis in siblings has been of recent admissions to an acute p,ediatric ward noted (Kunin, Deutscher and Paquin, 1964). in London were for urinary infections (Burke, 1961). On the other hand, in the Newcastle The Course and Prognosis of Childhood survey of 1,000 families, only 3 out of 847 Urinary Infections children were noted to have pyelonephritis in A tendency for the infection to relapse or http://pmj.bmj.com/ five years; all relapsed. The incidence of "signi- to become persistent is an alarming feature of ficant bacteriuria", which is often symptomless, oyelonephritis. Some 80-95%/, of treated primary (for definition see below) is higher, especially in infections are "cured" (when defined as free girls; 1% of schoolgirls in a recent large from bacteriuria six weeks after cessation of American survey were found to have this treatment), but about half of these have further (Kunin, Southall and Paquin, 1962; Kunin and periods of infection (Macaulay and Sutton, seem more others, 1964). Forty per cent of young women 1957; Lancet, 1963). Recurrences on September 26, 2021 by guest. with symptomless bacteriuria in early pregnancy common in older children than in infants later developed pyelitis of pregnancy (Kincaid- (Burke, 1961) and especially so in girls of the Smith, 1964; Percival, Brumfitt and Louvois, six to ten age group (Williams and Sturdy, 1964). The highest incidence of bacteriuria 1961). Persistence of infection is common, was found in girls aged between 15 and 19 mainly in girls (Dunn, Hine and MacGregor, (Kunin, Deutscher and Paquin, 1964). Most 1964; Woodruff and Everett. 1954), and one clinicians find that the onset of infection is third to one half of continuing infections are most frequent under one year old (Stansfeld, asymptomatic (Steele, Leadbetter and Crawford, 1954: Smellie, Hodson, Edwards and Normand, 1963: Dunn and others, 1964). Admittedly 1964), though some assert that the peak in- the significance of "significant bacteriuria" as cidence is among girls aged three to five the only finding is still debatable, but there (Deluca, Fisher and Swenson; Gross, Randolph seems to be little tendency for this to die out and Wise, 1963). spontaneously (Kass, 1956; Kleeman and others, 486 POSTGRADUATE MEDICAL JOURNAL August, 1965 Postgrad Med J: first published as 10.1136/pgmj.41.478.485 on 1 August 1965. Downloaded from 1960; Spence, Murphy, McGovern, Herdion years still show a 7% relapse rate afterwards and Pryles, 1964). Persistent infection has been (Campanacci, Bonomini and Zuchelli, 1963). found with different frequency in different sur- In chronic or recurrent infections in adults veys, in 10% (Burke, 1961), in 25% (Dunn there is only a 10% (Lancet, 1963) or 20% and others, 1964), in 39% (Woodruff and (Turck and others, 1962) cure rate, in spite of Everett, 1954). Of the chronic and recurrent really prolonged treatment (up to two years) groups the outcome varies, but the prognosis (Williams, 1963). In children, after conventional is believed to be worst when the onset is under treatment of acute infections there may be a two years of age. Some clear up, spontaneously 250/% persistence rate (Dunn and others, 1964). (Kunin, Deutsches and Paquin, 1964) or with There is not much evidence that prolonged treatment (Turck, Browder, Lindmeyer, Brown, drug treatment will produce better figures Anderson and Petersdorf, 1962; Macaulay, (Lancet, 1963), unless perhaps in infants (Stans- 1964) or at adolescence (Turner-Warwick, 1962; feld and Webb, 1954), though assertions are Williams, 1964). Others progress to renal failure made to the contrary (Smallpeice, 1958). In (Rosenheim, 1963). The follow-up in adults adults, non-antibiotic urinary disinfectants such after 20 years can be appalling. In a survey as methenamine mandelate (Holland and West, relating to the pre-antibiotic era, 43%/0 of young 1963) are capable of giving as good results as women who had been treated for acute pye- the powerful modem antibiotics tetracycline, lonephritis had serious urological disease after chloramphenicol and kanamycin (Turck and 16 years (Hanley, 1964). There is not yet much others, 1962), especially in older age groups information about the long-term prognosis for (Lindmeyer, Turck and Petersdorf, 1962). Be- children. The incidence of toxemia of pregnancy cause so many infections are clinically silent. essential and pyelitis of pregnancy is known to be un- prolonged follow-up of treated cases is Protected by copyright. usually high when there is a history of urinary (Lancet, 1963). Such follow-up studies in infection in childhood (Steele and others, 1963), children are in progress in a number of centres although a history of childhood infection was and should soon provide facts about the true found in only five out of 75 pregnant women prognosis in childhood. Early treatment of with pyelitis in one enquiry (Woodruff and primary infections is important (Deluca and Everett, 1954). There seems to be little correla- others, 1963), for delay in diagnosis increases tion between the number of recurrences and the the relapse rate (Stansfeld and Webb, 1954). effect after some years on the kidneys (Steele Once pyelonephritic scarring of a kidney has and others, 1963). The equal sex incidence occurred, infection is very difficult to eradicate of chronic pyelonephritis at autopsy in adults (British Medical Journal, 1964). Delay in diag- does not seem consistent with the much higher nosis is common, and averaged 18 months in incidence of symptomatic infections in girls, one recent survey (Deluca and others, 1963). suggesting that the one is not the direct ante- In another (Spence and others, 1964), 47% cedent of the other (Macaulay, 1964). However, of children sent to hospital had had symptoms http://pmj.bmj.com/ some girls with recurrent infections have been for one year or more, and in a third series, observed to develop progressive loss of kidney only 30%/O of children had been sent to hospital parenchyma with a fatal issue (Williams, 1965). with a suggestion of the correct diagnosis Although pvelonephritis is the second common- (Smellie and others, 1964). est cause of hypertension in adults, in two-thirds of such cases no history of recurrent urinary Clinical Features could be obtained (Kincaid-Smith. of vomiting infection In infancy, anorexia, loss weight, on September 26, 2021 by guest. McMichael and Murphy, 1958). Indeed, it is and failure to thrive are the main symptoms; said that a history of acute pyelonephritis is in older children, fever or abdominal pain rare in advanced chronic nvelonephritis (Kim- (Burke, 1961: Smellie and others, 1964). Only melstiel, Kim, Beres and Wellman. 1961). On 25%/, have micturition symptoms (Burke, 1961). the other hand, in a recent series of 200 children Hematuria occurs in 10% of acute attacks seen for urinary infection at a hospital, 13%/, (Kleeman and others, 1960; Burke, 1961). Re- had X-ray evidence of chronic pyelonephritis current febrile urinary infections are known to (Smellie and others, 1964). occur in older girls (Williams and Sturdy, 1961). Whatever its ultimate results, chronic urinary and the symptoms tend to be the same each infection is difficult to eradicate. With chemo- time (Burke, 1961). In older children chronic therapy the prognosis is still depressing (Mac- infection may be quite silent, but close question- aulay and Sutton, 1957). Uncomplicated primary ing will often uncover some disregarded urinary infections treated continuously for up to two symptom, such as enuresis, frequency or August, 1965 MAcGREGOR: Pyelonephritis in Children 487 Postgrad Med J: first published as 10.1136/pgmj.41.478.485 on 1 August 1965. Downloaded from dysuria (Dunn and others, 1964). Ureteric re- berg, 1964). The plastic bags, much used for flux occasionally gives rise to pain in the loin obtaining specimens from young children, are on micturition (Forsythe and Wallace, 1958).

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