Incidence of Recurrent UTI in Children Diagnosed with Vesicoureteral Reflux - Research Paper Example

? RESEARCH PROPOSAL First and October X PROJECT Incidence of Recurrent UTI in Children Diagnosed with VUR INTRODUCTION: Vesicoureteral reflux (VUR) is retrograde flow of urine from the bladder through the ureters towards the kidneys, which may lead to infection, damage and permanent scarring of the kidneys, hindering the excretory process initially, and leading to grave consequences if not treated appropriately. VUR can either be unilateral or bilateral and is strongly suspected to be a heritable disorder with a reported incidence rate of 10% in infants and young children (NIH). Primary VUR occurs when a child is born with an abnormally short ureter, a congenital defect. Secondary VUR occurs when an obstruction anywhere in the urinary tract occurs due to injury, torsion or anatomical abnormality. Treatment strategies are oriented around antibiotic therapy and surgical correction of the precipitating anatomical abnormalities. As VUR is a heterogeneous disorder, treatment strategies tried hitherto are still controversial as the disorder represents one of the most significant risk factors for acute pyelonephritis and subsequent kidney disease in children, characterized later by the manifestation of renal parenchymal injury, hypertension and chronic renal insufficiency which may be life threateneing (Cooper, 2009). Antibiotic prophylaxis in prone children has been the hallmark of therapeutic strategy against VUR till date. Incidence of repeated UTI infections in infants and young children are indicative of VUR and antibiotic therapy is initiated after confirmation of the diagnosis through cystourethrogram and ultrasound studies (NIH). The American Urological Association recommends continuous antibiotic therapy in young children once UTI infection has been diagnosed, and primary VUR grade III-V has been established. Latest research however reveals skepticism for this approach. Studies have indicated that antibiotic prophylaxis does not reduce the recurrence rate of pyelopnephritis and incidence of renal damage in children younger than 30 months of age diagnosed with VUR grade II through IV (Pennessi et al, 2011). Surgical intervention is recommended only when there has been no improvement in symptoms within one year (NIH). Secondary VUR is better amenable to treatment using surgical interventions for removing the obstruction. Current indications for the surgical correction of VUR depend on the presence or absence of renal scars. If no scars are present, anti reflux surgery is only indicated in high-grade bilateral VUR. Imaging studies for the diagnosis of VUR in children reveal that there is a good correlation between detection of renal scarring and existence of VUR in children aged less than one year, however the focus of imaging in older children should be the kidney as detection of reflux had a poor correlation with scarring (Gleeson & Gordon, 1991). Renal ultrasound studies have also failed to demonstrate sensitivity as well as specificity in detecting VUR in children diagnosed with UTI for the first time (Mahant et al, 2002). It has now been established that most children diagnosed with VUR do not improve with the currently available therapeutic modalities and treatment needs to be individualized according to peculiarities of a particular case (Cooper, 2009). Endoscopic subureteral injection of a dextranomer/hyaluronic acid copolymer has been suggested as an alternative therapeutic intervention, which is minimally invasive, can be carried out as an outpatient procedure with minimal rate of complications (Cooper, 2009). Initial studies have pointed out that the procedure has a success rate of 59-95% per treated ureter, with a much better prognosis after the second injection. Recommended for VUR grades II through IV, the compound is injected at the junction of the ureter with the bladder, where it prevents the retrograde flow of urine. Another study shows that the subureteral injection of polydimethylsiloxane showed a success rate of 82.3% on the first injection, and 98% after the second injection with a correction rate of 75%, 83%, 89%, 83%, 77% for grades I to V VUR respectively (Oh et al, 2008). The procedure has been identified as an effective and safe method of treatment of VUR with low associated morbidity (Herz et al, 2001). As the implant can be well documented with ultrasound, subsequent monitoring can be done (Herz et al, 2001). HYPOTHESIS BEING EXAMINED: [Due in the First Draft] The research proposed in this study will examine the following hypothesis: Null: Incidence of recurrent UTI in children with grade II - III VUR does not differ significantly between antibiotic prophylaxis and endoscopic subureteral injection Alternative: Incidence of recurrent UTI in children with grade II - III VUR does differ significantly between antibiotic prophylaxis and endoscopic subureteral injection. The variables of interest are: Dependent Variable: Incidence of recurrence, Events of renal scarring, Type of treatment administered. Independent Variable(s): Prevalence rate of infection in circumcised children, The ages of children & VUR grade. METHODS Sampling Plan To examine the above hypothesis, the study will be a retrospective one. Remission of VUR data will be collected from patients undergoing therapy either with prophylactic antibiotics or endoscopic subureteral injection of a recognized polymer under current usage. Radiological data on incidence of renal scarring will be collected and incidents of recurrence in each of the two groups will be enumerated and tabulated. Data from both groups will be compared using appropriate statistical software to analyze which therapy yields minimal incidence of recurrent UTI. Data Collection Data will be collected in the form of patient history, interventions undertaken on individual patients and remission of the condition. Age at first treatment, degree of improvement and the need for subsequent treatment and its periodicity will be compiled in tabulated forms. Care will be taken to involve an adequate number of participants in the study according to the statistical design and recommendations. Questionnaire’s will be prepared both for parents and attending physicians/other healthcare staff and the responses will be gathered in the form of Lickert scales which can yield pertinent and relevant information, as per the design of this study. REFERENCES Cooper, C S (2009). Diagnosis and management of vesicoureteral reflux in children, Nature Reviews Urology, VOL. 6, 481-489 Gleeson, FV, Gordon, I (1991). Imaging in urinary tract infection, Arch. Dis. Child, vol. 66, pp. 1282-1283 Herz, D, Hafez, A, Baqli, D et al (2001). Efficacy of endoscopic subureteral polydimethylsiloxane injection for treatment of vesicoureteral reflux in children: a North American clinical report, J.Urol., Vol. 166, No. 5, pp. 1880-6. Mahant, S, Friedman,J & MacArthur,C (2002). Renal ultrasound findings and vesicoureteral reflux in children hospitalised with urinary tract infection, Arch. Dis. Child, Vol. 86, pp. 419-421 NIH, "Vesicoureteral Reflux", Retrieved October 10, 2011 from: http://kidney.niddk.nih.gov/kudiseases/pubs/vesicoureteralreflux/ Oh, M M, Kim, H C, Bae, J H et al (2008).Technical Considerations of Endoscopic Subureteral Injection for the Treatment of Vesicoureteral Reflux, Chonnam Medical Journal, Vol.44, No. 1, pp. 17-22 Pennesi, M, Travan, L, Peratoner, L et al (2008). Is Antibiotic Prophylaxis in Children With Vesicoureteral Reflux Effective in Preventing Pyelonephritis and Renal Scars? A Randomized, Controlled Trial, Pediatrics, Vol. 121, No. 6, pp.e1489- e 1494 Read More