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尿路感染症(小児科)

著者: 張田豊 東京大学 生殖・発達・加齢医学専攻 小児医学講座

監修: 五十嵐隆 国立成育医療研究センター

著者校正/監修レビュー済:2020/04/09
参考ガイドライン:
  1. アメリカ小児科学会:Clinical Practice Guideline for the Diagnosis and Management of the Initial UTI in Febrile Infants and Children 2 to 24 Months
  1. 英国国立医療技術評価機構(NICE):Urinary tract infection in children
  1. 日本感染症学会・日本化学療法学会、JAID/JSC感染症治療ガイド・ガイドライン作成委員会編:JAID/JSC感染症治療ガイド2019
患者向け説明資料

概要・推奨   

  1. 熱源のはっきりしない小児に対しては抗菌薬投与前に尿検査および尿培養をとることが勧められる(推奨度1)。
  1. UTIの診断には尿検査に加えて正しく採取した尿培養により50,000CFU/mL以上の細菌の検出が必要である(推奨度1)。
  1. UTI症例に対しては全例腹部エコーにより腎臓および膀胱の評価を行う(推奨度1)。
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
張田豊 : 特に申告事項無し[2021年]
監修:五十嵐隆 : 特に申告事項無し[2021年]

改訂のポイント:
  1. 定期レビューを行い、治療について加筆修正を行った。

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 尿路感染症とは、腎臓、尿管、膀胱など尿路の感染症の総称である。尿路感染症(UTI)は男児の約1%、女児の3~5%が罹患する頻度の高い疾患である。
  1. 基礎疾患のない尿路感染症を単純性UTI、あるものを複雑性UTIとよぶ。
  1. 全UTIの30~40%に膀胱尿管逆流症(vesicoureteral reflux、VUR)を合併する。感染経路の大半は上行性であるが、新生児では一部血行性もあり得る。
  1. 起因菌は主にグラム陰性桿菌(3大起因菌:大腸菌、クレブシエラ、プロテウス)で、大腸菌がほとんどである。
問診・診察のポイント  
  1. 乳幼児初発UTIでは発熱以外の症状が哺乳不良・不機嫌・悪心・嘔吐など非特異的であるため、発熱児をみたら検尿をすべきである。

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文献 

著者: Subcommittee on Urinary Tract Infection, Steering Committee on Quality Improvement and Management, Kenneth B Roberts
雑誌名: Pediatrics. 2011 Sep;128(3):595-610. doi: 10.1542/peds.2011-1330. Epub 2011 Aug 28.
Abstract/Text OBJECTIVE: To revise the American Academy of Pediatrics practice parameter regarding the diagnosis and management of initial urinary tract infections (UTIs) in febrile infants and young children.
METHODS: Analysis of the medical literature published since the last version of the guideline was supplemented by analysis of data provided by authors of recent publications. The strength of evidence supporting each recommendation and the strength of the recommendation were assessed and graded.
RESULTS: Diagnosis is made on the basis of the presence of both pyuria and at least 50,000 colonies per mL of a single uropathogenic organism in an appropriately collected specimen of urine. After 7 to 14 days of antimicrobial treatment, close clinical follow-up monitoring should be maintained to permit prompt diagnosis and treatment of recurrent infections. Ultrasonography of the kidneys and bladder should be performed to detect anatomic abnormalities. Data from the most recent 6 studies do not support the use of antimicrobial prophylaxis to prevent febrile recurrent UTI in infants without vesicoureteral reflux (VUR) or with grade I to IV VUR. Therefore, a voiding cystourethrography (VCUG) is not recommended routinely after the first UTI; VCUG is indicated if renal and bladder ultrasonography reveals hydronephrosis, scarring, or other findings that would suggest either high-grade VUR or obstructive uropathy and in other atypical or complex clinical circumstances. VCUG should also be performed if there is a recurrence of a febrile UTI. The recommendations in this guideline do not indicate an exclusive course of treatment or serve as a standard of care; variations may be appropriate. Recommendations about antimicrobial prophylaxis and implications for performance of VCUG are based on currently available evidence. As with all American Academy of Pediatrics clinical guidelines, the recommendations will be reviewed routinely and incorporate new evidence, such as data from the Randomized Intervention for Children With Vesicoureteral Reflux (RIVUR) study.
CONCLUSIONS: Changes in this revision include criteria for the diagnosis of UTI and recommendations for imaging.

PMID 21873693  Pediatrics. 2011 Sep;128(3):595-610. doi: 10.1542/peds.・・・
著者: Gabrielle J Williams, Elisabeth H Hodson, David Isaacs, Jonathan C Craig
雑誌名: J Paediatr Child Health. 2012 Apr;48(4):296-301. doi: 10.1111/j.1440-1754.2010.01925.x. Epub 2010 Dec 29.
Abstract/Text A young child presents to their primary health provider with fever and irritability. How likely is a urinary tract infection? How should a urine sample be collected? How accurate are urinary dipsticks and microscopy compared with culture for the diagnosis? What route and type of antibiotics should be used? What imaging is indicated? Diagnosing and treating children with urinary tract infection presents many questions. This review summarises the most relevant recent primary studies, systematic reviews and guidelines.

© 2010 The Authors. Journal of Paediatrics and Child Health © 2010 Paediatrics and Child Health Division (Royal Australasian College of Physicians).
PMID 21199053  J Paediatr Child Health. 2012 Apr;48(4):296-301. doi: 1・・・
著者: J H Baumer, R W A Jones
雑誌名: Arch Dis Child Educ Pract Ed. 2007 Dec;92(6):189-92. doi: 10.1136/adc.2007.130799.
Abstract/Text
PMID 18032715  Arch Dis Child Educ Pract Ed. 2007 Dec;92(6):189-92. do・・・
著者: Craig A Peters, Steven J Skoog, Billy S Arant, Hillary L Copp, Jack S Elder, R Guy Hudson, Antoine E Khoury, Armando J Lorenzo, Hans G Pohl, Ellen Shapiro, Warren T Snodgrass, Mireya Diaz
雑誌名: J Urol. 2010 Sep;184(3):1134-44. doi: 10.1016/j.juro.2010.05.065. Epub 2010 Jul 21.
Abstract/Text PURPOSE: The American Urological Association established the Vesicoureteral Reflux Guideline Update Committee in July 2005 to update the management of primary vesicoureteral reflux in children guideline. The Panel defined the task into 5 topics pertaining to specific vesicoureteral reflux management issues, which correspond to the management of 3 distinct index patients and the screening of 2 distinct index patients. This report summarizes the existing evidence pertaining to children with diagnosed reflux including those young or older than 1 year without evidence of bladder and bowel dysfunction and those older than 1 year with evidence of bladder and bowel dysfunction. From this evidence clinical practice guidelines were developed to manage the clinical scenarios insofar as the data permit.
MATERIALS AND METHODS: The Panel searched the MEDLINE(R) database from 1994 to 2008 for all relevant articles dealing with the 5 chosen guideline topics. The database was reviewed and each abstract segregated into a specific topic area. Exclusions were case reports, basic science, secondary reflux, review articles and not relevant. The extracted article to be accepted should have assessed a cohort of children with vesicoureteral reflux and a defined care program that permitted identification of cohort specific clinical outcomes. The reporting of meta-analysis of observational studies elaborated by the MOOSE (Meta-analysis Of Observational Studies in Epidemiology) group was followed. The extracted data were analyzed and formulated into evidence-based recommendations.
RESULTS: A total of 2,028 articles were reviewed and data were extracted from 131 articles. Data from 17,972 patients were included in this analysis. This systematic meta-analysis identified increasing frequency of urinary tract infection, increasing grade of vesicoureteral reflux and presence of bladder and bowel dysfunction as unique risk factors for renal cortical scarring. The efficacy of continuous antibiotic prophylaxis could not be established with current data. However, its purported lack of efficacy, as reported in selected prospective clinical trials, also is unproven owing to significant limitations in these studies. Reflux resolution and endoscopic surgical success rates are dependent upon bladder and bowel dysfunction. The Panel then structured guidelines for clinical vesicoureteral reflux management based on the goals of minimizing the risk of acute infection and renal injury, while minimizing the morbidity of testing and management. These guidelines are specific to children based on age as well as the presence of bladder and bowel dysfunction. Recommendations for long-term followup based on risk level are also included.
CONCLUSIONS: Using a structured, formal meta-analytic technique with rigorous data selection, conditioning and quality assessment, we attempted to structure clinically relevant guidelines for managing vesicoureteral reflux in children. The lack of robust prospective randomized controlled trials limits the strength of these guidelines but they can serve to provide a framework for practice and set boundaries for safe and effective practice. As new data emerge, these guidelines will necessarily evolve.

2010 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.
PMID 20650499  J Urol. 2010 Sep;184(3):1134-44. doi: 10.1016/j.juro.20・・・
著者: RIVUR Trial Investigators, Alejandro Hoberman, Saul P Greenfield, Tej K Mattoo, Ron Keren, Ranjiv Mathews, Hans G Pohl, Bradley P Kropp, Steven J Skoog, Caleb P Nelson, Marva Moxey-Mims, Russell W Chesney, Myra A Carpenter
雑誌名: N Engl J Med. 2014 Jun 19;370(25):2367-76. doi: 10.1056/NEJMoa1401811. Epub 2014 May 4.
Abstract/Text BACKGROUND: Children with febrile urinary tract infection commonly have vesicoureteral reflux. Because trial results have been limited and inconsistent, the use of antimicrobial prophylaxis to prevent recurrences in children with reflux remains controversial.
METHODS: In this 2-year, multisite, randomized, placebo-controlled trial involving 607 children with vesicoureteral reflux that was diagnosed after a first or second febrile or symptomatic urinary tract infection, we evaluated the efficacy of trimethoprim-sulfamethoxazole prophylaxis in preventing recurrences (primary outcome). Secondary outcomes were renal scarring, treatment failure (a composite of recurrences and scarring), and antimicrobial resistance.
RESULTS: Recurrent urinary tract infection developed in 39 of 302 children who received prophylaxis as compared with 72 of 305 children who received placebo (relative risk, 0.55; 95% confidence interval [CI], 0.38 to 0.78). Prophylaxis reduced the risk of recurrences by 50% (hazard ratio, 0.50; 95% CI, 0.34 to 0.74) and was particularly effective in children whose index infection was febrile (hazard ratio, 0.41; 95% CI, 0.26 to 0.64) and in those with baseline bladder and bowel dysfunction (hazard ratio, 0.21; 95% CI, 0.08 to 0.58). The occurrence of renal scarring did not differ significantly between the prophylaxis and placebo groups (11.9% and 10.2%, respectively). Among 87 children with a first recurrence caused by Escherichia coli, the proportion of isolates that were resistant to trimethoprim-sulfamethoxazole was 63% in the prophylaxis group and 19% in the placebo group.
CONCLUSIONS: Among children with vesicoureteral reflux after urinary tract infection, antimicrobial prophylaxis was associated with a substantially reduced risk of recurrence but not of renal scarring. (Funded by the National Institute of Diabetes and Digestive and Kidney Diseases and others; RIVUR ClinicalTrials.gov number, NCT00405704.).

PMID 24795142  N Engl J Med. 2014 Jun 19;370(25):2367-76. doi: 10.1056・・・

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