QuestionSBA
QuestionChoice
The E. Coli grown is resistant to nitrofurantoin, which explains why the first course did not resolve the patient's symptoms. Extending the course will not alter the resistance and will not benefit the patient
33389
b
Extend course of nitrofurantoin to 7 days duration
QuestionChoice
Trimethoprim is the only sensitive result for this E. Coli that would be suitable for use alongside a penicillin allergy
33388
a
Trimethoprim
QuestionChoice
Although the E. Coli is sensitive to the co-amoxiclav, this woman has an allergy to penicillin, so this would not be an appropriate choice
33392
e
Co-amoxiclav
QuestionChoice
The E. Coli grown is resistant to ciprofloxacin, so this would not be an appropriate choice
33391
d
Ciprofloxacin
QuestionChoice
Although the E. Coli is sensitive to the cefalexin, this woman has an allergy to penicillin. Cephalosporin antibiotics still confer risk of cross-reactivity in patients with penicillin allergy and so should be avoided where there is another reasonable option
33390
c
Cefalexin
Concept
Chapter
# Summary

Vesicoureteral reflux (VUR) is a congenital condition where urine flows backwards from the bladder into the ureters and kidneys, increasing the risk of recurrent urinary tract infections (UTIs). Symptoms include recurrent UTIs, fevers, and abdominal pain, with severe cases leading to renal scarring and hypertension. Diagnosis can involve ultrasound, MCUG, MAG reflux test, and DMSA scan. Management includes prophylactic antibiotics, monitoring, and possibly surgery for severe cases. Complications include UTIs, pyelonephritis, and chronic kidney disease.

# Definition

Vesicoureteral reflux (VUR) is a condition where urine flows backwards from the bladder into the ureters and potentially the kidneys, rather than the usual one-way flow from the kidneys to the ureters and then to the bladder. This condition is typically present from birth and can lead to recurrent UTIs, as the backward flow of urine can carry bacteria up into the kidneys, causing an infection. It is a significant risk factor for atypical UTIs and recurrent infections.
 

# Epidemiology
 

VUR affects around 1-3% of all children and can occur in all age groups. It is more commonly diagnosed in children with UTIs, especially if these UTIs are recurrent or atypical. A familial predisposition is often present.
 

#  Pathophysiology

The abnormal flow of urine in VUR can occur due to a variety of reasons, including a shortened intravesical ureter (the part of the ureter that passes through the bladder wall), an improperly functioning valve where the ureter joins the bladder, or a neurological disorder affecting the bladder.
 

# Signs and Symptoms
 
VUR is often asymptomatic and may only be detected when investigating recurrent or atypical UTIs. 

Symptoms can include:

- Recurrent UTIs or persistent bacteriuria
- Unexplained fevers
- Abdominal or flank pain
- In severe cases, renal scarring can occur leading to hypertension and chronic kidney disease
 

# Investigations
 

In children with recurrent or atypical UTIs, investigations considering VUR include:
 
- Ultrasound of the kidneys and bladder is often performed initially 
    - Used to detect hydronephrosis, dilatation of renal pelvis or incomplete bladder voiding 
- Micturating Cystourethrogram (MCUG) 
    - Contrast is passed into the bladder, and the patient passes urine whilst x-rays are taken.
    - This enables the refluxing of urine to be visualised 
- MAG (mercapto acetyl triglycine 3) reflux test 
    - IV contrast recorded on x-ray whilst the child passes urine, to enable any reflux to be visualised 
- Dimercaptosuccinic acid (DMSA) scan
    - This can detect scarring or damage to the kidneys as a result of VUR
 

# Management
 

The management of VUR can be conservative or surgical, depending on the severity of the condition, the age of the patient, and the risk of kidney damage. 

- Conservative management:
    - Prophylactic antibiotics to prevent UTIs
    - Regular monitoring of kidney function and growth
    - Treatment of constipation if present
- Surgical treatment, such as ureteral reimplantation, may be considered in severe cases or when conservative management fails.
 

# Complications

Potential complications of VUR include:
 

 -  Recurrent UTIs
 -  Pyelonephritis
 -  Renal scarring and Chronic Kidney Disease (CKD)
 -  Hypertension
 
This highlights the importance of early detection and management of VUR, especially in children with recurrent or atypical UTIs.
 
#  NICE Guidelines 

[NICE Guideline Urinary tract infection in under 16s: diagnosis and management](https://www.nice.org.uk/guidance/ng224/chapter/Recommendations-for-research) 
 
# References

[Kidney Research UK Vesicoureteral reflux](https://www.kidneyresearchuk.org/conditions-symptoms/vesico-uretal-reflux/)
353
2678
Urinary tract infection in children
Topic
11
Renal Physiology
6678
A 35-year-old woman presents to her GP with no improvement in symptoms following a three day course of nitrofurantoin for a urinary tract infection (UTI). She has ongoing dysuria and urinary frequency. She is allergic to penicillin (rash).

A urine culture result is now available:

Moderate growth of E. Coli

- Amoxicillin - R
- Nitrofurantoin - R
- Cefalexin - S
- Co-amoxiclav - S
- Trimethoprim - S
- Ciprofloxacin - R

NB: R = Resistant and S = Sensitive

What is the most appropriate antibiotic choice to treat this woman's UTI?
a