What is the management for a toddler with a history of partial nephrectomy due to impaired renal function, presenting with recurrent culture-positive Urinary Tract Infections (UTIs)?

Management of Recurrent Culture-Positive UTIs in a Toddler with History of Partial Nephrectomy

Antibiotic prophylaxis is the cornerstone of management for this toddler with recurrent culture-positive UTIs and a history of partial nephrectomy due to decreased kidney function. 1

Initial Assessment and Imaging

• Renal and bladder ultrasonography should be performed to detect any anatomic abnormalities that may be contributing to recurrent UTIs 2, 1
• Consider voiding cystourethrography (VCUG) as this child has:
  • Recurrent UTIs (high-risk factor)
  • History of partial nephrectomy (suggesting underlying urological abnormality)
  • Higher likelihood of vesicoureteral reflux (VUR) 2, 1
• DMSA renal scan should be considered 4-6 months after the acute infection to evaluate for renal scarring, particularly important in this high-risk patient with prior renal surgery 2

Acute Treatment of Current UTI

1. Obtain urine culture before starting antibiotics to guide therapy 1
2. Empiric antibiotic therapy based on local resistance patterns:
   • Oral cephalosporins (first choice): cephalexin (50-100 mg/kg/day divided in 4 doses) or cefixime (8 mg/kg/day in 1 dose) 1, 3
   • Alternative options: amoxicillin-clavulanate (45 mg/kg/day divided in 2 doses) or trimethoprim-sulfamethoxazole (if local resistance <20%) 1, 4
   • Duration: 7-14 days for complicated UTI (this case is complicated due to history of partial nephrectomy) 1
3. Adjust antibiotics based on culture results and sensitivities 1
4. Clinical reassessment within 48-72 hours of initiating treatment 1

Long-term Management

Continuous Antibiotic Prophylaxis

• Strongly indicated in this case due to:

  • History of partial nephrectomy
  • Recurrent culture-positive UTIs
  • High risk of renal scarring 1, 5

• Prophylactic antibiotic options:

  • Trimethoprim-sulfamethoxazole (2-3 mg/kg of trimethoprim component once daily) 1
  • Nitrofurantoin (1-2 mg/kg once daily) 1
  • Use 1/3 to 1/4 of the therapeutic dose given once daily, preferably at bedtime 5

Additional Preventive Measures

• Ensure adequate hydration to promote frequent urination and bacterial clearance 1
• Address bowel and bladder dysfunction if present:
  • Evaluate for constipation
  • Establish regular voiding habits
  • Consider bladder training if age-appropriate 1
• Promote proper hygiene practices appropriate for toddler age 1
• Regular follow-up to monitor kidney function and detect early signs of infection 1

Special Considerations for Post-Nephrectomy Patients

• More frequent monitoring of renal function is necessary due to reduced renal mass
• Lower threshold for imaging studies and intervention with recurrent infections
• Higher risk of scarring in the remaining renal tissue, which could further compromise kidney function 6, 7
• Long-term follow-up is essential to identify predisposing factors, monitor for scarred kidneys, and diagnose and treat recurrences early 1

When to Consider Surgical Intervention

• If breakthrough infections occur despite antibiotic prophylaxis
• If imaging reveals correctable anatomical abnormalities contributing to recurrent UTIs
• If significant VUR is detected (grades III-V) that doesn't resolve with medical management 2, 1

Parental Education

• Instruct parents to seek prompt medical evaluation for future febrile illnesses
• Explain the importance of completing the full course of antibiotics
• Emphasize the need for regular follow-up appointments to monitor kidney function and growth

This comprehensive approach addresses both the immediate infection and long-term prevention strategies to protect the remaining kidney function in this high-risk toddler.