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• DEFINITION:
TISSUE RESPONSE TO
THE PRESENCE OF
SIGNIFICANT AMOUNT
OF BACTERIA IN THE
URINE
URINARY TRACT INFECTION
Prevalence:
In young children with fever
• Approximately 1-16% in febrile infants and young
children but varies by age, race/ethnicity, sex, and
circumcision status.
• White children have a two- to four-fold higher
prevalence of UTI than do black children.
• Girls have a two- to four-fold higher prevalence of UTI
than do circumcised boys.
• White girls with a temperature of ≥39ºC have a UTI
prevalence of 16 percent.
URINARY TRACT INFECTION
Prevalence:
In older children :
8-50% depending on the presence of
symptoms
URINARY TRACT INFECTION
MICROBIOLOGY
• Ascending infection
most UTI beyond the
newborn period are the
result of ascending
infection
• Descending infection
4 - 9 percent of children
with UTI are bacteremic
PATHOGENESIS
Host factors:
• Age
• Uncircumcised boys
• Female infants
• Race/ethnicity
• Genetic factors
• Urinary obstruction
• Neurogenic Bladder, Dysfunctional elimination
• Vesicoureteral reflux
• Sexual activity
• Bladder catheterization
PATHOGENESIS
Bacterial factors:
A variety of virulence factors
enable bacteria to ascend
into the bladder and kidney
CLINICAL PRESENTATION
CLINICAL PRESENTATION
• Younger children:
nonspecific
symptoms and
signs
CLINICAL PRESENTATION
Other Less common symptoms of UTI in
infants include
• conjugated hyperbilirubinemia (in those <28
days)
• irritability
• poor feeding
• failure to thrive
CLINICAL PRESENTATION
S & S most helpful in identifying young children
with UTI:
• History of previous UTI
• Temperature >40ºC
• Suprapubic tenderness
• Lack of circumcision
CLINICAL PRESENTATION
Older children:
• Fever
• Urinary symptoms
• Abdominal pain
• Back pain
• New onset urinary incontinence
• fever, chills, vomitting and flank pain are suggestive
of pyelonephritis in older children
• short stature, poor weight gain, or hypertension
secondary to renal scarring
• Suprapubic and costovertebral angle tenderness
CLINICAL PRESENTATION
Older children:
• Fever
• Urinary symptoms
• Abdominal pain
• Back pain
• New onset urinary incontinence
• fever, chills, vomitting and flank pain are suggestive
of pyelonephritis in older children
• short stature, poor weight gain, or hypertension
secondary to renal scarring
• Suprapubic and costovertebral angle tenderness
Clinical evaluation
HISTORY
history of the acute illness:
• documentation of the height and duration of fever
• urinary symptoms (dysuria, frequency, urgency,
incontinence),
• abdominal pain,
• suprapubic discomfort
• back pain
• vomiting
• recent illnesses
• antibiotics administered
• and sexual activity (if applicable).
Clinical evaluation
Clinical evaluation
HISTORY
past medical history :
• Chronic urinary symptoms — Incontinence, lack of proper stream,
frequency, urgency, withholding maneuvers
• Chronic constipation
• Previous UTI
• Vesicoureteral reflux (VUR)
• Antenatally diagnosed renal abnormality
• Elevated blood pressure
• Poor growth
• In sexually active girls, whether barrier contraception with spermicidal
agents is used
• Previous undiagnosed febrile illnesses
family history :
• of frequent UTI, VUR, other genitourinary abnormalities and renal failure.
Clinical evaluation
PHYSICAL EXAMINATION
• Documentation of blood pressure and temperature.
• Growth parameters.
• Abdominal examination for tenderness or masses
• Assessment of suprapubic and costovertebral
tenderness.
• Examination of the external genitalia.
• Evaluation of the lower back for signs of spina bifida
occulta.
• Evaluation for other sources of fever.
LABORATORY EVALUATION
LABORATORY EVALUATION
Urine:
• Dipstick
• microscopy
• Culture & sensitivity
LABORATORY EVALUATION
• Leukocytes
• Protein
• Red blood cells
• Leukocyte esterase
• Nitrite
LABORATORY EVALUATION
Microscopic exam
• White Blood Cells: in a
centrifuged sample of
unstained urine pyuria is
defined as ≥5 WBC/high
power field , or ≥10
WBC/mm3 in an
uncentrifuged sample
• Bacteria: bacteriuria is the
presence of any bacteria
per hpf.
• Gram stain
LABORATORY EVALUATION
Urine culture & sensitivity
• Urine culture is the gold
standard for the diagnosis
of UTI
Urine culture
• Midstream clean catch 10⁵ colony forming
units
• Bag 85% false ₊ve
• Cathterization 10⁴ CFU
• Suprapubic aspiration any growth
LABORATORY EVALUATION
Other laboratory tests
• Investigate the fever.
• Markers of inflammation (WBC, ESR, CRP)
• Serum creatinine
• Blood culture — Bacteremia occurs in 4-9 % of infants
with UTI
• Lumbar puncture — Infants <1 month of age with fever
and a positive urinalysis; approximately 1 % of infants with
UTI also have meningitis
DIFFERENTIAL DIAGNOSIS
• Occult bacteremia
• Urinary symptoms & bacteriuria can be
associated with vulvovaginitis, vaginal foreign
body and urinary calculi
• Fever, abd pain & pyuria can be the
presenting symptoms of kawasaki, group A
Strep. Infections.
• Dysfunctional voiding
MANAGEMENT
MANAGEMENT
GOALS:
• Elimination of infection and prevention of
urosepsis
• Relief of acute symptoms
• Prevention of recurrence and long-term
complications
MANAGEMENT
Decision to hospitalize:
• Age <2 months
• Clinical urosepsis or potential bacteremia
• Immunocompromised patient
• Vomiting or inability to tolerate oral
medication
• Lack of adequate outpatient follow-up
• Failure to respond to outpatient therapy
MANAGEMENT
ANTIBIOTIC THERAPY:
• Choice of agent: provide adequate coverage for
E. coli.
• Oral therapy: Cefixime, amoxicillin-clavulanate.
• Parenteral therapy: Third- or fourth-generation
cephalosporins and aminoglycosides are
appropriate first-line agents for empiric
treatment of UTI in children.
• In children receiving antibiotic prophylaxis.
MANAGEMENT
ANTIBIOTIC THERAPY
• Duration of therapy: 5-14 days
• Response to therapy:
Clinical response
Repeat urine culture
MANAGEMENT
FURTHER INVESTIGATIONS
Indications:
1. Girls younger than 3 years of age with a first UTI
2. Boys of any age with a first UTI
3. Children of any age with a febrile UTI
4. Children with recurrent UTI
5. First UTI in a child of any age with a family history
of renal disease, abnormal voiding pattern, poor
growth, hypertension
MANAGEMENT
Ultrasonograpy
MANAGEMENT
Voiding
cystourethrogram
(VCUG)
MANAGEMENT
Nuclear imaging:
DMSA scan
PROGNOSIS
Recurrent UTI
• 14 percent of children younger than 6 years
with UTI have a subsequent UTI
• associated with a higher risk of UTI recurrence
-white race
-age 3 to 5 years
-VUR of grade IV to V
PROGNOSIS
Long-term sequelae
• Approximately 40 percent
had VUR
WHY IMPORTANT????