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URINARY TRACT INFECTION

• 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

• Escherichia coli is the most common


bacterial cause of UTI 80 % of UTI in
children.
• Other gram-negative bacteria include
Klebsiella, Proteus, Enterobacter, and
Citrobacter.
• Gram-positive bacteria include
Staphylococcus saprophyticus,
Enterococcus, and, rarely,
Staphylococcus aureus.
URINARY TRACT INFECTION
MICROBIOLOGY
less common causes of UTI in
children

• Viruses (eg, adenovirus,


enteroviruses,
Coxsackieviruses, echoviruses)
• fungi (eg, Candida spp,
Aspergillus spp, Cryptococcus
neoformans, endemic
mycoses) less common causes
of UTI in children
PATHOGENESIS

• Upper urinary tract


infection:
Pyelonephritis

• Lower urinary tract


infection:
Cystitis
PATHOGENESIS

• 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 

Urine sampling: How to obtain???

• Midstream clean catch


• Bag
• Cathterization
• Suprapubic aspiration
LABORATORY EVALUATION 
Urine dipstick
88 % sensitive

• 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 obtained for culture


should be processed as
soon as possible after
collection
LABORATORY EVALUATION 

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

• Renal scars developed in


approximately 8 % of
patients, 15 % of those had
abnormal DMSA scan at the
time of diagnosis.
RENAL SCARRING
• The loss of renal parenchyma between the calyces and the
renal capsule, a potential complication of UTI.

• Long-term consequences include hypertension, decreased


renal function, proteinuria, and end-stage renal disease

• The development of renal scarring has been associated


with:
-Recurrent febrile UTI
-Delay in treatment of acute infection
-Dysfunctional elimination
-Obstructive malformations
-VUR
PREVENTION OF RECURRENT UTI 
Medical management
1. Prophylactic Antibiotics:
• TMP-SMX or nitrofurantoin
(1/4-1/2 therapeutic dose
QD)
2. Urine analysis, culture or
both should be done in any
subsequent episode of
fever.
3. Treatment of voiding
dysfunction.
4. Cranberry juice.
When to stop????
Surgical Management
THANK YOU
URINARY TRACT INFECTION

WHY IMPORTANT????

May lead to renal scarring


PATHOGENESIS
• Host factors:
• Age — highest in boys younger than 1 year and girls younger than 4 years
• Uncircumcised boys — four- to eight-fold higher prevalence of UTI than circumcised male
infants
• Female infants — two- to four-fold higher prevalence of UTI than male infants .
• Race/ethnicity —  white children have a two- to four-fold higher prevalence of UTI than do black
children
• Genetic factors — First-degree relatives of children with UTI are more likely to have UTI than
individuals without such a history
• Urinary obstruction — Predisposing obstructive abnormalities may be anatomic ,neurologic , or
functional.
• Dysfunctional elimination —  Up to 40 percent of toilet-trained children with their first UTI and
80 percent of children with recurrent (three or more) UTI report symptoms of dysfunctional
elimination. Dysfunctional elimination is also a risk factor for persistent VUR and renal scarring
An abnormal elimination pattern (frequent or infrequent voids, urgency, infrequent stools
[constipation])
Bladder and or bowel incontinence
Withholding maneuvers
• Vesicoureteral reflux —  It is the most common urologic anomaly in children. Children with VUR
are at increased risk for recurrent UTI.
• Sexual activity — The association between sexual intercourse and UTI in females has been well
documented
• Bladder catheterization — The risk of UTI increases with increasing duration of bladder
catheterization

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