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Pediatric uti by asogwa innocent kingsley

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  • 1. PEDIATRIC UTI PREPARED BY ASOGWA INNOCENT KINGSLEY ML-508
  • 2. DEFINITION Infection of the urinary tract is identified by growth of a significant number of organisms of a single species in the urine, in the presence of symptoms. Recurrent UTI, defined as the recurrence of symptoms with significant bacteriuria in patients who have recovered clinically following treatment, is common in girls.
  • 3. PREVALENCE  UTI is a common bacterial infection in infants and children.  The risk of having a UTI before the age of 14 yrs -1- 3% in boys - 3-10% in girls .  In girls, the first UTI usually occurs by the age of 5 yr, with peaks during infancy and toilet training.  In boys, most UTIs occur during the 1st yr of life; more common in uncircumcised boys.  During the 1st yr of life, -M : F ratio is 2.8–5.4 : 1.  Beyond 1–2 yr, -M : F ratio of 1 : 10.
  • 4. RISK FACTORS FOR URINARY TRACT INFECTION:  Anatomic risk factors  Vesiculoureteral reflux (VUR) More common in girls  Obstruction  Posterior urethral valves Boys  Voiding dysfunction  Bladder diverticulum
  • 5. RISK FACTORS FOR URINARY TRACT INFECTION:  Associated risk factors  Constipation  Encopresis(Involuntary defecation not attributable to physical defects or illness.)  Bladder instability  Infrequent voiding  Unsubstantiated risks  Bathing  Back-to-front wiping
  • 6. ETIOLOGY  The Culprits ◦ Escherichia Coli ◦ Enterococcus ◦ P. aeruginosa ◦ Klebsiella sp. ◦ Proteus sp. ◦ Enterobacter sp. ◦ Coag-negative staph ◦ Staph aureus ◦ Candida sp.
  • 7. BACTERIAL FACTORS  Virulence Factors ◦ Cell Wall Antigens ◦ Serum Resistance ◦ Hemolytic Capability ◦ Growth Dynamics ◦ Iron Scavenging  Adherence Factors ◦ P Fimbriae ◦ Type 1 Fimbriae ◦ DR Fimbriae
  • 8. HOST DEFENSE FACTORS  Urine pH / Vaginal pH  Local IgA Antibodies  Voiding Mechanics
  • 9.  Ascending Route of UTI ° Bacterial Colonization ° Migration to Periurethral Region ° Migration into Bladder ° Growth in Urine ° Bacterial Ascent to Kidney ° Colonization of Renal Medulla ° Focal Abscess Formation ° Bacteremia ° Kidney Re-infection PATHOGENESIS - UTI
  • 10. CLINICAL MANIFESTATIONS The 3 basic forms of UTI 1. Pyelonephritis 2. Cystitis 3. Asymptomatic bacteriuria
  • 11. PYELONEPHRITIS  Clinical pyelonephritis is characterized by any or all of the following: - abdominal or flank pain, - fever, - malaise, nausea, vomiting, and, - occasionally, diarrhoea.  In newborns show nonspecific symptoms : - poor feeding, irritability, and weight loss.  Pyelonephritis is the most common serious bacterial infection in infants <2 yrs of age who have fever without a focus .
  • 12. OUTCOMES OF PYELONEPHRITIS  Acute lobar nephronia (acute lobar nephritis) is a localized renal bacterial infection involving >1 lobe that represents either a complication of pyelonephritis or an early stage in the development of a renal abscess.  Renal abscess may occur following a pyelonephritis or may be secondary to a primary bacteremia (S. aureus).  Perinephric abscesses may be secondary to contiguous infection in the perirenal area (e.g., vertebral osteomyelitis, psoas abscess) or pyelonephritis that dissects to the renal capsule.
  • 13. XANTHOGRANULOMATOUS PYELONEPHRITIS  Xanthogranulomatous pyelonephritis is a rare type of renal infection characterized by granulomatous inflammation with giant cells and foamy histiocytes.  It may present clinically as a renal mass or an acute or chronic infection.  Renal calculi, obstruction, and infection with Proteus spp. or E. coli contribute to the development of this lesion, which usually requires total or partial nephrectomy.
  • 14. CYSTITIS  It indicates that there is bladder involvement.  Symptoms include : • dysuria, • urgency, • frequency, • suprapubic pain, • incontinence, and • malodorous urine.  Cystitis does not cause fever and does not result in renal injury.
  • 15. ASYMPTOMATIC BACTERIURIA It refers to a condition that results in a positive urine culture without any manifestations of infection. It is most common in girls. The incidence is 1–2% in preschool and school-age girls and 0.03% in boys. The incidence declines with increasing age.
  • 16.  Rapid evaluation and treatment of UTI is important to prevent renal parenchymal damage and renal scarring that can cause hypertension and progressive renal damage.  Diagnosis ◦ Culture Methods ◦ Screening Tests ◦ Anatomic / Functional Evaluation  Treatment ◦ Age of Patient ◦ Severity of Infection ◦ Prior History of UTI MANAGEMENT - UTI
  • 17.  Microscopic Analysis  Urine Dipstick Analysis ◦ Sensitivity 80-90% / Specificity 60-98% ◦ Leukocyte Esterase ◦ Nitrites  First Voided Urine Best  Dietary nitrates SCREENING TESTS
  • 18. Clean Voided Specimen ◦ 80% Accuracy Bagged Specimen Catheterized Specimen Suprapubic Aspiration CULTURE METHODS
  • 19. SPECIMEN COLLECTION  Newborns & Infants ◦ Bagged Specimens ◦ Suprapubic Aspiration ◦ Urethral Catheterization  Toddlers ◦ Bagged Specimens ◦ Clean Void ◦ Urethral Catheterization  School Age Children ◦ Midstream Clean Catch
  • 20.  - *Midstream Clean Catch Specimen <10,000 CFU Probable Contaminant >100,000 CFU Significant Colony Count  Enteric Gram Negative Bacteria QUANTITATIVE URINE CULTURE
  • 21. ANATOMIC / FUNCTIONAL EVALUATION  Goals ◦ Assess risk of Damage ◦ Assess Presence of Damage ◦ Identify Complicating Factors
  • 22. EVAUATION OF UTI  Physical Exam  Imaging Studies ◦ When to Evaluate? ◦ How To Evaluate? ◦ RUS ◦ IVP ◦ DMSA Scan ◦ Cystography  RNC  VCUG
  • 23. Girls  Initial Studies ◦ USN ◦ VCUG  Follow-up Studies ◦ USN ◦ VCUG Boys  Initial Studies ◦ USN ◦ VCUG  Follow-up Studies ◦ USN ◦ VCUG UTI IMAGING STUDIES
  • 24. UTI - ULTRASOUND  2-3 % Yield Obstructive Uropathy Bellman, 1995
  • 25. UTI - VOIDING STUDY  VCUG For 1st Study  Pyelonephritis Associated With Vesico-Ureteral Reflux 50% Bellman, 1995
  • 26. TREATMENT The patient’s age, features suggesting toxicity and dehydration, ability to retain oral intake and the likelihood of compliance with medication(s) help in deciding the need for hospitalization. Therapy should be prompt to reduce the morbidity of infection, minimize renal damage and subsequent complications.
  • 27. TREATMENT  Children less than 3 months of age and those with complicated UTI should be hospitalized and treated with parenteral antibiotics.  The choice of antibiotic should be guided by local sensitivity patterns.  A third generation cephalosporin is preferred.  Therapy with a single daily dose of an aminoglycoside may be used in children with normal renal function.  Intravenous therapy is given for the first 2-3 days followed by oral antibiotics once the clinical condition improves.
  • 28. TREATMENT Children with simple UTI and those above 3 months of age are treated with oral antibiotics.  With adequate therapy, there is resolution of fever and reduction of symptoms by 48- 72 hours.
  • 29. TREATMENT  The duration of therapy -14 days for infants and children with complicated UTI - 7-10 days for uncomplicated UTI.  Adolescents with cystitis may be treated with shorter duration of antibiotics, lasting 3 days.  Following the treatment of the UTI, prophylactic antibiotic therapy is initiated in children below 1 year of age, until appropriate imaging of the urinary tract is completed.
  • 30. EVALUATION AFTER THE FIRST UTI  The aim of investigations is to identify patients at high risk of renal damage, chiefly those below one year of age, and those with VUR or urinary tract obstruction.  Evaluation includes ultrasonography, DMSA renal scan and micturating cystourethrography (MCU) performed .  An ultrasonogram provides information on kidney size, number and location, presence of hydronephrosis, urinary bladder anomalies and post-void residual urine.  DMSA scintigraphy is a sensitive technique for detecting renal parenchymal infection and cortical scarring.  MCU detects VUR and provides anatomical details regarding the bladder and the urethra.
  • 31. EVALUATION AFTER THE FIRST UTI
  • 32. EVALUATION AFTER THE FIRST UTI Ultrasonography should be done soon after the diagnosis of UTI. The MCU is recommended 2-3 weeks later. The DMSA scan is carried out 2-3 months after treatment.
  • 33. PREVENTION OF RECURRENT UTI General Measures:  Adequate fluid intake and frequent voiding  constipation should be avoided  In children with VUR who are toilet trained, regular and volitional low pressure voiding with complete bladder emptying is encouraged.  Double voiding ensures emptying of the bladder of post void residual urine.  Circumcision reduces the risk of recurrent UTI in infant boys, and might therefore have benefits in patients with high grade reflux.
  • 34. ANTIBIOTIC PROPHYLAXIS  Long-term, low dose, antibacterial prophylaxis is used to prevent recurrent, febrile UTI.  The antibiotic used should be effective, non-toxic with few side effects and should not alter the growth of commensals or induce bacterial resistance .
  • 35. ANTIBIOTIC PROPHYLAXIS  Antibiotic prophylaxis is recommended for patients with (i) UTI below 1-yr of age, while awaiting imaging studies, (ii) VUR (iii)frequent febrile UTI (3 or more episodes in a year) even if the urinary tract is normal.
  • 36. VESICOURETERIC REFLUX •VUR is a bladder valve defect that allows urine to reflux from the bladder through one or both ureters and up to the Kidneys. •Febrile urinary tract infection (UTI) is the defining Symptom.
  • 37.  VUR is seen in 40-50% infants and 30-50% children with UTI, and resolves with age.  Its severity is graded using the International Study Classification from grade I to V, based on the appearance of the urinary tract on MCU.  The presence of moderate to severe VUR, particularly if bilateral, is an important risk factor for pyelonephritis and renal scarring, with subsequent risk of hypertension, albuminuria and progressive kidney disease.  The risk of scarring is highest in the first year of life
  • 38. VUR GRADES
  • 39. SCREENING OF SIBLINGS AND OFFSPRING:  Reflux is inherited in an autosomal dominant manner with incomplete penetrance; 27% siblings and 35% offspring of patients show VUR.  Ultrasonography is recommended to screen for the presence of reflux.  Further imaging is required if ultrasonography is abnormal