Urinary Tract Infections


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  • convenient, inexpensive, and require little training
  • convenient, inexpensive, and require little training
  • approximately 30 percent of children with a normal CRP have pyelonephritis
  • Second- and third-generation cephalosporins (eg, cefprozil, cefpodoxime, cefixime, cefotaxime, ceftriaxone) and aminoglycosides (eg, gentamicin, amikacin) are appropriate first-line agents for empiric treatment of UTI in children. However, these drugs are not effective in treating Enterococcus and should not be used for patients in whom enterococcal UTI are suspected (eg, those with a urinary catheter in place, instrumentation of the urinary tract, or an anatomical abnormality). In such patients, amoxicillin or ampicillin should be added.
  • Urinary Tract Infections

    1. 1. Urinary Tract Infections Dr. Kalpana Malla MD Pediatrics Manipal Teaching HospitalDownload more documents and slide shows on The Medical Post [ www.themedicalpost.net ]
    2. 2. UTI• Definition:- Invasion & multiplication of micro- organisms in the urinary system – any component of the urinary tract including • Urethritis • Cystitis • Pyelonephritis
    3. 3. Classification
    4. 4. UTI - Classification:-A. On the basis of underlying defect simple complicatedB. Based on symptoms Symptomatic UTI Asymptomatic UTI
    5. 5. ClassificationC. On the basis of region involved- Upper UTI - pyelonephritis- Lower UTI – Cystitis - Urethritis
    6. 6. Incidence:-• Newborn : M=F Hematogenous spread Cong. anomalies in males• >1 yr : F>M Ascending infection**Overall 1% boys & 3 % girls have UTI in 1st decade
    7. 7. Causes of UTI
    8. 8. Etiology - Microorganisms A. Bacteria:-• Gram negative bacteria• - Escherichia coli (80 %- 90 %)• - Klebsiella• - Proteus (30%)• Gram positive bacteria• - Enterobacter• - Citrobacter.• - Staph saprophyticus• - Group B streptococcus - H. Influenza• - Staph. Aureus
    9. 9. Etiology - Less commonB. Virus:- Ebstein Barr Adenovirus enteroviruses Coxsackie viruses echovirusesC) Fungus - Candida spp., Aspergillus spp. Cryptococcus neoformansD) Parasite
    10. 10. Risk Factors1.Host Factors:- a) Stasis -Urinary obstruction - infrequent & incomplete voiding - Constipation - Obstruction to flow-PUV,PUJ obs,stones,ureterocele - Neurogenic bladder - Vesicoureteral reflux
    11. 11. Host Factors:-b) Instrumentationc) Malnutritiond) Age/ Sexe )Uncircumcised boysf )Race/ethnicityg )Genetic factorsh) Length of urethrai) Urine itself j) DM
    12. 12. Risk Factors2. Agent-organism3. Size of inoculum- small/large
    13. 13. PATHOGENESIS• Ascending infection most UTI beyond the newborn period• Descending infection 4 - 9 percent of children with UTI are bacteremic
    14. 14. Clinical features
    15. 15. Presentations< 2 month - nonspecific symptoms and signs – fever , Jaundice2month -1 year:- Fever/Hypothermia Vomiting, Diarrhea Sepsis Irritability Lethargy Malodorous urine
    16. 16. Presentations1-5 years:-Abdominal pain- Flank /back/ Supra pubic - Vomiting ,diarrhea - Constipation - Abnormal voiding - Urgency, urinary incontinence, dysuria
    17. 17. 1-5 years- Malodorous Urine- Fever/febrile convulsion- Failure to thrive
    18. 18. Presentations>5years:-Dysuria Frequency Urgency Abdominal discomfort Fever Malodorous urine
    19. 19. Physical examinations• Temperature• Pallor• Anthropometry• Blood pressure• Tenderness-Lower abdomen• Renal angle• Renal mass• Palpable bladder
    20. 20. Physical examinations• Fecal mass• Signs of valvitis• Spine• Lower limb reflexes• Associated with UTI-Prune belly syndrome Anorectal anomalies
    21. 21. Localizing symptoms:Symptoms of urethritis:• Dysuria• Reluctance to void• Perineal discomfort• Vaginal irritation and erythema in girls• In older boys, urethral discharge• In adolescent girls associated with PID symptoms
    22. 22. Localizing symptoms:Features of cystitis:• Afebrile usually• Frequency• Enuresis• Dysuria• Reluctance to void
    23. 23. Localizing symptoms: Features of pyelonephritis: • Fever and systemic signs • Older children – Flank pain or abdominal pain • Younger children – Fever, irritability, vomiting, poor feeding
    24. 24. LABORATORY EVALUATION Dipstick Microscopy Culture & sensitivity
    25. 25. InvestigationsMethods of urine collection• Clean catch or midstream sample• Supra pubic aspiration –infancy• Urinary bag sample –small children• Catheter specimen –Severely ill
    26. 26. LABORATORY EVALUATIONUrine dipstick 88 % sensitive• Leukocytes• Protein• Red blood cells• Leukocyte esterase• Nitrite
    27. 27. LABORATORY EVALUATIONMicroscopic exam• Bacteria: bacteriuria is the presence of any bacteria per hpf.• Gram stain
    28. 28. Routine Microscopic Examination• Color-Hazy• Smell- malodorous• White Blood Cells: pyuria is defined as ≥5 WBC/PHF in centrifused or ≥10 WBC/mm3 in an uncentrifuged sample• Bacteria: bacteriuria is the presence of any bacteria per hpf. - Gram stain
    29. 29. Routine Microscopic Examination• RBC >5 /HPF• RBC+WBC casts+• Albumin –Trace to +Urine C/S- gold standard - should be processed as soon as possible after collection
    30. 30. LABORATORY EVALUATION Urine culture• Midstream clean catch  > 10⁵ colony forming units (girls) > 104 CFU (boys)• Catheterization  10⁵ CFU• Supra pubic aspiration any growth
    31. 31. LABORATORY EVALUATIONOther laboratory tests• Investigate the fever – CBC, 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
    32. 32. Imaging studies1.Radiological – MCU IVP X-ray KUB2. Nuclear- USG DMSA scan DTPA scan MAG scan
    33. 33. Renal scans• DMSA renal scan – anatomy of kidney (Scarring)• DTPA renal scan – Excretory function ,filtration function of kidney• MAG 3 with lasix renal scan – Obstruction at the ureterovesical junction - quantitative information regarding kidney function and drainage , assesses the degree of blockage
    34. 34. Principle of management1. Treatment of acute infection2. Prevention of further infection3. Adequate investigation4. Arrangement of further treatment5. Follow up - Prevention of recurrence and long-term complications
    35. 35. MANAGEMENTIndication for hospitalize:• Age <2 months• Sepsis or potential bacteremia• Immunocompromised patient• Vomiting or inability to tolerate oral medication• Lack of adequate outpatient follow-up• Failure to respond to outpatient therapy
    36. 36. Choice & route of TreatmentDepends on – Age Severity of illnessChoice of agent: provide adequate coverage for E. coli.
    37. 37. ANTIBIOTIC THERAPY:• Newborn + Infants Inj ampicillin + Inj. Gentamycin-14 days• Older children:- Oral – Co-timoxazole cephalosprins Nalidixic acid amoxicillin-clavulanate• Parenteral therapy: Ampicillin or Third- or fourth- generation cephalosporins and aminoglycosides - first-line agents for empiric treatment of UTI in children.
    38. 38. MANAGEMENTANTIBIOTIC THERAPY• Duration of therapy: 7-14 days• Response to therapy: Clinical response Repeat urine culture
    39. 39. Indications for further investigations:1. Girls younger than 3 years with a first UTI2. Boys of any age with a first UTI3. Children of any age with a febrile UTI4. Children with recurrent UTI5. First UTI in a child of any age with a family history of renal disease, abnormal voiding pattern, poor growth, hypertension
    40. 40. Prevention1. General measures:-• Fluid intake• Complete and periodic voiding• Vioding at bed time• Perineal hyiene• Treatment of worms• Prevention of constipation• Avoid catheterization
    41. 41. Prevention• Early treatment of cong anomalies• Circumcision2. Low dose chemoprophylaxis - UTI until radiological evaluation is complete - Recurrent UTI - VUR grade I- III - Post operative-PUJ,VUR IV & V, PUV
    42. 42. Prevention- Chronic cystitis - Neurogenic ladderCommonly used drugs for prophylaxis:-• Co-trimoxazole-2mg/kg/d• Nalidixic acid-12.5mg/Kg/d• Nitrofurantoin -1mg/kg/d
    43. 43. Follow up1. Clinical- During the year following infection 1 year after starting prophylaxis height, Blood pressure –recorded2. Urine C/S- 3 monthly-infancy Fever & symptoms –older children3.RFT 4. Imaging –when neded
    44. 44. Thank youDownload more documents and slide shows on The Medical Post [ www.themedicalpost.net ]