This presentation covers Urinary tract Infections (UTI). Their Definition, forms, epidemiology, risk factors, etiology, Clinical manifestation, Diagnostic procedures, Management, Complications and Education to the Patients are discussed in detail.

1. UTI in Pediatrics
Adrien Mugimbaho

2. Case
• A 4 months old female
• CC: Fever, vomiting, and loose stools
• HPI:
• Tactile fever for 3 days, 5-6 episodes of emesis on the first day of illness
• Consulted DH 2 days ago, where the impression was gastroenteritis.
• No labs or x-rays were done
• She returns to DH because of persistent fever. Vomiting and diarrhea have resolved,
but breast-feeding less well than usual.
• Her mother now noted that her urine seems "strong" and that she is not as playful as
usual.
• She has had no known ill contacts. She has no cough, URI symptoms, or rash.
• Past history is unremarkable and she is on no medications.

3. • Exam:
• VS: To 39.1, HR: 164, R T= 40, Wt. 5.3kg (15% percentile, and 150gm below
her pre-illness weight).
• General: Alert, smiling, active, not toxic, and in no distress.
• HEENT: Anterior fontanelle is soft and flat. Eyes and ENT exams are normal.
• CVS: Heart rate is regular without murmurs.
• RS: clear Lungs and non-labored respirations
• GIT: Abdomen is flat, soft, non-tender, without hepatosplenomegaly or
masses.
• GUS: External genitalia are normal.
• MSK: warm skin and well perfused, with no rash.
• CNS: Back exam reveals no deformities or cutaneous defects. Neurologic
exam shows normal tone, strength, and activity.

4. • Urine specimen obtained by transurethral catheterization yields a
small amount of cloudy urine, which is positive for leukocyte esterase
and nitrite tests.
• Sent for culture. Her FBC shows a WBC 9.4, H/H 9.3/27.5, platelets
389,000, 51% neutrophils, 44% lymphocytes, 3% monocytes, 2%
eosinophils.
• Urine culture is positive for greater than 100,000 colonies/ml of a
non-lactose fermenting organism, with identification and sensitivities
pending.
1. What is she suffering?
2. What is the management?
3. What additional investigation should she undergo?

5. Definition
Significant bacteriuria of a clinically relevant uropathogen in a
symptomatic patient.
One of the commonest infections in children
 Young infants- sepsis- mortality if not recognized
 Renal scarring- hypertension and progressive renal damage

6. • Uncomplicated: UTI without underlying renal or neurologic disease
• Complicated: UTI with underlying structural, medical or neurologic
disease
• Recurrent : > 3 symptomatic UTIs within 12 months following clinical
therapy
• Reinfection: recurrent UTI caused by a different pathogen at any
time
• Relapse: recurrent UTI caused by same species causing original UTI

7. Forms of UTI
pyelonephritis
Cystitis
Urethritis

8. Epidemiology
In young children (< 2 years) with fever:
 The overall prevalence of UTI is approx 7 %
It is highest among uncircumcised boys, particularly < 3 months
 Girls have a 2-4 fold higher prevalence than do circumcised boys
In older children:
The prevalence of UTI is 7.8%

9. Aetiology
Uropathogens
 mostly bacteria from stools
 ascending infection from peri-urethral area
 via bacteremia
Escherichia coli is ~80 %
Other gram-negative:
 Klebsiella, Proteus, Enterobacter, and Citrobacter
 Gram-positive
 Staphylococcus saprophyticus, Enterococcus, and, rarely, Staphylococcus aureus
 Viruses
 adenovirus, enteroviruses, Coxsackieviruses, echoviruses
 Fungal
 Candida spp, Aspergillus spp, Cryptococcus neoformans, endemic mycoses

10. Risk factors
Age <12 months :Boys & <4 years: Girls
Maximum reported temperature ≥39°C
Female : 2-4 fold
White ethnicity
Uncircumcised male
Urinary obstruction
Anatomic conditions, Neurologic conditions & Functional conditions
No other source of fever identified
Vesicoureteral reflux
Bladder catheterization
Sexual activity
Bladder and bowel dysfunction

11. Risk Factors for Renal Scarring
Recurrent febrile UTI
Delay in treatment of acute infection
Bladder and bowel dysfunction
 UT Obstructive malformations
VUR (high-grade)
Abnormal renal bladder US
Elevated inflammatory markers: CRP of >40 mg/L or PMNs >60 %
Temperature ≥39°C
organisms other than E. coli

12. Clinical Presentation
Younger children
Fever
Irritability
 poor feeding
 poor weight gain
foul-smelling urine
 gastrointestinal
symptoms (eg,
vomiting, diarrhea,
poor feeding)
Older children
Fever
 urinary symptoms
 abdominal pain
suprapubic tenderness
costovertebral angle tenderness
short stature
poor weight gain
hypertension

13. Clinical Presentation Cont’d
Upper UTI (PYELONEPHRITIS )
High grade fever
toxic look
Vomiting, nausea
Abdominal pain/ flanks
Diarrhea
Cystitis
Dysuria
Urgency
Frequency
Supra-pubic pain
Hematuria
Incontinence
Usually no fever

14. Pathogenesis
Colonization of the periurethral area
Pathogens attach to the uroepithelial cells via an active process
Bacterial attachment recruits toll-like receptors (TLR)
TLR binding triggers a cytokine response, which generates a local inflammatory response
In E. coli : pili, hair-like appendages on the cell surface enable bacteria to ascend into the
bladder and kidney.
In the kidney, the bacterial inoculum generates an intense inflammatory response, which
may ultimately lead to renal scarring

15. Clinical Evaluation
InvestigationsPhysical ExamHistory

16. History
History of acute illness
• fever
• urinary symptoms
• abdominal pain, suprapubic discomfort, back pain,
• vomiting
• recent illnesses, antibiotics administered
The PMHx should include risk factors for UTI:
• Chronic urinary symptoms
• Chronic constipation
• Previous UTI or previous undiagnosed febrile illnesses
• VUR
• Family hx of frequent UTI, VUR, and other genitourinary abnormalities
• Antenatally diagnosed renal abnormality
• chronic sequelae of UTI: Poor growth, Elevated blood pressure

17. Physical examination
VS: BP and Temp
Growth parameters: poor
weight gain, FTT (chronic or
recurrent UTI)
Evaluation for other sources of
fever
Evaluation of the lower back
for signs of occult
myelomeningocele
Examination of the external
genitalia for
• anatomic abnormalities
• Signs of vulvovaginitis,
vaginal foreign body,
Abdominal exam:
• suprapubic tenderness
• Abdominal mass (enlarged
bladder or enlarged kidney)
• costovertebral tenderness

18. LABORATORY EVALUATION
• The laboratory evaluation for the child with suspected UTI includes
obtaining a urine sample for
a dipstick and/or microscopic evaluation
Urine culture.
• Pyuria and significant bacteriuria on urine culture are necessary to make the diagnosis.

19. Specimen Collection
NB: Urine obtained in a sterile bag not be used for culture

20. Dipstick analysis
• 88 % sensitive
• Leukocyte esterase test
• Nitrite test
• highly specific, with a low false
positive rate.
Microscopic exam
• urine is examined for WBCs and bacteria.
• Pyuria:
>10 WBC/mm3 in uncentrifuged sample, or
>5 WBC/ mm3 in a centrifuged sample
• Bacteriuria: presence of any bacteria/hpf.
• sensitivity is at best 81 %
.

21. Urine culture
• The standard test for the diagnosis of UTI
• Should be performed for all children in whom UTI is a diagnostic
consideration
• Other lab Tests:
• Markers of inflammation
• Serum creatinine
• Blood culture
• Lumbar puncture

22. Differentials
• Asymptomatic bacteriuria
• Vulvovaginitis
• Urethritis
• urinary calculi
• vaginal foreign body
• Group A streptococcal infection
• Bladder and bowel dysfunction
• Appendicitis
• Kawasaki disease

23. Management
Goals of Treatment
Elimination of infection and prevention of urosepsis
Relief of acute symptoms
Prevention of recurrence and long-term complications and function
Hypertension
Renal scarring
Impaired renal growth and function

24. Admission Criteria
Age <2 months
Clinical urosepsis (e.g. toxic appearance, hypotension, poor capillary refill)
Immunocompromised patient
Vomiting or inability to tolerate oral medication
Failure to respond to outpatient therapy

25. Empiric Treatment
• Early and aggressive antibiotic therapy (eg, within 72 hours of
presentation) is necessary to prevent renal damage.
• Empiric antimicrobial therapy should be initiated immediately after
appropriate urine collection in children with suspected UTI and a
positive urinalysis. Especially for children who are at increased risk for
renal scarring, including those with:
• Fever (especially >39°C or >48 hours)
• Ill appearance
• Costovertebral angle tenderness
• Known immune deficiency
• Known urologic abnormality

26. Choice of the Agent
• A Gram-stained smear of the urine, can help guide decisions
regarding empiric therapy.
• The ultimate choice of antimicrobial therapy is based upon the
susceptibilities of the organism isolated.
• Escherichia coli accounts for 80% of UTI in children.
• Empiric therapy for UTI in infants and children should provide
adequate coverage for E. coli

27. • For E. coli:
• Approx 50 % are resistant to amoxicillin or ampicillin
• Resistance to 1 st-generation cephalosporins, Augmentin or ampicillin-
sulbactam, and TMP-SMX have been reported
• 3rd Generation Cephalosporins and aminoglycosides are appropriate 1 st-line
agents for UTI in children
• When Enterococcal UTI is suspected
• Those with a urinary catheter, instrumentation of the urinary tract, or an anatomical
abnormality
• Amoxicillin or Ampicillin should be added.

28. Oral Therapy
• Most children > 2 months of age who are not vomiting can be treated
with oral antimicrobials
• cephalosporin are the first-line oral agent in the treatment of UTI in
children w/o GU abnormalities
• Oral amoxicillin-clavulanate also was shown to be effective

29. Parenteral Therapy
• Cephalosporins and aminoglycosides are appropriate first-line parenteral agents
for empiric treatment of UTI in children
• Ampicillin should be included if enterococcal UTI is suspected
• Parenteral antibiotics should be continued until the patient is clinically improved
(eg, afebrile) and able to tolerate oral liquids and medications
• Ampicillin (100 mg/kg/day in 4 doses)
• Gentamicin (7.5 mg/kg/day IV in 3 doses)
• Ceftriaxone (50 to 75 mg/kg/day)
• Cefotaxime (150 mg/kg/day in 3-4 doses)
• Gentamicin if Beta lactam allergy

30. Duration
Infants and children with complicated UTI- 10-14 days
Uncomplicated UTI- 7-10 days
 Adolescents with cystitis- 3 days
Supportive measures- hydration

31. Adjunctive Therapy
• Dexamethasone
• Possible prevention of scar formation.

32. Imaging
• Identify abnormalities of the GUT that require additional evaluation
or management
• If such abnormalities are detected
• surgical intervention
• Antibiotic prophylaxis

33. Ultrasonography
• Children < 2 years of age with a first febrile UTI
• Children of any age with recurrent febrile UTIs
• Children of any age with a UTI who have a family history of renal or
urologic disease, poor growth, or hypertension
• Children who do not respond as expected to appropriate
antimicrobial therapy

34. Voiding Cystourethrogram
• VCUG is the test of choice to establish the presence and degree of
VUR
• VUR is an important risk factor for renal scarring
• (25 - 30 % of children < 18 years with a 1st UTI have VUR)

35. VCUG: indications
• Children of any age with ≥ 2 febrile UTIs
• Children of any age with a 1 st febrile UTI and:
• Any anomalies on RBUS
• The combination of Temp ≥39°C and a pathogen other than E. coli
• Poor growth or hypertension

36. International classification of vesicoureteral reflux

37. Recurrent UTI- risk factors
Bowel and bladder dysfunction
Structural abnormalities of the urinary tract VUR, PUV, duplex ureter
 Constipation
 Catheterization
Worm infestation
 Alteration of peri-urethral flora by antibiotic therapy

38. References
• Bajaj, A. L., & Bothner, J. (2019). Urine collection techniques in infants and
children with suspected urinary tract infection. Uptodate, 24p.
• Nader Shaikh, M. (2016). Urinary tract infections in children: Longterm
management and prevention. Uptodate, 1–5.
• Shaikh, N., Hoberman, A. (2016a). Urinary tract infections in infants and
children older than one month: Clinical features and diagnosis. Uptodate,
1–32. Retrieved from www.uptodate.com
• Shaikh, N., Hoberman, A. (2016b). Urinary tract infections in infants and
children older than one month: Clinical features and diagnosis. Uptodate,
1–35. Retrieved from www.uptodate.com
• Nelson TEXTBOOK of PEDIATRICS, 20th Edition
• The Harriet Lane Handbook, 20th Edition
• Donna, J. F. MD. (2019). Pediatric Urinary Tract Infection. Medscape.
Retrieved from emedicine.medscape.com