Uti in pediatric

1. URINARY TRACT
INFECTION
DR. HAFSA
DNB RESIDENT PAEDIATRICS

2.  Risk of UTI 1- 3 % IN BOYS ; 3- 10 % IN GIRLS
 Diagnosis of UTI is often missed in infants and young children since
symptoms are minimal and non specific
 Prompt identification and management are necessary to prevent renal
cortical scarring, progressive parenchymal damage, HTN.

3. DEFINITION
 Diagnosis is made by demonstration of significant bacteriuria on urine
culture in presence of symptoms
 Significant bacteriuria- colony count > 10 5 CFU/ml of a single bacterial
species in a midstream clean catch sample
 Asymptomatic bacteriuria- significant bacteriuria without symptoms of UTI
 Recurrent UTI- 2ND episode of UTI
 Complicated UTI- fever> 38*C, systemic toxicity, persistent vomiting,
dehydration, renal angle tenderness, raised serum creatinine

4.  Complicated UTI – Upper urinary tract infection or acute pyelonephritis
 Dysuria and increased frequency indicate lower urinary tract involvement
(cystitis, urethritis)

5. PYELONEPHRITIS
 Characterised by abdominal, back, flank pain, fever, malaise, nausea,
vomiting, diarrhea
 Fever can be only manifestation(Temp> 39*C without other source lasting
> 24 hr for males and > 48 hours for females
 Newborns- poor feeding, irritability, jaundice, weight loss
 Involvement of renal parenchyma- acute pyelonephritis
 Pyelitis- no parenchymal involvement
 Acute lobar nephronia is a localized renal parenchymal mass caused by
acute focal infection without liquefaction; can be early stage of renal
abcess

6. CYSTITIS
 Indicates bladder involvement- symptoms- dysuria, urgency, frequency,
suprapubic pain, incontinence.
 Does not cause high fever and does not result in renal injury
 Acute hemorrhagic cystitis- Ecoli, Adenovirus 11 and 21; patients receiving
immunosuppressive therapy are at higher risk

7. ETIOLOGY
 M.c organism- E.COLI
 Others- proteus, klebsiella, staphylococcus saprophyticus, enterococcus
and Enterobacter
 Infection with Candida may be seen in Preterm infants,
immunocompromised children and following prolonged antibiotic therapy

8. PATHOGENESIS
 Neonatal period- renal parenchymal infection can occur by hematogenous
spread
 Older children- ascending infection from urethra to bladder and kidneys
 Direct extension of infection occur in presence of fistulas from vagina or
intestine to urinary tract
 Irrational antibiotic therapy can lead to fecal recolonization with virulent
bacteria; which can predispose to bacteriuria by disrupting normal
periurethral flora

9. Risk factors for recurrent UTI
 Female sex
 Uncircumcised male
 Obstructive uropathy
 Voiding dysfunction
 Repeated pyelonephritis
 Constipation
 Repeated catheterization in neurogenic bladder
 Severe vesicoureteric reflux (Grade 111- V )

11. Clinical features
 Newborns with UTI- septicemia, jaundice, vomiting, shock
 Infancy- non specific- unexplained fever, diarrhea, vomiting, FTT
 Older children – dysuria, suprapubic pain, increased frequency
 Complicated UTI- s/o renal parenchymal involvement- fever, flank pain,
toxic appearance
 Structural abnormalities- distended bladder, palpable enlarged kidneys,
tight phimosis in a boy, vulval synechie in a girl, palpable fecal mass in the
colon, patulous anus, urinary incontinence, anorectal malformation,
meningomyelocele, previous surgery of urinary tract

12. DIAGNOSIS
 Criteria for diagnosis- on a culture of urine collected by a standard
midstream clean catch specimen, a colony count of > 10 5 CFU/ml should
be documented
 Colony count < 10 4 usually – urinary contamination
 Sample by suprapubic aspiration- any number of pathogen – UTI
 Sample by urethral catheterization- > 5 x 10 4 CFU/ml- UTI

14. COLLECTION OF URINE
 Specimen for urine culture should be obtained carefully to prevent
contamination by commensal flora in females
 Initial urinary stream washes away distal urethral organisms, should be
discarded
 For neonates and infants- best is suprapubic aspiration(1-2 cm above
pubic symphysis)
 Sample can be collected by temporary transurethral catheterization
 Bag specimen- high contamination rate

15.  Sample should be transported to lab as early as possible.
 If delay > 2 hour is anticipated, specimen can be stored in refrigerator @
4*C for upto 72 hours before plating
 This would preserve white cell count and prevent growth of contaminating
bacteria

16. MANAGEMENT
 Parenteral antibiotics- ceftriaxone(50 mg/ kg/24 hr), cefotaxime(100-150
mg/ kg/24 hr in 3-4 divided doses), amikacin, gentamicin, co- amoxiclav
 Treatment later modified according to antimicrobial sensitivity
 Oral antibiotics- clinically important- after 48- 72 hours of IV therapy
 Oral- cefixime, cephalexin, co- amoxiclav, ciprofloxacin, ofloxacin
 Duration of therapy- 10- 14 days- complicated UTI
7- 10 days for simple UTI
 Supportive therapy- maintenance of adequate hydration and control of
fever

17.  A repeat urine culture after the termination of treatment of UTI is routinely
not needed as urine cultures are typically negative within 24 hours of
initiation of antibiotic therapy

18. CHEMOPROPHYLAXIS
 Given in children < 1 year
 To keep the bladder sterile in children with VUR
 Cotrimoxazole- 1- 2 mg/kg/day
 Cephalexin – 10 mg/ kg/ day
 Cefadroxil – 5 mg/ kg/ day
 Nitrofurantoin – 1-2 mg/ kg/ day
 Given for 6- 24 months depending upon associated anomalies and UTI
recurrence

19. IMAGING
 Goal of imaging in children with UTI is to identify anatomical abnormalities
that predispose to infection
1. Bottom up method- renal sonogram + voiding cystourethrogram to
identify upper and lower urinary tract abnormalities, including VUR, bladder
bowel dysfunction, bladder abnormalities
2. Top down approach was intended to reduce the number of VCUG
examinations. It begins with DMSA renal scan to identify areas of acute
pyelonephritis and renal scarring

20.  USG- during acute illness (renal anomalies, dialated/ irregular pelvicalyceal
system)
 DMSA- 2 to 3 months following UTI - detect scarring
 MCU after adequate control of infection – detect VUR, bladder thickening
due to lower urinary tract obstruction or posterior urethral valves

22. < 1 year USG, MCU, DMSA
1 to 5 year
USG, DMSA
MCU- if either becomes abnormal
> 5 year
USG
If USG abnormal- MCU, DMSA

23. Thank you