medical pediatrics

1. URINARY TRACT INFECTIONS
DONE BY :DR HASAN MASRI
Supervised by :Dr Yahiya Al Jamal
8/9/2018
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2. Outline
1. Overview
2. Risk factors
3. Microbiology
4. Clinical features
5. Diagnosis
6. Management
7. Prophylaxis
8. Complications
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3. Overview
Urinary tract infection (UTI) is a common and important
clinical problem in childhood.
The clinical categories of UTI are pyelonephritis (upper
UTI) and cystitis (lower UTI)
Early recognition and prompt treatment of UTI are
important to prevent progression of infection to
pyelonephritis or urosepsis and to avoid late squeal such
as renal scarring or renal failure.
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4. Host factors
Age — The prevalence of UTI
is highest in boys younger
than one year and girls
younger than four years .
Lack of circumcision —
Uncircumcised male infants
with fever have 4- to 8 fold
higher prevalence of UTI than
circumcised male infants.
Female infants
Race
Genetic factors
Urinary obstruction
Bladder and bowel
dysfunction
Vesicoureteral reflux
Sexual activity
Bladder catheterization
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5. Microbiology
1. Escherichia coli is the most common bacterial cause of
UTI; it accounts for approximately 80 percent of UTI in
children.
2. Klebsiella, Proteus, Enterobacter, and Citrobacter.
include Staphylococcus saprophyticus, Enterococcus,
and, rarely, Staphylococcus aureus.
3. Viruses (eg, adenovirus, enteroviruses,
Coxsackieviruses, echoviruses).
4. fungi(eg, Candida spp, Aspergillus spp, Cryptococcus
neoformans, endemic mycoses) are uncommon causes
of UTI in children . 8/9/2018
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Masri

6. CLINICAL PRESENTATION
Urinary tract infections (UTI) :may present with nonspecific symptoms and
signs, particularly in infants and young children.
symptoms and sings suggested UTI
1. History of UTI
2. Temperature >40ºC
3. Suprapubic tenderness
4. Lack of circumcision
5. Temperature >39ºC for ≥48 hours in absence of another source for
fever
Fever in infants and children younger than two years can present as
only manifestation of UTI .
Other symptoms –conjugated hyperbilirubinemia (in those <28 days),
irritability, poor feeding, or failure to thrive .
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8. Symptoms of UTI in older children may
include:
 Fever
 urinary symptoms (dysuria,
urgency, frequency,
incontinence, macroscopic
hematuria), and abdominal
pain .
 Suprapubic tenderness and
costovertebral angle
tenderness may be present on
examination of older children
with UTI.
 Back pain
 Abdominal pain
 Dysuria, frequency, or both
 New-onset urinary incontinence
 fever, chills, and flank pain is
suggestive of pyelonephritis in
older children .
 Occasionally, older children may
present with short stature, poor
weight gain, or hypertension
secondary to renal scarring from
unrecognized UTI earlier in
childhood
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9. History
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The history of the illness should include:
 urinary symptoms (dysuria, frequency, urgency,
incontinence), abdominal pain, suprapubic discomfort, back
pain, vomiting, recent illnesses, antibiotics administered,
and sexual activity
 Chronic urinary symptoms – Incontinence, lack of proper
stream, frequency, urgency, withholding maneuvers
 Previous UTI,chronic constipation
 Vesicoureteral reflux (VUR)

10. cont ….History
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Previous undiagnosed febrile illnesses.
Family history of frequent UTI, VUR, and other genitourinary
abnormalities.
Antenatally diagnosed renal abnormality.
Elevated blood pressure.
Poor growth.
In sexually active girls, with barrier contraceptio or with
spermicidal agents .

11. Physical evaluation
Physical examination in the child with suspected UTI
include::
 Documentation of blood pressure and temperature
 Growth parameters (poor weight gain and/or failure
to thrive may be an indication of chronic or recurrent
UTI)
 Abdominal examination for tenderness or mass (eg,
enlarged bladder or enlarged kidney secondary to8/9/2018
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12. cont….Physical evaluation
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Assessment of suprapubic and costovertebral tenderness
Examination of the external genitalia for anatomic abnormalities
(eg, phimosis or labial adhesions) and signs of vulvovaginitis,
vaginal foreign body, sexually transmitted diseases (STDs)
Evaluation of the lower back for signs of occult myelodysplasia
(eg, midline pigmentation, lipoma, vascular lesion, sinus, tuft of
hair), which may be associated with a neurogenic bladder
Evaluation for other sources of fever .

13. Urine sample
The decision to obtain a urine sample for
culture is Depened on *age, *sex,
*circumcision status,presenting signs and
symptoms
LABORATORY EVALUATION
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14. Cont…. Urine samples
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Masri
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Urine samples and culture are generally
indicated in the following patients :
1-Girls and uncircumcised boys younger than two years with at least one
risk factor for UTI (history of UTI, temperature >39ºC, fever without
apparent source , ill appearance, suprapubic tenderness, fever >24
hours, or nonblack race)
2-Circumcised boys younger than two years with suprapubic tenderness
or at least two risk factors for UTI (history of UTI, temperature >39ºC,
fever without apparent source [particularly if the child will be treated
with antibiotics], ill appearance, suprapubic tenderness, fever >24
hours, or nonblack race)

15. Cont….
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Masri
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3-Girls and uncircumcised boys older than two years with
any of the following urinary symptoms: abdominal pain,
back pain, dysuria, frequency, high fever, or new-onset
incontinence
4-Circumcised boys older than two years with multiple
urinary symptoms (abdominal pain, back pain, dysuria,
frequency, high fever, or new-onset incontinence)
5-Febrile infants and children with abnormalities of the
urinary tract or family history of urinary tract disease

16. How to
obtain
Urine sample
Catheterization suprapubic
aspiration
Clean catch
Mid stream
urine
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17. Urine culture is the gold standard for the diagnosis of
UTI.
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 Urine obtained for culture should be
processed as soon as possible after
collection. A delay of even a few hours
increases both the false-positive and false-
negative rates substantially .
 urine obtained in a sterile bag not be used for
culture.

18. Other laboratory tests are not helpful in the diagnosis of UTI and are not
routinely necessary in children with suspected UTI.
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1. Elevated WBC, erythrocyte sedimentation rate (ESR), (CRP), and
procalcitonin (PCT) are indicators of acute inflammatory process. these
tests do not differentiate between children with cystitis and children with
pyelonephritis.
2. Serum creatinine –not routinely necessary in children with suspected
UTI. However, we suggest that serum creatinine be measured in children
with a history of multiple UTI and suspected renal involvement.
3. Blood culture –we do not routinely obtain a blood culture in children
older than two months of age who have UTI and do not require blood
culture for other reasons.
4. Lumbar puncture – Infants <1 month of age with fever and a positive
urinalysis should have a lumbar puncture performed; approximately 1

19. DIAGNOSIS OF UTI
 Quantitative urine culture is the standard test for the diagnosis
of UTI. UTI is best defined as significant bacteriuria with pyuria .
 Significant bacteriuria — depends upon the method of
collection and the identification of the isolated organism
 Clean catch sample ≥100,000 (CFU)/mL of a single
uropathogenic bacteria.
 Catheter sample –significant bacteriuria from catheterized
specimens ≥50,000 CFU/mL of a single uropathogenic bacteria
[19].
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20. CONT ….DIAGNOSIS OF UTI
 Suprapubic sample –growth of any uropathogenic
bacteria.
 Pyuria — presence of WBC in the urine is not
specific for UTI. However, true UTI without pyuria is
unusual [15].
 The absence of pyuria in the presence of significant
bacteriuria may occur under the following
circumstances : 8/9/2018
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21.  In children who are suspected of having UTI but
without pyuria detected on dipstick or microscopic
analysis
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22. Imaging studies
 child proven with UTI should have imaging
studies performed to R/O VUR or renal
anomalies.
 Imaging typically is delayed 3-6 weeks after the
infection as part of outpatient follow-up, except
in cases in which urinary tract obstruction is
suspected.
 Renal ultrasound
 A voiding cystourethrogram (VCUG) 8/9/2018
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23. DIFFERENTIAL DIAGNOSIS
1. Vulvovaginitis.
2. urinary calculi, urethritis secondary to a sexually
transmitted disease .
3. vaginal foreign body.
4. Gastro-intestinal disorders as appendicitis, and
Kawasaki disease may present with fever,
abdominal pain, and pyuria.
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24. Vesicoureteral reflux
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25. Watchful waiting: with low-grade reflux (Grades I and II
),and who are toilet-trained and able to communicate the
presence of UTI symptoms
Antibiotic prophylaxis:
●All patients who are not toilet-trained regardless of the
severity of VUR
●All patients with bladder and bowel dysfunction (BBD)
regardless of the severity of VUR
●All patients with high-grade reflux (Grade III to IV)
Surgical treatment :
●Children with Grade IV/V reflux
●Children with Grade III to IV reflux With specific condition .

26. ACUTE MANGEMENT
Goals — The goals of treatment for UTI include :
Elimination of infection and prevention of urosepsis.
Relief of acute symptoms (eg, fever, dysuria,
frequency).
Prevention of recurrence and long-term
complications including hypertension, renal scarring,
and impaired renal growth and function.
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27. Age <2 months
Clinical urosepsis
Immunocompromised patient
Vomiting or inability to tolerate oral medication
Lack of adequate outpatient follow-up
Failure to respond to outpatient therapy
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28. ANTIBIOTIC THERAPY
 Approximately 50 % of E. coli are resistant
to amoxicillin or ampicillin .
 Oral therapy — Most children older than two months of
age who are not vomiting can be treated with orally
administered antimicrobial .
 third-generation cephalosporin
(eg, cefixime cefdinir, ceftibuten) as the first-line oral
agent in the treatment of UTI in children without
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29. Cont…antibitic
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 third-generation cephalosporin (eg, cefixime cefdinir, ceftibuten) as
the first-line oral agent in the treatment of UTI in children without
genitourinary abnormalities .
 Fluoroquinolones (eg, ciprofloxacin) are effective for E. coli, and
resistance is rare.
 Parenteral therapy — Third- or fourth-generation
cephalosporins (eg, cefotaxime, ceftriaxone, cefepime) and
aminoglycosides (eg, gentamicin) are appropriate first-line
parenteral agents for empiric treatment of UTI in children.

30. Clinical response
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 Duration of therapy —Course of therapy for febrile children (usually 10
days, with a range of 7 to 14) and a short course of therapy (three to
five days) for immune competent children presenting without fever
 The clinical condition of most patients improves within 24 to 48 hours
of initiation of appropriate antimicrobial therapy
 The mean time to resolution of fever is 24 hours, but fever may persist
beyond 48 hours
 Not routinely repeat urine cultures during antimicrobial therapy to
document sterilization of the urine, provided that the child has had the
expected clinical response and the uropathogen is susceptible to the
antibiotic that is used for treatment .

31. 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
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32. Cont…
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ANTIBIOTIC PROPHYLAXIS
(TMP-SMX - Nitrofuantion−cefadroxl –cefalexin)
 Antibiotic prophylaxis is recommended for patients with
A. UTI below 1-yr of age, while awaiting imaging studies.
B. VUR
C. frequent febrile UTI (3 or more episodes in a year) even
if the urinary tract is normal.

33. EVALUATION AFTER THE FIRST UTI
 Ultrasonography should be done soon after the
diagnosis of UTI.
 micturating cystourethrogram( MCU) is
recommended 2-3 weeks later.
 The DMSA scan is carried out 2-3 months after
treatment.
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34. ADJUNCTIVE THERAPIES
 the role of of adjuvint threrapy to decrese the
parynchimal inflamation
 . An observational study demonstrated
that dexamethasone decreased urinary levels of
interleukin-6 and interleukin-8 in children,
suggesting a possible role for glucocorticoids in the
prevention of scar formation [55].
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35. SUMMARY AND HOME MESSAGE
 Fever may be the only sign of urinary tract infection (UTI) in infants
and young children.
 The examination of the child with suspected UTI should include
measurement of blood pressure, temperature, and growth parameters;
abdominal examination for tenderness or mass; assessment of
suprapubic and costovertebral tenderness; examination of the external
genitalia; evaluation of the lower back for signs of occult
myelodysplasia; and a search for other sources of fever.
 The laboratory evaluation for the child with suspected UTI includes
obtaining a urine sample for a dipstick and/or microscopic evaluation
and urine culture .
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36. SUMMARY AND HOME MESSAGE
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 Urine culture is the gold standard for the diagnosis of
UTI.
 Appropriate treatment, imaging, and follow-up prevent
long-term sequelae in patients with more severe
infections or chronic infections.
 Mild VUR usually resolves without permanent damage.
 Any child with proven UTI should have imaging studies
performed to R/O VUR or renal anomalies.

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