Urinary Tract Infection in Children

1. THE CHILD WITH URINARY TRACT
INFECTION
Presented by
Dr. Sushan Ekanayake

2. References
• Nelson Textbook of Paediatrics – 1st South Asia Edition
• National Guidelines for Managing UTI in Children
• NICE Guidelines – 2018
• The child with urinary tract infection : a dilemma for the
paediatrician – Prof. Chandra Abeysekera
• Revised AAP Guidelines

3. This is about…
• Impact
• Definitions and Terminology
• Prevalence
• Aetiology
• Risk Factors
• Clinical Presentation
• Approach to the patient
 History, Examination, Investigations
• Management
• Prevention
• Information and Advice
• VUR

4. Impact of childhood UTI
• 2-3% of hospital admissions
• 4-7% of febrile illnesses in childhood
• Frequently misdiagnosed and mismanaged
• structural abnormalities that may predispose them to
recurrent infections and kidney damage.

5. Improper investigations / treatment will lead to…
– Continuing/recurrent infection
– Gross renal scarring
– Hypertension/chronic renal failure
Prevention or delaying the progression of ESRF is more
important than RRT

6. Definition
Infection of the urinary tract is identified by the growth of a significant
number of organisms of a single species in a properly collected sample
of urine, in the presence of symptoms

7. Prevalence
• 1% of boys, 1-3% of girls
• Varys with age
– 1st year of life  M:F – 2.8-5.4:1
– Beyond 1-2 years  M:F – 1:10
• 1st UTI
– Boys – 1st year
– Girls – 5 years of age

8. Aetiology
• Bacterial (Common)
– E.coli
– Klebsiella spp.
– Proteus spp.
– Staphylococcus saphrophyticus
– Entrococcus
• Viral (Less Common)
– Adenovirus
– Other

9. Risk Factors
• Female gender
• Uncircumcised male
• Vesicoureteral reflux
• Toilet training
• Voiding dysfunction
• Obstructive uropathy
• Urethral instrumentation
• Tight clothing
• Wiping from back to front in
girls
• Pinworm infestation
• Constipation
• Anatomical abnormalities
• Neuropathic bladder
• Sexual activity
• pregnancy

11. The Basic forms of UTI
• Pyelonephritis  Renal / Peri-renal Abscess
– Acute Pyelonephritis  Pyelonephritic Scarring
– Pyelitis
– Acute Lobar Nephritis
– Xanthogranulomatous Pyelonephritis
• Cystitis
– Acute Haemorrhagic Cystitis
– Eosinophilic Cystitis
– Interstitial Cystitis
• Asymptomatic Bacteriuria

13. Atypical UTI:
• seriously ill
• poor urine flow
• abdominal or bladder mass
• raised creatinine
• septicaemia
• failure to respond to treatment with suitable antibiotics within 48 hours
• infection with non-E. coli organisms.
Recurrent UTI:
• two or more episodes of UTI with acute pyelonephritis/upper urinary tract
infection
• one episode of UTI with acute pyelonephritis/upper urinary tract infection
plus one or more episode of UTI with cystitis/lower urinary tract infection
• three or more episodes of UTI with cystitis/lower urinary tract infection.

14. Clinical Presentations

15. History and Examination
History
• Dysuria, straining, increased frequency, incontinence, poor urine flow
• Secondary enuresis
• Macroscopic hematuria or pyuria
• Unexplained lower abdominal pain, flank pain
• Infant and young child with unexplained fever (>38.50C) for more than three days or
persistent vomiting or irritability
• History suggesting previous UTI or confirmed previous UTI
• Recurrent fever of uncertain origin
• Antenatally diagnosed renal abnormality
• Family history of vesicoureteric reflux (VUR) or renal disease
• Constipation
* Exclude UTI in all neonates with septicaemia and prolonged jaundice

16. Examination
• Fever / Dehydration / General ill health
• Elevated blood pressure
• Palpable bladder (after voiding) – Can be due to acute retention. May
also be due to a neurogenic bladder or posterior urethral valves (PUV)
in a male child.
• Ballotable kidneys / Renal angle tenderness
• Spinal defects
• External genitalia:
- Labial adhesions
- Phimosis (fore skin is usually not retractable < 4 yrs)
- Signs of inflammation

18. NICE Recommendation
• Infants and children presenting with unexplained fever of
38oC or more should have a urine sample tested after 24H at
the latest
• Infants and children with symptoms and signs suggestive of
UTI should have a urine sample tested for infection

19. AAP recommendation
The presence of UTI should be considered in the presence of
unexplained fever in children <2yrs

20. Why <2y ?
Diagnosis and management of UTI in this group is
challenging
– No localizing signs – delay in diagnosis of UTI
– Collection of clean urine samples is difficult
– Delay in therapy – increases the risk of renal damage
– Increased incidence of underlying abnormalities
– 25% - 50% have underlying vesico-ureteic reflux

21. Investigations
• Urinalysis - supportive
• Urine for culture / ABST – Positive urine culture is the gold
standard of diagnosis
– Its validity depends on the proper collection
– A clean catch urine sample is the recommended method for urine
collection. If a clean catch urine sample is unobtainable, non-invasive
methods such as urine collection pads can be used.
– When it is not possible or not practical to collect urine by non-invasive
methods, catheter samples or supra-pubic aspiration (SPA) should be
used.

22. Sample Collection - Methods
Infant or young child who is not potty trained
1. Clean catch mid stream sample (CCMS)
2. Supra pubic aspiration (SPA)
3. Catheter samples (only in failed attempts of SPA)
Older child
1. CCMS
2. SPA (in special situations)

23. Advice to parents on collection of CCMS urine
sample
• Wash hands and genitalia with water - No antiseptics (Retract
the prepuce of the older boys)
• Do not wash the urine culture bottle and do not leave the lid
opened for a long time
• Send first few mLs of urine out and collect a mid stream
specimen directly into the sterile culture bottle without
contamination
• Close the cap and hand over immediately

24. Sample Transportation
• Method and time of collection must be stated in the request
form
• Send immediately to the lab
• If the specimen cannot be transported within 2 hours,
refrigerate immediately at 40C – maximum time of
refrigeration is 24 hours

25. Interpretation of Results
• Urinalysis: (centrifuged sample)
– WBC >10 /HPF – indicates significant pyuria
– Nitrites (Dipsticks) positive – suggestive of infection
• Urine Culture

26. Role of imaging studies
• Ultrasound Scan
• DMSA Scan (Dimercaptosuccinic Acid Scan)
• MCUG (Micturation Cysto-Urethrogram)

31. Other imaging studies
–DTPA scan (Diethylene Triamine Pentaacetic Acid)
• Suspected pelvi-ureteric or vesico-ureteric junction obstruction
–X-Ray KUB
• UTI associated with persistent or recurrent microscopic or
macroscopic haematuria

33. Other investigations:
• Febrile child – FBC, CRP
• Ill or septic child - Blood urea, serum creatinine, Serum
electrolytes, Blood culture, LP (if indicated)

34. Management

35. Management of Acute Phase
• Correct dehydration
• Control pain and fever (Liberal fluid intake reduces dysuria)
• persistent vomiting  Domperidone may be useful

36. • Admission criteria
1. Neonates and young infant
2. Ill, toxic and dehydrated child
3. Persistent vomiting
4. Symptoms and / or signs suggestive of obstruction or calculi

37. Acute Management :NICE Recommendation
• Infants and children with a high risk of serious illness
should be referred urgently to the care of a pediatric
specialist.
• Infants younger than 3 months with a possible UTI
should be referred immediately to the care of a
pediatric specialist.
• Treatment should be with parenteral antibiotics

38. • For infants and children 3 months or older with acute
pyelonephritis/upper urinary tract infection:
–Consider referral to secondary care.
–Treat with oral antibiotics for 7–10 days. Use an oral
antibiotic with low resistance patterns. Ex: cephalosporin
or co-amoxiclav.
–If oral antibiotics cannot be used, treat with an intravenous
(IV) antibiotic agent such as cefotaxime or ceftriaxone for
2–4 days followed by oral antibiotics for a total duration of
10 days.

39. For infants and children 3 months or older with cystitis/lower urinary
tract infection:
• Treat with oral antibiotics for 3 days. The choice of antibiotics should
be directed by locally developed multidisciplinary guidance.
Trimethoprim, nitrofurantoin, cephalosporin or amoxicillin may be
suitable.
• Infant or child has to be reassessed, if still unwell after 24–48 hours.
If an alternative diagnosis is not made, a urine sample should be
sent for culture to identify the presence of bacteria and determine
antibiotic sensitivity if urine culture has not already been carried
out

40. • For infants and children who receive aminoglycosides (gentamicin or
amikacin), once-daily dosing is recommended.
• If parenteral treatment is required and IV treatment is not possible,
intramuscular treatment should be considered.
• If an infant or child is receiving prophylactic medication and develops
an infection, treatment should be with a different antibiotic, not a
higher dose of the same antibiotic.
• Asymptomatic bacteriuria in infants and children should not be
treated with antibiotics.
• Laboratories should monitor resistance patterns of urinary pathogens
and make this information routinely available to prescribers

41. Antibiotics
• A valid urine sample must be obtained before antibiotic therapy and
this may warrant a SPA for infants and young children.
• Prompt treatment with the best guess antibiotic in appropriate
dosage must be started in all suspected cases of febrile UTI pending
the urine culture result and the drug can be changed according to the
ABST pattern later.
• Treatment can be delayed till urine culture report is available if the
child is afebrile and not ill.

43. Long term management : NICE Recommendation
Aim is to prevent recurrence
Risk factors for recurrence
• Infants younger than 6 months at the time of the first UTI, family history of UTI,
dilating VUR, infrequent voiding, poor fluid intake and functional stool retention may
be associated with an increased risk of recurrent UTI, but evidence is limited.
• Infrequent voiding, poor fluid intake, functional stool retention, inadequate genital
hygiene, dysfunctional voiding and bladder over-activity may coexist.
• Renal scarring : Recurrent UTI was significantly associated with renal parenchymal
defects seen on first UTI

44. Dysfunctional elimination syndromes and constipation
should be addressed in infants and children who have
had a UTI.
Children who have had a UTI should be encouraged to
drink an adequate amount, should have ready access to
clean toilets when required and should not be expected
to delay voiding.

45. Antibiotic Prophylaxis
Antibiotic prophylaxis aims to reduce the risk of recurrent,
symptomatic UTIs and the subsequent development of
pyelonephritic scarring characterised on imaging as renal
parenchymal defects.
• Antibiotic prophylaxis should not be routinely recommended in infants and
children following first-time UTI. (NICE)
• Antibiotic prophylaxis may be considered in infants and children with recurrent
UTI.
• Asymptomatic bacteriuria in infants and children should not be treated with
prophylactic antibiotics.

46. • Antibiotic prophylaxis is indicated for all children below 5 years following
the first attack of UTI until an USS of the kidneys is available.
• Drugs are given as a single dose in the night
• Continuation of prophylaxis is decided according to following factors.
First attack <1 year
a) If the USS is normal in infants with afebrile UTI, it is recommended to stop
the prophylaxis and to follow up without further investigations.
b) In infants with febrile UTI, it is continued till recommended imaging studies
are available or until their first birthday; whichever comes last.
c) Those with structural abnormalities or recurrent UTI need prophylaxis till 5
years or longer.

47. First attack between 1-5 years
a) Those children with normal USS following an afebrile or a
simple febrile UTI will be followed up without prophylaxis or
further investigations.
b) Those with structural abnormalities or recurrent UTI need
prophylaxis till 5 years or longer.

49. Longtermmanagementof
patientsfollowingUTI

50. Management of recurrent attacks of UTI
• Confirm the diagnosis, and obtain a urine sample via a SPA for
repeat culture, in children not potty trained.
• Treat promptly with an appropriate antibiotic pending the culture
report.
• Identify correctable risk factors e.g.: constipation, poor hygiene,
inappropriate voiding practices etc.
• Treat phimosis or labial adhesions appropriately. (They lead to
false positive culture reports)
• Imaging studies as indicated.
• Check the compliance, especially if the urine culture yields
organisms sensitive to the prophylactic antibiotic used.

51. Evidence based recommendations
• Ballooning of prepuce does not indicate phimosis. if the urine stream
is good circumcision is not necessary
• Afebrile symptomatic UTI indicate lower UTI or cystitis. No urgency to
commence treatment. Advanced imaging not necessary
• Asymptomatic positive cultures require no treatment. Most commonly
due to local colonization

52. Follow Up
• Infants and children who do not undergo imaging
investigations should not routinely be followed up.
• When results are normal, a follow-up outpatient
appointment is not routinely required.
• Infants and children who have recurrent UTI or abnormal
imaging results should be assessed by a pediatric specialist.
• Assessment of infants and children with renal parenchymal
defects should include height, weight, blood pressure and
routine testing for proteinuria.

53. • Infants and children with a minor, unilateral renal parenchymal
defect do not need long-term follow-up unless they have
recurrent UTI or family history or lifestyle risk factors for
hypertension.
• Infants and children who have bilateral renal abnormalities,
impaired kidney function, raised blood pressure and/or
proteinuria should receive monitoring and appropriate
management by a paediatric nephrologist to slow the progression
of chronic kidney disease.
• Infants and children who are asymptomatic following an episode
of UTI should not routinely have their urine re-tested for
infection.
• Asymptomatic bacteriuria is not an indication for follow-up.

54. Vesico-Ureteric Reflux

55. • VUR can be a risk factor for recurrent UTI. With bladder growth and
maturation there is a tendency for reflux to resolve or improve.
• Management of VUR:
– Prophylaxis is recommended for VUR till 5 years of age. Longer regimes are indicated for
recurrent UTI.
– Advice on double micturition.
– Recurrent attacks of UTI need prompt treatment.
– A repeat DMSA scan to assess new scar formation might be recommended in case of repeat
attacks of febrile UTI
– Repeat MCUG to assess the improvement of reflux is not usually recommended unless there is
a plan for surgery.
When micturating cystourethrogram (MCUG) is performed,
prophylactic antibiotics should be given orally for 3 days with MCUG
taking place on the second day. (NICE Guidelines)

56. • There is no world wide consensus regarding the indications for surgical
intervention in VUR. Each patient with reflux has to be assessed
individually.
• Definite indications for surgical intervention
– Recurrent break through infections
• Relative indications for surgical intervention
– Poor compliance for prophylaxis
– Recurrent infections in spite of prophylaxis.
– New scar formation
– Impaired renal function
– Persistent gross VUR (Grade IV - V) or persistent moderate VUR (grade III) with
recurrent infections after discontinuation of prophylaxis

57. Information and Advice
Healthcare professionals should offer children and young people
and/or their parents or carers appropriate advice and information
on:
• prompt recognition of symptoms
• urine collection, storage and testing
• appropriate treatment options and prevention of further attacks
• continuation of prophylactic treatment and avoiding predisposing
factors
• double micturition in patients with VUR

58. Simple measures to practice for prevention
• Avoid constipation
• Increase fluids
• Cleanliness
• Regular bladder emptying
• Attention to underwear

59. Take home message
UTI is a common bacterial infection in children. It may be difficult to
recognize UTI in children because the presenting signs and symptoms
are non specific, particularly in younger children. Urine collection and
interpretation of urine tests in children are not easy and therefore it may
not always be possible to unequivocally confirm the diagnosis
So the primary care clinician has a major role in this initial management,
which involves early and accurate diagnosis, prompt treatment and
appropriate referral for further evaluation.