The ppt about urinary tract infections explained about clinical features and management.

1. URINARY TRACT
INFECTION
PRESENTER: DR. LAKSHMI NARAYANA (1ST YEAR
PG)
MODERATOR : DR.JYOTHSNA (SENIOR RESIDENT IN
DEPARTMENT OF PEDIATRICS)

2. CONTENTS
• INTRODUCTION
• MICROBIOLOGY
• PREDISPOSING FACTORS
• PATHOGENESIS AND PATHOLOGY
• CLINICAL FEATURES
• CLASSIFICATION
• DIAGNOSIS
• TREATMENT
• IMAGING STUDIES
• PREVENTING RECURRENT UTI

3. INTRODUCTION
• Urinary tract infection is a common medical problem in
children, affecting 3-10% in girls and 1-3% in boys.
• They are an important cause of morbidity and mortality
result in renal damage,often in association with
VESICOURETERIC REFLEX.
• During infancy,UTIs are equally common in boys and
girls because the route of infection is often
hematogenous and boys have a higher incidence of
urinary tract anomalies.
• As the age progress girls are more prone to UTI than
boys.

4. MICROBIOLOGY
• UTIs are chiefly caused by E.coli the
predominant peri urethral flora, others include
KLEBSIELLA, ENTEROBACTER, and
STAPHYLOCOCCUS SAPROHLPHYTICUS.
• PROTEUS and PSEUDOMONAS infection occur
following obstruction or instrumentation.
• CANDIDA infection occurs in immuno
compromised children or after prolonged
antimicrobial therapy.

5. PREDISPOSING FACTORS
• Recurrent UTIs are observed in 30-50% children,
usually within 3 months of the first episode.
• Predisposing factors for recurrent UTIs include
female sex,age below 6months,obstructive
uropathy,severe VUR,voiding dysfunction,
constipation, repeated catheterization.e.g
NEUROGENIC BLADDER.
• Children with malnutrition and those receiving
Immunosuppressive therapy are also susceptible.

6. HOST FACTORS THAT
PROTECT UT FROM UTI
•Unobstructed urine transport
•Unidirectional urine flow
•Operative antimicrobial urothelial
activity
•Regular,complete bladder emptying
•Normal perineal resistance

7. FACTORS THAT POTENTIATE INVASIVE
BACTERIAL INFECTION OF UTI

8. PATHOGENESIS AND
PATHOLOGY
• Nearly all UTIs are ascending infections.
• The bacteria arise from the fecal flora,colonize the
perineum,and enter the bladder via the urethra.
• In uncircumcised males,the bacterial pathogens arise
from the flora beneath the prepuce.
• In some cases,the bacteria causing cystitis ascend to
the kidney to cause pyelonephritis.
• Rarely,renal infection occurs by hematogenous
spread, as in endocarditis or in some
bactetemicneonates.

9. PATHOGENESIS AND
PATHOLOGY CONTND...
• If bacteria ascend from the bladder to the kidney,acute
pyelonephritis can occur.
• Normally,the simple and compound papillae in the
kidney have an antireflux mechanism that prevents
urine in the renal pelvis from entering the collecting
tubules.
• However some compound papillae,typically in the
upper and lower poles of the kidney,allow intra renal
reflux.
• Infected urine stimulates an immunologic and
inflammatory response, causing renal injury and
scarring.

10. SCARRED KIDNEY FROM
RECURRENT UTI

11. CLINICAL FEATURES
• Neonates show features of sepsis with
fever,vomiting,Diarrhea,jaundice, poor
weight gain and lethargy.
• Gross haematuria is uncommon.
• The presence of crying or straining during
voiding, dribbling weak or abnormal urine
stream and palpable bladder suggest
urinary tract obstruction.

12. CLINICAL FEATURES
CONTND...
• It is difficult to distinguish between infection
localised to the bladder (cystitis) and upper
tracts (pyelonephritis)
• The distinction is not necessary since most UTI
in children below 5 years of age involve the
upper tracts.
• Patients with high fever(>37°C),systemic
toxicity, Persistant vomiting,dehydration,renal
angle tenderness or raised creatinine are
considered as complicated.

13. CLINICAL FEATURES
CONTND...
•Patients with low grade fever,
dysuria,frequency and urgency and
absence of symptoms of complicated
UTI are considered to have simple UTI.
•This distinction is important for
purposes of therapy.

14. CLINICAL FEATURES
CONTND...
• Important features on evaluation include
history of straining at micturition,incontinence
or poor urinary stream,voiding postponement
and surgery for meningomyelocele or
anorectal malformation.
• Finding of palpable kidneys,distended
bladder,tight phimosis,vulval synechiae and
neurological deficet in lower limbs suggest a
predisposing cause.

15. CLASSIFICATION OF UTI
•The two basic forms of UTI (defined as
symptoms and a positive culture) are
PYELONEPHRITIS AND CYSTITIS.
•Focal pyelonephritis (Lobar nephronia)
and renal abscesses are less common.

16. CLASSIFICATION OF UTI
CON...
• PYELONEPHRITIS
• Pyelonephritis is characterized by any or all of
the following:
• Abdominal,back,or flank
pain;fever;malaise;nausea;vomiting;and
occasionally diarrhoea.
• Fever may be the only
manifestation;particularly consideration
should occur for a temperature>39°c without
another source lasting more than 24 hrs for
males and more than 48 hrs for females.

17. PYELONEPHRITIS CON...

18. CLASSIFICATION OF UTI
CON...
• CYSTITIS
• Cystitis indicates that there is only bladder
involvement;symptoms include
dysuria,urgency,frequency,suprapubic
pain,incontinence,and possibly malodourous
urine.
• Cystitis does not cause high fever and does not
result in renal injury.
• Malodourous urine is not specific for a UTI.

19. CYSTITIS CONTND...
• Acute hemorrhagic cystitis,though uncommon in
children,is often caused by E.coli;it also has been
attributed to adenovirus types 11 and 21.
• Adenovirus cystitis is more common in boys;it is
self limiting,with haematuria lasting approximately
4 days.
• Patients receiving Immunosuppressive therapy are
at higher risk for hemorrhagic cystitis.
• Adenovirus and polyomaviruses are important
causes in immuno compromised populations.

20. DIAGNOSIS
• The diagnosis of UTI is based on growth of
significant number of a organisms in the
urine.
• Significant bacteriuria is a colony count of
>105/ml of a single species in a clean catch
sample.
• Urine may be obtained by suprapubic
bladder aspiration or urethral catheterization
in children below 2 years.

21. DIAGNOSIS CONTND...
•Any colonies on suprapubic aspiration
and >50000/ml on urethral
catheterization are considered
significant.
•The occurrence of significant bacteriuria
in absence of symptoms is termed
ASYMPTOMATIC BACTERURIA.

22. DIAGNOSIS CONTND...
• The presence of >10 leukocytes per mm3
in fresh uncentrifuged sample,or >5
leukocytes per high power field in
centrifuge sample is useful for screening.
• Dipstick examination, combining
leukocyte esterase and nitrite, has
moderate sensitivity and specificity for
detecting UTIs.

23. TREATMENT
• Once UTI is suspected,a urine specimen is sent
for culture and treatment started.
• Infants <3 months of age and children with
complicated UTI should initially receive
parenterel antibiotics.
• The initial choice of antibiotics is emperic and is
modified once culture result is available.
• Therapy with CEPHALOSPORINS is preffered but
single daily dose of AMINOGLYCOSIDES is aslo
safe and effective.

24. ANTIMICROBIALS FOR
TREATMENT OF UTI
MEDICATION DOSE(mg/kg/day)
CEFTRAIXONE 75-100,in 1-2 divided doses IV
CEFOTAXIME 100-150,in 2-3 divided doses IV
AMIKACIN 10-15,single dose IV or IM
CEFIXIME 8-10,in 2 divided doses oral
COAMOXICLAV 30-50 of amoxicillin,in 2 doses oral
CIPROFLOXACIN 10-20,in 2 divided doses oral
OFLOXACIN 15-20, in 2 divided doses oral
CEPHALEXIN 50-70,in 2-3 divided doses oral

25. TREATMENT CONTND...
• Once oral intake improves and symptoms
abate,usually after 48-72hrs,therapy is switched to an
oral antibiotics.
• The duration of treatment for complicated UTI is 10-
14 days.
• Older infants and patients with simple UTI should
receive treatment with an oral antibiotics for 7-10
days
• Adolescents with cystitis may receive shorter
duration of antibiotics,lasting for 72 hrs
• Asymptomatic bacteriuria do not require treatment.

26. TREATMENT CONTND...
• All Children with UTI are encouraged to take enough fluids
and empty bladder frequently.
• Routine alkalization of the urine is not necessary.
• With appropriate therapy fever and systemic toxicity reduce
and urine culture is sterile within 24-36 hrs.
• Failure to obtain such results suggests either lack of
bacterial sensitivity to the medication or presence of an
underlying anomaly of the urinary tract.
• A repeat urine culture is not required during or following
treatment,unless symptoms fail to resolve despite 72 hrs of
therapy symptoms recur,or contamination of initial culture
is suspected.

27. EVALUATION OF UTI
•Following treatment of the first episode
of UTI,plans are made for evaluation of
the urinary tract.
•The aim of the imaging studies is to
identify urological anomalies that
predispose to pyelonephritis,such as
obstruction or VUR,and detect evidence
of renal scarring.

28. EVALUATION OF UTI
AGE EVALUATION
Below 1 year Ultrasound
MCU
DMSA
1-5 years Ultrasound
DMSA
MCU, if usg or DMSA is
abnormal.
Above 5 years Ultrasound
If ultrasound
abnormal:MCU,DMSA.

29. EVALUATION OF UTI CON...
• The goal of imaging studies in children with a
UTI is to identify anatomic abnormalities that
predispose to infection,determine whether
there is active renal involvement,and assess
whether renal function is normal or at risk.
• There are two historical approaches to
imaging,the traditional
• 1 BOTTOM-UP
• 2 TOP-DOWN

30. EVALUATION OF UTI CON...
• BOTTOM-TOP:
• This method was a renal sonogram plus a voiding
cystourethrogram, which will identify upper and
lower urinary tract abnormalities,including
VUR,bladder-bowel dysfunction and bladder
abnormalities,such as para urethral diverticulum.
• TOP-DOWN
• This approach was intended to reduce the number of
VCUG examinations
• It begins with a DMSA renal scan,to identify areas of
acute pyelonephritis.

31. PREVENTION OF
RECURRENT UTI
• Prophylactic antibiotics are administered to young
infants until results of imaging are available.
• The medication used should be effective,nontoxic
and not alter the gut flora or induce bacterial
resistance.
• The medication is given as a single bedtime dose.
• Long term antibiotic prophylaxis is also
recommended in patients with VUR and in those with
frequent febrile UTI(3 or more episodes in a year),
even if the urinary tract is normal.

32. PREVENTION OF UTI CON...
• Circumcision reduces the risk of recurrent UTI in
Infant boys,and might have benefits in patients with
high grade VUR.
• Children with recurrent UTI and/or VUR might have
dysfunctional voiding and require appropriate advice.
• Constipation should be managed with dietary
modifications and medications as required.
• Some patients may require bladder
retraining,anticholinergic medication and/or
intermittent catheterization.

33. ANTIMICROBIALS FOR
PROPHYLAXIS OF UTI
MEDICATION DOSE(mg/kg/day) REMARKS
COTRIMAXAZOLE 1-2 of trimethoprim Avoid in Infants <3 months
old, G6PD deficiency.
NITROFURANTOIN 1-2 May cause vomiting and
nausea;avoid in <3 months
old, G6PD deficiency,renal
insufficiency.
CEPHALEXIN 10 Drug of choice in first 3-6
months of life.
CEFADROXIL 5 Alternative agent in early
infancy.

34. REFERENCES
1 NELSONS TEXTBOOK OF PEDIATRICS
2 PIYUSH GUPTA TEXTBOOK OF PEDIATRICS
3 OP GHAI ESSENTIALS OF PEDIATRICS

35. THANK YOU