Approach to pediatric UTI

1. Pediatric
Urinary Tract Infections
By Dr. Fahad

2. 1. Incidence
2. Etiology
3. Pathogenesis
4. Predisposing Factors
5. History and Physical Examination
6. Investigations
7. Management
8. Prognosis
Urinary Tract Infections

3. Cystitis
• Infection Localized to bladder
Pyelonephritis
• Infection involving the renal parenchyma, calyces and renal pelvis
Asymptomatic Bacteriuria
• Positive urine culture without any manifestations of infection
Urinary Tract Infections

4. Atypical infection:
Seriously ill
Poor urine flow
Abdominal or bladder mass
Raised creatinine
Failure to respond to suitable antibiotics in 48 hours
Non- E-coli infection

5. Recurrent infection:
≥2 episodes of upper UTI
or one episode of upper UTI plus ≥1 episode of lower
UTI
or ≥3 episodes of lower UTI.

6. Statistics
 Gender:
 Below 1 year : Boys > Girls  4 : 1
Above 1 year :Girls > Boys  10: 1
 Prevalence:
By age 10 years 2% boys and 8% girls will have experienced UTI once
 Recurrence:
Gender is not associated with risk of recurrence.
Risk of recurrence depends on presence of underlying abnormality
If the age of Febrile UTI is < 1 year 30% will go on to develop recurrent UTI.

7. Etiology:
Gram Stain Bacterial Organism Frequency Pre-disposition
Negative
E. Coli 75-80% Normal flora in GIT
Non- E.Coli
Klebsiella
3-5%
Genitourinary
abnormalities
Pseudomonas Indwelling catheters
Proteus Stones
Positive
Enterococcus Genitourinary
abnormalities
Staphylococcus
Saprophyticus
Normal flora in female
genital tract

8. Risk Factors:
Age Gender Race Genetic
Bowel Bladder
Dysfunction
Instrumentation
Urinary
obstruction

9. Defense Mechanism:
Uroepithelium
Low virulence strain of local bacteria
Wash effect of urine
Mucosal IgA
Acidic pH
High Urine Osmolality
Vesicoureteric Valve

10. Clinical Presentation:
Younger children < 2 years Older Children > 4 years
• Fever • Urinary Symptoms:
Dysuria , frequency, Urgency
or incontinence
• Suprapubic tenderness
• Lack of circumcision • Suprapubic tenderness
• Irritability • CVA tenderness*
• Poor feeding or appetite • Abdominal pain
• Failure to thrive • Back pain

11. History

12. History Of presenting
Illness
Age and Gender • Male < 1 year
• Female > 2 year
Hygiene techniques • Back to front sweep
Bowel Habits • Constipation
• Encopresis
Voiding patterns • Dysuria, frequency, urgency, incontinence
• Recurrence of enuresis
Diaper area Rash: • Incontinence
Past Medical History
• Previous undiagnosed febrile illness
• Diabetes mellitus
• Neurodegenerative disease
Birth History
• Antenatal Oligohydraminos.
• Natal LGA
• Postnatal Sequence,Malformation
Syndromes
Family history
• Recurrent UTI
• Genitourinary Abnormalities in family

13. Physical Examination

14. General Examination:
Dysmorphic features
Growth Charts :
Weight: Underweight
Length: Short stature
Head circumference: Macro or microcephaly
Vital Signs
Temperature: fever >38C
BP: High
CRT: >3 sec
Systemic Examination:
GIT: Suprapubic tenderness
Cost vertebral angle tenderness
Suprapubic mass
Flank mass
Back: Tuft of hair, sacral dimple,
CNS: Features of neurodegenerative
diseases
Genitalia Local signs of irritation
Phimosis
Labial adhesions

15. Investigations

16. Urinalysis
Urine culture
Radioimaging

17. Urinalysis and culture:
 How to collect it :
 Mid stream urine sample
 Catheterization
Suprapubic catheterization

18. Urinalysis:
Test Significant Sensitivity Specificity
Microscopy ( WBCS) > 5 WBCS/HPF 73% 78%
Leukocyte esterase test Positive 83% 81%
Nitrite test Positive 53% 98%
COMBINATION OF ABOVE TESTS 99% 70%

19. Urine Culture:
 Bacterial Cultures
Single pathogen is isolated
 Number of colony forming unit s depend on Sample type:
 Midstream Urine sample:  100,000 CFU
 Catheterized or Suprapubic aspirate:  50,000 CFU
 underlying urological abnormality:  10,000 CFU

20. Radioimaging :
 KUB
MCUG
Tc 99m-DMSA scan

21. Purpose of Radioimaging:
1. Anatomic abnormality
2. Active renal involvement
3. Assess renal function

22. Imaging Test Purpose
KUB US It is performed to exclude gross
anatomical abnormality such as
pyonephrosis, abscess and
hydronephrosis
MCUG to establish the presence and degree of
VUR
DMSA Scan  It is most useful in identifying areas of
scars or decreased uptake

23. MCUG:
1. Child is catheterized
2. Radioopaque dye is instilled
3. Series of x-rays are done during
voiding

24. Tc-99m DMSA Scan:
1. Tc99m-DMSA is injected IV
2. Patient waits for 2-4 hours
3. Images are taken by gamma camera
at different views
4. Then IV Frusemide is given and another
image is taken to identify
its clearance

26. NICE guidelines
Radioimaging First febrile UTI Atypical Infection Recurrent UTI
< 6
month
KUB Yes Yes Yes
DMSA - Yes Yes
MCUG If KUB abnormal Yes Yes
6 month-
3 years
KUB - Yes Yes
DMSA - Yes Yes
MCUG - Can do if KUB is showing hydronephrosis or VUR
in FH
> 3 years KUB - Yes Yes
DMSA - Yes Yes
MCUG - - -

27. Criteria to do Radioimaging:
Bottom Up approach: Renal USS followed by VCUG
Top Down approach: Renal USS and DMSA scan

28. Test Anatomy of Kidney Function of kidney Obstruction Reflux
KUB USS Yes (structural) no Identify changes as a result of
obstruction or reflux
MCUG Yes* ( structural
limited tolower ut )
no Yes * yes
DMSA Yes* ( functional ) Yes yes no

29. Management

30. Urine
M,C&S
<5 WBCs CFU
>5 WBCs Toxic
Yes
No

31. CFU
No growth No Rx
<50K Suspicion Repeat
>50K Rx
Toxic
Yes Rx
No CFU

32. Repeat <50K No Rx
CFU
<50K Suspicion Rx
>50k Rx

33. Inpatient vs Outpatient:
Inpatient :
< 3 months
Not tolerating oral antibiotics or
vomiting
Follow up cannot be guaranteed
Sick looking
Failed to respond to outpatient
therapy
Outpatient:
> 3 months
Tolerate antibiotics orally
Follow up can be maintained
Not Sick looking

34. Choice of Antimicrobial:
Depends on age of child
Prior pathogen isolated and its sensitivity pattern
Underlying urological abnormality and recurrence UTI
Immunosuppressed
Catheterized

35. Anti Microbials:
Latifah Hospital :
Inpatient:
Neonate: IV ampicillin +IV
Gentamycin
Other :
1st line: IV Augmentin
If penicillin allergic: IV cefuroxime
Total : 7-14 days
Uptodate:
Inpatient:
1st line: 3rd Generation
cephalosporin or
IV aminoglycoside

36. Anti Microbials:
Latifah Hospital :
Outpatient:
PO Augmentin
If penicillin allergic: PO
cefuroxime
Total : 7-14 days
Uptodate:
Outpatient:
PO cephalosporin (any
generation)

37. Supplemental therapy
Behavioral
Dietary
Laxative

38. Prophylaxis
Indication: ( no anatomic abnormality)
Three febrile UTIs in six months
Four total UTIs in one year
Anti-Microbial :
 TMP SMX
Nitrofurantoin
Duration:
6 months
Can be discontinued if no infection occurs during this period

39. Prognosis
1. If no renal abnormality prognosis is very good.
2. VUR is major determinant of renal damage, renal scar.
3. VUR grade 3 or higher are twice as likely to develop renal scar than lower
grade VUR.
4. Children with higher VUR without a UTI shown to have fewer scars than
higher grade VUR with UTI
5. Overall Risk of renal Scarring increases with young age at time of diagnosis,
delay in initiation of treatment , recurrent infections , Atypical organism.
6. 2% of history of UTI (pyelonephritis) as a primary cause go on to develop
renal insufficiency

40. Long-term Sequale of Recurrent UTI
1. Short stature
2. Poor weight gain or failure to thrive
3. Hypertension

41. Prevention:
 Avoid constipation
Proper hygiene technique
Toilet training
Hydration
 Course of antibiotics
Proper undergarments
 Worm infestations treatment