PEDIATRIC
UTI
PREPARED
BY
ASOGWA INNOCENT KINGSLEY
ML-508
DEFINITION
Infection of the urinary tract is identified
by growth of a significant number of
organisms of a single specie...
PREVALENCE
 UTI is a common bacterial infection in infants and
children.
 The risk of having a UTI before the age of 14 ...
RISK FACTORS FOR URINARY TRACT
INFECTION:
 Anatomic risk factors
 Vesiculoureteral reflux (VUR)
More common in girls
 ...
RISK FACTORS FOR URINARY TRACT
INFECTION:
 Associated risk factors
 Constipation
 Encopresis(Involuntary defecation not...
ETIOLOGY
 The Culprits
◦ Escherichia Coli
◦ Enterococcus
◦ P. aeruginosa
◦ Klebsiella sp.
◦ Proteus sp.
◦ Enterobacter sp...
BACTERIAL FACTORS
 Virulence Factors
◦ Cell Wall Antigens
◦ Serum Resistance
◦ Hemolytic Capability
◦ Growth Dynamics
◦ I...
HOST DEFENSE FACTORS
 Urine pH / Vaginal pH
 Local IgA Antibodies
 Voiding Mechanics
 Ascending Route of UTI
° Bacterial Colonization
° Migration to Periurethral Region
° Migration into Bladder
° Growth in ...
CLINICAL MANIFESTATIONS
The 3 basic forms of UTI
1. Pyelonephritis
2. Cystitis
3. Asymptomatic
bacteriuria
PYELONEPHRITIS
 Clinical pyelonephritis is characterized by any or all
of the following:
- abdominal or flank pain,
- fev...
OUTCOMES OF PYELONEPHRITIS
 Acute lobar nephronia (acute lobar nephritis) is a
localized renal bacterial infection involv...
XANTHOGRANULOMATOUS PYELONEPHRITIS
 Xanthogranulomatous pyelonephritis is a rare
type of renal infection characterized by...
CYSTITIS
 It indicates that there is bladder involvement.
 Symptoms include :
• dysuria,
• urgency,
• frequency,
• supra...
ASYMPTOMATIC
BACTERIURIA
It refers to a condition that results in a
positive urine culture without any
manifestations of ...
 Rapid evaluation and treatment of UTI is important
to prevent renal parenchymal damage and renal
scarring that can cause...
 Microscopic Analysis
 Urine Dipstick Analysis
◦ Sensitivity 80-90% / Specificity
60-98%
◦ Leukocyte Esterase
◦ Nitrites...
Clean Voided Specimen
◦ 80% Accuracy
Bagged Specimen
Catheterized Specimen
Suprapubic Aspiration
CULTURE METHODS
SPECIMEN COLLECTION
 Newborns & Infants
◦ Bagged Specimens
◦ Suprapubic Aspiration
◦ Urethral Catheterization
 Toddlers
...
 - *Midstream Clean Catch
Specimen
<10,000 CFU Probable
Contaminant
>100,000 CFU Significant Colony
Count
 Enteric Gram ...
ANATOMIC / FUNCTIONAL EVALUATION
 Goals
◦ Assess risk of
Damage
◦ Assess Presence
of Damage
◦ Identify
Complicating
Facto...
EVAUATION OF UTI
 Physical Exam
 Imaging Studies
◦ When to Evaluate?
◦ How To Evaluate?
◦ RUS
◦ IVP
◦ DMSA Scan
◦ Cystog...
Girls
 Initial Studies
◦ USN
◦ VCUG
 Follow-up Studies
◦ USN
◦ VCUG
Boys
 Initial Studies
◦ USN
◦ VCUG
 Follow-up Stud...
UTI - ULTRASOUND
 2-3 % Yield
Obstructive Uropathy
Bellman, 1995
UTI - VOIDING STUDY
 VCUG For 1st Study
 Pyelonephritis
Associated With
Vesico-Ureteral Reflux
50%
Bellman, 1995
TREATMENT
The patient’s age, features suggesting
toxicity and dehydration, ability to
retain oral intake and the likeliho...
TREATMENT
 Children less than 3 months of age and those with
complicated UTI should be hospitalized and treated
with pare...
TREATMENT
Children with simple UTI and
those above 3 months of age
are treated with oral
antibiotics.
 With adequate the...
TREATMENT
 The duration of therapy
-14 days for infants and children with complicated
UTI
- 7-10 days for uncomplicated U...
EVALUATION AFTER THE FIRST UTI
 The aim of investigations is to identify patients at high
risk of renal damage, chiefly t...
EVALUATION AFTER THE FIRST UTI
EVALUATION AFTER THE FIRST UTI
Ultrasonography should be
done soon after the diagnosis
of UTI.
The MCU is recommended 2-...
PREVENTION OF RECURRENT UTI
General Measures:
 Adequate fluid intake and frequent voiding
 constipation should be avoide...
ANTIBIOTIC PROPHYLAXIS
 Long-term, low dose, antibacterial prophylaxis is
used to prevent recurrent, febrile UTI.
 The a...
ANTIBIOTIC PROPHYLAXIS
 Antibiotic prophylaxis is recommended for
patients with
(i) UTI below 1-yr of age, while awaiting...
VESICOURETERIC REFLUX
•VUR is a bladder valve defect
that allows urine to reflux from
the bladder through one or both
uret...
 VUR is seen in 40-50% infants and 30-50%
children with UTI, and resolves with age.
 Its severity is graded using the In...
VUR GRADES
SCREENING OF SIBLINGS AND OFFSPRING:
 Reflux is inherited in an autosomal dominant
manner with incomplete penetrance; 27%...
Pediatric uti by asogwa innocent kingsley
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Pediatric uti by asogwa innocent kingsley

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Pediatric uti by asogwa innocent kingsley

  1. 1. PEDIATRIC UTI PREPARED BY ASOGWA INNOCENT KINGSLEY ML-508
  2. 2. DEFINITION Infection of the urinary tract is identified by growth of a significant number of organisms of a single species in the urine, in the presence of symptoms. Recurrent UTI, defined as the recurrence of symptoms with significant bacteriuria in patients who have recovered clinically following treatment, is common in girls.
  3. 3. PREVALENCE  UTI is a common bacterial infection in infants and children.  The risk of having a UTI before the age of 14 yrs -1- 3% in boys - 3-10% in girls .  In girls, the first UTI usually occurs by the age of 5 yr, with peaks during infancy and toilet training.  In boys, most UTIs occur during the 1st yr of life; more common in uncircumcised boys.  During the 1st yr of life, -M : F ratio is 2.8–5.4 : 1.  Beyond 1–2 yr, -M : F ratio of 1 : 10.
  4. 4. RISK FACTORS FOR URINARY TRACT INFECTION:  Anatomic risk factors  Vesiculoureteral reflux (VUR) More common in girls  Obstruction  Posterior urethral valves Boys  Voiding dysfunction  Bladder diverticulum
  5. 5. RISK FACTORS FOR URINARY TRACT INFECTION:  Associated risk factors  Constipation  Encopresis(Involuntary defecation not attributable to physical defects or illness.)  Bladder instability  Infrequent voiding  Unsubstantiated risks  Bathing  Back-to-front wiping
  6. 6. ETIOLOGY  The Culprits ◦ Escherichia Coli ◦ Enterococcus ◦ P. aeruginosa ◦ Klebsiella sp. ◦ Proteus sp. ◦ Enterobacter sp. ◦ Coag-negative staph ◦ Staph aureus ◦ Candida sp.
  7. 7. BACTERIAL FACTORS  Virulence Factors ◦ Cell Wall Antigens ◦ Serum Resistance ◦ Hemolytic Capability ◦ Growth Dynamics ◦ Iron Scavenging  Adherence Factors ◦ P Fimbriae ◦ Type 1 Fimbriae ◦ DR Fimbriae
  8. 8. HOST DEFENSE FACTORS  Urine pH / Vaginal pH  Local IgA Antibodies  Voiding Mechanics
  9. 9.  Ascending Route of UTI ° Bacterial Colonization ° Migration to Periurethral Region ° Migration into Bladder ° Growth in Urine ° Bacterial Ascent to Kidney ° Colonization of Renal Medulla ° Focal Abscess Formation ° Bacteremia ° Kidney Re-infection PATHOGENESIS - UTI
  10. 10. CLINICAL MANIFESTATIONS The 3 basic forms of UTI 1. Pyelonephritis 2. Cystitis 3. Asymptomatic bacteriuria
  11. 11. PYELONEPHRITIS  Clinical pyelonephritis is characterized by any or all of the following: - abdominal or flank pain, - fever, - malaise, nausea, vomiting, and, - occasionally, diarrhoea.  In newborns show nonspecific symptoms : - poor feeding, irritability, and weight loss.  Pyelonephritis is the most common serious bacterial infection in infants <2 yrs of age who have fever without a focus .
  12. 12. OUTCOMES OF PYELONEPHRITIS  Acute lobar nephronia (acute lobar nephritis) is a localized renal bacterial infection involving >1 lobe that represents either a complication of pyelonephritis or an early stage in the development of a renal abscess.  Renal abscess may occur following a pyelonephritis or may be secondary to a primary bacteremia (S. aureus).  Perinephric abscesses may be secondary to contiguous infection in the perirenal area (e.g., vertebral osteomyelitis, psoas abscess) or pyelonephritis that dissects to the renal capsule.
  13. 13. XANTHOGRANULOMATOUS PYELONEPHRITIS  Xanthogranulomatous pyelonephritis is a rare type of renal infection characterized by granulomatous inflammation with giant cells and foamy histiocytes.  It may present clinically as a renal mass or an acute or chronic infection.  Renal calculi, obstruction, and infection with Proteus spp. or E. coli contribute to the development of this lesion, which usually requires total or partial nephrectomy.
  14. 14. CYSTITIS  It indicates that there is bladder involvement.  Symptoms include : • dysuria, • urgency, • frequency, • suprapubic pain, • incontinence, and • malodorous urine.  Cystitis does not cause fever and does not result in renal injury.
  15. 15. ASYMPTOMATIC BACTERIURIA It refers to a condition that results in a positive urine culture without any manifestations of infection. It is most common in girls. The incidence is 1–2% in preschool and school-age girls and 0.03% in boys. The incidence declines with increasing age.
  16. 16.  Rapid evaluation and treatment of UTI is important to prevent renal parenchymal damage and renal scarring that can cause hypertension and progressive renal damage.  Diagnosis ◦ Culture Methods ◦ Screening Tests ◦ Anatomic / Functional Evaluation  Treatment ◦ Age of Patient ◦ Severity of Infection ◦ Prior History of UTI MANAGEMENT - UTI
  17. 17.  Microscopic Analysis  Urine Dipstick Analysis ◦ Sensitivity 80-90% / Specificity 60-98% ◦ Leukocyte Esterase ◦ Nitrites  First Voided Urine Best  Dietary nitrates SCREENING TESTS
  18. 18. Clean Voided Specimen ◦ 80% Accuracy Bagged Specimen Catheterized Specimen Suprapubic Aspiration CULTURE METHODS
  19. 19. SPECIMEN COLLECTION  Newborns & Infants ◦ Bagged Specimens ◦ Suprapubic Aspiration ◦ Urethral Catheterization  Toddlers ◦ Bagged Specimens ◦ Clean Void ◦ Urethral Catheterization  School Age Children ◦ Midstream Clean Catch
  20. 20.  - *Midstream Clean Catch Specimen <10,000 CFU Probable Contaminant >100,000 CFU Significant Colony Count  Enteric Gram Negative Bacteria QUANTITATIVE URINE CULTURE
  21. 21. ANATOMIC / FUNCTIONAL EVALUATION  Goals ◦ Assess risk of Damage ◦ Assess Presence of Damage ◦ Identify Complicating Factors
  22. 22. EVAUATION OF UTI  Physical Exam  Imaging Studies ◦ When to Evaluate? ◦ How To Evaluate? ◦ RUS ◦ IVP ◦ DMSA Scan ◦ Cystography  RNC  VCUG
  23. 23. Girls  Initial Studies ◦ USN ◦ VCUG  Follow-up Studies ◦ USN ◦ VCUG Boys  Initial Studies ◦ USN ◦ VCUG  Follow-up Studies ◦ USN ◦ VCUG UTI IMAGING STUDIES
  24. 24. UTI - ULTRASOUND  2-3 % Yield Obstructive Uropathy Bellman, 1995
  25. 25. UTI - VOIDING STUDY  VCUG For 1st Study  Pyelonephritis Associated With Vesico-Ureteral Reflux 50% Bellman, 1995
  26. 26. TREATMENT The patient’s age, features suggesting toxicity and dehydration, ability to retain oral intake and the likelihood of compliance with medication(s) help in deciding the need for hospitalization. Therapy should be prompt to reduce the morbidity of infection, minimize renal damage and subsequent complications.
  27. 27. TREATMENT  Children less than 3 months of age and those with complicated UTI should be hospitalized and treated with parenteral antibiotics.  The choice of antibiotic should be guided by local sensitivity patterns.  A third generation cephalosporin is preferred.  Therapy with a single daily dose of an aminoglycoside may be used in children with normal renal function.  Intravenous therapy is given for the first 2-3 days followed by oral antibiotics once the clinical condition improves.
  28. 28. TREATMENT Children with simple UTI and those above 3 months of age are treated with oral antibiotics.  With adequate therapy, there is resolution of fever and reduction of symptoms by 48- 72 hours.
  29. 29. TREATMENT  The duration of therapy -14 days for infants and children with complicated UTI - 7-10 days for uncomplicated UTI.  Adolescents with cystitis may be treated with shorter duration of antibiotics, lasting 3 days.  Following the treatment of the UTI, prophylactic antibiotic therapy is initiated in children below 1 year of age, until appropriate imaging of the urinary tract is completed.
  30. 30. EVALUATION AFTER THE FIRST UTI  The aim of investigations is to identify patients at high risk of renal damage, chiefly those below one year of age, and those with VUR or urinary tract obstruction.  Evaluation includes ultrasonography, DMSA renal scan and micturating cystourethrography (MCU) performed .  An ultrasonogram provides information on kidney size, number and location, presence of hydronephrosis, urinary bladder anomalies and post-void residual urine.  DMSA scintigraphy is a sensitive technique for detecting renal parenchymal infection and cortical scarring.  MCU detects VUR and provides anatomical details regarding the bladder and the urethra.
  31. 31. EVALUATION AFTER THE FIRST UTI
  32. 32. EVALUATION AFTER THE FIRST UTI Ultrasonography should be done soon after the diagnosis of UTI. The MCU is recommended 2-3 weeks later. The DMSA scan is carried out 2-3 months after treatment.
  33. 33. 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 in infant boys, and might therefore have benefits in patients with high grade reflux.
  34. 34. ANTIBIOTIC PROPHYLAXIS  Long-term, low dose, antibacterial prophylaxis is used to prevent recurrent, febrile UTI.  The antibiotic used should be effective, non-toxic with few side effects and should not alter the growth of commensals or induce bacterial resistance .
  35. 35. ANTIBIOTIC PROPHYLAXIS  Antibiotic prophylaxis is recommended for patients with (i) UTI below 1-yr of age, while awaiting imaging studies, (ii) VUR (iii)frequent febrile UTI (3 or more episodes in a year) even if the urinary tract is normal.
  36. 36. VESICOURETERIC REFLUX •VUR is a bladder valve defect that allows urine to reflux from the bladder through one or both ureters and up to the Kidneys. •Febrile urinary tract infection (UTI) is the defining Symptom.
  37. 37.  VUR is seen in 40-50% infants and 30-50% children with UTI, and resolves with age.  Its severity is graded using the International Study Classification from grade I to V, based on the appearance of the urinary tract on MCU.  The presence of moderate to severe VUR, particularly if bilateral, is an important risk factor for pyelonephritis and renal scarring, with subsequent risk of hypertension, albuminuria and progressive kidney disease.  The risk of scarring is highest in the first year of life
  38. 38. VUR GRADES
  39. 39. SCREENING OF SIBLINGS AND OFFSPRING:  Reflux is inherited in an autosomal dominant manner with incomplete penetrance; 27% siblings and 35% offspring of patients show VUR.  Ultrasonography is recommended to screen for the presence of reflux.  Further imaging is required if ultrasonography is abnormal

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