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Pediatric
Urinary Tract Infections
By Dr. Fahad
1. Incidence
2. Etiology
3. Pathogenesis
4. Predisposing Factors
5. History and Physical Examination
6. Investigations
7. Management
8. Prognosis
Urinary Tract Infections
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
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
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.
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.
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
Risk Factors:
Age Gender Race Genetic
Bowel Bladder
Dysfunction
Instrumentation
Urinary
obstruction
Defense Mechanism:
Uroepithelium
Low virulence strain of local bacteria
Wash effect of urine
Mucosal IgA
Acidic pH
High Urine Osmolality
Vesicoureteric Valve
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
History
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
Physical Examination
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
Investigations
Urinalysis
Urine culture
Radioimaging
Urinalysis and culture:
 How to collect it :
 Mid stream urine sample
 Catheterization
Suprapubic catheterization
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%
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
Radioimaging :
 KUB
MCUG
Tc 99m-DMSA scan
Purpose of Radioimaging:
1. Anatomic abnormality
2. Active renal involvement
3. Assess renal function
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
MCUG:
1. Child is catheterized
2. Radioopaque dye is instilled
3. Series of x-rays are done during
voiding
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
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 - - -
Criteria to do Radioimaging:
Bottom Up approach: Renal USS followed by VCUG
Top Down approach: Renal USS and DMSA scan
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
Management
Urine
M,C&S
<5 WBCs CFU
>5 WBCs Toxic
Yes
No
CFU
No growth No Rx
<50K Suspicion Repeat
>50K Rx
Toxic
Yes Rx
No CFU
Repeat <50K No Rx
CFU
<50K Suspicion Rx
>50k Rx
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
Choice of Antimicrobial:
Depends on age of child
Prior pathogen isolated and its sensitivity pattern
Underlying urological abnormality and recurrence UTI
Immunosuppressed
Catheterized
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
Anti Microbials:
Latifah Hospital :
Outpatient:
PO Augmentin
If penicillin allergic: PO
cefuroxime
Total : 7-14 days
Uptodate:
Outpatient:
PO cephalosporin (any
generation)
Supplemental therapy
Behavioral
Dietary
Laxative
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
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
Long-term Sequale of Recurrent UTI
1. Short stature
2. Poor weight gain or failure to thrive
3. Hypertension
Prevention:
 Avoid constipation
Proper hygiene technique
Toilet training
Hydration
 Course of antibiotics
Proper undergarments
 Worm infestations treatment

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Pediatric Urinary tract Infections

  • 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
  • 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
  • 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
  • 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
  • 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
  • 25.
  • 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
  • 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)
  • 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

Editor's Notes

  1. AGE: UTI is highest in boys younger than one year and girls younger than four years Gender: > 2years girls due to shorter urethra Race/ethnicity — For reasons that are not completely understood, white children have a two- to fourfold higher prevalence of UTI than do black children Genetic: On the other hand, individuals with mutations in the toll-like receptor (TLR) signaling pathway do not mount a significant inflammatory response, even when virulent bacteria are present  Bladder and bowel dysfunction — Bladder and bowel dysfunction, of which bladder dysfunction is a subset, is characterized by: ●An abnormal elimination pattern (frequent or infrequent voids, daytime wetting, urgency, infrequent stools [constipation]) ●Bladder and/or bowel incontinence ●Withholding maneuvers Bladder catheterization — The risk of UTI increases with increasing duration of bladder catheterization. Urinary obstruction — Children with obstructive urologic abnormalities are at increased risk of developing UTI; stagnant urine is an excellent culture medium for most uropathogens. Predisposing obstructive abnormalities may be anatomic (posterior urethral valves, ureteropelvic junction obstruction), neurologic (eg, myelomeningocele with neurogenic bladder), or functional (eg, bladder and bowel dysfunction). (See appropriate topic reviews.)
  2. YOUNG CHILD: These findings were consistent with high rate of diagnosis of UTI in children in respective groups The incidence was highest when Fever especially temperature> 38C for > 48 hours UTI should always be considered part of unexplained fever in young children (AAP) OLD CHILD: The constellation of Fever , Chills , flank pain and CVA tenderness in older children point to Pyelonephritis LAST: Parental reporting of foul-smelling urine or gastrointestinal symptoms (vomiting, diarrhea, and poor feeding) is generally not helpful in diagnosing UTI
  3. Age: Males < 1y  3-6: 1 Females: >2y 10:1 Hygiene : back to front contamination with stool pathogens Ecoli Bowel Habits: Constipation: increases urinary stasis and thus infection Voiding Patterns: Enuresis Past Medical History: previous unrecognized febrile illness UTI , DM: immunodeficiency, NDD: Gaucher, Niemanpick, Leukodystrophies Birth History: Ante: oligohydraminos: IPKD, high ACEase ? Meningiomyelocele Natal: oligohydraminos LGA Post: PUVPotter seq. Meningiomyelocele neurogenic bladder, 13, 18 ,21  Renal dysgenesis infection FH: recurrent UTI and genitourinary abnormality  PCKD , MCDK, Renal dysgenesis
  4. GE: Potter Sequence, trisomies, turner, prune belly syndrome: Renal dysgenesis or general appearance: spasticity, para or quadriplegia signs suggestive of neurodegenerative disease neurogenic bladder GC: FTT, Short stature, underweight  Chronic or recurrent UTI Macro: leukodystrophies(white) Micro: Rett, Gaucher, nieman pick (gray) VS: Fever: 38C points to upper UTI, BP: High inidicates renal scarring , CRT: urosepsis Systemic Exam: GIT: Suprapubic mass: enlarged bladder PUV , Flank mass: Hydronephrosis, renal mass ( tumor) Back: lesion: meningiomyelocele ,Tuft of hair: occult myelocele, sacral dimple: tethered cord neurogenic bladder CNS: features suggestive of degenerative disease :Macrocephaly Mental retardation , spasticity, para or quadriplegia
  5. Other investigations as part of work up if child is sick looking such as CBC, Blood Culture, CRP, creatinine
  6. Bag sample is seldom used: its only significance is when we have a negative culture( helps exclude UTI) Mid stream urine sample: toilet trained Sterile Catheterization: in non toilet trained Suprapubic aspirate; seldom performed either because of lack of hands on experience or ward protocols
  7. Microscopy : > 5 WBCS/HPF on centrifuged and unstained , not all bacterias produce pyuria and not all pyuria are UTIs Pyuria may be less likely with certain pathogens (eg, Enterococcus species, Klebsiella species, P. aeruginosa) LET: is basically a dipstick version to detect wbcs in urine NT: urine must remain in the bladder for at least four hours to accumulate a detectable amount of nitrite, AND NOT ALL BACTERIA PRODUCE NITRITES, and sometimes when more than 100,000 CFU
  8. In immunocompetenet individual we don’t do viral or fungal cultures Viral Cultures are sometime performed in : Immunocompromised and gross hematuria with no pathogen isolated. (adenovirus, Polyomavirus, CMV) Number of pathogens: Multiple it is contaminated Number of CFU: according to uptodate and AAP
  9. DMSA Dimercaptosuccinic acid EC  ethylcysteine
  10. MCUG involves catheterization to fill the bladder with a radiopaque or radioactive liquid and recording of VUR during voiding. VCUG is expensive, invasive, and may miss a significant portion of children who are at risk for renal scarring
  11. Can be immediately– pyelonephritis Performed 4-6 weeks after -- scarring
  12. Bottom up : Renal USS followed by VCUG: bladder bowel dysfunction: incomplete voiding , VUR , Bladder anamolies such as diverticula. Disadvantage is we don’t know the renal damage/condition Top down : Renal USS and DMSA scan ; involved areas of kidney have reduced uptake, This is followed VCUG as 90% of children with dilating reflux have positive DMSA scan
  13. MCUG: Anatomy* delineate the anatomy of bladder and urethra Obstruction* within the bladder and below DMSA scan: (Localize in the cortex) Anatomy* morphology but KUB is superior in precise measurements
  14.  >2 months : Urinary tract infection (UTI) in neonates (infants ≤30 days of age) is associated with bacteremia and congenital anomalies of the kidney and urinary tract (CAKUT). Upper tract infections (ie, acute pyelonephritis) may result in renal parenchymal scarring and chronic kidney disease. Neonates with UTI should be evaluated for associated systemic infection, and anatomic or functional abnormalities of the kidneys and urinary tract.
  15. Neonate it is IV ampicillin vs gentamycin Underlying urological abnormality , immunosuppressed ; consider treating with more potent antibiotic ( 3rd generation and carbapenem) Cathterized ( consider covering for Enterococcus and pseudomonas ) augmentin and Aminoglycoside
  16. Uptodate: 50% of Ecoli resistant to Augmentin Total 7-14 days ( pyelonephritis, it is shorter in case of cystitis ) and provided patient responded in 48 hours otherwise adding an antibiotic or changing antibiotic, and repeating of urine culture may be considered which may alter the duration
  17. Uptodate: 50% of Ecoli resistant to Augmentin Total 7-14 days ( pyelonephritis, it is shorter in case of cystitis ) ,
  18. Behavioural  encopresis, constipation, rectifying habit holding urine Dietary: increased hydration Laxative: constipation
  19. If no renal abnormality , even subsequent UTIs are unlikely to cause permanent renal damage. VUR  pyelonephritis Renal Scar It is a small number Primarily because of prompt recognition and treatment of pyelonephritis. For Reflux uropathy  5% and obstructive uropathy  16%
  20.  older children may present with short stature, poor weight gain, or hypertension secondary to renal scarring from unrecognized UTI earlier in childhood