A seminar on urinary tract infections (UTIs) was presented. UTIs are common in children and can lead to complications if not treated properly. The presentation covered the definition, causes, risk factors, clinical presentation, investigations, treatment, and follow-up management of UTIs in children of different ages. Proper diagnosis and treatment of UTIs as well as preventing recurrence are important to avoid long-term issues like renal scarring and kidney damage.

1. SEMINAR
On
Presented By:
Dr. Iffat Anjum Shaon
Dr. Rezwana Rahman
Phase-A,Year-1 Resident
Paediatric Hematology and Oncology
URINARY TRACT INFECTION

2. Scenario-1
A newborn male baby 14 days old delivered normally
at home at term. Now C/O-
Fever-1day
Poor feeding
Vomited Once
Poor wt. gain
O/E:
Temp-390C
Reflexes-Poor
Others-Normal.

3. Scenario-2
A 3yrs. old girl C/O.
Crying during Urination
Increased frequency of micturition.
No fever
O/E:
Temp-N
Vulval redness and
Signs of inflammation

4. What will be the probable

6. What is UTI?
Urinary tract infection
(UTI) is defined as the
invasion and multiplication
of micro- organism in
significant number in the
urinary tract.

7. Why UTI is so Important?
 3rd commonest infection
 VUR-30-40% of all children following first
UTI.
 Renal Scar : 20-40%
 Hypertension: 20-25%
 ESRD : 7-17%
 Cong. Anomalies:
• Boys-10%
• Girls-2%

8. INCIDENCE:
Varies with age & sex.
NEWBORN:
Term: 0.5-1%
Preterm: 3-5%
RATIO:
Age Male Female
< 1 years 2.8-5.4 : 1
> 1-2 years 1 : 10

9. AETIOLOGY:
A) Bacterial:
• E. Coli- 90% of first time UTI & 70% of recurrent
infection.
•Klebseilla
• Proteus-30%(Boys)
Others-
Pseudomonas
Staph. epidermidis
Staps. saprophyticus
strept. fecalis

10. B) VIRAL:
Adenovirus
C) FUNGAL:
Candida albicans
Cryptococcus
D) OTHERS:
Chlamydia
Mycoplasma
Schistosoma haematobium
Rare

11. CLASSIFICATION:
A) Depending upon severity :
Uncomplicated or Simple
Complicated
B) According to region involved:
Upper UTI: Pyelonephritis, Pyelitis Ureteritis
Lower UTI: Cystitis, Urethritis

12. C) According to symptom:
 Symptomatic
Acute Pyelonephritis
Acute cystitis
Unspecified
 Asymptomatic Bacteriuria.

13. Predisposing factors for UTI:
 Infrequent and incomplete voiding
 Obstructive uropathy
 Neurogenic bladder
 Constipation
 Uncircumcised boys
10 times more chance
 Female child

14.  Thread worm infestation
 Use of broad spectrum antibiotic for
minor illness
 Anatomical abnormalities
 Malnutrition
 Urethral instrumentation
 Wiping from back to front in girls
 Tight clothing (underwear)
 P1 blood group.

15. PATHOGENESIS:
A) Host Defense:
1) Normal Periurethral flora
2) Bladder defense
3) Secretory Ig A in Urine
4) Breast feeding
5) Normal free flow of Urine

16. B) Bacterial Virulence:
1) P-fimbriae
2) O-Antigen
3) K-Antigen
4) Biofilm.

19. Pathogenesis of Pyelonephritic scaring
Intrarenal reflux of Bacteria
Bacterial Endotoxin
Chemotaxis(Garanulocyte)
Phogocytosis of Bacteria
Superoxide Release
Tubular Cell Death
Interristitial Inflammation
Microabscess
Renal Scar
Bacterial Killing
Lysosome release
Granulocyte aggregation
Capillary obstruction
Renal Ischemia
Reperfusion

20. SPREAD OF INFECTION:
A) Ascending Infection
 Most common route.
 Organisms ascend through urethra into bladder.
organism
Colonize in perineal
and periurethral areas
UTI
Ascend to bladder,
kidneys

21. B) Haematogenous:
Occurs in:
 Neonates
 Sepsis
 Severely ill children with
multiorgan disease.

24. CLINICAL PRESENTATION:
Depends on-
 Age
 Site and
 Severity of infection

25. Clinical Presentation According to Age:
Age Most Common Features Least Common
Infants
younger
than 3
months
Infants and
children, 3
months
or older
Fever/Hypothermia
Vomiting
Lethargy/Irritability
Unexplained fever
Frequency
Dysuria
Voiding dysfunc.
-incontinence
-Poor stream
-Straining
Poor feeding
FTT
Abdominal
Pain
Loin
tenderness
Vomiting
Poor feeding
Persistence of
Physiological
Jaundice
Seizure, Shock
Lethargy
Irritability
Hematuria
Offensive Urine
FTT

27. Clinical manifestations depending on
site of infection:
Pyelonephritis:
 Fever with chills and rigor
 Nausea and vomiting
 Malaise, irritability
 Back or flank pain
 Diarrhoea

28. Cystitis:
 Dysuria
 Urgency
 Frequency
 Suprapubic pain
 Incontinence
 Malodourous urine

29. Urethritis:
 Discomfort in voiding
 Dysuria
 Urgency
 frequency

30. Asymptomatic Bacteriuria:
 Positive urine culture without any
symptom or sign
 Most common in Girls
 Benign and does not cause renal injury
 Pathogens of low virulence (E.coli) does
not invade in urinary tract
 No treatment required
 80% chance of recurrence

31. Recurrent UTI:
• ≥ 2 episodes of UTI with acute Pyelonephritis /
upper UTI or
• 1 episode of acute pyelonephritis/ upper UTI + ≥ 1
episode of UTI with cystitis/lower UTI or
• ≥ 3 or more UTI with cystitis/lower tract UTI

32.  Girls
 Obstructive Uropathy
 Severe VUR (G-III-IV)
 Constipation
 Neurogenic bladder
 Structural abnormality
e.g.-Phimosis, PUV,
Meatal Stenosis,
Labial adhesion etc.
 Thread worm
infestation
 Uncircumcised boys.
Risk Factors for Recurrent UTI:

33. Investigation

34. Urine microscopy:
• Sample should be fresh
• If delayed, stored at 40C not
more that 24 hrs.
To be looked for
 Protein
 Sugar
 Microscopy: Pus cells, RBC, Cast & Bacteria.
 Pus Cells
o > 10/HPF significant in uncentrifuged urine
o > 5/HPF significant in centrifuged urine

35. Dip Stick Tests: Based on
• Nitrite reduction which can be detected as
color change and
• Detection of leukocytic esterase

36. Work up: NICE Guideline
Leukocyte
Esterase (+)
Leukocyte
Esterase (-)
Nitrite (+) Send Urine C/S
Treat as UTI, start
antibiotic
Send Urine C/S
Start antibiotic
Nitrite (-) Send Urine R/E, C/S
Start antibiotic if
good evidence of
UTI is present
Not UTI

37. Urine Culture & Sensitivity:
Methods of urine collection:
 Clean catch midstream urine
 Suprapubic aspiration
 Urethral catheterization
 Bag specimen collection

38. Interpretation of Urine Culture:
Method of
Collection
Colony Count/Ml Probability
infection
Suprapubic
aspiration
Any number 99%
Midstream clean
catch Urine
>105
104-105
103-104
103 or Less
90-95%
Very likely
Suspicious
Unlikely
Urethral
Catheterization
> 105
103-105
103-Less
95%
Very likely
Unlikely

39. To Find out present Status:
 Blood Count
 C-reactive protein
 Blood Urea & Serum Creatinine
 Blood Culture in Infant

40. To see structural & Functional Abnormality
In Urinary Tract & Kidney:
 USG of Kidney, Bladder & Ureters
 DMSA to see renal scar
 MCUG to see VUR, Bladder & Urethra
 DTPA
 MAG-3 see function of kidney
 DRCG to see VUR & for Follow up

41. Ultrasound Examination
Normal Abnormal
< 2 years
MCU and
DMSA scan
2-5 years
DMSA scan
MCU if:
Scar on DMSA scan
DMSA scan not available
> 5 years
No further
evaluation
MCU and
DMSA scan
Imaging Studies In First Proven UTI

42. MANAGEMENT

43. Goals of treatment:
 Elimination of infection
 Relief of acute symptoms
 Prevention of recurrence and long term
complications

44. Indication of Hospitalization:
 < 2 months
 Clinical Urosepsis
 Vomiting unable to oral medication
 Immunocompromised child
 Complications

45. General Measure:
 Increased Fluid Intake
 Acetaminophen & NSAID
 Treatment of constipation
 Treatment of thread worm infestation
 Proper Nutrition
 Frequent Voiding
 Double Voiding habit

46. Specific Measure:
Infants < 12 wks with febrile UTI
Inj Ceftriaxone
or
Dose 50-75 mg/kg/day
i/m/ i/v single or bid
Inj Cefotaxime
or
Dose 150 mg/kg/day
i/v/i/m divided 8 hrly
Inj Ampicillin +
Inj Gentamicin
100 mg/kg/ day
I/V/ I/M divided 12 hrly
For Neonate
For 10-14 days

47. Infant & Children 3 months to 3 yrs
IF C/F suggestive, start Antibiotic therapy, send
urine analysis & for culture then treat accordingly.

48. Antibiotic Agents for Oral Therapy
Drugs Dose (mg/kg/day)
Amoxicillin +
Clavulanic Acid
30-50 in 3 div
Cotrimoxazole 6-8 in 2 div dose
Cefaclor 40 in 3 div dose
Cephalexin 50-70 in 3 div
Cefixime 8 mg/Kg/dose 2 div
Nalidixic Acid 50 in 3 divided doses
Norfloxacin 10-12 in 2 div
Ciprofloxacin 10-20 in 2 div

49. Antibiotic Agents for Parenteral Therapy
Drugs Dose (mg/kg/day)
Gentamicin 5-6 in 1-2 divided dose
Amikacin 15-20 in 2 divided dose
Cefotaxime 100-150 in 2-3 divided dose
Ceftriaxone 75-100 in 1-2 divided dose

50. Treament of Complicated UTI
Hospitalization
Parenteral Fluid (1-1.5 Times the usual maintenance)
Injectable third generation Cephalosporin
Ceftriaxone or Cefotaxime
+
 Ampicillin if gm +ve cocci in urinary sediment
Or
Gentamicin, alternative agent for children sensitive
to cephalosporin
Then change according to sensitivity continue
I/V antibiotic till afebrile for 24-36 hrs, then oral
antibiotic

51. TREATMENT OF UNDERLYING CAUSE
VUR
PUV
Other anatomical abnormality
Surgical intervention

52. Prevention of Reinfection/prophylaxis
Cotrimoxazole 1-2 mg/kg/day trimethoprin
Nitrofurantoin 1-2 mg/kg/day
Cephalexin 10-12 mg/kg/day
Cefixime 2mg/kg/day
All are in single dose

53. Indication of Prophylaxis of UTI
Following treatment of
First UTI in all children < 2 years
Complicated UTI in Children < 5 yrs while
awaiting imaging studies.
Children with VUR
Patients showing renal scar after UTI may be
stopped after 6 months if scan report normal
Children with frequent febrile UTI (3 or
more episodes in a yr even if urinary tract is
normal)

54. Break through UTI
UTI during prophylaxis due to poor compliance
and bacterial resistance.
Treatment-
Change of the drug

55. FOLLOW-UP
Till VCUG obtained Some Clinicians
discontinue antibiotic 1-2 days after
VCUG if no VUR
Roughly ½ of Upper UTI develop VUR &
½ have no radiographically identificable
Reflux
Reinfection common in first 6 months
after initial infection

56. For VUR 6 monthly BP, HT, WT, S Creatinine
1 yearly USG of Kidney & Urinary tract
12-18 monthly DRCG/MCU

57. Complications:
Allergic Reaction to antibiotics
Pyelonephritis may cause lobar inflammation of
kidney or renal abscess.
Renal scar
Hypertension
Impaired renal function
ESRD

58. Prevention of UTI
Avoid constipation
Wiping from front to Back direction after voiding
/ defaecation
Avoid irritating soaps & bubble bath
Maintain personal hygiene
Emptying of bladder properly-
2-3 hrly emptying
double voiding

59. Drink enough fluid during day time &
empty bladder properly before sleep at night
correct under wear
Advice for completion of antibiotic course
Avoid unnecessary antibiotic for minor illness
Circumcision

60. Prognosis
Most child with UTI have an excellent prognosis.
The risk of complications in a small groups specially in
those with hypo plastic or dysplastic congenital anomalies
and dilated VUR.
The process of scaring after APN is slow it takes 1-2 year
for a scar to develop fully.
In children with bilateral renal damage GFR is often
decreased and the risk of progressive deterioration is greater.

61. Paediatric Urinary Tract Infection: A Hospital Based
Experience
Khursheed Ahmed Wani1 , Mohd Ashraf2 , Javaid Ahmed Bhat3 ,
Nazir Ahmed Parry4 , Lubna Shaheen5 , Sartaj Ali Bhat6
Paediatric UTI at times remains a diagnostic dilemma,
and a miss in diagnosis can prove a future catastrophe for
an affected child. A prevalence of 13.2% of paediatric UTI
among the hospital visiting children favors to have a
heightened awareness among the treating pediatricians
and general public about this otherwise easily
manageable entity.