UTI IN PEDIATRICS, RENAL TRACT INFECTION

1. UTI INCHILDREN
Dr. Virendra Kumar Gupta
MD Pediatrics
Asst. Prof.,Department Of Pediatrics
Nims University Jaipur

2. DEFINITION:
 Infection of the urinary tract-
Significant number of organisms
Presence of symptoms
inflammation of urinary tract
 Recurrent UTI-
Recurrence of symptoms
Significant bacteriuria
Patients who have recovered clinically
following treatment
Common in girls.

3. EPIDEMIOLOGY
 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.  Rapid evaluation and treatment of UTI is important
to prevent renal parenchymal damage and renal
scarring that can cause hypertension and
progressive renal damage.

5. • Significant bacteriuria:
Presence of at least 105
bacteria/ml of urine.
• Asymptomatic bacteriuria :
Bacteriuria with no symptoms.
• Urethritis:
infection of anterior urethral tract *dysuria, urgency and
frequency of urination.
• Cystitis:
infection to urinary bladder *dysuria, frequency and
urgency, pyuria and haematuria.

6. • Acute pyelonephritis:
infection of one/both kidneys;
sometimes lower tract also.
*pyuria, fever, painful micturition
• Chronic pyelonephritis:
particular type of pathology of kidney;
may/may not be due to infection.

7. UTI - TERMINOLOGY
• Uncomplicated: UTI without underlying renal or
neurologic disease.
• Complicated: UTI with underlying structural,
medical or neurologic disease.
• Recurrent : > 3 symptomatic UTIs within 12
months following clinical therapy.
• Reinfection: recurrent UTI caused by a different
pathogen at any time
• Relapse: recurrent UTI caused by same species
causing original UTI within 2 wks after therapy.

8. CAUSE AND COURSE :
G u t f l o r a B a c t e r i a l v i r u l e n c e
U r o p a t h o g e n i c s t r a i n
C o l o n i s a t i o n o f t h e u r e t h r a a n d t h e
p e r i n e u m
( i n f e m a l e s t h e v a g i n a )
M u c o s a b a r r i e r e
H o s t
I n c r e a s e d a d h e r e n c e
i m m u n s t a t u s
V U R
o b s t r u c t i o n
f o r e i g n b o d y
p r e v i o u s i n f l a m m a t i o n s
c y s t i t i s
a k u t e p y e l o n e p h r i t i s
h e a l e d u r o s e p s i s s c a r
h y p e r t e n s i o n
C R F . . .

9. ETIOLOGY:
Most common infecting pathogen :
Escherichia Coli 80% of UTI.
Other pathogens: -
Staphylococcus & Streptococcus Species
Enterobacteria ( Klebsiella, Proteus, pseudomonas)
Occasionally Candida albicans

10. RISK FACTORS FOR URINARY
TRACT INFECTION:
 Female gender
 Uncircumcised male
 Vesicoureteral reflux
 Toilet training
 Voiding dysfunction
 Obstructive uropathy
 Urethral instrumentation
 Wiping from back to front in females
 Bubble bath?
 Tight clothing
 Pinworm infestation
 Constipation
 Bacteria with P fimbriae
 Anatomic abnormality (labial adhesion)
 Neuropathic bladder
 Sexual activity
 Pregnancy

11. CLINICAL MANIFESTATIONS:
 The 3 Basic forms of UTI
1. Pyelonephritis
2. Cystitis
3. Asymptomatic bacteriuria

12. PYELONEPHRITIS
 Characterized by any or all of the following:
abdominal or flank pain
fever
malaise
nausea
vomiting
occasionally diarrhea.
 In newborns show nonspecific symptoms:
poor feeding, irritability, and weight loss.

13.  Acute lobar nephronia (acute lobar nephritis):
localized renal bacterial infection involving >1 lobe
 Renal abscess :
following a pyelonephritis or
may be secondary to a primary bacteremia
 Perinephric abscesses:
may be secondary to contiguous infection in
the perirenal area

14. CYSTITIS
 Bladder involvement.
 Symptoms include
dysuria
urgency
frequency
suprapubic pain
incontinence
malodorous urine.
 Cystitis does not cause fever and does not result
in renal injury.

15. ASYMPTOMATIC BACTERIURIA
 Positive urine culture without any 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. DIAGNOSIS:
 While urinalysis enables a provisional diagnosis
of UTI, a specimen must be obtained for culture
prior to therapy with antibiotics
 Based on positive culture of a properly collected
specimen of urine.

17.  Significant pyuria
defined as
>10 WBC/mm3 in uncentrifuged sample,or
>5 WBC/ mm3 in a centrifuged sample.
 Rapid dipstick based tests
detect leukocyte esterase and nitrite useful
in screening for UTI.
 A combination of these tests has moderate
sensitivity and specificity for detecting UTI, and is
diagnostically as useful as microscopy

18. COLLECTION OF SPECIMEN FOR
CULTURE
 Clean-catch midstream Sample
used to minimize contamination
washing the genitalia with soap and water
forced retraction of the prepuce are not advised
Suprapubic aspiration And/or
Transurethral catheterization
In neonates and infants, urine sample is obtained
by either above
Both techniques are safe and easy to perform.

19.  The urine specimen should be promptly plated within
one hour of collection.
 If delay is anticipated, the sample can be stored in a
refrigerator at 4ºC for up to 12-24 hours
 Cultures of specimens collected from urine bags have
high false positive rates, and are not recommended.

20.  A urine culture repeat in case contamination is
suspected:
mixed growth of two or more pathogens, or
growth of organisms that normally constitute the
periurethral flora (lacto-bacilli in healthy girls;
enterococci in infants and toddlers)
strongly suspected but colony counts are
equivocal

22.  With acute renal infection
leukocytosis, neutrophilia, and
elevated ESR and CRP are common.
 With a renal abscess
the white blood cell count is markedly elevated to
>20,000–25,000/mm3.
Because sepsis is common in pyelonephritis,
particularly in infants and in any child with obstructive
uropathy, blood cultures should be considered.

23. 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.

24. Hospitalized and treated with parenteral antibiotics
Choice of antibiotic- local sensitivity patterns
A third generation cephalosporin is preferred.
Aminoglycoside -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.
Children less than 3 months of age and
Those with complicated UTI

25. Are treated with oral antibiotics
With adequate therapy, there is resolution of fever
and reduction of symptoms by 48-72 hours
Failure to respond may be due to presence of
resistant pathogens, complicating factors or
noncompliance; these patients require re-evaluation.
Children with simple UTI and
Those above 3 months of age

26.  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.

27. IMAGING STUDY IN FEBRILE 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/VCUG) performed
 USG 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 / VCUG detects VUR and provides anatomical
details regarding the bladder and the urethra.

29.  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.

30. 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.

31. 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 .

32.  Antibiotic prophylaxis is recommended for patients
with
UTI below 1-yr of age, while awaiting imaging studies
VUR
Frequent febrile UTI (3 or more episodes in a year) even
if the urinary tract is normal.

33. 1- VUR (it might be a complication of UTI, or primary causing UTI.
2- Scarring. Might lead to HTN, if multiple it might lead to renal
insufficiency.
3- HTN
4- Renal insufficiency.
Normal DMSA Acute Pyelonephritis
Scarring
VUR
Acute: no
irregular
borders and no
scarring and no
change in size
In chronic: irregular
borders and
scarring.

34. 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.

35.  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

36. VUR GRADES

38. 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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