This document discusses urinary tract infections (UTIs) in children. It covers the classification of UTIs as uncomplicated or complicated, the symptoms and diagnosis of cystitis and pyelonephritis. Treatment involves antibiotics, with ceftriaxone, cefotaxime and amoxicillin being recommended options. For pyelonephritis specifically, the document outlines the acute vs chronic forms and how they are diagnosed based on symptoms, lab tests and imaging. Differential diagnosis with other conditions like acute appendicitis is also addressed.

1. ASTANA MEDICAL UNIVERSITY
KAZAKHSTAN (NJSC)
SPECIALTY: GENERALMEDICINE
SUBJECT: Fundamentalsof childhooddiseases
CHECKEDBY- Lyazzat Yerzhanovna
PreparedBy : MANDEEPSINGH
COURSE : 4RD year
Group : 478
SESSION– 2022-2023
IWS

3.  Urinary tract infection
 CLASSIFICATION
 DIAGNOSIS
 Differential Diagnosis
 Instrumental Research
 TREATMENT
 Pyelonephritis
 CLASSIFICATION
 DIAGNOSIS
 Differential Diagnosis
 TREATMENT
 MEDICAL TREATMENT
 Cystitis
 CLASSIFICATION
 DIAGNOSIS
 TREATMENT
 REFERENCE

4.  The term urinary tract infection (UTI) encompasses a group of diseases characterized by the
growth of bacteria in the urinary tract.
 Urinary tract infections (UTIs) in children are fairly common, but not usually serious. They can
be effectively treated with antibiotics. A UTI may be classed as either: an upper UTI – if it's a
kidney infection or an infection of the ureters, the tubes connecting the kidneys to the bladder.
 Etiology - With uncomplicated UTI - E. Coli; in complicated UTIs, Proteus, Pseudomonas,
Klebsiella, fungi are more common.
 The source of uropathogenic microorganisms is the intestine, anal region, vestibule of the
vagina and periurethral region. Inflammation most often develops in conditions of disturbed
outflow of urine in combination with a decrease in the overall reactivity of the body.


5. Types of ICs Criteria
Significant bacteriuria Presence of one species of bacteria >105/mL in an average portion of a clean urine sample
Asymptomatic bacteriuria Significant bacteriuria in the absence of UTI symptoms
Return IC
2 or more episodes of UTI with acute pyelonephritis
1 episode of UTI with acute pyelonephritis+1 or more episodes of uncomplicated UTI
3 or more episodes of uncomplicated UTI
Complicated UTI (acute pyelonephritis) Presence of fever >39°C, symptoms of intoxication, persistent vomiting, dehydration, renal
hypersensitivity, elevated creatinine
Uncomplicated UTI (cystitis) UTI with mild fever, dysuria, frequent urination, and no symptoms of complicated UTI
Atypical UTI (urosepsis)
Severe condition, fever, weak urine stream, abdominal and bladder swelling, creatinine
elevation, septicemia, poor response to standard antibiotics after 48 hours, non-E. coli
infection
There are infections of the upper (pyelonephritis) and lower urinary tract (cystitis, prostatitis, urethritis)

6.  Complaints:
 • increase in body temperature;
 • weakness, lethargy, lack of appetite;
 • pain, straining when urinating, imperative urges;
 • frequent urination in small portions, urinary incontinence;
 • pain in the lumbar region, abdomen;
 • discoloration of urine.

Anamnesis:
 • rises in temperature of unclear etiology;
 • pain in the abdomen without a clear localization with / without nausea, vomiting;
 • history of episodes of urinary infection;
 • constipation;
 • vulvitis, vulvovaginitis in girls;
 • phimosis, balanoposthitis in boys.

7.  Physical examination:
 • symptoms of intoxication of varying severity;
 • urinary symptoms: frequent urination, cloudy urine with an unpleasant odor,
urinary incontinence • anomalies of an urination and a tone of a rectum;
 • anomalies of the spine;
 • phimosis, synechia;
 • palpation of the bladder and abdominal cavity: faeces, palpable kidneys
Laboratory studies of
KLA: increased ESR, leukocytosis, neutrophilia;
Biochemical blood test: increased CRP, hyponatremia, hypokalemia, hypochloremia,
possibly increased creatinine, urea in the development of CKD;
TAM : >5 leukocytes in a centrifuged urine sample and 10 leukocytes in unspun
urine
Bacteriological examination of urine is the gold standard in the diagnosis of
UTIs culture isolation of E. coli and Gram "-" microorganisms,

8. sign Uncomplicated UTI Complicated UTI
Hyperthermia ≤39°C >39°C
Symptoms of intoxication Minor Expressed
Vomiting, dehydration - +
Pain in the abdomen (lower
back)
- Often
Dysuric phenomena ++ +
Leukocyturia, bacteriuria + +

9.  Ultrasound of the kidneys - an increase in the size of the
kidneys, asymmetry in the size of the kidneys (a decrease in the
size of one or two kidneys), an expansion of the excretory system
of the kidneys, a decrease in the renal parenchyma. If
ultrasound of the urinary system does not reveal anomalies,
then other imaging methods of examination should not be
performed.
Voiding cystography - the presence of vesicoureteral reflux on
one or both sides;
Nephroscintigraphy with DMSA - a decrease in renal function of
one kidney.

10.  Non-drug treatment:
 • balanced diet, adequate intake of protein (1.5-2g/kg), calories;
 • drinking mode (plentiful drink).
 Drug therapy
Antibacterial therapy
 Principles of antibiotic therapy according to NICE
 • children ≤3 months of age: intravenous antibiotics for 2-3 days, then switching to
oral administration if clinically improved;
 • children >3 months of age with upper UTIs (acute pyelonephritis): intravenous
antibiotics for 2-4 days if vomiting occurs, then oral antibiotics, total course of 10 days;
 • children >3 months of age with lower UTIs (acute cystitis): oral antibiotics for 3 days;
 • in case of a repeated episode of UTI against the background of antibiotic prophylaxis,
it is necessary to prescribe an antibacterial drug, instead of increasing the dose of the
prophylactic drug;
 • Antibiotic prophylaxis is not recommended unless UTI recurs.
 Antibacterial drugs used in the treatment of UTIs are listed in

11.  Detoxification therapy
Indications: complicated UTI, atypical UTI. The total volume of infusions is 60 ml / kg / day at a rate of 5-8 ml / kg /
hour (sodium chloride solution 0.9% / dextrose solution 5%).
Renal protective therapy (for CKD stage 2-4):
• fosinopril 5-10 mg/day.
Antibiotics Dosage (mg/kg/day)
parenteral
Ceftriaxone 75–100, in 1–2 intravenous injections
Cefotaxime 100-150, in 2-3 intravenous injections
Amikacin 10–15, once intravenously or intramuscularly [18]
Gentamicin 5-6, single intravenous or intramuscular
Amoxicillin + clavulanic acid amoxicillin + clavulanate) 50-80 for amoxicillin, 2 injections intravenously
Oral
Cefixime 8, in 2 doses (or once a day)
Amoxicillin + Clavulanic acid (Co-amoxiclav) 30-35 on amoxicillin, in 2 divided doses
Ciprofloxacin 10-20, 2 receptions
Ofloxacin 15-20, in 2 divided doses
Cefalexin 50-70, in 2-3 doses

12.  Pyelonephritis is a non-specific bacterial inflammation of the renal
parenchyma and the collecting system of the kidneys, manifested
by a picture of an infectious disease, especially in young children,
characterized by leukocyturia and bacteriuria, as well as a violation
of the functional state of the kidneys.
 According to the classification of the World Health Organization
(WHO), pyelonephritis belongs to the group of tubulointerstitial
nephritis and is actually tubulointerstitial nephritis of infectious
genesis

13.  In pediatric practice, there are 2 main forms of pyelonephritis in children:
 1) primary pyelonephritis;
 2) secondary pyelonephritis.
 In primary pyelonephritis, the microbial-inflammatory process initially develops in the kidneys.
Secondary pyelonephritis is caused by other factors.
 In turn, secondary pyelonephritis in children can be dysmetabolic (non-obstructive) and obstructive.
 Depending on the characteristics and prescription of the manifestations of the pathological process,
chronic and acute pyelonephritis in children are distinguished.
 In acute pyelonephritis in children, there are:
 1) active period;
 2) the period of reverse development;
 3) complete clinical and laboratory remission.
 pyelonephritic process has two stages-sclerotic and infiltrative.
 A sign of chronic pyelonephritis in children is the persistence of symptoms of a urinary tract infection for
more than 6 months or the occurrence of at least 2 exacerbations over a given period oftime.
 The nature of the course of chronic pyelonephritis in children is:
 1) latent (only with a urinary symptom):
 2) recurrent (periods of exacerbations and remissions).

14.  Complaints and anamnesis:
- chills, fever 38°C;
- general weakness, malaise, refusal to eat
- there may be pain in the lumbar region
- symptoms of dysuria, swelling may appear.
 Physical examination:
- subfebrile or normal body temperature
- positive Pasternatsky's syndrome on palpation
Laboratory studies
- increased ESR 20 mm/hour;
- increase in CRP 10-20 mg/l;
- increased PCT in serum 2 ng/ml.
Instrumental studies
- Ultrasound of the kidneys: congenital malformations, cysts, stones
- Cystography - vesicoureteral reflux or condition after antireflux surgery
- Nephroscintigraphy - lesions of the kidney parenchyma
- In tubulointerstitial nephritis - diagnostic puncture biopsy of the kidney (with parental consent)
Indications for specialist consultation :
Consultation of a urologist, pediatric gynecologist
According to the testimony of an andrologist, oculist, otolaryngologist, phthisiatrician, clinical
immunologist, dentist, neurologist

15. DIAGNOSIS or cause of disease In favor of the diagnosis
Acute glomerulonephritis
Glomerulonephritis almost always develops against a
background of already normal body temperature and is rarely
accompanied by dysuric disorders. Edema or pastosity of
tissues, arterial hypertension, observed in most patients with
glomerulonephritis, are also not characteristic of
pyelonephritis. Oliguria of the initial period of
glomerulonephritis contrasts with polyuria, often detected in
the early days of acute pyelonephritis.
Acute appendicitis
per rectum examination, which reveals a painful infiltrate in
the right iliac region, and repeated urinalysis
Renal amyloidosis
in the initial stage, manifested only by slight proteinuria and
very poor urinary sediment, can simulate a latent form of
chronic pyelonephritis. However, unlike pyelonephritis,
leukocyturia is absent in amyloidosis, active leukocytes and
bacteriuria are not detected

16.  Non-drug treatment
 - Mode: bed for the entire period of fever, then general.
 - Diet number 7:
 - by age, balanced on the main nutrients, without protein restrictions;
 - restriction of extractives, spices, marinades, smoked meats, products with a sharp
taste (garlic, onion, cilantro) and products containing excess sodium;
 - plentiful drinking (50% more than the age norm) with alternating weakly alkaline
mineral waters.
 - Compliance with the regime of "regular" urination (after 2-3 hours - depending on
age);
 - Daily hygiene measures (shower, bath, rubbing, thorough toilet of the external
genitalia);

17.  - Symptomatic therapy: antipyretic, detoxification, infusion - usually
carried out in the first 1-3 days;
- Antibacterial therapy in 3 stages:
- Stage 1 - antibiotic therapy - 10-14 days;
Empirical (starting) choice of antibiotics:
- "Protected" penicillins: amoxicillin / clavulanate, amoxicillin /
sulbactam;
- III generation cephalosporins: cefotaxime, ceftazidime,
ceftriaxone, cefixime, ceftibuten.
Severe flow:
- Aminoglycosides: netromycin, amikacin, gentamicin;
- Carbapenems: imipenem, meropenem;
- IV generation cephalosporins (cefepime).
Duration of antibiotic therapy:
- Severe course (fever ≥39 °, dehydration, repeated vomiting):
intravenous antibiotics until the temperature normalizes (average 2-3
days) followed by a transition to oral administration (step therapy) up to
10-14 days;
- Mild course (moderate fever, no severe dehydration, adequate fluid
intake): oral antibiotics for at least 10 days. Perhaps a single intravenous
administration in case of doubtful compliance.
(Protected penicillins) Amoxicillin/clavulanate 40-60 mg/kg/24 h (as amoxicillin) in 2-3 doses inside and in / in
Cefotaxime 3rd generation cephalosporins Children under 3 months - 50 mg / kg / 8 hours Children
over 3 months - 50-100 mg / kg / 24 hours
2-3 times a day; in / in, in / m
Cefipim IV generation cephalosporins
Children >2 months - 50 mg/kg/24 hours 3 times a day; i/v
Gentamicin Aminoglycosides Children under 3 months - 2.5 mg / kg / 8 hours Children
over 3 months - 3-5 mg / kg / 24 hours
1-2 times a day; in / in, in / m
Imipenem (Carbapenems)
Children under 3 months - 25 mg / kg / 8 hours Children
over 3 months with body weight:
<40 kg - 15-25 mg / kg / 6 hours
> 40 kg - 0.5-1.0 g / 6-8 hours, no more than 2.0 g/24 h
3-4 times a day; i/v

18.  Stage 2 - uroseptic therapy (14-28 days).
1. Derivatives of 5-nitrofuran:
 - Furagin - 7.5-8 mg / kg (no more than 400 mg / 24 hours) in 3-4 doses;

2. Non-fluorinated quinolones:
 - Negram, nevigramon (in children older than 3 months) - 55 mg / kg / 24 hours in 3-4 doses;
 - Palin (in children older than 12 months) - 15 mg / kg / 24 hours in 2 divided doses.

Stage 3 - preventive anti-relapse therapy.
Indications for long-term antimicrobial prophylaxis of UTIs in children:
 - ≥3 UTI recurrences within a year
 - VMR, OMS anomalies, severe neurogenic bladder dysfunction;
 Young children who have had an episode of pyelonephritis:
 - in the presence of scars in the kidneys according to DMSA, ICD, dysuric phenomena and all girls with a history of UTI.
- 6 months - if the interval between relapses is from 3 weeks to 3 months;
 - 12 months - if the interval between relapses is less than 3 weeks;
Other treatments
 - Cranberry: the use of cranberry extract or juice reduces the adhesive properties of uropathogenic E.coli strains and reduces the number

19.  Cystitis, an inflammation of the
bladder, is the most common urinary
tract infection. In girls, cystitis is
more common than in boys (this is
due physiologically - girls have a
shorter urethra, it is easier for
bacteria to enter the bladder).
 It is very painful, the child does not
feel well, moreover, without
treatment, cystitis can lead to
complications - a kidney infection.

20.  1. According to the course of the disease, acute and chronic cystitis are
distinguished.
 2. By origin, primary and secondary are distinguished: with pyelonephritis, with
diseases of the bladder, prostate, urethra.
 3. According to etiology and pathogenesis, infectious, chemical, radiation, parasitic,
in diabetes mellitus, in spinal patients, allergic, metabolic, iatrogenic, cystitis after
adenomectomy, neurogenic are distinguished.
 4. According to the localization and prevalence of the inflammatory process: diffuse,
cervical, trigonitis.
 5. By the nature of morphological changes: catarrhal, hemorrhagic, ulcerative and
fibro-ulcerative, gangrenous, encrusting, tumor, interstitial.

21. •Constant (often false) urge to urinate
•Pain and burning
•The presence of blood in the urine
•Cloudy urine, strong odor
•The temperature may rise up to 38 degrees
•Urinary incontinence (common with cystitis in
young children).

22.  In most cases, the diagnosis of cystitis is not difficult. Since acute cystitis and
chronic cystitis in the acute stage are accompanied by characteristic complaints of
frequent painful urination with pain, anamnestic data on a sudden acute onset
and rapid increase in symptoms with their maximum severity in the first days
(with acute cystitis) or pre-existing cystitis are important ( with chronic cystitis).
 Urinalysis reveals objective signs of cystitis in the form of leukocyturia and
hematuria . Deep palpation of the suprapubic region is painful. With
inflammation of the lower wall of the bladder and with severe local inflammation
of its neck, palpation from the side of the rectum and from the side of the vagina is
also sharply painful.
 In the diagnosis of chronic cystitis and the identification of the causes that
support inflammation, cystoscopy and cystography are of paramount importance

23.  In the diagnosis of chronic cystitis and the identification of the causes that support
inflammation, cystoscopy and cystography are of paramount importance .At the same
time, the degree of damage to the bladder, the form of cystitis, the presence of a tumor,
urinary stone, foreign body, diverticulum, fistula, ulcers are determined. In some
cases, during cystoscopy, signs of kidney and ureter disease accompanying cystitis are
found. Cystoscopy can be performed under the condition of satisfactory patency of the
urethra, sufficient capacity of the bladder - at least 50 ml and transparency of the
medium in it. To study the configuration of the bladder and identify pathological
processes in it, contrast cystography is used by introducing iodine-containing drugs
into it, a suspension of barium sulfate, oxygen or carbon dioxide.
 The most physiological is descending cystography, which is obtained 20-30 minutes
after intravenous administration of a radiopaque preparation.
 A biopsy of the mucous membrane of the bladder, as a rule, is performed in patients
with chronic cystitis, as well as for the purpose of differential diagnosis.

24.  Treatment of cystitis is most often carried out at home. The mucous membrane of the
bladder quickly recovers and the disease disappears without a trace.
 Antibiotics (monural or fluoroquinolones) must be prescribed. All patients with cystitis
are advised to stay in bed until the pain disappears completely.
 The diet is prescribed with the exception of spicy, sour, fatty and fried foods, strong
coffee and alcoholic beverages.
 The need to follow a diet for cystitis is explained by the fact that any aggressive food
irritates the mucous membrane of the bladder, provoking an exacerbation of the
disease. Patients are recommended dairy food, fruits and vegetables.
 The treatment of chronic cystitis includes not only the treatment of inflammation of
the bladder itself (similar to the treatment of acute cystitis), but also a set of measures
aimed at eliminating the underlying disease.
 The patient's regimen and his diet during an exacerbation of chronic cystitis are the
same as in acute cystitis. In modern conditions, iontophoresis, UHF, inductothermy
and other physiotherapeutic procedures are used to treat cystitis

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