Urinary tract infections (UTIs) are common, especially in females and young children. UTIs are caused by bacterial invasion of the urinary tract and result in inflammation. Common symptoms include fever, urinary urgency, and abdominal pain. UTIs are usually treated with antibiotics like trimethoprim-sulfamethoxazole or fluoroquinolones. Severe or recurrent UTIs may require imaging and long-term preventative management to address risk factors and complications like renal scarring.

1. URINARY TRACT INFECTIONs
By MURAGIJEYEZU Emmanuel
Intern student
Pediatric rotation- KDH

2. CASE.
• A y.o female G5P5005

3. DEFINITION
• UTI is an inflammatory response of the
urothelium to bacterial invasion that is usually
associated with concomitant symptoms :
fever ,
bacteriuria
pyuria .
Campbell walsh urology vol4 11ed

4. UTI affects people of all age men and women but :
children.
Common in girls than in boys in 1 year of life in
5.4:2.8 ratio .
Up to 20% of pregnancies are complicated by UTI
and around 10% during antepartum
hospitalizations.
Blueprint G/O (2013) 6ED.
Nelson textbook ped. 2015 20 ed

5. Predisposing factors in female
• Poor anal hygiene
• Sexual intercourse and negligency of post-
coital bladder voiding.
• Use of antiseptics for vaginal hygiene
• Spermicide use for contraception purpose
• Estrogen deficiency in post-menopause
women.
• STDs
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6. Patients risk factors: urological abnormalities
• Obstructive uropathies ( vesicourethra reflux )
• Urolithiasis
• High bladder urine residue after micturition
• Immunosuppression morbidities such as
diabetes mellitus, HIV, …
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7. Pediatric
• Poor anal hygiene .
• Uncircumcised boy
• undiagnosed febrile illnesses or previous Hx.
• Family history of frequent UTI, VUR, and other
genitourinary abnormalities
• Antenatal diagnosed renal abnormality
• Sexual active girls.
https://www.uptodate.com/contents/urinary-tract-infections-in-infants-and-
children-older-than-one-month-clinical-features-and-diagnosis

8. • Ascending infections from the fecal flora, colonize the
perineum, and enter the bladder via the urethra.
•
In uncircumcised boys, the bacterial pathogens arise
from the flora
beneath the prepuce.
• In some cases, the bacteria causing cystitis ascend
to the kidney to cause pyelonephritis. Rarely, renal
infection occurs by hematogenous spread, as in
endocarditis or in some neonates.

9. Why female ???
 Shorter urethra ,
 Continuous contamination of the external one-third of the
urethra by pathogenic bacteria from the vagina and
rectum,
 Failure of women to empty their bladders as completely as
men, and
 Movement of bacteria into the female bladder during
sexual intercourse.
Blueprint O/G 2013 6ed.

10. WHY UTI and PREGNANCY ???
• Decreased smooth muscle tone ( effect of
progesterone )
 decrease bladder tone ,
 ureteral and renal pelvis dilation, as well
 decreased ureteral peristalsis, resulting in physiologic
hydronephrosis of pregnancy.
• Obstructed ureters by mechanical compression by
enlarged uterus , leading to stasis.

11. CLASSIFICATION
LOCATION
• UPPER UTI : (renal
parenchyma ).
 PYELONEPHRITIS
• LOWER UTI : ( URETHRA ,
BLADDER )
 URETHRATIS
 CYSTITIS
SEVERITY
• Complicated
• Uncomplicated

12. • Uncomplicated:
Generally considered in otherwise healthy
nonpregnant female patient and
Urinary Tract abnormalities boys .
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13. Complicated:
Pregnancy
Past History of UTI
Broad-spectrum antimicrobial resistant uropathogen
Hospital acquired infection
Renal failure
Urinary tract obstruction
Anatomic abnormality of the urinary tract
Renal transplantation
Immunosuppression( DM , HIV ,….)

14. Pathogenic causes
• Mostly by facultative anaerobes usually originating
from the bowel flora along the tract .
• E. coli accounting for 85% of community-acquired
and 50% of hospital acquired infections.
• A research study of 269 participant was done at KFH
in a period of 6 month : Ashok R., KFH

15. Organisms isolated from March - August 2009 in urine
specimen: Total no of organism= 269 (Ashok R., KFH)
ORGANISM URINE
ACIENTOBACTER 7 2.6
CITROBACTER 6 2.2
E.COLI 180 66.9
ENTEROBACTER 11 4.1
KLEBSIELLA 35 13.0
PROTEUS 25 9.3
PSEUDOMONAS 2 0.7
S.AUREUS 1 0.4
SERRATIA 2 0.7
TOTAL 269 100.0
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16. UTI Result from interactions between :
the uropathogens and the host defence mechanism .
 by virulence factor of the bacteria, the inoculum size, and
 the inadequacy of host defense mechanisms.

17. PATHOGENESIS
• ASCENDING ROUTE
• HEMATOGENOUS SPREAD
• LYMPHATIC ROUTE
Campbell walsh urology vol4 11ed

18. CLINICAL MANIFESTATIONs
• The feature of UTI varies :
Asymptomatic ( most pediatrics )
Symptomatic ( UPPER vs LOWER ).

19. LOWER UTI
• Urethritis , cystitis , prostatitis and
epididymitis
• Dysuria, urinary frequency, urethra discharge
, urinary urgency , hematuria with a positive
urine culture.
• By mostly pediatric patients present with
only fever of unknown origin.

20. Likelihood of UTI in kids
• Temperature >39ºC for ≥48 hours in absence
of another source for fever.
• Temperature <39ºC, presence of another
source for fever.
Uptodate 2013 version

21. Pyelonephritis
• Ascend from the bladder to the kidney.
• Normally the simple and compound papillae in the kidney have an
antireflux mechanism that prevents urine in the renal
pelvis from entering the collecting tubules. However, some
compound papillae, typically in the upper and lower poles of the
kidney, allow intrarenal reflux. Infected urine then stimulates an
immunologic and inflammatory response.
• The result can cause renal injury and scarring
• Complicated : progression of upper UTI to:
 Emphysematous pyelonephritis,
 Renal corticomedullary abscess,
 Perinephric abscess, and
 Papillary necrosis
Up to date 2013 version

22. S/S suggesting Pyelonephritis
• flank pain, nausea/vomiting,
• fever (>38ºC), and/or
• costovertebral angle tenderness.
 May present with sepsis, multiple organ
system dysfunction, shock, and/or acute renal
failure.
Up to date 2013 version

23. Investigation
• FBC
• URINALYSIS
– Macroscopy
– Chemistry
– Microscopy
– Cytology
• URINE CULTURE and
• BACTERIOGRAM (if possible )

24. • Imaging : Ultrasound , CT scan , cystourethrography
Indication :
UT abnormalities
persistent symptoms after 48 to 72 hours despite ATBs.
In pyelonephritis with S/S of renal colic or history of
renal stones, diabetes, Hx of prior urologic surgery,
recurrent pyelonephritis, or urosepsis.

25. Management of UTI
Acute cystitis :
• Encourage drinking
• consider antibiotics:
 fluoroquinolones (3 days),
 Trimethoprim-sulphamethoxazole (3 days),
Nitrofurantoin (3-5mg/kg/day in 3doses for
5 days), ..

26. • Pyelonephritis :
• Moderate to severe : cephalosporins or
fluoroquinolones;
• Fluoroquinolones, amino-penicillin plus beta
lactamase inhibitor, cephalosporins (2nd or
3rd), aminoglycoside for 5 days.

27. Complication
• Urethra stricture,
• Renal scarring,
• Renal abscess,
• Perinephric abscess,
• Hypertension, and
• End-stage renal disease

28. Urosepsis
• When UTI becomes systemic
• The systemic inflammatory response
syndrome: fever or hypothermia,
hyperleucocytosis or leucopenia, tachycardia,
tachypnoea
• Management: rescussitation, antiotherapy and
prompt management of urological abnormality
especially appropriate of obstruction (very
often vital emergency that require drainage of
abcess)
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29. REFERENCE
• Up to date ‘’Long-term management and
prevention of urinary tract infections in
children’’2013 .
• Blueprint G/O (2013) 6 ed
• Nelson text book of pediatrics (2015) 20 ed.