A PowerPoint presentation for medical students about urinary tract infections in children

1. URINARY TRACT INFECTIONS IN CHILDREN
IBRAHIM SANDOKJI, MD, FAAP
Pediatric Nephrologist, Assistant Professor
Board Certified by the American Board of Pediatrics
Taibah University
isandokji@taibahu.edu.sa
+966 50 632 5770

2. While you are in the ER, a
4-year-old girl is brought
with fever, dysuria and
abdominal pain.
Her temperature is 38.5 C,
and her abdominal
examination shows
suprapubic tenderness.
You obtained screening
labs which show:

3. EPIDEMIOLOGY
 UTIs are the 2nd most common infections
in children after respiratory infections
 Females > males (except uncircumcised boys <3 mo)
 Ascending infection → most common
pathway
 Microbiology:
 Enterobacteriaceae (gram negative) bacteria are
the most common cause of UTI
 Escherichia coli is the most common pathogen
 Group B streptococci cause UTI in neonates
 S. aureus can cause renal abscess

4. SYMPTOMS

5. CVA tenderness → pyelonephritis
UTI symptoms vary with age
Young babies might present with only
fever and/or hematuria
Remember, UTI is the most common cause of hematuria in children

6. LABORATORY EVALUATION
 Urine collection method:
 Not toilet trained → urine catheter (or suprapubic
aspiration)
 Toilet trained → clean-catch (midstream) specimen
Clean-catch (midstream) specimen

7. LABORATORY
EVALUATION
 Urine dipstick
 Leukocyte esterase (presence of white cells in the urine) (highly
sensitivity)
 Nitrite (nitrates → nitrites by gram-negative bacteria) (high
specificity)
 Urine microscopy
 WBCs (≥5 WBC/hpf)
 Bacteria
 Urine culture
 >50,000 cfu/dL of a single organism

8. Other investigations
 If there are signs of pyelonephritis (fever, chills, flank pain & CVA tenderness):
 CBC (look for leukocytosis)
 Inflammatory markers (ESR, CRP or PCT)
 Serum creatinine
 Blood culture
 Such patient will need to be admitted to the hospital for monitoring & possible IV
antibiotic

9. MANAGEMENT
 Most children with UTI can be managed as outpatients
 Empiric therapy with an antibiotic that covers
Escherichia coli
 Cephalosporin (first-line oral agent) 2nd or 3rd generation
 Trimethoprim/Sulfamethoxazole
 Amoxicillin/clavulanate
 Check your local antibiogram

10. Fever is gone & child is ready to go home, any other work up is
needed?
AAP guidelines
 After any child’s first febrile UTI → renal
ultrasound
 Looking for congenital anomalies, hydronephrosis or
scarring
 If abnormal →
 Voiding cystourethrogram (VCUG)
 To rule out vesicoureteral reflux (VUR)
 Possible antibiotic prophylaxis and/or surgery
 If recurrent UTI → nuclear scan → look for scarring

11. LONG-TERM COMPLICATIONS
CKD/ESRD
Renal
scarring
Hypertension
UTI recurrence

12. HOME READING

13. RISK FACTORS FOR UTI
 Female gender
 Genetic factors
 Urinary tract anomalies
 Bladder and bowel dysfunction
 Vesicoureteral reflux (VUR)
 Sexual activity
 Bladder catheterization

15. STERILE PYURIA
 Urine WBCs (≥5
WBC/hpf) and maybe +
leukocyte esterase
 But no bacteria on urine
culture

17. Indications for hospitalization in a child with
UTI
 Age <2 months
 Acute pyelonephritis or clinical urosepsis
 Immunocompromised patient
 Vomiting or inability to tolerate oral medication
 Lack of outpatient follow-up
 Resistant organism e.g. Extended Spectrum Beta-
Lactamase (ESBL)
 Failure to respond to outpatient therapy