This document discusses urinary tract infections (UTIs) in children. It notes that UTIs are common in childhood and can lead to renal scarring if not treated properly. Escherichia coli is the most common cause of UTIs in children. The diagnosis of a UTI requires a positive urine culture. Treatment depends on factors like age and infection severity, but commonly involves antibiotics. Recurrent UTIs and vesicoureteral reflux increase the risk of renal damage, so preventative measures and follow-up are important.

1. Dr.Praful Bambharoliya

2.  Urinary tract infections (UTI) are a common
and important clinical problem in childhood.
 Upper urinary tract infections (ie, acute
pyelonephritis) may lead to renal scarring,
hypertension, and end-stage renal disease.
 Difficult on clinical grounds to distinguish
cystitis from pyelonephritis, particularly in
young children (those younger than 2 years)

3.  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.

4.  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.

5.  Infection of the urinary tract is identified by
growth of a significant number of organisms
of a single species in the urine, in the
presence of symptoms.
 Recurrent UTI, defined as the recurrence of
symptoms with significant bacteriuria in
patients who have recovered clinically
following treatment, is common in girls.

6.  Escherichia coli is the most common
bacterial cause of UTI (80%)
 Other gram-negative bacterial pathogens
include Klebsiella, Proteus, Enterobacter,
and Citrobacter.
 Gram-positive bacterial pathogens include
Staphylococcus saprophyticus,
Enterococcus, and, rarely, Staphylococcus
aureus.

7.  Viruses (eg, adenovirus, enteroviruses) and
fungi (eg, Candida spp, Aspergillus spp,
Cryptococcus neoformans, endemic mycoses)
are less common causes of UTI in children
 Viral UTI are usually limited to the lower
urinary tract.
 Risk factors for fungal UTI include
immunosuppression and long-term use of
broad-spectrum antibiotic therapy, and
indwelling urinary catheter

8.  The result of ascending infection.
 Colonization of the periurethral area by
uropathogenic enteric pathogens is the first
step in the development of a UTI.
 In E. Coli: pili, hair-like appendages on the
cell surface aid in attaching to epithelium.
 In the kidney, the bacterial inoculum
generates an intense inflammatory response,
which may ultimately lead to renal scarring.

9.  Female gender
 Uncircumcised male
 Vesicoureteral reflux
 Toilet training
 Voiding dysfunction
 Obstructive uropathy
 Urethral instrumentation
 Wiping from back to front in females

10.  Tight clothing
 Pinworm infestation
 Constipation
 Bacteria with P fimbriae
 Anatomic abnormality (labial adhesion)
 Neuropathic bladder
 Sexual activity
 Pregnancy

11.  The 3 basic forms of UTI
1. Pyelonephritis
2. Cystitis
3. Asymptomatic bacteriuria

12.  Clinical pyelonephritis is characterized by any
or all of the following: abdominal or flank
pain, fever, malaise, nausea, vomiting, and,
occasionally, diarrhea.
 In newborns show nonspecific symptoms
:poor feeding, irritability, and weight loss.
 Pyelonephritis is the most common serious
bacterial infection in infants <2 yrs of age
who have fever without a focus .

13.  Acute lobar nephronia (acute lobar nephritis) is a
localized renal bacterial infection involving >1
lobe that represents either a complication of
pyelonephritis or an early stage in the
development of a renal abscess.
 Renal abscess may occur following a
pyelonephritis or may be secondary to a primary
bacteremia (S. aureus).
 Perinephric abscesses may be secondary to
contiguous infection in the perirenal area (e.g.,
vertebral osteomyelitis, psoas abscess) or
pyelonephritis that dissects to the renal capsule.

14.  It indicates that there is bladder involvement.
 Symptoms include dysuria, urgency,
frequency, suprapubic pain, incontinence,
and malodorous urine.
 Cystitis does not cause fever and does not
result in renal injury.

15.  It refers to a condition that results in a
positive urine culture without any
manifestations of 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.  The diagnosis of UTI is based on positive
culture of a properly collected specimen of
urine.
 While urinalysis enables a provisional
diagnosis of UTI, a specimen must be
obtained for culture prior to therapy with
antibiotics

17.  Significant pyuria is defined as >10 leukocytes
per mm3 in a fresh uncentrifuged sample, or >5
leukocytes per high power field in a centrifuged
sample.
 Leukocyturia might occur in conditions such as
fever, glomerulonephritis, renal stones or
presence of foreign body in the urinary tract.
 Rapid dipstick based tests, which detect
leukocyte esterase and nitrite, are 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.  A clean-catch midstream specimen is used to
minimize contamination by periurethral flora.
Contamination can be minimized by washing
the genitalia with soap and water.
 Antiseptic washes and forced retraction of the
prepuce are not advised.
 In neonates and infants, urine sample is
obtained by either suprapubic aspiration or
transurethral bladder catheterization.
 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.  If the culture shows >50,000 colonies of a
single pathogen (suprapubic or catheter
sample), or if there are 10,000 colonies and
the child is symptomatic, the child is
considered to have a UTI.
 In a bag sample,if the urinalysis result is
positive, the patient is symptomatic, and
there is a single organism cultured with a
colony count >100,000, there is a presumed
UTI.

21.  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.

22.  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.

23.  Children less than 3 months of age and those
with complicated UTI should be hospitalized and
treated with parenteral antibiotics.
 The choice of antibiotic should be guided by
local sensitivity patterns.
 A third generation cephalosporin is preferred.
 Therapy with a single daily dose of an
aminoglycoside may be used 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.

24.  Children with simple UTI and those above 3
months of age are treated with oral
antibiotics

25.  The duration of therapy
-14 days for infants and children with
complicated UTI
- 7-10 days for uncomplicated UTI

27. 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.

28. recommended for patients with
(i) UTI below 1-yr of age, while awaiting
imaging studies,
(ii) VUR
(iii)frequent febrile UTI (3 or more episodes in
a year) even if the urinary tract is normal.

30. •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.

31.  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

32. Grade: I II III IV
V

34.  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