1. Urinary Tract Infections
Dr. Kalpana Malla
MD Pediatrics
Manipal Teaching Hospital
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2. UTI
• Definition:-
Invasion & multiplication of micro-
organisms in the urinary system
– any component of the urinary tract including
• Urethritis
• Cystitis
• Pyelonephritis

3. Classification

4. UTI - Classification:-
A. On the basis of underlying defect
simple
complicated
B. Based on symptoms
Symptomatic UTI
Asymptomatic UTI

5. Classification
C. On the basis of region
involved
- Upper UTI -
pyelonephritis
- Lower UTI
– Cystitis
- Urethritis

6. Incidence:-
• Newborn : M=F
Hematogenous spread
Cong. anomalies in males
• >1 yr : F>M
Ascending infection
**Overall 1% boys & 3 % girls have UTI in 1st
decade

7. Causes of UTI

8. Etiology - Microorganisms
A. Bacteria:-
• Gram negative bacteria
• - Escherichia coli (80 %- 90 %)
• - Klebsiella
• - Proteus (30%)
• Gram positive bacteria
• - Enterobacter
• - Citrobacter.
• - Staph saprophyticus
• - Group B streptococcus
- H. Influenza
• - Staph. Aureus

9. Etiology - Less common
B. Virus:-
Ebstein Barr
Adenovirus
enteroviruses
Coxsackie viruses
echoviruses
C) Fungus - Candida spp., Aspergillus spp.
Cryptococcus neoformans
D) Parasite

10. Risk Factors
1.Host Factors:-
a) Stasis -Urinary obstruction
- infrequent & incomplete voiding
- Constipation
- Obstruction to flow-PUV,PUJ
obs,stones,ureterocele
- Neurogenic bladder
- Vesicoureteral reflux

11. Host Factors:-
b) Instrumentation
c) Malnutrition
d) Age/ Sex
e )Uncircumcised boys
f )Race/ethnicity
g )Genetic factors
h) Length of urethra
i) Urine itself j) DM

12. Risk Factors
2. Agent-organism
3. Size of inoculum- small/large

13. PATHOGENESIS
• Ascending infection most
UTI beyond the newborn
period
• Descending infection
4 - 9 percent of children
with UTI are bacteremic

14. Clinical features

15. Presentations
< 2 month - nonspecific symptoms and signs –
fever , Jaundice
2month -1 year:- Fever/Hypothermia
Vomiting, Diarrhea
Sepsis
Irritability
Lethargy
Malodorous urine

16. Presentations
1-5 years:-Abdominal pain- Flank /back/
Supra pubic
- Vomiting ,diarrhea
- Constipation
- Abnormal voiding - Urgency,
urinary incontinence, dysuria

17. 1-5 years
- Malodorous Urine
- Fever/febrile convulsion
- Failure to thrive

18. Presentations
>5years:-Dysuria
Frequency
Urgency
Abdominal discomfort
Fever
Malodorous urine

19. Physical examinations
• Temperature
• Pallor
• Anthropometry
• Blood pressure
• Tenderness-Lower abdomen
• Renal angle
• Renal mass
• Palpable bladder

20. Physical examinations
• Fecal mass
• Signs of valvitis
• Spine
• Lower limb reflexes
• Associated with UTI-Prune belly syndrome
Anorectal anomalies

21. Localizing symptoms:
Symptoms of urethritis:
• Dysuria
• Reluctance to void
• Perineal discomfort
• Vaginal irritation and erythema in girls
• In older boys, urethral discharge
• In adolescent girls associated with PID
symptoms

22. Localizing symptoms:
Features of cystitis:
• Afebrile usually
• Frequency
• Enuresis
• Dysuria
• Reluctance to void

23. Localizing symptoms:
Features of pyelonephritis:
• Fever and systemic signs
• Older children
– Flank pain or abdominal pain
• Younger children
– Fever, irritability, vomiting, poor feeding

24. LABORATORY EVALUATION
Dipstick
Microscopy
Culture & sensitivity

25. Investigations
Methods of urine collection
• Clean catch or midstream sample
• Supra pubic aspiration –infancy
• Urinary bag sample –small children
• Catheter specimen –Severely ill

26. LABORATORY EVALUATION
Urine dipstick
88 % sensitive
• Leukocytes
• Protein
• Red blood cells
• Leukocyte esterase
• Nitrite

27. LABORATORY EVALUATION
Microscopic exam
• Bacteria: bacteriuria
is the presence of
any bacteria per hpf.
• Gram stain

28. Routine Microscopic Examination
• Color-Hazy
• Smell- malodorous
• White Blood Cells: pyuria is defined as ≥5
WBC/PHF in centrifused or ≥10 WBC/mm3 in
an uncentrifuged sample
• Bacteria: bacteriuria is the presence of any
bacteria per hpf. - Gram stain

29. Routine Microscopic Examination
• RBC >5 /HPF
• RBC+WBC casts+
• Albumin –Trace to +
Urine C/S- gold standard
- should be processed as soon as
possible after collection

30. LABORATORY EVALUATION
Urine culture
• Midstream clean catch 
> 10⁵ colony forming units (girls)
> 104 CFU (boys)
• Catheterization  10⁵ CFU
• Supra pubic aspiration any growth

31. LABORATORY EVALUATION
Other laboratory
tests
• Investigate the fever – CBC, CRP
• Serum creatinine
• Blood culture — Bacteremia occurs in 4-9 %
of infants with UTI
• Lumbar puncture — Infants <1 month of age
with fever and a positive urinalysis;
approximately 1 % of infants with UTI also have
meningitis

32. Imaging studies
1.Radiological – MCU
IVP
X-ray KUB
2. Nuclear- USG
DMSA scan
DTPA scan
MAG scan

33. Renal scans
• DMSA renal scan – anatomy of kidney
(Scarring)
• DTPA renal scan – Excretory function ,filtration
function of kidney
• MAG 3 with lasix renal scan – Obstruction at
the ureterovesical junction - quantitative
information regarding kidney function and
drainage , assesses the degree of blockage

34. Principle of management
1. Treatment of acute infection
2. Prevention of further infection
3. Adequate investigation
4. Arrangement of further treatment
5. Follow up - Prevention of recurrence and
long-term complications

35. MANAGEMENT
Indication for hospitalize:
• Age <2 months
• Sepsis or potential bacteremia
• Immunocompromised patient
• Vomiting or inability to tolerate oral
medication
• Lack of adequate outpatient follow-up
• Failure to respond to outpatient therapy

36. Choice & route of Treatment
Depends on – Age
Severity of illness
Choice of agent: provide adequate coverage
for E. coli.

37. ANTIBIOTIC THERAPY:
• Newborn + Infants
Inj ampicillin + Inj. Gentamycin-14 days
• Older children:-
Oral – Co-timoxazole
cephalosprins
Nalidixic acid
amoxicillin-clavulanate
• Parenteral therapy: Ampicillin or Third- or fourth-
generation cephalosporins and aminoglycosides
- first-line agents for empiric treatment of UTI in
children.

38. MANAGEMENT
ANTIBIOTIC THERAPY
• Duration of therapy: 7-14 days
• Response to therapy:
Clinical response
Repeat urine culture

39. Indications for further
investigations:
1. Girls younger than 3 years with a first UTI
2. Boys of any age with a first UTI
3. Children of any age with a febrile UTI
4. Children with recurrent UTI
5. First UTI in a child of any age with a family
history of renal disease, abnormal voiding
pattern, poor growth, hypertension

40. Prevention
1. General measures:-
• Fluid intake
• Complete and periodic voiding
• Vioding at bed time
• Perineal hyiene
• Treatment of worms
• Prevention of constipation
• Avoid catheterization

41. Prevention
• Early treatment of cong anomalies
• Circumcision
2. Low dose chemoprophylaxis
- UTI until radiological evaluation is complete
- Recurrent UTI
- VUR grade I- III
- Post operative-PUJ,VUR IV & V, PUV

42. Prevention
- Chronic cystitis
- Neurogenic ladder
Commonly used drugs for prophylaxis:-
• Co-trimoxazole-2mg/kg/d
• Nalidixic acid-12.5mg/Kg/d
• Nitrofurantoin -1mg/kg/d

43. Follow up
1. Clinical-
During the year following infection
1 year after starting prophylaxis
height, Blood pressure –recorded
2. Urine C/S-
3 monthly-infancy
Fever & symptoms –older children
3.RFT 4. Imaging –when neded

44. Thank you
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