Childhood Urinary Tract Childhood Urinary Tract InfectionInfection

Definition and Definition and classificationclassification

It is an infection of both upper and lower urinary tract.

Upper : pyelonephritis, renal abscess.

Lower : cystitis , urethritis

Epidemiology Epidemiology UTI is one of the most common bacterial

infections of childhood. Affects up to 10% by the teenage years.Before age of 1 year boys : girls = 3 : 1After age of 1 year girls : boys = 10 : 1

40% of children with UTI will have anatomic or functional abnormalities of the urinary tract.

e.g. reflux, malpositions, duplications, megaureter and hydronephrosis.

EtiologyEtiologySource of infection:Mostly ascending.The bacteria arise from the fecal flora, colonize

the perineum, and enter the bladder via the urethra

In neonates ……………… HEMATOGENEUS.

Etiological organisms:Escherichia coli: (80%), Klebsiella and Proteus.Staphylococcus saprophyticus in adolesent

girls. Viral infections (adenovirus), can cause cystitis.Fungal infections

Risk FactorsRisk Factors

Type of patient:-Female )short

urethra)-Uncircumcised

male.-Tight clothing.-Urethral

instrumentation

Abnormal Urinary tract:

-Vesicoureteral reflux.

-Obstructive uropathy (major risk factor):

Hydronephrosis

-Neurogenic bladder

Clinical Manifestations

Pyelonephritis Constitutional symptoms: Fever, malaise, chills. Nausea, vomiting ±

diarrhea. Localizing symptoms:

Abdominal or flank pain.

Clinical Manifestations (cont)Cystitis

Usually afebrileDysurea Urgency Frequency IncontinenceHematuria Malodorous urine.Suprapubic pain & tenderness.

Clinical Manifestations (cont)

Urethritis-Dysurea-Reluctance to void-Perineal discomfort, erythema-Vulval irritation & erythema (girls)-Urethral discharge in older boys

Symptoms of UTI Neonates & infants

Change in urine color (or odor) as well as, crying during micturation in an infant may be noted by the mother.

BUT Nonspecific symptoms: Jaundice Poor feeding Irritability Weight loss (or poor weight

gain)

Asymptomatic bacteriurea

Refers to individuals who have a positive urine culture without any manifestations of infection.

Occurs almost exclusively in girls. This condition is benign and does

not cause renal injury.

ComplicationsComplications

recurrance ( up to 25% to 40% )( follow up)

bacteremia (more in infants) focal renal abscess ( uncommon

)

cont.

Acute pyelonephritis may result in renal injury

“pyelonephritic scarring”

HypertensionIf recurrent scarring

Chronic renal failure

Diagnosis of UTI

Diagnosis of UTIDiagnosis of UTI

Suspect: Symptoms Findings on urinalysis, or both.

Confirm: Urine culture.

The diagnosis of UTI depends on having the proper sample of

urine

Urine analysisUrine analysis

Urine microscopy: Pus cells White cell cast ………

RBCs …….. Gram stainingUrine dipstick: - Leucocyte estrase - Nitrite

Collecting the urine Collecting the urine samplesample

Collecting the urine sampleCollecting the urine sample

In toilet-trained children

midstream urine sample Satisfactory if

The culture shows greater than 100,000 colonies of a single pathogen.

There are 10,000 colonies and the child is symptomatic, it is considered a UTI.

Collecting the urine sample (cont):Collecting the urine sample (cont):

In infants: (1) Clean catch sample.

(2) Urine collection bag. contamination is

possible (3) In & out urinary

catheterization.

(4) Suprapubic urine sample

Notes about urine analysis & Notes about urine analysis & culture:culture:Prompt plating of the urine sample is important - not more than one hour.

A urinalysis should be obtained from the same specimen as that cultured.

Pyuria (leukocytes in the urine) suggests infection, but infection can occur in the absence of pyuria.

Treatment of UTITreatment of UTI

TreatmentTreatment

In acute febrile infections suggestive of pyelonephritis: Parenteral treatment with ceftriaxone or ampicillin with gentamicin for 10-14 days.

Treatment of UTI (cont):Treatment of UTI (cont):

Acute cystitis: Should be treated promptly to prevent its

possible progression to pyelonephritis. trimethoprim-sulfamethoxazole . Nitrofurantoin for 3-5

days Amoxicillin

If the symptoms are mild and the diagnosis is doubtful, treatment can be delayed until the results of culture are known, and the culture can be repeated if the results are uncertain

FOLLOW UPFOLLOW UPWe usually do urine culture 1

week after stopping of antibiotics ; then periodic reassessment for the next 1-2 years .

Imaging StudiesImaging Studies

The goal of imaging The goal of imaging studies in children with a studies in children with a UTIUTIThe goal of imaging studies in children with a UTI is to identify anatomic abnormalities that predispose to infection and to

If there are any UTI complications

Renal ultrasonogram

Renal ultrasonogramRenal ultrasonogram

- hydronephrosis - renal or perirenal abscesses- Pyelonephritis- renal scars ( 30%)

VCUG( MCUG)VCUG( MCUG)

Voiding cystourethrogram Voiding cystourethrogram (VCUG) Miturating (VCUG) Miturating cystourethrogram cystourethrogram (MCUG)(MCUG)

Indications:All children younger than 5 yr with a UTI,

School-aged girls who have had two or more UTIs

Any male with a UTI

The most common finding is vesicoureteric reflux

DMSA scan & DTPA DMSA scan & DTPA scan scan

DMSA scan: Technetium-labeledAcute pyelonephritisStructural malformations of the kidney

DTPA scan: Dynamic study for: Excretory Function Reflux

DETPA

Prevention of reccurrence of UTIPrevention of reccurrence of UTI

Prevention of reccurrence of UTIPrevention of reccurrence of UTI

Aderss and treat underlying cause.

Manage constipation.Correct bottom wiping.Encourage drinking adequate fluid.

Advice child not to delay voiding.Use of prophylactic antibiotics …………..

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