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BASICS INTRODUCTION It Is A Potential Serious Infection The Highest Incidence In The First Year Of Life It May Be Pyelonephritis Or Cystitis The Commonest Error In The Management Of UTI In Children, And Especially In Infants, Is Failure To Establish Is The Diagnosis
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URINARY TRACT INFECTION
P R O T O C O L BY
AHMED SOLIMAN ABDELHALIM SOLIMAN ,MDLECTURER OF PEDIATRICS
PEDIATRIC NEPHROLOGY &DIALYSIS UNITBENHA UNIVERISITY
EL HADA ARMED FORCES HOSPITAL ,TAIF, KSA(LAST UPDATE NOVEMBER 2014)
BASICS INTRODUCTION • It Is A Potential Serious Infection• The Highest Incidence In The First
Year Of Life• It May Be Pyelonephritis Or
Cystitis • The Commonest Error In The
Management Of UTI In Children, And Especially In Infants, Is Failure To Establish Is The Diagnosis
• Escherichia coli remains the predominant uropathogen.
• Other organisms such as klebsiella , proteus and enterobacter species , staphylococci, and Streptococcus faecalis , GBS.
• Hematogenous spread is common in
newborns and infants in contrast to ascending infection in older children
BASICS Organisms
E.COLI VIRULENCE FACTORS
BASICS DEFINITIONS (CLASSFICATION)
CLINICAL APPROACH OF
UTI
STEP 1 : HOW TO SUSPECT UTI ?
STEP2: HOW TO DIAGNOSE UTI (CULTURE)?
STEP 3 : IDENTIFY THE SITE OF UTI
STEP 4 : ANTIBIOTIC THERAPY FOR UTI
STEP 5 : WHAT IS THE UNDERLYING PATHOLOGY ?
STEP6: FOLLOW UP FOR RECURRENCE ?
CLINICAL UTI APPROACHO C T O B E R 2 0 1 3
NICE guidelines recommend the testing of urine in infants and children with: • Symptoms and signs of UTI. • Unexplained fever of 38 ° C or higher • An alternative site of infection but who remain unwell .
STEP (1 ) :How to suspect UTI? O C T O B E R 2 0 1 3
The gold standard for diagnosis of UTI is the urine culture.
Tests That Help Improve the Predictive Value of UTI • Presence of >10 white blood (HPF)
(77%,89%)• Nitrate reductase test (50%,98%)• Leukocyte esterase test (84% ,78%) • The combination of leukocyte esterase
and nitrite tests(72%,96%)
STEP 2:Diagnosis
NICE recommended techniques • Catheter sample or suprapubic aspiration (SPA),
• method of choice in the severely ill infant under 1 year,
• requiring urgent diagnosis and treatment, and in cases where
Alternatives (not NICE recommended) An adhesive plastic bag (screening test). midstream sample.
STEP2 : Diagnosis
STEP3 :IDENTIFY SITE
• Abdominal us (not sensitive)• DMSA (most senstive)• CT with contrast (risky)• MRI with contrast
(expensive)
DMSA
CT (contrast)
MRI (contrast)
• Age • Pyleonephritis or cystitis • General conditions • Choice of antibiotics • Doses of antibiotics .
STEP 4:Treatment
Below 3 months of age
Start parentral antibiotics for 2-4 days then oral for
10 days
Above 3 months of age
Pyleonephritis Cystitis
start oral antibiotics for 7
days unless vomiting Start
parentral antibiotics for 2-4 days then oral for
10 days Oral antibiotics for 3
days
NICE guidelines regarding antibiotic treatment 2007 are as follows
Treatment
Step 5 :Identify underlying pathology
Role out obstructive uropathy especially VUR
Recurrent UTI
Two attacks in less than 6 monthsRecurrence is seen in 30–50 % The risk factors for recurrent UTI
• Girls • Age <6 months • Phimosis/labial adhesions • Obstructive uropathy • Voiding dysfunction • Constipation • High-grade vesico-ureteral reflux
(VUR)
Recurrent UTI : VUR
Recurrent UTIChemoprophylaxis “AAP 2013”
Recurrent without VUR
Recurrent with VUR
evidence that prophylactic antibiotics prevent recurrent
UTI in children without VUR is weak.
• Antibiotic prophylaxis may not be warranted in children with low-grade (grade I–II) VUR.
• antibiotic prophylaxis may have a role in grade III–V VUR, especially in children <5 years of age
Recurrent UTIChemoprophylaxis choice
BENHA UNIVERISITY BENHA UNIVERISITY HOSPITALS
PEDIATRIC NEPHROLOGY & DIALYSIS UNIT