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