Urinary Tract Infection In Children

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Urinary Tract Infection In Children
Dr. Alia Al-Ibrahim Consultant Pediatric
Nephrology Clinical Assistant Professor
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Contents 1- Definition of UTI 2- Etiology
pathogenesis 3- Predisposing Factors 4- Clinical
presentations 5-Investigations 6- Management 7-
Complications 8- Special problems in UTI
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UTI in Children
Definition Presence of bacteria in urine
along with symptoms of infection. Incidence 5
in Girls 1-2 in Boys During the 1st year
of life more common in boys due to higher risk of
anomalies and after age of one more in
girls Males and females are equally affected in
the neonatal period. Etiology Most common
infecting pathogen Escherichia Coli 80 of
UTI. Other pathogens - Staphylococcus
Streptococcus Species
- Enterobacteria ( Klebsiella, Proteus,
pseudomonas) -
Occasionally Candida albicans
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Route of infection Neonate Hematogenous Later
Ascension of bacteria into the Urinary
tract. Development of UTI depend on 1-
Virulence of the invading bacteria. 2-
Susceptibility of the host some families and
structural abnormalities. Predisposing
factors 1- Conditions lead to urinary stasis
renal calculi, Obstructive Uropathy , VUR,
Voiding disorder. 2- Immune deficiency 3- Broad-
spectrum antibiotics ( amoxicillin,
cephalexin). 4- constipation by organism moving
from anus to urethra. 5- uncircumcised male
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Clinical Presentation 1- Upper UTI
(Pyelonephritis). 2- Lower UTI ( Cystitis). The
history clinical coarse varies with the
patients age specific diagnosis.
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• 0-2months sepsis. Which also the presentation in
  premature infants along with poor feeding
• 2mon-2yrs different presentation
• Unexplained fever (low or high grade fever)
• Irritability, poor oral intake, lower abdominal
  pain, vomiting, loose bowel movement (diarrhea).
• Voiding symptoms of cystitis (frequency, urgency,
  hesitancy)
• Crying on urination (burning urination)
• Smelly urine
• No fever or mild
• 2yrs
• Pyelonephritis( fever, irritability,
  poor appetite, abdominal flank
• pain back
  pain, voiding symptoms, tenderness in
• 
  costovertebral angle or flank.
• cystitis voiding symptoms (
  urgency, frequency, hesitancy, dysuria,
• urinary incontinence)
• mild or no fever,
  Suprapubic or abdominal pain

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• Urine analysis dipstick High index of
  suspicion for UTI in febrile children
  particularly those with unexplained fever. Lasts
  for 2-3days
• gt 5 WBC/ hpf in centrifuged fresh urine positive
  screening test.
• gtBacteria in cent. non cent. Or phase contrast
  suggestible of UTI.

• gtPyuria, proteinuria Hematuria may occur with
  or without UTI.
• gtNitrite concentrations leukocyte estrase.
  Nitrite is positive in pseudomonas mostly ,
  klebsiella or proteus infection. If nitrite is
  positive think of structural abnormality.
  Nitrite alone is not diagnostic, we need high WBC
  and suggestive signs and symptoms.
• Pyuria and bacteruria are not diagnostic.
• POSITIVE URINE CULTURE IS ESSENTIAL FOR DIAGNOSIS
  OF UTI.
• Urine culture the most diagnostic if the patient
  is not receiving any antibiotics.
• Suprapubic aspiration is common in kids lt1 any
  number of colonies is diagnostic.
• IN-and- out catheterization gt 10³, if more than
  one year and if not possible do MSU.
  
• Midstream clean-catch urine collection gt 10,000
• usually a single organism
• 2 or more organism on the culture indicates
  contamination.
  
• Blood culture neonate infant
• Pyelonephritis CBC neutrophlic leukocytosis
  
• high ESR
• C-reactive protein
  (ESR and C-reactive protein are non-specific and
  are elevated more in pyelonephritis than cystits
  .
• Distinction between upper lower difficult in
  children

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Management lt 5 yrs With systemic signs 1- Iv
antibiotics (covering Ecoli) shift to oral after
improvement for 10 -14 days. Start after taking
the culture but dont wait for the results, start
them immediately. 2- US, renal cortical
scintigraphy ( DMSA) , MCUG. If abnormal US,
follow by DMSA No systemic signs 1- oral
antibiotics for 7-10 days US, MCUG( if
indicated) gt 5 yrs and Female
Female Male with
signs 1- no signs oral antibiotics
Like lt 5 yrs Male (even if
after 1 episode of UTI or female with recurrent
UTI 1- No signs oral antibiotics 2- US,
MCUG We do U/S to detect structural
abnormality. DMSA is done after 2 months of the
acute infection to detect scarring. MCUG is done
to detect reflux.
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COMPLICATIONS 1- VUR (it might be a complication
of UTI, or primary causing UTI. 2- Scarring.
Might lead to HTN, if multiple it might lead to
renal insufficiency. 3- HTN 4- Renal
insufficiency.
VUR
Scarring
Acute no irregular borders and no scarring and
no change in size
In chronic irregular borders and scarring.
Normal DMSA
Acute Pyelonephritis
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Special problems 1-Reurrent UTI Two or more
UTIs over a six months period. There will be a
period of remission followed by a recurrence of
the infection. Causes Inadequate treatment
either due to compliance or improper
prescription. unrecognized site
of bacterial persistence such as small infected
calculus or un recognized anatomic
abnormality. 2-VUR Abnormal backwash of urine
into ureter or kidney Radiological evaluation
VCUG, Isotope cystogrm
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• 3-Breakthrough UTI
• Caused by
• 1- change in the resistance pattern of organisms
  colonizing the
• urethra.
• 2- noncompliance.
• 3- VUR
• 4- Voiding dysfunction.( delay in urination or
  structural abnormality)
• 4-Voiding dysfunction
• Detrusor instability incomplete bladder
  emptying
• Associated with daytime enuresis constipation.
• Increase risk of UTI VUR.
• RX 1- Timed voiding
• 2- Treatment of constipation.
• 3- Prophylactic antibiotics.
• 4- Anticholinergic medications.
• 5-Asymptomatic bacteruria
• No need for antibiotics to prevent resistance and
  recurrence would be with a more virulent
  organism, low risk of scarring.