diagnosis and treatment of UTI

Diagnosis and Treatment of UTI in children Novina Firlia 0961050083

TABLE OF CONTENTS

Table of content.......................................................................................................................1

List of table and figure..............................................................................................................2

Chapter I..................................................................................................................................3

Prelude.........................................................................................................................3

Chapter II.................................................................................................................................5

Diagnosis and Treatment of Urinary tract infection in

children........................................................................................................................5

2.1 Definition and Epidemiolog........................................................................5

2.2 Etiology and Pathogenesis..........................................................................6

2.3 Signs and Symptoms...................................................................................8

2.4 Diagnosis of UTI.........................................................................................9

2.5 Treatments of UTI.......................................................................................13

Chapter III..............................................................................................................................16

Conclusion...................................................................................................................16

Reference.................................................................................................................................17

1


LIST OF TABLES

Table 1. etiology of UTIs.........................................................................................................6

Table 2. Signs and Symptoms..................................................................................................8

Table 3. Treatment of UTIs.....................................................................................................14

LIST OF FIGURES

Figure 1. Algorithm for urine testing in children with suspected urinary tract infection (UTI).........11

Figure 2. Algorithm for imaging decisions in children with urinary tract infection...........................13

2


Chapter I

Prelude

Urinary tract infections (UTIs) are common in kids. By the time they're 5 years old,

about 8% of girls and about 1-2% of boys have had at least one. In older kids, UTIs may

cause obvious symptoms such as burning or pain with urination (peeing). In infants and

young children, UTIs may be harder to detect because symptoms are less specific. In fact,

fever is sometimes the only sign.1

The most common pathogen is Escherichia coli, accounting for approximately 85

percent of urinary tract infections in children. Renal parenchymal defects are present in 3 to

15 percent of children within one to two years of their first diagnosed urinary tract infection.1

In a study of infants presenting to pediatric emergency departments, the prevalence of

UTI in infants younger than 60 days with a temperature greater than 100.4°F (38°C) was 9

percent. Clinical signs and symptoms of a UTI depend on the age of the child. Newborns with

UTI may present with jaundice, sepsis, failure to thrive, vomiting, or fever. In infants and

young children, typical signs and symptoms include fever, strong-smelling urine, hematuria,

abdominal or flank pain, and new-onset urinary incontinence. School-aged children may have

symptoms similar to adults, including dysuria, frequency, or urgency. Boys are at increased

risk of UTI if younger than six months, or if younger than 12 months and uncircumcised.

Girls are generally at an increased risk of UTI, particularly if younger than one year. Physical

examination findings can be nonspecific but may include suprapubic tenderness or

costovertebral angle tenderness.1

Evaluation of older children may depend on the clinical presentation and symptoms

that point toward a urinary source (e.g., leukocyte esterase or nitrite present on dipstick

3


testing; pyuria of at least 10 white blood cells per high-power field and bacteriuria on

microscopy). Increased rates of E. coli resistance have made amoxicillin a less acceptable

choice for treatment, and studies have found higher cure rates with

trimethoprim/sulfamethoxazole. Other treatment options include amoxicillin/clavulanate and

cephalosporins. Prophylactic antibiotics do not reduce the risk of subsequent urinary tract

infections, even in children with mild to moderate vesicoureteral reflux. Constipation should

be avoided to help prevent urinary tract infections. Ultrasonography, cystography, and a renal

cortical scan should be considered in children with urinary tract infections.2

Adequate treatment of acute UTI depends on knowledge of the local pattern of

causative pathogens, their antimicrobial resistance and the associated underlying risk factors.

The changing pattern of antimicrobial susceptibility of bacterial pathogens causing acute UTI

is a growing problem. Consequently, many organisms including those causing acute UTI may

ultimately develop high resistance to many antibiotics in current use. Moreover, organisms

not known to be common in causing acute UTI may emerge as important causative

pathogens. Therefore, the knowledge of the local pattern of urinary pathogens and their

susceptibility to various antimicrobials are essential for selection of the appropriate empiric

therapy for children with acute UTI.3

Chapter II

Diagnosis and Treatments of UTI in children

4


2.1 Definition and Epidemiology

Urinary tract infection (UTI) is defined by the presence of microorganisms within the

urinary tract, which is usually sterile. Since asymptomatic colonization of the urinary tract

can occur, definitive diagnosis often relies upon a constellation of features that might include

history and examination findings, elevated inflammatory markers, and repeat urine cultures.

UTIs are typically divided into lower tract disease, where infection is localized to the bladder

and urethra (cystitis and urethritis), and upper tract disease, where it extends to the ureter and

kidney (pyelonephritis). Although both upper and lower tract disease may result in significant

morbidity, pyelonephritis in particular is associated with renal scarring and subsequent

hypertension, chronic renal disease, and preeclampsia.3

UTIs are the most common serious bacterial infections affecting infants and young

children. In recent decades, UTI has been increasingly recognized as an important occult

cause of fever in young children. Rates of UTI vary widely with respect to age, gender, race,

and other factors. Screening studies performed in emergency departments suggest an overall

prevalence of UTI of up to 5% in febrile children younger than 2 years. Peak incidence of

UTI occurs in the first year of life for all children, with a second peak occurring among

female adolescents. After infancy, females are far more likely than males to have a UTI.1,3

A population-based European study reported a cumulative UTI incidence of 7.8% for

girls by age 7 years. One factor influencing the relatively higher rates of UTI in male infants

is circumcision status; uncircumcised males younger than a year are approximately 10 times

more likely to develop UTI than their circumcised counterparts.

In young children, race appears to be an independent risk factor for UTI. In an

emergency department study, Caucasian females younger than 2 years with fever 39oC have

a UTI prevalence of 16% compared to a 2.7% prevalence among nonwhite girls.3

2.2 Etiology and Pathogenesis

5


The normal urinary tract is sterile. Contamination by bowel flora may result in urinary

infection if a virulent organism is involved or if the child is immunosuppressed. In neonates,

infection may originate from other sources. Escherichia coli accounts for about 75 percent of

all pathogens. Proteus is more common in boys (one study found that proteus caused 33

percent of UTI infections in boys one to 16 years of age, compared with 0 percent of UTI

infections in girls of the same age). Obstructive anomalies are found in up to 4 percent and

vesicoureteric reflux in 8 to 40 percent of children being evaluated for their first UTI.

Although vesicoureteric reflux is a major risk factor for adverse outcome, other factors, some

of which have not yet been identified, are also important.4

Table 1 etiology of UTIs in children3

Almost all clinically significant urinary infections are monomicrobial rather than

polymicrobial. Most uncomplicated UTIs are caused by the gram-negative

Enterobacteriaceae family. causes the vast majority of acute infections. Organisms such as

Proteus, Enterobacter, Citrobacter, and Klebsiella spp. are more commonly encountered in

cases of recurrent UTI, particularly in cases of urinary anomalies.

Pseudomonas sp., while not usually a cause of UTI in healthy children, is a significant

pathogen for hospitalized children, immunocompromised children, and children with

indwelling catheters or frequent bladder instrumentation.Gram-positive organisms account 6


for a minority of uncomplicated UTIs (approximately 5–10%); those most commonly

encountered include Enterococcus sp., Staphylococcus saprophyticus, and group B

streptococci. S. saprophyticus tends to infect sexually active adolescent females. Candidal

UTIs typically occur in children with indwelling catheters who are receiving broad-spectrum

antibiotics or in children in the neonatal intensive care unit.3,4

Risk factors — Some children have a higher chance of developing a UTI. The

following are some risk factors for UTI5 :

Young age; boys younger than one year old, and girls younger than four years of age

are at highest risk.

Being uncircumcised; there is a four to 10 times higher risk of UTIs in uncircumcised

boys. Still, most uncircumcised boys do NOT develop UTIs. (See "Patient

information: Circumcision in baby boys (Beyond the Basics)".)

Having a bladder catheter for a prolonged period of time.

Having parts of the urinary tract that did not form correctly before birth.

Having a bladder that does not work properly.

Having one UTI slightly increases the chance of getting another UTI.

2.2 Signs and Symptoms

Symptoms of a UTI range from slight burning with urination or unusual-smelling

urine to severe pain and high fever. A child with a UTI may also have no symptoms. A UTI

causes irritation of the lining of the bladder, urethra, ureters, and kidneys, just as the inside of

the nose or the throat becomes irritated with a cold. In infants or children who are only a few

years old, the signs of a UTI may not be clear because children that young cannot express

exactly how they feel. Children may have a high fever, be irritable, or not eat.7

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http://www.uptodate.com/contents/circumcision-in-baby-boys-beyond-the-basics?source=see_link

http://www.uptodate.com/contents/circumcision-in-baby-boys-beyond-the-basics?source=see_link


Table 2 Signs and Symptom6

On the other hand, children may have only a low-grade fever; experience nausea,

vomiting, and diarrhea; or just not seem healthy. Children who have a high fever and appear

sick for more than a day without signs of a runny nose or other obvious cause for discomfort

should be checked for a UTI.

Older children with UTIs may complain of pain in the middle and lower abdomen.

They may urinate often. Crying or complaining that it hurts to urinate and producing only a

few drops of urine at a time are other signs of a UTI. Children may leak urine into clothing or

bedsheets. The urine may look cloudy or bloody. If a kidney is infected, children may

complain of pain in the back or side below the ribs.6,7

2.3 Diagnosis of UTI

The physical examination of a child with suspected urinary tract infection should start

with the vital signs (temperature, pulse, breathing rate, and blood pressure, which is often

measured with the vital signs). The presence of fever (especially over 102.2 F or 39 C) is

highly correlated with the presence of a UTI.10 All febrile children between two and 24

months of age with no obvious cause of infection should be evaluated for UTI, with the

exception of circumcised boys older than 12 months. Older children should be evaluated if

the clinical presentation points toward a urinary source.9

8


Blood pressure and assessment of height and weight provide helpful reassurance if

normal or stable long-term renal function. Visual examination of the abdomen for

enlargement related to potentially oversized kidney(s) or bladder is important. Tenderness

during palpation of the abdomen (especially the suprapubic region containing the bladder) or

the flank area (where the kidneys are situated) is very helpful in establishing the diagnosis.

Examination of the genitalia is also very important to see if there is evidence of

vaginal irritation (redness, discharge, evidence of trauma or foreign body). An uncircumcised

male (especially with a foreskin which is difficult to retract) is more likely to experience a

UTI when compared to a population of similar infant boys who have been circumcised.

Lastly, consideration of other conditions that might be responsible for fever and abdominal

pain is important.10

The National Institute for Health and Clinical Excellence in the United Kingdom

endorses incorporating specific strategies for urine testing based on the child's age. In this

model, microscopy and urine culture should be performed in children younger than three

years instead of dipstick testing.1 The presence of pyuria of at least 10 white blood cells per

high-power field and bacteriuria are recommended as the criteria for diagnosing UTI with

microscopy. In young children, urine samples collected with a bag are unreliable compared

with samples collected with a catheter. Therefore, in a child who is unable to provide a clean-

catch specimen, catheterization should be considered.1,7

Urine culture is the gold standard for diagnosis of UTI, but results are unavailable for

24–48 hours. As such, several rapid diagnostic tests are available for faster UTI detection.

These include: Urine dipstick testing for leukocyte esterase (LE) and nitrites; traditional

urinalysis, which is typically done by microscopy on a centrifuged specimen; and enhanced

urinalysis, using a hemocytometer cell count and Gram stain of unspun urine.

Urine Culture -- Although growth of pathogenic bacteria from the normally sterile

urine is the gold standard for diagnosis of UTI, what constitutes a significant colony count

varies by collection method. Children who are toilet trained can use the clean-catch method,

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which is susceptible to urethral contamination. Using this modality, UTI is often defined as

>105 colony-forming units (CFU) of a single pathogen.

Diagnostic Test -- Dipstick tests for UTI include leukocyte esterase, nitrite, blood, and

protein. Leukocyte esterase is the most sensitive single test in children with a suspected UTI.

The test for nitrite is more specific but less sensitive. A negative leukocyte esterase result

greatly reduces the likelihood of UTI, whereas a positive nitrite result makes it much more

likely; the converse is not true, however. Dipstick tests for blood and protein have poor

sensitivity and specificity in the detection of UTI and may be misleading. Accuracy of

positive findings is as follows (assumes a 10 percent pretest probability):

Nitrite: 53 percent sensitivity, 98 percent specificity, 75 percent probability of UTI

Bacteria on microscopy: 81 percent sensitivity, 83 percent specificity, 35 percent

probability of UTI

Leukocytes on microscopy: 73 percent sensitivity, 81 percent specificity, 30

percent probability of UTI

Leukocyte esterase: 83 percent sensitivity, 78 percent specificity, 30 percent

probability of UTI

Leukocyte esterase or nitrite: 93 percent sensitivity, 72 percent specificity, 27

percent probability of UTI

Blood: 47 percent sensitivity, 78 percent specificity, 19 percent probability of UTI

Protein: 50 percent sensitivity, 76 percent specificity, 19 percent probability of UTI

10


Figure 1. Algorithm for urine testing in children with suspected urinary tract infection (UTI).1

Laboratory Testing -- A few laboratory parameters have been examined to help

determine not only whether bacteriuria is consistent with acute infection, but also the location

of the infection within the urinary tract. Commonly used markers of inflammation such as

white blood cell count, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP)

cannot reliably distinguish pyelonephritis and cystitis.While CRP is the best among these and

has a sensitivity of greater than 92% for pyelonephritis, it has a low specificity, which limits

its applicability. Although not as widely available (although a rapid test exists in some

centers), multiple studies35–38 have found that an elevated serum procalcitonin level appears

to be more highly correlated with renal involvement than an elevated CRP. If made more

available, this test could potentially alter the management and disposition of febrile patients

with UTI. 3,11

A blood culture should be performed in young infants with UTI since they are at

higher risk of bacteremia. Febrile infants older than 2 months with UTI do not routinely

require lumbar puncture. Concomitant invasive meningitis appears to be rare; an association

of UTI with aseptic meningitis has been reported but is controversial and may represent

coincidental CSF infection and bacteruria.3

Imaging procedures with the highest ratings from the American College of Radiology

Appropriateness Criteria for further evaluation of select children with UTIs are renal and

bladder ultrasonography, radionuclide cystography or voiding cystourethrography, and renal

cortical scan.12 Renal and bladder ultrasonography is effective for evaluating anatomy, but is

unreliable for detecting vesicoureteral reflux. Radionuclide cystography or voiding

cystourethrography is effective for screening and grading vesicoureteral reflux, but involves

radiation exposure and catheterization. Although voiding cystourethrography is suggested for

either girls or boys, radionuclide cystography is suggested only for girls because voiding 11


cystourethrography is needed for adequate anatomic imaging of the urethra and bladder in

boys. A renal cortical scan (also called scintigraphy or DMSA scan) uses technetium and is

effective for assessing renal scarring, but requires intravenous injection of radioisotope.1

Long-term outcome studies have not been performed to determine the best initial

imaging study in children diagnosed with UTI. Guidelines based on observational studies and

expert opinion recommend that all boys, girls younger than three years, and girls three to

seven years of age with a temperature of 101.3°F (38.5°C) or greater receive cystography and

ultrasonography with a first-time UTI.1,13 An optional imaging strategy for febrile children

with UTI, especially those older than three years, is to first perform ultrasonography and a

renal cortical scan. This strategy avoids bladder catheterization with cystography and

minimizes radiation exposure if the results of the scan are normal. However, if pyelonephritis

or cortical scarring is found on the renal cortical scan, cystography is indicated. Observation

without imaging should be considered in girls three years or older with a temperature less

than 101.3° F and in all girls older than seven years.13

Figure 2. Algorithm for imaging decisions in children with urinary tract infection.1

2.3 Treatments of UTI

Although amoxicillin has traditionally been a first-line antibiotic for UTI, increased

rates of E. coliresistance have made it a less acceptable choice, and studies have found higher

12


cure rates with trimethoprim/sulfamethoxazole (Bactrim, Septra). Other choices include

amoxicillin/clavulanate (Augmentin) or cephalosporins, such as cefixime (Suprax),

cefpodoxime, cefprozil (Cefzil), or cephalexin (Keflex). There was no significant difference

between short- and standard-duration therapies in the development of resistant organisms at

the end of treatment.1 Thus, a two- to four-day course of oral antibiotics appears to be as

effective as a seven- to 14-day course in children with lower UTIs. A single-dose or single-

day course may be less effective than longer courses of oral antibiotics and is not

recommended.1,2

When the presenting symptoms are nonspecific for a UTI or the urine dipstick test is

nondiagnostic, there may be a delay in treatment while culture results are pending. Parents

can be reassured that antibiotics initiated 24 hours after the onset of fever are not associated

with a higher risk of parenchymal defects than immediate antibiotics in children younger than

two years.5 However, delaying antibiotics by four days or more may increase the risk of renal

scarring.1

Table 3 Antibiotics Commonly Used to Treat Urinary Tract Infections in Children1

ANTIBIOTIC DOSING

COMMON ADVERSE

EFFECTS

Amoxicillin/clavulanate

(Augmentin)

25 to 45 mg per

kg per day,

divided every 12

hours

Diarrhea, nausea/vomiting,

rash

Cefixime (Suprax) 8 mg per kg every

24 hours or

divided every 12

hours

Abdominal pain, diarrhea,

flatulence, rash

Cefpodoxime 10 mg per kg per

day, divided every

12 hours


nausea, rash

13


ANTIBIOTIC DOSING

COMMON ADVERSE

EFFECTS

Cefprozil (Cefzil) 30 mg per kg per

day, divided every

12 hours


elevated results on liver

function tests, nausea

Cephalexin (Keflex) 25 to 50 mg per

kg per day,

divided every 6 to

12 hours

Diarrhea, headache,

nausea/vomiting, rash

Trimethoprim/sulfamethoxazole

(Bactrim, Septra)

8 to 10 mg per kg

per day, divided

every 12 hours

Diarrhea, nausea/vomiting,

photosensitivity, rash

Follow-up assessment to confirm an appropriate clinical response should be

performed 48 to 72 hours after initiating antimicrobial therapy in all children with UTI.

Culture and susceptibility results may indicate that a change of antibiotic is necessary. If

expected clinical improvement does not occur, consider further evaluation (e.g., laboratory

studies, imaging, consultation with subspecialists). Referral to a subspecialist is indicated if

vesicoureteral reflux, renal scarring, anatomic abnormalities, or renal calculi are discovered,

or if invasive imaging procedures are considered.1

14


Chapter III

Conclusion

In conclusion, increased vigilance on the part of practitioners and screening for UTI in

febrile young children has dramatically reduced the morbidity associated with this diagnosis.

Although there are several areas that remain ripe for further study, there is good evidence

about the epidemiology, diagnosis, and treatment of UTI in children. Key principles of

improving outcomes for pediatric UTI include maintaining a high index of suspicion,

particularly in young children with fever; understanding the strengths and limitations of

screening tests for UTI; and using evidence-based guidelines to approach further anatomic

work-up of UTI, while recognizing the limitations of current knowledge in this area.

15


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2009; Page; 408 - 419

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Sedgefield,UK. November 2010. 15:82 (10) Page; 1252 – 1254

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5. Subcommittee on Urinary Tract Infection, Steering Committee on Quality

Improvement and Management, Roberts KB. Urinary tract infection: clinical practice

guideline for the diagnosis and management of the initial UTI in febrile infants and

children 2 to 24 months. Pediatrics 2011; 128:595.

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Management and Refferal, In : Local Practice Guidelines. Bristol – UK : University

Hospital Bristol, March 2010; Page 01-06, NHS-Journal.

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8. Finnell SM, Carroll AE,DownsSM, et al. Technical report: diagnosis and

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Pediatrics. 2011;128(3):e749

9. Clinical Knowledge Summaries (CKS). Urinary tract infection - children. CKS; 2009. Available from: www.cks.nhs.uk (Accessed August, 2013).

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infection child.http://www.acr.org/SecondaryMainMenuCategories/quality_safety/

app_criteria/pdf/ExpertPanelonPediatricImaging/

UrinaryTractInfectionChildDoc10.aspx. 2010. Accessed in August 2013-08-12

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Evidence-based care guideline for medical management of first urinary tract infection

in children 12 years of age or

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Accessed in August 2013

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http://www.cincinnatichildrens.org/svc/alpha/h/health-policy/uti.htm

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diagnosis and treatment of UTI