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Urinary Tract Infections
Dr. Kalpana MallaMD Pediatrics
Manipal Teaching Hospital
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UTI
• Definition:- Invasion & multiplication of micro-
organisms in the urinary system– any component of the urinary tract
including• Urethritis• Cystitis• Pyelonephritis
Classification
UTI - Classification:-
A. On the basis of underlying defect simple complicatedB. Based on symptoms Symptomatic UTI Asymptomatic UTI
Classification C. On the basis of region
involved - Upper UTI -
pyelonephritis
- Lower UTI – Cystitis - Urethritis
Incidence:-
• Newborn : M=F Hematogenous spread Cong. anomalies in males• >1 yr : F>M Ascending infection**Overall 1% boys & 3 % girls have UTI in 1st
decade
Causes of UTI
Etiology - Microorganisms
• Gram negative bacteria• - Escherichia coli (80 %- 90 %) • - Klebsiella• - Proteus (30%)• Gram positive bacteria• - Enterobacter• - Citrobacter. • - Staph saprophyticus• - Group B streptococcus - H. Influenza• - Staph. Aureus
A. Bacteria:-
Etiology - Less common B. Virus:- Ebstein Barr Adenovirus enteroviruses Coxsackie viruses echoviruses C) Fungus - Candida spp., Aspergillus spp. Cryptococcus neoformans
D) Parasite
Risk Factors
1.Host Factors:- a) Stasis -Urinary obstruction - infrequent & incomplete voiding - Constipation - Obstruction to flow-PUV,PUJ obs,stones,ureterocele - Neurogenic bladder - Vesicoureteral reflux
Host Factors:-
b) Instrumentationc) Malnutrition d) Age/ Sexe )Uncircumcised boysf )Race/ethnicity g )Genetic factorsh) Length of urethrai) Urine itself j) DM
Risk Factors
2. Agent-organism3. Size of inoculum- small/large
PATHOGENESIS
• Ascending infection most UTI beyond the newborn period
• Descending infection 4 - 9 percent of children
with UTI are bacteremic
Clinical features
Presentations
< 2 month - nonspecific symptoms and signs – fever , Jaundice
2month -1 year:- Fever/Hypothermia Vomiting, Diarrhea Sepsis Irritability Lethargy Malodorous urine
Presentations
1-5 years:-Abdominal pain- Flank /back/ Supra pubic - Vomiting ,diarrhea - Constipation - Abnormal voiding - Urgency, urinary incontinence,
dysuria
1-5 years
- Malodorous Urine - Fever/febrile convulsion
- Failure to thrive
Presentations
>5years:-Dysuria Frequency Urgency Abdominal discomfort Fever Malodorous urine
Physical examinations
• Temperature• Pallor• Anthropometry• Blood pressure• Tenderness-Lower abdomen• Renal angle• Renal mass• Palpable bladder
Physical examinations
• Fecal mass• Signs of valvitis• Spine• Lower limb reflexes• Associated with UTI-Prune belly syndrome Anorectal anomalies
Localizing symptoms:
Symptoms of urethritis:• Dysuria• Reluctance to void• Perineal discomfort• Vaginal irritation and erythema in
girls• In older boys, urethral discharge• In adolescent girls associated with
PID symptoms
Features of cystitis:• Afebrile usually• Frequency• Enuresis• Dysuria• Reluctance to void
Localizing symptoms:
Features of pyelonephritis:• Fever and systemic signs • Older children –Flank pain or abdominal pain
• Younger children–Fever, irritability, vomiting, poor
feeding
Localizing symptoms:
LABORATORY EVALUATION
DipstickMicroscopy
Culture & sensitivity
Investigations
Methods of urine collection• Clean catch or midstream sample• Supra pubic aspiration –infancy• Urinary bag sample –small children• Catheter specimen –Severely ill
LABORATORY EVALUATION
Urine dipstick
88 % sensitive
• Leukocytes• Protein• Red blood cells • Leukocyte esterase• Nitrite
LABORATORY EVALUATION
Microscopic exam
• Bacteria: bacteriuria is the presence of any bacteria per hpf.
• Gram stain
Routine Microscopic Examination
• Color-Hazy• Smell- malodorous• White Blood Cells: pyuria is defined as ≥5
WBC/PHF in centrifused or ≥10 WBC/mm3 in an uncentrifuged sample
• Bacteria: bacteriuria is the presence of any bacteria per hpf. - Gram stain
Routine Microscopic Examination
• RBC >5 /HPF• RBC+WBC casts+• Albumin –Trace to +Urine C/S- gold standard - should be processed as
soon as possible after collection
LABORATORY EVALUATION
Urine culture • Midstream clean catch > 10⁵ colony forming units (girls) > 104 CFU (boys)• Catheterization 10⁵ CFU• Supra pubic aspiration any growth
LABORATORY EVALUATION
• Investigate the fever – CBC, CRP • Serum creatinine• Blood culture — Bacteremia occurs in 4-
9 % of infants with UTI
• Lumbar puncture — Infants <1 month of age with fever and a positive urinalysis; approximately 1 % of infants with UTI also have meningitis
Other laboratory tests
Imaging studies
1.Radiological – MCU IVP X-ray KUB2. Nuclear- USG DMSA scan DTPA scan MAG scan
Renal scans
• DMSA renal scan – anatomy of kidney (Scarring)
• DTPA renal scan – Excretory function ,filtration function of kidney
• MAG 3 with lasix renal scan – Obstruction at the ureterovesical junction - quantitative information regarding kidney function and drainage , assesses the degree of blockage
Principle of management
1. Treatment of acute infection2. Prevention of further infection3. Adequate investigation4. Arrangement of further treatment5. Follow up - Prevention of recurrence
and long-term complications
MANAGEMENT
Indication for hospitalize:• Age <2 months • Sepsis or potential bacteremia • Immunocompromised patient • Vomiting or inability to tolerate oral
medication • Lack of adequate outpatient follow-up• Failure to respond to outpatient therapy
Choice & route of Treatment
Depends on – Age Severity of illness
Choice of agent: provide adequate coverage for E. coli.
ANTIBIOTIC THERAPY:
• Newborn + Infants Inj ampicillin + Inj. Gentamycin-14 days
• Older children:- Oral – Co-timoxazole cephalosprins Nalidixic acid amoxicillin-clavulanate• Parenteral therapy: Ampicillin or Third- or
fourth-generation cephalosporins and aminoglycosides - first-line agents for empiric treatment of UTI in children.
MANAGEMENT
ANTIBIOTIC THERAPY• Duration of therapy: 7-14 days • Response to therapy: Clinical response Repeat urine culture
Indications for further investigations:
1. Girls younger than 3 years with a first UTI
2. Boys of any age with a first UTI 3. Children of any age with a febrile UTI 4. Children with recurrent UTI5. First UTI in a child of any age with a
family history of renal disease, abnormal voiding pattern, poor growth, hypertension
Prevention
1. General measures:-• Fluid intake• Complete and periodic voiding• Vioding at bed time• Perineal hyiene• Treatment of worms• Prevention of constipation• Avoid catheterization
Prevention
• Early treatment of cong anomalies• Circumcision2. Low dose chemoprophylaxis - UTI until radiological evaluation is complete - Recurrent UTI - VUR grade I- III - Post operative-PUJ,VUR IV & V, PUV
Prevention
- Chronic cystitis - Neurogenic ladderCommonly used drugs for prophylaxis:-• Co-trimoxazole-2mg/kg/d• Nalidixic acid-12.5mg/Kg/d• Nitrofurantoin -1mg/kg/d
Follow up
1. Clinical- During the year following infection 1 year after starting prophylaxis height, Blood pressure –recorded2. Urine C/S- 3 monthly-infancy Fever & symptoms –older children3.RFT 4. Imaging –when neded
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