Urinary tract infection

By Dr S. Kabir MBBS BUK

synopsis
Introduction Anatomy of UT Epidemiology Pathogenesis Microbiology Clinical presentation Diagnosis Investigation Deferential diagnosis Treatment Complication Prevention referance

Introduction
UTI is define as a pure growth of bacteria > or = 100,000bacteria per ml of urine. This 105 is referred as kass critical figure and is applied to both symp. & asymp.UTI UTI can be complicated or uncomplicated

Uncomplicated
Anatomically & physiol. Normal UT. Normal renal function No assocd. Disorder w/c impair defense mechanism of UT

Anatomy of urinary tract

Epidemiology
UTI is 2nd most common bacterial infection in childhood more commoner in girls world wide. In Britain 1.7/ 1000boys/ yr and 3.1/1000girls/yr. however the incidence is reverse in infant.( more congenital anomalies in male) In research conducted at port Harcourt TH in all children presenting to the hosp. the prevalence is about 10times >British 1.6% & M:F 0.9:1

PATHOGENESIS
UT like RT & GIT end on the body surface and therefore can never be sterile throughout it length. However, the tract is anatomically and phys. Normal organisms are only confined to lower end of urethra By far the commonest route of infection is ascending infection from bowel flora. However, heamatogenous route occur particularly in neonate

Predisposing factors
1- Age- extreme of age, UTI is the source of infection in up to 6-8% of febrile infants in the first 3 months of life. 2- sex- females more affected than male uncircumcised male are more affected 3- vesico-urinary ruflux 4- Urinary obstruction post. Urethral valve bladder diverticulum urethral defect eg hypospedias

5- Dysfuctional voiding eg neurogenic bladder, 6- poor toilet and hygiene habits 7- the use of bubble baths or soaps that irritate the urethra 8- family history of UTIs

MICROBIOLOGY OF UTI
E. coli account for about 75% of UTI and up to 90% in some studies. virulent factor of E.coli and other enteric bacteria include; -K(capsular) antigen w/c inhibit phagocytosis and bacteriacidal effect of complement proteins. -Special fimbia that have ability to adhere to uroepithelium.

Other coliforms causing UTI include; Klebsiella spp ; common in neonate. Proteus marabilis Staph. Aureus Pseudomonas sp Strept. Faecalis Staph. saprophyticus

Acute Uncomplicated UTI is cause by one type of bacteria, while chronic complicated UTI is caused by multiful bacteria spp.

CLINICAL FEATURES
Depend on age; Fever is the most important feature, any infant presenting with fever most have his urine send for m/c/s within 24hrs, as well as other children even if there is working diagnosis.

In younger children and infants, the symptoms may be very general. -The child may seem irritable - poor feed -vomiting. - fever. -Prolong jaundice in new borne

In older kids, pain, burning, sensation when urinating Urgency frequent urination fever Enuresis (wetting problems) abdominal pain; suprapubic, loin & low back pain Foul or fishy-smelling, cloudy urine haematuria

 examination

DIAGONOSIS
The diagnosis depend on; -Xtics clinical features -Demonstration of = or > 105 organism /ml of MSU or clean catch urine, or any organism in suprapubic aspirate specimen. -Pyuria > 10 WBC/ml of uncentrifuge urine

INVESTIGATION
1- Urine examination; This is simple and the most important tool in diagnosis of UTI. a-Sample collection; In older children:- MSU In babies: - clean catch - Self adhesive plaster - suprapubic aspirate - catheter specimen

 b- Transport of specimen Bacteria multiply in urine, sample must be collected to the lab within 2-4hrs. If this is not possible one of the ff. must be done -Refrigerate specimen at 40 C - using container with boric acid or other bacteriostatic preservative

 Direct examination -Wet film for Presence of pus cell, Blood cells or Cast -Gram strain film. E-coli Gram negative bacilli.

Culture/ sensitivity
Is done on Macconkey agar or cled Colonies are Observe and cell are counted per ml of urine. >100,000- UTI 10 100,000 -doubtful result <10,000 -contamination

STERILE PYURIa
Presence of pus cell without growth of any bacteria. This occur in renal Tuberculosis, urine AFBx3 Must be done.

2- URINALYSIS.
Is done to determine presence of; -Blood -Nitrite Nitrate is converted to Nitrite by bacteria in the bladder. -proteinuria- is present in complicated pyelonephritis

3- IMAGINE STUDIES.
Uss- pyelonepheritis, cystitis, stones. plain Abd. X-ray:- calculi, and vertebral abnormalities in pt with Neurogenic bladder. Micturating cystourethrogram in pt with PUV, diverticulum & urethral abnormalities. Intravenous pyelogram

 CT-SCAN & MRI Nuclear scans

4- RENAL FUNCTION TEST

U/E + Cr

Deferential diagnosis
malaria Pneumonia Appendicitis Bacteremia and Sepsis Gastroenteritis Pinworms Renal Calculi Urinary Obstruction Vaginitis Vulvovaginitis pregnancy

Treatment
Treatment of UTI depend on age and presence or absence of systemic symptoms. When UTI is suspected urine sample most be send for m/c/s and broad spectrum antibiotic started b4 the culture result is available.

 Antibiotic that can be use for emperical treatment are chosen for coverage of E coli and for Enterococcus, Proteus, and Klebsiella species. For suspected pyelonephritis, a combination of parenteral antibiotics is recommended. These drug include;

 1- Ampicillin at dose of 100- 200mg /kg/day in 4divide dose. IM/IV 2- Gentamycin at dose of; <5 years: 2.5 mg/kg/dose IV/IM q8h >5 years: 1.5-2.5 mg/kg/dose IV/IM q8h 3- Amoxicillin at dose of 30-50 mg/kg/d PO, IM/IV divided q8h

 4- Trimethoprim and sulfamethoxazole (septrin) <2 months: Not recommended >2 months: 5-10 mg/kg/d PO divided q12h, based on TMP component 5- cephalosporin -Cephalexin (Keflex) 250-1000 mg PO q6h for 10-14 d; not to exceed 4 g/d

-Cefotaxime (Claforan) 100-200 mg/kg/d IV/IM divided q6-8h -Cefixime (Suprax) 8 mg/kg PO qd; not to exceed 400 mg/d

 Start specific antibiotics after m/c/s are obtained. A 10- 14day course.

Algorism for mgt of UTI

Antibiotic prophylaxis in UTI

Is recommended 4pt. With; - VUR & other structural abnormalities -Recurrent UTI (3episodes in 1yr) A single nightly dose of; Nitrofurantoin (1- 2 mg/ kg per day), or Septrin (2 mg/ kg of TMP/day, may be used for 6mnt or more.

Indications for admission

Toxemic or septic pt. Signs of urinary obstruction or significant underlying disease Patients unable to tolerate adequate PO fluids or medications Infants younger than 3 months with febrile UTI (presumed pyelonephritis) All infants younger than 1 month with suspected UTI even if not febrile

Complications of UTI
Dehydration is the most common complication septicaemia (eg, urosepsis). Long-term complications include; -renal parenchyma scarring, -hypertension, - decreased renal function, - renal failure.

Prevention of UTI

Primary prevention

Primary prevention -Frequent diaper changes -Teach kids good hygiene -Girls should wipe from front rear -Kids should also be taught not to "hold it in"

-School-age girls should avoid bubble baths & Irritative soap, -wear cotton underwear instead of nylon -Drinking enough fluids

 Secondary prevention Early diagnosis and adequate Rx of xtural defect and UTI including prophylaxis

 Tertiary prevention Early detection of complication and mgt.

Reference
1- www.emedicine - paediatric UTI & pyelonephritis article by Ann G Egland : Feb 27, 2006 2- www.kidhealth UTI in children article by larissa hirsch, MD Nov 2006 3- www.urologyhealth.org UTI in children article by Linthicum, MD Dec 2005 4- www.mediline plus medical encyclopedia : UTI in children article by Marc A. Greenstein oct 2008

5- www.nhs health encyclopedia UTI April 2008 6- J C Azubuike, Peadiatrics and child health in the tropic 7- Douglas & Timbury, text book of medical microbiology. Third edition 1993 8- Edward et al, Devidson principles and practice of medicine 21st edition 2007

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