Urinary Tract Disorder

MANAGEMENT OF CHIDHOOD
URYNARY TRACT INFECTION

A. Definition of Terms
Urinary tract infection (UTI)

Presence of proliferating bacteria in the

urinary tract causing tissue invasion and
inflammation

Upper UTI or pylonephritis

Infection involving the renalparenchyma

causing systemic and local sympstoms

Lower UTI or cystitis

Infection limited to the lower urinary tract

(with acute volding sympstoms as the major
feature)

Asymtomatic or covert bacteriuria

Colonizationof the urinary tract by

uropatoghens without causing any
sympstoms

Atypical or complicated UTI

UTI associated with anatomical or functional

abnormalities of the urinary tracrt :
a) Evidence of obstructive uropathy:
i. Poor urine flow
ii. Abdominal or bladder mass
b) Seriously ill (toxic)
c) Septicema
d) Raised creatinie
e) Failure to respond to antibiotic treatment
within 48 hours.

Recurrent UTI

a) 2 episodes of acute pyelonephritis or

b) 1 episode of acute pyelonephritis/upper UTI
+ 1 episode of cytitis/lower UTI or
c) 3 episodes of cytilis/lower UTI

B. Diagnosis of UTI

0c
I. Guidelines for diagnosis:
1. All infants and children with unexplained fever 38.5

2. Infants and children with alternative site of infection who

remained unwell.
3. Infants and children wih signs and symtomps suggestive of UTI

II. Signs and symptoms

1. Signs and symptoms of UTI differ according to
age :
Infants present with non-specific signs and symptoms
and there fore of UTI requires a HIGH INDEX of
suspicion

Age group

Signs and symptoms from most common to least

common

Infants <3 months

Fever
vomiting
Lethargy
Irritability

Poor feeding
Failure to thrive

Abdominal pain
Jaundice
Hematuria
Offensive urine

Preverbal

Fever

Abdominal pain
Loin tenderness
Vomiting
Poor feeding

Lethargy
Irritability
Hematuria
Offensive urine
Failure to thrive

Verbal

Frequency
Dysuria

Dysfunctional
voiding Changes
in continence
Abdominal pain
Loin tenderness

Fever
Malaise Vomiting
Hematuria
Offensive urine
cloudy urine

Infants and
children 3
months

2. Differetiating between upper and lower tract UTI:

Clinical

Upper tract

Lower tract

Age

<3 years

3 years

Fever

Voiding dysfunction

Suprapubic pain

Loin pain

Raise

Normal

Creative protein
Renal involvement :
a) Raised creatinine
b) Area of edema on power
Doppler ultrasound
c) Photopenic area on DMSA scan

III. Work-up
1. Dipstik
Leucocyte (+)

Leucocyte (-)

Nitrite (+)

Send for urine

Treat as UTI
Start antiiotics

Send for urine culture

Start antibiotics (if
freshly voided stample
was obtained)

Nitrite (-)

Send for microscopy

and culture
Start antibiotics only if
with good
Evidence of UTI

Not UTI
Explore other causes of
fever
Send for microscopy if
with known structural
abnormalities

*Dipstick (positive leucocyte esterase and nitrite) is useful to

rule in UTI in children2 years
7

3. Urine culture is the gold standard in diagnosing UTI

Method of collection

Colony count/ml (pure

culture)

Probability of infection
(%)*

Suprapubic
Aspiration

Gram-negative bacilli : any

number
Gram-positive cocci :>103

>99%

Transurethral
Catheterization

>105

95%
Infection likely
Suspicious, repeat
Infection unilikely

Clean void
Boy
Girl

104
3 specimens 105
2 specimen 105
1 specimens 105
5 x 104 to 105
104 to 5 x 104
<104

5 x 104
103 -<5x 104
103

Infection likely
95%
90%
80%
Suspicious, repeat
Symptomatic:
Suspicious, repeat
Asymptomatic:
infection
Unlikely
Infection unlikely

*Criteria from the Academy of Pediatrics, 1999, 2011

a.The following should be considered indeterminate and shoud be

repeated :
i. Significant growth of 2 pathogens
ii. A predominant pathogen with a contaminant
iii. Intermediate growth of a single pathogen.
b. Contamination rate of urine obtained by the following are :
i. Bag specimen : 62,8 %
ii. Catheterization : 9,1 %
c. Infants whose urine was obtained by bag versus catheter were 4
to 5 times more likely to have unnecessary treatment and
radilogical investigation, 12- fold more likely to have unnecessary
hospitalization, and were more likely to have delayed diagnosis
and treatment.

C. Imaging

The prevalence of structural abnormalities in the urinary tract in infants

and childreb with UTI ranges fro 10 75 %
About 5-35% have significant obstruction requiring surgery

I. Goals of imaging :
1. To identify those with underlying structural renal abnormalities, especially
obstructive uropathies requiring surgery
2. To identify those with factors predisposing them to increased risk of recurrent
UTI
3. To identify those with renal parenchymal damage (primarity in those with
severe or bilateral disease), predisposing them to increased risk of:
a. Hypertension (38%)
b. Pre-eclampsia in pregnancy
10

II. Renal ultrasound:

Non-invasive procedure
Gives information on :
a.Renal size and shape
b.Bladder size and configuration, bladder wall thickness
c.Presence or absence of pelvicalyceal and ureteral
dilatation.
Recommendation:
Renal ultrasound scan should be done as initial investigation to detct
dilatation secondary to obstruction and other abnormalities in:
All children with presumptive upper tract UTI
Infants age <6 months with lower tract UTI
Children with recurrent UTI

III Micturating cystourethrogram (MCUG):

Gives information on :
a.Bladder lesions
b.Urethral lesions especially posterior urethral valves in boys
c.Competence of vesicoureteric junction and the grade of
vesicoureteric reflux (VUR) if present

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IV. 99mTecnetium Dimercaptosuccinic acid (DMSA) scan

Gives information on :
a.Focal areas of decreased uptake indicating:
i. Acute pyelonephritis in the acute stage
ii. Established scars when DMSA done 3 months later
Note: 50% of children with scarring had normal MCUG
b. Differential function of the 2 kidneys
Recommendation:
DMSA scan is indicated in :
All children age <3 years with febrile UTI
Children age 3 years with clinical evidence of acute
pyelonephritis or recurrent UTI
Established scars can only be diagnosed 3 monts after an acute pyelonephritic
episode. If DMSA scan is done within 3 months of the acute infection in young
children, this should be repeated after 5 years when IV sedation is not required for
the procedure

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V. Diuretic renography with 99mTecnetium Mercaptoacetyltriglycine

(MAG3)
If there is delayed excretion, furosemide at1 mg/kg is given after
minutes.
Gives information on:
a.Renal perfusion
b.Uptake, excretion and drainage of radotracer
c.Differentisl function of both kidneys
Note : To distinguish between a true mechanical obstruction and
nonobstructive pelvicalyceal dilatation. T >20 minutes suggest the
presence of an underlying mechanical obstruction.
Recommendaion :
MAG3 renogram is indicated when :
Pelvicalyceal dilatation 1 cm on ultrasound examination
Vesicoureteric stenosis is suspected in the presence of uteric
dilatation on ultrasound examination and absence of
vesicoureteric reflux on MCUG

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VI. Algorithm for investigation of UTI

1. Boys
Ultrasound of urinary
tract
PC dilatation
21 cm

0,4 to <1 cm

ureter not seenureter seen

None
DMSA
Observe

MAG3 Renogram + VCUG

DMSA

VCUG
Atypical UTI
Recurrent UTI
Ultrasound :
Small kidney
Dilated ureter
Thickened
bladder wall

16

2. Girls

Ultrasound of urinary
tract
PC dilatation

<1cm

21cm
Age <6 yrs

Age 6 yeas

DMSA

Observe

ureter not seen ureter seen

MAG3 Renogram + VCUG

(+) SCAR

No scar
recurrent UTI

DMSA + VCUG

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D. Treatment
I. Principles of treatment
1. The drug of choice should be based on the resistance
patterns of the uropatogens in the hospital as well as of
recent antibacterial treatment received by the patient.
2. The drug should have minimal adverse effects on the
major organ systems.
3. A high concentration of the drug should be preesnt in the
urine after administration.
4. Oral antibiotics are efficacious in both lower and upper
tract infections.
5. Second and third generation cephalosporins should be
avoided as empiric therapy in non-atypical UTI to avoid
increase in antibiotic resistance.
6. Urinaru antiseptics such as nalidixic acid and
nitrofurantoin should not be the initial drug choice in
upper tract UTI

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Antibiotic

Frequency

Therapeutic dose
(mg/kg/dose)

Prophylactic dose
(mg/kg ON)

Ampicilin/sulbactam
(Unasyn)

Q12H

15-25 (ampicilin)
(maximum 2 g)

Amoxcilin

Q8H

10-25 (maximum 1g)

Amoxycilin/Clauvulani
c acid (Augmentin 7:1)

Q12H

10-25 (amoxcilin)
(maximum 1g)

Cefaclor

Q8H

10-15 (maximum
500mg)

10

Cephalexin

Q6H
Q12H

7.5 (maximum 250 mg)

15 (maximum 500mg)

7.5

Cefuroxime

Q12-24H

10-15 (maximum 500

mg)

Co-trimoxazole*
Trimethoprim
(TMP1 mg)
Sulphamethoxazole
(SMX 5 mg)
OR Trimethoprim

Q12H

3-4 (TMP)

Q12H

3-4

Nalidixic acid*#

Q6H

7.5-15 (maximum 100

mg). Reduce to 7.5
mg/kg/dose after 2
weeks (maximum 50

15 Q12H

10

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II. Intranvenous antibiotics

1. Intravenous antibiotics are indicated in :
a.Infants <3 months of age
b.Poor oral intake
c.Organism resistant to effective oral antibiotics
d.Dilating vesicoureteric reflux grades III-V
e.Atypical or complicated UTI
2. Intravenous single high dose gentamicin is the treatment of
choice in all age groups changing to oral antibiotics depending
on culture results.
3. Intravenous gentamicin and ampicilin should be used in
neonates until culture results are available. Ampicilin is included
in the regimen to cover the small percentage of infants with
enterococcal UTI

4. Second and third generation cephalosporins should be avoided in

non-atypical UTI to avoid increase in antibiotic resistance.
5. Intravenous cefriaxone is the drug of choice in atypical or
complicated UTI. Cefriaxone should be avoided in the first 2 weeks
of life as it may affect bilirubin transport in the liver.
6. In atypical or complicated UTI, if an aminoglycoside is required
based on antibiotic sensitivity results, amikacin is the
aminoglycoside is required based on antibiotic sensitivity results,
amikacin is the aminoglycoside of choice as its nephrotoxic
potential may be lower than gentamicin
7. Commonly used parenteral antibiotics-intravenous (IV) and
intramuscular (IM)

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Antibiotic

Route

Frequency

Dose (mg/kg
dose)

Comment

Amikacin

IV,IM

Single daily dose

Term Neonate: 15
1 week to 10
years: 25 (D1),
then 18>10
years:20 (D1),
then 15
(maximum 1.5
g/day)

Monitor levels
Through level <5
mg/L
Renal adjusment

Ampicilin

IV,IM

Q12H (W1)
Q6 H (W2-4)
Q4-6H (W4+)

10-25
Severe : 50
(maximum 2 g)

Renal Adjusment

Augmentin

IV, IM

Q8H

30 (maximum 1.2
g/dose)
10-25 (amoxcilin)
Severe :50
(amoxcilin)

Renal adjusment

Cefazolin

IV.IM

Q6H
Q4-6H

10-15(adult 0,5 g)
Severe :50
(maximum 2 g)

Renal adjusment

Cefriaxone

IV, IM

Q12-24H
Q24H(W1)
Q12H(W2+)

25 (Adult 1 g)
Severe : 50
(maximum 2g)

Use with caution

in neonates

Cefuroxime

IV

Q8H
Q12H (W1)
Q8H (W2)
Q6H (>W2)

25 (Adult 1 g)
50 (maximum 2 g)

Gentamicin

IV,IM

Q8H
Q12H(W1)
Q8H (W2)
Q6H(>W2)

15-25 (Adult 0.51g)

Severe : 50
(maximum 2 g)

Renal adjusment

Gentamicin

IV,IM

Q24H

Term neonate to

Monitor levels