Urinary tract infection

Done by
Dr Ali Abdul-Razak

Urinary tract infection

Urinary tract infection (UTI) is
one of the most common
infections of childhood.

It distresses the child, concerns

the parents, and may cause
permanent kidney damage.

Incidence
During the first year of life male to
female ratio is 2.8-5.5:1,this is
because of periuretheral colonization
with E.coli, enterococci and proteus
species.
The rate in uncircumcised boys is 5 to
20 times higher than in circumcised
boys.
Beyond 1-2 yr the male to female
ratio will be 1: 10.

Causes
Almost all UTIs are ascending in origin,
bacteria arise from the fecal flora,
colonize the perineum & enter the bladder
via the urethra.
In females 75-90% of infections caused by
Escherichia coli , followed by Klebsiella
and proteus.
In male proteus commoner than E.coli,
other organisms include staph.
Saprophyticus.

Clinical manifestations
There are three basic forms of UTI:
1.Pyelonephritis: (upper UTI)
characterized by abdominal or flank
pain, fever, malaise, nausea,
vomiting & occasionally diarrhea.
Some newborns & infants may show
non specific symptoms: jaundice,
poor feeding, irritability, & weight
loss, or signs of septicemia.

unexplained high fever in a

young child with little or no
systemic symptoms and no
focus of infection should rise a
suspicion of UTI.

The older children with

pyelonephritis often have
tenderness of the flank or
costovertebral angle.

2.Cystitis : (lower UTI)

characterized by dysuria,
urgency, frequency, suprapubic
pain, incontinence & malodorous
urine.
Cystitis does not cause fever &
does not result in renal injury.
The older children with cystitis
may have suprapubic tenderness.

3.Asymptomatic bacteriuria:
Refers to patients who have
positive urine culture
without any manifestations
of infection & occurs almost
exclusively in girls, this
condition is benign & does
not cause renal injury.

Risk factors for UTI

1. Female gender
2. Uncircumcised
male
3. Vesicoureteric
reflux
4. Toilet training
5. Voiding
dysfunction
6. Obstructive
uropathy
7. Anatomic
abnormality
(labial
adhesion)

8. Urethral
instrumentation
9.Wiping from
back to front
10. Tight
underwear
11. Pinworm
infestation
12. Constipation
13. Neurogenic
bladder
14. Sexual activity

Diagnosis
UTI may be suspected based on
symptoms or findings on
urinalysis or both.
The diagnosis is based on
quantitative cultures of a properly
collected urine specimen

Methods of urine collection:

1.A midstream, clean-catch
specimen may be obtained from
children who have urinary control.
2.Urinary specimen may be
collected from a sterile bag
attached to the perineal area,
however, the false-positive rate is
so high that this method of urine
collection is not suitable for
diagnosing a UTI.

3.

Urethral catheterization.

4.Suprapubic aspiration is the

method of choice for
obtaining urine from children
of either sex with clinically
significant periuretheral
irritation.

Quantitative Urine Culture

for the Diagnosis of UTI:
1.Suprapubic aspiration If a
UTI is present, bacteria are
likely to be proliferating in
bladder urine with growth of
any organism.

 If the culture shows >100,000

colonies of a single pathogen
or if there are 10,000 colonies and
the child is symptomatic, the child is
considered to have a UTI.
In a bag sample, if the urinalysis
result is positive, the patient is
symptomatic, and there is a single
organism cultured with a colony
count >100,000, there is a presumed
UTI
If any of these criteria are not met,
confirmation of infection with a
catheterized sample is recommended.

 Other tests:
Urinalysis:
Does not substitute for urine culture
to document the presence of a UTI.
Urine should be freshly voided ,and
well centrifuged.
Pyuria suggest infection, but infection
can occur in the absence of pyuria.
(normal WBC in urine is< 5/mm)
Microscopic hematuria is common in
cystitis, while blood cell cast suggest
renal involvement.(normal RBC in
urine < 5/mm).

Nitrites and leukocyte esterase

usually are positive in infected
urine.
Complete blood count:
Leukocytosis, neutrophilia,
increased ESR & C-reactive protein
are common.
Perform blood cultures in febrile
infants and older patients who are
clinically ill, toxic, or severely
febrile.

 Imaging studies:
1. Renal ultrasound
should be obtained to rule out
hydronephrosis & renal or perirenal
abscess, obstructive uropathy, renal
calculi, single or ectopic kidney and
some patients with moderate renal
damage caused by Pyelonephritis.

Indications for renal US:

1.In children with their 1st episode of
clinical pyelonephritisthose with a
febrile UTI
2.or, in infants, those with systemic
illnessand a positive urine culture,
irrespective of temperature

Renal scanning with technetiumlabeled DMSA for detection of

acute pyelonephritis, and
presence of renal parenchymal
injury (scarring)
DMSA = Dimercaptosuccinic Acid.
2.

3. Voiding cystourethrogram
(VCUG) , done if there is positive
DMSA scan, to look for
vesicoureteric reflux.

Recommendations for imaging

studies:
1.Which children should undergo
ultrasonography of the urinary tract
after a first febrile UTI?
o Patients who have a delayed or
unsatisfactory response to treatment
of the first febrile UTI
o Children with an abdominal mass or
abnormal voiding (dribbling of urine).

o Any child with a first febrile UTI in

whom good follow-up cannot be
ensured.
o a first febrile UTI caused by an
organism other than E coli.
o recurrence of a febrile UTI after
they have a satisfactory response
to treatment of the initial febrile
UTI.

Treatment
IV antibiotics-Indications:
Any person of any age who appears
clinically toxic or who has neutropenia.
Infants <1 mo until bacteremia, sepsis, &
meningitis ruled out.
Children unable to tolerate oral antibiotics
Immunocompromised patients
it is reasonable to initiate treatment with
IV antibiotics until these symptoms usually
resolve in three days, then complete 10-14
days of therapy with an oral antibiotic.

Neonates
Ampicillin plus a second antibiotic (usually
gentamycin or cefotaxime) to cover for
GBS, Listeria, as well as gram negative
organisms
Vancomycin may be indicated for toxic
patients or those unresponsive to initial
therapy.

Older infants and children

Parenteral treatment with a third-generation
cephalosporin, such as ceftriaxone or
cefotaxime .
Then oral Cefixime (Suprax)
The total duration of therapy 10-14 days in
case of pyelonephritis.

 Antibiotic Agents for Parenteral Treatment of a

UTI
Drug
Dosage and route
Comment
Ceftriaxone

50-75 mg/kg/d IV/IM

as a single dose or
divided q12h
100 mg/kg/d IV/IM

Cefotaxime divided q6-8h

Do not use in infants <6

wk of age; may displace
bilirubin from albumin
Safe to use in infants
<6 wk of age; used with
ampicillin in infants
aged 2-8 wk
Used with gentamicin in
neonates <2 wk of age;
for enterococci and
patients allergic to
cephalosporins

Ampicillin

100 mg/kg/d IV/IM

divided q8h

Gentamicin

Term neonates <7 d:

3.5-5 mg/kg/dose
Monitor blood levels
IV/24h
and kidney function if
Infants and children : therapy extends >48 h
2- 2.5 mg/kg/dose IV
q8h

 Antibiotic Agents for the Oral Treatment of UTI

Antibacterial Agent

Daily Dosage

Sulfamethoxazole and
trimethoprim

6-12 mg/kg TMP, 30-60 mg/kg

SMZ divided q12h

Amoxicillin and clavulanic

acid

20-40 mg/kg divided q8h

Cephalexin

20-50 mg/kg divided q6h

Cefixime

8 mg/kg divided q12-24h

Cefpodoxime

10 mg/kg divided q12h

Nitrofurantoin*

5-7 mg/kg divided q6h

Nitrofurantoin may be used to treat lower UTIs.

However, because of its limited tissue
penetration, nitrofurantoin is not suitable for the
treatment of kidney infection.

 Urine culture performed 1 wk

after the termination of
treatment of any UTI to ensure
the urine is sterile( not routinely
needed)
if there is possibility of recurrent
UTI follow-up urine culture
should be performed periodically
for 1-2 yr, even when the child is
asymptomatic.

 Children with cystitis :

Symptomatic relief for dysuria consists of
increasing fluid intake to enhance urine
dilution and output, acetaminophen, and
nonsteroidal anti-inflammatory drugs.

A 5-day course of an oral antibiotic agent is

recommended for the treatment of cystitis
(trimethoprim-sulfamethoxazole (TMPSMX), Nitrofurantoin, and Amoxicillin ).
If the clinical response is not satisfactory
after 2-3 days, alter therapy on the basis of
antibiotic susceptibility.

Complications
1. Children with pyelonephritis may
develop renal abscess.
2. Any inflammation of the renal
parenchyma may lead to scar
formation.
3. Long-term complications of
pyelonephritis are hypertension,
impaired renal function, and ESRD .