Good Morning All! Happy March!Morning Report: Thursday, March 1st

UTIs in Infants and Children

*Definitions, Epidemiology, and Host Factors

Infection of the urinary tract anywhere from the urethra to the renal parenchyma• Most are infection of the mucosal surface of

the urinary tractOverall incidence of childhood UTIs:• Girls: 8%• Boys: 1-2%

Uncircumcised males: 0.7% Circumcised males: ~0.2%

*Definitions, Epidemiology, and Host Factors Age matters!• *Prevalence of UTIs in febrile infants

without an obvious source of infection 7-9% in infants <3mo 2% in males >3mo 2% in females >12mo

*Definitions, Epidemiology, and Host Factors Host factors• *Age• *Sex• Race• Circumcision status• GU abnormalities• Immune status

Methods for Diagnosis

Urinalysis• Nitrite

Demonstrates the presence of gram-negative bacteria

Specific but not sensitive• Leukocyte esterase

Detects presence of leukocytes Sensitive but not specific

• *Not alone sufficient to diagnose a UTI

Methods for Diagnosis

Urine culture• Gold standard when obtained by

Suprapubic aspiration Urethral catheterization “Clean catch” midstream specimen

*Microbiology

E.Coli• 70% of infections!

Pseudomonas aeruginosa Enterococcus faecalis Klebsiella pneumoniae Group B Streptococcus (neonates) Staphylococcus aureus Proteus mirabilis Coagulase-negative Staphylococcus

Pathogenesis

Uropathogenic bacterial strains have distinctive antigens and genes that enhance virulence• P-fimbriae, protectins, toxins and siderophores

*Constipation• Compression of bladder and bladder neck

increase of bladder storage pressure and PVR• Distended colon/ fecal soiling provides

abundant reservoir of pathogens

Clinical Presentation

Infant 0-3 mos Fever Hypothermia Vomiting Diarrhea Jaundice Feeding difficulty Malodorous urine Irritability FTT Hematuria

Infants 3-24mos

Cloudy/ malodorous urine

Frequency Hematuria Fever without a

source

Clinical Presentation

Preschool (2-6yo)

Abdominal or suprapubic pain

CVA pain Dysuria Urgency Secondary enuresis

Management

Action Statement 1

Action Statement 2

Action Statement 2

Let’s break it down, shall we?• If you feel the infant is well enough to

hold off on antibiotics then you should assess the likelihood of the patient having a UTI• So, how do I do that??

Action Statement 2

Febrile infant girls>boysUncircumcised boys> circumcised boysPresence of another clinically obvious

infection reduces likelihood of UTI by one-half

Action Statement 2

Action Statement 3

Action Statement 4

Action Statement 4

Action Statement 5

Action Statement 5

When to you perform the RUS?• If clinical illness is severe or substantial

clinical improvement is not occurring perform within the first 2 days of illness• If substantial clinical improvement is

demonstrated, imaging does not need to occur early during the acute infection and can be misleading

Action Statement 6

Action Statement 7

A Question…

You are evaluating a 5 yo girl who has a UTI. She has had four lower UTIs in the last 2 years, all of which resolved completely with oral antibiotics. She denies symptoms of urgency and frequency. The only significant finding on her medical history is constipation. Results of her RUS and VCUG are normal. Her growth parameters and PE findings are normal. You prescribe oral trimethoprim-sulfamethoxazole. Of the following, the MOST appropriate additional step to help reduce the incidence of further UTI is to:• A. Begin an evaluation for immunodeficiency• B. Perform renal scintigraphy• C. Prescribe a stool softener and regular bowel routine• D. Prescribe oral oxybutynin • E. Refer her to a pediatric nephrologist

Thanks for your attention!Noon Conference: Common Mouth and Throat Infections, Dr. Riojas