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Pediatric Urinary

Tract Infections

Partini P. Trihono

Child Health Department-FMUI


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Background:

problems of UTI in infants

Urinary tract infection (UTI) iscommon in infants

UTI often signal an underlying genitourinary tract

abnormalityUTI is difficult to recognise

Collecting urine and interpreting laboratory results

is not easyDiagnosis is not always confirmed

UTI in infants may have long-term sequelae


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a. Adequate urine volume

b. Free-flow from kidneys through urinary

meatus

c. Complete bladder emptyingd. Normal acidity of urine

e. Peristaltic activity of ureters and competent

ureterovesical junction

f. Increased intravesicular pressure preventingreflux

g. In males, antibacterial effect of zinc in prostatic

fluid

Normal mechanisms that maintain

sterility of urine


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Definition:

Urinary Tract Infection

Symptomatic inflammatory response of theurothelium to bacterial invasion associated

with bacteruria & pyuria involving >105

colony counts / ml of urine

Infection of any component of the urinary

tract includingUrethritis

Cystitis

Pyelonephritis


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TERMINOLOGY

SIGNIFICANT BACTERIURIAThe presence of > 100.000 CFU/ml fresh voided clean catch or

catheterized urine specimen

SYMPTOMATIC UTI

Clinical symptoms: dysuria, frequency, urgency

with or without fever and flank pain

1. Acute cystitis (lower UTI)

2. Acute pyelonephritis

ASYMPTOMATIC BACTERIURIA (ABU)

RECURRENT UTI- Repeated symptomatic episode of UTI with symptom-free intervals

- Caused by reinfection

RELAPSE UTI:

persistence of the same bacterial species


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Epidemiology

It is reported as second most common infection inchildren

5.3% ED visit for fever in infants are due to UTI

Occurs in about 7% of children

Infants :~


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Overview of UTI by age and sex


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Factor Predisposing to UrinaryTract Infection

Ability to grow

Rapid doubling time Ability to colonize the gut Adherence to urothelium Porins Capsule Hemolysin Aerobactin P-Fimpriae

Maternal UTI Lack of breast feeding Receptors for

uropathogens Defective bladder

mucosal factor

Presence of the prepuce Antibacterial eradication

of vaginal flora Urinary secretory IgA Blood group type

Bacterial Factors Host Factors


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Pathogenesis

Access to GU tract include ascending,

hematogenous, lymphatic and direct

extension

Most common pathogens include enteric

gram-negative bacilli (Escherichia coli),

Enterobacter, Klebsiella and Proteus spp


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Virulence Factors:

Flagella

Fimbriae (Pili) -important for

coloniaztion of hosttissue

Exotoxins

Escherichia coli


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Bowel flora

Emergence of uropathogenic strainPerineal and anterior urethral colonization

(vaginal colonizat ion in females)

Normal mucosal defence barriers

BACTERIAL VIRULENCE

CYSTITIS

Acute PN

Renal scarring urosepsis

PATHOGENESIS OF ASCENDING UTI


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Signs and Symptoms

Newborns (


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Signs and Symptoms

Children 2 months to 2 years

Feverusually unexplained

Vomiting and/or diarrhea

Abdominal Pain

Failure to thrive

Malodorous urine

Crying on urination


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Signs and Symptoms

Children >2 Fever

Vomiting and/or diarrhea

Abdominal pain

Malodorous urine

Frequency and/or urgency Dysuria

New incontinence


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CLINICAL EVALUATION

HISTORY

Voiding history if toilet trained

Bowel habits

Family historyEXAMINATION

Abdomen- masses, bladder, faeces

Genitalia - circumcision, meatus, labial

adhesions, vulvovaginitis

Neuro - back, perineum, lower limbs

Blood pressure


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Investigations

Specimen Collection

BAG

clean catch

SPA

Catheterization

Storage

Transfer within 30minutes of collection

Refrigerated at 4c

Stored at 4c for 48 h

is suitable for culture,not for microscopy

Bed side Detection

Dipstick

Microscopy

Laboratory Urinalysis

Culture

Imaging

USG

MCU

DMSA


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Sensitivity and Specificity ofComponents of the UA

Test

Sensitivity %

(Range)

Specificity %

(Range)

Leukocyte esterase

Nitrite

Leukocyte esterase or nitrite positive

Microscopy: white blood cells

Microscopy: bacteria

Leukocyte esterase or nitrite or

Microscopy positive

83 (67-94)

53 (15-82)

93 (90-100)

73 (32-100)

81 (16-99)

99.8 (99-100)

78 (64-92)

98 (90-100)

72 (58-91)

81 (45-98)

83 (11-100)

70 (60-92)


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Table. Criteria for the diagnosis of urinary tract infection*

Method of collection Colony count(pure culture)

Probability of infection

Suprapubic aspiration

Transurethralcatheterization

Clean void

Gram-negative bacilli:

any numberGram-positive cocci:

> a few thousand

> 105

104 to 105

103 to 104

< 103

Boy: > 104Girl: 3 specimens 1052 specimens 1051 specimens 1055 x 104 to 10510 to4 5 x 104

< 10

4

> 99%

95%Infection likely

Suspicious; repeatInfection unlikely

Infection likely95%90%80%Suspicious; repeatAsymptomatic: infection

unlikely

Infection unlikelyHellerstein, 1982


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RADIOLOGIC EVALUATION

THE AIMS

1. To uncover any underlying urologic abnomarlity (VUR,duplicate collecting system, obstruction)

2. To identify patients with chronic renal damage / scarringfrom previously UTI

3. To assist the diagnosis of acute PN

INDICATION / GUIDELINES FOR SELECTION

All neonates with first UTI

All males with first UTI at any age

All patients with recurrent UTI

All patients with PN


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USG DMSA IVP MCU Urodynamicstudy

Kidney

anatomy

+++ + ++urethra

Renal function Diff GFR +

VUR +++

Scarring + +++ ++

Bladder

dysfunction

+ + +++

Table. Imaging studies after first-time UTI


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MANAGEMENT

General principle:

Rapid diagnosis

Immediate antibacterial treatment, while awaitingconfirmation of diagnosis

Prevention of further infection pending investigation

Adequate investigation of first known UTI

Arrangement for appropriate further treatment

Follow-up until symptoms are controlled


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ANTIBACTERIAL TREATMENT

The choice of drugs and route of

administration will depend on:

Age, condition of the child: oral/parenteral route

Local community or hospital antibact. resistance

History of recent antibacterial treatment

The possible effect of the chosen drug on the bowelflora resistance pattern


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American Academy of Pediatrics (AAP) 1999

Subcommitte on UTI

2 month 2 years old

with suspected UTI

- toxic

- dehydrated

- unable to retainoral intake

- Parenteral antibiotic

- Hospitalization

Urine culture

positive?Oral or parenteral

antibiotics

NO

No UTI

NO

YES

7-14 days

antibiotic therapy

Prophylactic dose

YES

Evaluation of UTIs in Febrile infants & young children


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2 mo to 2 yrs of age with unexplained fever 1 : strong(S)

Consider UTI

2 (S): Does the infants toxicitywarrant

immediate antimicrobial therapy?

3 : Good (G)

Obtain urine specimen by SPA or

transurethral catheterization; culture urine

Yes

Option: Performurinalysis on specimencollected by mostconvenient method

Option: Obtain urinefor culture by SPAor transurethralcatheterization

No

4 : (G)

Initiate antimicrobialtherapy parenterally;consider hospitalization

Option:Urinalysis maybe helpful inguiding initialantimicrobialtherapy

6 : consensus

Urinalysis positive for LE, nitrite or WBCs?Yes4b

Urine culture positive? 7 to 14 days ofantimicrobial therapy;guided by culture results

Yes 7:(G)

UTI unlikely in theabsence of specific

symptoms. Followclinical course.

Reconsider UTI if feverpersists.

No4aNo UTI

No

Clinical responsewithin 48 hours?

Urine culture andurinary tractultrasound now

Urinary tractultrasoundas soon asconvenient

VCUG of RNCstrongly

encouraged,

as soon asconvenient

Yes

No 11Fair(F)

9:(S)

10:(G)Prophylactic

treatment

obstrt

VUR (+)

F

Evaluation of UTIs in Febrile infants & young children

5:(G)

8(G)

S f f


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Table. Some antimicrobials for oral treatment of UTI

Antimicrobial Dosage

Amoxicillin (?)

Amox-clav.acid

Sulfonamide

TMP in combination

With SMXSulfisoxazole

Nitrofurantoin

Cephalosporin

CefiximeCefpodixime

Cefprozil

Cephalexin

Cefuroxime

20-40 mg/kg/d in 3 doses

50 mg/kg/d in 3 doses

6-12 mg TMP, 30-60 mg

SMX per kg per d in 2 doses120-150 mg/kg/d in 4 doses


8 mg/kg/d in 2 doses10 mg/kg/d in 2 doses





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Table. Some antimicrobials for parenteral treatment of UTI

ANTIMICROBIAL DAILY DOSAGECeftriaxone

Cefotaxime

CeftazidimeCefazolin

Gentamicin

Tobramycin

Ticarcillin

Ampicillin

75 mg/kg/d

150 mg/kg/d

150 mg/kg/d50 mg/kg/d

7.5 mg/kg/d

5 mg/kg/d

100 mg/kg/d

100 mg/kg/d


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