1 Urinary tract infections

Urinary Tract Infections

Definitions:
Urinary tract infection (UTI) is defined by the presence of bacteria in
bladder urine. Once the diagnosis of UTI is made, it is important to
classify the location and severity of tissue invasion.

▪ Acute pyelonephritis is an infection which involves the bacterial

invasion of renal parenchyma.

▪ Acute cystitis is an infection limited to superficial invasion of the

bladder.

▪ Asymptomatic bacteriuria refers to the presence of infected

urine which produces no-clinical symptoms.

Epidemiology:
▪ Awareness of the prevalence of UTI in various subgroups of
children enables the clinician to grossly estimate the probability
of infection in the patient.

▪ In young children (<2 years) with fever :

1. The overall prevalence of UTI is approximately 7 percent

in febrile infants and young children but varies by age,
race/ethnicity, sex, and circumcision status.

2. Girls have a two- to four-fold higher prevalence of UTI

than do circumcised boys.

3. White girls with a temperature of ≥39ºC have a UTI

prevalence of 16 percent.

▪ In older children:

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1. The prevalence of UTI in older children is probably

underestimated.

2. Older children are more likely to present with urinary

symptoms in association with a UTI than younger children
but not as commonly as in adults.

3. The discrepancy in prevalence between children and

adults presenting with urinary symptoms may be related
to:

▪ Higher frequency of non-specific vulvovaginitis in

children.

▪ Better ability of adults to recognize symptoms of

UTI.

Pathogenesis
▪ Most UTI beyond the newborn period are the result of
ascending infection. Colonization of the periurethral area by
uropathogenic enteric pathogens is the first step in the development
of a UTI.

▪ Attachment of bacteria to the uroepithelial cells is an active

process mediated by specific bacterial adhesins and specific
receptor sites on the epithelial cells.

▪ Host factors:

▪ A variety of host factors influence the predisposition to UTI in

children.
1. Age:

▪ The prevalence of UTI is highest in boys younger than 1

year and girls younger than 4 years.

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2. Lack of circumcision:

▪ Uncircumcised male infants with fever have a four- to eight-

fold higher prevalence of UTI than circumcised male infants.

3. Gender:

▪ Female infants have a two- to four-fold higher prevalence of

UTI than male infants.

▪ This may be the result of the shorter female urethra.

Because the incidence of UTI in male neonates is as high, if
not higher, than female neonates.

4. Race/ethnicity:

▪ White children have a two- to four-fold higher prevalence of

UTI than do black children for not completely understood
reasons.

5. Genetic factors:

▪ First-degree relatives of children with UTI are more likely to

have UTI than individuals without such a history.

▪ Adherence of bacteria may be genetically determined.

6. Anatomic abnormalities:

▪ Urinary obstruction:

▪ Children with obstructive urologic abnormalities are at

increased risk of developing UTI.

▪ Stagnant urine is an excellent culture medium for

most uropathogens.

▪ Obstructive abnormalities may be:

▪ Anatomic:

▪ Posterior urethral valves, ureteropelvic

junction obstruction.

▪ Neurologic:

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▪ myelomeningocele with neurogenic

bladder.

▪ Functional.

▪ Vesicoureteral reflux:

▪ Vesicoureteral reflux (VUR) is the retrograde passage

of urine from the bladder into the upper urinary tract.

▪ It is the most common urologic anomaly in children.

▪ Children with VUR are at increased risk for recurrent

UTI.

7. Dysfunctional elimination:

▪ Dysfunctional elimination is characterized by:

▪ An abnormal elimination pattern (frequent or

infrequent voids, urgency, constipation)

▪ Bladder and or bowel incontinence

▪ Withholding maneuvers

8. Bladder catheterization:

▪ The risk of UTI increases with increasing duration of bladder

catheterization.

▪ Risk factors for renal scarring:

The development of renal scarring has been associated with:

1. Recurrent febrile UTI.

2. Delay in treatment of acute infection.

3. Dysfunctional elimination.

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4. Obstructive malformations.

5. VUR.

CLINICAL PRESENTATIONS

▪ UTI may present with nonspecific symptoms and signs,

particularly in infants and young children.

▪ Younger children :

❖ Non specific: vomiting, diarrhea and fever.

❖ Symptoms and signs of UTI in children younger than two

years.

➢ Suprapubic tenderness.

➢ Lack of circumcision.

❖ Less common symptoms of UTI in neonates and infants

include:

➢ Conjugated hyperbilirubinemia (in those <28 days).

➢ Irritability, poor feeding, or failure to thrive.

▪ Older children:

• Symptoms of UTI in older children:

 Fever, urinary symptoms (dysuria, urgency, frequency,

incontinence, macroscopic hematuria), and abdominal
pain.

 The constellation of fever, chills, and flank pain is

suggestive of pyelonephritis.

▪ Physical examination:

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▪ Important aspects of the physical examination in the child with

suspected UTI include :
1. Documentation of blood pressure and temperature.

2. Growth parameters (poor weight gain and/or failure to thrive may be an

indication of chronic or recurrent UTI).

3. Abdominal examination for tenderness or mass (eg, enlarged bladder

or enlarged kidney secondary to urinary obstruction)

4. Assessment of suprapubic and costovertebral tenderness.

5. Examination of the external genitalia for anatomic abnormalities (eg,

phimosis or labial adhesions) and signs of vulvovaginitis, vaginal
foreign body, sexually transmitted diseases.

6. Evaluation of the lower back for signs of occult myelodysplasia (eg,

midline pigmentation, lipoma, vascular lesion, sinus, tuft of hair), which
may be associated with a neurogenic bladder.

7. Evaluation for other sources of fever.

✓ Laboratory Evaluation:

The laboratory evaluation for the child with suspected UTI includes
obtaining a urine sample for a dipstick and/or microscopic
evaluation and urine culture. Urine culture is necessary to make
the diagnosis.

1. Dipstick analysis —

▪ Dipstick tests are convenient, inexpensive, and require little

training.

▪ Leukocyte esterase —

• The presence of leukocyte esterase on dipstick

analysis is suggestive of UTI. However, a positive
leukocyte esterase test does not always signal a true
UTI.

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• Test principle: Leukocyte esterase is present in the

neutrophils and can be assayed in the urine by dipstick
strips.

• False-negative tests may be caused by the presence

of ascorbicacid,highurinary protein ,glycosuria
,urobilinogen ,gentamicin ,nitrofurantoin ,cephalexin
and boricacid.

• False-positive tests can results from the presence of

imipenem and clavulanic acid in the urine.

• Test sensitivity: 84%

• Test specificity: 78%

▪ Nitrite —

• A child with a positive nitrite test is likely to have a UTI.

• Test principle: This test is based on the fact that the

bacterial enzyme nitrate reductase can convert urinary
nitrate to nitrite.

• The nitrite test does not identify patients with Gram-

positive infections, because they lack the nitrate
reductase enzyme.

• The nitrite test is highly specific, with a low false-

positive rate.

• Test sensitivity: 50%

• Test specificity: 98%

2. Microscopic exam —

▪ In standard microscopy, a centrifuged sample of unstained

urine is examined for white blood cells (WBC) and bacteria

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▪ When performed in this way, pyuria is defined as ≥5

WBC/high power field (hpf) and bacteriuria as the presence
of any bacteria per hpf.

3. Urine culture —

▪ Urine culture is the gold standard for the diagnosis of UTI.

▪ Urine culture should be performed in the following groups,

even if the dipstick and microscopic analysis are negative.

* Girls and uncircumcised boys younger than two years

with at least one risk factor for UTI

* Circumcised boys younger than two years with

suprapubic tenderness or at least two risk factors for UTI.

* Girls and uncircumcised boys older than two years with

any of the following urinary or abdominal symptoms
(abdominal pain, back pain, dysuria, frequency, high fever,
or new-onset incontinence).

* Circumcised boys older than two years with multiple

urinary symptoms (abdominal pain, back pain, dysuria,
frequency, high fever, or new-onset incontinence).

* Febrile infants and children with abnormalities of the

urinary tract, or family history of urinary tract disease.

DIAGNOSIS OF UTI

1. UTI is diagnosed if there is significant bacteriuria —

▪ What constitutes significant bacteriuria depends upon the

method of collection

▪ Clean catch sample

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• Significant bacteriuria from a clean catch urine specimen in

children is growth of ≥100,000 colony forming units (CFU)/mL of
a single uropathogenic bacterium.

▪ Catheter sample
• Significant bacteriuria from catheterized specimens in children is
growth of ≥10,000 CFU/mL of single uropathogenic bacteria.

▪ Suprapubic sample
• Growth of any gram-negative uropathogen from a suprapubic
specimen is significant, but requires more than a few thousand
CFU/mL for gram-positive pathogens.

▪ False negatives:
• A bacteriostatic antimicrobial agent is present in the urine

• Rapid rate of urine flow with reduced incubation time

• Obstruction of the ureter that interferes with the discharge of

bacteria into the bladder.

2. Pyuria —
▪ The presence of WBC in the urine is not specific for UTI.

▪ True UTI without positive leukocyte esterase on dipstick analysis and

≥5 WBC/hpf with standardized microscopy is unusual.

▪ The absence of pyuria in the presence of significant bacteriuria may

occur under the following circumstances:

1. Early in the course of UTI (before the local inflammatory

response develops)

2. Bacterial contamination of the urine sample (eg, from the

urethra or periurethra)

3. Colonization of the urinary tract (eg, asymptomatic bacteriuria)

IMAGING —

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• To identify abnormalities of the genitourinary tract, including VUR and

obstructive uropathies.

• Include:

a) Renal ultrasonography.

b) Voiding cystourethrogram.

-Helpful in grading of VUR as following:

• Grade I: Reflux into the ureter only.

• Grade II: Reflux into the collecting system, without blunting

of calyces.

• Grade III: Reflux into the collecting system, with mild blunting
of calyces and preservation of papillary impressions; ureter
may be mildly dilated.

• Grade IV: Reflux into the collecting system, with moderate

blunting of calyces, some loss of papillary impressions, and
occasional complete loss of papillary impressions (clubbing);
ureter dilated and tortuous.

• Grade V: Clubbing of most of calyces. Ureter is dilated and

tortuous

• Indications:

1. Girls younger than 3 years of age with a first UTI.

2. Boys of any age with a first UTI.

3. Children of any age with a febrile UTI

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4. Children with recurrent UTI .

5. First UTI in a child of any age with a family history of renal

disease, abnormal voiding pattern, poor growth,
hypertension or abnormalities of the urinary tract

Treatment
• Goals — The goals of treatment for UTI include:

▪ Elimination of infection and prevention of urosepsis.

▪ Prevention of recurrence and long-term complications including

hypertension, renal scarring, and impaired renal growth and function.

▪ Relief of acute symptoms (eg, fever, dysuria, frequency).

➢ ANTIBIOTIC THERAPY —

• The mortality of UTI was as high as 20 percent in the preantibiotic era. In

contrast, when UTI are appropriately treated with antibiotics, acute
complications, including death, are uncommon.

• Empiric therapy:

o Early and aggressive antibiotic therapy is necessary to prevent

renal damage.

o It is initiated while awaiting culture results in infants and young

children who are at increased risk for UTI and children with
underlying urologic abnormalities.

o Oral therapy :

▪ Oral third generation cephalosporins: (eg. cefixime, cefdinir,

ceftibuten) are the first-line oral agent in the treatment of UTI
in children.

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• Cefixime (16 mg/kg/day in two divided doses on the

first day, followed by 8 mg/kg once /day to complete
therapy).

• Cefdinir (14 mg/kg/day divided in two doses).

• Ceftibuten (9 mg/kg once per day)

o Parenteral therapy:

▪ Third or fourth-generation cephalosporins and

aminoglycosides (eg, gentamicin) are appropriate first-line
parenteral agents for empiric treatment of UTI in children.

▪ The doses are as follows:

• Ampicillin (100 mg/kg/day IV divided in four doses)

• Gentamicin (7.5 mg/kg/day divided in three doses)

• Cefotaxime (150 mg/kg per day IV divided in three

doses)

• Ceftriaxone (50 to 100 mg/kg per day IV).

• Other medications :

o Sulpha combinations(TMP-SMX), amoxicillin,

penicillin, or nitrofurantoin

• Duration of therapy —

• Children younger than 2 years and children with febrile or recurrent UTI
are usually treated for 10 days.

• Children older than 2 years who are afebrile, and without abnormalities of
the urinary tract or previous episodes of UTI are usually treated for five
days.

Prognosis:
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1. Recurrent UTI :

• Approximately 14 percent of children younger than 6 years with

UTI have a subsequent UTI.

2. Hypertension.

• Hypertension can result from renal scar formation in patients who

have had acute pyelonephritis, often in association with VUR or
another urinary tract anomaly.

3. Renal scarring.

• Acute pyelonephritis has the potential to cause tubulointerstitial

damage and renal scar formation.

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