URINARY TRACT

INFECTION

University of Al-Ameed / College of

Medicine Department of Paediatrics

DR.MOHAIMEN A.M ALKABI

Urinary Tract

Female Male
EPIDEMIOLOGY

 UTI are the most common genitourinary disease of childhood.

 The prevalence of UTI at all ages is :
1-3% of girls
1% of boys.

 Below 1 year ≈ male: female 4:1, especially among uncircumcised males

 but after 1 year male: female ratio is 1:10.
ETIOLOGY

 UTI is mainly caused by colonic bacteria and mainly gram–negative bacteria

 Escherichia coli is the most common bacterial cause of UTI; it accounts for approximately 80 percent of UTI in
children
 Other gram-negative bacterial pathogens include Klebsiella, Proteus, Enterobacter, and Citrobacter

 Infrequently it caused by Staphylococcus saprophyticus and enterococcus as well as to viral infection e.g.
adenovirus
PATHOLOGY

 Virtually all UTIs are ascending infections. The bacteria arise from the fecal flora
and enter the bladder via urethra.
 Rarely, in some neonates, renal infection may occur by hematogenous spread.
RISK FACTOR FOR URINARY TRACT INFECTION
CLINICAL MANIFESTATIONS:

 The symptoms and signs of UTI vary with age

Neonate :commonly presents with
1. FTT
2. feeding problem
3. diarrhea, vomiting
4. Fever
5. Prolong jaundice
1month-2 year infant
usually has non urinary tract manifestations
1. FTT
2. feeding problems
3. diarrhea
4. unexplained fever
5. gastrointestinal illness
6. such as colic, irritability, screaming periods.
At 2 years of age, children begin to show the classic signs of UTI such as
1. urgency
2. Dysuria
3. Frequency
4. abdominal or back pain
TYPES OF UTI

1-Asymptomatic Bacteriuria
refers to a condition that results in a positive urine culture without any
manifestations of infection. It is most common in girls.
2-Cystitis (infection of bladder lower UTI)
1. Dysuria
2. urgency
3. frequency
4. suprapubic pain
5. incontinence
6. malodorous urine
7. It does not cause fever or renal injury.
3-Pyelonephritis (upper UTI) is clinically manifested as
1. abdominal or flank pain
2. Fever
3. Malaise
4. Nausea
5. Vomiting
6. occasionally diarrhea.
DIAGNOSIS

1- Dipstick analysis – Dipstick tests are convenient, inexpensive, and require little training for proper usage; they
may be the only test available in some settings.

A. White blood cells (WBCs) may be present in the urine in other conditions
B. Leukocyte esterase – Positive leukocyte esterase on dipstick analysis is suggestive of UTI but is nonspecific
C. Nitrite – Positive nitrites on dipstick analysis indicate that UTI is likely
D. Microscopic hematuria is common in acute cystitis
Urine dipstick
STERILE PYURIA

Sterile pyuria (positive leukocytes, negative culture) may occur in:

1. partially treated bacterial UTIs

2. viral infections
3. Infection with atypical organism ,such as chlamydia , ureaplasma urealyticum or tuberculosis
4. renal abscess
5. urinary obstruction
6. inflammation near the ureter or bladder eg.appendicitis
7. Kawasaki disease
MICROSCOPICAL EXAM

Pus cells in
urine
2-Urine culture is diagnostic
 the presence of both pyuria and at least 50,000 CFU/mL of a single pathogenic organism.
 For older children and adolescents, >100,000 CFU/mL indicates infection
HOW TO OBTAIN A URINE SAMPLE ?
URINE SAMPLE COLLECTION

In toilet-trained children:
 a midstream urine sample usually is satisfactory; the area should be cleaned before obtaining the specimen.
Children 2-24 months:
 a catheterized or suprapubic aspirate urine sample should be obtained. sterile urine bag after disinfection of the
skin can be useful only if the culture is negative.
IMAGING STUDIES

 Ultrasonography of the bladder and kidneys is recommended for infants with febrile UTIs to exclude
structural abnormalities or detect hydronephrosis.
 Voiding cystourethrogram : (VCUG) is indicated if the ultrasound is abnormal (hydronephrosis, scarring, or
other findings to suggest obstruction or congenital abnormality).
 A technetium-99m DMSA scan can identify acute pyelonephritis and is most useful to define renal scarring as
a late effect of UTI.
TREATMENT

Acute cystitis
should be treated promptly to prevent progression to pyelonephritis, a 3-5 day course of
1)trimethoprim-sulfamethoxazole (TMP-SMX) or trimethoprim is effective against many strains of E. coli.
2) Nitrofurantoin (5-7 mg/ kg/24 hr. in 3-4 divided doses) has the advantage of being active against Klebsiella and
Enterobacter organisms.
3)Amoxicillin (50 mg/kg/24 hr.).also is effective as initial treatment but has a high rate of bacterial resistance.
Acute pyelonephritis
a 7-14 day course of broad-spectrum antibiotics is preferable
1)Ceftriaxone (50-75 mg/kg/24 hr., Not to exceed 2 g)
2) Cefotaxime (100 mg/kg/24 hr.),
3) Ampicillin (100 mg/ kg/24 hr.) With an aminoglycoside such as gentamicin (3-5 mg/kg/24 hr. in 1-3 divided doses) is preferable.
Treatment with aminoglycosides is particularly effective against Pseudomonas spp .
4)Oral third-generation cephalosporins such as cefixime are as effective as parenteral ceftriaxone against a variety of Gram-ve organisms
other than Pseudomonas, and these medications are considered to be the treatment of choice for oral outpatient therapy.
5) Ciprofloxacin is an alternative agent for resistant microorganisms, particularly Pseudomonas.
•In some children with a febrile UTI, intramuscular injection of a loading dose of ceftriaxone followed by oral therapy with a third-
generation cephalosporin is effective
 Children should be admitted to the hospital for IV rehydration and IV antibiotic
therapy :
1. Dehydrated
2. Vomiting
3. unable to drink fluids,
4. 1 mo. of age or younger,
5. have complicated infection, or in whom urosepsis is a possibility.
VESICOURETEIC REFLEX

Vesicoureteral reflux (VUR ) describes the retrograde flow of urine from the bladder to the ureter and kidney.
 The ureteral attachment to the bladder normally is oblique, between the bladder mucosa and detrusor muscle,
creating a flap-valve mechanism that prevents VUR
 VUR occurs when the submucosal tunnel between the mucosa and detrusor muscle is short or absent.
 Affecting 1-2% of children, VUR usually is congenital and often is familial.
 VUR is present in approximately 30% of females who had a urinary tract infection and in 5-15% of infants with
antenatal hydronephrosis.
 Most children with VUR are asymptomatic
 Reflux increases risk of urinary tract infection or acute pyelonephritis, so testing for reflux may be performed
after a child has one or more infections.
GRADING OF VESICOURETERAL REFLUX
Grade I: VUR into a non dilated ureter.
Grade II: VUR into the upper collecting system without dilation.
Grade III: VUR into dilated ureter and/or blunting of calyceal
fornices.
Grade IV: VUR into a grossly dilated ureter.
Grade V:massive VUR, with significant ureteral dilation and
tortuosity and loss of the papillary impression.
Reflux Seen on Voiding
Cystourethrogram (VCUG) using
transurethral contrast
TREATMENT

 85% of grade I & II cases of VUR will resolve spontaneously. 50% of grade III cases and a lower percentage of
higher grades will also resolve spontaneously
 The goal of treatment is to minimize infections by prophylactic antibiotics, as it is infections that cause renal
scarring and not the vesicoureteral reflux
 When medical management fails to prevent recurrent UTI, or if the kidneys show progressive renal scarring then
surgical interventions may be necessary

 Medical management is recommended in children with Grade I-III VUR. A trial of medical treatment is indicated
in patients with Grade IV VUR . Of the patients with Grade V VUR surgery is the only option .