URINARY

TRACT
INFECTION
Dr Darwitha
Supervised by Dr Wong SS
1 CLINICAL CASE COVERING
01 02
ETIOPATHOGENESIS PRESENTATION
RISK FACTORS, PATHOPHYSIOLOGY SIGNS, SYMPTOMS

03 04
MANAGEMENT COMPLICATIONS
COMPLICATIONS,
INVESTIGATION AND TREATMENT
RECOMMENDATIONS
URINARY TRACT
INFECTION
GROWTH OF BACTERIA IN THE URINARY
TRACT, OR COMBINATION OF CLINICAL
FEATURES WITH PRESENCE OF BACTERIA IN
THE URINE

UPPER URINARY TRACT: KIDNEYS, URETER

LOWER URINARY TRACT; BLADDER, URETHRA,

PROSTATE
 PATHOGENESIS

ASCENDING HEMATOGENOUS
INFECTION SPREAD
Contamination → Periurethral Pathogens from a different
colonization from gut foci of infection spread via
pathogen → Biofilm formation bloodstream to the urinary
→ upper urinary tract tract
CASE HISTORY
M, 5 year 5 month old boy

Term/ SVD/ Perinatal uneventful

BW 2.64 KG, Latest Wt 15.6KG

Immunization and development up to age

H/O Complicated UTI with multiple hospitalizations

and underlying bilateral VUR

Seen at KP3 on 22/9/23 for routine TCA to review

UFEME and USG KUB
During this visit, noted that child was
asymptomatic
Child is active, well at home
No fever/ vomiting/ diarrhoea
No increased urinary frequency/ dysuria/
nocturia/ incontinence/ hematuria
No URTI ssx
BO daily → soft stool, on lactulose
No abdominal pain, PS 0
Dry by day and night, no incontinence
PU regular → not on CIC, double voiding
Compliant to cephalexin
Child drinking 1L/day
 PREVERBAL
HISTORY VERBAL

FEVER PAIN
> 38, no apparent Loin pain,
source suprapubic pain

NON LUTS
SPECIFIC Dysuria, frequency,
hematuria, urgency,
Irritability, prolonged
nocturia, urinary
jaundice, failure to
incontinence
thrive
COMORBID CONDITIONS/ Signs of STI
SURGERIES
 PAST MEDICAL HISTORY 5

1. Bilateral vesicoureteric reflux, hydronephrosis and hydroureter with renal scarring,

CKD stage III
2. Recurrent asymptomatic UTI (H/O Complicated UTI with multiple admissions)

14 July 2022 4 Aug 2022

1st UTI (SSX) 11 Aug 2022
ESBL Klebsiella
MCUG 2nd UTI
Right VUR grade IV,
pneumoniae + USG Enterobacter
Left VUR grade V
findings

3 Feb 2023 7 April 2023

DMSA 10 Mac 2023 MRI
4th UTI
Satisfactory renal fxn 3rd UTI + left
Enterobacter
with B/L scarring pyelonephritis
(58%, 42%) cloacae

11 April 2023 surveillance

USG KUB Aug 2023 PO Cephalexin 200 mg
ON
suggestive of Done circumcision Repeated UFEME and
residual cystitis USG KUB at intervals
 6
RISK FACTORS
URINARY TRACT
GENDER
ANOMALIES
CAKUT, cyst, Female → shorter urethra
urolithiasis Uncircumcised male

IMMUNO OTHERS
DEFICIENT Bladder & bowel dysfunction
dysfunction (BSS)
Immunocompromised
Neurogenic bladder
states, DM
Urethral instrumentation
Hygiene

AAP guideline to diagnose UTI in SO WHAT RISKS FACTORS OUR PATIENT

febrile child HAVE?
PHYSICAL EXAMINATION
O/E active, not toxic looking, pink, not Lungs: clear
tachypneic, good PV, CRT<2s,
CVS: DRNM
Anthropometric measurement and V/S not
available P/A: soft, not distended, non tender, no
palpable bladder, bilateral renal punch -ve
 SIGNS
Fever Poor
Tachycardia weight
Low BP gain

Vital signs Anthropometry

Renal punch
Ballotable
kidneys To detect
Suprapubic neurogenic
tenderness bladder
Palpable
bladder Abdominal + genitalia examination Spine + neurology examination
AAP RECOMMENDATION
WHAT IS
VUR?
 VESICOURETERAL REFLUX
retrograde flow of urine from the bladder into the ureter

Commonest radiological abnormality in UTI (30 - 40%)

 CLASSIFICATIONS
Congenital
anomaly of the
vesicoureteral PRIMARY
junction

CAUSES OF
VUR
High pressure
voiding secondary
to posterior
urethral valve,
SECONDARY
neuropathic
bladder or voiding
dysfunction
 PRESENTATION
VUR does not cause any specific signs or symptoms unless complicated
by urinary tract infection (UTI)
 American Association of urology

MANAGEMENT
OF VUR
● ACTIVE SURVEILLANCE
● ANTIBIOTICS PROPHYLAXIS
● MANAGING DES
● SURGICAL/ ENDOSCOPIC TX
● PUV WARRANTS REFERRAL
TO UROLOGIST

Indication: Recurrent symptomatic UTI and infants/children

with VUR grade III and above
6
 RECURRENT STRATEGIES TO REDUCE
INCIDENCE OF RECURRENT UTI
UTI
● Circumcision
● ≥3 episodes of cystitis ● Antibiotic prophylaxis
● Simple hygiene measures
● ≥2 episodes of UTI including ● Active management to prevent
at least one episode of DES
pyelonephritis.
*Insufficient evidence to support
cranberry prophylaxis or probiotics

6
 DURING TCA
OUR PRACTICE
1. Review well being
V
2. Review UFEME and RP
3. Review USG KUB
S
American Association of urology
1
8
AAP RECOMMENDATION
 IMAGING
Early identification of patients at risk for the development of acquired renal scarring

USG KUB DMSA

Detect anatomical abnormalities/ Detects APN and renal scarring
complications Any of the risk factors
<3Y/O, > 3Y/O with risk factors

DTPA
MCUG
Recurrent UTI, risk factors, X RAY KUB
dilatation on USG, family If indicated
H/O VUR
AAP RECOMMENDATION
UFEME 21/9/23: Nitr +ve, Leu 3+, blood
1+, bact 4+, WBC 320

RP 21/9/23: Urea 5.6/ K+ 4.3/ Creat 46

USG KUB 21/9/23

1. Left central calyceal dilatation (UTD
P1)
2. Internal debris within urinary
bladder possible cystitis
 DIAGNOSIS OF UTI
UFEME Enhanced urinalysis aid the diagnosis

Presence of > 100 000 CFUs of a single urinary

URINE C&S pathogen per ml of freshly voided urine, , gold
standard
AAP RECOMMENDATION
 Impression: Chronic cystitis

Plan in KP3:
1. Urine C&S STAT
2. Start PO Cefuroxime 250mg BD x 1/52
3. TCA 2/52 to repeat UFEME and Urine
C&S
4. USG KUB in 4 to 6 weeks
5. Avoid constipation, increase dietary
fibre, double voiding, regular PU
 Slide 25:
SUBSEQUENTLY
AAP RECOMMENDATION
 Upon tracing urine C&S on
25/9/23

Pseudomonas Aeruginosa
Sensitive to Amikacin, ceftazidime,
ciprofloxacin, tazocin, cefepime
COMMONLY ASSOCIATED PATHOGENS
(TYPICAL PATHOGENS)

Escherichia Enterobacter Klebsiella Proteus

Coli aerogenes Pneumoniae Mirabilis

80 to 90% of the Boys > girls

infection
 PAEDS PROTOCOL

AAP
OUR CHILD WAS ALSO ASYMPTOMATIC FOR UTI BUT WHY DID WE TREAT?
WHAT IS THE EVIDENCE FOR BENEFIT IN TREATMENT?
COMPLICATED UTI
UNCOMPLICATED COMPLICATED
UTI UTI

● Structurally and
● Structurally and
functionally Slide
functionally 26:
abnormal urinary SUBSE
normal urinary
tract QUEN
tract TLY
● Abnormal renal
● Normal renal
function
function
● Immunocompro 6
● Competent
mised
immune system
● Atypical
● Typical
pathogens
pathogens
● Sepsis
● Simple course
● Male
 SUBSEQUENTLY
Patient was admitted to W2
Imp: Pseudomonas aeruginosa UTI

Plan:
1. Start IV Ceftazidime 890 mg TDS
2. Withhold cephalexin
3. Repeat USG KUB prior to discharge
4. Full septic workup + UFEME/ UC&S +
AXR
5. Preventive measures of DES
6. Referred to surgical
 UPDATE ON CONDITION
IX TAKEN PRIOR TO ABX
1. UFEME 26/9/23: Leu 3+/ Nitr +ve/ WBC 464/ Bact 2+
2. Urine C&S 26/9/23: NG
3. Blood C&S: NG

IX TAKEN 4 DAYS POST ABX

1. UFEME 30/9//23: Leu 1+/ Nitr -ve
2. Urine C&S 30/9/23: NG

Current plan to complete IV Ceftazidime for 1/52

Paeds Surgical team plan for bilateral ureteric reimplant later

 DISCHARGE PLAN

● TCA 6/52 with UFEME and RP

● Discharge with PO Bactrim 36mg ON as UTI
prophylaxis and PO Lactulose 10ml BD
● USG KUB on 21/12/23
ARE WE AT PAR WITH THE
CURRENT GUIDELINES?
 COMPLICATIONS OF UTI
★ Acute pyelonephritis
★ Bacteremia → septic shock
★ Failure to thrive
★ Renal scarring → Renal insufficiency → Hypertension
★ Extensive infection: renal abscess, pyonephrosis,
emphysematous pyelonephritis, and
xanthogranulomatous pyelonephritis
RESOURCES
 THANKS!
DO YOU HAVE ANY QUESTIONS?

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