URINARY TRACT INFECTION IN

CHILDREN

Dr Nada Qawasmi
Alquds Faculty of Medicine
INTRODUCTION
 UTIs most common serious bacterial infection in childhood.
 UTI occurs in 1.6% of boys and 7.8% of girls.
 1st 3 months of life: more common in boys (3.7% vs 2.0%).
 Higher incidence in older children presenting with bladder and
bowel dysfunction .
 Febrile UTIs in children, with or without VUR renal scarring
CKD.
 Early guidelines advocated aggressive treatment and extensive
imaging to detect VUR and kidney scarring.
RENAL SCARRING

Normal kidney Scarred kidney

CLASSIFICATION OF UTI

Asymptomatic
bacteruria

Is defined as a growth of a significant number of an isolated organism

[usually >100,000 colony-forming units (CFU/ml) from urine culture
found in children without symptoms with no pyuria. This should not
be treated as the inappropriate use of antibiotics may promote
antibiotic resistance leading to symptomatic disease and does not
confer any long-term benefit
CLASSIFICATION OF UTI CONT…

Cystitis

Is defined as infection limited to the urethra and bladder;

symptoms include frequency, urgency, dysuria, lower
abdominal discomfort or pain and or cloudy urine.

Acute
pyelonephritis
Is defined as the presence of high ≥ 38.5°C and/or
systemic involvement, except in some very young
infants
CLASSIFICATION OF UTI CONT…

Simple UTI
Denotes features of lower urinary tract
involvement. These children have only mild pyrexia,
but are able to take fluids and oral medication. They
are only slightly or not dehydrated and generally have
good compliance with medication.

Severe UTI
Is defined as the presence of fever of ≥ 39°C, the
feeling being ill, persistent vomiting, and moderate or
severe dehydration. When a child with a simple UTI
has a low level of compliance, such a child should be
managed as one with a severe UTI
CLASSIFICATION OF UTI CONT…

Uncomplicated Is defined as the invasion of a structurally and functionally

UTI normal urinary tract by a non-resident infectious organism.

Complicated Refers to the occurrence of infection in patients with an

UTI abnormal structural or functional urinary tract, or both, that
involves upper urinary tract and thus manifests as
pyelonephritis.

Is defined as the following: ≥ 2 episodes of UTI with acute

Recurrent UTI pyelonephritis plus one episode of UTI with acute
pyelonephritis plus one or more episodes of UTI with cystitis
or lower UTI or three or more episodes of UTI with cystitis or
lower UTI.
CLASSIFICATION OF UTI CONT…
Atypical UTIs Are defined as those that fail to respond after 48 hours of
appropriate antibiotic treatment, have poor urine flow, abnormal
kidney function, bladder or abdominal mass, infection by an
organism other than E.coli and onset of septicaemia.

Relapsing Is defined as a prompt recurrent infection with the same organism

UTI that occurs following treatment and implies there has been failure to
eradicate the infection

Is defined as a renal mass caused by focal infection with liquefaction

and may lead to the development of a renal abscess later on.
Acute lobar
nephronia (acute
lobar nephritis)
PATHOGENESIS OF UTI
 Colonisation of distal urethral and peri-urethral area from GIT tract

competitively inhibits colonisation by potential pathogenic bacteria.

 Assent of pathogenic bacteria into UT occurs if there is colonisation by

pathogenic bacteria.

 Systemic spread of infection to kidneys uncommon except in

uncompromised patients.
PATHOGENESIS OF UTI CONT..
 Enhanced by the following factors:
 Use of broad spectrum antibiotics
 Soiling around perineum
 Catheters
 Spermicidal agents
 Turbulent urinary flow e.g. voiding dysfunction, instrumentation.
 UT obstruction – overdetention of epithelial lining and pooling of urine

 Genetic factors – defects in CXCR1 receptor

 Bacterial virulence factors.
OTHER FACTORS PREDISPOSING TO
RECURRENT UTI

 Age <6 months

 Female sex

 Bladder and bowel dysfunction

 Grade of reflux (III – V)

 Constipation

 Infrequent voiding

 Poor perineal hygiene

COMMON PATHOGENS CAUSING UTI

Pathogens Common contaminants of urine cultures

• Enterobacteriaceae • Candida species

- E. coli (most common) • Enterococcus spp.
- K. pneumoniae • Gardnerella vaginalis
- Enterobacter spp. • Mycoplasma hominus
- Proteus spp. • Ureaplasma urealyticum

• Coagulase negative staphylococci

- S. saprophyticus

• Group B streptococcus

• Enterococcus spp.
CLINICAL PRESENTATION
a. Fever
 most common symptom
 may take several days to resolve
 temp >38⁰C

b. Malodorous urine
 18 -29% of children
 may be present in children with UTI.

c. Feeding problems

d. FTT, pallor, lethagy

e. Diarrhoea and vomiting

CLINICAL PRESENTATION
Older children
 Dysuria
 Hesitancy
 Enuresis
 Nausea
 Vomiting
 Flank pain
 Suprapubic tenderness
 Dribbling and prolonged voiding

Must exclude sexual abuse, particularly in female patients.

IMAGING OF CHILDREN WITH UTIS

 Used to detect genitourinary tract abnormalities.

 Modifying correctable factors decreases number of UTIs

and prevents renal scarring.

IMAGING STUDIES
 US
 VCUG
 Radionuclear cystography
 Renal scintigraphy
 DMSA
 DTPA
 MAG3
 Others e.g. CT, MRI, video urodynamics
GRADES OF VUR
IMPACT OF VUR IN UTI IN CHILDREN

 VUR is the retrograde flow of urine from the bladder into the

ureter and renal pelvis.

 Prevalence 1-6%

 Diagnosed in 1/3 of children first UTI.

 More likely to have long-term sequelae with subsequent

scarring in 10-40% of children.

 Children <1 year more likely to complicate .

MANAGEMENT
MANAGEMENT OF THE FIRST EPISODE OF UTI

Infant >1 -5 years >5years

US US +DMSA US

If abnormal If US or DMSA abnormal if US abnormal

VCUG +DMSA VCUG VCUG and DMSA

COMMON ANTIMICROBIAL AGENTS USED
Antimicrobial Dosage Common adverse effects
agent  
Parenteral    
 
Amoxicillin/clavulanate (>3 60-100 mg/kg body weight 8 Gastrointestinal upsets, urticaria, pruritis,
months) hourly stomatitis, oral and perineal candidiasis,
elevated liver enzymes, anaphylaxis
Astreonam (>3 months) 50-100 mg/kg daily Phlebitis, gastrointestinal upsets, elevated liver
enzymes, eosinphilia, nephrotoxicity
Ceftriaxone 75 mg/kg, every 24 h Eosinophylia, elevated liver enzymes,
thrombocytosis, leukopenia, diarrhoea
Cefotaxime 150 mg/kg per day, divided every Rash, pruritus, fever, eosinophilia, fever
6-8 hours
Ceftazidine 100-150 mg/kg per day, divided Gastrointestinal upsets, rash, pruritus,
every 8 hours headaches, elevated liver enzymes,
nephrotoxicity
Gentamicin 5 mg/kg per day, (8 or 24 hourly Nephrotoxicity, dizziness, vertigo, tennitus,
>12 months) hearing loss
Tobramycin 5 mg/kg per day, divided every 8 Same as gentamycin
hours Same as gentamycin
Piperacillin 300 mg/kg per day, divided every Gastrointestinal upsets, cardiac disturbances,
6-8 hours central nervous system effects, allergic
COMMON ANTIMICROBIAL AGENTS USED CONT…

Antimicrobial agent Dosage Common adverse effects

Oral
Amoxicillin clavulanate 20-40 mg/kg per day in three doses Diarrhea, nausea/vomiting, rash

Trimethoprim sulfamethoxazole 6-12 mg/kg trimethoprim and 30-60 mg/kg Diarrhea, nausea/vomiting
sulfamethoxazole per day in two doses Photosensitivity rash

Sulfisoxazole 120-150 mg/kg per day in four doses

Cefixime 8 mg/kg per day in one dose Abdominal pain, diarrhea, Flatulence, rash

Cefpodoxime 10 mg/kg per day in two dose Abdominal pain, diarrhea, nausea, rash

Cefprozil 30mg/kg per day in two doses Abdominal pain, diarrhea, elevated
results on liver function tests, nausea

Cefuroxime axetil 20-30 mg/kg per day in two doses Anaemia, eosinophilia, nephrotoxicity,
diarrhoea, elevated liver enzymes

Cephalexin 50-100 mg/kg per day in two doses Diarrhea, headache, nausea/ vomiting,
rash
ANTIMICROBIAL PROPHYLAXIS
 50% reduction of risk of recurrent UTIs in children <72 months.
 Few adverse events with use of prophylaxis (>5% developed fever,
otitis media, diarrhoea, phargyngitis, rash, viral infections)
 40% developed UTI with sensitive E.coli (SMZ/TMP).
 This may suggest that compliance may have been poor in these
children.
 No statistically significant difference in the development of
TMP/SMZ–resistant UTI in both groups.
 No impact or renal scanning
SURGICAL CORRECTION OF VUR
 Indicated in following groups of children.
 Higher grades of VUR (III – V) with breakthrough infections being
Rx with prophylactic antibiotics.
 Non compliance with prophylaxis.
 Parenteral preference.
 Deteriorating kidney function
 Correction may be by ureteric re-implantation or endoscopic
injection of a bulking agent (dextranomer/hyaloronic
copolymer).
 Endoscopic treatment has a significant recurrence rate after 2
years necessitating repeating the procedure.
CONCLUSION

 UTIs are common in childhood.

 Requires appropriate management of acute episode as well as
prevention to minimise risk of kidney scarring as well as CKD.
 Prophylaxis may be associated with low risk of recurrent
infection in selected groups of children.
 Surgical intervention required in only a small number of
patients.
 Endoscopic surgery is now used increasingly in most centres.