Welcome All to Our Seminar

On

“Urinary Tract Infection”

 Presented by

Dr. Priyanka Saha Piu, IMO.

Dr. Madhuri Das Rakhi, IMO.
Department of Paediatrics,
Jalalabad Ragib-Rabeya Medical
College & Hospital, Sylhet.
Date : 1st November,2021
 What is UTI ?

Urinary tract infection imply invasion of urinary

tract by pathogens, which may involve the upper or
lower tract depending on the infection in the
kidney or bladder & urethra.
 Prevalence

• UTI is a common bacterial infection in children.

• The risk of having symptomatic UTI before the age
of 14 years
- 1-3 % in boys
- 3-10% in girls.
• In girls, the first UTI usually occurs by the age of 5
years, with peaks during infancy & toilet training.
• In boys, most UTIs occur during 1 st year of life,
much more common in uncircumcised boys.
• Newborn:
Term: 0.5-1%
Preterm: 3-5%

• During the 1st yr of life,

M : F ratio is 2.8- 5.4:1

• Beyond 1-2 yr,

M : F ratio is 1:10.
 ETIOLOGY

• 90% of first symptomatic UTI and 70% of recurrent UTI are due
to E.coli

In Girls In Boys >1 yr In both sex

E.coli- 75-90% Proteus = E.coli Staphylococcus
Klebsiella Gram positive saprophyticus and
Proteus organism enterococcus

• Recurrent UTI- Proteus and Pseudomonas ( also in instrumentation

and nosocomial infections)
• Fungi – in immunocompromised
Candida albicans- in preterms
• VIRAL:
Adenovirus

• OTHERS:
Chlamydia Rare
Mycoplasma
Schistosoma haematobium
 Normal Periurethral Bacterial Flora

• Healthy girls – Lactobacilli

• In infants & toddlers – E.coli & Enterococci

 Pathogenesis

• In the neonatal period, renal parenchymal infection

due to hematogenous spread. Acute bacterial
pyelonephritis may cause or follow septicemia.

• Other ages, bacteria reach the urethra and bladder

through the ascending rout and ureter and kidney
through VUR.
 Predisposing Factors

• Female gender
• Uncircumcised male
• Obstructive uropathy
• Vesicoureteric reflux
• At the onset of toilet training
• Constipation
• Pinworm infestation
• Urethral instrumentation
• Anatomic abnormality
• Bacteria with P fimbriae
 Classification

There are three basic form Of UTI :

1. Clinical Pyelonephritis
2. Cystitis
3. Asymptomatic Bacteriuria
 Clinical Features

1. Pyelonephritis:
• Abdominal, back or flank pain, fever, malaise, nausea
& vomiting, occasionally diarrhoea
• Newborns- poor feeding, irritability, jaundice, weight
loss
• Most common in <24 months
• Renal injury – pyelonephritic scarring
• Acute lobar nephritis – renal mass→ renal abscess
 Xanthogranulomatous Pyelonephritis

• Rare type of renal infection

• Granulomatous inflammation with giant cells and
foamy histiocytes
• Cause - Renal calculi, obstruction and Proteus or E-
coli infection
• Total and partial nephrectomy usually required.
 Cystitis

• Indicates that there is bladder involvement.

• Symptomes include – dysuria, urgency,
frequency, suprapubic pain, incontinence,
malodorous urine.
• Doesn’t cause fever & doesn’t result in renal
injury.
 Acute hemorrhagic cystitis
• By E.coli, adenovirus type 11 and 21.
• Adenovirus cystitis more common in boys.
• It is self limiting , with hematuria lasting approximately 4
days.
 Eosinophilic Cystitis

• Hematuria, ureteral dilatation and

ocassional hydronephrosis
• USG – Multiple solid bladder mass.
• Bladder biopsy – Inflammatory
infiltrate with eosinophil
• Treatment- Antihistamines and
NSAIDS .
 Interstitial Cystitis

• Voiding symptoms and pelvic pain relieved by voiding

• Negative urine culture
• Adolescent girls , idiopathic
• Cystoscopic observation of mucosal ulcers
• Treatment- bladder hydrodistension and laser ablation
of ulcered area.
 Asymptomatic Bacteriuria

• Positive urine culture without any

manifestation of infection.
• Most common in girls.
• The incidence is <1% in preschool &
school age girls & is rare in boys.
• Benign and does not cause renal injury
• Pathogens of low virulence (E.coli) does
not invade in urinary tract
• No treatment required
 Atypical UTI
• Seriously ill child
• Poor urine flow
• Abdominal or bladder mass
• Raised creatinine
• Septicaemia
• Failure to respond to treatment with suitable
antibiotics within 48 hours
• Infection with non- E.coli
 Recurrent UTI:
• ≥ 2 episodes of UTI with acute Pyelonephritis /
upper UTI or

• 1 episode of acute pyelonephritis/ upper UTI + ≥

1 episode of UTI with cystitis/lower UTI or

• ≥ 3 or more UTI with cystitis / lower UTI

• 2nd positive urine culture with symptoms within 2

or more weeks after the termination of 1st UTI.
 Vesicoureteric Reflux

Vesicoureteric reflux (VUR) is the retrograde flow of urine from

the bladder to the ureter and renal pelvis.

Causes

• Primary- Congenital incompetence of the vulvular mechanism of

the vesicoureteral junction.
• Secondary:
1. Neuropathic bladder
2. Severe bacterial cystitis
3. Foreigh body
4. Vesical calculi.
• Grade I: Reflux into a non-dilated ureter.
• Grade II: Reflux into the upper collecting system without
dilation.
• Grade III: Reflux into dilated ureter.
• Grade IV: Reflux into a grossly dilated ureter.
• Grade V: Massive reflux,with significant ureteral dilation
and tortuosity and loss of papillary impressions.
Vesicoureteric Reflux
Investigation
 Urine Examination

• Urine microscopy

• Dipstick test

• Urine for culture and sensitivity

 Collection Method

• Mid stream clean catch

• Catheterization

• Supra-pubic aspiration
 Mid stream clean-catch method
• The first voided morning specimen is particularly valuable
because it is usually more concentrated. It is also relatively
free of dietary influences and of changes caused by physical
activity.
• Wash your hands and genitalia of the child with soap water
• Boys – pull back foreskin, Girls-hold apart labia
• Ready with the container open
• Caution! Don’t touch the rim
• Let pass some urine outside
• Catch some urine in the container without stopping flow
• Finish passing the rest outside the container.
 Mid stream clean-catch method

Incase of infant who are not toilet trained

• Feed well the baby one hour before.

• Tap gently with a finger at the bottom of the
tummy.
• Be ready with the bottle open.
• Within 5 mins the baby will pass the urine .
• Catch the middle part of the flow.
 Urethral Catheterization

• If a urine specimen is obtained from an

indwelling catheter, it may be necessary to clamp
off the catheter, 1-2 cm distal to meatus, for about
15 to 30 minutes before obtaining the sample
with needle and syringe,

• Clean the specimen port (in the tubing) with

antiseptic before aspirating the urine sample with
a needle and syringe.

• Strict aseptic precaution should be taken.

Suprapubic aspiration
 Suprapubic aspiration

• In neonates and infants , the most reliable method for obtaining

an uncontaminated urine specimen is by suprapubic aspiration
from the bladder.

• Less or no chance of contamination.

• It can be performed safely using a 21 gauge needle, inserted 1 to

2 cm above the pubic symphysis to a depth of 2 to 3 cm.
Fullness of the bladder should be ensured by purcussion, if
necessary by ultrasonography.
 Urine preservation

• The specimen should be transported to laboratory as early

as possible less than 1 hour after voiding or can be stored
up to 4 hours after voiding at 4`C.
 Urine preservation
If the specimen is not refrigerated within 1 hour
of collection, the following changes in
composition may occur
• Increased pH from the breakdown of urea to ammonia by urease-
producing bacteria
• Decreased glucose from glycolysis and bacterial utilization
• Decreased ketones because of volatilization
• Decreased bilirubin from exposure to light
• Decreased urobilinogen as a result of its oxidation to urobilin
• Increased nitrite from bacterial reduction of nitrate
• Increased bacteria from bacterial reproduction
• Increased turbidity caused by bacterial growth and possible
precipitation of amorphous material
• Disintegration of red blood cells and casts, particularly in dilute
alkaline urine
• Changes in color caused by oxidation or reduction of metabolites
 Significant pyuria is defined as
Pus cell >5/HPF in a centrifuged specimen
Pus cell >10/HPF in an un-centrifuged urine

Sterile pyuria: ( positive leukocytes, negative culture)

 Partially treated bacterial UTIs
 Viral infections
 Renal tuberculosis
 Renal abscess
 UTI in the presence of urinary obstruction
 Urethritis
 Interstitial nephritis
Gold Standard Test for UTI: Urine Culture and
Sensitivity Test
method of Colony count/ml Probability of infection
collection (%)

Any number of gram >99%

Suprapubic negative bacilli
aspiration

Trans urethral >105 95%

catheterization
104 -105 Infection likely

103-104 Suspicious, repeat

<103 Infection unlikely

Gold Standard Test for UTI: Urine Culture and
Sensitivity Test
Method of collection Colony count/ml Probability of
(pure culture) infection(%)

Mid stream clean catch

Boy >104 very likely

Girl >105 90-95%

104 to 105 Suspicious, repeat

<104 Infection unlikely

 Non specific markers

 Leukocytosis

 Raised ESR

 Procalcitonin

 C- reactive protein
 RENAL IMAGING

• Renal ultrasound

• Micturating cystourethrogram(MCUG)

• 99m Technetium Dimercaptosuccinic

acid(DMSA) scan

• Diethylenetriamine pentacetic acid (DTPA) scan

 Renal Imaging- Importance

• Prevalence of structural abnormality in

children with UTI- 10 to 75%

• About 5-35% have significant obstruction

requiring surgery .
 Renal ultrasound

• Non invasive
• Gives information on
• Renal size and shape.
• Bladder size and configuration, bladder
wall thickness.
• Post void residue.
• Pelvicalyceal and ureteral dilatation.
 Micturating Cystourethrogram

Gives information on

• Bladder lesion

• Urethral lesion- posterior urethral valve

• VUR- diagnosis and classification

 99m Technitium Dimercapto succinic acid
(DMSA) scan

• It is done in VUR to assess the degree of

scarring and suspicion of acute pyelonephritis.
In apporximately 50% of children with febrile
UTI, irrespective of age, the DMSA scan
demonstrate parencheymal involvement.
Among children with grade III, IV and V reflux
and a febrile UTI, 80-90% show acute
pylonephritis.
 DTPA scan

• It helps to differentiate obstruction from

dilatation. It is an excellent agent for visualizing
the pelvi-calyceal collecting system and ureters,
it can confirm obstruction at pelviureteric
junction and can assess GFR.
 Imaging Studies In First Proven UTI

Age < 2 years Age 2-5 years Age> 5 years

• USG • USG • USG
• MCU and • DMSA scan ± • IVU,DMSA
• DMSA MCU if and MCU if
scan USG or DMSA is USG is
abnormal abnormal
Renal Imaging according to National Institute for Health and Care Excellence
Imaging < 6 months of age
Responds well to treatment(within24 hours)-
• Ultrasound within 6 weeks
• If ultrasound is abnormal consider MCUG

Atypical UTI:
• Ultrasound during acute infection
• DMSA 4-6 months following acute infection
• MCUG- after urine become sterile
Recurrent UTI:
• Ultrasound during acute infection
• DMSA 4-6 months following acute infection
• MCUG after urine become sterile
 Imaging for 6months-<3years
Responds well to treatment within 48 hours :
• No imaging should be done.

Atypical UTI:
• Ultrasound during the acute infection.
• DMSA 4-6 months following infection.
• MCUG should be considered if -
• Dilatation on USG.
• Poor urine flow.
• Non E.coli infection.
• Family H/O UTI.
Recurrent UTI:
• Ultrasound within 6 weeks.
• DMSA 4-6 months following infection.
 Imaging for ≥3years age
Responds well to treatment within 48 hours:
• No imaging should be done

Atypical UTI:
• Ultrasound during acute infection
• DMSA 4-6 months following infection

Recurrent UTI:
• Ultrasound within 6 weeks.
• DMSA 4-6 months following infection
MANAGEMENT
 Goals of treatment:

• Elimination of infection
• Relief of acute symptoms
• Prevention of recurrence and long term
complications
 Principles of treatment:
Drug choice should be based on the-
• Resistance pattern of drug as well as of recent antibacterial
treatment received by the patient.
• Minimal side effects.
• High conc. in urine.
• Oral is equally effective in both upper and lower UTI
• 2nd and 3rd generation of cephalosporin should be avoided
as empiric therapy in non atypical UTI.
 Indication of Hospitalization:
• Age < 3 months
• Clinical Urosepsis
• Severe vomiting, unable to take oral
medication
• Immunocompromised child
• Complications
 Indication of Intravenous antibiotics:

• Age < 3 months

• Organism resistant to effective oral antibiotic.
• Severe vomiting unable to take oral medication.
• Atypical or complicated UTI.
• Dilating vesicoureteric reflux grades III-V.
 Lower UTI

• Acute cystitis should be treated promptly

• Send a urine sample for urine analysis and culture
• oral antibiotic for 3 -5 days
• Trimethoprim-sulfamethoxazole/nitrfurantoin
• Reassess if the child remain unwell after 24-48
hours
 Upper UTI

• I/V antibiotic if patient cannot take orally

switched to oral form when able to take
• Oral antibiotic is equally effective
• Start with broad spectrum antibiotic then
according to culture report
• Duration 7-14 days
 The Duration Of Therapy

-14 days for infants and children with

complicated UTI
- 7-10 days for uncomplicated UTI.
- 3-5 days in case of cystitis.
 Failure to respond therapy:

-may be due to presence of resistant pathogens,

-noncompliance
-these patients require re evaluation.
 General Management

• Plenty of water intake

• Paracetamol for fever
• Avoidance of constipation
• Proper Nutrition
• Frequent Voiding(Atleast 6 times/day)
 Antibiotic used for Oral Therapy

Drugs Dose (mg/kg/day)

Amoxicillin + 30-50 in 2-3 div
Clavulanic Acid
Cotrimoxazole 6-8 in 2 div dose
Cefadroxil 30-40 in 3 div dose
Cephalexin 30-50 in 3 div
Cefixime 10 , 2 div
Nalidixic Acid 50 in 3 div doses
Norfloxacin 10-12 in 2 div
Ciprofloxacin 10-20 in 2 div
Antibiotic used for Parenteral Therapy

Drugs Dose (mg/kg/day)

Gentamicin 5-6 in 1-2 divided dose
Amikacin 10-15 in 1- 2 divided dose
Cefotaxime 100 in 2-3 divided dose
Ceftriaxone 75-100 in 1-2 divided dose
 Indication of Prophylaxis of UTI

Following treatment of
• First UTI in all children < 2 years
• Complicated UTI in Children < 5 years while
awaiting imaging studies.
 Children with VUR: Patients showing renal scar
following UTI.
 Children with frequent febrile UTI (3 or more
episodes in a year even if the urinary tract is
normal).
 Antibiotic prophylaxis
Drug Dosage Remarks
(mg/kg/day
)
Co-trimoxazole 1-2 mg of Maintain adequate fluid intake,
trimethotri avoid in infants under 6 weeks
m
Nitrofurantoin 1-2 Considerable GI upset.
Contra Indicated in G6PD
deficiency, infants < 3 months,
and renal insufficiency

Cephalexin 10 May be used in young infants.

Trimethoprim 1-2 Reasonably safe.

 Complications
Allergic Reaction to antibiotics
Renal abscess
Renal scar
Hypertension
Impaired renal function
ESRD
 Prevention of UTI
Avoid constipation.
Wiping from front to Back direction after
defaecation.
Maintain personal hygiene
Emptying of bladder properly-
• 2-3 hrly emptying
• double voiding training.
• cranberry juice
 Drink enough fluid during day time.
 Empty bladder properly before sleep at night.
 To use cotton fabric loose fitting under wear.
 Advice for completion of antibiotic course.
 Avoid unnecessary antibiotic for minor illness
 Circumcision.
 Strict hygiene for child caregiver .
Cranberry juice

Prevents bacterial
adhesion
Prevents biofilm
formation
Double Voiding Training:
is a technique for bladder emptying ,those who have urinary
retention. The person is taught to urinate ,relax for five
minutes and repeat urination.
 Follow up

• Clinical evaluation-Ht, Wt, BP - every 6 months.

• Investigations-urine analysis for proteinuria- every
6months, Urine for c/s- if feature of UTI.
• USG-yearly to monitor renal growth and cortical scarring.
• Blood level of urea and creatinine- every 6months.
• DMSA scan-if breakthrough UTI.
• If renal scar-twice yearly.
 Prognosis
 Most child with UTI have an excellent prognosis.
 The risk of complications in a small groups specially
in those with hypo plastic or dysplastic congenital
anomalies and dilated VUR.
 The process of scaring after APN is slow, it takes 1-2
year for a scar to develop fully.
 In children with bilateral renal damage GFR is often
decreased and the risk of progressive deterioration
is greater.
 Take Home Message
• UTI should be suspected in all cases of fever without
focus.
• Most cases of UTI are simple, uncomplicated, and
respond readily to outpatient antibiotic treatments
without further sequelae.
• Definition of recurrent UTI in children needs no
duration.
• Appropriate treatment, imaging, and follow-up
prevent long-term sequelae in patients with more
severe infections or chronic infections.
• Any child with proven UTI should have imaging
studies performed to R/O VUR or renal anomalies.