JOURNAL CLUB:

MARYAMUL AZEAN
BINTI MAULUD URINARY TRACT
INFECTION
INTRODUCTION

UTI is the most common bacteria infections in childhood,

holding 6-8%

Prevalence varying in ages-peaking in young infant, toddler and

adolescent female due to
• Bacterial skin flora under nappy  
• shorter female urethra distance
• Foreskin surface in uncircumcised males
• Toddler due to toilet training lead to volitional holding and bladder stasis
• Adolescent female when sexual activity disrupt normal flora over uretheral orifice

Condition that cause impaired of urinary flow which lead to

urinary stasis which lead as a reservoir
• Structural - urogenital anomalies
• Functional- neurogenic bladder, constipation and behavioral witholding
• Altered immune function
 30% of recurrent UTI may develop form
patient with UTI

 Common risk factor include

 VUR
 Bladder bowel dysfunction
 older non continent children ( developmental
delay)
AETIOLOGY

 E.coli ( 80%)
 Klebsiella sp
 Proteus sp
 Enterobacter sp
 Enterococcus sp
UPPER
AND
LOWER
TRACT UTI
Short term Long term

Systemic features- Renal injury

lethargy, dehydration and scarring
MORBIDITY
Local complication-
perinephric abscess
Renal
dysfuction
IN UTI
formation

Bacteremia Hypertension

Urosepsis CKD

Meningitis
DIAGNOSIS

 It is important to consider in infant with fever without focus

 Non specific symptoms includes lethargy, irritability, poor feeding and
vomiting may overlap with other cause of infection
 Malodorous urine or change in urine colour in nappy
 Localizing symptoms such as dysuria, flank pain in bigger child
 Clincical diagnosis is unreliable, therefore urine sample is important for
further evaluation
URINE SAMPLE COLLECTION
SCREENING
 By using Urine disptick
 Chemical colour change in present of leucocytes and
nitrites
 They are not specific or sensitive in UTI but useful
screening test when use in combination as some 
infections may presented with sterile pyuria 
 Enterococcus, Klebsiella and pseudomonas less likely
to produce pyuria
 Enterococcus and Klebsiella not usually release nitrates
 If UTI is unlikely, a negative result have good predictive
value to exclude the diagnosis
 If presence of symptoms, and positive result in either
lecucocytes or nitrites, empirical antibiotic is indicated
DIAGNOSIS

 Urine C+S is the gold standard for diagnosis

 Urine obtain is sterile, therefore evidence of
growth in specific amount with active
infection, suggest UTI
Historical 100000 CFU/mL  Quantitiy of bacterial growth varies based on
guideline
NICE no specific recommnedation  Any growth from SPA sample is abnormal
AAP 50000 CFU/ml with concurrent  Diagnostic treshold are non binary
pyuria in SPA/ catheter
 Low colony may represent early
Proposed 10000 CFU/ml  infection/contamination or
asymptomatic bacteriuria. 
 Pyuria also may absent in early infection
or immunocompromised.
  Require targeted antibiotics and supportive
care
 Most case of UTI can be manage at home

MANAGEMEN  Admission requirement usually due to

T  Small infant
 Very unwell child
 Significant renal tract abnormalities
 Not responding to oral antibiotics
ANTIBIOTICS THERAPY

 Local choice of antibiotics guided by local guideline

 The suitability of initial agent should be review after
culture result is obtained
 Younger and sicker child require initial IV therapy
 For child less than 3 months, admission, IV
antibioticd and septic workout is recommended
 Aim to switch to oral therapy after 48H if there is
clinical improvement 
ANTIBIOTICS THERAPY

 Antibiotics resistance become more common and increase morbidity and cost
 Due to
 Acquisition of beta lactamase activity
 rug resistance properties due to evolution of enzymes-activity to hydolyse and inactivate
extended spectrum beta lactamase and cephalosporin. 
IMAGING

 Previuosly, guideline recommend aggressive imaging follow up to identify renal

scarring and complication of UTI.
 Now child with structural abnormalities are at high risk to develop
complications.
 Therefore many recent guidelines suggest less or no imaging after first
uncomplicated UTI for older children and less aggressive imaging after recurrent
UTI 
DMSA

 Nuclear isotope uptake

scan. 
 Reduce uptake may
reflect acute dusfunction
in pyelonephritis or long
term damage scarring
depending on time of the
test.
 Recommeded if UTI is
atypical, recurrent or
initial ultrasound is
significantly abnormal
VCUG

 Use fluoroscopy to identify the course of contrast

inserted by bladder catheterization
 Bladder filling, emptying and ureteric reflux xan be
identify
 gold strandart for identifying and quantifying VUR,
it has risk of radiationa nd invasive
SPECIAL CASE: STATE FLUX

 Previously, it is assumed that  VUR  could lead to

significant long term renal damage
 Now, there is increase awareness that much renal
disease based on reflux is congenital
 Mild hydronephrosis and VUR as normal
physiological state and resolved spontaneously
 Aggressive identification of VUR is unwarranted as
lower grade of VUR is less unlikely to cause
scarring
 more active management is needed in high grade
VUR 
SPECIAL CASE: ANATOMICAL
ABNORMALITIES

 Anatomical anomalies can predispose to UTI but

early detection can be obtain on routine ultrasound
screening
 Significant abnormalities still warrant for follow up
and management
PROPHULAXIS AND PREVENTION IN
RECURRENT UTI

 Circumcision reduce risk of UTI in males

 Antibiotics prophylaxis has modest benefit and increase risk of resistance and not
indicated after first or second UTI in otherwise healthy infection
 For children with VUR, antibiotic prophylaxis reduce UTI risk, but not reduce
risk if scarring
 Simple hygiene such as wiping front to back can prevent bacteria into uretheral
orifice
 Active management for toilet training and constipation help to prevent functional
bladder bowel dysfunction 
UTI: SUMMARY
 UTI is a common bacterial infection in childhood
 Since clinical diagnosis is unreliable, urine sample is required for
diagnosis
 Positive urine dipstick can inform initial management while
awaiting for culture
 Management is aim to prevent short term and long term
complications
 Less aggresive imaging can be used following uncomplicated UTI
 International guidelines has conflicting recommendations
regarding sample collection method antibitocs duration and
imaging, therefore targeted research is required