Urinary Tract Infections

Dr. Ali Althabhawi

2023-2024
 Urinary tract infection
Urinary tract infections (UTIs) commonly occur in children of all
ages, UTIs are most common in children under age 1 yr
 1-3% of girls and 1% in boys
 In girls, Peak via infancy and toilet training, after the 1st
attack of girls, 60-80% will develop 2nd attack of UTI, within
18 months
 In boys, more common in 1st year and much more common
in uncircumcised,
 In 1st year M/F 2.8:5.4, beyond infancy , the ratio is 1:10
Atiology
 Mainly by colonic bacteria, in female, 54–67% due to E-coli
followed by proteus and Kliebsiella .
 In male, older than 4 year , proteus common as E-coli,
reported G+ve in male
 Staph-saprophyticus is a pathogen in both sex
 Virus(adeno) 11,21 cystitis
 UTI have been consider as imported cause in development of
renal insufficiency and end stage renal disease
 Pathogenasis
Nearly all UTI are secondary from bacteria arise from fecal flora , colonized
the perineum and enter the bladder via urethra, or from bacteria beneath the
prepuse in uncircumcised boy , it may lead to pyelonephritis.
Rarely hematogenous spread
Risk Factors of UTI

The incidence of UTI in breast fed babies is less than formula fed.
 Clinical features
1- Pyelonephritis
 Is characterized by any or all of the following
n un

 Abd pain(flank)=> bilateral flank pain usually related to muscle not to renal Cause .

 Fever(may be the only manifestation), particular consideration

should occur for a temperature > 39°C without another source
lasting more than 24 hr for males and more than 48 hr for
females . Considered
=> with
as UTI of other of fever
exclusion causes such and
respiratory as CNS

 Malaise
 Nausea
 Vomiting
 Accasionlly diarrhea => due to irritation of bladder .

 In newborn and infant, nonspecific (irritability, jaundice, poor

feeding, weight loss).
 Pyelonephritis is the most common serious bacterial infection in
infants <24 mo of age who have fever without an obvious focus
Involvement of renal parenchyma is termed
acute pyelonephritis whereas if there is no
parenchymal involvement, the condition
maybe termed pyelitis.

Renal abscess typically occurs following

hematogenous spread with S. aureus or can
occur following a pyelonephritic infection
caused by the usual uropathogens

Acute pyelonephritis can result in renal

injury, termed pyelonephritic scarring.
2- Cystitis
Bladder involvement, dysuria, frequency, urgency,
suprapubic pain, incontinence, malodorous urine (is not
specific for a UTI), no renal damage, no fever
 Acute hemorrhagic cystitis, though uncommon in
children, is often caused by E. coli; it also has been
attributed to adenovirus types 11 and 21.
 Adenovirus cystitis is more common in boys; it is
self-limiting, with hematuria lasting approximately 4
days.
 Patients receiving immunosuppressive therapy are at
higher risk for hemorrhagic cystitis
3- Asymptomatic bacteruria
+ve urine culture but no manifestation, benign
condition , no treatment require except in pregnancy
 Diagnosis
 Suspected from symptoms and/or finding of urine
analysis or both.
 +culture is necessary for confirmation and
appropriate treatment
 the Dx of UTI, depend on proper sampling of urine(4
ways)
 1- Midstream urine = in child having toilet training
(in uncircumcised boy, the prepuce should be
retracted).
 +ve if the colony count more than 100,000 colony –
forming units(CFU) of single MO
 or child is symptomatic, and 10,000 CFU is consider
UTI,
2- Adhesive , sealed , sterile collecting urine bag in
infant, after disinfection of skin of genitalia.
false-positive rate too high to be suitable for
diagnosing UTI;
however, a negative culture is strong evidence that
UTI is absent.

+ve if the colony count more than 100,000 CFU of

single MO and child is symptamatic, and +ve urine
analysis

however if any of this criteria are not met , we may

need next way
3. Catheterized sample= proper skin preparation , gentle
technique of catheter is important, feeding tube poly thene nu 5 or 8
nu with lubricant in older child to decrease risk of trauma,
+ve if more than 10 000 CFU
4- Suprapubic puncture = +ve if any MO best method

NOTE
Prompt plating of urine sample is important (stay in room temp for 60
min, lead to over growth of minor contamination the may suggest
UTI), put it in refrigerator.
single MO
Others indicators of UTI
A- pyuria (pus cell in urine A WBC count on urinalysis above 3-6
WBCs/high-powerfield) suggest UTI, this finding is more
confirmatory than diagnostic.
Conversely, pyuria can be present without UTI., so its absence does
not exclude UTI(sterile pyuria)
Sterile pyuria (positive leukocytes, negative culture) occurs in
1- partially treated bacterial UTIs
2-viral infections
3-renal tuberculosis
4- renal abscess
5- UTI in the presence of urinary obstruction,
6- urethritis due to a sexually transmitted infection
7-inflammation near the ureter or bladder (appendicitis, Crohn
disease),
8- interstitial nephritis (eosinophils)

If a child asymptomatic, GUA normal, it is unlikely UTI, however, if child

B- Nitrite and leukocytestrase +ve in urine
C- Microscopic hematuria is common in acute cystitis, but
microhematuria alone does not suggest UTI.
D- Blood (neutrophilia, increase ESR, CRP, in renal abscess,
WBC 20,000-25,000, blood culture is indicated sepsis in
infant
E-Renal Scanning with Techneutiaium- labeled
DMSA(DiMarcoptoSuccinic Acid)
Is the most sensitive and accurate way to detect the renal scaring.
F- Urogram less sensitive than DMSA in detecting the renal
scaring, and need 1-2 year to detect the pathology , risk of
radiation
G- CT of abdomin to detect the scaring in some time.
Treatment -
if Symptomatic (sever)
antibiotic immediately
=> Send for Culture and
give oral

without fever osI

1- Acute Cystitis -
if
symptomatic
result
(mild)

after the
=> Send for Culture and wait the

>
-
result

should be treated to prevent pyelonephritis

oral antibiotic
accordingly give
,

A- if symptomatic (sever), urine culture should be obtained, a 3- to 5-

day course of therapy with
Trimethoprim-sulfamethoxazole (TMP-SMX) (6-12 mg TMP/kg/day
in 2 divided doses) or trimethoprim is effective against many strains of
E. coli.
Nitrofurantoin (5-7 mg/kg/24 hr in 3-4 divided doses) also is effective
and has the advantage of being active against Klebsiella and
Enterobacter
sit
organisms.
resistance
Amoxicillin (50 mg/kg/24 hr in 2 divided doses) also may be effective
as initial treatment but has a high rate of bacterial resistance.
B- if symptomatic (less sever ),treatment started till result of urine
culture.
2- Pyelonephritis
14 days course of broad spectrum of AB
(Ampicillin 100mg/kg+Gentamycin 3-5mg/kg, cefotaxime
100 mg/kg/24 hr, or Ceftriaxone 50-75mg/kg not exceed 2
gram)is preferable (less ototoxicity and nephrrotoxicity).

serum Cr and level of Gentamycin should be obtained before

and during treatment if prolonged.
Indications of hospitalization
A- dehydration
B- unable to drink
C-possipble sepsis
D-age less than 1month
 Alkalization of urine is valuable in treatment of proteus with Gentamycin.
 Oral 3rd generation cephalosporin (Cefixim) is effective in G-ve other than
Pseudomonas
 quinolone derivative is effective(contraindicated below age of 17years, effect
the growing cartilage ), occasion for short-course therapy in younger children
with Pseudomonas UTI
Levofloxacin is an alternative quinolone with a good safety profile in children
 Some outhers suggest loading dose of Ceftriaxone then oral 3rd generation
cephalosporin(cefixim).
 In abscess percutaneous drainage +parental AB
 Urine culture should be obtained 1week after complete the treatment (should
be sterile)
In recurrent UTI and in absence of risk factor , periodic urine culture every
3months for 2 years (if child asymptomatic) is indicated.
In recurrent UTI , identify the risk factor and treat it and give AB
prophylactic(1/3 of therapeutic dose) , Trimetheprime, Nitrofurantuine ,
Nalidixic acid., indicated in
1- neurogenic bladder
2- stasis due to obustruction
3- VUR
4- stone
Amoxil, Keflex is effective but increase risk of breaking through
UTI(become resistant)

Probiotic,
cranberry juice
Imaging Study
1-1st episode of clinical pyelonephritis
2-Those with a febrile UTI
3- In infants, those with systemic illness
4-A positive urine culture, irrespective of temperature,
a sonogram of kidneys and bladder should be
performed to assess
1- Kidney size
2-Detect hydronephrosis
3- Ureteral dilation,
4- Identify the duplicated urinary tract
5- Evaluate bladder anatomy.
Next, a DMSA scan is performed to identify whether the child has
acute pyelonephritis. If the DMSA scan is positive and shows either
acute pyelonephritis or renal scarring,
.
a voiding cystourethrogram (VCUG) is
performed in(AAP)
1-Ultrasound study is abnormal.
2-Atypical features.
3- Recurrent febrile UTI
. If reflux is identified, clinician needs to
decide on whether to send the child to a facility
with DMSA capability(if available) or instead
do a VCUG
VCUR
Time= 2-6 week after infection
2types 1- Radionucltide less radiation, less
anatomical differentiation
2- Contrast more radiation , good
differentiation
Definitions of atypical and recurrent UTI
Atypical UTI
UTI associated with sepsis or bacteraemia
Concern regarding obstructive uropathy
Failure to respond to antibiotics within 48 hours
Associated impaired renal function (elevated creatinine level)
Infection with a non E. coli organism
.

Recurrent UTI:
 Two or more episodes of UTI with acute pyelonephritis/upper
urinary tract infection, or
 One episode of UTI with acute pyelonephritis/upper urinary tract
infection plus one or more episode of UTI with cystitis/lower
urinary tract infection, or
 Three or more episodes of UTI with cystitis/lower urinary tract
infection.
 VesicoUretric Reflux(VUR)
is retrograde flow of urine from the bladder to the ureter
and renal pelvis

Normally , ureter is attached to the bladder in oblique

direction perforating between the bladder mucosa and
detroser muscle , creating a flap-valve mechanisim that
prevent reflux.

Reflux occur when the tunnel between the mucosa and

detroser muscle is short or obliterated.
 Affecting 1–2% of children
 VUR usually is congenital and often is familial.
 35% of sibling of a child with reflux also have a
reflux
 VUR in 50% in boy with posterior urethral valve,
25% in neuropathic bladder, 15% in renal agenasis
 VUR is present in approximately 30% of females
who had a urinary tract infection
 in 5–15% of infants with antenatal
hydronephrosis.
 20% of ESRD, gave a history of reflux
 VUR is important cause of HT in children
Clinical feature
Usually discovered during evaluation of UTI, 80% in
female , average age is 2-3 year
Renal insufficiency, HT
DIAGNOSIS
1- VCUG, reflux occurring during bladder filling is
called (low pressure)or passive and less likely to
show spontaneous resolution,
high pressure or active more likely to show
spontaneous resolution,
2- Renal U/S
3- DMSA
4- Check the Bpr , ht, wt, urine culture
Natural History
1- Grade 1 and 2 ,whether uni or bilateral
spontenous resolution
2- Grade 3 younger age and unilateral
high rate of resolution
3- Grade 4 bilateral less likely to resolve
than unilateral
4- Grade 5 rarely resolve
The main age of spontaneous resolution is 6
years
Treatment
The goal are to 1- prevent pyelonephritis
2- renal insufficiency
3- others reflux complication
Treatment contain the following
 AB prophylaxis , urine culture
 VCUG every 12-18 month
 Check the Bpr , ht, wt frequently
The above medical treatment is successful when
 No infection.
 No scar .
 Reflux resolve
Surgical treatment indicated in
 New scar
 Breakthrough UTI
 Not resolve at the age more than 7 year(failure of
medical treatment)
 Grade 4 and 5
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