Urinary Tract Infections
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OUTLINE
• Introduction
• Prevalence and etiology
• Pathogenesis
• Classification and clinical manifestation
• Diagnosis
• Treatment
• Reference
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Introduction
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URINARY TRACT INFECTION
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Prevalence and Etiology
• The prevalence varies with age.
• Most common in children under age 1 yr
• A febrile symptomatic UTIs in children over age 1 yr is~8%
• In febrile infants is 7%.
• During the first yr of life, Male:Female ratio is 2.8 : 5.4.
• Beyond 1-2 yr, there is a female preponderance, Male:Female ratio of 1 : 10.
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• Much more common in uncircumcised males - 20% in febrile
uncircumcised males under age 1 yr.
• In females, the first UTI usually occurs by the age of 5 yr, with peaks
during infancy, toilet training, and onset of sexual activity.
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• Primarily by colonic bacteria -Escherichia coli(54–67% ) ,Klebsiella
spp ,Proteus spp, Enterococcus, and Pseudomonas
• Others - Staphylococcus saprophyticus, group B streptococcus,
Staphylococcus aureus, and Salmonella spp ,Candida spp ,adenovirus
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Pathogenesis and Pathology
• Nearly all UTIs are ascending infections
• Fecal flora, colonize the perineum, and enter the bladder via the
urethra.
• In uncircumcised males, the bacterial pathogens arise from the flora
beneath the prepuce
• Rarely, renal infection occurs by hematogenous spread
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• Defect in anti reflux mechanism that prevents urine in the renal pelvis
from entering the collecting tubules
• Passive anti reflux mechanism –passive compression of the ceiling of
intravesical ureter against underlying detrusor muscle ,intravesical
ureter length and diameter
• Active anti reflux mechanism –active shortening of the longitudinal
muscle layer of transmural and submucosal ureter –active valve
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• The presence of bacterial pili or fimbriae on the bacterial surface
• Two types of fimbriae, type I and type II.
• type II - Mannose resistant, P fimbriae are more likely to cause
pyelonephritis
• Between 76% and 94% of pyelonephritogenic strains of E. coli have P
fimbriae, compared with 19–23% of cystitis strains.
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Classification and Clinical Manifestations
Upper /lower UTI
• Pyelonephritis and cystitis.
• Focal pyelonephritis (lobar nephronia) and renal abscesses -less
common.
Simple /complicated UTI
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Pyelonephritis
• Involvement of the renal parenchyma is termed acute pyelonephritis
• No parenchymal involvement, the condition may be termed pyelitis.
• Pyelonephritic scarring
• Acute lobar nephronia (acute lobar nephritis) - localized renal
parenchymal, more commonly occurs in older children, early phase of
renal abscess .
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• Any or all of the following: abdominal, back, or flank pain;
fever ,malaise, nausea,vomiting ,and, occasionally, diarrhea.
• Fever may be the only manifestation:a temperature > 39°C without
another source , lasting more than 24 hr for males and more than 48 hr
for females
• Newborns - poor feeding, irritability, jaundice, and weight loss.
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• Renal abscess - following hematogenous spread with S. aureus or
pyelonephritic infection caused by the usual uropathogens.
• Most abscesses are unilateral , right sided and can affect children of all ages
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Perinephric abscess
• Diffuse throughout the capsule and is not walled off
• Contiguous infection in the perirenal area (e.g., vertebral
osteomyelitis, psoas abscess) or pyelonephritis that dissects to the
renal capsule
• The most common organisms -S. aureus and E. coli.
• Abnormal findings may not be seen on urinalysis or culture.
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Xanthogranulomatous pyelonephritis
• Granulomatous inflammation with giant cells and foamy histiocytes
• As a renal mass or an acute or chronic infection.
• Renal calculi, obstruction, and infection with Proteus spp. or E. coli
• Usually requires total or partial nephrectomy.
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Cystitis
• Only bladder involvement
• Dysuria, urgency, frequency, suprapubic pain, incontinence, and
possibly malodorous urine.
• Does not cause high fever and does not result in renal injury.
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• Uncomplicated cystitis — limited to the lower urinary tract ,children
older than two years with no underlying medical problems or anatomic
or physiologic abnormalities.
• Complicated cystitis — Coexisting upper UTI, multiple-drug
resistant uropathogens, or hosts with special considerations
( Anatomic or physiologic abnormality of the urinary tract, indwelling
bladder catheter, malignancy, diabetes)
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Acute hemorrhagic cystitis
• Uncommon in children
• E. coli ,adenovirus types 11 and 21( more common in boys; it is self-
limiting, with hematuria lasting approximately 4 days )
• Patients receiving immunosuppressive therapy -adenoviruses and
polyomaviruses (i.e., JC virus and BK virus)
Eosinophilic cystitis or interstitial cystitis
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Diagnosis
• Suspected based on symptoms or findings on urinalysis, or both
• Urine culture is necessary for confirmation and appropriate therapy
• Ways to obtain a urine sample-
toilet-trained children(a midstream urine sample)
In uncircumcised males(the prepuce must be retracted)
Not toilet trained - a catheterized or suprapubic aspirate urine sample
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• If the culture shows > 50,000 colony-forming units/mL of a single
pathogen (suprapubic or catheter sample) and the urinalysis has pyuria
or bacteriuria in a symptomatic child.
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Urine analysis
• Leucocyte esterase ,Nitrate
• Pyuria -A WBC count on urinalysis above 3-6 WBCs/high-power field is
indicative of infection
• WBC casts
• Microscopic hematuria - acute cystitis
• Sterile pyuria - positive leukocytes, negative culture,
• May occur in partially treated bacterial UTIs, viral infections,
urolithiasis, renal tuberculosis, renal abscess, urinary obstruction,
urethritis, inflammation near the ureter or bladder
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• Refrigeration is a reliable method of storing the urine until it can be
cultured
• Leukocytosis and neutrophilia are noted on the complete blood count
• An elevated serum erythrocyte sedimentation rate, procalcitonin level,
and C-reactive protein are common
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• Bacteremia - 3–20% of patients and is most common in infants less
than 90 days old and in any child with obstructive uropathy.
• Atypical features - failure to respond with in 48 hr of appropriate
antibiotics, poor urine flow, an abdominal flank or suprapubic mass,
non–E. coli pathogen, urosepsis, and an elevated creatinine level.
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Imaging Findings
• Imaging is not needed to make the clinical diagnosis of UTI or
pyelonephritis
• Acute lobar nephronia or renal abscess ,obstructive
uropathy ,anatomic abnormalities
• Renal ultrasound is the first-line
• CT scan
• Voiding cystoureterography
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• The AAP practice parameter recommends initial ultrasound of the
kidneys, ureters, and bladder for children 2-24 mo with a first episode
of UTI.
• VCUG is indicated only if the ultrasound study indicates
hydronephrosis, scarring or other findings suggestive of reflux or
obstructive uropathy, or if the patient has other atypical complex
features , recurrent febrile UTI
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Treatment
Acute cystitis
• 3- to 5-day course of therapy with trimethoprim-sulfamethoxazole
(TMP-SMX) (6-12 mgTMP/kg/day in 2 divided doses)
• Nitrofurantoin (5-7 mg/kg/24 hr in 3-4 divided doses)
• Amoxicillin (50 mg/kg/24 hr in 2 divided doses)
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Acute febrile UTIs
• 7-14 days , oral and parental routes are equally efficacious
• Dehydrated, are vomiting, are unable to drink fluids, have complicated
infection, or in whom urosepsis is a possibility should be admitted to
the hospital for intravenous (IV) rehydration and IV antibiotic therapy
• Ceftriaxone (50 mg/kg/24 hr, not to exceed 2 g) or cefepime (100
mg/kg/24 hr q 12 h) or cefotaxime (100-150 mg/kg/24 hr in 3-4
divided doses)
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• Oral 3rd-generation cephalosporins
• Urine cultures are typically negative within 24 hr of initiation of
antibiotic therapy
• Acute lobar nephronia is treated with the same antibiotics as
pyelonephritis. The duration of treatment is recommended for 14-21
days.
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• Renal or perirenal abscess or with infection in obstructed urinary tracts-
surgical or percutaneous drainage in addition to antibiotic therapy
• Long-term antibiotic prophylaxis - Neuropathic bladder, urinary tract stasis
and obstruction, severe VUR , and urinary calculi.
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Long term consequence
• Kidney loss - 10–20% of cases of renal abscess
• Arterial hypertension
• End-stage renal insufficiency
• The rate of renal scarring increases between days 2 and 3 of fever,
number of episodes of pyelonephritis and with the grade of reflux.
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Predictors of renal scarring included:
• High-grade VUR
• Abnormal renal bladder ultrasonography
• Elevated inflammatory markers including a C-reactive protein of >40
mg/L or a polymorphonuclear cell count >60 percent
• Temperature ≥39°C (102.2°F)
• UTI caused by organism other than E. coli
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Prevention of Recurrences
• Bowel and bladder dysfunction
• Constipation
• Intermittent clean catheterization
• Treat underlying causes
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REFFERENCE
• Nelson Textbook of Pediatrics, 21th edition 2020
• Up-to-date 2023
• Textbook of medical physiology,11th edition
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THANK YOU!!
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