Urinary tract infections Pediatrics.pptx

Urinary tract infections Pediatrics.pptx

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  A N DU A L E M B E L A Y , M D , N O VE M B E R 20 22 Urinary Tract Infection (UTI)
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  Outline  Introduction  Etiology Pathogenesis  Risk factors  Clinical manifestation  Diagnosis  Treatment  Complications
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  Introduction  Urinary tractinfections (UTIs) occur in 1-3% of girls and 1% of boys.  During the 1st yr of life, the male : female ratio is 2.8 - 5.4 : 1.  Beyond 1-2 yr, there is a female preponderance, with a male : female ratio of 1 : 10.  UTI: growth of a significant number of organisms of a single species in the urine, in the presence of symptoms
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  Etiology  UTIs arecaused mainly by colonic bacteria.  In girls, 75-90% of all infections are caused by Escherichia coli, followed by Klebsiella spp and Proteus spp.  In boys >1 yr of age, Proteus is as common a cause as E. coli; others report a preponderance of gram-positive organisms in boys.  Adenovirus and other viral infections also can occur, especially as a cause of cystitis.
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  Pathogenesis  Most UTIsare ascending infections.  The bacteria arise from the fecal flora, colonize the perineum, and enter the bladder via the urethra.  In uncircumcised boys, the bacterial pathogens arise from the flora beneath the prepuce.  In some cases, the bacteria causing cystitis ascend to the kidney to cause pyelonephritis.  Hematogenous is rare and is seen mostly in neonates
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  Antireflux mechanism inthe papilla vesico uretral reflux risk Infected urine stimulate immunologic and inflammatory response resulting in pyelonephritic scar,ESRF,HTN
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  RISK FACTORS  Femalegender  Uncircumcised male  Vesicoureteral reflux  Toilet training  Obstructive uropathy  voiding dysfunction  Instrumentation  Wiping from back to front  Tight under wear  Constipation  Pin worm infestation  Neurological bladder  Sexual activity  Anatomic abnormalities
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  Clinical Manifestation Three forms 1)Pyelonephritis 2) cystitis 3) Asymptomatic bacteriuria
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  pyelonephritis cystitis
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  - Clinical pyelonephritisis characterized by any or all of the following:  abdominal, back, or flank pain;  fever; malaise; nausea; vomiting; and,  occasionally, diarrhea.  Fever may be the only manifestation. - Acute pyelonephritis can result in renal injury, termed pyelonephritic scarring.
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  Cystitis indicates thatthere is bladder involvement; symptoms include  dysuria, urgency, frequency,  suprapubic pain, incontinence, and  malodorous urine. - Cystitis does not cause fever and does not result in renal injury.
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  - Asymptomatic bacteriuriarefers to a condition in which there is a positive urine culture without any manifestations of infection. - It is most common in girls. The incidence is <1% in preschool and school-age girls and is rare in boys.  It is benign & doesn’t cause renal injury, except in pregnant women, in whom if left untreated, can result in a symptomatic UTI  Antibiotic has no benefit
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  Diagnosis  UTI maybe suspected based on symptoms or findings on urinalysis, or both;  A urine culture is necessary for confirmation and appropriate therapy.  If the culture shows >100,000 colonies of a single pathogen, or if there are 10,000 colonies and the child is symptomatic, the child is considered to have a UTI.  Correct Dx of UTI depends on having the proper sample of urine
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   Criteria fordiagnosis of UTI based on CULTURE  Suprapubic aspiration: Any number of pathogens  Urethral catheterization: > 5 x 104 CFU/mL  Midstream clean catch: > 105 CFU/mL  Urinalysis (combination of the following)  Pyuria  > 10 leukocytes per mm3 in a fresh uncentrifuged sample, OR > 5 leukocytes per high power field in a centrifuged sample  DDx of pyuria: Fever, GN, renal stones or presence of foreign body in the urinary tract  Leukocyte esterase positive  Nitrite positive
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   With acuterenal infection,  Leukocytosis, neutrophilia, &  Elevated ESR & CRP are common  Blood culture especially in infants and obstructive uropathy and urosepsis
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  Treatment  Acute cystitisshould be treated promptly to prevent possible progression to pyelonephritis  A 3- to 5-day course of therapy with trimethoprim- sulfamethoxazole is effective against most strains of E. coli.  Nitrofurantoin (5-7 mg/kg/24 hr in 3-4 divided doses)  Amoxicillin (50 mg/kg/24 hr) also is effective as initial treatment but has no clear advantages over
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   In acutefebrile infections suggesting pyelonephritis,  a 10- to 14-day course of broad-spectrum antibiotics capable of reaching significant tissue levels is preferable.  Parenteral treatment with  ceftriaxone (50-75 mg/kg/24 hr, not to exceed 2 g) or  cefotaxime (100 mg/kg/24 hr), or  ampicillin (100 mg/kg/24 hr) with an aminoglycoside such as gentamicin (3-5 mg/kg/24 hr in 1-3 divided doses) is preferable.
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  Complications  Dehydration isthe most common complication of UTI in the pediatric population. IV fluid replacement is necessary in more severe cases.  Treat febrile UTI as pyelonephritis, and consider parenteral antibiotics and admission for these patients.  Untreated UTI may progress to renal involvement with systemic infection (e.g., urosepsis).  Urea splitting bacteria will cause alkalization of urine → stone  Long-term complications include renal parenchyma scarring, hypertension, decreased renal function, and, in severe cases, renal failure.
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  FOLLOW UP Chemoprophylaxis  Trimethoprin–sufamethozazole, Nitrofurantoin INDICATION  Recurrent UTI  Persisting vesico uretral reflux  Neurogenic bladder  Urinary tract obstruction  Calculi
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