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Urinary Tract Infections in Children

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Presentation on theme: "Urinary Tract Infections in Children"— Presentation transcript:

1 Urinary Tract Infections in Children
Dr. Rim El-Rifai Consultant Paediatrician QMHC

2 Outline of talk Cases Introduction and definitions Evaluation of UTI
Management Summary

3 7 year old girl Initial referral to investigate secondary enuresis,
had a “positive urine for UTI” Main concern nocturnal enuresis Dysuria and dark offensive urine History of PUO’s for 2 days at a time No abnormal physical findings on examination

4 investigations Ultrasound scan KUB: DMSA:
Small capacity bladder, dilated distal ureter and urothelial thickening in Lt renal pelvis and large left kidney on USS DMSA: left Duplex with scarring of upper pole- has patient had MCU?

5 3 weeks old girl Initial presentation to A&E: vomiting
Treated with IV AB’s 2 urine samples had mixed growth but > 100 WBC on SPA FH: brother had pyloric stenosis and UTI when 4 mo old TMP ran out after 2 weeks- did not get prescription

6 Investigations KUB USS normal Abdo. USS: Pyloric Stenosis
MCUG and DMSA awaited

7 6 years old girl Referred by GP for frequency and day time wetting at school Urine showed no WBC but grew Enterococcus treated as UTI with oral TMP History: frequency and urgency but not unwell or febrile Further urine dipstick and KUB normal On questioning: urine collected in make shift jar at home


9 What is a UTI? An inflammatory response of urothelium to bacterial invasion that is usually associated with bacteriuria and pyuria i.e. MSU shows: WBC > 10 Pure growth of organisms > 107

10 Bacteriuria Presence of bacteria in the urine in numbers exceeding the numbers caused by contamination from skin, urethra Not a contaminant from the skin, vagina, prepuce Collection technique sensitive May be asymptomatic

11 Pyuria Presence of white blood cells (WBCs) in the urine
Generally indicative of an inflammation of the urothelium as a response to bacterial invasion

12 Sites of origin of UTI Acute pyelonephritis:
acute bacterial infection of the kidney Fever, rigors Flank pain Bacteriuria and pyuria Unwell child, usually febrile

13 Sites of origin of UTI Bacterial Cystitis: Inflammation of the bladder
Abrupt onset of dysuria Frequency Urgency Suprapubic pain Non-bacterial cystitis: chemical

14 Sites of origin of UTI Urethritis Inflammation of the urethra
Symptoms difficult to differentiate from cystitis Seen in girls with vulvovaginitis

15 UTI in Childhood Features commonly non-specific
Associated with anatomical Urological abnormalities Difficulty in obtaining meaningful urine samples Tendency to cause renal scarring May lead to End Stage Renal Disease and Hypertension in adult life

16 UTI in Childhood Always regarded as complicated
Treatment very effective Recurrence is frequent following first UTI: 40% in females, 32% in males

17 Childhood UTI : Epidemiology
Prevalence is age and sex dependent Overall F > M In 2-10% of children 2 mo – 2 yrs of age with unexplained fevers

18 Incidence: age UTI diagnosed in 3% of prepubertal girls, and 1% boys
In children less than 1 year: M (2.7%) > F (0.7%)

19 Incidence: sex Most male infections under 3 months
10 times more common in uncircumcised males After first year 0.08% in boys 3-4% in girls until 6 years Up to 8% of girls are affected by UTI

20 Access of bacteria Haematogenous spread with bacteraemia in first 12 weeks After 3 months by ascending seeding through urethra

21 Pathogens Most common: E. Coli Other: Proteus spp (in boys) Klebsiella
Pseudomonas Enterococcus Staphylococcus epidermidis Staphylococcus aureus

22 Predisposing factors

23 Most commonly Constipation Vesico-ureteric reflux
Dysfunctional voiding- poor emptying Infected periurethral area Urinary stasis: PUJ, VUJ obstruction Ureteral duplication and ectopic ureters

24 Causes for recurrent UTI
Vesico-ureteric reflux Urinary stasis, constipation Infected periurethral area Infected atrophic kidney Ureteral duplication and ectopic ureters Infected urachal cysts, infected ureteral stump Foreign bodies Stones

25 Vesico-Ureteric Reflux

26 Vesico-ureteric Reflux
VUR demonstrated in 1-2% of healthy children More prevalent in infants and young children An intermittent phenomenon Increased detection rate due to antenatal screening Can be provoked by elevated voiding pressures

27 Vesico-ureteric Reflux and UTI
Reported in 30-50% of children with UTI A large number still present after their first UTI Reflux nephropathy is the cause for end-stage renal failure in 3-25% of children and 10-15% of adults

28 Evaluation of UTI

29 Presentation/Evaluation
History in infants and toddlers: Fever, irritability Poor weight gain (FTT) Smelly urine Abdominal Pain Dysuria, frequency, urgency Haematuria Enuresis and dysfunctional voiding Constipation, thread worm infection, sore vulva

30 Presentation/Evaluation
History in children: Fever Abdominal Pain (Flank/loin pain) Dysuria, frequency, urgency Haematuria “smelly urine” Enuresis and dysfunctional voiding Constipation, thread worm infection, sore vulva

31 History/ evaluation History in Lower urinary tract infection:
irritability Abdominal Pain Dysuria, frequency, urgency Haematuria “smelly urine” Enuresis and dysfunctional voiding Constipation, thread worm infection, sore vulva

32 History in enuresis/ incontinence
Nocturnal symptoms: Timing and onset of enuresis Frequency of wetting (wet nights/week) Times of wetting at night (one/several) Amount of urine passed (small/large) Daytime symptoms: Urinary frequency (frequent/infrequent) Urgency and urge incontinence Quality of stream Complete emptying? Posturing (Vincent curtsey)

33 Evaluation Physical examination: full examination including:
Growth BP genitalia Urine test imaging

34 Neuropathic Bladder Sacral Agenesis

35 Laboratory assessment
Urine dipstick for Nitrites, Leukocytes Urinalysis (clean catch sample) Direct microscopy and gram staining Culture and sensitivities

36 AAP and RCPCH guidelines for diagnosis of UTI in infants and young children
UTI should be ruled out in infants and children assessed to be sufficiently ill to require antibiotics treatment Diagnosis of UTI requires a culture of urine

37 Imaging

38 Urinary Tract Imaging Plain Abdominal x-ray Ultrasound- any age
Micturating cystourethrogram < 1 year Nuclear Imaging- any age IVU CT scan

39 Ultrasound Renal size and position
Scars, corticomedullary differentiation, cysts, masses, calcification, calculi Pelvis and calyceal size and appearance Pelvis-calyceal dilatation, urothelial thickening Ureters Dilatation, urothelial thickening, calculi Bladder outline, wall thickness, volume, residual volume

40 DMSA Renal cortical morphology Scars Overall function
Differential function No information on VUR

41 MAG 3 Quantify renal excretory function Flow imaging PUJ obstruction
Indirect cystogram

42 MCUG: Bilateral VUR DMSA: Left renal scarring

43 Imaging of urinary tract after first febrile UTI in Young children :
USS during acute illness of limited value MCUG useful in young age group where AB prophylaxis considered to reduce re-infection and renal scarring DMSA at presentation and 6 months later identifies renal scarring Pittsburgh SM N E J M, Jan 2003

44 Complications of UTI

45 Complications Acute: Short term: Long term:
Systemic illness, sepsis, renal abscess Short term: Renal scarring, recurrence of UTI Long term: Hypertension End-stage renal disease (overall 0.5%-5% of ESRD on dialysis have reflux nephropathy)

46 Renal scarring and VUR: International Reflux Study in Children
5 yr follow up 302 patients (10 yrs in 5/8 European centres)- serial IVU and DMSA Grade III, IV, V VUR and symptomatic UTI Medical vs Surgical treatment of VUR New scars in 21 surgical and 19 medical New scars mostly in children < 5years old New scars more frequent in Grade IV New scars in 2 females > 5 years Olbing H et al, Ped Nephrol, Oct 2003

47 Complications of UTI in Children
Hypertension Pyelonephritic scarring is the most common cause for hypertension in childhood Prevalence of hypertension independent of the degree of scarring

48 Treatment

49 E. Coli Resistance trends
Ampicillin 39-45% Trimethoprim-sulfamethoxazole 14-31% Nitrofurantoin % Fluoroquinolones (Ciprofloxacin) % Mazzuli T, J Urol 2002

50 Drugs for Treatment TMP 4 mg/kg BD for 7-10 days
Cephalosporins (Cefuroxime, Cephalexin) Gentamicin Ciprofloxacin Ampicillin? Nitrofurantoin (over 3 mon)?

51 Duration of treatment Uncomplicated UTI: > 5 days is associated with higher cure rates Tran D et al, meta-analysis of 1279 patients J Pediatr 2001 In Children < 2years of age: 7-14 days AAP, Pediatrics 1999 and RCPCH appraisal

52 Drugs for prophylaxis Trimethoprim 2 mg/kg nocte
Cephalexin 12.5 mg/kg (up to 125 mg) nocte Nitrofurantoin (over 3 mon) 1 mg/kg nocte

53 Cessation of prophylaxis
By age 4 years When urinary continence achieved and infection free Safe in patients in whom VUR fails to resolve Thompson et al J Urol 2001

54 Surgery When? Anti-reflux open procedures: 95-98% success
Endoscopic subureteric injections: 75-90% success Teflon- no longer approved by FDA (success 60-84%) Collagen Macroplastique Deflux (Dextranomer/hyaluronic acid copolymer) 70% success When? Breakthrough UTI Persistence of VUR Parental preference

55 Treatment: Bladder Retraining
Aims at increasing functional bladder capacity and reduction in residual volume 2-3 hourly voiding Double voiding Increasing retention capacity Isolated success in continence rate 35%

56 Prevention

57 Breast feeding Lactoferrin and oligosaccharides act as analogues for microbial receptors Prevents mucosal attachment Lactoferrin can kill bacteria, viruses and fungi

58 Prevention Healthy voiding pattern Avoidance of constipation
Avoidance of local colonization Circumcision? Cranberry juice? Probiotics?

59 Points to remember Accurate diagnosis of UTI
Low threshold to investigate in younger children (<4 years) Appropriate treatment of acute events Consider other problems when managing UTI

60 Points to remember The need to recognize the relationship between: VUR
Recurrent UTI’s Voiding dysfunction Renal scarring Treatment should target each factor


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