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URINARY TRACT INFECTION IN CHILDREN
AGNES ALARILLA-ALBA MD
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Urinary Tract Infection
An 2 mos old male infant was noted to have high grade fever documented at 39 C of two days duration. It was associated with chills and vomiting. Patient was noted to have flat fontanelle with no note of neck rigidity.
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INITIAL IMPRESSION??? A) Systemic Viral Infection B) Meningitis
C) Urinary Tract Infection D) Sepsis
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Important Points in the History…..
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Points to Ponder AGE of the patient SEX of the patient
signs and symptoms of UTI according to age
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[1] The neonates presenting with clinical signs and symptoms.
The Suspect [1] The neonates presenting with clinical signs and symptoms. [2] Febrile infants [>38 C] below 2 years of age without any focus of infection. [3] Older children manifesting symptoms referable to the urinary tract . Table 1 Table 1 Table 1 The evidence for this recommendation A/II. Hoberman A[6,7,8]; Shaw [9], Downs [5].
![[1] The neonates presenting with clinical signs and symptoms.](http://slideplayer.com/slide/8355591/34/images/6/%5B1%5D+The+neonates+presenting+with+clinical+signs+and+symptoms..jpg "The Suspect. [1] The neonates presenting with clinical signs and symptoms. [2] Febrile infants [>38 C] below 2 years of age without any focus of infection. [3] Older children manifesting symptoms referable to the urinary tract . Table 1. Table 1. Table 1. The evidence for this recommendation A/II. Hoberman A[6,7,8]; Shaw [9], Downs [5].")
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TABLE I. Clinical S/SX Neonates Older Infants School Age/ Adol Septic
In general manifestations of urinary tract infections are non-specific. However, there are some signs and symptoms that are associated with UTI: TABLE I. Clinical S/SX Neonates Older Infants School Age/ Adol Septic [+] Temp instability Poor feeding Vomiting Lethargy/Irritab Jaundice Fever
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Table I. Clinical S/Sx Neonates Older Infants School Age/ Adol Poor wt gain /FFT [+] Diarrhea Abdominal pain Freq,drib, urge, dysuria Weak urinary str Malodorous urine Enuresis Flank pains
![Table I. Clinical S/Sx. Neonates. Older Infants. School Age/ Adol. Poor wt gain /FFT. [+] Diarrhea.](http://slideplayer.com/slide/8355591/34/images/8/Table+I.+Clinical+S%2FSx.+Neonates.+Older+Infants.+School+Age%2F+Adol.+Poor+wt+gain+%2FFFT.+%5B%2B%5D+Diarrhea..jpg "Abdominal pain. Freq,drib, urge, dysuria. Weak urinary str. Malodorous urine. Enuresis. Flank pains.")
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NOTES: In management of UTI --> no discrimination between Males and females 5.3% of febrile infants have positive culture for UTI If age of patient is less that 2 years old--> non specific signs and symptoms
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NOTES GIRLS BOYS 3-5% of GIrls Peaks at infancy and at toilet training
After 1st uti 60% will develop recurr Beyond 1-2 yrs old 1:10 1% of BOYS Usually on first year of life Uncircumcised boys first year of life: of M: F ratio is :1 after
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ETIOLOGY E Coli Klebsiella Proteus F
Proteus and E Coli + gram positive org for males Staph Saprophyticus and Enterococcus in both sexes Adenovirus for cystitis
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NOTES: ONLY 2 proven risk factors : UNCIRCUMCISED MALES CONSTIPATION
UTI -> higher by 5 to 20% if uncircumcised
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URINARY TRACT INFECTION
ACUTE PYELONEPHRITIS Asymptomatic Bacteriuria CYSTITIS
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Suspected Urinary Tract Infection
II. Algorithm on the Diagnosis, Work-up, Treatment and Follow-up of Children with UTI Suspected Urinary Tract Infection Urinalysis [suggestive of UTI] History Pyuria >5 WBC/ hpf or 10/mm3 [+] leucocyte esterase or nitrite test Bacteruria in unspun urine, GS Urine culture of properly collected specimen Physical Exam FEVER > 38.5 C
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RISK FACTORS female Uncircumcised male Toilet training Reflux
Vioding dysfunction Obstructive uropathy Urethral instrumentation Wiping from front to back Bubble bath Pin worm infestation Tight clothing Constipation Labial adhesion Neuropathic bladder pregnancy
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Important points in the PHYSICAL EXAMINATION
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III. Diagnosis PHYSICAL EXAMINATION A thorough PE is a must.
Look for congenital defects. Back examination – dimples, hair tufts in the lumbosacral area [neurogenic bladders] Lower extremities Rectal exam Neurologic examination
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Examination of the back
Slide courtesy of DTBolong MD
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What laboratory test will you request to help in the diagnosis?
A) URINALYSIS B) URINE Culture and sensitivity C) ultrasound of the KUB D) VCUG E.) DMSA F) A and B G) A , B and C H) all of the above
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Suspected Urinary Tract Infection
II. Algorithm on the Diagnosis, Work-up, Treatment and Follow-up of Children with UTI Suspected Urinary Tract Infection Urinalysis [suggestive of UTI] History Pyuria >5 WBC/ hpf or 10/mm3 [+] leucocyte esterase or nitrite test Bacteruria in unspun urine, GS Urine culture of properly collected specimen Physical Exam FEVER > 38.5 C
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URINALYSIS Must have pyuria and bacteriuria--> to be more specific and sensitive must be collected properly if less than one year old SUPRAPUBIC TAP if not feasible cathetherization
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URINALYSIS if greater than two--> midstream clean catch
bag collection : false positve by 20%-85% Cleaning of ANTISEPTIC is not recommended Send immediately to lab--> exponential rise ( one hour) if stored in 4C--> 24 hours
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URINE CULTURE and SENSITIVITY
The GOLD STANDARD must be 100,000 CFU of SINGLE organism if suprapubic tap --> exception Lactobacillus, corynebacterium and coagulase negative staph -> must be interpreted with caution.
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URINE CULTURE: Interpretation
III. Diagnosis URINE CULTURE: Interpretation Table II. METHOD OF COLLECTION Quantitative Culture : UTI present Suprapubic aspiration Growth of urinary pathogen in any number [exception is up to 2-3 x 103 CFU/ml of coagulase[-] staph Catheterization Febrile infants of children usually have 50,000 CFU/ml evidence of a single pathogen, but infection may be present with counts from>1000CFU/ml Midstream clean void, Symptomatic patients Usually have 105 CFU/ml of a single urinary pathogen Midstream clean void, Asymptomatic patients At least 2 specimens of different days with 105 CFU of the same pathogen
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URINE CULTURE: Interpretation
III. Diagnosis URINE CULTURE: Interpretation Significant bacteriuria [1] Clean catch > 100,000 cfu/ml [2] Catheterized > 50,000 cfu/ml specimen [3] Suprapubic any bacteria [4] Bagged specimen: only significant if it is negative
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ULTRASOUND OF THE KUB Infants and children who do not demonstrate expected response in two days -->may do US imaging--> to detect dilatations timing is not crucial according to study
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Normal Kidney Hydronephrosis
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VCUG to do if you suspect anatomical abnormality to detect reflux
VUR incidence in patients with UTI is 50% if not done may maintain patient on prophylaxis
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Urinary Tract Infection
The Prevalence of VUR as a function of patient age. The prevalence of VUR reported in 54 studies of UTI in children. AAP 1999 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 Prevalence of VUR Average Age [yrs]
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International Classification of Vesicoureteral Reflux
Pediatrics 1981; 67:392 Grade I Grade II Grade III Grade IV Grade V Slide courtesy of RHFrancisco, MD
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Vesico Cysto Urethro Graphy Vesicoureteral Reflux
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DMSA to detect renal scars
earliest is six months after the incidence of UTI
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DMSA Renal Scan Pyelonephritis
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How will I treat? A) ampicillin and an aminoglycoside
B) aminoglycoside C) third gen cephalosporin D) ciprofloxacin E) cotrimoxazole
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TREATMENT See age of the patient
if initially considering sepsis then may start with double- if U c/s is out shift to sensitivity if toxic looking and greater than two y/o third gen IV aminoglycosides
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TREATMENT if not sick looking--> child with symptoms of UTI_-> DOC still COTRIMOXAZOLE Co amoxiclav --> good bladder retention third gen--> cefixime --> good alternative
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TREATMENT may initially start with IV but once condition improves in 24 to 48 hours shift to oral as dictated by sensitivity how long? May give 7 to 10 days but if initially sick looking experts prefer 14 days
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Some Oral Antimicrobials Dose
III. TREATMENT Some Oral Antimicrobials Dose Amoxycillin 20-40 mkday in 3 doses TMP – SMX TMP[6-12mg], SMX [30-60] mkday in 2 doses Sulfisoxazole mkday in 4 doses Cefixime 8 mkday, 2 doses Cephalexin mkday in 4 doses Cefdoxime 10 mkday in 2 doses Cefprozil 30 mkday in 2 doses
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Some Parenteral Antimicrobials Dose
III. TREATMENT Some Parenteral Antimicrobials Dose Cetriaxone 75mkday, OD Cefotaxime 150 mkday , 4 divided doses Cefazolin 50 mkday, 3 divided doses Gentamycin 7.5 mkday, 3 divided doses Tobramycin 5 mkday, 3 divided doses Ticarcillin 300 mkday, 4 divided doses Ampicillin 100 mkday, 4 divided doses
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Some Prophylactic Antimicrobials Dose
III. TREATMENT Some Prophylactic Antimicrobials Dose TMP + SMX TMP 2 mkdose, SMX 10 mkdose Nitrofurantoin 1 – 2 mkdose Nalidixic Acid 30 mkday, 2 divided doses IV. TREATMENT – Surgical Intervention
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General Management Principles
increase fluid intake regular and complete emptying increase dietary fiber intake may give Vit C ( not proven) perineal hygiene bladder exercise
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Urinary Tract Infections
Take home message … Urinary Tract Infections in infants and children warrant special attention because they serve as a marker for anatomic abnormalities in the GUT.
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Complications of UTI Renal Scarring
Mackenzie, % Hodson, % Hypertension Jackobson, % [27 year follow-up] Renal Failure Jackobson, % [27 year follow-up]
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THANK YOU MARAMING SALAMAT PO!!!
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Some Parenteral Antimicrobials Dose
III. TREATMENT Some Parenteral Antimicrobials Dose Cetriaxone 75mkday, OD Cefotaxime 150 mkday , 4 divided doses Cefazolin 50 mkday, 3 divided doses Gentamycin 7.5 mkday, 3 divided doses Tobramycin 5 mkday, 3 divided doses Ticarcillin 300 mkday, 4 divided doses Ampicillin 100 mkday, 4 divided doses
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Other ISSUES of interest...
Asymptomatic Bacteriuria will I treat or not…. Recommendation is NO RCT done in UK revealed that onlong term follow up patient treated with antibiotics are more likely to develop UTI with more virulent strains
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When to refer to specialist..
Recurrent infection VUR renal damage possible obstruction nephrolithiasis
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Other issues of interest..
HOW if all the test (US, VCUG) turned out to be negative and still has recurrent UTI CONSIDER: DYSFUNCTIONAL ELIMINATION SYNDROME voiding disorder constipation
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Other issues of INTEREST..
Patients with recurrent UTI VUR % Anatomical Abnormalities 4.6% DES Voiding Dysfunction 21% Constipation % Idiopathic
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VOIDING DYSFUNCTION increased frequency decreased bladder capacity
interrupted voiding
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DES is suspected in... Frequent urination infrequent urination
incontinence (daytime and nighttime) constipation unexplained recurrent UTI unresolved reflux
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Bladder Disorder A. Lazy Bladder syndrome 14.3%
B. Overactive Bladder 28% C. Bladder Sphincter Dysenergia
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LAZY BLADDER Prophylaxis timed voiding- double void , triple void
Clean intermittent catheterization use of alpha blocker
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Overreactive Bladder compute for bladder capacity
age in years plus 2 X 30 prepare a diary for 72 hours check for daytime and night time incontinence check for holding manuevers
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Overreactive Bladder treatment ANTICHOLINERGICS-- OXYBUTIN
TIMED VOIDING ELECTRICAL STIMULATION POSTERIOR TIBIAL *CONSTIPATION
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THANK YOU GOOD DAY
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