By Dr. Athal Humo

Objectives To understand the causative agents in U.T.I. To know the risk factors To study the main signs and symptoms of U.T.I. in different ages in pediatrics To do the useful investigations. To out lines the treatment strategies To know how you prevent UTI.

Urinary tract infections (UTI) is common in the pediatric age group. Early recognition and prompt treatment of UTI are important to prevent progression of infection to pyelonephritis or urosepsis and to avoid late sequelae such as renal scarring or renal failure.

UTI include : cystitis, infection localized to the bladder pyelonephritis, infection of the renal parenchyma, calyces, and renal pelvis renal abscess, which may be intrarenal or perinephric

Prevalence : UTI is more frequent in females than males at all ages with the exception of the infantile period Approximately 5% of girls and 1% of boys have a UTI by 11 years of age. In boys, most UTIs occur during the 1st yr of life; UTIs are much more common in uncircumcised boys. The prevalence of UTIs varies with age: ▫During the 1st yr of life, ▫During the 1st yr of life, the male : female ratio is : 1. ▫Beyond 1-2 yr, ▫Beyond 1-2 yr, there is a female preponderance, with a male : female ratio of 1 : 10.

Etiology Gram-negative Escherichia coli, 80–85%Klebsiella, Proteus, UTIs are caused mainly by colonic bacteria. Gram-negative enteric bacteria of the Enterobacteriaceae family cause most UTIs in children of all ages. This includes: Escherichia coli, which are responsible for 80–85% of all UTIs among children. Klebsiella, Proteus, and Enterobacter spp., and the other members of the Enterobacteriaceae family are less frequent causes of UTI. Gram-positiveLess commonly, Pseudomonas aeruginosa, Gram-positive organisms such as Enterococcus and Staphylococcus, and Group B Streptococcus also cause UTI in children. Group B Streptococcus is almost exclusively seen as a cause of UTI in neonates, whereas Staphylococcus saprophyticus is typically seen in adolescent. Staphylococcus aureus is an uncommon cause of UTI and may be the result of hematogenous spread to the kidney. Infection with S. aureus often results in focal renal lesions, such as intrarenal and perinephric abscesses.

Adenovirus hemorrhagic cystitisAdenovirus infections also can occur, especially as a cause of hemorrhagic cystitis and it more common in male. fungal and parasitic immunocompromisedfungal and parasitic and other viral infections of the urinary tract are also encountered especially in immunocompromised and susceptible subpopulations.

In neonates, hematogenous In neonates, infection of the urinary tract is assumed to be due to hematogenous rather than ascending infection. This etiology may explain the nonspecific symptoms associated with UTI in these patients.

Risk Factors For UTI : 1.Female gender 2.Uncircumcised male 3.Vesicoureteral reflux 4.Toilet training 5.Voiding dysfunction 6.Obstructive uropathy 7.Urethral instrumentation 8.Wiping from back to front in girls 9.Bubble bath 10.Tight clothing (underwear) 11.Pinworm infestation 12.Constipation 13.Anatomic abnormality 14.Neuropathic bladder 15.Sexual activity

Management: There are four main steps in the clinical management of UTIs in childhood:  Diagnosis of UTI  Determination of the site of the infection  Search for the cause of the UTI  Treatment

 Diagnosis of UTI Diagnosis of UTI depend on clinical presentations & investigations. Manifestations of UTI vary with: age site of infection within the urinary tract severity of infection.

HISTORY  Urinary tract infections may occur without symptoms, with symptoms that direct attention to the urinary system, or with symptoms that divert the attention to other organ systems  Thus, the clinician must maintain a high index of suspicion for UTI, particularly in infants and young children with vague or nonspecific infectious symptoms

In neonates & 1st 3 mo  lethargy, irritability, poor feeding, vomiting, diarrhea, apnea, fever or hypothermia, and prolonged jaundice are all frequent findings. Although very nonspecific and often more suggestive of acute gastroenteritis than UTI, the diagnosis is rarely missed, since a urinalysis and urine culture are routinely part of the septic screen evaluation performed in this age group.

3mo to 3years old:  Fever, constitutional complaints, abdominal discomfort, and GI symptoms are common in pyelonephritis.  Whereas frequency and irritability on micturition are often the only indicators of cystitis.

In older children who are both verbal and toilet trained the diagnosis becomes more straightforward. cystitis  With cystitis, all or some combination of the classic signs of dysuria, frequency, urgency, suprapubic discomfort, daytime or nocturnal enuresis, and perhaps low-grade fever are present. pyelonephritis  With pyelonephritis, high fever, clinical toxicity, vomiting, and abdominal and/or flank pain are most common. These upper tract symptoms may or may not be accompanied by lower tract complaints.

PHYSICAL FINDINGS fever irritability.Findings in infants who have a UTI may be normal except for fever and irritability. tendernessOlder children may report direct tenderness on palpation of the abdomen, suprapubic area, or costovertebral angle (CVA) (Murphy test), if -ve is not reliable to exclude parenchymal infection in young children. However, when present it is helpful and should be performed as part of the physical examination of all children suspected of UTI. masses.Patients who have urinary tract obstruction may have palpable abdominal masses. Dribbling,Dribbling, poor stream, or straining to void external genitalia Examine external genitalia for signs of irritation, pinworms, vaginitis, trauma, phimosis or meatal stenosis. HypertensionHypertension should raise suspicion of hydronephrosis or renal parenchyma disease.

 Localization of the UTI The differentiation between upper (pyelonephritis) and lower (cystitis) UTI is very important. It particularly has major clinical implications in young children. The risk of renal scarring is significant with pyelonephritis, and not a concern with cystitis. Therefore the management (investigations, antibiotic used, length of therapy) is totally different for pyelonephritis and cystitis. The location of the site of infection is based on a combination of clinical, laboratory and imaging findings.

In the cystitis syndrome, In the cystitis syndrome, the bladder/voiding symptoms is common such as frequency, pain with micturition, suprapubic discomfort, difficulty in voiding (retention) or hesitancy, urgency, and enuresis. Back and suprapubic pain, as well as fever, may occur. Gross hematuria (without casts) is a common finding. Bacterial infection, particularly E.coli cause hematuria in girls whereas in boys, adenovirus infection occurs frequently. The urine culture will reveal the offending organisms in the former instance and will be sterile in the latter

In the classic pyelonephritis syndrome, In the classic pyelonephritis syndrome, the patient has generalized symptoms that may include a toxic appearance, high fever, chills, vomiting, diarrhea, and abdominal pain in addition to the urinary outlet symptoms The urinalysis usually reveals typical pyuria and bacteria, and often, white blood cell (WBC) casts are observed

Investigation The definitive diagnosis of UTI is critical and involves a number of important considerations. False positive diagnosis may lead to unnecessary treatment, as well as invasive and expensive clinical and radiographic examinations. False positive diagnoses are frequent in infants and small children because reliable collection of urine specimens without contamination is difficult. On the other hand, false negative diagnosis dramatically increases the risks of renal scarring and its attendant morbidity: hypertension, complications of pregnancy in women, and end stage renal disease.

Urine color and smell: Turbid urine may be an indication of pyuria and UTI. abnormal smell may be suggestive of onset of UTI but it is a poor indicator of screening for UTI. Urine microscopy: ▫Bacteriuria ▫Bacteriuria, Detection of any bacteria in the uncentrifuged urine slide stained with Gram stain has been used as the gold standard for presumptive diagnosis of UTI. ▫Pyuria, ▫Pyuria, or light-microscopy visualization of more than 10 WBCs/hpf in centrifuged urinary sediment is considered presumptive evidence of UTI.  Urinalysis

Leukocyte esterase: False-negative False-positive Testing for leukocyte esterase may overcome some of the limitations of urinary microscopy in identifying leukocyturia. Leukocyte esterase is present in the neutrophils and can be assayed in the urine by dipstick strips. False-negative tests may be caused by the presence of ascorbic acid, high urinary protein, glycosuria, urobilinogen, gentamicin, nitrofurantoin, cephalexin, and boric acid. False-positive tests can results from the presence of imipenem and clavulanic acid in the urine. Nitrite test: This test is based on the fact that the bacterial enzyme nitrate reductase can convert urinary nitrate to nitrite, which can be detected by several chemical methods.

Urine culture  Culturing urine is gold standard for confirming the diagnosis of UTI.  Methods to Obtain Urine Specimens: suprapubic aspiration 1.The gold standard for obtaining urine in an infant is by suprapubic aspiration. By using this method the risk of contamination is very low. Complications are rare with the use of ultrasound guidance. 2.Urinary catheterization 2.Urinary catheterization is also a very reliable method for obtaining urine without contamination

3.Clean-catch mid-stream urine specimens 3.Clean-catch mid-stream urine specimens can be collected in toilet-trained children. 4.Urine collected in bags 4.Urine collected in bags is generally not suitable for culture because of the high incidence of contamination, If a scaled adhesive bag is to be used for collection of urine sample, the following conditions should be considered for better results :  The skin should be dried thoroughly after cleaning the periurethral area  The child should be kept in an upright position to prevent having urine come in contact with the skin or entering the vagina  The bag should be removed immediately after the child has voided Cultures from bagged urine specimens are significant only if there is no growth.

The urine should examined withen 20 min, or refrigerated immediately at +4c until cultured to prevent growth of contaminating bacteria and it is essential that this temperature be maintained during transport. The interpretation of culture depends on the : ▫Method of urine collection ▫Clinical background (signs & symptoms) ▫Number of colony forming units per ml ▫Result of urinalysis

suprapubic aspiration,If urine obtained by suprapubic aspiration, any growth is considered significant. In catheterized specimens,In catheterized specimens, the cutoff level suggested is 50,000 CFU/ml. In midstream urine sample,In midstream urine sample, 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. In collection bag,In collection bag, can be useful, particularly if the culture is negative, A positive culture may reflect a contaminant, particularly in girls and uncircumcised boys. In such cases, if the urinalysis result is positive, the patient is symptomatic, and there is a single organism cultured with a colony count greater than 100,000, there is a presumed UTI. If any of these criteria are not met, confirmation of infection with a catheterized sample is recommended.

 Imaging Studies The goal of imaging studies in children with a UTI is to identify: ▫ anatomic abnormalities ▫active renal involvement ▫renal scaring ▫assess renal function. Ultrasonography, VCUG, radionuclide cystography, renal nucleotide scans, and CT or MRI can be used for anatomic and functional assessment of the urinary tract. Ultrasound provides limited information about renal scarring and is performed to exclude an anatomic abnormality. VCUG is the best imaging study for determining the presence or absence of vesicoureteral reflux. A technetium-99m DMSA scan can identify acute pyelonephritis, but is most useful to define renal scarring as a late effect of UTI.

The NICE (National Institute for Health and Clinical Excellence, UK) guidelines recommendations include upper tract imaging with a DMSA scan for : <6 mo 1.all <6 mo with a UTI <3 yr 2.all children <3 yr with an:  atypical UTI ((sepsis, non–E. coli UTI, suprapubic mass, elevated serum creatinine, hypertension).  recurrent UTI. >3 yr, 3.for children >3 yr, a DMSA scan is recommended only for recurrent UTI. DMSA scan

Indication of renal US: 1.In children with their 1st episode of clinical pyelonephritis (those with a febrile UTI, or, in infants, those with systemic illness) 2.positive urine culture, irrespective of temperature. A sonogram of kidneys and bladder should be performed to assess kidney size, detect hydronephrosis and ureteral dilation, identify the duplicated urinary tract, and evaluate bladder anatomy.

vesicoureteral reflux, The most common finding is vesicoureteral reflux, which is identified in approximately 40% of patients VCUG

CT scan CT is another diagnostic tool that can image acute pyelonephritis, but clinical experience with DMSA is much greater, and CT scans have more radiation.

 Treatment The aims of antimicrobial treatment for urinary tract infection are:  To clear the acute infection  To prevent urosepsis  To reduce the likelihood of renal damage.

should be treated promptly to prevent possible progression to pyelonephritis. If the symptoms are severe,If the symptoms are severe, presumptive treatment is started pending results of the culture. If the symptoms are mild or the diagnosis is doubtful,If the symptoms are mild or the diagnosis is doubtful, treatment can be delayed until the results of culture are known, and the culture can be repeated if the results are uncertain. If treatment is initiated before the results of a culture and sensitivities are available, a 5-7day course of therapy with: trimethoprim-sulfamethoxazole or trimethoprim trimethoprim-sulfamethoxazole or trimethoprim is effective against most strains of E. coli. Nitrofurantoin 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 organisms. Amoxicillin Amoxicillin (50 mg/kg/24 hr) also is effective as initial treatment but has no clear advantages over sulfonamides or nitrofurantoin. Acute cystitis

 10- to 14-day course of broad-spectrum antibiotics capable of reaching significant tissue levels is preferable.  Indication of hospitalization for IV rehydration and IV antibiotic therapy include: 1.Children who are dehydrated 2.Vomiting. 3. are unable to drink fluids. 4.are ≤1mo of age. 5.in whom urosepsis is a possibility.  Parenteral treatment with: ceftriaxonecefotaxime ceftriaxone (50-75 mg/kg/24 hr) or cefotaxime (100 mg/kg/24 hr) ampicillinaminoglycoside 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.  Treatment with aminoglycosides is particularly effective against Pseudomonas spp, and alkalinization of urine with sodium bicarbonate increases its effectiveness in the urinary tract. Acute pyelonephritis

 Oral therapy: Oral 3rd-generation cephalosporins Oral 3rd-generation cephalosporins such as cefixime considered the treatment of choice for oral outpatient therapy. Nitrofurantoin Nitrofurantoin should not be used routinely in children with a febrile UTI because it does not achieve significant renal tissue levels.  A urine culture 1 wk after the termination of treatment of a UTI ensures that the urine is sterile but is not routinely needed.  Children with a renal or perirenal abscess or with infection in obstructed urinary tracts can require surgical or percutaneous drainage in addition to antibiotic therapy and other supportive measures.

Recurrent Urinary Tract Infections voiding dysfunction,  In a child with recurrent UTIs, identification of predisposing factors & treated it is beneficial, as voiding dysfunction, Some children with UTIs void infrequently, and many also have severe constipation.  Counseling of parents and patients  Counseling of parents and patients to try to establish more normal patterns of voiding and defecation is most important in controlling recurrences.  Prophylaxis against reinfection,  Prophylaxis against reinfection, using TMP-SMX, trimethoprim, or nitrofurantoin at 30% of the normal therapeutic dose once a day, is one approach to this problem. Prophylaxis with amoxicillin or cephalexin can also be effective, but the risk of breakthrough UTI may be higher because bacterial resistance may be induced.

high risk conditions  Other more high risk conditions for recurrent UTIs that might need long-term prophylaxis include neurogenic bladder, urinary tract stasis and obstruction, reflux, and calculi. The main consequences of chronic renal damage  The main consequences of chronic renal damage caused by pyelonephritis are arterial hypertension and end-stage renal insufficiency; when they are found they should be treated appropriately.

Prevention of UTI: Avoid constipation.Avoid constipation. worms If your child has any problems with worms let the doctor know. Wiping Wiping should be done in a front to back direction. showerIt is better to take a shower rather than a bath. Always avoid irritating soaps and bubble baths. Emptying the bladder propablyEmptying the bladder propably is very important. drinkAlways encourage your child to drink as much as possible during the day, and to Empty the bladder propably last thing at night. Correct underwearCorrect underwear, avoid tight underpants or pantyhose. They prevent air from circulating freely and encourage the warm, moist environment which favors infection. full courseWhen taking antibiotics, the full course must be taken at the time required. Any proplems should be reported to the doctor.Any proplems such as burning when passing urine, going to the toilet frequently, or blood in the urine should be reported to the doctor.