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Childhood Urinary Tract Childhood Urinary Tract InfectionInfection
Definition and Definition and classificationclassification
It is an infection of both upper and lower urinary tract.
Upper : pyelonephritis, renal abscess.
Lower : cystitis , urethritis
Epidemiology Epidemiology UTI is one of the most common bacterial
infections of childhood. Affects up to 10% by the teenage years.Before age of 1 year boys : girls = 3 : 1After age of 1 year girls : boys = 10 : 1
40% of children with UTI will have anatomic or functional abnormalities of the urinary tract.
e.g. reflux, malpositions, duplications, megaureter and hydronephrosis.
EtiologyEtiologySource of infection:Mostly ascending.The bacteria arise from the fecal flora, colonize
the perineum, and enter the bladder via the urethra
In neonates ……………… HEMATOGENEUS.
Etiological organisms:Escherichia coli: (80%), Klebsiella and Proteus.Staphylococcus saprophyticus in adolesent
girls. Viral infections (adenovirus), can cause cystitis.Fungal infections
Risk FactorsRisk Factors
Type of patient:-Female )short
urethra)-Uncircumcised
male.-Tight clothing.-Urethral
instrumentation
Abnormal Urinary tract:
-Vesicoureteral reflux.
-Obstructive uropathy (major risk factor):
Hydronephrosis
-Neurogenic bladder
Clinical Manifestations
Pyelonephritis Constitutional symptoms: Fever, malaise, chills. Nausea, vomiting ±
diarrhea. Localizing symptoms:
Abdominal or flank pain.
Clinical Manifestations (cont)Cystitis
Usually afebrileDysurea Urgency Frequency IncontinenceHematuria Malodorous urine.Suprapubic pain & tenderness.
Clinical Manifestations (cont)
Urethritis-Dysurea-Reluctance to void-Perineal discomfort, erythema-Vulval irritation & erythema (girls)-Urethral discharge in older boys
Symptoms of UTI Neonates & infants
Change in urine color (or odor) as well as, crying during micturation in an infant may be noted by the mother.
BUT Nonspecific symptoms: Jaundice Poor feeding Irritability Weight loss (or poor weight
gain)
Asymptomatic bacteriurea
Refers to individuals who have a positive urine culture without any manifestations of infection.
Occurs almost exclusively in girls. This condition is benign and does
not cause renal injury.
ComplicationsComplications
recurrance ( up to 25% to 40% )( follow up)
bacteremia (more in infants) focal renal abscess ( uncommon
)
cont.
Acute pyelonephritis may result in renal injury
“pyelonephritic scarring”
HypertensionIf recurrent scarring
Chronic renal failure
Diagnosis of UTI
Diagnosis of UTIDiagnosis of UTI
Suspect: Symptoms Findings on urinalysis, or both.
Confirm: Urine culture.
The diagnosis of UTI depends on having the proper sample of
urine
Urine analysisUrine analysis
Urine microscopy: Pus cells White cell cast ………
RBCs …….. Gram stainingUrine dipstick: - Leucocyte estrase - Nitrite
Collecting the urine Collecting the urine samplesample
Collecting the urine sampleCollecting the urine sample
In toilet-trained children
midstream urine sample Satisfactory if
The culture shows greater than 100,000 colonies of a single pathogen.
There are 10,000 colonies and the child is symptomatic, it is considered a UTI.
Collecting the urine sample (cont):Collecting the urine sample (cont):
In infants: (1) Clean catch sample.
(2) Urine collection bag. contamination is
possible (3) In & out urinary
catheterization.
(4) Suprapubic urine sample
Notes about urine analysis & Notes about urine analysis & culture:culture:Prompt plating of the urine sample is important - not more than one hour.
A urinalysis should be obtained from the same specimen as that cultured.
Pyuria (leukocytes in the urine) suggests infection, but infection can occur in the absence of pyuria.
Treatment of UTITreatment of UTI
TreatmentTreatment
In acute febrile infections suggestive of pyelonephritis: Parenteral treatment with ceftriaxone or ampicillin with gentamicin for 10-14 days.
Treatment of UTI (cont):Treatment of UTI (cont):
Acute cystitis: Should be treated promptly to prevent its
possible progression to pyelonephritis. trimethoprim-sulfamethoxazole . Nitrofurantoin for 3-5
days Amoxicillin
If the symptoms are mild and 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
FOLLOW UPFOLLOW UPWe usually do urine culture 1
week after stopping of antibiotics ; then periodic reassessment for the next 1-2 years .
Imaging StudiesImaging Studies
The goal of imaging The goal of imaging studies in children with a studies in children with a UTIUTIThe goal of imaging studies in children with a UTI is to identify anatomic abnormalities that predispose to infection and to
If there are any UTI complications
Renal ultrasonogram
Renal ultrasonogramRenal ultrasonogram
- hydronephrosis - renal or perirenal abscesses- Pyelonephritis- renal scars ( 30%)
VCUG( MCUG)VCUG( MCUG)
Voiding cystourethrogram Voiding cystourethrogram (VCUG) Miturating (VCUG) Miturating cystourethrogram cystourethrogram (MCUG)(MCUG)
Indications:All children younger than 5 yr with a UTI,
School-aged girls who have had two or more UTIs
Any male with a UTI
The most common finding is vesicoureteric reflux
DMSA scan & DTPA DMSA scan & DTPA scan scan
DMSA scan: Technetium-labeledAcute pyelonephritisStructural malformations of the kidney
DTPA scan: Dynamic study for: Excretory Function Reflux
DETPA
Prevention of reccurrence of UTIPrevention of reccurrence of UTI
Prevention of reccurrence of UTIPrevention of reccurrence of UTI
Aderss and treat underlying cause.
Manage constipation.Correct bottom wiping.Encourage drinking adequate fluid.
Advice child not to delay voiding.Use of prophylactic antibiotics …………..
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