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*Definitions, Epidemiology, and Host Factors
Infection of the urinary tract anywhere from the urethra to the renal parenchyma
• Most are infection of the mucosal surface of the urinary tract
Overall incidence of childhood UTIs:
• Girls: 8%
• Boys: 1-2%
Uncircumcised males: 0.7%
Circumcised males: ~0.2%
*Definitions, Epidemiology, and Host Factors
Age matters!
• *Prevalence of UTIs in febrile infants without an obvious source of infection
7-9% in infants <3mo
2% in males >3mo
2% in females >12mo
*Definitions, Epidemiology, and Host Factors
Host factors
• *Age
• *Sex
• Race
• Circumcision status
• GU abnormalities
• Immune status
Methods for Diagnosis
Urinalysis
• Nitrite
Demonstrates the presence of gram-negative bacteria
Specific but not sensitive
• Leukocyte esterase
Detects presence of leukocytes
Sensitive but not specific
• *Not alone sufficient to diagnose a UTI
Methods for Diagnosis
Urine culture
• Gold standard when obtained by
Suprapubic aspiration
Urethral catheterization
“Clean catch” midstream specimen
*Microbiology
E.Coli
• 70% of infections!
Pseudomonas aeruginosa
Enterococcus faecalis
Klebsiella pneumoniae
Group B Streptococcus (neonates)
Staphylococcus aureus
Proteus mirabilis
Coagulase-negative Staphylococcus
Pathogenesis
Uropathogenic bacterial strains have distinctive antigens and genes that enhance virulence
• P-fimbriae, protectins, toxins and siderophores
*Constipation
• Compression of bladder and bladder neck increase of bladder storage pressure and PVR
• Distended colon/ fecal soiling provides abundant reservoir of pathogens
Clinical Presentation
Infant 0-3 mos
Fever
Hypothermia
Vomiting
Diarrhea
Jaundice
Feeding difficulty
Malodorous urine
Irritability
FTT
Hematuria
Infants 3-24mos
Cloudy/ malodorous urine
Frequency
Hematuria
Fever without a source
Clinical Presentation
Preschool (2-6yo)
Abdominal or suprapubic pain
CVA pain
Dysuria
Urgency
Secondary enuresis
Action Statement 2
Let’s break it down, shall we?
• If you feel the infant is well enough to hold off on antibiotics then you should assess the likelihood of the patient having a UTI
• So, how do I do that??
Action Statement 2
Febrile infant girls>boys
Uncircumcised boys> circumcised boys
Presence of another clinically obvious infection reduces likelihood of UTI by one-half
Action Statement 5
When to you perform the RUS?
• If clinical illness is severe or substantial clinical improvement is not occurring perform within the first 2 days of illness
• If substantial clinical improvement is demonstrated, imaging does not need to occur early during the acute infection and can be misleading
A Question…
You are evaluating a 5 yo girl who has a UTI. She has had four lower UTIs in the last 2 years, all of which resolved completely with oral antibiotics. She denies symptoms of urgency and frequency. The only significant finding on her medical history is constipation. Results of her RUS and VCUG are normal. Her growth parameters and PE findings are normal. You prescribe oral trimethoprim-sulfamethoxazole. Of the following, the MOST appropriate additional step to help reduce the incidence of further UTI is to:
• A. Begin an evaluation for immunodeficiency
• B. Perform renal scintigraphy
• C. Prescribe a stool softener and regular bowel routine
• D. Prescribe oral oxybutynin
• E. Refer her to a pediatric nephrologist