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Urinary Tract Infection In Children. Dr. Alia Al-Ibrahim Consultant Pediatric Nephrology Clinical Assistant Professor. Contents: 1- Definition of UTI 2- Etiology & pathogenesis 3- Predisposing Factors 4- Clinical presentations 5-Investigations 6- Management 7- Complications

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slide1

Urinary Tract Infection In Children

Dr. Alia Al-Ibrahim

Consultant Pediatric Nephrology

Clinical Assistant Professor

slide2

Contents:

1- Definition of UTI

2- Etiology & pathogenesis

3- Predisposing Factors

4- Clinical presentations

5-Investigations

6- Management

7- Complications

8- Special problems in UTI

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UTI in Children

Definition:

Presence of bacteria in urine along with symptoms of infection.

Incidence:

5% in Girls 1-2% in Boys

During the 1st yr of life more common in boys, after age of one more in girls

Etiology:

Most common infecting pathogen : Escherichia Coli 80% of UTI.

Other pathogens: - Staphylococcus & Streptococcus Species

- Enterobacteria ( Klebsiella, Proteus, pseudomonas)

- Occasionally Candida albicans

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Route of infection:

Neonate: Hematogenous

Later : Ascension of bacteria into the Urinary tract.

Development of UTI depend on:

1- Virulence of the invading bacteria.

2- Susceptibility of the host.

Predisposing factors:

1- Conditions lead to urinary stasis : renal calculi, Obstructive Uropathy ,

VUR, & Voiding disorder.

2- Immune deficiency

3- Broad- spectrum antibiotics ( amoxicillin, cephalexin).

4- constipation

5- uncircumcised male

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Clinical Presentation:

1- Upper UTI (Pyelonephritis).

2- Lower UTI ( Cystitis).

The history & clinical coarse varies with the patient’s age & specific diagnosis.

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0-2months: sepsis

  • 2mon-2yrs: unexplained fever
  • irritability, poor oral intake, abdominal pain, vomiting, loose
  • bowel movement.
  • voiding symptoms of cystitis
  • crying on urination
  • smelly urine
  • no fever or mild
  • 2yrs :
  • Pyelonephritis( fever, irritability, poor appetite, abdominal flank
  • pain back pain, voiding symptoms, tenderness in
  • costovertebral angle or flank.
  • cystitis : voiding symptoms ( urgency, frequency, hesitancy, dysuria,
  • urinary incontinence)
  • mild or no fever, Suprapubic or abdominal pain
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Urine analysis & dipstick:High index of suspicion for UTI in febrile children particularly those with unexplained fever. Lasts for 2-3days;

  • > 5 WBC/ hpf in centrifuged fresh urine positive screening test.
  • >Bacteria in cent. & non cent. Or phase contrast suggestible of UTI.
  • >Pyuria, proteinuria & Hematuria may occur with or without UTI.
  • >Nitrite concentrations & leukocyte estrase
  • POSITIVE URINE CULTURE IS ESSENTIAL FOR DIAGNOSIS OF UTI.
  • Urine culture:
  • Suprapubic : any number of colonies.
  • IN-and- out catheterization: > 10³. E.COLI
  • Midstream clean-catch urine collection > 10,000
  • Single organism
  • 2 or more contamination. E.COLI
  • Blood culture :neonate & infant
  • Pyelonephritis: CBC: neutrophlic leukocytosis
  • high ESR
  • C-reactive protein. Proteus Pseudomonas
  • Distinction between upper & lower difficult in children
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Management:

  • < 5 yrs:
  • With systemic signs:
  • 1- Iv antibiotics shift to oral after improvement , duration 10 -14 days.
  • 2- US , renal cortical scintigraphy ( DMSA) , MCUG.
  • No systemic signs:
  • 1- oral antibiotics for 7-10 days
  • US, MCUG( if indicated)
  • 5 yrs
  • Female: Female & Male with signs
  • 1- no signs : oral antibiotics Like < 5 yrs
  • Male:
  • 1- No signs: oral antibiotics
  • 2- US, MCUG
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COMPLICATIONS:

1- VUR

2- Scarring

3- HTN

4- Renal insufficiency.

VUR

Normal DMSA

Acute Pyelonephritis

Scarring

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Special problems

1-Reurrent UTI:

Two or more UTIs over a six –months period.

Causes: Inadequate treatment.

unrecognized site of bacterial persistence such as small infected

calculus or un recognized anatomic abnormality.

2-VUR:

Abnormal backwash of urine into ureter or kidney

Radiological evaluation VCUG, Isotope cystogrm

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3-Breakthrough UTI:

  • Caused by:
  • 1- change in the resistance pattern of organisms colonizing the
  • urethra.
  • 2- noncompliance.
  • 3- VUR
  • 4- Voiding dysfunction.
  • 4-Voiding dysfunction:
  • Detrusor instability & incomplete bladder emptying
  • Associated with daytime enuresis & constipation.
  • Increase risk of UTI & VUR.
  • RX: 1- Timed voiding
  • 2- Treatment of constipation.
  • 3- Prophylactic antibiotics.
  • 4- Anticholinergic medications.
  • 5-Asymptomatic bacteruria:
  • No need for antibiotics, low risk of scarring.
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