Urinary tract infections
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Urinary Tract Infections. Objectives. Know the predominant organisms causing urinary tract infection in children Be able to evaluate a pre-school age child with a urinary tract infection Differentiate between upper and lower urinary tract infections in patients of differing ages

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Objectives
Objectives

  • Know the predominant organisms causing urinary tract infection in children

  • Be able to evaluate a pre-school age child with a urinary tract infection

  • Differentiate between upper and lower urinary tract infections in patients of differing ages

  • Know the appropriate antibiotic treatment for acute cystitis and the role of imaging


Background
Background

  • Overall prevalence of UTI in febrile infants 5%

  • Recurrent UTIs may lead to:

    • Renal scarring

    • HTN

    • Renal dysfunction and failure

  • Presence of another source of fever (URI, AOM) does NOT rule out UTI

  • Parents reporting “foul-smelling” urine does NOT correlate with UTI


Host factors associated with uti
Host Factors Associated with UTI

  • Caucasian 2-4x prevalence

  • Females 2-4x prevalence vs. circumcised males

  • Uncircumcised 4x higher than circumcised Males males until 1 year of age

  • Breastfed Lower rates due to IgA Infants

  • Familial History Genetic Predisposition

  • Anatomic GU Reflux most common at 1% prevalence; 40-50% of young children with febrile UTI


Based on data from Hoberman, A, et al. Prevalence or urinary tract infection in febrile infants. J Pediatr 1993; and Shaw, KN et al. Prevalence of urinary tract infection in febrile young children in the emergency department. Pediatrics 1998.


Host factors associated with uti1
Host Factors Associated with UTI tract infection in febrile infants. J Pediatr 1993; and Shaw, KN et al. Prevalence of urinary tract infection in febrile young children in the emergency department. Pediatrics 1998.

  • Sexual Activity Not well documented; use of spermicidal condoms and jelly associated with E. coli bacteruria

  • Physiologic Dysfunctional voiding – Abnormality 40% of toilet trained children with first UTI and 80% with recurrent UTI


Symptoms of dysfunctional voiding
Symptoms of Dysfunctional Voiding tract infection in febrile infants. J Pediatr 1993; and Shaw, KN et al. Prevalence of urinary tract infection in febrile young children in the emergency department. Pediatrics 1998.

  • Withholding behaviors – squatting, leg crossing

  • Bladder/bowel incontinence – diurnal enuresis

  • Abnormal elimination pattern – small frequent voids with incomplete emptying

    • Failure to relax urinary sphincter and pelvic musculature results in overactive detrusor contractions causing bladder-sphincter dyssynergy

    • It is estimated that 15% of pediatric population have dysfunctional voiding – consider diabetes neurogenic bladder


Differential
Differential tract infection in febrile infants. J Pediatr 1993; and Shaw, KN et al. Prevalence of urinary tract infection in febrile young children in the emergency department. Pediatrics 1998.

  • Vulvovaginitis

  • Viral cystitis (eg adenovirus)

  • Enterbiasis (pinworms)

  • Urinary calculi

  • STD

  • Vaginal foreign body

  • Epididymitis


Evaluation
Evaluation tract infection in febrile infants. J Pediatr 1993; and Shaw, KN et al. Prevalence of urinary tract infection in febrile young children in the emergency department. Pediatrics 1998.

  • UTI diagnosis SHOULD NOT be established by a culture of urine collected in a bag

    • Correct diagnosis requires culture of clean catch, catheterized, or suprapubic tap specimen

  • Urine dipstick can rule out UTI, but positive result is insufficient to diagnose UTI due to potential for false positives

  • CBC/CRP are unnecessary


Understanding the ua
Understanding the UA tract infection in febrile infants. J Pediatr 1993; and Shaw, KN et al. Prevalence of urinary tract infection in febrile young children in the emergency department. Pediatrics 1998.

  • Nitrite

    • produced by conversion of nitrate by the enzyme nitrate reductase contained by some bacteria, such as E. coli, Klebsiella and Proteus

    • False positives occur when bacterial overgrowth occurs in the setting of delay prior to lab testing

    • Urine must remain in the bladder 4 hours to accumulate detectable amount of nitrite, therefore an uncommon finding in young children

    • Positive nitrite very likely to indicate UTI

    • Staph saprophyticus does not produce nitrite.


Understanding the ua1
Understanding the UA tract infection in febrile infants. J Pediatr 1993; and Shaw, KN et al. Prevalence of urinary tract infection in febrile young children in the emergency department. Pediatrics 1998.

  • Leukocyte esterase (LE)

    • enzymatic marker for WBCs

    • suggestive of UTI, however, does not always signal a true UTI.


Sensitivity and specificity of components of urinalysis
Sensitivity and Specificity of Components of Urinalysis tract infection in febrile infants. J Pediatr 1993; and Shaw, KN et al. Prevalence of urinary tract infection in febrile young children in the emergency department. Pediatrics 1998.


Definition of uti
Definition of UTI tract infection in febrile infants. J Pediatr 1993; and Shaw, KN et al. Prevalence of urinary tract infection in febrile young children in the emergency department. Pediatrics 1998.

  • Clean catch

    • > 100,000 organisms of one bacteria

  • Catheterized

    • >50,000 cfu/ml in children < 2 yr

    • If 10,000-50,000 repeat urine cx suggested

      • >10,000 on repeat  UTI

  • Suprapubic (gold standard)

    • Any growth


Radiologic imaging
Radiologic Imaging tract infection in febrile infants. J Pediatr 1993; and Shaw, KN et al. Prevalence of urinary tract infection in febrile young children in the emergency department. Pediatrics 1998.

  • Ultrasound of Kidneys

    • Assess for structural anomalies

    • Urgent ultrasound may be necessary if there is inappropriate response to treatment within 24-48 hours - rule out obstruction or abscess

  • VCUG

    • Rule out vesico-ureteral reflux (VUR)

    • It has been shown that there is no difference in VUR if VCUG is performed early or late, and is generally acceptable once patient is afebrile.

    • Patients are placed on antibiotic prophylaxis until completion of imaging studies


When to consider imaging
When to Consider Imaging tract infection in febrile infants. J Pediatr 1993; and Shaw, KN et al. Prevalence of urinary tract infection in febrile young children in the emergency department. Pediatrics 1998.

  • Children < 5yr with febrile UTI

  • Girls under 3 yr with first UTI

  • Males of any age with a first UTI

  • Kids with recurrent or resistant UTI


When to hospitalize
When to Hospitalize tract infection in febrile infants. J Pediatr 1993; and Shaw, KN et al. Prevalence of urinary tract infection in febrile young children in the emergency department. Pediatrics 1998.

  • Literature states that infants > 2mo can be managed as outpatients on oral meds with close follow-up unless toxic and unable to tolerate oral hydration and meds, in which case hospitalization is necessary


Microbiology
Microbiology tract infection in febrile infants. J Pediatr 1993; and Shaw, KN et al. Prevalence of urinary tract infection in febrile young children in the emergency department. Pediatrics 1998.

  • E. coli accounts for about 80% of UTIs in children.

  • Other bacteria include: Gram negative species (Klebsiella, Proteus, Enterobacter, and Citrobacter) and Gram positive species (Staph saprophyticus, Enterococcus, and rarely, S. aureus).


Treatment
Treatment tract infection in febrile infants. J Pediatr 1993; and Shaw, KN et al. Prevalence of urinary tract infection in febrile young children in the emergency department. Pediatrics 1998.

  • Generally treated with: TMP/SFX or cephalosporins for:

    • 7-14 days in children 2mo – 2 years old with cystitis

    • 10-14 days for pyelonephritis

  • Choice of antibiotic ultimately guided by sensitivity of bacterial isolate

    • neonates usually hospitalized and treated with IV antibiotics, followed by oral. Generally, patients are switched to oral antibiotics following 2-4 days of IV antibiotics


Treatment in outpatient setting
Treatment in Outpatient Setting tract infection in febrile infants. J Pediatr 1993; and Shaw, KN et al. Prevalence of urinary tract infection in febrile young children in the emergency department. Pediatrics 1998.

  • TMP/SMX – contraindicated in infants < 2months

  • Cephalosporins (cefixime) - no enterococcus or pseudomonas coverage

    • Ceftriaxone if patient noncompliant or emesis is concern

  • Nitrofuantoin, Amoxicillin – not adequate for pyelonephritis


Prophylaxis
Prophylaxis tract infection in febrile infants. J Pediatr 1993; and Shaw, KN et al. Prevalence of urinary tract infection in febrile young children in the emergency department. Pediatrics 1998.

  • TMP/SMX

  • Nitrofurantoin

  • Amoxicillin


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