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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
slide5

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
  • 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
  • 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
  • Vulvovaginitis
  • Viral cystitis (eg adenovirus)
  • Enterbiasis (pinworms)
  • Urinary calculi
  • STD
  • Vaginal foreign body
  • Epididymitis
evaluation
Evaluation
  • 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
  • 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
  • Leukocyte esterase (LE)
    • enzymatic marker for WBCs
    • suggestive of UTI, however, does not always signal a true UTI.
definition of uti
Definition of UTI
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • TMP/SMX
  • Nitrofurantoin
  • Amoxicillin
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