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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Urinary Tract Infections

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Urinary tract infections

Urinary Tract Infections


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

  • Caucasian2-4x prevalence

  • Females 2-4x prevalence vs. circumcised males

  • Uncircumcised4x higher than circumcised Malesmales until 1 year of age

  • Breastfed Lower rates due to IgA Infants

  • Familial HistoryGenetic Predisposition

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


Urinary tract infections

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 ActivityNot well documented; use of spermicidal condoms and jelly associated with E. coli bacteruria

  • PhysiologicDysfunctional voiding – Abnormality40% 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.


Sensitivity and specificity of components of urinalysis

Sensitivity and Specificity of Components of Urinalysis


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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