UTI

UTI
Asymptomatic bacteriuria: means +ve culture without any symptoms

- All age groups including infants.
- More in school age females.
- No need for treatment if no underlying urologic abnormalities or renal scars.
Hospital acquired (nosocomial) UTI:

- not uncommon.
-14.2/1000 pediatric admissions.
- F.B ↑ risk.
Microbiology:
• E. Coli is the commonest cause of UTI + ABU in all ages group
• then: other Gram –ve = Klebsiella, Proteus, Pseudomonas
• Staph
• Strep. Fecalis
• Candida
Route of infection :
➢ Hematogenous: more in boys.
➢ Ascending Urosepis: more in girls.
Pathogenesis:
Complex: - host factors - invading organism
A. Host Factors:
Normal defense mechanism: “Anatomic abnormalities interfere with these”
▪ voiding washout
▪ Tamm Horsfall protein
▪ Spontaneous exfoliation of uro-epithelial cells
▪ Urinary immunoglobulins
• Incidence: 40-50% (VUR “vesicoureteric reflux” is the commonest)
• The commonest childhood infection after upper respiratory tract infections.
• More common in girls except for the 1st 3 months of life (more in boys).
• Host factors Predisposing to
UTI 1- Anatomic factors =
- VUR
- Urinary tract obstruction
- F.B
- Duplicated collecting system
- Ureterocele
2- Increased Uro-epithelial cell adherence: ?Unknown
mechanism 3- Non-secretors with P or Lewis blood group
antigens
B. Organism:
➢ Uropathogenic virulence: UTI in anatomically normal UT.
e.g. E coli with serologic OKH were isolated from patients with acute pyelonephritis but not in ABU.
Other bacterial virulence factors: *MCQ Q*
1. Having P fimbriae
2. Adherence Property
3. Produce hemolysin or aerobactin
Urine collection:
✓ Bag specimens should be avoided.
Hydronephrosis ←
✓ For older children: mid-stream urine after cleaning the perineum or hydroureter
✓ For infants: - Clean – catch urine
- Catheter sample
- Supra-pubic aspiration (SPA) → e.g. DTPA
PELVIC URETERIC ←
JUNCTION
False +ve urine culture in case of:
- Bag specimen → due to contamination.
- If the sample isn’t fresh → (Remember that the bacterial colony double every 20 minutes) so the
specimen should be fresh (within one hour). If not possible, take it before you start antibiotic then keep in
the refrigerator at 4°C temperature or use dip slide method.
Diagnosis:
* SPA: - Gram +ve: > 1000 – Gram –ve: any growth
* Other samples: > 100,000 organism/mL with a single species. ( clean catch, MSU and catheter) Why?
Because of long pathway.
* If in doubt, repeat specimen
* Positive nitrite and white cell esterase sticks are supportive of UTI but often are not sensitive enough in
children (bacterial reductase converts nitrate to nitrite) better in early morning sample.
* Low urine SG in first morning sample is presumtive of acute PN.
Clinical Manifestations: Vary with the age and location of infection.

- D/D of dysuria: * Vaginitis
* Urethritis
- D/D of pyuria: * Dehydration
* Vaginitis
* Meatal or uretheral irritation
* Renal stones
* RTA “renal tubular acidosis”
* Interstitial nephritis
* Cystic renal disease
* GN
* Appendicitis
Lab tests indicative of acute PN = *MCQ Q*
↑ESR ↑ CRP
↓ Urinary concentrating ability
Pyuria with WBC casts
DMSA “nuclear scan”: If the patient is clinically ill or having symptoms suggestive of upper UTI,
then DMSA is indicated from the start.
Note: MCUG should only be done after having negative urine culture and you may need to give SBE
prophylaxis if there is a congenital heart disease.
Treatment:
- Oral antibiotics for at least 7 days
- Unless the patient is < 1 year or generally ill then treat with IV antibiotics with a total duration of 10-14
days.
The choice of antibiotics:

rd
1. Neonate and infant: Ampicillin + Gentamycin Or Ampicillin + 3 generation cephalosporin
2. >1 year: Cotrimoxazole (Bactrim) Or Augmentin (Amoxacillin+ clavulinic acid) or Cephalexine
(Keflex) or Nitrofurantoin (provided that GFR > 40ml/min/1.73 m2)
- If there is no response to treatment, the antibiotics should be changed according to the culture sensitivity.
Prophylaxis
• All patients, who were diagnosed with UTI, should be kept on antibiotic prophylaxis after treatment until
all the investigations are completed.
• The prophylactic antibiotic may need to be changed according to the sensitivity of the latest urine culture.
The choice of prophylactic antibiotics:

1. First 3 months of life: Trimethoprim alone without sulfa component OrAmoxacillin Or cephalexine (Keflex)
2. Children > 3 months: Cotrimoxazole or Nitrofurantoin or Augmentin
Indications for long term Prophylaxis:

1. Vesico Ureteric Reflux (VUR)
2. Structural anomalies of the urinary tract
3. Recurrent UTI without underlying abnormality → Ab given for one year then the case reassessed.
Other Prophylactic measures:

1. Avoid constipation.
2. Treat worms promptly.
3. Advise for proper wiping (particularly for girls) → wash from front to back.
4. Clean under-wear.
5. Complete voiding at bed time.
6. Avoid bubble baths.
Follow up:
1. After the 1st UTI, the child need to be followed for 1 year with regular urine culture every month (if <1
year) or every 3 months (if > 1 year) or when symptomatic.
2. Those patients where antibiotic prophylaxis is indicated (see above) need to be followed until the
problem resolve.
Note: During follow-up, the following parameters need to monitored in addition to the urine culture:
1. Growth parameters
2. Blood pressure
3. Renal growth by U/SS (yearly)
4. Kidney function (by blood chemistry)
Surgical Treatment :
• Ureteroceles:
- Cystic dilatation of the distal end of the ureter.
- looks like copra head in xray.
- can be effectively treated by endoscopic de-roofing.
- Ureteroceles that produce bladder outlet obstruction are best
treated by excision and reimplantation of the ureter.
• VUR:
VUR
grades
Grade 1 Grade 2 Grade 3 Grade 4 Grade 5
Contrast up Up to renal pelvic Up to renal pelvic With ureteric dilatation
to without
ureters ureteric dilatation Sharp angle papillary impression Fornix
fornix fornix looks
like Sac
with loss
of papillary
impression
- Normally it decreases one grade every 6m-1year.

- Normal urethral implantation is Oblique and Intramural part is long.
- Secondary VUR “breakthrough infection, infection on top of
Ab” may necessitate reimplantation of the ureter.
• PUV:
- Bilateral hydronephrosis with hydro ureters.
- Always in boys.
• Duplicated ureters with uretrocele:
MSQ:
-most common cause of UTI? VUR
-in less than 1 year m with vur you do? MCU64
-most common cause of hydronephrosis ? VUR
-which grade in VUR grossly dilated ureter? 4 (IV)
-all signs of URTI exept ? intercostal, subcostal
-the BEST for urine culture...suprapubic aspiration
The best modalities to investigate child with UTI for lower tract is.?MCUG
Class IV of UVR .. grossly dilated ureter .
Post urethral valve, best diagnosed by: VUG
Class IV Vesico uretral reflux finding? Gross dilatation of ureters
case of febrile infant in ER .what you should do ? Admit. Full septic work up . LP . antibiotic.
Case Pt present with hemolytic anemia ,thrombocytopenia , acute renal faillar wich commenst
bactiria can cuse those symp ? E.coli

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Asymptomatic bacteriuria: means +ve culture without any symptoms

Hospital acquired (nosocomial) UTI:

Clinical Manifestations: Vary with the age and location of infection.

The choice of antibiotics:

The choice of prophylactic antibiotics:

Indications for long term Prophylaxis:

Other Prophylactic measures:

- Normally it decreases one grade every 6m-1year.

• Duplicated ureters with uretrocele:

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