L22. Urinary Tract Infections. Undergrad

Urinary tract infections
P D MAKANDA-CHARAMBIRA
DEFN
Infection of the urinary tract identified by growth of a significant number of

organisms of a single species in the urine, in the presence of symptoms.
Case 1
2 week old boy SK

 3 days of poor feeding and fever
 Septic screen – urinalysis positive leucocytes and negative nitrites , BC and urine
culture positive staph aureus, LP normal
Questions
 How would you collect urine spec in this child ?
 How would you treat SK ?
 Any further investigations ?
Case 2
4 year old female DM

 Had MMC and atonic bladder with incomplete emptying, does 3 hrly bladder
catheterizations.
 Came for routine follow up and urinalysis has positive leucocytes ,negative nitrites,
culture shows mixed growth
 Child otherwise well and asymptomatic
Questions
 Does DM have a UTI ?
 How are you going to treat DM?
 Any further investigations?
Case 3
2 year old male TK

 Known with CKD ?cause
 Presented with fever 39⁰C, vomiting
 Urinalysis positive nitrites and leuc, growth of >10ᶺ5 CFU of Ecoli
Question
 Does TK have a UTI ?
 How would you treat TK ?
Case 4
6 year old girl MM

 Complaining of dysuria and frequency for 4 days, no fever
 Has a long standing history of constipation
 Urinalysis – pos leuc and nitrites, urine culture >10ᶺ5 Proteus species
Question
 Does MM Have a UTI ?
 How would you have collected urine specimen from MM ?
 How would you treat her ?
 Any further investigations ?
Epidemiology
Etiology
1. Ecoli commonest cause up to 80%

2. Other organisms are Klebsiela, Proteus, enterobacter, Staphylococcus
saprophyticus, Enterococcus, and, rarely, Staphylococcus aureus.
3. Viruses (eg, adenovirus, enteroviruses, Coxsackieviruses, echoviruses) and
fungi (eg, Candida spp, Aspergillus spp, Cryptococcus neoformans, endemic
mycoses) are uncommon causes of UTI in children
Infection with an organism other than E. coli is associated with a higher

likelihood of renal scarring.
Risk factors for uti
1. Age
2. Sex
3. Ethnicity – more in whites than blacks
4. Genetics
5. Presence of urinary tract obstruction
6. Bladder bowel dysfunction
7. Vesicoureteric reflux (family hx in 30-50% cases)
8. Sexual activity
Presentation in <2years
Commonest is fever
conjugated hyperbilirubinemia (in those <28 days),
irritability,
poor feeding, or
failure to thrive.
Presentation >2yrs
 fever,
 urinary symptoms (dysuria, urgency, frequency, incontinence, macroscopic
hematuria), and
 abdominal pain
 short stature, poor weight gain, or hypertension secondary to renal scarring from
unrecognized UTI earlier in childhood
Collection of specimen of urine
 A clean catch urine sample is the recommended method for urine collection.
 If a clean catch urine sample is unobtainable:
1. urine collection pads
2. catheter samples or suprapubic aspiration (SPA)
Before SPA is attempted, ultrasound guidance should be used to demonstrate the
presence of urine in the bladder.
 Adhesive plastic bag has false positive rate of 85% - only used for screening. A
neg result excludes UTI
Urine preservation
 IDEALY URINE SHOULD BE ANALYZED WITHIN 1 HOUR OF

COLLECTION..
 If urine cannot be cultured within 4hours of collection, the sample should be
refrigerated (at 4 ⁰C for up to 12 to 24 hours) or preserved with boric acid.
Urinalysis for diagnosis of UTI
Urinalysis for UTI
 Urine needs to remain in the bladder for at least four hours to accumulate a
detectable amount of nitrite. Thus, a negative nitrite test does not exclude a UTI
 Positive leukocyte esterase on dipstick analysis is suggestive of UTI. However, a
positive leukocyte esterase test does not always signal a true UTI – fever, GN,
Catheterization
Microscopy
 ≥5 WBC/high power field (hpf) in centrifuged sample or >10 WBC per ml in a

fresh uncentrifuged sample – pyuria
 Other causes other than UTI are fever, glomerulonephritis, renal stones or
presence of a foreign body.
Colony counts
Suprapubic aspiration:
 Any Gram neg bacilli
 >10ᶺ3 CFU/ml of gram positive cocci
Catheterization:
 >10ᶺ5 CFU of a single organism/ml
Clean catch:
 ≥10ᶺ5 CFU of a single organism/ml
Mixed growth usually represents contamination

Clinical differentiation between acute upper urinary
tract infection and cystitis
Upper UTI Cystitis

 Bacteriuria and fever of 38⁰C  Bacteriuria but no systemic features
 Bacteriuria, loin pain/ tenderness and

fever of <38⁰C
C-reactive protein alone should not be used to differentiate acute

pyelonephritis/upper urinary tract infection from cystitis/lower urinary tract infection
in infants and children.
Management
 <3 months of age- 2-3 days ivi followed by oral antibiotics once clinical
improvement.
 >3 months of age with upper UTI – oral antibiotic for 7-10 days, ivi if vomiting
then switch to oral for 10 days.
 >3 months with lower UTI – oral for 3 days
Antibiotics used include

 Third generation cephalosporins – preferred treatment
 Daily gentamycin if renal function is normal
 Oral antibiotics – cephalexin, ofloxacin. Ciprofloxacin, coamoxiclav, cefixime
Duration of treatment
Clinical resolution of fever and reduction of symptoms should take 48-72hrs

otherwise suspect complication or non compliance – repeat urine culture
Complications of uti
 Renal scarring
 Hypertension
 Chronic Kidney failure
 Growth failure
Risk factors for renal scarring
1. Recurrent febrile UTI

2. Delay in treatment of acute infection- delay of 48 hrs increases scarring risk
by up to 50%
3. Bladder and bowel dysfunction
4. Obstructive urinary tract malformations
5. Vesicoureteral reflux (VUR)
Antibiotic prophylaxis
 Not routinely given.

 Increased risk of antibiotic resistance.
Evaluation after first uti
 Guidelines differ
 Every child with first UTI should have USS KUB.
 Further imaging if USS KUB is abnormal.
Prevention of uti
 Circumcision in infant boys – 100 circumcisions needed to prevent 1 UTI.

 Prevent constipation
 Treat causes of urinary obstruction
Indications for referral to a paediatric
nephrologist
 Recurrent UTI
 UTI with bladder bowel dysfunction
 VUR
 Underlying urologic or renal abnormalities
 Children with renal scar, deranged renal function and hypertension.
Thank you !!!

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Urinary tract infections

Infection of the urinary tract identified by growth of a significant number of

2 week old boy SK

4 year old female DM

2 year old male TK

6 year old girl MM

1. Ecoli commonest cause up to 80%

Infection with an organism other than E. coli is associated with a higher

 IDEALY URINE SHOULD BE ANALYZED WITHIN 1 HOUR OF

 ≥5 WBC/high power field (hpf) in centrifuged sample or >10 WBC per ml in a

Mixed growth usually represents contamination

Upper UTI Cystitis

 Bacteriuria, loin pain/ tenderness and

C-reactive protein alone should not be used to differentiate acute

Antibiotics used include

Clinical resolution of fever and reduction of symptoms should take 48-72hrs

1. Recurrent febrile UTI

 Not routinely given.

 Circumcision in infant boys – 100 circumcisions needed to prevent 1 UTI.

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