Urinary Tract Infection Lecture N

Urinary Tract Infection
Dr. Radi Hamed Siouf

Consultant Pediatric Nephrologist
Associate Professor
The Hashemite University
Definition:
The presence of a “significant number” of
bacteria in urine.
+
Symptoms
Incidence
Boys: 1%
Girls: 3%
Onset
30 % < 1 year
70 % < 6 years
Primary Renal Diseases in 202 Jordanian Children
with Chronic Renal Failure (CKD)
The spectrum of chronic renal failure among Jordanian children
Radi M. A. Hamed - Department of Pediatrics, Jordan University Hospital,
Amman – Jordan. J NEPHROL. 2002; 15: 130-135
Etiology .No %
Urinary tract abnormalities 85 42.1
)anomalies(
Hereditary renal disorders 60 29.7
Glomerulonephritis 29 14.4
Renal hypoplasia / dysplasia 10 5
Vascular abnormalities 9 4.5
Unclassified (idiopathic) 9 4.5
:Classification (Localization)
• Lower U.T.I
Urethritis
Cystitis
• Upper U.T.I
Pyelonephritis
Classification:
• Obstructive
1. Structural:
Congenital
Acquired
2. Functional:
Neurogenic bladder (dys-synergia).
Constipation.
• Non-obstructive
e.g - Primary vesico-ureteral reflux.
- Cystitis.
Symptoms
Neonates / Nonspecific
%
Weight loss/failure to thrive 76
Fever/sepsis 50
Cyanosis (Dusky) 40
Abdominal distention 16
Prolonged Jaundice 07
Vomiting
Symptoms
In infants
• Fever
• Irritability
• Abdominal pain
• Gastrointestinal symptoms
• Crying upon micturition
• Turbid urine/strong-smelling urine
• Failure to thrive (25%)
Symptoms
In older children
• Bladder irritation signs:
dysuria, frequency, urgency
• Incontinence: ? new onset
(nocturnal enuresis, day-time incontinence)
• Loin/flank pain.
• Fever, Chills-Rigors.
• Hematuria.
Pertinent physical findings
• palpable abdominal mass.

• Palpable urinary bladder post voiding.
- Bladder outlet obstruction
- Neurogenic bladder
• wrinkled, prune-like abdominal wall skin.
• Meatal stenosis / hypospadias.
• Diminished anal sphincter tone.
• Fecal accumulation.
• ? Uncircumcised.
• Supra-pubic tenderness.
Loin tenderness.
Pertinent physical findings
• Examination of the lower spine.
• - Sacral agenesis.
• - Evidence of occult spinal dysraphism:
hairy patch, sacral dimple, sinus, dermoid
Meningomyelocele
Diagnosis
• Pyuria: >5 WBCs/HPF

• Leukocyte esterase.
(the most sensitive single test in children with a suspected UTI).
• nitrite test.
(more specific but less sensitive).
• Positive urine culture (main criterion).
Rapid predictors of U.T.I
Tests
1. Bacteria seen under high power field on a non-centrifuged urine.

2. Nitrite test:
(reduction of urinary nitrate by bacteria).
Sensitivity in infants 50%, 98 % specificity.
3. Diptest for WBCs (Leukocyte esterase).
Urine culture
(Immediate C/S, or store at 4°C)
• Supra-pubic tap (<6 months).

• Urine-bag collection (infants).
• Catheter sample (any age).
• Mid-stream urine / clean catch.
(older children)
Urine culture
Significant growth
(Number of organisms of one species per ml of fresh uncentrifuged

urine)
• Suprapubic: any growth.

• Catheter sample: > 10³ /ml
• Midstream urine: > 105 /ml
• Bag specimen: > 105 /ml
Plastic bag collections (unreliable)
Principles
• Meticulous washing of the genital region.

(renew every 3 hours)
• Use soap and water for cleaning.
(avoid alcohol & iodine)
• Detach the bag within 15 minutes of voiding.
Urine C/S
Bag collections
Reliability
>105/ml organisms (single species).

50-80%
Unreliable.
(10% of samples from healthy infants grew 50,000
CFU/ml)
Urinary Pathogens
• Gram negative rods (Escherichia coli)

• Proteus spp.
• Klebsiella spp.
• Citrobacter spp “coliforms”
• Enterobacter spp (Pseudomonas spp.)
• Enterococci (Strept. fecalis)
• Gram positive cocci, Staph. aureus,
Staph. saprophyticus,
Staph. albus)
• Candida.
UTI
Investigation
Y ou ng ch ild
L e ss tha n 5 -7 yea rs
B oy or G irl
F irst U T I
U ltra sou nd
If ultrasound is abnormal; consider
Voiding Cysto-Urethro-Gram
(VCUG = MCUG)
- Contrast material instilled in the UB (catheter).
-Problems: Invasive / high radiation exposure – gonads.
•Bladder:
shape
size
trabeculations
haustrations
diverticulae
• Urethra.
• Ureters (reflux).
Grades of VUR
Normal urinary bladder & urethra
UTI
Investigations in children
Additional tests:
• Radionuclide renal scans (isotopes-99Tc):
- Dynamic (Function test) DTPA, MAG-3
- Static (“anatomy”) DMSA
• CT-urogram.
• MRI - with/without contrast.
• “Intravenous urogram (IVU)”; rarely indicated (Duplex)
• Cystoscopy.
T99-DMSA scintigraphy
(static isotope)
Dynamic isotope renal scan (T-99)
MAG-III
DTPA
Vesico-ureteral reflux
Vesico-ureteral reflux
• Common cause of UTI.

• Primary, secondary (bladder outlet obstruction/neurogenic bladder).
• Sterile reflux >> renal damage (significantly increased
with infection) .
• Primary - may disappear with time.
Mild (grade I, II) 85-90%
Moderate (grade III) 80%
Severe (grade IV, V) 40%
Primary VUR
• Familial incidence:
Up to 30% of siblings of children with VUR can
have asymptomatic VUR.
• Need for screening of siblings:
Radionuclide cystogram
Complications
• Renal scars (Higher risk in young children).

• Hypertension.
• Chronic kidney disease (CKD).
• Failure to thrive.
• Renal stones (mixed stones / struvite).
Treatment
• Antibiotic choice: Sensitivity testing.
• Outpatient: Co-trimoxazole
2nd generation cephalosporins
Fluoroquinolones
Other antibiotics.
• Inpatient: Aminoglycosides.
3rd/4th generation cephalosporins.
Carbapenems.
Pipracillin/tazobactam.
Quinolones. / other antibiotics.
• Duration: 5 days in lower UTI.
10-14 days in upper UTI (pyelonephritis)
• Repeat C/S: 3rd day,
Whenever symptomatic.
Regular follow-up in susceptible patients.
UTI
Consideration for Prophyalctic Antibiotics
Controversial
• In vesico-ureteral reflux.
• Conditions associated with urinary stasis / obstructive
uropathies.
• Increased the risk of resistant uropathogens.
Dose: One quarter the therapeutic dose.

Given at bed time.
Drugs: Nalidixic acid
Nitrofurantoin
Cephalosporins
Co-trimoxazole
Amoxicillin (newborns, infants)
END
Percent chance of reflux persistence for 1–5 years
following presentation
Treatment
• Children with acute pyelonephritis can be treated
effectively with oral antibiotics (e.g., Cefuroxime,
Cefixime, Amoxicillin/clavulanate) for 10 to 14 days or
with short courses (2-4 days) of IV therapy followed by
oral therapy.
• In sick, febrile, young (infants & newborns), patients

should be admitted to hospital and treated with
parenteral antibiotics + other supportive measures.

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Urinary Tract Infection

Dr. Radi Hamed Siouf

• palpable abdominal mass.

• Pyuria: >5 WBCs/HPF

1. Bacteria seen under high power field on a non-centrifuged urine.

• Supra-pubic tap (<6 months).

(Number of organisms of one species per ml of fresh uncentrifuged

• Suprapubic: any growth.

• Meticulous washing of the genital region.

>105/ml organisms (single species).

• Gram negative rods (Escherichia coli)

• MRI - with/without contrast.

• “Intravenous urogram (IVU)”; rarely indicated (Duplex)

• Common cause of UTI.

• Renal scars (Higher risk in young children).

Dose: One quarter the therapeutic dose.

• In sick, febrile, young (infants & newborns), patients

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