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Pediatric Urinary tract Infections

Description of Urinary tract infections of pediatric age group, signs and symptoms, presentations, diagnosis, investigations, prognosis and management plan

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Pediatric Urinary tract Infections

  1. 1. Pediatric Urinary Tract Infections By Dr. Fahad
  2. 2. 1. Incidence 2. Etiology 3. Pathogenesis 4. Predisposing Factors 5. History and Physical Examination 6. Investigations 7. Management 8. Prognosis Urinary Tract Infections
  3. 3. Cystitis • Infection Localized to bladder Pyelonephritis • Infection involving the renal parenchyma, calyces and renal pelvis Asymptomatic Bacteriuria • Positive urine culture without any manifestations of infection Urinary Tract Infections
  4. 4. Atypical infection: Seriously ill Poor urine flow Abdominal or bladder mass Raised creatinine Failure to respond to suitable antibiotics in 48 hours Non- E-coli infection
  5. 5. Recurrent infection: ≥2 episodes of upper UTI or one episode of upper UTI plus ≥1 episode of lower UTI or ≥3 episodes of lower UTI.
  6. 6. Statistics  Gender:  Below 1 year : Boys > Girls  4 : 1 Above 1 year :Girls > Boys  10: 1  Prevalence: By age 10 years 2% boys and 8% girls will have experienced UTI once  Recurrence: Gender is not associated with risk of recurrence. Risk of recurrence depends on presence of underlying abnormality If the age of Febrile UTI is < 1 year 30% will go on to develop recurrent UTI.
  7. 7. Etiology: Gram Stain Bacterial Organism Frequency Pre-disposition Negative E. Coli 75-80% Normal flora in GIT Non- E.Coli Klebsiella 3-5% Genitourinary abnormalities Pseudomonas Indwelling catheters Proteus Stones Positive Enterococcus Genitourinary abnormalities Staphylococcus Saprophyticus Normal flora in female genital tract
  8. 8. Risk Factors: Age Gender Race Genetic Bowel Bladder Dysfunction Instrumentation Urinary obstruction
  9. 9. Defense Mechanism: Uroepithelium Low virulence strain of local bacteria Wash effect of urine Mucosal IgA Acidic pH High Urine Osmolality Vesicoureteric Valve
  10. 10. Clinical Presentation: Younger children < 2 years Older Children > 4 years • Fever • Urinary Symptoms: Dysuria , frequency, Urgency or incontinence • Suprapubic tenderness • Lack of circumcision • Suprapubic tenderness • Irritability • CVA tenderness* • Poor feeding or appetite • Abdominal pain • Failure to thrive • Back pain
  11. 11. History
  12. 12. History Of presenting Illness Age and Gender • Male < 1 year • Female > 2 year Hygiene techniques • Back to front sweep Bowel Habits • Constipation • Encopresis Voiding patterns • Dysuria, frequency, urgency, incontinence • Recurrence of enuresis Diaper area Rash: • Incontinence Past Medical History • Previous undiagnosed febrile illness • Diabetes mellitus • Neurodegenerative disease Birth History • Antenatal Oligohydraminos. • Natal LGA • Postnatal Sequence,Malformation Syndromes Family history • Recurrent UTI • Genitourinary Abnormalities in family
  13. 13. Physical Examination
  14. 14. General Examination: Dysmorphic features Growth Charts : Weight: Underweight Length: Short stature Head circumference: Macro or microcephaly Vital Signs Temperature: fever >38C BP: High CRT: >3 sec Systemic Examination: GIT: Suprapubic tenderness Cost vertebral angle tenderness Suprapubic mass Flank mass Back: Tuft of hair, sacral dimple, CNS: Features of neurodegenerative diseases Genitalia Local signs of irritation Phimosis Labial adhesions
  15. 15. Investigations
  16. 16. Urinalysis Urine culture Radioimaging
  17. 17. Urinalysis and culture:  How to collect it :  Mid stream urine sample  Catheterization Suprapubic catheterization
  18. 18. Urinalysis: Test Significant Sensitivity Specificity Microscopy ( WBCS) > 5 WBCS/HPF 73% 78% Leukocyte esterase test Positive 83% 81% Nitrite test Positive 53% 98% COMBINATION OF ABOVE TESTS 99% 70%
  19. 19. Urine Culture:  Bacterial Cultures Single pathogen is isolated  Number of colony forming unit s depend on Sample type:  Midstream Urine sample:  100,000 CFU  Catheterized or Suprapubic aspirate:  50,000 CFU  underlying urological abnormality:  10,000 CFU
  20. 20. Radioimaging :  KUB MCUG Tc 99m-DMSA scan
  21. 21. Purpose of Radioimaging: 1. Anatomic abnormality 2. Active renal involvement 3. Assess renal function
  22. 22. Imaging Test Purpose KUB US It is performed to exclude gross anatomical abnormality such as pyonephrosis, abscess and hydronephrosis MCUG to establish the presence and degree of VUR DMSA Scan  It is most useful in identifying areas of scars or decreased uptake
  23. 23. MCUG: 1. Child is catheterized 2. Radioopaque dye is instilled 3. Series of x-rays are done during voiding
  24. 24. Tc-99m DMSA Scan: 1. Tc99m-DMSA is injected IV 2. Patient waits for 2-4 hours 3. Images are taken by gamma camera at different views 4. Then IV Frusemide is given and another image is taken to identify its clearance
  25. 25. NICE guidelines Radioimaging First febrile UTI Atypical Infection Recurrent UTI < 6 month KUB Yes Yes Yes DMSA - Yes Yes MCUG If KUB abnormal Yes Yes 6 month- 3 years KUB - Yes Yes DMSA - Yes Yes MCUG - Can do if KUB is showing hydronephrosis or VUR in FH > 3 years KUB - Yes Yes DMSA - Yes Yes MCUG - - -
  26. 26. Criteria to do Radioimaging: Bottom Up approach: Renal USS followed by VCUG Top Down approach: Renal USS and DMSA scan
  27. 27. Test Anatomy of Kidney Function of kidney Obstruction Reflux KUB USS Yes (structural) no Identify changes as a result of obstruction or reflux MCUG Yes* ( structural limited tolower ut ) no Yes * yes DMSA Yes* ( functional ) Yes yes no
  28. 28. Management
  29. 29. Urine M,C&S <5 WBCs CFU >5 WBCs Toxic Yes No
  30. 30. CFU No growth No Rx <50K Suspicion Repeat >50K Rx Toxic Yes Rx No CFU
  31. 31. Repeat <50K No Rx CFU <50K Suspicion Rx >50k Rx
  32. 32. Inpatient vs Outpatient: Inpatient : < 3 months Not tolerating oral antibiotics or vomiting Follow up cannot be guaranteed Sick looking Failed to respond to outpatient therapy Outpatient: > 3 months Tolerate antibiotics orally Follow up can be maintained Not Sick looking
  33. 33. Choice of Antimicrobial: Depends on age of child Prior pathogen isolated and its sensitivity pattern Underlying urological abnormality and recurrence UTI Immunosuppressed Catheterized
  34. 34. Anti Microbials: Latifah Hospital : Inpatient: Neonate: IV ampicillin +IV Gentamycin Other : 1st line: IV Augmentin If penicillin allergic: IV cefuroxime Total : 7-14 days Uptodate: Inpatient: 1st line: 3rd Generation cephalosporin or IV aminoglycoside
  35. 35. Anti Microbials: Latifah Hospital : Outpatient: PO Augmentin If penicillin allergic: PO cefuroxime Total : 7-14 days Uptodate: Outpatient: PO cephalosporin (any generation)
  36. 36. Supplemental therapy Behavioral Dietary Laxative
  37. 37. Prophylaxis Indication: ( no anatomic abnormality) Three febrile UTIs in six months Four total UTIs in one year Anti-Microbial :  TMP SMX Nitrofurantoin Duration: 6 months Can be discontinued if no infection occurs during this period
  38. 38. Prognosis 1. If no renal abnormality prognosis is very good. 2. VUR is major determinant of renal damage, renal scar. 3. VUR grade 3 or higher are twice as likely to develop renal scar than lower grade VUR. 4. Children with higher VUR without a UTI shown to have fewer scars than higher grade VUR with UTI 5. Overall Risk of renal Scarring increases with young age at time of diagnosis, delay in initiation of treatment , recurrent infections , Atypical organism. 6. 2% of history of UTI (pyelonephritis) as a primary cause go on to develop renal insufficiency
  39. 39. Long-term Sequale of Recurrent UTI 1. Short stature 2. Poor weight gain or failure to thrive 3. Hypertension
  40. 40. Prevention:  Avoid constipation Proper hygiene technique Toilet training Hydration  Course of antibiotics Proper undergarments  Worm infestations treatment

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