MFC 2010 AL Batch

UTI in Children

UTI in childhood is important because,
50% have a structural abnormality of their urinary tract
Pyelonephritis damage the growing kidney forming a scar
Predisposing to hypertension
Chronic renal failure if the scarring is bilateral

Predisposing factors
Incomplete bladder emptying ( infrequent voiding, incomplete micturition, neuropathic bladder)
Constipation
Vesicoureteric reflux

Organisms
Newborn more likely to be haematogenous spread
E. coli (commonest), Klebsiella (often in newborns), Proteus, Pseudomonas, Streptococcus faecalis
Proteus predispose to phosphate stones
Pseudomonas may indicate the presence of some structural abnormality in the urinary tract affecting
drainage

Clinical features
Infants < 3 months
(non specific)

Fever usually, but not always present
Lethargy
Vomiting
Irritability
Poor feeding
Failure to thrive
Jaundice
Offensive urine
Septicaemia


Clinical features suggestive of recurrent UTI & serious pathology
Poor urinary flow
Previous UTI
Recurrent fever of unknown origin
Antenatally diagnosed renal abnormality
Family hx of vesico-ureteral reflux(VUR) or renal disease

Symptoms less severe in - repeated infections
recurrence close to an earlier infection
Infants & children 3 months

Fever +/- rigors
Dysuria (crying during micturition), frequency
Abdominal pain, loin tenderness
Vomiting, diarrhoea
Offensive, cloudy urine
Haematuria
Lethargy, anorexia
Febrile convulsion
Recurrence of enuresis

MFC 2010 AL Batch


























Investigating a child with UTI

Investigati
on
Description Infants < 6 months > 6 months < 3 years > 3 years
USS Urinary obstruction
Solid/cystic masses
Bladder capacity,
residual urine
Renal size, volume
Poor at identifying
renal scars, VUR
If responding well to
treatment within 48 hours
not urgent Do within 6
weeks
Atypical UTI, recurrent UTI -
during the acute infection
If atypical - in the acute
stage
Recurrent within 6 weeks
If responding well to
treatment within 48 hours
not recommended (but
done-in SL setup)
Acute stage
only if
typical??

DMSA Differential renal
function
Renal scarring
Functional image of
kidney based on
tubular activity
In atypical & recurrent UTI
6 months after the acute
episode Not done in acute
stage
Not indicated if responding to
treatment within 48 hours
Atypical/recurrent

In 6 months
only if
recurrent

MCUG
Micturatin
g
Cystouret
hrogram
Invasive test
Radiation exposure
VUR & posterior
urethral valve
Bladder, neck, urethra
Atypical or recurrent UTI
Not indicated if responding
to treatment within 48
hours
Usually not indicated in
atypical/recurrent
If atypical/ recurrent with a
poor urine flow
VUR family hx.
Not indicated
(unless very
large structural
defect)
Pyelonephritis/ Upper UTI

Bacteriuria
Fever 38C
Loin pain, tenderness

( Bacteriuria + Fever 38C or
Bacteriuria + loin pain/ tenderness
even if the fever is < 38C )
Cystitis/ Lower UTI

Dysuria
But no systemic symptoms or signs
Atypical UTI

Seriously ill/ septicemia
Poor urine flow
Abdominal/ bladder mass
(Posterior urethral valves with a palpable
bladder, ballotable kidneys-hydronephrosis)
Raised creatinine (renal impairment)
Septicemia
Failure to respond to suitable antibiotics
within 48 hours
Infection with non E. coli organisms

Recurrent UTI

2 Upper UTI/ pyelonephritis
1 Upper UTI + 1 lower UTI/ cystitis
3 Lower UTI/ cystitis

MFC 2010 AL Batch
Urine culture
Gold standard
Collect sample before starting antibiotics
Specimen collection Ask mother to wash hands. Wash the child from umbilicus to mid thigh. Do not try the
areas. Separate the labia/foreskin. Collect midstream sample.
Suprapubic aspiration in neonates
Try to avoid catheter samples
A bacterial culture of 10
5
CFU of a single organism/ml in a properly collected and transported specimen (clean
catch mid stream sample)
90% probability of infection
Growth of mixed organisms contamination
Any bacterial growth of a single organism/ ml in a catheter sample or Suprapubic aspirate Diagnostic of
infection

Dipstick testing
(screening test)
Nitrite stick testing If (+) , very likely to indicate a UTI
But some children with UTI are nitrite (-)
Leucocyte esterase stick testing (for WBC) Urinary WBC not a reliable feature of a UTI
Maybe present in children with UTI, but also maybe (-)
Present in children with febrile illness without UTI, balanitis, vulvovaginitis

Urine Microscopy - A normal WBC count does not exclude a UTI
Suggests renal involvement if WBC casts present

A urine sample should be tested in all infants with an unexplained fever >38C

Treating a child with UTI

Acute management















Other measures control of fever, fluid intake
Repeat culture to ensure adequacy of treatment.
< 3 months

IV antibiotics
Eg. Cefotaxime
When the temperature has
settled oral antibiotics
3 months

Acute pyelonephritis/ Upper UTI

Oral antibiotics with low
resistance patterns
Eg.- Co-amoxiclav 7-10 days

Or, IV antibiotics eg.- cefotaxime
2-4 days Oral antibiotics
total of 7-10 days
Cystitis/ Lower UTI

Oral antibiotics 3 days
MFC 2010 AL Batch
Surgical management

Not routinely recommended for vesico-ureteral reflux
Mild reflux usually resolves spontaneously
Significant blocks posterior urethral valve

Prophylaxis

Not indicated after 1
st
UTI
Only if recurrent UTI, significant UT anomalies, significant kidney damage
Nitrofurantoin, Nalidixic acid (cannot be used in a small child), Cephalexin, Trimethoprim
Broad spectrum, poorly absorbed antibiotics (eg. Amoxicillin) Should be avoided

Follow up

If no imaging planned - no need to follow up
When imaging available is normal no need to follow up
1
st
episode of UTI asymptomatic since no need to do urine cultures

Asymptomatic bacteriuria No place for antibiotics
Do not do urine cultures in asymptomatic patients

Preventing recurrent UTI

High fluid intake high urine output
Regular voiding
Ensuring complete bladder emptying double micturition
Avoid constipation cause urine to be stagnant in bladder (obstruction by a loaded rectum)
Good perineal hygiene (fecal contamination)
Lactobacillus acidophilus colonization of the gut by this organism reduces the number of pathogenic
organisms