Urinary Tract Infections بسم الله الرحمن الرحيم Urinary Tract Infections Dr Satti Abdulrahim Satti Pediatric Consultant

Etiology In 5% of girls & 1% of boys. In infancy more common in males. More common in uncircumcised boys. Incidence in breast fed infants is lower than in those fed with formula.

UTIs is a risk for development of renal insufficiency or end-stage renal disease. Caused by : # E. Coli (in 90%) # Klebsiella organism. # Proteus “ . # Staph. Saprophyticus. # Adenovirus (as cystitis)

Pathogenesis & Pathology An ascending infection from fecal flora or flora beneath the prepuce. Rarely a hematogenous spread. Renal injury & scarring.

!! Vesicoureteral reflux. Risk factors for UTI : !! Vesicoureteral reflux. !! Obstructive uropathy. !! Instrumentation or Cathet. !! Uncircumcision . !! Tight clothing . !! Neuropathic bladder. !! Pinworm infection. !! Voiding dysfunction. !! Constipation.

Clinical M. & Classification There are 3 basic forms of UTI (1) Pyelonephritis # Acute pyelonephritis or Pyelitis. # Characterized by : Abd. or flank pain, Nausia & Vomiting, Fever, Malaise & Diarrhea (occasionally). # Acute pyelonephritis may result in scarring.

# Nonspecific symptoms in newborns & infants : > Poor feeding. > Irritability . > Jaundice . > Wt. loss.

Cystitis Bladder involvement with: # Dysuria & Urgency. # Frequency & Incontinence. # Suprapubic pain . # Malodorous urine . # No fever or renal scarring.

(3) Asymptomatic bacteriuria @ A +ve urine culture without any manifestations . @ Only in girls . @ Benign with no scarring.

Diagnosis Clinically . Urine analysis. Urine culture (confirm & therapy) Ways to obtain a urine sample : & Midstream urine sample. & Sterile collection bag (infants) & Catheterized specimen . Put urine in fridge until it can be cultured.

Culture : ≥ 100 000 colonies (+ve) ≤ 10 000 “ ( -ve) Pyuria & WBC casts. Positive Nitrites & Leukocyte esterase. Microscopic hematuria. ↑ WBC, ↑ ESR & +ve CRP.

Treatment

!! Children with a nontoxic appearance are treated with oral fluids and antibiotics. !! Toxic-appearing children must be treated with intravenous (IV) fluids and parenteral antibiotics.

!! Initial treatment may consist of a single dose of ceftriaxone (75 mg/kg IV/IM q12-24h). !! Treatment may be with gentamicin (2.5 mg/kg IV/IM as a single dose). !! Then switch to an oral antibacterial agent.

Acute Cystitis @ Nitrofurantoin 5 mg/Kg/d in 3-4 doses . @ Sulfamethoxazole-trimethoprim. Septrin (Bactrim) @ Nitrofurantoin 5 mg/Kg/d in 3-4 doses . @ Amoxicillin 50 mg/Kg/d

Pyelonephritis @ Ceftriaxone 50-75 mg/Kg/d Inj. @ Ampicillin 100 mg/Kg/d “ + @ Gentamycin 5 mg/Kg/d “ @ Amoxicillin/ Clavulanate PO @ Oral Cefixime . @ Ciprofloxacin in older children.

@ Do urine C/S after 1 wk from termination of treatment . @ Follow up urine C/S for 1-2 y. @ For prophylaxis against reinfection: > Use septrin or nitrofurantoin. > ⅓ rd of therapeutic dose OD.

Imaging Studies To identify anatomic abnormalities. Hydronephrosis. Renal Ultrasound : Abscesses . Hydronephrosis. Acute pyelonephritis(↑kidney) Show 30% of renal scars. 40% of reflux cases.

Voiding Cystourethrogram (VCUG) € Indicated in:All children <5 y with a UTI. A child with a febrile UTI. Girls with 2 or more UTIs. Any male with a UTI. € May show Vesicoureteral reflux . Computed Tomography (CT) Effective in renal scanning.

Renal Scanning with DMSA > For acute pyelonephritis (photopenia) > To detect renal scarring.

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