Urinary Tract Infection in the pediatric patient Meaghan Eddy, RN, BSN FNP student

Definition Includes bacterial infection of any structure within the urinary tract A majority of UTI’s are located in the bladder or urethra The higher up the Urinary tract, the more serious

Severe and recurrent infections may lead to: Renal scarring Hypertension End-Stage Renal Dysfunction in adulthood May be life threatening in the neonate/infant

Common Pathogens E. Coli- the most common cause of uncomplicated UTI. Estimates range from 75-95% on infections Staphylococcus saprophyticus- generally more aggressive, more likely to evolve to a pyelonephritis or result in recurrent UTIs. Entereobacteriaceae such as proteus and klebsiella less common Group B strep- more in neonates

History/ROS Previous UTI’s? Hygiene habits? Voiding/Bowel habits? (frequency, dribbling, weak urinary stream, daytime enuresis) Sexual activity, sexual abuse Family history of VUR, recurrent UTI, kidney problems? Presence of diaper rash, pinworms?

Physiologic predisposition Uti should be a top differential in children with known: Known vesicoureteral reflux Congenital malformations of urinary tract structures Disturbances in neurologic function such as a myelomeningeoceal, hydrocephalus, cerebral palsy

Risk Factors in General Population Caucasians (2-4x higher than AA) Females (2-4x higher than circumcised males) Preterm and Low Birth-weight infants Uncircumcised males during first year of life Bottle-fed infants (lack of IgA provided in breastfeeding to fight mucosal invasion by bacteria)

Risk Factors Cont’d Dysfunctional Voiding Familial Predisposition Sexual Activity, specifically use of spermicidal condoms/foams Dysfunctional Voiding cause in 40% of toilet trained children with first UTI, 80% in those with recurrent UTI

Clinical Findings (by age group)

Neonates Jaundice Hypothermia FTT Sepsis Vomiting/Diarrhea Cyanosis Abdominal Distension Lethargy

Infants Malaise Irritability Difficulty Feeding FTT Fever (esp. in pyelonephritis) Vomiting/Diarrhea Malodorous Urine Abdominal Pain/colic

Toddlers/Preschoolers Changes to voiding pattern Malodorous urine Abdominal/Flank pain (esp. in pyelonephritis) Enuresis Vomiting/diarrhea (esp. in pyelonephritis) Fever Diaper rash if not potty trained

School-Age to Adolescence Frequency, Urgency, Discomfort Malodorous Urine Abdominal/Flank Pain (esp in pyelonephritis) Suprapubic tenderness Fever/Chills (esp. in pyelonephritis) Malaise Vomiting/diarrhea (esp. in pyelonephritis)

Other physical exam findings Females may have vaginal erythema, edema, irritation, or discharge; presence of labial adhesions Parents may report a weak, dribbling stream with urination Presence of sacral dimpling, decrease in perineal sensation, decrease in lower extremity reflexes

not all collection methods are created equal! Diagnostic studies Urine Specimen not all collection methods are created equal! Suprapubic bladder aspiration -99% accurate -should consider in very ill children Clean catch -catch midstream void -first morning’s urine -refrigerate until culture -have female sit backward on toilet to separate labia and decrease contamination Bag collection -high degree of contaminants -only useful to rule out UTI Straight cath -95% sensitivity -should be used in very ill children and infants

Pertinent findings on UA **UA is not diagnostic** Cloudiness suspicious Leukocyte esterase: detects pyuria Nitrites- will only be present in urine sitting in bladder >4 hours, with gram-negative bacteria presence of more than five white blood cells bacteria viewed per high-powered microscope field of the spun urinary sediment

?? Differential Diagnosis ?? Infants: bacteremia, meningitis Children: Vulvovaginitis, STI, Vaginal foreign body, Sexual Abuse, Abdominal Disease, Renal Calculi, dysfunctional voiding, dysuria-pyuria syndrome, appendicitis, pelvic abscess, pelvic inflammatory disease

Urine Culture/Sensitivity *Diagnostic of UTI* Always order in presence of suspicious symptoms, even if UA is normal Positive organism ID and sensitivity Culture results of more than 100,000 cfu/ml, 50,000 in children 2-24mo per AAP guidelines Repeat culture if growth is around 10,000 cfu/ml unless collected by aspiration/catheterization- then diagnostic

Additional Labs to think about: CBC ESR C-reactive Protein BUN/Cr Blood Cultures If the child appears ill, is less than 12 months, or pyelonephritis is suspected

Recommendations for anti-microbial therapy Inpatient treatment Intravenous options: Ceftriaxone 75 mg/kg every 24 h Cefotaxime 150 mg/kg/d divided every 6 h Ceftazidime 150 mg/kg/d divided every 6 h Cefazolin 50 mg/kg/d divided every 8 h Gentamicin 7.5 mg/kg/d divided every 8 h Tobramycin 5 mg/kg/d divided every 8 h Ticarcillin 300 mg/kg/d divided every 6 h Ampicillin 100 mg/kg/d divided every 6 h

Oral Antibiotic options Amoxicillin 20–40 mg/kg/d in 3 doses Sulfonamides: -TMP in combination with SMX (6–12 mg TMP, 30–60 mg SMX per kg per d in 2 doses)   -Sulfisoxazole 120–150 mg/kg/d in 4 doses Cephalosporins: -Cefixime 8 mg/kg/d in 2 doses   -Cefpodixime 10 mg/kg/d in 2 doses   -Cefprozil 30 mg/kg/d in 2 doses  -Cephalexin 50–100 mg/kg/d in 4 doses  -Loracarbef 15–30 mg/kg/d in 2 doses 10-14 day Courses with Best cure rates per AAP

Patient/Parent Education (for the uncomplicated patient) Avoid bubble baths Avoid Tight fitting clothing (girls) Wipe “back to front” Don’t hold urine for long periods of time

So, a UTI is diagnosed, antibiotics are started… So, a UTI is diagnosed, antibiotics are started…. but When is further testing needed? New AAP guidelines released August 2011 Children ages 2-24 months included in the new guidelines Options for further testing include: Renal/bladder ultrasound Voiding cystourethrography (VCUG) Intravenous pyelogram (IVP) DSMA scan

Children 2-24 months Ultrasound should be performed of kidneys/bladder for detection of anatomic abnormalities in all pts. Perform U/S promptly if no improvement of symptoms after 48 hours of antibiotics VCUG no longer recommended after febrile UTI unless ultrasound is abnormal or this is a recurrent problem No recommendations for prophylactic antibiotics in children with no VUR, or VUR grades I-IV.

Children older than 24 months Recommendations vary greatly Most recommend ultrasound at minimum for any child with pyelonephritis, suspicious factors such as HTN, weak urine stream, family history of UTI, known abnormal voiding patterns VCUG recommended in children less than 5, with abnormal ultrasound, presence of abnormal voiding before uti Consider VCUG in a febrile or highly complicated UTI **VCUG should be done 4-6 weeks after infection is cleared**

Degrees of Vesicoureteral reflux

What Next? Consider DMSA scan to determine renal scarring in the presence of VUR Grades i-iv may spontaneously resolve, less likely in older children prophylactic antibiotics are recommended by Dept of Ped. Urology at Johns Hopkins, not recommended by AAP for 2-24mo children. recommendation is Bactrim/Septra Consider referral to Pediatric Urology

Prophylaxis options TMP in combination with SMX 2 mg of TMP, 10 mg of SMX per kg as single bedtime dose or 5 mg of TMP, 25 mg of SMX per kg twice per week Nitrofurantoin 1–2 mg/kg as single daily dose Sulfisoxazole 10–20 mg/kg divided every 12 h Nalidixic acid 30 mg/kg divided every 12 h Methenamine mandelate 75 mg/kg divided every 12 h

References American Academy of Pediatrics. (2011). Practice Parameter: The Diagnosis, Treatment, and Evaluation of the Initial Urinary Tract Infection in Febrile Infants and Young Children. Pediatrics, 103(4), 843-852. Burns, C.E., Dunn, A.M., Brady, M.A., Starr, N.B., & Blosser, C.G. (2009). Pediatric Primary Care (4th ed.). St. Louis, MO: Saunders Elsevier Johns Hopkins Medicine. (2012). Vesicoureteral Reflux. Retrieved from http://urology.jhu.edu/pediatric/diseases/reflux.php .