Good Morning All! Happy March! Morning Report: Thursday, March 1st

UTIs in Infants and Children

*Definitions, Epidemiology, and Host Factors  Infection of the urinary tract anywhere from the urethra to the renal parenchyma Most are infection of the mucosal surface of the urinary tract  Overall incidence of childhood UTIs: Girls: 8% Boys: 1-2%  Uncircumcised males: 0.7%  Circumcised males: ~0.2%

*Definitions, Epidemiology, and Host Factors  Age matters! *Prevalence of UTIs in febrile infants without an obvious source of infection  7-9% in infants <3mo  2% in males >3mo  2% in females >12mo

*Definitions, Epidemiology, and Host Factors  Host factors *Age *Sex Race Circumcision status GU abnormalities Immune status

Methods for Diagnosis  Urinalysis Nitrite  Demonstrates the presence of gram-negative bacteria  Specific but not sensitive Leukocyte esterase  Detects presence of leukocytes  Sensitive but not specific *Not alone sufficient to diagnose a UTI

Methods for Diagnosis  Urine culture Gold standard when obtained by  Suprapubic aspiration  Urethral catheterization  “Clean catch” midstream specimen

*Microbiology  E.Coli 70% of infections!  Pseudomonas aeruginosa  Enterococcus faecalis  Klebsiella pneumoniae  Group B Streptococcus (neonates)  Staphylococcus aureus  Proteus mirabilis  Coagulase-negative Staphylococcus

Pathogenesis  Uropathogenic bacterial strains have distinctive antigens and genes that enhance virulence P-fimbriae, protectins, toxins and siderophores  *Constipation Compression of bladder and bladder neck  increase of bladder storage pressure and PVR Distended colon/ fecal soiling provides abundant reservoir of pathogens

Clinical Presentation Infant 0-3 mos  Fever  Hypothermia  Vomiting  Diarrhea  Jaundice  Feeding difficulty  Malodorous urine  Irritability  FTT  Hematuria Infants 3-24mos  Cloudy/ malodorous urine  Frequency  Hematuria  Fever without a source

Clinical Presentation Preschool (2-6yo)  Abdominal or suprapubic pain  CVA pain  Dysuria  Urgency  Secondary enuresis

Management

Action Statement 1

Action Statement 2

 Let’s break it down, shall we? If you feel the infant is well enough to hold off on antibiotics then you should assess the likelihood of the patient having a UTI So, how do I do that??

Action Statement 2  Febrile infant girls>boys  Uncircumcised boys> circumcised boys  Presence of another clinically obvious infection reduces likelihood of UTI by one-half

Action Statement 2

Action Statement 3

Action Statement 4

Action Statement 5

 When to you perform the RUS? If clinical illness is severe or substantial clinical improvement is not occurring  perform within the first 2 days of illness If substantial clinical improvement is demonstrated, imaging does not need to occur early during the acute infection and can be misleading

Action Statement 6

Action Statement 7

A Question… YYou are evaluating a 5 yo girl who has a UTI. She has had four lower UTIs in the last 2 years, all of which resolved completely with oral antibiotics. She denies symptoms of urgency and frequency. The only significant finding on her medical history is constipation. Results of her RUS and VCUG are normal. Her growth parameters and PE findings are normal. You prescribe oral trimethoprim-sulfamethoxazole. Of the following, the MOST appropriate additional step to help reduce the incidence of further UTI is to: A. Begin an evaluation for immunodeficiency B. Perform renal scintigraphy C. Prescribe a stool softener and regular bowel routine D. Prescribe oral oxybutynin E. Refer her to a pediatric nephrologist

Thanks for your attention! Noon Conference: Common Mouth and Throat Infections, Dr. Riojas