URINARY TRACT INFECTION IN CHILDREN AGNES ALARILLA-ALBA MD

Urinary Tract Infection An 2 mos old male infant was noted to have high grade fever documented at 39 C of two days duration. It was associated with chills and vomiting. Patient was noted to have flat fontanelle with no note of neck rigidity.

INITIAL IMPRESSION??? A) Systemic Viral Infection B) Meningitis C) Urinary Tract Infection D) Sepsis

Important Points in the History…..

Points to Ponder AGE of the patient SEX of the patient signs and symptoms of UTI according to age

[1] The neonates presenting with clinical signs and symptoms. The Suspect [1] The neonates presenting with clinical signs and symptoms. [2] Febrile infants [>38 C] below 2 years of age without any focus of infection. [3] Older children manifesting symptoms referable to the urinary tract . Table 1 Table 1 Table 1 The evidence for this recommendation A/II. Hoberman A[6,7,8]; Shaw [9], Downs [5].

TABLE I. Clinical S/SX Neonates Older Infants School Age/ Adol Septic In general manifestations of urinary tract infections are non-specific. However, there are some signs and symptoms that are associated with UTI: TABLE I. Clinical S/SX Neonates Older Infants School Age/ Adol Septic [+] Temp instability Poor feeding Vomiting Lethargy/Irritab Jaundice Fever

Table I. Clinical S/Sx Neonates Older Infants School Age/ Adol Poor wt gain /FFT [+] Diarrhea Abdominal pain Freq,drib, urge, dysuria Weak urinary str Malodorous urine Enuresis Flank pains

NOTES: In management of UTI --> no discrimination between Males and females 5.3% of febrile infants have positive culture for UTI If age of patient is less that 2 years old--> non specific signs and symptoms

NOTES GIRLS BOYS 3-5% of GIrls Peaks at infancy and at toilet training After 1st uti 60% will develop recurr Beyond 1-2 yrs old 1:10 1% of BOYS Usually on first year of life Uncircumcised boys first year of life: of M: F ratio is 2.8-5.4:1 after

ETIOLOGY E Coli  Klebsiella Proteus F Proteus and E Coli + gram positive org for males Staph Saprophyticus and Enterococcus in both sexes Adenovirus for cystitis

NOTES: ONLY 2 proven risk factors : UNCIRCUMCISED MALES CONSTIPATION UTI -> higher by 5 to 20% if uncircumcised

URINARY TRACT INFECTION ACUTE PYELONEPHRITIS Asymptomatic Bacteriuria CYSTITIS

Suspected Urinary Tract Infection II. Algorithm on the Diagnosis, Work-up, Treatment and Follow-up of Children with UTI Suspected Urinary Tract Infection Urinalysis [suggestive of UTI] History Pyuria >5 WBC/ hpf or 10/mm3 [+] leucocyte esterase or nitrite test Bacteruria in unspun urine, GS Urine culture of properly collected specimen Physical Exam FEVER > 38.5 C

RISK FACTORS female Uncircumcised male Toilet training Reflux Vioding dysfunction Obstructive uropathy Urethral instrumentation Wiping from front to back Bubble bath Pin worm infestation Tight clothing Constipation Labial adhesion Neuropathic bladder pregnancy

Important points in the PHYSICAL EXAMINATION

III. Diagnosis PHYSICAL EXAMINATION A thorough PE is a must. Look for congenital defects. Back examination – dimples, hair tufts in the lumbosacral area [neurogenic bladders] Lower extremities Rectal exam Neurologic examination

Examination of the back Slide courtesy of DTBolong MD

What laboratory test will you request to help in the diagnosis? A) URINALYSIS B) URINE Culture and sensitivity C) ultrasound of the KUB D) VCUG E.) DMSA F) A and B G) A , B and C H) all of the above

Suspected Urinary Tract Infection II. Algorithm on the Diagnosis, Work-up, Treatment and Follow-up of Children with UTI Suspected Urinary Tract Infection Urinalysis [suggestive of UTI] History Pyuria >5 WBC/ hpf or 10/mm3 [+] leucocyte esterase or nitrite test Bacteruria in unspun urine, GS Urine culture of properly collected specimen Physical Exam FEVER > 38.5 C

URINALYSIS Must have pyuria and bacteriuria--> to be more specific and sensitive must be collected properly if less than one year old SUPRAPUBIC TAP if not feasible cathetherization

URINALYSIS if greater than two--> midstream clean catch bag collection : false positve by 20%-85% Cleaning of ANTISEPTIC is not recommended Send immediately to lab--> exponential rise ( one hour) if stored in 4C--> 24 hours

URINE CULTURE and SENSITIVITY The GOLD STANDARD must be 100,000 CFU of SINGLE organism if suprapubic tap --> exception Lactobacillus, corynebacterium and coagulase negative staph -> must be interpreted with caution.

URINE CULTURE: Interpretation III. Diagnosis URINE CULTURE: Interpretation Table II. METHOD OF COLLECTION Quantitative Culture : UTI present Suprapubic aspiration Growth of urinary pathogen in any number [exception is up to 2-3 x 103 CFU/ml of coagulase[-] staph Catheterization Febrile infants of children usually have 50,000 CFU/ml evidence of a single pathogen, but infection may be present with counts from>1000CFU/ml Midstream clean void, Symptomatic patients Usually have 105 CFU/ml of a single urinary pathogen Midstream clean void, Asymptomatic patients At least 2 specimens of different days with 105 CFU of the same pathogen

URINE CULTURE: Interpretation III. Diagnosis URINE CULTURE: Interpretation Significant bacteriuria [1] Clean catch > 100,000 cfu/ml [2] Catheterized > 50,000 cfu/ml specimen [3] Suprapubic any bacteria [4] Bagged specimen: only significant if it is negative

ULTRASOUND OF THE KUB Infants and children who do not demonstrate expected response in two days -->may do US imaging--> to detect dilatations timing is not crucial according to study

Normal Kidney Hydronephrosis

VCUG to do if you suspect anatomical abnormality to detect reflux VUR incidence in patients with UTI is 50% if not done may maintain patient on prophylaxis

Urinary Tract Infection The Prevalence of VUR as a function of patient age. The prevalence of VUR reported in 54 studies of UTI in children. AAP 1999 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 Prevalence of VUR 0 1 2 3 4 5 6 7 8 Average Age [yrs]

International Classification of Vesicoureteral Reflux Pediatrics 1981; 67:392 Grade I Grade II Grade III Grade IV Grade V Slide courtesy of RHFrancisco, MD

Vesico Cysto Urethro Graphy Vesicoureteral Reflux

DMSA to detect renal scars earliest is six months after the incidence of UTI

DMSA Renal Scan Pyelonephritis

How will I treat? A) ampicillin and an aminoglycoside B) aminoglycoside C) third gen cephalosporin D) ciprofloxacin E) cotrimoxazole

TREATMENT See age of the patient if initially considering sepsis then may start with double- if U c/s is out shift to sensitivity if toxic looking and greater than two y/o third gen IV aminoglycosides

TREATMENT if not sick looking--> child with symptoms of UTI_-> DOC still COTRIMOXAZOLE Co amoxiclav --> good bladder retention third gen--> cefixime --> good alternative

TREATMENT may initially start with IV but once condition improves in 24 to 48 hours shift to oral as dictated by sensitivity how long? May give 7 to 10 days but if initially sick looking experts prefer 14 days

Some Oral Antimicrobials Dose III. TREATMENT Some Oral Antimicrobials Dose Amoxycillin 20-40 mkday in 3 doses TMP – SMX TMP[6-12mg], SMX [30-60] mkday in 2 doses Sulfisoxazole 120-150 mkday in 4 doses Cefixime 8 mkday, 2 doses Cephalexin 50-100 mkday in 4 doses Cefdoxime 10 mkday in 2 doses Cefprozil 30 mkday in 2 doses

Some Parenteral Antimicrobials Dose III. TREATMENT Some Parenteral Antimicrobials Dose Cetriaxone 75mkday, OD Cefotaxime 150 mkday , 4 divided doses Cefazolin 50 mkday, 3 divided doses Gentamycin 7.5 mkday, 3 divided doses Tobramycin 5 mkday, 3 divided doses Ticarcillin 300 mkday, 4 divided doses Ampicillin 100 mkday, 4 divided doses

Some Prophylactic Antimicrobials Dose III. TREATMENT Some Prophylactic Antimicrobials Dose TMP + SMX TMP 2 mkdose, SMX 10 mkdose Nitrofurantoin 1 – 2 mkdose Nalidixic Acid 30 mkday, 2 divided doses IV. TREATMENT – Surgical Intervention

General Management Principles increase fluid intake regular and complete emptying increase dietary fiber intake may give Vit C ( not proven) perineal hygiene bladder exercise

Urinary Tract Infections Take home message … Urinary Tract Infections in infants and children warrant special attention because they serve as a marker for anatomic abnormalities in the GUT.

Complications of UTI Renal Scarring Mackenzie, 1994 12% Hodson, 1966 10-25% Hypertension Jackobson, 1989 23% [27 year follow-up] Renal Failure Jackobson, 1989 10% [27 year follow-up]

THANK YOU MARAMING SALAMAT PO!!!

Some Parenteral Antimicrobials Dose III. TREATMENT Some Parenteral Antimicrobials Dose Cetriaxone 75mkday, OD Cefotaxime 150 mkday , 4 divided doses Cefazolin 50 mkday, 3 divided doses Gentamycin 7.5 mkday, 3 divided doses Tobramycin 5 mkday, 3 divided doses Ticarcillin 300 mkday, 4 divided doses Ampicillin 100 mkday, 4 divided doses

Other ISSUES of interest... Asymptomatic Bacteriuria will I treat or not…. Recommendation is NO RCT done in UK revealed that onlong term follow up patient treated with antibiotics are more likely to develop UTI with more virulent strains

When to refer to specialist.. Recurrent infection VUR renal damage possible obstruction nephrolithiasis

Other issues of interest.. HOW if all the test (US, VCUG) turned out to be negative and still has recurrent UTI CONSIDER: DYSFUNCTIONAL ELIMINATION SYNDROME voiding disorder constipation

Other issues of INTEREST.. Patients with recurrent UTI VUR 32% Anatomical Abnormalities 4.6% DES Voiding Dysfunction 21% Constipation 11% Idiopathic

VOIDING DYSFUNCTION increased frequency decreased bladder capacity interrupted voiding

DES is suspected in... Frequent urination infrequent urination incontinence (daytime and nighttime) constipation unexplained recurrent UTI unresolved reflux

Bladder Disorder A. Lazy Bladder syndrome 14.3% B. Overactive Bladder 28% C. Bladder Sphincter Dysenergia

LAZY BLADDER Prophylaxis timed voiding- double void , triple void Clean intermittent catheterization use of alpha blocker

Overreactive Bladder compute for bladder capacity age in years plus 2 X 30 prepare a diary for 72 hours check for daytime and night time incontinence check for holding manuevers

Overreactive Bladder treatment ANTICHOLINERGICS-- OXYBUTIN TIMED VOIDING ELECTRICAL STIMULATION POSTERIOR TIBIAL *CONSTIPATION

THANK YOU GOOD DAY