1. Urinary Tract Infections د.ندى العلي استاذ مساعد في طب الاطفال Urinary Tract Infections د.ندى العلي استاذ مساعد في طب الاطفال

2. objectives 1-What are the risk factors of U.T.I. in children 2-What are the the signs and symptoms in different age group 3-How you diagnose 4-treatment and complication 5-Prevention-

3. EPIDEMIOLOGY Approximately 8% of girls and 2% of boys have a UTI by 11 years of age. In infants, boys are affected more than five times as often as girls. After 12 months of age, UTI in healthy children usually is seen in girls.

4. EPIDEMIOLOGY A short urethra predisposes girls to UTI. Uncircumcised male infants are at 5- to 12-fold increased risk for UTI compared with circumcised male infants.

5. EPIDEMIOLOGY  Obstruction to urine flow and urinary stasis is the major risk factor and may result from anatomic abnormalities, nephrolithiasis, renal tumor, indwelling urinary catheter, ureteropelvic junction obstruction, megaureter, extrinsic compression, and pregnancy.

6. EPIDEMIOLOGY  Vesicoureteral reflux, whether primary (70% of cases) or secondary to urinary tract obstruction, predisposes to chronic infection and renal scarring. Scarring also may develop in the absence of reflux

7. EPIDEMIOLOGY  The urinary tract and urine are normally sterile. Escherichia coli, ascending from bowel flora, accounts for 90% of first infections and 75% of recurrent infections.

8. CLINICAL MANIFESTATIONS  The symptoms and signs of UTI vary markedly with age. Few have high positive predictive values in neonates, with failure to thrive, feeding problems, and fever the most consistent symptoms. Direct hyperbilirubinemia may develop secondary to gram-negative endotoxin.

9. CLINICAL MANIFESTATIONS  Infants 1 month to 2 years old may present with feeding problems, failure to thrive, diarrhea, vomiting

10. CLINICAL MANIFESTATIONS  At 2 years of age, children begin to show the classic signs of UTI such as urgency, dysuria, frequency, and abdominal or back pain. The presence of UTI should be suspected in all infants and young children with unexplained fever and in patients of all ages with fever and congenital anomalies of the urinary tract.

11. LABORATORY AND IMAGING STUDIES  Urine obtained by midstream, (for older children and adolescents) is considered significant i.e the patient considered to have u.t.i.with bacterial growth of a single organism of more than 100,000 colony- forming units/unit or if there is10,000&the the child is symptomatic

12. LABORATORY AND IMAGING STUDIES  In infants(not trained)the use of adhesive sterile collecting bag can be useful if negative to exclude infection or if positive100,000 in symptomatic with positive urine culture if any of these criteria not met then confirmation by catheterized sample

13. LABORATORY AND IMAGING STUDIES  Urine obtained by catheterization is considered significant with bacterial growth of more than 10,000 CFU/mL. Urine obtained by suprapubic aspiration is considered significant with any bacterial growth.

14. LABORATORY AND IMAGING STUDIES  Suprapubic percutaneous aspiration of the bladder may be performed in young infants if they have not voided for 1 to 3 hours. Perineal bags for urine collection are prone to contamination and are not recommended for urine collection for culture.

15. LABORATORY AND IMAGING STUDIES  The diagnosis of UTI requires a culture of the urine. Urine samples for urinalysis should be examined promptly (within 20 minutes) or refrigerated until cultured

16. LABORATORY AND IMAGING STUDIES  Urinalysis showing pyuria (leukocyturia of >5 white blood cells suggests infection  The presence of numerous motile bacteria in freshly voided, uncentrifuged urine from symptomatic infants and children has a 94% correlation with a positive culture )

17. LABORATORY AND IMAGING STUDIES  VCUG is done after3weeks&is the best imaging study for determining the presence or absence of vesicoureteral reflux, which is ranked from grade I (ureter only) to grade V (complete gross dilation of the ureter and obliteration of caliceal and pelvic anatomy)

18. LABORATORY AND IMAGING STUDIES  Ultrasound which done in the acute illness provides limited information about renal scarring and is performed to exclude an anatomic abnormality

19. LABORATORY AND IMAGING STUDIES  renal nucleotide scans, and computed tomography (CT) or magnetic resonance imaging (MRI) can be used for anatomic and functional assessment of the urinary A technetium-99m DMSA scan can identify acute pyelonephritis and is most useful to define renal scarring as a late effect of UTI. tract

20. Grades of reflux

21.  Grade1 reflux into non dilated ureter  Grade2 reflux into upper collecting with out dilatation  Grade3 reflux into dilated ureter and or blunting collecting system  Grade4 reflux into grossly dilated ureter  Grade5 massive reflux with tortuosity and loss of impression

25. DIFFERENTIAL DIAGNOSIS  The manifestations of UTI overlap with signs of sepsis seen in young infants and with enteritis, appendicitis, mesenteric lymphadenitis, and pneumonia in older children. Dysuria may indicate pinworm infection, hypersensitivity to soaps or detergents, vaginitis, or sexual abuse and infection

26. DIFFERENTIAL DIAGNOSIS Localization of a UTI is important because upper UTI is associated more frequently with bacteremia and with anatomic abnormalities than is cystitis. The clinical manifestations of UTI do not reliably distinguish the site of infection in neonates, infants, and toddlers. Fever and abdominal pain may occur with either lower or upper UTI, although high fever, costovertebral tenderness, high erythrocyte sedimentation rate (ESR), leukocytosis, and bacteremia each suggest upper tract involvement. Indirect findings such as WBC casts, inability to concentrate urine maximally, presence of antibody-coated bacteria detected by immunofluorescence, are of limited value in localizing the site of the UTI to the upper tract. DMSA scan is sensitive for detecting acute pyelonephritis. The clinical manifestations of UTI do not reliably distinguish the site of infection in neonates, infants, and toddlers. Fever and abdominal pain may occur with either lower or upper UTI, although high fever, costovertebral tenderness, high erythrocyte sedimentation rate (ESR), leukocytosis, and bacteremia each suggest upper tract involvement. Indirect findings such as WBC casts, inability to concentrate urine maximally, presence of antibody-coated bacteria detected by immunofluorescence, are of limited value in localizing the site of the UTI to the upper tract. DMSA scan is sensitive for detecting acute pyelonephritis.

27. TREATMENT Neonates with UTI are treated for 14 days with parenteral antibiotics because of the higher rate of bacteremia. Older children with acute cystitis are treated for 7 to 14 days with an oral antibiotic Older children with acute cystitis are treated for 7 to 14 days with an oral antibiotic Increasing bacterial resistance has limited the usefulness of some antibiotics such as amoxicillin. Oral third-generation cephalosporins such as cefixime and cefpodoxime are effective Oral third-generation cephalosporins such as cefixime and cefpodoxime are effective

28. TREATMENT  Children with high fever or other manifestations of acute pyelonephritis often are hospitalized for initial treatment with parenteral antibiotics as cefotaxime and gentamicin or another aminoglycosid. Then after initial improvement therapy can be continued orally for a total of 14 days

29. TREATMENT  The degree of toxicity, dehydration, and ability to retain oral intake of fluids should be assessed carefully.  Restoring or maintaining adequate hydration, including correction of electrolyte abnormalities that are often associated with vomiting or poor oral intake, is important.

30. Infants and children who do not show the expected clinical response within 2 days of starting antimicrobial therapy should be re-evaluated, have another urine specimen obtained for culture, and undergo ultrasound

31. COMPLICATIONS AND PROGNOSIS Bacteremia occurs in 2% to 5% of episodes of pyelonephritis and is more likely in infants than in older children. Focal renal abscesses are an uncommon complication

32. COMPLICATIONS AND PROGNOSIS The relapse rate of UTI is approximately 25% to 40% Most relapses occur within 2 to 3 weeks of treatment. Follow-up urine cultures should be obtained 1 to 2 weeks after completing therapy to document sterility of the urine

33. COMPLICATIONS AND PROGNOSIS  Prophylactic antibiotics should be administered until the VCUG has been completed and the presence of reflux is known. TMP-SMZ (2 mg/kg TMP, 10 mg/kg SMZ) and nitrofurantoin (1 to 2 mg/kg) given once daily at bedtime are recommended as prophylactic agents, which, in contrast to amoxicillin and cephalosporins, are associated with low rates of developing antibiotic resistance.

34. COMPLICATIONS AND PROGNOSIS Clinical follow-up for at least 2 to 3 years is prudent, with repeat urine culture as indicated. Some experts recommend that follow-up urine cultures after recurrent cystitis or pyelonephritis are obtained monthly for 3 months, at 3-month intervals for 6 months, then yearly for 2 to 3 years. Some experts recommend that follow-up urine cultures after recurrent cystitis or pyelonephritis are obtained monthly for 3 months, at 3-month intervals for 6 months, then yearly for 2 to 3 years.

35.  Grade 1 to 3 reflux resolves at a rate of about 13% per year and is treated medically, Grade 4 to 5 reflux resolves at a rate of about 5% per year and its treated surgically. Bilateral reflux resolves more slowly than unilateral reflux

36. PREVENTION  Primary prevention is achieved by promoting good perineal hygiene and managing underlying risk factors for UTI, such as chronic constipation, encopresis, and daytime and nighttime urinary incontinence.

37. Secondary prevention of UTI with antibiotic prophylaxis given once daily is directed toward preventing recurrent infections, although the impact of secondary prophylaxis to prevent renal scarring is unknown

38. Prevention of urinary tract infections Instruction to mothers: Avoid constipation. If your child has any problems with WORMS let the doctor know. WIPING should be done in a front to back direction. It is better to take a shower rather than a bath. Always avoid irritating soaps and bubble baths. CLEANLINESS is very important to help prevent infection. EMPTYING THE BLADDER PROPERLY IS VERY IMPORTANT. Always encourage your child to DRINK as much as possible during the day, and to EMPTY THE BLADDER PROPERLY LAST THING AT NIGHT. CORRECT UNDERWEAR. Avoid tight underpants or pantyhose. They prevent air from circulating freely and encourage the warm, moist environment which favors infection. When taking antibiotics the full course must be taken at the time required. Any PROBLEMS such as burning when passing water, going to the toilet often, or blood in the water SHOULD BE REPORTED to the doctor.

39. When to Hospitalize Treatment of suspected pyelonephritis in an infant younger than 3 months of age or patients who have clinical urosepsis Patients who have clinical pyelonephritis whose symptoms worsen despite 24 hours of appropriate antibiotics Patients who have clinical pyelonephritis whose symptoms worsen despite 24 hours of appropriate antibiotics or those not significantly improved within 48 to 72 hours For initiation of parenteral therapy if home treatment compliance is in question For initiation of parenteral therapy if home treatment compliance is in question