1. Urinary Tract Infection In Children Dr. Alia Al-Ibrahim Consultant Pediatric Nephrology Clinical Assistant Professor

2. Contents: 1- Definition of UTI 2- Etiology & pathogenesis 3- Predisposing Factors 4- Clinical presentations 5-Investigations 6- Management 7- Complications 8- Special problems in UTI

3. Definition: Presence of bacteria in urine along with symptoms of infection. Incidence: 5% in Girls 1-2% in Boys During the 1 st yr of life more common in boys, after age of one more in girls Etiology: Most common infecting pathogen : Escherichia Coli 80% of UTI. Other pathogens: - Staphylococcus & Streptococcus Species - Enterobacteria ( Klebsiella, Proteus, pseudomonas) - Occasionally Candida albicans UTI in Children

4. Route of infection: Neonate: Hematogenous Later : Ascension of bacteria into the Urinary tract. Development of UTI depend on: 1- Virulence of the invading bacteria. 2- Susceptibility of the host. Predisposing factors: 1- Conditions lead to urinary stasis : renal calculi, Obstructive Uropathy, VUR, & Voiding disorder. 2- Immune deficiency 3- Broad- spectrum antibiotics ( amoxicillin, cephalexin). 4- constipation 5- uncircumcised male

5. Clinical Presentation: 1- Upper UTI (Pyelonephritis). 2- Lower UTI ( Cystitis). The history & clinical coarse varies with the patient’s age & specific diagnosis.

6. 0-2months: sepsis 2mon-2yrs: unexplained fever irritability, poor oral intake, abdominal pain, vomiting, loose bowel movement. voiding symptoms of cystitis crying on urination smelly urine no fever or mild  2yrs : Pyelonephritis( fever, irritability, poor appetite, abdominal flank pain back pain, voiding symptoms, tenderness in costovertebral angle or flank. cystitis : voiding symptoms ( urgency, frequency, hesitancy, dysuria, urinary incontinence) mild or no fever, Suprapubic or abdominal pain

7. >Pyuria, proteinuria & Hematuria may occur with or without UTI. >Nitrite concentrations & leukocyte estrase POSITIVE URINE CULTURE IS ESSENTIAL FOR DIAGNOSIS OF UTI. Urine culture: -Suprapubic : any number of colonies. - IN-and- out catheterization: > 10³. E.COLI - Midstream clean-catch urine collection > 10,000 -Single organism - 2 or more contamination. E.COLI -Blood culture :neonate & infant -Pyelonephritis: CBC: neutrophlic leukocytosis high ESR C-reactive protein. Proteus Pseudomonas Distinction between upper & lower difficult in children -Urine analysis & dipstick:High index of suspicion for UTI in febrile children particularly those with unexplained fever. Lasts for 2-3days; -> 5 WBC/ hpf in centrifuged fresh urine positive screening test. - >Bacteria in cent. & non cent. Or phase contrast suggestible of UTI.

8. Management: < 5 yrs: With systemic signs: 1- Iv antibiotics shift to oral after improvement, duration 10 -14 days. 2- US, renal cortical scintigraphy ( DMSA), MCUG. No systemic signs: 1- oral antibiotics for 7-10 days US, MCUG( if indicated)  5 yrs  Female: Female & Male with signs 1- no signs : oral antibiotics Like < 5 yrs Male: 1- No signs: oral antibiotics 2- US, MCUG

9. COMPLICATIONS: 1- VUR 2- Scarring 3- HTN 4- Renal insufficiency. Normal DMSA Acute PyelonephritisScarring VUR

10. Special problems 1-Reurrent UTI: Two or more UTIs over a six –months period. Causes: Inadequate treatment. unrecognized site of bacterial persistence such as small infected calculus or un recognized anatomic abnormality. 2-VUR: Abnormal backwash of urine into ureter or kidney Radiological evaluation VCUG, Isotope cystogrm

11. 3-Breakthrough UTI: Caused by: 1- change in the resistance pattern of organisms colonizing the urethra. 2- noncompliance. 3- VUR 4- Voiding dysfunction. 4-Voiding dysfunction: Detrusor instability & incomplete bladder emptying -Associated with daytime enuresis & constipation. - Increase risk of UTI & VUR. -RX: 1- Timed voiding 2- Treatment of constipation. 3- Prophylactic antibiotics. 4- Anticholinergic medications. 5-Asymptomatic bacteruria: No need for antibiotics, low risk of scarring.