Types ,presentation ,microorganisms ,diagnosis ,differential diagnosis ,investigations , traetment ,prevension ,prognosis of reflux

1. Prof . Dr. Saad S Al Ani
Senior Pediatric
Consultant
Head of Pediatric
Department
Khorfakkan Hospital
Sharjah ,UAE
saadsalani@aol.com
Childhood Urinary Tract Infection

2. Introduction
Normally the urinary tract and
urine are sterile
9/3/2015
Childhood UTI Prof.Dr. Saad S Al Ani
Khorfakkan Hospital
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3. Introduction (cont.)
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Childhood UTI Prof.Dr. Saad S Al Ani
Khorfakkan Hospital
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Childhood urinary tract infection
are fairly common and are generally
caused by bacteria

4. Introduction(cont.)
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Childhood UTI Prof.Dr. Saad S Al Ani
Khorfakkan Hospital
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Recurrent UTIs in children may
be indicative of malformation or
malfunction of the urinary tract.

5. Urinary Tract Infection (UTI)
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Childhood UTI Prof.Dr. Saad S Al Ani
Khorfakkan Hospital
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UTI
Cystitis
Renal
Abscess
Pyelone
phritis

6. Urinary Tract Infection (UTI) (cont.)
Escherichia coli (E. coli) (Ascending
from the bowel flora) is the causative
agent in 90% of first urinary tract
infection and in 75% of recurrent
infection
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Childhood UTI Prof.Dr. Saad S Al Ani
Khorfakkan Hospital
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7. Urinary Tract Infection (UTI) (cont.)
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Childhood UTI Prof.Dr. Saad S Al Ani
Khorfakkan Hospital
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Over 90% of nephrogenic E. coli
posses P fimbriae that binds to
uroepithelial cells and P blood
group antigen

8. Urinary Tract Infection (UTI) (cont.)
People with high-level expression of P1
blood group antigen are predisposed to:
•Pyelonephritis
•Bacteremia
•Recurrent UTIs
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Childhood UTI Prof.Dr. Saad S Al Ani
Khorfakkan Hospital
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9. Urinary Tract Infection (UTI) (cont.)
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Childhood UTI Prof.Dr. Saad S Al Ani
Khorfakkan Hospital
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Other bacteria commonly causing
UTI include:
• Klebsiella
• Proteus
• Enterococcus
• Pseudomonas
klebsiella-pneumoniae.org
web.uconn.edu
www.buddycom.com
taphonomy.wikispaces.com
taphonomy.wikispaces.com

10. Urinary Tract Infection (UTI) (cont.)
Staphylococcus saprophyticum
associated with UTI in some children
and in sexually active adolescent girls
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Childhood UTI Prof.Dr. Saad S Al Ani
Khorfakkan Hospital
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www.corbisimages.com

11. Epidemiology
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Childhood UTI Prof.Dr. Saad S Al Ani
Khorfakkan Hospital
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• By the 11 years of age ,8% of girls
and 2% have UTI
• Approximately 75% of infants younger
than 3 months of age with bacteruria are
males compared to only 10% between
3 -8 months of age
• After 12 months of age UTI is more in
girls

12. Predisposing anatomic factors
• Short urethra predisposes girls to UTI
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Childhood UTI Prof.Dr. Saad S Al Ani
Khorfakkan Hospital
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• Uncircumcised male infant are 5 -12
folds increase risk of UTI compared
to circumcised

13. Predisposing anatomic factors(cont.)
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Childhood UTI Prof.Dr. Saad S Al Ani
Khorfakkan Hospital
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Obstruction to urine flow and urinary
stasis is the major risk factor that may
result from:
• Anatomic abnormalities
• Nephrolithiasis
• Renal tumor
• Indwelling urinary catheter
• Ureteropelvic junction obstruction
• Mega ureter
• Extrinsic compression

14. Clinical manifestations
The symptoms and signs of UTI
vary markedly with age
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Childhood UTI Prof.Dr. Saad S Al Ani
Khorfakkan Hospital
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15. Clinical manifestations (cont.)
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Childhood UTI Prof.Dr. Saad S Al Ani
Khorfakkan Hospital
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In neonates
the most constant symptoms are:
• Failure to thrive
• Feeding problems
• Fever
Direct hyperbilirubinemia may be the
presentation

16. Clinical manifestations (cont.)
Infant 1 mo. -3 years old:
• Feeding problems
• Failure to thrive
• Diarrhea and vomiting
• Unexplained fever
Gastrointestinal symptoms as colic
irritability and screaming
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Childhood UTI Prof.Dr. Saad S Al Ani
Khorfakkan Hospital
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17. Clinical manifestations (cont.)
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Childhood UTI Prof.Dr. Saad S Al Ani
Khorfakkan Hospital
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At 2 years of age:
Classical signs of UTI:
• Urgency
• Dysuria
• Frequency
And abdominal or back pain

18. Clinical manifestations (cont.)
• UTI should be suspected in all infants
and young children with unexplained
fever
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Childhood UTI Prof.Dr. Saad S Al Ani
Khorfakkan Hospital
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• In all ages :
fever and congenital anomalies of
urinary tract

19. Urinary Tract Infection (UTI) :
Diagnosis
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Childhood UTI Prof.Dr. Saad S Al Ani
Khorfakkan Hospital
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The diagnosis of UTI requires culture
of the urine

20. Urinary Tract Infection (UTI) :
Diagnosis (cont.)
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Childhood UTI Prof.Dr. Saad S Al Ani
Khorfakkan Hospital
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No. of Colony-forming unitMethod of obtaining urine
> 100,000 CFU/ mlMidstream clear-catch (older
children & adolescence)
> 10,000 CFU/ mlCatheterization
>1000 CFU /mlSuprapubic aspiration
Of single organism

21. Urinary Tract Infection (UTI)
Diagnosis (cont.)
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Childhood UTI Prof.Dr. Saad S Al Ani
Khorfakkan Hospital
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• Urinalysis:
Pyuria =Leucocytes > 10 WBCs/ mm3
signify urinary tract infection
• Other causes of pyuria include:
 Urethritis
 Vaginitis
 Nephrolithiasis
 Glomerulonephritis
 Interstitial nephritis

22. Urinary Tract Infection (UTI)
Diagnosis (cont.)
Other investigations include:
- Ultrasonography
-Voiding cystourethrography (VCUG)
-Radionuclide cystography
-Renal nucleotide scans
-Computed tomography
-Magnatic resonance imaging (MRI)
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Childhood UTI Prof.Dr. Saad S Al Ani
Khorfakkan Hospital
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23. Urinary Tract Infection (UTI)
Diagnosis (cont.)
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Childhood UTI Prof.Dr. Saad S Al Ani
Khorfakkan Hospital
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VCUG is the best imaging study for
determining the presence or absence of
vesicouretral reflux

24. Urinary Tract Infection (UTI)
Diagnosis (cont.)
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Childhood UTI Prof.Dr. Saad S Al Ani
Khorfakkan Hospital
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adiopaedia.org

25. Urinary Tract Infection (UTI)
Diagnosis (cont.)
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Childhood UTI Prof.Dr. Saad S Al Ani
Khorfakkan Hospital
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Technetium 99 m DMSA scan is :
• useful to identify acute pyelonephritis
• Most useful to define renal scaring

26. Urinary Tract Infection (UTI)
Diagnosis (cont.)
• Diagnosis of UTI does not distinguish
between upper & lower urinary tract
infection
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Childhood UTI Prof.Dr. Saad S Al Ani
Khorfakkan Hospital
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• Each of the following suggest upper UTI:
 High fever
 Costo-vertebral tenderness
 High ESR
 Leukocytosis
 Bacteremia

27. Urinary Tract Infection (UTI) (cont.)
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Childhood UTI Prof.Dr. Saad S Al Ani
Khorfakkan Hospital
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Differential diagnosis:
• Sepsis
• Enteritis
• Appendicitis
• Mesenteric lymphadenitis
• Lower lobe pneumonia

28. Urinary Tract Infection (UTI) :
Treatment
• Neonates with UTI are treated for 10-14
days with parenteral antibiotics
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Childhood UTI Prof.Dr. Saad S Al Ani
Khorfakkan Hospital
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• Older children with cystitis are treated
for 7 -14 days with oral antibiotics

29. Urinary Tract Infection (UTI)
Treatment(cont.)
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Childhood UTI Prof.Dr. Saad S Al Ani
Khorfakkan Hospital
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• Trimethoprim –sulfamethoxazole
(TMP-SMZ) is used frequently
• Alternative oral third –generation
cephalosporin as cefixime
,cefprodoxime

30. Urinary Tract Infection (UTI)
Treatment (cont.)
• Hospitalized children with high fever
and other manifestations of acute
pyelonephritis need parenteral
antibiotics as iv cefotaxime +
gentamycin or other aminoglycosides
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Childhood UTI Prof.Dr. Saad S Al Ani
Khorfakkan Hospital
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31. Urinary Tract Infection (UTI)
Treatment (cont.)
• Bacteremia occurs in 2% -5% of
episodes of pyelonephritis
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Childhood UTI Prof.Dr. Saad S Al Ani
Khorfakkan Hospital
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• Focal renal abscess are rare
• Relapse of UTI occurs in 25% -40%
most relapse occurs within 2-3 weeks
of treatment

32. Urinary Tract Infection (UTI) :
Prophylaxis
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Childhood UTI Prof.Dr. Saad S Al Ani
Khorfakkan Hospital
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Prophylactic antibiotics should be
administered until:
1.The VCUG has been completed
2. The presence of reflex is known

33. Urinary Tract Infection (UTI)
Prophylaxis (cont.)
• (TMP-SMZ)
(2mg/kg TMP,10mg/kg SMZ)
Or
• Nitrofurantoin (1-2 mg/kg)
Given once daily at bedtime as
prophylaxis
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Childhood UTI Prof.Dr. Saad S Al Ani
Khorfakkan Hospital
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34. Urinary Tract Infection (UTI)
Follow up
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Childhood UTI Prof.Dr. Saad S Al Ani
Khorfakkan Hospital
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Clinical follow up for at least 2-3
years is recommended with repeated
urine culture

35. Urinary Tract Infection (UTI)
Follow up (cont.)
The period of follow up urine culture after
recurrent cystitis or pyelonephritis as
follow:
• Monthly → 3 months
• At 3 month interval→ 6 months
• Yearly → 2 -3 years
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Childhood UTI Prof.Dr. Saad S Al Ani
Khorfakkan Hospital
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36. Urinary Tract Infection (UTI) :
Reflux prognosis
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Childhood UTI Prof.Dr. Saad S Al Ani
Khorfakkan Hospital
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• Grade 1 -3 reflux resolve at a
rate of 13% per year of the first
5 years then 3.5% per year
• Grade 4 -5 reflux resolve at rate
of 5% per year

37. Urinary Tract Infection (UTI) (cont.)
Primary prevention:
• Good perianal hygiene
• Managing underline risk factors:
 Chronic constipation
 Encopresis
 Daytime and nighttime urinary
incontinence
Secondary prevention :
• Usage of antibiotics
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Childhood UTI Prof.Dr. Saad S Al Ani
Khorfakkan Hospital
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38. Summary
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Childhood UTI Prof.Dr. Saad S Al Ani
Khorfakkan Hospital
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medacad.wikispaces.com

39. References
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Childhood UTI Prof.Dr. Saad S Al Ani
Khorfakkan Hospital
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1. http://www.medicinenet.com/urinary_tract_infections_in_children/article.htm
2. http://emedicine.medscape.com/article/969643-overview
3. https://www.nice.org.uk/guidance/cg54/chapter/1-Guidance
4. http://www.aafp.org/afp/2011/0215/p409.html
5. http://www.msdmanuals.com/professional/pediatrics/miscellaneous-infections-in-
infants-and-children/urinary-tract-infection-in-children-uti
6. https://www.nice.org.uk/guidance/cg54/resources/guidance-urinary-tract-infection-
in-children-pdf
7. http://www.cps.ca/documents/position/urinary-tract-infections-in-children
8. medacad.wikispaces.com
9. newscenter.lbl.gov

40. Thank you
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Childhood UTI Prof.Dr. Saad S Al Ani
Khorfakkan Hospital
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