pediatric urinary tract infection

1. Pediatric Urinary tract infection
Dr. Srinivasaraghavan. R
AP, Department of Pediatrics

2. Objectives
• Forms of UTI in children
• Diagnosis of UTI
• Treatment of UTI
• Complications
• Recurrent UTI- risk factors

3. Why know about pediatric UTI?
• One of the commonest infections in children
• Young infants- sepsis- mortality if not
recognized
• Renal scarring- hypertension and progressive
renal damage

4. Epidemiology
• 1% of all boys and 1-3% of all girls- UTI
• 1st yr- M:F- 2.8-5.4 : 1
• Beyond 1-2 yr- M:F -1 : 10

5. Forms
UTI
FORMS
CYSTITIS/
LOWER UTI
PYELONEPHRITIS/
UPPER UTI

6. Etiologic organisms
• Uropathogens- mostly bacteria from stools-
ascending infection from peri-urethral area or
via bacteremia
• Bacteria- E.coli (most common- 75-90%),
Klebsiella, Proteus, Pseudomonas aeruginosa,
Staphylococcus saprophyticus, GBS
• Candida
• Adenovirus- hemorrhagic cystitis

7. Symptoms
Upper UTI
• High grade fever,
toxic look
• Vomiting, nausea
• Abdominal pain-
flanks
• Diarrhea
Cystitis
• Dysuria
• Urgency
• Frequency
• Supra-pubic pain
• Hematuria
• Usually no fever

8. Simple vs complicated UTI
• Complicated
– Presence of fever >39 ⁰C
– systemic toxicity
– persistent vomiting
– dehydration
– renal angle tenderness
– raised creatinine
• Simple
– low grade fever
– Dysuria, frequency, and urgency
– absence of symptoms of complicated UTI

9. Symptoms contd..
• 0-2 months- sepsis- poor feeding, lethargy-
rarely cholestasis and failure to thrive
• 2months- 2 years- fever without focus
• Older children- may present as secondary
enuresis

10. Evaluation
• Fever? Other symptoms?
• Feeding well? Vomiting?
• Toxic? Dehydrated?
• Shock features? Sepsis?
• Spine examination and genitalia- Bladder-
bowel dysfunction

11. Phimosis

12. Phimosis

13. Diagnosis
• Counts- WBC counts high in upper UTI, serum creatinine
• Screening
– Urine microscopy- leukocytes
– Rapid dipstick tests- leukocyte esterase and nitrite
• Obtaining sample:
– Midstream clean catch- cleaning with soap and water
– Urine bag samples- not good
– Neonates and infants- suprapubic aspiration/ transurethral
bladder catheterization
• Plate within 1 hour- if delay anticipated- refrigerator at 4⁰C
for up to 12-24 hours

14. Diagnosis
• Urine culture- gold standard

15. Treatment
• < 3 months of age and those with complicated
UTI- hospitalized, parenteral antibiotics
• Ceftriaxone/ Cefotaxime/ Amikacin/ Gentamicin
• Others- oral therapy- Cefixime/ Cephalexin/
Amoxy-clav/ Ciprofloxacin
• Symptoms mild/ diagnosis doubtful- delayed until
the results of culture

16. Duration
• Infants and children with complicated UTI- 10-
14 days
• Uncomplicated UTI- 7-10 days
• Adolescents with cystitis- 3 days
• Supportive measures- hydration

17. Culture proven UTI- Follow up
Investigation < 1 yr 1- 5 yr > 5 yr
USG + + +
DMSA + +
Only if
USG
abnormalMCU +
Only if any
of the above
is abnormal

18. DMSA
• Right lower pole and
left kidney scarring +
• Normal study

19. Recuurent UTI- risk factors
• Bowel and bladder dysfunction
• Structural abnormalities of the urinary tract-
VUR, PUV, duplex ureter
• Constipation
• Catheterization
• Worm infestation
• Alteration of peri-urethral flora by antibiotic
therapy

20. Prevention
• Adequate fluid intake
• Frequent voiding
• Constipation- avoided
• Circumcision- high grade reflux in children

21. VUR
• 40-50% infants and 30-50% children with UTI
• Primary vs secondary
• Secondary VUR- bladder outflow obstruction,
as with posterior urethral valves, neurogenic
bladder or a functional voiding disorder

22. VUR Grades
• Classification- based on MCU appearance-
grade I to V- I to III- Low grade, IV and V- high
grade
• Bilateral grade IV and grade V- risk factor for
pyelonephritis and scarring

23. MCU

24. Treatment
• Prevention of recurrent UTI- Antibiotic
prophylaxis till 5 years of age
• Low grade VUR- subsides spontaneously
• High grades- need surgical repair

25. Take home messages
• Causes of UTI in children
• Upper UTI vs Lower UTI
• Diagnosis
• Treatment guidelines