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Introduction

The incidence of UTI in infants 0.1- 1.0 % ,

10 % in low-birth-weight

In the school-age group, the incidence of

bacteriuria among girls is 30 times as much
as boys

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UTI, is defined as:
- the presence of bacteria in urine
- with symptoms of infection

(Syed M.A,1998,Zorc et al.,2005).

 can become serious if undetected

 lead to permanent kidney damage.

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 Definition
• Lodgment and multiplication of bacteria in
the urinary tract from pelvis to bladder

• Renal and urethral infections excluded

• Asymptomatic bacteriuria : significant of

bacteriuria without symptom and sign.
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Recurrent UTI is defined as
-Two or more UTI over a six-month period
(Ditchfield, 1994, Shaw et al.,1998)

 caused by inadequate treatment ?

 Recurrent UTI increases the risk of

subsequent renal scarring.

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Urinary Tract
Only lower part of urethra has a
resident bacterial flora

Rest of the urinary tract is normally

sterile

Flushing effect of urine flow

Local phagocytic activity

Mucosal IgA and secretions from

prostatic and urethral glands

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Definitions
Bacteriuria Presence of bacteria in the urine

Pyuria Presence of WBCs in the urine

Cystitis UTI associated with superficial mucosa o f

bladder

Pyelonephritis UTI of renal parenchyma

Uncomplicated UTI Infection involving structurally and functionally

normal urinary tract (simple UTI)

Complicated UTI Infection involving structurally and functionally

abnormal urinary tract

Urethritis Infection of the urethra

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 Concept of Significant
Bacteriuria
• Up to 104/ml considered normal i.e.
Insignificant

• 105/ml and above considered to be

Significant

• Concept valid only for voided

specimen of urine

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Predisposing factors for UTI
Shortness of female urethra

Sexual intercourse (honeymoon cystitis)

Pregnancy & Contraceptive devices

Prostatic hypertrophy

Neurogenic bladder

Abnormal kidney &

bladder or stones

Catheterization or surgical
instrumentation
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 Other Risk Factors of UTI
• Urinary Tract abnormality
• Sepsis
• Immune deficiency
• Catheterization
• Bed rest

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 Immunity

Ascending (90%)
Hematogenous (3%) UTI
Limphogenous (6%)

Predisposition:

(1). Obstructive: a. Congenital

b. Acquired
(2). Renal calculi
(3). VU reflux
(4). Voiding disorders
(5). Congenital Anomaly of urinary track (biureter, bippelvis
renalis
(6). Metabolic diseases (diabetes mellitus)
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 Etiology

Escherichia coli is the most common infectious

pathogen in children, >80 % of UTI.

Other : Staphylococcus, Streptococcus species,

enterobacteria (e.g., Klebsiella, Proteus), Candida
albicans. adenovirus

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 Congenital Abnormalities

I. Non Obstructive

1. Polycystic
2. Hypoplastic
3. Ectopic vesical urinary
4. Persistent Urachus

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II. Obstructive

1. Lower VU
 Phimosis
 Urethral Posterior Valve
 Vesicourethral obstruction

2. Upper VU
 Stricture Ureter
 Vesical Ureter
/ Pelvic-Ureter stenosis

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 Classification of vesical reflux

I. Reflux to 1/3 of lower ureter.

II. Reflux to the pelvic without damage of calix.
III. Reflux to the pelvic with damage of calix.
IV. Reflux accompanied by hydroureter and
hydronephrosis.

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 Clinical Classification
1. Simple / uncomplicated urinary track infection
2. Complicated urinary infection :
• Obstruction (calculi, renal abces, renal cyst,
neoplasm)
• Vesico urethral refluks
• Renal diseases (renal failure, GNA, pyelonefritis)
• Residual urine (Neurogenic bladder, stricture
urethra, prostate hypertrophy)
• Instruments (catheterization, urethral stent,
cystoscopy, nephrostomi, pyelografi retrograd)
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Clinical manifestations

Urgency

Frequency

Dysuria

Pain & tenderness - above the

symphysis pubis (lower), loin (upper)

Fever
Bed wettings in children
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Signs and Symptoms of Urinary Tract Infection in
Children
Urinary tract signs and symptoms
Dysuria
Frequency
Dripping / hesitancy
Enuresis after successful toilet training
Hematuria
Squatting
Abdominal/suprapubic pain

• Systemic signs and symptoms

Fever
Vomiting/diarrhea
Flank/back pain 18
 Collection of Specimens
• Clean catch mid-stream specimen of urine
• Early morning sample preferred
• Catheter specimen
• Suprapubic aspiration
• Differential specimen from two ureters
• Instructions to the patients
• Early transport to the lab essential
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 Instruction for collection of mid stream urine
Sterile specimen container

Female patients Male patients

Begin passing urine
Spread Stop flow in midstream Retract
labia, prepuce,
Pass several ml into pen container
without touching rim using plain
using plain soap or
soap or Stop flow before it ends
antiseptic
antiseptic Recap container clean glans.
wipe front Pass remaining urine into lavatory Dry with
to back, tissues.
Send specimen to laboratory
dry with immediately
tissues (refrigerate if prolonged transport 20
time)
Lab Diagnosis of UTI
Specimens Urine Mid stream urine (MSU)
Catheter specimen urine (CSU)
Supra pubic aspiration (SPA)

Urine transport device (boric acid or refrigerate)

Microscopy Pus cells / hpf

wet mount Bacteria / crystals/ casts

Gram stain GNB/GPC (1 bacterium / field is significant)

Urine
Culture To know significant bacteriruria
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Suprapubic Aspiration

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 Treatment

Although conventional therapy lasts

seven to 10 days, a three- to seven-day
trial of oral antibiotics has been
suggested for uncomplicated infection of
the lower urinary tract

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 Follow-up and Chemoprophylaxis

A urine culture should be obtained

three to seven days after the
completion of treatment to exclude
relapse.

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 Table Parenteral Antibiotics for treatment of UTI
Drug Dose(mg/kg/day) frequency Comments
Cefotaxime 150(mg/kg/day) Divided every 8 hours Monotherapy for infants > 2
(Claforance) months of age. If > 2 weeks
but <2 months often combined
with Ampicillin

Ampicillin 100 (mg/kg/day) Divided every 6 hours Ussuly in combination with

Gentamicin for < 2 weeks of
age or Cefotaxime for infants 2
months of age because higher
incidence of enteroccocus

Gentamicin o 1 month old or less: 3
mg/kg/dose every hours
o Between 1 to3 months 2.5
mg/kg/dose every 12 hours
Veriees by age Ussually use with Ampicillin for
all infants 2 weeks of age or
selectivly for those between 2-
4 weeks of age

Ceftriaxon 50-100 (mg/kg/day) IV or IM QD IM use ussually considered

(Rocephin) only if >2-3 mo of age
(Consesus of focal experts).
Use with caution in jaundiced
infant) (Baskin, O’Rourke, &
Fleisher, 1992). 27
 Table Antibiotics for outpatient treatment of UTI
Drug Dose (mg/kg/day) frequency Comments
Sulfamethoxazole/Trimet Trimetthonprim Oral Divided BID For use in children >6 weeks of age,
hoprim (200mg/40mg 8-10 (mg/kg/day) not recommended for pateints with
per 5ml) (Bactrim, renal inssuficiency
Septra, Generic)
Cefixime 100 mg/5 ml 8 (mg/kg/day) Oral once daily Recommended if patients >1 month
(Suprax) of age with high likelihood of
resistant organisms or pyelonephritis
and unknown sensitivities

Cephalexin 25-50 (mg/kg/day Oral Divided Often used as an alternative choice

TID-QID pending return of cultures

Nitrofurantoin 5-7-100 (mg/kg/day) Oral Divided QID Not considered adequat for treatment
for pyelonephritis because of poor
tissue penetration. May be useful in
older children with cytitis.
Ceftriaxone (Rocephin) 50-100 (mg/kg/day) IV or IM daily Ussually recommended only if
prefered oral drugs are not tolerated.
IM use ussualy considered if > 2-3
mo of age (Consensus of local
experts). Use with caution in
jaundiced infant (Baskin, O’Rourke,
28 &
Fleisher, 1992)
 Table Prophylactic antibiotics recommended while futher evaluastion result are
pending and to limit of UTI

Drug Dose (mg/kg/day) Frequency Comments

Sulfamethoxazole 2 (mg/kg/day TMP) Daily at bedtime (HS)
(SMX)/Tremethoprim
(TMP)
(200mg/40mg per
5ml) (Bactrim,
Septra, Generic)
Nitrofuratoin or 1-2 (mg/kg/day) Daily at bedtime (HS)
Macrodantin

Cephalexin 10 (mg/kg/day) Daily at bedtime (HS) These wo choices are not

preferred but use occasionally for
selected patients.

Cefixime 4 (mg/kg/day) Daily at bedtime (HS) These wo choices are not

preferred but use occasionally for
selected patients.
Amoxicillin 10 (mg/kg/day) Daily at bedtime (HS) For young infants

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