URINARY TRACT INFECTION

DEFINITION: TISSUE RESPONSE TO THE PRESENCE OF SIGNIFICANT AMOUNT OF BACTERIA IN THE URINE

Age-Related Changes in the Urinary System

Structure
Glomeruli

Change
number surface area thickened membrane fatty degeneration shortening stiffening narrowing expandability & compressibility of bladder

Impact
 

filtration of blood glomerular filtration rate by 30-40% 30tubule transport urineurine-concentrating capacity Na conservation renal acidification

Tubules

   

Renal vasculature

blood flow  efficiency in removal of waste product

  

Connective tissue

bladder capacity residual urine volume after voiding

URINARY TRACT INFECTION

Prevalence:
In young children with fever Approximately 1-16% in febrile infants and young children but varies by age, race/ethnicity, sex, and circumcision status. White children have a two- to four-fold higher prevalence of UTI than do black children. Girls have a two- to four-fold higher prevalence of UTI than do circumcised boys. In older children : 8-50% depending on the presence of symptoms

URINARY TRACT INFECTION

MICROBIOLOGY Escherichia coli is the most common bacterial cause of UTI 80 % of UTI in children. Other gram-negative bacteria include Klebsiella, Proteus, Enterobacter, and Citrobacter. Gram-positive bacteria include Staphylococcus saprophyticus, Enterococcus, and, rarely, Staphylococcus aureus.

URINARY TRACT INFECTION

MICROBIOLOGY
less common causes of UTI in children Viruses (eg, adenovirus, enteroviruses, Coxsackieviruses, echoviruses) fungi (eg, Candida spp, Aspergillus spp, Cryptococcus neoformans, endemic mycoses) less common causes of UTI in children

PATHOGENESIS
Upper urinary tract infection: Pyelonephritis

Lower urinary tract infection: Cystitis

PATHOGENESIS
Ascending infection most UTI beyond the newborn period are the result of ascending infection Descending infection 4 - 9 percent of children with UTI are bacteremic

Pathogenesis of UTI
Host defences:
Urinary bladder is usually resistant to bacterial colonisation. Bacteria accessing the bladder are eliminated by: - flushing mechanism - urine inhibitors (PH, osmolality, urea) - uroepithelial defences (cytokines,PMNs) - Tamm- Horsfall protien

Pathogenesis of UTI
Organism features:
Most E.coli causing UTI belong to O,K and H serotypes. Uropathogenic E.coli virulence factors: - Have fimbria (for adherence). - Secrete hemolysin & aerobactin. - Resist serum bacterical action. - Have higher K capsular antigen. Adherence is important in other bacteria.

Pathogenesis of UTI
Periutheral area & urethra are colonised by bacteria. Bacteria enter bladder in susceptable host. Adherence properties enable pathogens to colonise bladder. Pathogens attach to uroepithelial mucosa secretion of cytokines recruitment of PMNs inflammation. Pathogens may ascend through ureter to kidney pyelonephritis.

Clinical presentation of UTI

Asymptomatic bacteriuria:
Common in females & elderly. 25% develop symptomatic UTI . 25% clear spontaneously. Spontaneous cure & reinfection are common.

Cystitis:
Frequency, dysurea , urgency. Suprapubic discomfort +/- tenderness. Fever is often absent.

Clinical presentation of UTI

Acute pyelonephritis:
Fever, abdominal pain, vomiting. Dysuria ,frequency, flank or loin pain. Flank or loin tenderness. In elderly: symptoms are often atypical. Bacteremia is common.

Special situations
UTI in pregnancy:
Asymptomatic bacteriuria occurs in 4-8%. Of these: 25% develop acute pyelonephritis. Pyelonephritis in pregnancy predisposes to:
- premature delivery. - low birth weight infant. - increased newborn mortality.

Special situations
Catheter associated UTI :
Bacteriuria occurs in 10-15% of cathed pts. All chronicly cathed pts. develop bacteriuria. Organisms: E.coli, Proteus, Klebsiella, Serratia
Pseudomonas, Enterococci, Candida.

Antibiotic resistance is common. Symptoms are often absent or minimal. Intermittent cathing reduces infections.

Host factors:

PATHOGENESIS

Age Uncircumcised boys Female infants Race/ethnicity Urinary obstruction Neurogenic Bladder, Dysfunctional elimination Vesicoureteral reflux Sexual activity Bladder catheterization Bacterial factors: A variety of virulence factors enable bacteria to ascend into the bladder and kidney

CLINICAL PRESENTATION
Older children:
Fever Urinary symptoms Abdominal pain Back pain New onset urinary incontinence fever, chills, vomitting and flank pain are suggestive of pyelonephritis in older children short stature, poor weight gain, or hypertension secondary to renal scarring Suprapubic and costovertebral angle tenderness

Clinical evaluation
HISTORY history of the acute illness: documentation of the height and duration of fever urinary symptoms (dysuria, frequency, urgency, incontinence), abdominal pain, suprapubic discomfort back pain vomiting recent illnesses antibiotics administered and sexual activity (if applicable).

Clinical evaluation

Clinical evaluation
HISTORY past medical history : Chronic urinary symptoms Incontinence, lack of proper stream, frequency, urgency, withholding maneuvers Chronic constipation Previous UTI Vesicoureteral reflux (VUR) Antenatally diagnosed renal abnormality Elevated blood pressure Poor growth In sexually active girls, whether barrier contraception with spermicidal agents is used Previous undiagnosed febrile illnesses family history : of frequent UTI, VUR, other genitourinary abnormalities and renal failure.

Clinical evaluation
PHYSICAL EXAMINATION Documentation of blood pressure and temperature. Growth parameters. Abdominal examination for tenderness or masses Assessment of suprapubic and costovertebral tenderness. Examination of the external genitalia. Evaluation of the lower back for signs of spina bifida occulta. Evaluation for other sources of fever.

LABORATORY EVALUATION
Urine:
Dipstick microscopy Culture & sensitivity

LABORATORY EVALUATION
Urine dipstick
88 % sensitive Leukocytes Protein Red blood cells Leukocyte esterase Nitrite

LABORATORY EVALUATION
Microscopic exam
White Blood Cells: in a centrifuged sample of unstained urine pyuria is defined as 5 WBC/high power field , or 10 WBC/mm3 in an uncentrifuged sample Bacteria: bacteriuria is the presence of any bacteria per hpf. Gram stain

LABORATORY EVALUATION
Urine culture & sensitivity
Urine culture is the gold standard for the diagnosis of UTI Urine obtained for culture should be processed as soon as possible after collection

LABORATORY EVALUATION
Urine culture
Midstream clean catch 10 colony forming units Bag 85% false ve Cathterization 10 CFU Suprapubic aspiration any growth

LABORATORY EVALUATION
Other laboratory tests Investigate the fever. Markers of inflammation (WBC, ESR, CRP) Serum creatinine Blood culture Bacteremia occurs in 4-9 % of infants
with UTI Infants <1 month of age with fever and a positive urinalysis; approximately 1 % of infants with UTI also have meningitis

Lumbar puncture

DIFFERENTIAL DIAGNOSIS
Occult bacteremia Urinary symptoms & bacteriuria can be associated with vulvovaginitis, vaginal foreign body and urinary calculi Fever, abd pain & pyuria can be the presenting symptoms of kawasaki, group A Strep. Infections. Dysfunctional voiding

MANAGEMENT

MANAGEMENT
GOALS: Elimination of infection and prevention of urosepsis Relief of acute symptoms Prevention of recurrence and long-term complications

MANAGEMENT
Decision to hospitalize: Age <2 months Clinical urosepsis or potential bacteremia Immunocompromised patient Vomiting or inability to tolerate oral medication Lack of adequate outpatient follow-up Failure to respond to outpatient therapy

MANAGEMENT
ANTIBIOTIC THERAPY: Choice of agent: provide adequate coverage for E. coli. Oral therapy: Cefixime, amoxicillin-clavulanate. Parenteral therapy: Third- or fourth-generation cephalosporins and aminoglycosides are appropriate first-line agents for empiric treatment of UTI in children. In children receiving antibiotic prophylaxis.

MANAGEMENT
ANTIBIOTIC THERAPY Duration of therapy: 5-14 days Response to therapy: Clinical response Repeat urine culture

MANAGEMENT
FURTHER INVESTIGATIONS Indications:
1. 2. 3. 4. 5. Girls younger than 3 years of age with a first UTI Boys of any age with a first UTI Children of any age with a febrile UTI Children with recurrent UTI First UTI in a child of any age with a family history of renal disease, abnormal voiding pattern, poor growth, hypertension

MANAGEMENT

Ultrasonograpy

MANAGEMENT
Voiding cystourethrogram
(VCUG)

MANAGEMENT
Nuclear imaging: DMSA scan

PROGNOSIS
Recurrent UTI 14 percent of children younger than 6 years with UTI have a subsequent UTI associated with a higher risk of UTI recurrence -white race -age 3 to 5 years -VUR of grade IV to V

PROGNOSIS
Long-term sequelae
Approximately 40 percent had VUR Renal scars developed in approximately 8 % of patients, 15 % of those had abnormal DMSA scan at the time of diagnosis.

RENAL SCARRING
The loss of renal parenchyma between the calyces and the renal capsule, a potential complication of UTI. Long-term consequences include hypertension, decreased renal function, proteinuria, and end-stage renal disease The development of renal scarring has been associated with: -Recurrent febrile UTI -Delay in treatment of acute infection -Dysfunctional elimination -Obstructive malformations -VUR

PREVENTION OF RECURRENT UTI

Medical management
1. Prophylactic Antibiotics: TMP-SMX or nitrofurantoin (1/4-1/2 therapeutic dose QD) 2. Urine analysis, culture or both should be done in any subsequent episode of fever. 3. Treatment of voiding dysfunction. 4. Cranberry juice.

Surgical Management

URINARY TRACT INFECTION

WHY IMPORTANT???? May lead to renal scarring

PATHOGENESIS

Host factors:

Age highest in boys younger than 1 year and girls younger than 4 years Uncircumcised boys four- to eight-fold higher prevalence of UTI than circumcised male infants Female infants two- to four-fold higher prevalence of UTI than male infants . Race/ethnicity white children have a two- to four-fold higher prevalence of UTI than do black children Genetic factors First-degree relatives of children with UTI are more likely to have UTI than individuals without such a history Urinary obstruction Predisposing obstructive abnormalities may be anatomic ,neurologic , or functional. Dysfunctional elimination Up to 40 percent of toilet-trained children with their first UTI and 80 percent of children with recurrent (three or more) UTI report symptoms of dysfunctional elimination. Dysfunctional elimination is also a risk factor for persistent VUR and renal scarring An abnormal elimination pattern (frequent or infrequent voids, urgency, infrequent stools [constipation]) Bladder and or bowel incontinence Withholding maneuvers Vesicoureteral reflux It is the most common urologic anomaly in children. Children with VUR are at increased risk for recurrent UTI. Sexual activity The association between sexual intercourse and UTI in females has been well documented Bladder catheterization The risk of UTI increases with increasing duration of bladder catheterization