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UTI On A Background of Obstructive Nephropathy

Master Sasmitha, an 8-year old boy, has a history of obstructive uropathy requiring two pyeloplasty surgeries. He has since experienced recurrent urinary tract infections, with the most recent episode presenting as dizziness and nausea. Testing showed the presence of pus cells, red cells, and Pseudomonas Aeruginosa in his urine. He has been admitted for intravenous antibiotics to treat his infection. The case presentation discusses recurrent UTIs in the context of obstructive uropathy, outlines the boy's medical history, and describes appropriate management and follow-up care.

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Aminath Meesan
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99 views

UTI On A Background of Obstructive Nephropathy

Master Sasmitha, an 8-year old boy, has a history of obstructive uropathy requiring two pyeloplasty surgeries. He has since experienced recurrent urinary tract infections, with the most recent episode presenting as dizziness and nausea. Testing showed the presence of pus cells, red cells, and Pseudomonas Aeruginosa in his urine. He has been admitted for intravenous antibiotics to treat his infection. The case presentation discusses recurrent UTIs in the context of obstructive uropathy, outlines the boy's medical history, and describes appropriate management and follow-up care.

Uploaded by

Aminath Meesan
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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Case

presentation
Recurrent Urinary Tract Infection in a
background of Obstructive Uropathy
History
Master Sasmitha an 8 year old boy came to our ward
On 30th may

P/c - Dizziness and Nausea for 3 days duration

H/pc - Apparently well three days ago after which developed lower
abdominal pain and nausea
On oral antibiotics for a UTI
Past Medical and surgical Hx
• At the age of 1 and ½ years the child started developing colicky type
lower abdominal pain with vomiting
• Several investigations were done one of which was an USS KUB
• It showed distention of the right renal calyces and pelvis.
• with further investigations he was found to have right sided
ureteropelvic junction obstruction
• At 2 years of age he underwent a pyeloplasty, surgery was successful
and he was symptom free for 6 months
• After 6 months of his surgery he again started having lower
abdominal pain
• Uss scan showed dilatation on the left side
• Left sided pyeloplasty was done.
• 4 months after the second surgery was done he started passing red
colored urine
• This red colour was passed through out the stream, with no passage
of clots, no pain or fever
• There was no associated dysuria or frequency
• UFR showed presence of pus cells, red cells and few granular casts
• Urine culture isolated growth of Pseudomonas Aeruginosa
• He was admitted and treated with iv antibiotics
• Over the past five years – he was admitted to the hospital with similar
symptoms on 8 different occasions where he was treated with iv
antibiotics
Birth history
• Primi mother with no antenatal complications, delivered at POA of 42
weeks
• LSCS – low fetal heart rate
• Birthweight – 2.9Kg
• Found to have delayed passage of urination
• Breast feeding established after 4 hours
• Exclusive breast feeding for 4 months
Urinary Tract Infection in Children
• About 3-7% of girls and 1-2% of boys
have atleast one symptomatic UTI
before the age of 6 years
• Caused mainly by colonic bacteria
Prevalence and • In girls 75-90% of all infections are
caused by E.coli followed by klebsiella
Etiology spp and proteus spp.
• In boys proteus is as common as E.coli
• Staphylococcus saptophyticus and
enterococcus are pathogens in both
sexes.
Clinical features and
classification

• Three basic forms

1. Pyelonephritis
2. Cystitis
3. Asymptomatic bacteriuria
Pyelonephritis

• Characterized by
• Abdominal, back, or flank
pain, fever, malaise,
nausea, vomitting and
occasionally diarrhea.
• Newborns show nonspecific
such as poor feeding,
lethargy, jaundice,
irritability or weight loss
Cystitis

• Indicates there is bladder involvement


• Symptoms include dysuria, urgency, frequency, suprapubic pain, incontinence and
malodorous urine
• These classical symptoms become more apparent with increasing age
• Dysuria alone can occur due to vulvitis in girls and balanitis in uncircumcised boys
• Most UTIs are ascending infections
• Arise from fecal flora, colonize the
perineum and enter the bladder via the
urethra.
• In uncircumcised boys , pathogens may
Pathogenesis arise from the flora beneath prepuce.
• The bacteria causing cystitis may ascend
to the kidney to cause pyelonephritis
• Rarely can occur due to hematogenous
spread (endocarditis) or in neonate.
Risk factors
Diagnosis
• UTI may be suspected based on symptoms or
findings on urine analysis or both
• Urine culture is necessary for confirmation and
appropriate therapy
• In toilet trained children a midstream urine sample
is satisfactory – the introitus should be cleaned
before obtaining the specimen
• If not toilet trained or in an urgency a catheterized
sample is an option
• The application of an adhesive, sealed sterile
collection bag after disinfection of the skin of
genitals can be useful.
• However a positive culture can result due to
contamination from skin, particularly in girls
• Supra pubic aspiration, when a fine needle
attached to a syringe is inserted directly into
the bladder just above the symphysis pubis
under uss guidance
• Maybe used in severely ill infants requiring
urgent diagnosis and treatment
• Pyuria – suggests infection, but
infection can occur without pyuria.
This is more confirmatory than
diagnostic
• Sterile pyuria – positive for
leukocytes but culture negative
• This occurs in partially treated UTIs,
viral infections, renal
tuberculosis, renal abscess, UTI in
the presence of an
obstruction, urethritis due to an STI,
inflammation near the urethera or
bladder (appendicitis) and
interstitial nephritis

Microscopic examination of
urine – pus cells
• Nitrites and leucocyte esterase –
usually positive in infected urine
• Microscopic hematuria is
common in acute cystitis, but
hematuria alone is not suggestive
of a UTI
• If asymptomatic and urine
analysis is normal it is unlikely to
be a UTI.
• But if symptomatic, UTI is
possible even if urine analysis
is negative
• A bacterial culture of more than 10^5 colony
forming units of a single organism per mililitre in a
properly collected specimen gives a 90% probability
of an infection
• A growth of mixed organisms usually represents a
contamination
• Any bacterial growth of a single organism per
mililitre in a catheter sample or suprapubic aspirate
is considered diagnostic of infection.
Imaging and its use

Initial ultrasound will identify


• Serious structural abnormalities and urinary obstruction
• Renal defects – although not gold standard for detecting renal scars
Radio isotope Renography (tc 99m)
• Diethylenetriaminepentacetate (DTPA) - neither secreted nor absorbed
• Dimercaptosuccinic acid (DMSA) - strong affinity to renal tubular cells
• MCUG
DTPA

• Evaluates the functioning of


the kidneys
• Differentiates between
passive dilatation and
obstruction
DMSA

• Used in assessing renal


morphology, structure and
function
• Usually static in contrast to
DTPA
• Use indicated to detect and
evaluate renal scars following
VUR, in renal agenesis,
characterization of certain
renal masses, evaluation of
hypertension etc.
First UTI –
protocol for initial
management and
investigation
Management

• < 3m age with UTI suspicion OR if seriously


ill:
- Admit immediately
- IV antibiotic therapy 5-7 days, continue
prophylactic oral antibiotics if required
• >3m age and children with Acute
Pyelonephritis / upper UTI:
- Oral antibiotics ( Trimethoprim 7d) OR
- IV antibiotics 2-4d followed by oral antibiotics
of total 7-10d
- Change antibiotics according to culture
sensitivity
• Cystitis/ Lower UTI:
- Oral antibiotics (Trimethoprim/
nitrofurantoin) 3d
Prevention of UTI
• High fluid intake for high urine output
• Regular voiding
• Ensure complete bladder emptying
by encouraging child to void again
after a minute or two
• Treatment and/or prevention of
constipation
• Good perineal hygiene
• Probiotics (Lactobacillus acidophilus)
• Antibiotic prohylaxis in congenital
abnormalities of urinary tract/
previous upper UTI/ severe reflux
until out of nappies
In children with:

- Recurrent UTI

- Renal scarring

- Reflux

Urine dipstick with UFR and culture for any nonspecific illness

Follow up Long term, low dose antibiotics can be used

Consider circumcision in boys

Anti VUR surgery if there is progressive scarring with ongoing VUR

Check BP annually if renal defects present

UFR for proteinuria: indicative of progressive CKD

Regular assessment of renal growth and function if bilateral defects present


Thank you

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