Urinary tract infection in children

Introduction
• Urinary tract infections (UTI) is common in the
pediatric age group.

• Early recognition and prompt treatment of UTI are

important to prevent progression of infection to
pyelonephritis or urosepsis and to avoid late
sequelae such as renal scarring or renal failure.
• Infants and young children with UTI may present with
few specific symptoms.

• Older pediatric patients are more likely to have

symptoms and findings attributable to an infection of
the urinary tract.
Etiology
• Bacterial infections are the most common.
• E-coli is the most common. Other bacteria include:
• Klebsiella species
• Proteus species
• Enterococcus species
• Staphylococcus saprophyticus
• Adenovirus (rare)
• Fungal in immune compromised patients
 Pathophysiology

• UTI generally begins in the bladder due to ascending

infection from perineal contaminants, usually bowel flora
such as Escherichia coli.

• In neonates, infection of the urinary tract is assumed to

be due to hematogenous rather than ascending
infection. This etiology may explain the nonspecific
symptoms associated with UTI in these patients.
Clinical Course
• Generalized bacteremia or sepsis may follow UTI.

• If left untreated, simple cystitis may progress to

pyelonephritis. More severe cases have the potential
for kidney damage, which may lead to hypertension
or renal insufficiency.
Frequency of UTI
• UTI is more frequent in females than males at all
ages with the exception of the neonatal period,
during which UTI may be the cause of an
overwhelming septic syndrome in male infants
younger than 2 months.

• Uncircumcised males have a higher incidence than

circumcised males.
Risk Factors
1. Bacterial virulence
2. Host factors :
 Anatomical
• VUR
• Urinary tract obstruction
• Indwelling catheter

 Functional : such as neurogenic bladder in spina bifida patients, and

inappropriate detrusor muscle contractions
 Immunologic ; in immune deficiency
Symptoms
 History:
vary with the age of the patient. History is dependent upon
the caregiver in younger children.
 Symptoms in Neonates:
• Jaundice
• Hypothermia or fever
• Failure to thrive
• Poor feeding
• Vomiting
 Symptoms in Infants:
• Poor feeding
• Fever
• Vomiting, diarrhea
• Strong-smelling urine
Symptoms
 Preschoolers
• Vomiting, diarrhea, abdominal pain
• Fever
• Strong-smelling urine, enuresis, dysuria, urgency, frequency
 School-aged children
• Fever
• Vomiting, abdominal pain
• Strong-smelling urine, frequency, urgency, dysuria, flank pain,
or new enuresis
 Adolescents are more likely to have some of the classic adult
symptoms. Adolescent girls are more likely to have vaginitis than
UTI .
 Physical Examination
• Hypertension should raise suspicion of
hydronephrosis or renal parenchyma disease.
• Abdominal tenderness or mass
• Palpable bladder
• Dribbling, poor stream, or straining to void
• Examine external genitalia for signs of irritation,
pinworms, vaginitis, trauma, sexual abuse, phimosis
or meatal stenosis .
Investigations
Lab Studies
• Urinalysis: A urine specimen that is found to be
positive for nitrite, leukocyte esterase, or blood may
indicate a UTI.
• Microscopic examination can evaluate presence of
WBCs (>5 per high-power field), RBCs, bacteria, casts,
and skin contamination (e.g., epithelial cells).
• A midstream clean catch is appropriate if the patient
is old enough to cooperate.
• In neonates & infants sample obtained by
Suprapubic bladder puncture is the best
 Specimen Collection

Plastic Bag
Only –ve culture is valid

False positive
Perineal and rectal flora
 UTI CHILDREN
Specimen Collection
SP puncture Midstream
void

Catheterizati
on
Investigations
• Urine cultures should be sent to the laboratory even if
urinalysis results are inconclusive. Approximately 20% of
pediatric patients with UTI have normal urinalyses results.

• A clean-catch urine sample with more than 100,000 colony-

forming units (CFU) of a single organism is classic criteria for
UTI.
• Urine collected in bags is generally not suitable for culture
because of the high incidence of contamination.
Imaging studies
• Imaging typically is delayed after the infection as part of
outpatient follow-up, except in cases in which urinary tract
obstruction is suspected.

• Renal ultrasound
• This study adequately depicts kidney size and shape, but it
poorly depicts ureters and provides no information on
function.

• A renal ultrasound can diagnose urolithiasis, hydronephrosis,

hydroureter, ureteroceles, and bladder distention and has
replaced the intravenous pyelogram (IVP) in many cases.
 Sonography
Initial study
for pediatric
kidneys &
UTI
Hydronephros
is
 VCUG
adequately depicts urethral and bladder anatomy and detects vesicoureteral reflux (VUR).

A The MCU showing a

dilated posterior urethra,
mildly irregular appearance
of the
edge of the bladder
(reflective and trabeculation)
and bilateral
vesicoureteric reflux into
dilated tortuous ureters.
B Hydronephrosis with
'clubbing' of the calyces.
VCUG
Images
AP, Oblique
During voiding
Post-voiding images
Renal area

Bladder
VCUG
Urethral
abnormalities

PUV
Imaging studies/2
 Nuclear scanning
• This study most frequently uses technetium Tc 99m
dimercaptosuccinic acid (DMSA).
• This study detects tubular damage and scarring and shows the
kidney outline, but it does not show the collecting system.
 Cortical
DMSA scarrin
g

More sensitive
than IVP & renal
US: Acute
PN
§ Acute
pyelonephritis.
§ Pyelonephritic
renal scarring.
 Treatment UTI Children
Febrile
Management
strategies
Minimize renal damage.
Minimize risk of re-infection.

Early Antimicrobial Therapy

 Treatment UTI Children
Febrile
Severe UTI Simple UTI
Parenteral antibiotics. Single dose parenteral
Hydration. Cephalosporine (3rdrd)
Gentamyicin.
Cephalosporine (3rdrd)
Amoxicillin/calvulanate (cocci)

Oral Therapy 10-14 days

 Treatment UTI Children
Normal Urinary Tract
Antimicrobial Single dose
3-5 days. Parenteral
Aminoglycosides.
Treatment
• Emergency Department Care: Treatment must be tailored to the
presentation of the patient.

• Septic or toxic patients require aggressive management in the ER.

Intravenous fluid replacement and parenteral antibiotics should be
started after collection of laboratory samples.

• Initially, all ill-appearing patients with febrile UTI should be treated with
parenteral antibiotics and monitored as an inpatient. The ER consultant
or the pediatrician should be informed.

• Oral fluids and medications on outpatient basis may be used for patients
with cystitis who are less seriously ill at presentation.

• Consultation with a urologist is not required at presentation unless there

is evidence of obstruction of the urinary tract.
 Follow-up
• Hospitalization is necessary for the following
individuals:
• Patients who are toxemic or septic
• Patients with signs of urinary obstruction or
significant underlying disease
• Patients unable to tolerate adequate PO fluids or
medications
• Infants younger than 3 months with febrile UTI
(presumed pyelonephritis)
• All infants younger than 1 month with suspected UTI
even if not febrile
Complications
• Dehydration is the most common complication of UTI in the
pediatric population. IV fluid replacement is necessary in
more severe cases. Treat febrile UTI as pyelonephritis, and
consider parenteral antibiotics and admission for these
patients.
• Untreated UTI may progress to renal involvement with
systemic infection (e.g., urosepsis).
• Long-term complications include renal parenchyma scarring,
hypertension, decreased renal function, and, in severe cases,
renal failure.
 Take home message
• Most cases of UTI are simple, uncomplicated, and respond readily to
outpatient antibiotic treatments without further sequelae.

• Appropriate treatment, imaging, and follow-up prevent long-term

sequelae in patients with more severe infections or chronic infections.

• Mild VUR usually resolves without permanent damage.

• Any child with proven UTI should have imaging studies performed to
R/O VUR or renal anomalies.
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