URINARY TRACT

INFECTION IN
CHILDREN
LEARNING OUTCOME
• Urinary tract infection

 Describe the normal anatomy of the renal system

 List the predisposing factors for developing UTI

 Name the common micro-organisms causing urinary tract infections in

different age groups

 Describe the clinical features of urinary tract infections according to the

age

 Outline the relevant investigations and the findings

 Describe the management of urinary tract infection in children

 List the complications. 

 Why know about pediatric
UTI?
• One of the commonest infections in
children(2nd )
• Young infants- sepsis- mortality if not
recognized
• Almost ½ (40%) will have structural
abnormalities
• Renal scarring- hypertension and
progressive renal damage
 PREVALENCE
 UTI is a common bacterial infection in infants and
children.
 2% of males and 7% of females will have UTI by
7 years old
 30% of febrile infants under the age of 3 months
is due to Urinary tract infection
 In boys, most UTIs occur during the 1st yr of life; more
common in uncircumcised boys.
 Recurrence rate within 1 yr is 10 to 30%
 During the 1st yr of life,
-M > F under <3 mth
-F>M after 3 mth
Definition A) Urinary tract infection is pure growth of bacteria of > 10⁵ colony forming
units (CFU /mL) in a appropriately collected urine sample with clinical features consistent with a UTI

Method of Colony Count (CFU/mL)

Collection
Clean catch ≥10 5
Catheter ≥5 × 10 4
Suprapubic Any

B) Acute pyelonephritis is bacteriuria presenting clinically with fever > 38⁰C

and/or loin pain and tenderness. It carries a higher risk of renal scarring

C) Acute cystitis is infection limited to the lower urinary tract presenting

clinically with acute voiding symptoms: dysuria, urgency, frequency,
suprapubic pain or incontinence.

D) Asymptomatic bacteriuria is presence of bacteriuria in the urine in an

otherwise asymptomatic child.
 Acute pyelonephritis: Has
constitutional symptoms, fever,
malaise,irritablilty, nausea, vomiting
abdominal flank or loin pain.
Can cause renal damage

Aa UPPER URINARY TRACT

------------------------------------------------------------------------------------

LOWER URINARY TRACT

Cystitis : Has only dysuria, urgency,
frequency, suprapubic pain,
incontinence.
Does not cause renal damage.
Signs and symptoms
• The history and clinical course of a UTI vary with the patient's age .
• No one specific sign or symptom can be used to identify UTI in
infants and children.

• Children aged 0-3 months

Neonates and infants up to age 3 months who have pyelonephritis usually do
not have symptoms localized to the urinary tract. UTI is discovered as part of
an evaluation for neonatal sepsis. Neonates with UTI may display the
following symptoms.
 Fever
 Irritability lethargy and malaise
 Poor feeding
 Failure to thrive
 Vomiting
 Jaundice
Signs and symptoms of UTI in children aged between 3 mths and 3
years

Infants with UTI may display the following symptoms:

 Fever
 Poor feeding
 Vomiting
 Abdominal pain
 Irritability
 Children older than 3 years old

• School-aged children with UTI can display the following symptoms:

• Fever
• Vomiting, abdominal pain
• Flank/back pain
• Strong-smelling urine
• Urinary symptoms (dysuria, urgency, frequency)
• Enuresis
• Incontinence
 Si

Foul smelling
urine
• Diagnosis of Urinary Tract Infection
 SPECIMEN COLLECTION
Newborns and infants
Bagged specimen
Clean catch
Catheterization
Suprapubic aspiration

Toddlers
Bagged specimen
Clean catch
Catheterization
Suprapubic aspiration

School age children

Clean catch
• Alternatively, the application of an adhesive, sealed,
sterile collection bag after disinfection of the skin of
the genitals can be useful only if the culture is negative
or if a single uropathogen is identified.
• However, a positive culture can result from skin
contamination, particularly in girls and uncircumcised
boys.
• If treatment is planned immediately after obtaining the
urine culture, a bagged specimen should not be the
method because of a high rate of contamination often
with mixed organisms.
• A suprapubic aspirate generally is unnecessary.
Urine Dipstick is a useful screening test for UTI
• Leucocyte esterase
Certain White Blood Cells contain leucocyte esterase
enzyme. If this is present in urine, then the presence of
WBCs and thus infection can be inferred.
• Positive esterase has a sensitivity of 80% for UTI
• Nitrite
Nitrate is excreted in the urine as a byproduct of
vegetable ingestion. Certain bacteria convert the
nitrate to nitrite which, if present, infers the presence
of bacteria.
• If positive has a specificity of 97% UTI
Methods of dipstick testing
Nitrite stick testing Positive result useful as very likely to indicate a true
urinary tract infection (UTI)
But some children with a UTI are nitrite negative
Leucocyte esterase stick testing (for white blood cells) May be present in children with UTI but may also be
negative
Present in children with febrile illness without UTIs
Positive in balanitis and vulvovaginitis

Interpretation of results
Leucocyte esterase and nitrite positive Regard as UTI
Leucocyte esterase negative and nitrite positive Start antibiotic treatment if clinical evidence of UTI
Diagnosis depends on urine culture
Leucocyte esterase positive and nitrite negative Only start antibiotic treatment if clinical evidence of UTI
Diagnosis depends on urine culture
Leucocyte esterase and nitrite negative UTI unlikely. Repeat or send urine for culture if clinical
history suggests UTI
Blood, protein, and glucose present on stick testing Useful in any unwell child to identify other diseases,
e.g. nephritis, diabetes mellitus, but will not
discriminate between children with and without UTIs
Urine for microscopy
• Must be fresh and properly collected
• Presence of bacteria on microscopy with gram staining and presence
of WBC > 10 white cells/µL >90% sensitive and specific.
 Interpretation of Urine Culture

Probability of
Method of collection Colony count
infection (%)

Urinary pathogen in any

Suprapubic aspiration 99
number

Urethral catheterization >=50X103 CFU/ml 95

5
Midstream clean catch  >10 CFU / ml  90-95

CFU: colony forming units

• What are the common organisms causing UTI?
AETIOLOGY
• E coli is the most frequent pathogen, causing 80-90%
of UTIs.
• Klebsiella species and group B streptococcus—more
common in neonatal period
• Proteus species –more common in boys over 1-year old
• Enterococcus species-resistant to Gentamicin
• Pseudomonas aeruginosa-common in those with
urinary malformations
• Adenovirus is a rare cause of UTI and may cause
haemorrhagic cystitis.
 PATHOGENESIS -
UTI
 Ascending Route of UTI
° Bacterial Colonization
° Migration to Periurethral Region
° Migration into Bladder
° Growth in Urine
° Bacterial Ascent to Kidney
° Colonization of Renal Medulla
° Focal Abscess Formation
° Bacteremia
° Kidney Re-infection
MANAGEMENT
• Admit for IV antibiotics
All infants(<6-mths)
Ill child
unable to tolerate oral antibiotics with UTI
pyelonephritis.
 Less than 6 months old febrile or unable to take orally, IV Amoxycillin and
Gentamicin
 For Pyelonephritis ( upper UTI): E.coli or proteus infection, IV Cefotaxime or
Cefuroxime IV for 10 – 14 days.
 Acute cystitis: treat with oral Trimethoprim or Trimethoprim-
sulphamethoxazole for 1 wk.
• In children with prior antibiotics : give oral cephalexin or cefuroxime
• Repeat urine culture if not better after 48 hrs of antibiotics.
 Antimicrobials Used in UTI
parentera oral
l
ceftriaxone 75-100 divided B.D cefixime 8-10 BD
cefotaxime 100-150 B.D or TID coamoxiclav 30-35 of amox, BD
amikacin 10-15, single dose IV or IM ciprofloxacin 10-20 BD
gentamycin 5-6 single dose IV or IM
ofloxacin 15-20 BD
coamoxiclav 30-35 of amoxicillin,
in 2 divided doses IV cephalexin 50-70 , BD or TID
• SUPPORTIVE THERAPY
• Maintain adequate hydration
• Routine alkalinisation- not necessary
• Paracetamol for fever
• Repeat urine culture not necessary unless persistence of fever and
toxicity despite 72 hrs of antibiotics
Complications of urinary tract infection

Acute phase
1. Sepsis( urosepsis)
2. Renal abscess

After discharge
1 Recurrent UTI
2. Renal scarring from versicouteric reflux
3. Progressive Renal damage and failure
 Imaging Studies:
• The goal of imaging studies in children with a
UTI is to:
 identify anatomic abnormalities that
predispose to infection,
 determine whether there is active renal
involvement, and
 to assess whether renal function is normal or
at risk.
EVALUATION OF 1ST
UTI
• 3 modalities--USG, DMSA scan and MCU
• USG- kidney size, hydronephrosis bladder
anomalies and post void residual urine
• DMSA scintigraphy-renal parenchymal infection
and cortical scarring
• MCU- VUR and anatomic details of bladder and
urethra
EVALUATION AFTER THE FIRST UTI

 Ultrasonography should be
done soon after the
diagnosis of UTI.
 The MCU is recommended 2-

3 weeks later.
 The DMSA scan is carried out

2-3 months after treatment.

Ultrasound exam of kidney
• Kidney scar, thinning of
Normal
cortex

USG- can assess the kidney size, hydronephrosis

bladder anomalies and post void residual urine
Ultra-sound showing a perinephric abscess
 DMS
A
• Normal study
DMSA scintigraphy-renal parenchymal
infection and cortical scarring

• Right lower pole and

left kidney scarring
+
Renal scaring, DMSA scan

Hypodense areas
noted on the left
medial and lateral
lower half of the
kidney
MCU Micturating Cysto-Urethrogram
G

MCU- VUR and anatomic details of bladder and urethra

Voiding cystourethrogram revealing bilateral grade 3 reflux into small, scarred
kidneys.
Grade 5 Vesicoureteral reflux
 VESICOURETERIC REFLUX

• VUR is a bladder valve defect that allows urine to reflux

from the bladder through one or both ureters and up to
the Kidneys.

•Febrile urinary tract infection (UTI) is the defining

Symptom.
 VUR is seen in 40-50% infants and 30-50%
children with UTI, and resolves with age.
 Its severity is graded using the International
Study Classification from grade I to V, based on
the appearance of the urinary tract on MCU.
 The presence of moderate to severe
VUR, particularly if bilateral, is an important risk
factor for pyelonephritis and renal scarring, with
subsequent risk of hypertension, albuminuria and
progressive kidney disease.
 The risk of scarring is highest in the first year of
life
PREVENTION OF RECURRENT UTI
General Measures:
 Adequate fluid intake and frequent voiding

 constipation should be avoided

 In children with VUR who are toilet trained, regular

and volitional low pressure voiding with complete
bladder emptying is encouraged.
 Double voiding ensures emptying of the bladder of
post void residual urine.
 Circumcision reduces the risk of recurrent UTI in
infant boys, and might therefore have benefits
in patients with high grade reflux.
Fluid intake
Adequate fluid intake help to reduce frequency of UTI
Increase bladder capacity and frequency of voiding
Recommended intake
6 to 8 drinks /day
toddlers 100 to 120 ml (800ml to 1000ml)
5 years old 160 to 180ml (1000 t0 1400ml)
10 years old 200 to 220 ml(1600 to 2000ml)
Make sure urine is clear and good volume

3 Constipation. High fiber diet, stool softener, regular toilet

habit