UTI pdf - د. بسمة عادل

Dr.Basma Adel

Fifth grade

2017-2018

12/3/2017

At the end of this lecture you
should know:



Epidemiology



Etiology



Pathology



Risk factors of UTI



Clinical manifestation



Investigations



Complications



Treatment



Vesico ureteral reflux

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• UTI are

the most common genitourinary

disease of childhood.

The prevalence of UTI at all ages is :

1-3% of girls



1% of boys

Below 1 year

≈

male: female 4:1

, especially

among uncircumcised males

but after 1 year

male: female ratio is 1:10.

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Etiology:

• UTI is mainly caused by colonic bacteria e.g.

E coli

followed by

Klebsiella and Proteus

. Infrequently it caused

by Staphylococcus saprophyticus and enterococcus as

well as to viral infection e.g. adenovirus

Pathology

• Virtually all UTIs are

ascending infections

. The bacteria

arise from the fecal flora and enter the bladder via

urethra.

•

Rarely, in some neonates, renal infection may occur by

hematogenous spread.

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Female gender

Uncircumcised male

Vesicoureteral reflux

Voiding dysfunction

Obstructive uropathy

Neuropathic bladder

Urethral instrumentation

Constipation

Bacteria with P fimbriae

Pinworm infestation

Tight clothing

Toilet training

Anatomic abnormality (labial

adhesion)

Wiping from back to front in

females

Bubble bath

Sexual activity& Pregnancy.

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Clinical manifestations:

• The symptoms and signs of UTI vary with age:

•

Neonate

:commonly presents with

 FTT
 feeding problem
 diarrhea, vomiting
 Fever
 hyperbilirubinemia

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•

1month-2 year infant

• usually has

non

urinary tract manifestations

• FTT

• feeding problems

• diarrhea

• unexplained fever

• gastrointestinal illness

such as colic, irritability, screaming periods.

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•

2-6 years old child

may have GIT symptoms

  and classic signs of UTI such
  as urgency, dysuria, frequency
  and abdominal pain.

•

6-18years old

most commonly

•  will have urgency,
•  frequency,
•  abdominal or flank pain.

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There are 3 main types of UTI

• 1. Asymptomatic Bacteriuria

refers to a condition that results in a positive

urine culture without any manifestations of
infection. It is most common in girls.

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2. Cystitis (infection of bladder lower UTI)

→

dysuria, urgency, frequency,
suprapubic pain, incontinence,
and malodorous urine.
It

does not

cause fever or

renal injury.

3. Pyelonephritis (upper UTI)

is clinically manifested as
abdominal or flank pain,
fever,

malaise,

nausea,

vomiting,

and

occasionally diarrhea.

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Chronic recurrent UTI →

renal scarring
which result in
chronic hypertension
& renal insufficiency

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Investigations

  UTI may be suspected based on :
• symptoms
• urinalysis,
• and urine culture
• Imaging studies

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•

In toilet-trained children:

a midstream urine sample usually is satisfactory;

the area should be cleaned before obtaining the
specimen

• Children 2-24 months:

a catheterized or suprapubic aspirate urine sample
should be obtained.
Alternatively, the application of an adhesive sealed,
sterile urine bag after disinfection of the skin
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

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How to obtain a urine sample

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• Pyuria (leukocytes on urine microscopy)

suggests infection, but infection can occur in
the absence of pyuria; this finding is more
confirmatory than diagnostic.

• Nitrites and leukocyte esterase usually are

positive in infected urine.

• Microscopic hematuria is common in acute

cystitis, but microhematuria alone does not
suggest UTI

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Sterile pyuria (positive leukocytes, negative
culture) may occur in:

• partially treated bacterial UTIs
• viral infections
• renal tuberculosis
• renal abscess
• urinary obstruction
• inflammation near the ureter or bladder

eg.appendicitis

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Urine culture

If the culture (suprapubic or catheter

sample) shows

>50,000

colonies of a single

pathogen regardless of symptoms, or if

there are

10,000

colonies with symptoms,

the child is considered to have a UTI.

In (bag sample), if the urinalysis result is

positive, the patient is symptomatic, and

there is a single organism cultured with a

colony count >

100.000

there is a presumed

UTI

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B-CBP in upper UTI, there is leukocytosis
(neutrophilia), ↑ ESR & CRP

C- blood cultures should be drawn before
starting antibiotics if possible as sepsis is
common in pyelonephritis, particularly in infants
and any child with obstructive uropathy

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Imaging studies are used to identify the

anatomical abnormalities ,these include

1. Ultrasound of kidney

is indicated

initially for all

infants

with UTI To exclude obstruction and determine

the size of the kidney, rule out hydronephrosis, renal
abscess .

VCUG

is indicated if the

U/S study is abnormal, the

patient has atypical features, or after a recurrent
febrile UTI.

The timing of VCUG 2-6 wk. after treatment (to

allow inflammation in bladder to resolve to reduce the
incidence of VUR

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3.IV pyelography

to evaluate kidney size ,

calyceal blunting ,urethral dilatation.

4.Renal scanning using DMSA

(di-mercapto-

succenic acid) is used to detect renal scars that
usually develop after severe or recurrent upper
UTI.

5.CT scan

can also detect renal scars

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Treatment:

• Acute cystitis

should be treated promptly to prevent progression

to pyelonephritis,

a 3-5 day

course of

1) trimethoprim-sulfamethoxazole (TMP-SMX) or

trimethoprim

is effective against many strains of

E. coli.

Nitrofurantoin (5-7 mg/ kg/24 hr. in 3-4 divided

doses)

has the advantage of being active against

Klebsiella and Enterobacter organisms.

3) Amoxicillin (50 mg/kg/24 hr.)

.also is effective as

initial treatment but has a high rate of bacterial

resistance.

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• Acute pyelonephritis, a 7-14 day

course of

broad-spectrum antibiotics is preferable.



Children should be admitted to the hospital for IV

rehydration and IV antibiotic therapy

dehydrated,

ii.  vomiting,
iii.  unable to drink fluids,
iv.  1 mo. of age or younger,
v. have complicated infection, or in whom urosepsis is

a possibility

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1) Ceftriaxone (50-75 mg/kg/24 hr., Not to

exceed 2 g)

2) Cefotaxime (100 mg/kg/24 hr.),
3) Ampicillin (100 mg/ kg/24 hr.) With an

aminoglycoside such as gentamicin (3-5
mg/kg/24 hr. in 1-3 divided doses) is
preferable.

Treatment with aminoglycosides

is particularly effective against Pseudomonas
spp .

• Parenteral treatment with:

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4. Oral third-generation cephalosporins such as

cefixime

are as effective as parenteral ceftriaxone

against a variety of Gram-ve organisms other than

Pseudomonas, and these medications are

considered to be the treatment of choice for oral

outpatient therapy.
5.

Ciprofloxacin

is an alternative agent for resistant

microorganisms, particularly Pseudomonas, in

patients older than age 17 yr.
• In some children with a febrile UTI,

intramuscular

injection of a loading dose of ceftriaxone

followed by oral therapy with a third-generation

cephalosporin is effective

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 Note

A urine culture 1 wk. after the termination of
treatment of a UTI ensures that the urine is sterile

• Urologic conditions for recurrent UTIs that might

benefit from long-term prophylaxis include :

 neuropathic bladder
  urinary tract stasis and obstruction and urinary calculi.
  severe vesicoureteral reflux
  In a child with recurrent UTIs.
  Antimicrobial prophylaxis using

trimethoprim or

nitrofurantoin at 30% of the normal therapeutic dose
once a day. TMP-SMZ, amoxicillin, or cephalexin can also
be effective

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Vesico ureteral reflux:

• VUR is a condition in which urine flows from the

bladder into the ureters/kidneys.

• Most children with VUR are asymptomatic
• Reflux increases risk of urinary tract infection or

acute pyelonephritis, so testing for reflux may be

performed after a child has one or more

infections.

• May be congenital or acquired like in Posterior

urethral valves; urethral or meatal stenosis,

bladder instability, neurogenic bladder . UTI may

cause reflux due to the elevated pressures

associated with inflammation.

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International Classification of Vesicoureteral Reflux

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Treatment:

85% of grade I & II cases of VUR will resolve spontaneously.

50% of grade III cases and a lower percentage of higher grades

will also resolve spontaneously

• The goal of treatment is to minimize infections by

prophylactic antibiotics, as it is infections that cause renal

scarring and not the vesicoureteral reflux

• When medical management fails to prevent recurrent UTI,

or if the kidneys show progressive renal scarring then

surgical interventions may be necessary

• Medical management is recommended in children with

Grade I-III VUR. A trial of medical treatment is indicated in

patients with Grade IV VUR . Of the patients with Grade V

VUR surgery is the only option .

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1.Types of urine casts and its clinical
significance?
2. Causes of albumin in urine?

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