DRKAUSHAMBI BASU DCHMDPEDIATRICS TUTORPEDIATRIC MEDICINE CNMCH POINTS OF DISCUSSION INTRODUCTION CLINICAL FEATURES DIAGNOSIS TREATMENT IMAGING AFTER FEBRILE UTI VUR RECURRENT UTI ANTIBIOTIC PROPHYLAXIS ID: 914007
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Slide1
URINARY TRACT INFECTIONS IN CHILDREN:AN UPDATE
DR.KAUSHAMBI BASUDCH,MD(PEDIATRICS) TUTOR,PEDIATRIC MEDICINECNMCH
Slide2POINTS OF DISCUSSION
INTRODUCTION CLINICAL FEATURESDIAGNOSISTREATMENTIMAGING AFTER FEBRILE UTIVUR RECURRENT UTIANTIBIOTIC PROPHYLAXIS
Slide3DEFINITIONS
URINARY TRACT INFECTION(UTI):Infection of urinary tract as identified by growth of significant number of organisms of a single uropathogen in the urine, in presence of symptoms.
ASYMPTOMATIC BACTERIURIA:Significant bacteriuria in the absence of symptoms of UTI.
Do not need treatment.
SIGNIFICANT BACTERIURIA:
Colony count of more than 10^5/ml of a single species in a mid-stream clean catch urine.
Slide4EPIDEMIOLOGY
AGE GROUPINFANCY MALE : FEMALE = 1 : 2BEYOND 1-2 YEARS MALE : FEMALE = 1 : 10
ETIOLOGYCOLONIC BACTERIA Like Escherichia coli,
Klebsiella, Proteus, Enterococcus, Pseudomonas
Other Agents :
Staphylococcus saprophyticus, group B
Streptococcus, Staphylococcus
aureus, Candida, Salmonella
Slide5CLINICAL FEATURES OF UTI
Till 2 months
2months to 2 years
*
malodourous
urine: neither sensitive nor specific for UTI
Above 2 years
Slide6CLASSIFYING UTIs
SIMPLE UTI
COMPLICATED UTI
Dysuria
Urgency
Frequency
Fever >39 degree
Toxicity
Recurrent
Vomiting
Dehydration
Renal angle tenderness
Slide7PATHOGENESIS
Ascending infection : Faecal flora uncircumscribed prepuce vagina
infected urinary bladder Haematogenous spread : Bacteraemia
Septicaemia
Endocarditis
In new-borns: Mostly as a part of septicaemia
Slide8RISK FACTORS
FEMALE GENDEROBSTRUCTIVE UROPATHY(any level)
UROLITHIASISCONSTIPATIONBOWEL-BLADDER DYSFUNCTIONPERI-URETHRAL COLONISATION
VESICO-URETERAL REFLUX
Slide9DIAGNOSIS
ROUTINE EXAMINATION OF URINE(MICROSCOPY)URINE DIPSTICK EXAMINATION LEUKOCYTE ESTERASE & NITRITE*URINE CULTURE
*
While earlier, Dipstick tests were discouraged in children less than 2 years, recent data agree on its use
.
EXAMINE
URINE IN 30-60
mins
CULTURE
IN 4hrs.Else keep in
Fridge(4-8◦ Centigrade) for a period of 24
hrs
(max)
Slide10NO LONGER RECOMMENDED
RECOMMENDED IN PRIMARY SETTING
2
ND
CHOICE IN HOSPITAL
CONTROVERSIAL AS PER DIFF.GUIDELINES
QUICK WEE
METHOD
1
ST
CHOICE IN HOSPITAL SETTING
CRITICALLY ILL CHILDREN
GOLD STANDARD METHOD
NOT FEASIBLE IN ROUTINE PRIMARY CARE
HOW TO COLLECT URINE:
Toilet –trained children: Mid-stream clean catch
Neonates & Infants : Suprapubic aspiration/Transurethral
catheterisation/quick wee method
Urine bag/diaper are not advised
METHODS OF COLLECTION OF URINE
Slide11ROUTINE EXAMINATION OF URINE
SIGNIFICANT PYURIA: more than
5 leucocytes/hpf
in centrifuged urine
LEUKOCYTURIA
Fever, Glomerulonephritis, Renal stones,
presence of FB in Urinary tract.
MICROSCOPIC HEMATURIA/Excess RBC
common
not diagnostic.
Slide12URINE DIPSTICK INTERPRETATION OF RESULT OF NITRITE AND LEUKOCYTE ESTERASE
TEST
INTERPRETATION
ACTION
NITRITE
+
LEUKOCYTE ESTERASE
+
VERY LIKELY
PERFORM URINE CULTURE
START
ANTIBIOTICS EMPIRICALLY
NITRITE
-
LEUKOCYTE ESTERASE
+
LIKELY
PERFORM URINE CULTURE
START
ANTIBIOTICS EMPIRICALLY
NITRITE
-LEUKOCYTE ESTERASE -QUITE UNLIKELYNO CULTURE NEEDEDSEARCH FOR ALTERNATE DIAGNOSISCLINICAL FU & NEW DIPSTICK TEST IF FEVER PERSISTSNITRITE +LEUKOCYTE ESTERSE -DOUBTFULPERFORM URINE CULTUREEVALUATE FOR BACTERIURIAREPEAT DIPSTICK,IF FEVER PERSISTS
*Acta
Paediatrica. 2020;109:236–247
NITRITES NEGATIVE IN FREQUENT VOIDING / BACTERIA NOT CONVERTING NITRATES TO NITRITES
Slide13INTERPRETATION OF CULTURE RESULTS
METHOD OF COLLECTION
COLONY COUNT
SUPRAPUBIC
METHOD
ANY COUNT
TRANS-URETHRAL
CATHETER
>50,000 colonies/ml
MID
-STREAM
>100,000 colonies/ml
Low colony
counts
of a single organism also significant ,if a child is
symptomatic.
Slide14STERILE PYURIA
( LEUKOCYTES +,CULTURE -)PARTIALLY TREATED BACTERIAL UTIVIRAL INFECTIONSRENAL TUBERCULOSIS UROLITHIASISKAWASAKI DISEASEGLOMERULONEPHRITIS
INTERSTITIAL NEPHRITISSCHISTOSOMIASIS
Slide15BLOOD INVESTIGATIONS
CBC: LEUKOCYTOSIS,NEUTROPHILIA,ESRPRO-CALCITONIN ELEVATEDCRPRENAL FUNCTION TESTBLOOD CULTURE : BACTEREMIA
(INFANTS UPTO 3MONTHS, OBSTRUCTIVE UROPATHY)
Slide16IMAGING
USG ABDOMEN : Limited use
Renal abscess/Acute Lobar Nephronia/
Perinephric
abscess
CT ABDOMEN
: More specific & sensitive for Acute lobar
nephronia
or Renal Abscess.
Slide17INDICATIONS OF HOSPITALISATION
CRITICALLY ILL CHILD(SEPSIS/DEHYDRATION/VOMITING)NON-COMPLIANCE TO ORAL DRUGSFEVER PERSISTING DESPITE 3 DAYS OF APPROPRIATE ANTIBIOTIC,AS SHOWN BY SENSITIVITY PATTERN
Slide18TREATMENT
1.EMPIRICAL ANTIBIOTICS 2.AS PER C/S REPORT
ORAL
INTRAVENOUS
Simple UTI Complicated UTI
Well-appearing Toxic look
Persisting Fever
<
3
months age
Low compliance to oral drugs
Slide19CHOICE OF ANTIBIOTICS
ORAL INTRAVENOUS Cefixime 3
rd generation Cephalosporin Co-Amoxyclav
(Ceftriaxone/
Cefotaxime
)
FluoroQuinolones Co-
Amoxyclav
Ceftibuten
Co-
trimoxazole
: not used for treatment empirically
Nitrofurantoin : does not achieve significant renal tissue
levels
ANTIFUNGALS : Fluconazole(Oral/Intravenous) Amphotericin B(IV)
Slide20DURATION OF THERAPY
TYPE
OF UTI
DURATION
CYSTITIS
7-10 DAYS
PYELONEPHRITIS
10-14 DAYS
UROSEPSIS
14 DAYS
RENAL ABSCESS/ACUTE LOBAR NEPHRONIA
10-14 DAYS IV ,then 2-4 WEEKS ORAL
Slide21RESPONSE TO TREATMENT
Failure to response due to: a)presence of complicating factors b)non-sensitivity to pathogens
c)non-complianceRepeat urine culture ,if no response in 48 hrs.
No indication of Repeat Urine Culture on completion of Therapy
Slide22IMAGING STUDIES IN CHILDREN WITH FEBRILE UTI
Slide23IMAGING AFTER 1
ST FEBRILE UTI
GUIDELINES
ULTRASOUND
VCUG*
LATE DMSA*
ISPN 2011 <1YR
YES
YES
YES
>1YR
YES
NO
YES
>5 YRS
YES
NO
NO
NICE 2007 <6months
YES
ATYPICAL
UTIATYPICAL UTI >6monthsATYPICAL UTIRISK FACTORS/ATYPICALATYPICAL UTIAAP 2011YESNO-
ITALIAN SOCIETY ,2019
(
Acta Paediatrica. 2020;109:236–247
.)
YES
NO
YES, If
UTI Non-
E.coli
/ USG ABNORMAL
NO
YES,IF VCUG SHOWS GR IV/V VUR
*NORMAL USG
Slide24VESICO-URETERAL REFLUX
40-50% infants and 30-50% children with UTISeverity graded by VCUG/MCU using International Study ClassificationTreatment Antibiotic Prophylaxis Endoscopic Deflux
injection Surgery
Slide25RECURRENT UTI
2nd episode of UTIPredisposing factors: infants uncircumscribed males
females
Bladder-Bowel dysfunction(BBD)
VUR
Obstructive uropathy
30%
cases :
no identifiable factor
Slide26PREVENTION OF RECURRENT UTI
GENERAL MEASURES: Adequate Fluid intake Low pressure voiding Double voiding Perineal hygiene
BOWEL BLADDER DYSFUNCTION TREATMENT: Treatment of constipation
Avoidance of Urinary stasis
ANTIBIOTIC PROPHYLAXIS
Slide27ANTIBIOTIC PROPHYLAXIS
Effective against most pathogensAchieve high urinary concentration
Low Resistance
Preferred
Agents:
Co-
trimoxazole
(
to be used in infants more than 6 months)
Nitrofurantoin
(
to
be used in infants more than
3
months)
Cephalexin (
ideal in first 3 months of age)
Slide28DURATION OF ANTIBIOTIC PROPHYLAXIS
GUIDELINES
VUR after UTI
GR I-II
VUR AFTER
UTI
GR III-V
ISPN,2011
1
yr
5
yr
Italian
Guidelines,2019
No prophylaxis
Yes,5
yrs
AAP,2011
No prophylaxis
No prophylaxis
No evidence as to prevention in scarring/permanent renal damage
Slide29OTHER POTENTIAL OPTIONS FORPREVENTION OF RECURRENT UTI
Cranberry juiceVitamin C
Probiotics: Non-uropathogenic E.coli
Nissle
1917
Circumcision
in infants with VUR
Slide30GAPS IN KNOWLEDGE
Role of steroids in scar preventionNitrites in absence of Leukocyturia
Slide31TAKE HOME MESSAGES
High index of suspicion for UTIUrinary Dipstick very useful in office practiceConfirmation by Urine Culture Sensitivity Proper method of collection of urine sampleAsymptomatic Bacteriuria need not be treatedTreatment of Febrile UTIs is grossly incomplete without Imaging studies
Slide32REFERENCES
Acta Pediatrica,2019,Updated Italian recommendations for diagnosis, treatment and follow up of first UTI in young childrenUrinary Tract Infections in children : Diagnosis, Treatment and Long-term management ,NICE Guidelines,2007
Urinary Tract Infection: Clinical Practice Guideline for the Diagnosis and Management of the Initial UTI in Febrile Infants and Children 2 to 24 Months
Paediatrics
September
2011, 128 (3) 595-610
(AAP Guidelines,2011)
Revised Statement on Management of Urinary Tract
Infections, Indian
Paediatrics
2011;48: 709-717
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