education

1. 4/25/2024 1
DepartmentofPediatrics
L.N.MedicalCollege&ResearchCentre,

2. APPROACH TO UTI
MODERATOR –( UNIT 1) DR. RASHMI DWIVEDI (H.O.D MAM)
DR. RASHMI VISHWAKARMA
DR . SWADESH VERMA
PRESENTOR – DR. RAJENDER SINGH (PGJR1)

3. REFERENCE
• GHAI ESSENTIAL PEDIATRICS 9 EDI.
• NELSON TEXTBOOK OF PEDIATRICS 21 EDI .
• IMAGES – SOURCE (INTERNET )

4. CONTENT

5. DEFINITION
• Invasionofurinary tractbypathogen,whichmayinvolvethe upper or lower
tractdependingupon theinfectioninthe kidney,bladderor urethra.
• Includes infectionof any component of the urinarytract including
•Pyelonephritis
•Cystitis
•Urethritis
• Asymptomatic bacteriuria:a positive urine culturewithoutany urinary
symptoms, common in adolescentgirls

6. PYELON EPHRITIS
• Involvementof therenalparenchymais termedacutepyelonephritis .
• Pyelonephritisis characterizedbyanyor allof thefollowing:abdominal, back,or
flankpain;fever;malaise;nausea;vomiting;and,occasionally, diarrhea.
• Fevermaybetheonly manifestation;particularconsiderationshould occur for
atemperature> 39°C without another source lastingmore than24 hr for
malesandmore than48 hr for females .

7. • Newbornscanshownonspecificsymptoms,suchas poor feeding,irritabilityand
weightloss.
• Pyelonephritisisthemost common seriousbacterial infectionininfantsyounger
than24 mo ofagewho havefeverwithoutanobvious focus.

8. CYSTITIS
• Cystitis indicatesthatthere is only bladderinvolvement;
• symptomsincludedysuria,urgency,frequency,suprapubicpain,incontinence,and
possibly malodorousurine.
• Cystitis does notcause high fever

9. DEFINITIONS
• Simple UTI:UTI with low grade fever,dysuria, frequency,andurgency;andabsenceofsymptoms of
complicatedUTI
• ComplicatedUTI:Presence of fever>39ºC,systemic toxicity,persistent vomiting, dehydration, renal angle
tendernessand raised creatinine.
• Recurrent infection:Second episode of UTI.
• Significantbacteriuria:Colony count of 100,000 /mL ofasinglespeciesinamidstreamcleancatchsample.
• Asymptomaticbacteriuria:Significantbacteriuriain the absence of symptoms of urinary tractinfection
(UTI).

10. ETIOLOGY
• UTIs are chiefly caused by E. coli the predominant periurethral flora, others include
Klebsiella,EnterobacterandStaphylococcus saprophyticus.
• Proteus andPseudomons infectionsoccur following obstruction or
instrumentation.
• Candida infectionoccurs inimmunocompromised childrenor afterprolonged
antimicrcbial therapy.

11. OTHER CAUSATIVEORGANISMS
Fungalinfections,particularlyCandida,usually in:
1. Nosocomial Infections
2. Complicated UTI
3. Catheter‐associatedUTI
Viral infections‐under‐recognized because of difficulties
with culture and identification, but have been associated
with cystitis,esp.adenovirus
Cytomegalovirus frequently seen in
immunocompromised patients,particularly following
organtransplantation

12. PATHOGENESIS
Ascending infection :
•Bacteria from fecalfloracolonize
viaurethra.
perineum and enter bladder
•In uncircumcised boys :pathogens arise from flora beneath the
prepuce
•Rarely,bacteriacausingcystitisascend tothe kidneytocause
pyelonephritis
Hematogenousinfection‐unusual
•Neonates (GBS, E.coli,Listeria)
•GI disease with peritonitis,sepsis
•Severely illchildren with multi‐organdisease
•Presence of urinarycatheter

13. PATHOGENESIS continued………………….
• pathogenesisofUTI is basedinpart on thepresenceof bacterialpilior fimbriaeon thebacterialsurface.
• two typesoffimbriae,typeI andtypeII.
• TypeI fimbriaearefound in most strainsofE.coli.Becauseattachmentto targetcellscan beblockedbyD -
mannose, thesefimbriaearereferredto as mannose sensitive.
• They haveno role inpyelonephritis.
• The attachmentoftypeII fimbriaeis not inhibitedbymannose,and theseareknown asmannose resistant.

14. • receptor for typeII fimbriaeisaglycosphingolipidthatis presenton both theuroepithelialcellmembrane and
red blood cells.
• Gal 1-4 Gal oligosaccharidefractionis thespecific receptor.BecausethesefimbriaecanagglutinatebyPblood
group erythrocytes,theyareknown asPfimbriae.
• Bacteriawith Pfimbriaearemore likelyto causepyelonephritis.Between76% and94% of
pyelonephritogenicstrainsofE.colihavePfimbriae, comparedwith19 -23% ofcystitis strains.
CONTINUED………………

15. RISK FACTORS
Female gender
Uncircumcised male
Vesicoureteral reflux
Toilet training
Voiding dysfunction
Obstructive uropathy
Urethral instrumentation
Sources of external irritation(such as tight
clothing, pinworm infestation)
Constipation
Anatomic abnormality (labial adhesion)
Neuropathic bladder

16. PRESENTING COMPLAINTS
NEONATE INFANT CHILD
Usually part of
septicemia and presents
with fever, vomiting,
lethargy, diarrhea, poor
feeding , irritability
,jaundice and poor
weight gain .
Fever , painful
micturation ,Diarrhoea,
foul smelling diapers,
vomiting etc
Fever without focus
Nausea, vomiting,
abdominalpain,dysuria,d
ay time urgency‐
frequency, hesitancy,
incontinence, secondary
enuresis cloudy urine
and Rarely‐flank pain

17. SCHOOL-AGE TO ADOLESCENCE
• Frequency, Urgency, Discomfort
• Malodorous Urine
• Abdominal/Flank Pain (esp in pyelonephritis)
• Suprapubic tenderness
• Fever/Chills (esp. in pyelonephritis)
• Malaise
• Vomiting/diarrhea (esp. in pyelonephritis)

18. HISTORY
• The history of the acute illness should include documentation of ;
• Fever, grade and duration
• Urinary symptoms (dysuria, frequency, urgency, incontinence)
• Abdominal pain
• Suprapubic discomfort
• Back pain
• Vomiting
• Recent illnesses, antibiotics administered

19. PAST MEDICAL HISTORY:
• Chronic urinary symptoms – Incontinence, lack of
proper stream, frequency, urgency, withholding .
• Chronic constipation
• Previous UTI
• Vesicoureteral reflux (VUR)
• Previous undiagnosed febrile illnesses

20. • Family history of frequent UTI, VUR, and other genitourinary
abnormalities.
• Antenatally diagnosed renal abnormality
• Elevated blood pressure
• Poor growth

21. PHYSICAL EXAMINATION
• Important aspects include :
• Documentation of blood pressure and temperature.
• Growth parameters (poor weight gain and/or failure to thrive may be an
indication of chronic or recurrent UTI)
• Abdominal examination for tenderness or mass (eg, enlarged bladder or enlarged
kidney secondary to urinary obstruction)
• Assessment of suprapubic and costovertebral
tenderness

22. • Examination of the external genitalia for anatomic
abnormalities (eg, phimosis or labial adhesions) and
signs of vulvovaginitis, vaginal foreign body.
• Evaluation of the lower back for signs of occult
myelodysplasia (eg, midline pigmentation, lipoma,
vascular lesion, sinus, tuft of hair), which may be
associated with a neurogenic bladder.
• Evaluation for other sources of fever .

23. DIFFERENTIAL DIAGNOSIS
• Asymptomatic bacteriuria — Asymptomatic bacteriuria (ie, colonization of the
urinary tract with bacteria in the absence of inflammation) occurs in 1 to 3 percent
of infants and preschool age children, and approximately 1 percent of older
children .
• Other differential diagnosis depends on the presenting symptom

24. • Infants: bacteremia, meningitis
• Children: Vulvovaginitis, STI, Vaginal foreign body, Sexual Abuse,
Abdominal Disease, Renal Calculi, dysfunctional voiding, dysuria-
pyuria syndrome, appendicitis, pelvic abscess, pelvic inflammatory
disease

25. •Urine
•Blood
•Imaging
INVESTIGATIONS

26. URINE
• UTI may be suspected based on symptoms or
findings on urinalysis, or both;
• a urine culture is necessary for confirmation and
appropriate therapy.
• In toilet-trained children, a midstream urine sample
usually is satisfactory; the introitus should be cleaned
before obtaining the specimen.
• In uncircumcised boys, the prepuce must be
retracted.
• In children who are not toilet trained, a catheterized
urine sample should be obtained.

27. • 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.

28. • Pyuria (leukocytes in the urine) suggests infection, but
infection can occur in the absence of pyuria; this finding is
more confirmatory than diagnostic. Conversely, pyuria can
be present without UTI.
• Sterile pyuria (positive leukocytes, negative culture) occurs
in partially treated bacterial UTIs, viral infections, renal
tuberculosis, renal abscess, UTI in the presence of urinary
obstruction, urethritis due to a sexually transmitted infection
(STI) , inflammation near the ureter or bladder (appendicitis,
Crohn disease), and interstitial nephritis (eosinophils).
Diagnos
is

29. • Nitrites and leukocyte esterase usually are positive in
infected urine.
• Microscopic hematuria is common in acute cystitis, but
microhematuria alone does not suggest UTI.
• White blood cell casts in the urinary sediment suggest renal
involvement, but in practice these are rarely seen.
• If the child is asymptomatic and the urinalysis result is
normal, it is unlikely that there is a UTI. However, if the child
is symptomatic, a UTI is possible, even if the urinalysis result
is negative.
Diagnos
is

30. DIPSTICKTEST

31. • Prompt plating of the urine sample for culture is important,
because if the urine sits at room temperature for more than
60 min, overgrowth of a minor contaminant can suggest a
UTI when the urine might not be infected.
• Refrigeration is a reliable method of storing the urine
until it can be cultured.
Diagnos
is

32. Method Colonycount Probability
Suprapubic Any number 99%
Catheter > 50 x103 95%
Midstream > 105 CFU/ml 90‐95%
Bagspecimen Unacceptable
(lower counts significant ifsymptoms persistent,antibiotics,
diuretics)
Note:Prompt platingof theurine sample Or refrigerationuntil
plated
URINE CULTURE - SIGNIFICANCE

33. •Contaminationis suspected, e.g.,mixed growth of two or more
pathogens,
•Growth of organisms that normally constitute the periurethral
flora (lactobacilli in healthy girls; enterococci ininfants).
•UTIis strongly suspectedbut colony counts areequivocal.
REPEAT URINECULTURE

34. BLOOD INVESTIGATIONS
With acute renal infection, leukocytosis and neutrophilia are noted
on the complete blood count (CBC);
an elevated serum erythrocyte sedimentation rate,
C-reactive protein

35. IMAGING STUDIES IN CHILDRENWITHA FEBRILE UTI
 FollowingtreatmentofthefirstepisodeofUTI, plansare madeforevaluationoftheurinary tract.
 The airmofimaging studiesisto identifyurologic anomaliesthatpredispose to pyelonephritis,such as
obstruction or vesicouretericreflux,and detectevidenceofrenal scarring.
 There aretwo historicalapproachesto imaging,the traditional“bottom-up”and“top-down” approaches.
 The “bottom-up”method was a renalsonogram plusavoiding cystourethrogram (VCUG), whichwill
identifyupper andlower urinary tractabnormalities,includingVUR, bladder–bowel dysfunction,and
bladderabnormalities,such asa paraureteral diverticulum.

36. • The “top-down”approachwas intendedto reducethenumber ofVCUG examinations.
• Itbeginswithadimercaptosuccinicacid (DMSA) renalscan,to identifyareasofacutepyelonephritis.The
DMSA scaninyoungerchildrengenerallyrequires sedation.
• Renalultrasonography isusefulindetectinghydronephrosis or anomaliesoftheurinary bladderandmaybe
performed even during therapyfor UTI.
CONTINUED………………..

37. • Micturatingcystourethrogramis necessaryfor thediagnosis andgradingof
VUR anddefinesurethralandbladder anatomyThisprocedure maybe
performed 2-4 weeks after treatmentofthe UTI.
• DMSA scintigraphydetectscorticalscars,whichareregions ofdecreased
uptakewithloss ofrenalcontours or presence ofcorticalthinningwith
decreasedvolume.In order to distinguishscars from reversiblechangesof
pyelonephritis, thisprocedure is done 3-4 months aftertherapyfor UTI.
• All infants(<1 year)requireevaluationusingultrasonography, MCU and
DMSA scan,sincetheyareatthehighestrisk ofUTI recurrence andscarring.
EarlydetectionofhighgradeVUR or obstructiveuropathyallows
interventionsto prevent progressivekidney damage.

40. RECOMMENDATIONS OFTHE INDIAN SOCIETYOF
PEDIATRIC NEPHROLOGY ON EVALUATION
FOLLOWINGTHE FIRST UTIARE SUMMARIZEDAS:

41. WHEN TO DO ADMISSION ????????
CHILDREN WHO ARE -:
Dehydrated, are vomiting, are unable to drink fluids, have complicated infection, or in whom
urosepsis is a possibility should be admitted to the hospital for intravenous(IV) rehydration and
IV antibiotic therapy.
Local antimicrobial sensitivity patterns should be considered when selecting empirical antibiotic
treatment.
For hospitalized children, parenteral treatment with ceftriaxone(50 mg/kg/24 hr, not to exceed 2
g) or cefepime (100 mg/kg/24 hrq 12 h) or cefotaxime (100-150 mg/kg/24 hr in 3-4 divided
doses) (when available) is a reasonable choice until culture results are back to determine
whether a narrower-spectrum antibiotic can be used.

42. TREATMENT
 Once UTI is suspected,a urine specimenis sentfor cultureand treatmentstarted.
 Infantsbelow 3 months ofageandchildren withcomplicatedUTI should initiallyreceiveparenteral
antibiotics.
 The initialchoiceofantibioticsis empiricandis modifiedonce cultureresultis available.
 While athirdgenerationcephalosporin is preferred, therapyOnce oral intakeimproves andsymptoms abate,
usuallyafter 48-72 hours, therapyis switchedto anoral antibiotic.
 The durationoftreatmentfor complicatedUTI is 10-14 days. Older infantsandpatientswithsimpleUTI
should receive treatmentwithanoral antibioticfor 7-10 days.

43. • All childrenwithUTI areencouragedto takeenough fluidsand emptythebladder
frequently.
• With appropriatetherapy,feverandsystemictoxicityreduce andurine cultureis
sterilewithin24-36 hours.

44. ANTI MICROBIAL FORTREATMENT OF UTI
• PARENTERAL ANTIBIOTICS
• CEFTRIAXONE
• CEFIPIME
• CEFOTAXIME
• AMIKACIN
DOSE (mg/kg/day)
75-100, 1-2 divided doses IV
100 , in 2 divided dose
100-150 ,in3 divideddose
15 , single dose IV or IM

45. • ORALANTIBIOTICS
• CEFIXIME
• CIPROFLOXACIN
• OFLOXACIN
• COAMOXICLAV
DOSE (mg/kg/day )
10 ,in 2 divideddose
10 -20 ,in 2 divideddose
15-20,in 2 divided dose
30-50of amoxicillin ,in 2divideddose

46. • There is interest in probiotic therapy, which replaces
pathologic urogenital flora, and
• Cranberry juice, which prevents bacterial adhesion and
biofilm formation, but these agents have not proved
beneficial in preventing UTI in children.
Treatme
nt
OTHERS

47. • Infants and children incomplicatedUTI:10‐14 days.
• Simple UTI:7‐10days.
• Adolescents with cystitis:3days
• Following treatmentprophylactic antibiotictherapyis initiated
inchildrenbelow1 yearofage.
DURATION OFTREATMENT

48. Immediatecomplications
•Sepsis
•Perinephricabscess
Long termsequelae
•Renalscar
•Hypertension(HT)
•End‐stage renal disease(ESRD)
COMPLICATIONS

49. PREVENTION OF RECURRENTUTI‐GENERAL
• Adequate fluidintakeand frequentvoiding.
• Constipation should beavoided.
• In childrenwithVUR regular and volitional low pressurevoidingwithcompletebladderemptyingis
encouraged.
• Double voiding.
• Circumcision reduces the riskofrecurrent UTI in infantboys,and thereforehavebenefits inpatients with
high gradereflux.

50. • Atany age should undergo detailedimagingwith
ultrasonography,
• MCU and DMSAscintigraphy.
RECURRENTUTI

51. PREVENTION OF RECURRENTUTI‐ANTIBIOTIC PROPYLAXIS
Indications forprophylaxis
• UTIbelow1‐yrofage,whileawaiting imagingstudies
• VUR
•frequentfebrileUTI(3or more episodes even if
the urinary tractis normal in a year )

52. Dose, mg/kg/day Remarks
• Medication
• Cotrimoxazole 1‐2oftrimethoprim Avoid ininfants
<3 mo,glucose‐6‐phosphate dehydrogenasedeficiency
• Nitrofurantoin 1‐2 May cause vomiting
and nausea; avoid ininfants<3 mo,G6PD deficiency, renal
insufficiency
ANTIMICROBIALS ‐PROPHYLAXIS OFUTI

53. • Medication Dose,mg/kg/day Remarks
• Cephalexin 10 Drug ofchoicein
first3‐6 mo of life
• Cefadroxil
earlyinfancy
5 An alternativeagentin
ANTIMICROBIALS ‐PROPHYLAXIS OFUTI

54. PATIENT/PARENT EDUCATION
Avoid bubble baths
Avoid Tight fitting clothing (girls)
Wipe “back to front”
Don’t hold urine for long periods of time