Urinary Tract Infections Prevalence and Etiology. Urinary tract infections (UTIs) occur in 3-5% of girls and 1% of boys.

of boys. In girls, the first UTI usually occurs by the age of 5 yr, with peaks during infancy and toilet training. After the first UTI, 60-80% of girls will develop a second UTI within 18 mo. In boys, most UTIs occur during the 1st yr of life; UTIs are much more common in uncircumcised boys. The prevalence of UTIs varies with age During the 1st yr of life, the male:female ratio is 2.8-5.4:1 Beyond 1-2 yr, there is a striking female preponderance, with a male:female ratio of 1:10. UTIs are caused mainly by colonic bacteria In females, 75-90% of all infections are caused by Escherichia coli, followed by Klebsiella and Proteus Staphylococcus saprophyticus is a pathogen in both sexes. Viral infections, particularly adenovirus, may also occur, especially as a cause of cystitis.

Clinical Manifestations and Classification. There are three basic forms of UTI: Pyelonephritis Cystitis asymptomatic bacteriuria Pyelonephritis characterized by any or all of the following: abdominal or flank pain, fever, malaise, nausea, vomiting, and occasionally diarrhea Newborns and infants may show nonspecific symptoms such as jaundice, poor feeding, irritability, and weight loss Involvement of the renal parenchyma is termed acute pyelonephritis if there is no parenchymal involvement, the condition may be termed pyelitis Acute pyelonephritis may result in renal injury, which is termed pyelonephritic scarring Cystitis there is bladder involvement and symptoms include dysuria, urgency, frequency, suprapubic pain, incontinence, and malodorous urine Cystitis does not cause fever and does not result in renal injury Asymptomatic bacteriuria refers to individuals who have a positive urine culture without any manifestations of infection occurs almost exclusively in girls Pathogenesis and Pathology. Nearly all UTIs are ascending infections The bacteria arise from the fecal flora, colonize the perineum, and enter the bladder via the urethra In uncircumcised boys, the bacterial pathogens arise from the flora beneath the prepuce Renal infection may occur by hematogenous spread If bacteria ascend from the bladder to the kidney, acute pyelonephritis may occur Simple and compound papillae in the kidney have an antireflux mechanism that prevents urine from flowing in a retrograde manner into the collecting tubules compound papillae in the upper and lower poles of the kidney, allow intrarenal reflux. Infected urine then stimulates an immunologic and inflammatory response

The result may cause renal injury and scarring In girls, UTIs often occur at the onset of toilet training because of voiding dysfunction that occurs at that age Voiding dysfunction may occur in the toilet-trained child who voids infrequently Obstructive uropathy resulting in hydronephrosis increases the risk of UTI because of urinary stasis Urethral instrumentation during a voiding cystourethrogram or nonsterile catheterization may infect the bladder with a pathogen Constipation can increase the risk of UTI because it may cause voiding dysfunction

The pathogenesis of UTI is based in part on the presence of bacterial pili or fimbriae on the bacterial surface Type I fimbriae are found on most strains of E. coli "mannose-sensitive" They have no role in pyelonephritis Type II fimbriae "mannose-resistant." These fimbriae are expressed by only certain strains of E. coli The receptor for type II fimbriae is a glycosphingolipid that is present on both the uroepithelial cell membrane and red blood cells. The Gal 1-4 Gal oligosaccharide fraction is the specific receptor Because these fimbriae can agglutinate by P blood group erythrocytes, they are known as P fimbriae Bacteria with P fimbriae are more likely to cause pyelonephritis

Other host factors for UTI: anatomic abnormalities precluding normal micturition, such as a labial adhesion A neuropathic bladder may cause UTIs if there is incomplete bladder emptying or detrusorsphincter dyssynergia, or both Sexual activity is associated with UTIs in girls, in part because of incomplete bladder emptying Xanthogranulomatous pyelonephritis rare type of renal infection characterized by granulomatous inflammation with giant cells and foamy histiocytes may present clinically as a renal mass or an acute or chronic infection Renal calculi, obstruction, and infection with Proteus or E. coli contribute to the development of this lesion, which usually requires total or partial nephrectomy. Diagnosis. A UTI may be suspected based on: symptoms or findings on urinalysis, or both a urine culture is necessary for confirmation and appropriate therapy Methods of urine collection: In toilet-trained children a midstream urine sample is usually satisfactory If the culture shows greater than 100,000 colonies of a single pathogen, or if there are 10,000 colonies and the child is symptomatic, it is considered a UT In uncircumcised males, the prepuce must be retracted; if the prepuce is not retractable, this method of urine collection is unreliable. In infants the application of an adhesive, sealed, sterile collection bag after disinfection of the skin of the genitals can be useful

If the urinalysis result is positive, the patient is symptomatic, and there is a single organism cultured with a colony count greater than 100,000, there is a presumed UTI if any of these criteria are not met, confirmation of infection with a catheterized sample is recommended

When greater assurance as to the possibility of infection is needed catheterized specimen must be obtained The use of a No. 5 French polyethylene feeding tube in infants No. 8 French tube with proper lubrication in older children minimizes the chance of urethral trauma and contamination If the urine sits at room temperature for more than 60 min, overgrowth of a minor contaminant may suggest a UTI, when in fact the urine may not be infected Placing the sample in a refrigerator is a reliable method of storing the urine until it can be cultured Urinalyis A urinalysis should be obtained from the same specimen as that cultured Pyuria suggests infection, but infection can occur in the absence of pyuria; consequently, this finding is more confirmatory than diagnostic Pyuria can be present without UTI. Nitrites and leukocyte esterase are usually positive in infected urine Microscopic hematuria is common in acute cystitis White blood cell casts in the urinary sediment suggest renal involvement, but these are rarely seen If the child is asymptomatic and the urinalysis result is normal, it is unlikely that the urine is infected However, if the child is symptomatic, a UTI is possible, even if the urinalysis result is negative leukocytosis, neutrophilia, and elevated erythrocyte sedimentation rate and C-reactive protein are common. The latter two are nonspecific markers of bacterial infection With a renal abscess, the white blood cell count is markedly elevated to greater than 20,000 to 25,000/mm3 Acute hemorrhagic cystitis frequently caused by E. coli attributed also to adenovirus types 11 and 21 Adenovirus cystitis is more frequent in males it is self-limiting, with hematuria lasting approximately 4 days Eosinophilic cystitis rare form of cystitis of obscure origin that occasionally is found in children The usual symptoms are those of cystitis with hematuria, ureteral dilatation with occasional hydronephrosis, and filling defects in the bladder caused by masses that consist histologically of inflammatory infiltrates with eosinophils Children with eosinophilic cystitis may have had exposure to an allergen Frequently, bladder biopsy is necessary to exclude a neoplastic process Treatment usually includes antihistamines and nonsteroidal anti-inflammatory agents, but in some cases intravesical dimethyl sulfoxide instillation is necessary Interstitial cystitis irritative voiding symptoms such as urgency, frequency, and dysuria, and bladder and pelvic pain relieved by voiding with a negative urine culture The disorder is most likely to affect adolescent girls and is idiopathic Diagnosis is made by cystoscopic observation of mucosal ulcers with bladder distention Treatments have included bladder hydrodistention and laser ablation of ulcerated areas, but no treatment yields sustained relief.

Treatment. If the symptoms are mild or the diagnosis is doubtful, treatment can be delayed until the results of culture are known, and the culture can be repeated if the results are uncertain If treatment is initiated before the results of a culture and sensitivities are available: 3- to 5-day course of therapy with trimethoprim-sulfamethoxazole is effective against most strains of E. coli Nitrofurantoin (5-7 mg/kg/24 hr in three to four divided doses) is also effective and has the advantage of being active against Klebsiella-Enterobacter organisms Amoxicillin (50 mg/kg/24 hr) is also effective as initial treatment but has no clear advantages over the sulfonamides or nitrofurantoin In acute febrile infections suggestive of pyelonephritis 14-day course of broad-spectrum antibiotics capable of reaching significant tissue levels is preferable Children who are dehydrated, are unable to drink fluids, or in whom sepsis is a possibility admitted to the hospital for intravenous rehydration and intravenous antibiotic therap Parenteral treatment with ceftriaxone (50-75 mg/kg/24 hr, not to exceed 2 g) or ampicillin (100 mg/kg/24 hr) with an aminoglycoside such as gentamicin (3 to 5 mg/kg/24 hr in one to three divided doses) is preferable The potential ototoxicity and nephrotoxicity of aminoglycosides should be considered, and serum creatinine and trough gentamicin levels must be obtained before initiating treatment as Treatment with aminoglycosides effective against Pseudomonas, and alkalinization of urine with sodium bicarbonate increases their effectiveness in the urinary tract Oral third-generation cephalosporins such as cefixime As effective as parenteral ceftriaxone against a variety of gram-negative organisms other than Pseudomonas considered by some authorities to be the treatment of choice for oral therapy Nitrofurantoin not be used in children with a febrile UTI because it does not achieve significant renal tissue levels The oral fluoroquinolone ciprofloxacin alternative agent for resistant microorganisms, particularly Pseudomonas, in patients older than 17 yrs clinical use of fluoroquinolones in children should be restricted because of potential cartilage damage that occurred in research with immature animals safety and efficacy of oral ciprofloxacin in children is under study. In some children with a febrile UTI, intramuscular injection of a loading dose of ceftriaxone followed by oral therapy with a thirdgeneration cephalosporin is effective. Children with a renal or perirenal abscess or with infection in obstructed urinary tracts require surgical or percutaneous drainage in addition to antibiotic therapy and other supportive measures

A urine culture should be performed 1 wk after the termination of treatment of any UTI to ensure that the urine is sterile Given the tendency of urinary tract infections to recur even in the absence of predisposing anatomic factors, a follow-up urine culture should be performed periodically for 1-2 yr, even when the child is asymptomatic. The main consequences of chronic renal damage caused by pyelonephritis: arterial hypertension renal insufficiency Imaging Studies. The goal of imaging studies in children with a UTI is to identify anatomic abnormalities that predispose to infection A renal ultrasonogram obtained to rule out hydronephrosis and renal or perirenal abscesses may show acute pyelonephritis (in 30-60% of cases) by demonstrating an enlarged kidney Power Doppler ultrasonography has been slightly more sensitive but is unreliable in identifying all cases. Ultrasonography demonstrates 30% of renal scars Normally, the difference in renal lengths between the two kidneys is less than 1 cm, and a larger disparity may be an indication of impaired renal growth In a child with acute pyelonephritis, a small kidney may be enlarged because of the infection, giving the erroneous impression that the kidneys are equal in size also sensitive for detecting pyonephrosis, a condition that may require prompt drainage of the collecting system by percutaneous nephrostomy

A voiding cystourethrogram (VCUG) Also indicated in all children: younger than 5 yr with a UTI child with a febrile UTI school-aged girls who have had two or more UTIs The most common finding is vesicoureteral reflux, which is identified in approximately 40% of patients (Timing of the VCUG is controversial In some centers the study is delayed for 2-6 wk to allow inflammation in the bladder to resolve However, the incidence of reflux is identical, irrespective of whether the VCUG is obtained during treatment of the UTI or after 6 wk Consequently, obtaining the VCUG before the child is discharged from the hospital is recommended If available, a radionuclide VCUG instead of a contrast VCUG can be used in girls this technique causes less radiation exposure to the gonads than does the contrast study the radioisotopic VCUG does not provide anatomic definition of the bladder, allow precise grading of reflux, demonstrate a paraureteral diverticulum, or show whether reflux is occurring into a duplicated collecting system or an ectopic ureter In boys, radiographic definition of the urethra is important; accordingly, contrast VCUG is recommended for the initial work-up. Because of concern that the VCUG is traumatic to the child, some parents question the need for a VCUG if the ultrasonogram is normal However, ultrasonography is insensitive in detecting reflux; only 40% of children with reflux have any abnormality on the ultrasonogram

The VCUG should not be performed using general anesthesia, because the study is incomplete without a voiding phase and it subjects the child unnecessarily to the risk and cost of anesthesia oral or nasal midazolam (up to 0.5 mg/kg oral route, 0.2 mg/kg nasal route), which causes anterograde amnesia and anxiolysis, may be used We have found that this medication is efficacious and safe and provides an acceptable experience with VCUG. Vital signs are monitored and pulse oximetry is used; no anesthesiologist is present.

When the diagnosis of acute pyelonephritis is uncertain renal scanning with technetium-labeled DMSA or glucoheptonate is useful presence of photopenia supports the diagnosis of pyelonephritis In approximately 50% of children with a febrile UTI, irrespective of age, the DMSA scan demonstrates parenchymal involvement. In children with grade III, IV, or V reflux and a febrile UTI, 80-90% show acute pyelonephritis. If the DMSA scan shows acute pyelonephritis, approximately 50% will acquire a scar in that site over the following 5 mo. However if the DMSA scan is normal during a febrile UTI, no scarring results from that particular infection Computed tomography can diagnose acute pyelonephritis clinical experience with DMSA is much greater If vesicoureteral reflux is present DMSA scan often is performed to assess whether renal scarring is present The DMSA is the most sensitive and accurate study for demonstrating scarring Excretory urography not as sensitive as the DMSA scan in demonstrating renal scarring visualization of the collecting system in infants and young children often is suboptimal, there is a slight risk of a contrast allergy, and it can take 1-2 yr for a renal scar to appear on the urogram Computed tomography used by some to evaluate the upper urinary tract effective in demonstrating renal scarring

Source: Nelsons Textbook of Pediatrics 19th Ed.