Childhood

Urinary Tract
Infection
dr. Kristia Hermawan, MSc, Sp.A

Pediatric Nephrology Sub-division

Department of Child Health
Faculty of Medicine, Universitas Gadjah Mada
Sardjito Hospital Yogyakarta
2013
 Definition
UTI: the presence of proliferating
bacteria in the urinary tract (renal
parenchym to bladder), causing tissue
invasion and inflamation. a,b

Recurrent UTI
Defined as 2 incident of UTI within 6
moths and caused by organism
different form previous infection
 Terminology
Upper UTI
Infection in renal parenchym (Pyelonephritis)
Lower UTI
Infection of bladder or urethra (Cystitis)
The border : vesicouretheral junction.

Simple UTI
Infection without anatomical or functional defect of urinary
tract
Complex UTI
proven anatomical and/or functional lesion of urinary
tract, either as a consequence of infection or as an
underlying cause.
 Epidemilogy
UTI occurs in as many as 5 % of girls and 1- 2 %
of boys
Incidence in sepcific age category:
Newborn: 0.1- 1.0 % to as high as 10 % in LBW
Infant < 1 year old: Male predominance
Preschool-age: prevalence of asymptomatic
infections diagnosed by suprapubic aspiration in
girls: boys is 0.8%: 0.2% .
School-age group: Incidence of bacteriuria among
girls is 30 times as much as boys (1.2 %: 0.04%)
Etiology
 Pathogenesis
(3%)

Lymphogenous (6%)

(90%)
c

7
Pathogenesis of UTI ascending ec
E.colli
Presdisposing Factors
Urinary tract Instrument: indwelling catheter
Congenital anomaly
Non obstructive: polycystic, hypoplastic,
persistent urachus, fistula, ectopic VU, biureter
Obstructive:
Lower tract: phimosis, PUV
Upper tract: ureter stenosis, pelvico-ureer
junction stenosis
Urolithiasis
Disorder of vesico urinary voiding (VUR,
neurogenic bladder)

Childhood Urinary
Tract Infection
CLINICAL APPROACH
History
History of the acute
documentation of the
illness Past medical history
height and duration of
fever
urinary symptoms
(dysuria, frequency,
urgency, incontinence)
abdominal pain,
suprapubic discomfort,
back pain,
vomiting,
recent illnesses,
antibiotics administered,
sexual activity (if
applicable).
Chronic urinary symptoms:
incontinence, lack of proper
stream, frequency, urgency,
withholding maneuvers
Chronic constipation
Previous UTI
Vesicoureteral reflux (VUR)
Previous undiagnosed febrile
illnesses
Family history of frequent UTI,
VUR, and other genitourinary
abnormalities
Elevated blood pressure
Poor growth
 Physical examination
Blood pressure and temperature
Growth parameters (poor weight gain and/or failure to thrive)
Abdominal tenderness or mass (eg, enlarged bladder or
enlarged kidney)
Suprapubic and costovertebral tenderness
External genitalia: anatomic abnormalities (eg, phimosis or
labial adhesions) and signs of vulvovaginitis, vaginal foreign
body, sexually transmitted diseases (STDs)
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
 Likelihood ratios for selected
symptoms and signs of urinary tract
infection in children 0 24 months

FINDING LR + LR -
History of prior UTI 2.9 (95% CI 1.2-7.1) 0.95 (95% CI 0.89-1.02)
Temperature (T) >39C 1.4 (95% CI 1.2-1.7) 0.78 (95% CI 0.65-0.81)
T >40 3.3 (95% CI 1.3-8.3) 0.66 (95% CI 0.35-1.25)
Fever >24 hours 2.0 (95% CI 1.4-2.9) 0.90 (95% CI 0.83-0.97)
Fever >48 hours 1.3 (95% CI 0.8-1.9) 0.95 (95% CI 0.85-1.06)
Ill appearance
infants <3 mo 1.1 (95% CI 0.9-1.3) 0.95 (95% CI 0.84-1.08)
children 3-24 mo 1.9 (95% CI 1.5-2.4) 0.68 (95% CI 0.53-0.88)
Suprapubic tenderness 4.4 (95% CI 1.6-12.4) 0.96 (95% CI 0.9-1.01)
No other source for
fever on examination 1.4 (95% CI 1.1-1.8) 0.69 (95% CI 0.55-0.8)
Uncircumcised male 2.8 (95% CI 1.9-4.3) 0.33 (95% CI 0.18-0.63)
 Positive likelihood ratios for
combination of symptoms and signs of
urinary tract infection in children 0
24 months

Combination of finding LR +
T > 39C for >48 hours and no 4 (95% CI 1.2-13)
potential source for fever
T >38C for >48 hours and no 3.6 (95% CI 1.4-8.8)
potential source for fever
T >39C and no potential source for 2 (95% CI 1.8-2.4)
fever
T >39C for >48 hours 1.7 (95% CI 0.9-2.9)
T >39C with a potential source for 0.86 (95% CI 0.5-
fever: 1.47)
T <39C and potential source for 0.37 (95% CI 0.16-
fever: 0.85)
potential sources of fever: upper respiratory infection, acute
otitis media, and acute gastroenteritis
 Likelihood ratios for selected
symptoms and signs of urinary tract
infection in verbal children

FINDING LR + LR-
Abdominal pain 6.3 (95% CI 2.5-16) 0.8 (95% CI 0.65-0.99)

Back pain 3.6 (95% CI 2.1-6.1) 0.84 (95% CI 0.75-0.95)

Dysuria/frequency 2.2 (95% CI 1.1-4.3) 0.71 (95% CI 0.45-1.13)

New-onset urinary incontinence

4.6 (95% CI 2.8-7.6) 0.79 (95% CI 0.69-0.90)

Shaikh N, Morone NE, Lopez J, et al. Does this child have a urinary tract infection?
JAMA 2007; 298:2895
 Laboratory Examination
Catheterization/ suprapubic tap urine samples for urinalysis (dipstick and
microscopic examination) and culture are indicated in the following
patients:
younger than two years
Girls and uncircumcised boys with at least one risk factor for UTI
Circumcised boys younger than two years with suprapubic tenderness or at least two risk
factors for UTI

history of UTI, temperature >39C, fever without apparent source [particularly if the child will
be treated with antibiotics], ill appearance, suprapubic tenderness, fever >24 hours, or
nonblack race

boys older than two years

Circumcised boys with multiple urinary symptoms
Girls and uncircumcised with any of the following urinary symptoms

abdominal pain, back pain, dysuria, frequency, high fever, or new-onset incontinence

Febrile infants and children with abnormalities of the urinary tract or family
history of urinary tract disease
 Obtaining Urine Sample
Catheterization or suprapubic aspiration is the preferred method of
urine collection for dipstick, microscopic examination, and culture of the
urine in infants and young children who are not toilet-trained.
Clean catch is the preferred method of collection in toilet-trained
children
All urine specimens should be examined as soon as possible. A delay of
even a few hours increases both the false-positive and false-negative
rates substantially
We specifically recommend a suprapubic aspirate when:
Catheterization is not feasible (eg, severe phimosis or penile adhesions in boys;
labial adhesions in girls)
Results from a catheterized specimen are inconclusive (eg, repeated
contaminated specimen or repeated low colony counts)
Urine obtained in a sterile bag notbe used for culture.
Supportive examination
Urine Culture
is recommended when there are symptoms
indicating UTI but with normal urinalysis and for
patients with pyelonephitis.
Urine speciment has to be inoculated in a
medium immediately or be stored at
temperature of 4 C if there is delay more than
10 minutes.
 Significant bacteriuria
Depends upon method of collection and organism identification
Lactobacillusspp, coagulase-negative staphylococci, and
Corynebacteriumspp not clinically relevant uropathogens
Clean catchsample growth of 100,000 CFU/mL of a single
uropathogenic bacteria.
Catheter sample growth of 50,000 CFU/mL of a single
uropathogenic bacteria. Growth of 10,000 to 50,000 CFU/mL
from an initial catheterized specimen should have a repeat
culture, consider ed to have UTI if the second culture grows
10,000 CFU/mL and pyuria is present
Suprapubic sample growth of any uropathogenic bacteria.
Urinalysis examination
PYURIA
The presence of WBC in the urine is not specific for UTI.
True UTI without pyuria is unusual.
The absence of pyuria in the presence of significant
bacteriuria may occur in:
Early in the course of UTI (before the local inflammatory response
develops)
Colonization of the urinary tract (eg, asymptomatic bacteriuria)
Children who are suspected of having UTI but in whom
pyuria is not detected urynalisis should be repeated
The presence of pyuria and bacteriuria on the second sample is
suggestive of UTI
The absence of pyuria and bacteriuria on the second sample is
suggestive of bacterial contamination of the initial sample
Bacteriuria without pyuria on the second sample is suggestive of
asymptomatic bacteriuria
Urynalisis examination
Nitrit:
very specific but less sensitive
good when used on fresh urine
speciment
is produced by bacteria metabolizing
nitrit such as E. Coli, Klebsiela, proteus.
false-negative tests are common,
because urine needs to remain in the
bladder for at least four hours to
accumulate a detectable amount of
nitrite.
Shaikh N, Morone
NE, Lopez L, et al.
Does this child
have a urinary
tract infection?
JAMA 2008;
298:2895
Shaikh N, Morone NE, Lopez L, et al. Does this child have a urinary tract infection? JAMA
2008; 298:2895
Shaikh N, Morone NE, Lopez L, et al. Does this child have a urinary tract infection? JAMA
2008; 298:2895
Supportive examination
Imaging
To rule out anatomical/ functional problem
simple/ complex UTI??
To reveal sign of inflamation in specific site
Urinary tract sonography: hydronephrosis, stone,
specific lession (diverticle, mass)
VCUG (Voiding cysto-uretherography): voiding
function/ bladder contractility, vesico-urteheral
refluxs
 Renal-Bladeder
Ultrasound
Suggest RBUS for the following children:
Children younger than two years of age with
a first febrile UTI
Children of any age with recurrent febrile
UTIs
Children of any age with a UTI who have a
family history of renal or urologic disease,
poor growth, or hypertension
Children who do not respond as expected to
appropriate antimicrobial therapy
 Management
Goals
Elimination of infection and prevention of urosepsis
Prevention of recurrence and long-term complications including
hypertension, renal scarring, and impaired renal growth and function
Relief of acute symptoms (eg, fever, dysuria, frequency)

Indications for hospitalization and/or parenteral therapy

Age <2 months
Clinical urosepsis (eg, toxic appearance, hypotension, poor capillary
refill)
Immunocompromised patient
Vomiting or inability to tolerate oral medication
Lack of adequate outpatient follow-up (eg, no telephone, live far from
hospital, etc)
Failure to respond to outpatient therapy
Management
Early and aggressive antibiotic therapy (eg, within 72 hours
of presentation) is necessary to prevent renal damage.
Antimicrobial therapy be initiated immediately after
appropriate urine collection in children with suspected UTI
and a positive urinalysis.
Particularly for children who are at increased risk for renal
scarring if UTI is not promptly treated, including children
who present with:
Fever (especially >39C [102.2F] or >48 hours)
Ill appearance
Costovertebral angle tenderness
Known immune deficiency
Known urologic abnormality

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 Empiric therapy
A Gram-stained smear of the urine, can help
guide decisions regarding empiric therapy.
Escherichia coliis the most common
bacterial cause of UTI; it accounts for
approximately 80 percent of UTI in children
empiric therapy should include an
antibiotic that provides adequate coverage
for E. coli.
The agent of choice should be guided by
local resistance patterns.
Oral antibiotics for UTI
 Oral antibiotic
a third-generation cephalosporin (eg, cefiximecefdinir, ceftibuten) as the first-line
oral agent in the treatment of UTI in children without genitourinary abnormalities

In a randomized, controlled trial of 306 children 1 to 24 months of age with a

febrile UTI, oral therapy with cefixime for 14 days was as effective as intravenous
therapy with cefotaximefor three days followed by oral therapy with cefixime. The
rates of symptom resolution (mean time to defervescence approximately 24
hours), sterilization of the urine (100 percent), reinfection (4.6 and 7.2 percent),
and renal scarring at six months (9.8 and 7.2 percent) did not differ between
groups.

Oral amoxicillin-clavulanate(50 mg/kg per day in three divided doses) also was
shown to be as effective as parenteral therapy followed by oral therapy in a
multicenter, randomized trial. However, amoxicillin-clavulanate is associated with
increasing rates of resistance.

Ciprofloxacin should not be used as a first-line agent. The American Academy of

Pediatrics (AAP) Committee on Infectious Diseases recommends that the use of
ciprofloxacin for UTI in children be limited to UTI caused by Pseudomonas
aeruginosaor other multidrug-resistant, gram-negative bacteria
Parenteral antibiotics for UTI
Prophylactic antibiotics for
UTI
 Duration of treatment
systematic review short course antimicrobial therapy
(two to four days) was as effective as standard duration
(7 to 14 days) therapy in eradicating bacteria in children
with suspected lower urinary tract infection (ie, afebrile
children)

few data to guide duration of antimicrobial therapy in

children with febrile UTIs.

longer course of therapy for febrile children (usually 10

days, with a range of 7 to 14) and a short course of
therapy (three to five days) for immune competent
children presenting without fever.
 Complication
Vesico-urethral reflux
I. Reflux to 1/3 of lower ureter.
II. Reflux to the pelvic without damage of
calix.
III. Reflux to the pelvic with damage of
calix.
IV. Reflux accompanied by hydroureter
and hydronephrosis.

Renal scaring renal failure

Septicemia
 PROGNOSIS
The short-term outcome of first UTI in children (<19 years)
[systematic review of 33 studies, including 4891 children]
Twenty-five percent had VUR; 2.5 percent had grade IV or V VUR
VUR was associated with an increased risk of developing acute
pyelonephritis (relative risk [RR] 1.5, 95% CI 1.1-1.9) and renal scarring (RR
2.6, 95% CI 1.7-3.9); grade III VUR was associated with increased risk of
renal scarring compared with lower grades (RR 2.1, 95% CI 1.4-3.2)
Fifteen percent (95% CI 11-18 percent) of children had evidence of renal
scarring on follow-up DMSA scan (5 to 24 months later)
Eight percent (95% CI 5-11 percent) of children had at least one recurrence
Risk factors for recurrence among children younger than six years include:
white race (hazard ratio [HR], 2.0)
age three to five years (HR ~2.5)
and grade IV to V VUR (HR 4.38)
Thank
You dr.kryzt@gmail.com

Division of Pediatric Nephrology

Department of Child Health
Faculty of Medicine, Universitas Gadjah Mada
Sardjito Hospital Yogyakarta
2013