Journal Reading

Urinary Tract Infections in Children

Ariski Pratama Johan, S.Ked I4061172043

Pembimbing : Dr. Alexander, Sp. A
Rumah Sakit TK II Kartika Husada Kesehatan Daerah Militer XII/Tanjungpura
2019
Educational Gap (Important concepts not
always known to the medical community)
• Consideration of risk factors for urinary tract infections (UTIs) in young
children with fever is critical for accurate diagnosis, as well as prevention
of overtesting.
• The use of perineal bags to collect urine from young children should be
limited to specific indications in the diagnosis of urinary tract infections.
• Screening for and managing bowel and bladder dysfunction reduces
the risk of UTIs in older children.
Objectives
1. Recognize the risk factors for urinary tract infections (UTIs) in
children.
2. Review the interpretation of urinalysis and urine cultures.
3. Review antibiotic therapy choices for UTIs.
4. Describe which children need imaging after febrile UTIs.
5. Discuss prevention strategies to discuss with families.
Case Study
Charlotte is a 13-month-old girl with a history of 2 febrile urinary tract
infections (UTIs) 4 and 6 months ago. She had normal renal and
bladder ultrasonographic findings 6 months ago. She presents with a
fever that began yesterday. She has no other new symptoms.
Her 4-year-old brother had a self-limited febrile illness 1 week ago,
which resolved. At examination, she is fussy but consolable and alert.
She is non–toxic appearing. Her physical examination findings show
tachycardia with a heart rate of 130 beats/min, without murmur. Her
respiratory rate is 28 breaths/min, without distress or retractions. Her
lungs are clear bilaterally. Her tympanic membranes appear normal.
Case Study
Her abdomen is soft and nontender. Her genital examination findings appear
normal, without erythema or labial adhesions. Her temperature is 102.5°F
(39.2°C). A bag is placed to collect a urine sample. The urinalysis from
the bag sample has 5 to 10 white blood cells (WBCs) per high-power
field, a 1+ leukocyte esterase result, and a 1+ ketone result.
Should a bag have been placed to collect urine? Does Charlotte have a
UTI? How should she be treated at this point?
Epidemiology
Children under 24 months of age (infants and toddlers)
• UTIs are common! (7% of febrile infants)
• Race is important. 10% of white infants with fever without a source have a
UTI, while only about 2% of black infants with fever without a source have a
UTI.
• Age is important. So is sex. Febrile female infants 12 months of age or
less have a 6%-8% risk of UTI, while febrile girls older than 12 months have
a 2% risk.
• For male subjects, it depends whether they are circumcised. Febrile
uncircumcised male infants less than 3 months of age have a 20% risk of
UTI, while febrile circumcised male infants less than 3 months have a 2.4%
risk of UTI. After 3 months of age, the risk decreases for both groups.
Epidemiology
Children 2 years old and older
• This age group can generally describe typical symptoms, such as
dysuria and urinary hesitancy. Children with these symptoms have about
an 8% risk of UTI.
• Important factors that affect risk in this age group include the presence
of bladder-or bowel-withholding behaviors, congenital anomalies of
the urinary tract, and previous history of UTI.
Pathogenesis
• Usually, UTIs are an ascending infection, meaning bacteria travel against
the flow of urine, from the urethra to the bladder to the ureters, then
sometimes to the kidney(s).
• Escherichia coli is the most common bacteria that causes UTIs in all
ages and accounts for 54%-67% of UTIs in children.
• Klebsiella(6%-7%), Proteus(5%-12%), Enterococcus(3%-9%), and
Pseudomonas(2%-6%) are other common causative organisms (4).
• Hematogenous spread to the urinary system is a rare cause of UTI but
can occur in neonates and children with immunodeficiency.
Clinical Presentation
• Infants and toddlers less than 24 months of age present with fever.
• Children older than 24 months of age are able to localize symptoms
and therefore present with dysuria, urinary hesitancy, and/or abdominal
pain.
 Estimating Risk of UTI for Children 2 to24
Months of Age

Use the American

Academy of Pediatrics
Urinary Tract Infection
Guidelines table when
assessing risk factors.

The guidelines allow clinicians to calculate a pretest probability of UTI to make

an informed decision about which children need further evaluation for UTI.
Diagnosis
• The diagnosis of UTI in children is based on the results of urinalysis
and urine culture.
• Demonstration of inflammation in the urine (white blood cells,
leukocyte esterase) and bacteria growing in culture are critical.
• There are diseases that cause urinary inflammation without bacteria
(sterile pyuria) in the urine (Kawasaki disease, viral infections).
• Bacteria may be present in the urinary tract without causing
inflammation and infection (asymptomatic bacteriuria).
• Consider conditions that predispose the patient to or mimic UTIs,
such as labial adhesions, Candida infection, and vulvovaginitis, in
female patients. In male patients, an obstructed urinary stream (such
as dribbling of urine from the urethra) may suggest posterior urethral
valves or phimosis.
Diagnosis in Children Less Than 24
Months of Age
• Urine Collection
• Infants are generally not able to submit a clean-caught voided
specimen; therefore, catheterization is often performed to collect a urine
sample for urinalysis and culture. Urine collection with a bag is also an
option with special considerations, but the urine collected should be
analyzed only for urinalysis and not culture.
Diagnosis in Children Less Than 24
Months of Age
• Interpretation of the Urinalysis
• Interpret carefully!
Diagnosis in Children Less Than 24
Months of Age
Interpretation of the Urine Culture
• Generally, 50,000 CFU/mL or higher represents considerable urine
bacterial growth and is clinically significant.
• However, 10,000 to 50,000 CFU/mL may represent UTI, especially in
neonates, children with immunodeficiency, urinary tract
abnormalities, or children already taking antimicrobial therapy.
Children with Neurogenic Bladder Dysfunction
• These children are not able to empty the bladder normally and require
clean intermittent catheterization to prevent chronic renal disease from
both high urinary pressures and chronic UTIs. Examples include children
with spina bifida and spinal cord injury.
• Children with neurogenic bladder dysfunction have a high prevalence of
asymptomatic bacteruria; therefore, the presence of bacteria at culture
should not alone suggest a UTI. The definition of a UTI in this
population has not been widely established, but most agree that all of
the following should be established to make a diagnosis: presence of
symptoms(fever, pain, incontinence, or cloudy urine), inflammation at
urinalysis, and significant growth of a single bacterial species in urine
culture.
Management
• The management of children with UTIs requires consideration of the
child’s age, medical history, risk factors, degree of current illness, and
other unique circumstances.
• Oral antibiotics alone are as effective as IV antibiotics for UTIs,
including pyelonephritis. However, IV antibiotics should be
administered when a child is clinically toxic appearing and may also
have bacteremia or sepsis or when they cannot tolerate oral antibiotics.
• The choice of the empirical antibiotic should be tailored to local
bacterial susceptibility data, patient compliance, medication cost, and, if
the patient has a history of prior UTI, the individual susceptibility pattern
in prior infections.
Some Empirical Antimicrobial Agents for
Parental (Right) and Oral (Left) Treatment of
UTI
Imaging
• Renal and bladder ultrasonography is recommended for children less
than 24 months of age after a febrile UTI to detect anatomic
abnormalities, such as an obstructive process.
• Voiding cystourethrography (VCUG) should not be routinely
performed in children after a first UTI. VCUG is, however,
recommended in children less than 24 months of age who have had a
febrile UTI and who had an abnormal renal and bladder
ultrasonographic finding, because these children are at higher risk of
grade V vesicoureteral reflux.
Prophylaxis of UTIs
• The decision to routinely start antibiotic prophlyaxis in children with
vesicoureteral reflux remains controversial.
• Antibiotic prophylaxis with trimethoprim-sulfamethaxole for children
with vesicoureteral reflux reduces the risk of UTI occurrence by half.
However, more than 5,500 doses of antibiotic are needed to prevent 1 UTI.
Antibiotic prophylaxis has not been shown to reduce renal scarring.
Twice-daily administration of an antibiotic may also lead to antibiotic
resistance.
Prevention by Recognizing Bowel and
Bladder Dysfunction
• Preventing UTIs by screening for, identifying, and treating bowel and
bladder dysfunction is not controversial and is underrecognized,
effective, and safe. Inquiring about constipation symptoms, daytime
wetting, and withholding behaviors will help identify children with bowel or
bladder dysfunction.
• Bladder dysfunction can be treated by recommending scheduled voiding,
for example urine until the last minute. every 3-4 hours, to prevent the
child from voluntarily withholding
Summary
• On the basis of strong research evidence, clinicians treating young
children with fever without an apparent source should include UTI as
part of the differential diagnosis. Clinicians should evaluate risk factors
for UTI, including age, race, temperature, fever duration, and, in male
patients, circumcision status.
• On the basis of strong research evidence, young children with symptoms
who are not at low risk for UTI should undergo urinalysis. The urine for
urinalysis can be obtained via either bag or catheterization. Urine obtained
from bags can be helpful to rule out UTI if the results of the urinalysis are
normal. However, if the urinalysis from the bag specimen has evidence of
inflammation, catheterization is necessary for culture and repeat
urinalysis. A culture should not be sent from a bag specimen.
Summary
• On the basis of some research evidence, as well as consensus, the
diagnosis of a UTI should include clinical symptoms, a urinalysis
with evidence of inflammation (leukocyte esterase and/or at least 5
WBC/hpf), and culture results of at least 50,000 CFU/mL of a typical
uropathogen.
• On the basis of strong research evidence, the choice of antibiotic
therapy should take into account local susceptibility data, cost of the
antibiotic, and patient compliance issues. Typical good choices,
depending on local susceptibility, include cephalexin and
trimethoprim–sulfamethoxazole. Trimethoprim-sulfamethoxazole
should not be used in infants less than 2 months of age.
Summary
• On the basis of some research evidence, as well as consensus, young
children with a febrile UTI should undergo renal and bladder
ultrasonography to rule out anatomic abnormalities or signs of
obstruction. VCUG should not be performed routinely after the first
febrile UTI.
• On the basis of some research evidence, as well as consensus, clinicians
should screen for and manage bowel and bladder dysfunction in older
children. Appropriately managing bowel and bladder dysfunction reduces
UTIs.