Urinary Tract Infection

Urinary tract
infection
Prepared by: Dr. Ahlam
Abdulmalik
Definitions
• Cystitis: Infection localized to urinary bladder
• Pyelonephritis: Infection of renal parenchyma , calyces and renal
pelvis
• Renal abscess: localized pus collection may be intra renal or
perinephric
• Urinary tract and urine are normally sterile
Etiology
• In neonates: group B streptococcal bacteria
• Escherichia coli: ascending from bowel (perineum), account for 85%
of first infection
• Other gram negative bacteria : Klebsiella, Proteus, Enterococcus,
pseudomonas
• Staphylococcus saprophyticus is associated with UTI in some children
and account for 15% of UTI in adoulescent girl
Epidemiology
• Approximately 3% of girls and 1% of boys have UTI during their
prepubertal years, with heights incidence in the first year of life
• In the first year of life male affected more than female, but after that
female affected more
• Uncircumcised boys have 10 fold greater risk of developing UTI
compared with circumcised boys
Risk factors
• Obstruction to urinary flow as a result of anatomical abnormality, and urinary
stasis
• Nephrolithiasis
• Indwelling urinary catheter
• Uretro pelvic junction obstruction
• Exterinsic compression
• Severe vesico uretral reflux predisposed to chronic renal scarring
• Constipation or withholding urine
• Neurogenic bladder
• Uncicumcised male
Vesicourteral
reflux
Clinical manifestations
• Symptoms and signs of UTI vary markedly with age
• The presence of UTI should be suspected in all children with
unexplained fever and in patients of all ages with fever and congenital
anomalies of urinary tract
• In neonates and infants : non specific symptoms as:
Fever
Feeding difficulties and failure to thrive
Irritability
Diarrhea and vomiting
Screaming during urination
Clinical manifestations in older children
pyelonephritis Cystitis
• Fever • Fever is absent or low grade
• Rigor • Dysuria ( painful micturition )
• Loin pain • Urgency ( intense desire of
urination)
• Nausea and vomiting
• Frequency ( frequent micturition)
• Chronic pyelonephritis leads to
• Incontinence ( urine leakage )
hypertension and renal
insufficiency • Secondary enuresis
• Suprapubic pain
Diagnosis
• The correct diagnosis depends on having a proper urine sample
• Methods of urine collection:
 Mid stream urine collection in toilet trained children ( the best is early
morning sample )
 Bladder catheterization ( not from urine bag )
 Suprapubic aspiration ( the most sterile sample )
Investigations
• Urine analysis:
 pyuria: ≥5 cells per high power field is suggestive of UTI, WBCs cast is
suggestive of pyelonephritis . Pyuria is not reliable test because of false
positive and false negative results
 Nitrite test: detect products of reduction of dietary nitrate by urinary gram
negative bacterial species (E.coli, Klebsiella, Proteus )
 Leuckocytes esterase test: detect esterase released from leuckocytes lysis
 If these three tests are positive, this give positive predictive value for UTI
reaches to 100%
Investigations
• Urine culture:
 Bagged specimens should not be used to collect urine culture
 For clean catch mid stream urine > 100,000 colony forming unit per ml is
necessary for diagnosis
 Trans catheterization or suprapubic aspiration > 50,000 CFU / ml is diagnostic
for UTI
Investigations
• Imaging:
 Ultrasonography for bladder and kidney: is recommended for infants and
non-toilet-trained children with first time febrile UIT, and other children with
recurrent UTI. To exclude structural abnormalities or detect hydronephrosis
 Voiding cystouretheogram ( VCUG): evaluate bladder anatomy and looks for
signs of vesicourteral reflux, indicated in recurrent pyelonephritis or abnormal
renal or bladder anatomy
 Technetium-99 dimercaptosuccinic acid ( DMSA ) scan: useful to detect renal
scarring
Voiding
cytourethrogram-
unilateral reflux
Treatment
• For infants and children who not appear ill: oral Antibiotic therapy
should be initiated
• Infants and children who are toxic, dehydrated or unable to take orally
due to vomiting: initial Antibiotic therapy should be administered
parentrally
• Neonates with UTI should be treated with parentral Antibiotics
• Duration of treatment: 7-14 days for febrile UTI, 3-5 days for
uncomplicated UTI
Treatment
• Type of Antibiotic used: according to result of urine culture
• Common used empirical drug:
• Parentral: ampicillin, ceftriaxone, gentamicin
• Oral: cephalexin, amoxicillin calvulinic acid, trimethoprim-sulfamethoxazole
Prevention
• Primary prevention is achieved by promoting good perineal hygiene
• Management of underlying risk factors as chronic constipation,
encopresis, daytime and night time urinary incontinence
• Secondary Antibiotic prophylaxis for advanced cases of vesicourteral
reflux

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