Pediatric Urinary Tract Infections

1. Pediatric Urinary Tract Infections Dr.AmmarDeeb Department of Urology 2014

2. Introduction • In infants and children, the urinary tract is a relatively common site of infection. • Urinary Tract Infections(UTIs) result in significant acute morbidity , as well as long-term medical problems including : delayed Hypertensionand progressive renal dysfunction

3. Why do UTIs in children have that much importance? • Difficulty of diagnosis : unclear clinical features – • Accurate diagnosis and timely treatment are vital in limiting theses long-term sequelae, because the pediatric kidney is susceptible to scarring and permanent renal damage • UTI results in recognitionof some important underlying structural or neurogenic abnormalityof the urinary tract

4. Incidence • The incidence of UTIs in the pediatric population varies based on genderand age • Occurrences of first-time, symptomatic UTIs are highest in boys and girls during the first year of life and markedly decrease after that • overall prevalence of UTI in infants presenting with fever was 7.0% • By age, the rates in girls were as follows: • 0-3 months - 7.5% • 3-6 months - 5.7% • 6-12 months - 8.3% • >12 months - 2.1%

5. In febrile boys less than 3 months of age, 2.4% of circumcised boys and 20.1%of uncircumcised boys had a UTI. • During the first six months of life uncircumcised males have a 10 to 12-fold increased risk compared to circumcised males for development of UTIs • Only during the first year of life do males have a higher incidence of UTIs when compared to females.

7. Pathogenesis ofurinary tract infection

8. uropathogenscolonized the periurethral area ascend to the bladder. can spread up the urinary tract to the kidneys and possibly to the bloodstream (bacteremia). • Urine is normally sterile. • Entry of bacteria can result from turbulent flow during normal voiding, voiding dysfunction, or catheterization • sexual intercourse or genital manipulation may foster the entry of bacteria into the urinary bladder

9. Hematogenousspread is uncommon and usually occurs in children who are immunocompromised,during systemic bacteremia (sepsis) Organisms that may spread hematogenously to the urinarytract include Staphylococcus aureus, Candida species, and tuberculosis • Genitourinary tract fistulas, such as vesicovaginalcan result in UTI infections by direct extension

10. Aetiology • Bacterial infections, with E coli being the most frequent pathogen, causing 75-90% of UTIs. Other bacterial : • Klebsiellaspecies • Proteus species • Enterococcus species • Staphylococcus saprophyticus, especially among female adolescents and sexually active females • Streptococcus group B, especially among neonates • Pseudomonasaeruginosa • Fungi (Candida species) especially after instrumentation • Adenovirus is a rare cause of hemorrhagic cystitis

12. Risk factors • Alteration of the periurethral flora by antibiotic therapy • Children who receive antibiotics (eg, amoxicillin, cephalexin) for other infections are at increased risk for UTI. • These agents may alter gastrointestinal (GI) and periurethral flora, disturbing the urinary tract's natural defense against colonization by pathogenic bacteria

13. Anatomic anomaly------ VUR • VUR is common in children with UTI. • Epidemiologic surveys have shown that between 21% and 57% of children who have had bacteriuria are subsequently found to have VUR. • However, no correlationbetween reflux and UT predispositionhas been found. • The importance of reflux lies in the fact that it allows bladder bacteria renal access with subsequent potential for renal damage.

17. Bladder dysfunction • Many Studies did not establish causality between UTI and voiding dysfunction, UTI may initiate symptoms of bladder dysfunction with variable persistence. • In some situations, treatment of constipation or voiding abnormalities, or both, has resulted in decreased frequency of urinary infections.

18. Circumcision and UTI • For male infants, neonatal circumcision substantially decreases the risk of UTI. • during the first year of life, the rate of UTI was 2.15% in uncircumcised boys, versus 0.22% in circumcised boys. • Risk is particularly high during the first 3 months of life. • in febrile boys younger than 3 months, UTI was present in 2.4% of circumcised boys and in 20.1% of uncircumcised boys

19. Consider circumcision of male neonates. • The AAP policy statement on circumcision is that • “the health benefits of newborn male circumcision outweigh the risks and that the procedure's benefits justify access to this procedure for families who choose it”

21. CLASSIFICATION • Previously, UTIs were classified in numerous descriptive ways such as complicated versus uncomplicated, or upperversus lower tract. • For practical purposes, pediatric UTIs may simply be categorized into two types: first infections and recurrent infections. • The recurrent infections may then be categorized as • (1) unresolved bacteriuriaduring therapy, • (2) bacterial persistence at an anatomic site, • (3) re-infections.

23. DIAGNOSIS • The febrile infant or child who has no other site of infection to explain the fever, even in the absence of systemic symptoms, should be assessed for the likelihood of pyelonephritis (upper UTI). • Most episodes of UTI during the first year of life are pyelonephritis.

24. Guidelines from the American Academy of Pediatrics recommend considering the diagnosis of UTI in patients aged 2 months to 2 years withunexplained fever. • identify any risk factors for the UTI. (recent broad-spectrum antibiotic therapy, an anatomic anomaly, voiding dysfunction, and constipation.)

25. SIGNS and SYMPTOMS: • The history and clinical course of a UTI vary with the patient's age and the specific diagnosis. • No one specific sign or symptom can be used to identify UTI in infants and children.

26. Children aged 0-2 months • usually do not have symptoms localized to the urinary tract. UTI is discovered as part of an evaluation for neonatal sepsis. • Neonates with UTI may display the following symptoms: • Jaundice • Fever • Failure to thrive • Poor feeding • Vomiting • Irritability

27. Infants and children aged  2 months to 2 years Infants with UTI may display the following symptoms: • Poor feeding • Fever • Vomiting • Strong-smelling urine • Abdominal pain • Irritability

28. Children aged 2-6 years • Preschoolers with UTI can display the following symptoms: • Vomiting • Abdominal pain • Fever • Strong-smelling urine • Enuresis • Urinary symptoms (dysuria, urgency, frequency)

29. Children older than 6 years and adolescents School-aged children with UTI can display the following symptoms: • Fever • Vomiting, abdominal pain • Flank/back pain • Strong-smelling urine • Urinary symptoms (dysuria, urgency, frequency) • Enuresis • Incontinence ??!

31. Physical examination findings in pediatric patients with UTI can be summarized as follows: • Costovertebral angle tenderness • Abdominal tenderness to palpation • Suprapubic tenderness to palpation • Palpable bladder • Dribbling, poor stream, or straining to void

32. URINE ANALYSIS • The diagnosis of UTI is predicated on obtaining a good urinary specimen, which can be difficult in children. Routinely, there are four ways that urinary specimens are obtained in children. In order of least to most reliable for UTI diagnosis, they are • (1) plastic bag attached to the perineum • (2) midstream void, • (3) catheter specimen, or • (4) a suprapubicbladder aspirate

33. (AAP) criteria for the diagnosis of UTI in children 2-24 months are the presence of pyuria and/or bacteriuriaon urinalysis and of at least 50,000 (CFU) per mL of a uropathogen. • In neonates younger than 2 months of age, criteria include the presence of lower amounts of a single pathogen (10,000-50,000 CFU/mL.)

34. Significant pyuriais defined as >10 WBC/mm3. • The concentration of motile bacteria can also be quantified, with 107 bacteria per ml being deemed significant. This figure corresponds to 8 organisms per highpowered field. • The gold standard for the diagnosis of UTI is quantitative urinary culture.

36. Haematology Studies: • Hematologic studies do not tend to help in the diagnosis of UTIs, although they should be obtained in patients who appear ill. • Obtain a complete blood count (CBC) and basic metabolic panel for children with a presumptive diagnosis of pyelonephritis. • Perform blood cultures in febrile infants and older patients who are clinically ill, toxic, or severely febrile.

37. Renal function can be measured by serum creatinineand blood urea nitrogen (BUN) levels; both may be elevated in severe disease • Electrolyteabnormalities may be present. • Procalcitonin, a propeptide of calcitonin that has been found to be elevated in response to bacterial endotoxins, has shown promise in helping to diagnose pyelonephritis and early renal damage.

38. Imaging Studies • Imaging evaluation is important to the diagnosis and management of UTI with the goal of altering or preventing further morbidity • It should be kept in mind that imaging studies are recommended only if their findings may change clinical management .

39. Necessary V/S Not cost-effective it's important to adopt a selective approach which avoids submitting normal children to unnecessarily invasive and costly investigations while at the same time identifying those children who have significant abnormalities such as reflux and renal scarring.

40. The clinician's judgment should guide the decision regarding imaging studies, rather than a rigid rule

41. Imaging studies are not indicated for infants and children with a first episode of cystitis or for those with a first febrile UTI who meet the following criteria: • Assured follow-up • Prompt response to treatment (afebrile within 72 h) • A normal voiding pattern (no dribbling) • No abdominal mass

42. Ultrasonography Ultrasonography of the urinary tract is the imaging initial study of choice in children with UTI Urinary ultrasonography is safe, noninvasive study, and easy to perform. It is useful in excluding obstructive uropathy, as well as in identifying a solitary or ectopic kidney and, in some cases, moderate renal damage caused by pyelonephritis

43. Indications for renal and bladder ultrasonography: • Febrile UTI in infants aged 2-24 months. • Delayed or unsatisfactory response to treatment of a first febrile UTI • An abdominal mass or abnormal voiding (dribbling of urine) • Recurrence of febrile UTI after a satisfactory response to treatment • Finally, renal ultrasonography should be considered for any child with a first febrile UTI in whom good follow-up cannot be ensured.

44. Voiding cystourethrography((VCUG • may be indicated after a first febrile UTI if renal and bladder ultrasonography reveal hydronephrosis, scarring, obstructive uropathy, or masses or if complex medical conditions are associated with the UT • VCUG is recommended after a second episode of febrile UT even if previous ultrasonographic examination findings were unremarkable

45. Children who respond to treatment for a UTI but afterwards demonstrate an abnormal voiding pattern may need to undergo standard VCUG • The routine use of VCUG after the first UTI is not recommended, since data do not support the use of antimicrobial prophylaxis to prevent recurrent febrile UTI in infants unless they have VUR above grade 4.

47. DMSA Scan • DMSA imaging to detect renal scars is indicated in the clinically high-risk group. • younger than 1 year of age who present with systemic symptoms, • may have an unusual microorganism in their urine, • show resistance to antibiotic treatment, • have started treatment with antibiotics late.