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Pediatric Urinary Tract Infections

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Pediatric Urinary Tract Infections

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    1. 1 Pediatric Urinary Tract Infections

    2. 2 Objectives Define epidemiology Identify risk factors Review methods for diagnosis Discuss use of imaging studies Summarize treatment options

    3. 3 Introduction Often signal genitourinary tract abnormality. Can lead to renal scarring. symptoms are non-specific.

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    5. 5 Epidemiology Prevalence Girls—6.5-8% Boys—2-3% Uncircumcised boys have a 5-20 X increase in UTIs. 7% of children <2 present with PUO.

    6. 6 Epidemiology (continued) VUR is 1% in children < 2 y UTI. renal scarring twice as common in this age group. Incidence of scarring increases with each subsequent UTI

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    9. 9 Pathogenesis ascending route (most common) or hematogenous routes Most common pathogens: E.coli (80%) Others: Klebsiella, Proteus, Enterococcus, Staph species

    10. 10 Risk Factors Age <1 year Female gender Uncircumcised males Constipation Voiding dysfunction Improper wiping Genitourinary abnormalities Vesicoureteral reflux Obstruction Colonization with virulent E. Coli

    11. 11 Signs and Symptoms – Children 2 months to 2 years Fever—usually unexplained Vomiting and/or diarrhea Abdominal Pain Failure to thrive Malodorous urine Crying on urination

    12. 12 Signs and Symptoms – Children >2 Fever Vomiting and/or diarrhea Abdominal pain Malodorous urine Frequency and/or urgency Dysuria New incontinence

    13. 13 Diagnosis Urinalysis Can be obtained by most convenient means if infant is not ill UTI CANNOT be diagnosed with UA alone If suspicious UA, the Urine Culture must be obtained via SPA or catheter specimen If UA does not suggest UTI, it is reasonable to follow child clinically

    14. 14 Diagnosis Urine Culture MUST be collected via catheter or SPA UTI CANNOT be diagnosed from a bag specimen Diagnosis of UTI requires Urine Culture

    15. 15 Urine Collection: Suprapubic Aspirate “Gold standard” - >99% specificity Positive culture: any number of g- bacilli

    16. 16 Urine Collection: Transuretheral Catherization >105 CFU - 95% specificity 104 – 105 CFU – infection is likely 103 – 104 CFU – Suspicious <103 CFU – infection unlikely

    17. 17 Treatment May initiate treatment either orally or parenterally Admit and use parenteral antibiotics if toxic, dehydrated or unable to take PO Choices: TMP/SMX Cephalosporin Amoxicillin (check local resistance)

    18. 18 Treatment--continued Improvement should be seen in 24-48 hours If not responding in 2 days, re-culture, consider changing antibiotics and do imaging studies Complete 7-14 day course of antibiotics 14 days should be given for those that were ill with clinical evidence of pyelonephritis

    19. 19 Prophylaxis After completion of initial antibiotics, until imaging studies complete Antibiotic should have high urinary excretion and low serum and fecal levels.

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    21. 21 Imaging Needs to be performed in ALL children <2 years old with initial UTI

    22. 22 Ultrasound Should be done on all infants < 2y after their initial UTI Helps to detect hydronephrosis and ureteral dilation Has replaced IVP Need additional study to evalute VUR Is not as sensitive as renal cortical scintigraphy (DMSA) for detecting inflamation and scarring

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    25. 25 Voiding Cystourethrography (VCUG) Used to identify and grade reflux Also evaluates the urethra and bladder for abnormalities Radionuclide cystography (RNC) – can also evaluate reflux.

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    29. 29 Renal Cortical Scintigraphy (DMSA) Very sensitive for evaluating acute pyelonephritis as well as renal scarring Role in clinical management is still unclear

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    31. 31 Summary Urinary tract infections are a common cause of fever without a source in children <2 and can lead to renal scarring, HTN or ESRD. Rapid treatment is essential. Symptoms are non-specific and thus a high level of suspicion is required Urine culture is required for diagnosis, and should be obtained by catheterization or SPA when child is ill or infection is suspected Treatment requires a 7-14d course of antibiotics Prophylactic abx are required after initial treatment All Children <2 require 2 imaging studies after initial UTI

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