Approach to Urinary tract infections.pptx

Approach to a case of UTI and complications and riskfactors

1. URINARY TRACT INFECTIONS

2. OBJECTIVES Etiology Predisposing factors Pathogenesis and pathology Clinical features and classification Diagnosis Treatment Prevention

3. DEFINITION Urinary Tract infections (UTI) imply invasion of urinary tract by pathogens , which may involve the upper or lower tract depending on the infection in the kidney, or bladder and urethra Reference : Pediatric Nephrology 5 th edition by RN Srivastava and Arvind bagga

4. EPIDEMIOLOGY UTIs are most common in children under 1 year of age . In first 3 months of life - Uncircumcised febrile males > Circumcised males > Females (1:8:2 or 3) After 6 months of age – Females > Males Reference : Nelson Textbook of Pediatrics 22 nd edition , 2024

5. E TIOLOGY Bacterial – Escherichia coli causes the majority of UTI’s Fungal – Candida (common in immunocompromised patients) Viral – Adenovirus. (cause hemorrhagic cystitis) Reference : Nelson Textbook of Pediatrics 22 nd edition , 2024

6. PREDISPOSING FACTORS Female anatomy Uncircumcised male age ≤1 years Vesicoureteral reflux Toilet training Voiding dysfunction E xternal irritation Obstructive uropathy Urethral instrumentation Constipation Anatomic abnormality Neurogenic bladder Reference : Nelson Textbook of Pediatrics 22 nd edition , 2024

7. PATHOGENESIS AND PATHOLOGY F ecal flora Colonize the perineum Enter the bladder C ystitis Hematogenous spread A scend to the kidney to cause pyelonephritis Sepsis I ntrarenal reflux I mmunologic and inflammatory response that can cause renal injury and scarring Via urethra Reference : Nelson Textbook of Pediatrics 22 nd edition , 2024

8. BOWEL BLADDER DYSFUNCTION The child is trying to retain urine to stay dry Uninhibited contractions of bladder F orces urine out High- pressure, turbulent urine flow and incomplete bladder emptying Bacteriuria Bladder dysfunction is manifested by urgency, wetting , and especially “Vincent’s curtsy” (children squat on their heels in response to an uninhibited bladder contraction) Reference : Nelson Textbook of Pediatrics 22 nd edition , 2024

9. Constipation with fecal impaction Bladder dysfunction UTI Grade III, IV, or V VUR and a febrile UTI Acute pyelonephritis Obstructive uropathy Urinary stasis Hydronephrosis UTI Neurogenic bladder Incomplete bladder emptying and/or detrusor- sphincter dyssynergia Need for frequent catheterization UTI Reference : Nelson Textbook of Pediatrics 22 nd edition , 2024

10. PATHOGENESIS Reference : Pediatric Nephrology 5 th edition by RN Srivastava and Arvind bagga

11. Bacterial adhesion Activation of cytokines Production of adhesin molecules and chemotaxis of leukocytes . Development of biofilm Leads to which in turn induces Once bacterial adhesion has taken place, their persistence and multiplication depend upon the formation of biofilm on epithelial surface Reference : Pediatric Nephrology 5 th edition by RN Srivastava and Arvind bagga

12. Intracellular bacterial communities Quiscent Intracellular reservoirs

13. CLASSIFICATION PYELONEPHRITIS Abdominal, back, or flank pain Fever (temp ≥39°C (102.2°F) without another source lasting more than 48 hours in infants .) Malaise Nausea Vomiting Occasionally diarrhea Reference : Nelson Textbook of Pediatrics 22 nd edition , 2024 CYSTITIS Dysuria Urgency Frequency Suprapubic pain Incontinence Possibly malodorous urine (Cystitis does not cause high fever and does not result in renal injury)

14. Involvement of the renal parenchyma - A cute pyelonephritis whereas N o parenchymal involvement - P yelitis. Acute pyelonephritis can result in renal injury, termed pyelonephritic scarring. Reference : Nelson Textbook of Pediatrics 22 nd edition , 2024

15. DIAGNOSIS Confirmation - Urine culture Urine microscopy - Helpful in making a presumptive diagnosis of UTI Facilitates initiation of empirical treatment Dipstick test Reference : Pediatric Nephrology 5 th edition by RN Srivastava and Arvind bagga

16. URINE COLLECTION T oilet-trained children- Clean-catch method N on-toiled trained stable children - Clean-catch should be attempted initially if unsuccessful C atheterization or S uprapubic aspiration . S ick infants - Catheterization and suprapubic aspiration

17. DIPSTICK TEST Urinary bacteria convert nitrate to nitrite detected as a color change on chemically coated paper strips . The intensity of color change is proportional to the number of bacteria in the urine. Production of esterase - By neutrophils in the urine Simultaneous detection of both is highly suggestive of UTI .

18. URINE MICROSCOPY Should be performed in a freshly voided sample (within 1–2 h at room temperature or 4 h with refrigeration). Uncentrifuged sample - >10 WBCs/mm 3 Centrifuged sample - >5 WBCs/high power field Pyuria

19. Partially treated bacterial UTI Viral infections Urolithiasis Renal tuberculosis Renal abscess UTI in the presence of urinary obstruction Inflammation near the ureter or bladder (appendicitis, Crohn disease) Kawasaki disease COVID- 19– associated multisystem inflammatory syndrome in children schistosomiasis neoplasm renal transplant rejection interstitial nephritis (eosinophils) Sterile pyuria ( positive leukocytes, negative culture ) may occur in

20. URINE CULTURE The growth of single uropathogenic bacteria in urine ≥ 10 3 CFU/mL – by Suprapubic aspiration ≥ 10 ⁴ CFU/mL - by Catheterization ≥ 10 4-5 CFU/mL – by C lean catch Suggestive of UTI

21. OTHER LABORATORY INVESTIGATIONS Blood culture - Should be done in neonates and infants CBC - In acute pyelonephritis there is a neutrophilic leukocytosis ESR - >30 mm at one hour C-reactive protein - > 20 mg/dl indicate host inflammatory response

22. IMAGING Imaging is not needed to make the diagnosis of UTI. - Ultra sound - first- line imaging for screening (Demonstrate - enlarged kidney with a possible mass ) - CT scan - more sensitive and specific for lobar nephronia (show a wedge- shaped, lower- density area after contrast administration)

23. TREATMENT Complicated UTI vs Uncomplicated UTI Fever > 39°C Marked toxicity Persistent vomiting Dehydration Renal angle tenderness Suggests complicated UTI

24. ACUTE LOBAR NEPHRONIA (ACUTE FOCAL BACTERIAL NEPHRITIS): L ocalized renal parenchymal mass - caused by acute focal infection without liquefaction M ore commonly occurs in older children. May be an e arly stage in the development of a renal abscess Reference : Nelson Textbook of Pediatrics 22 nd edition , 2024 COMPLICATIONS

25. RENAL ABSCESS Can occur following a pyelonephritic infection Caused by - U sual U ropathogens or H ematogenous spread with S. Aureus. Most abscesses are unilateral and right- sided and can affect children of all ages Reference : Nelson Textbook of Pediatrics 22 nd edition , 2024

26. PERINEPHRIC ABSCESS Occur secondary to contiguous infection in the perirenal area (e.g. Vertebral osteomyelitis, psoas abscess) or Pyelonephritis that dissects to the renal capsule. D iffers from renal abscess in that it is diffuse throughout the capsule and is not walled off , although it can develop septations . Reference : Nelson Textbook of Pediatrics 22 nd edition , 2024

27. XANTHOGRANULOMATOUS PYELONEPHRITIS R are type of chronic renal infection C haracterized by granulomatous inflammation with hematuria . Risk factors include Urinary tract instrumentation Congenital uropathies/anomalies Chronic illness Immune suppression . Reference : Nelson Textbook of Pediatrics 22 nd edition , 2024

28. ACUTE HEMORRHAGIC CYSTITIS Patients receiving immunosuppressive therapy (e.g. Solid- organ or bone marrow transplantation) are at higher risk for hemorrhagic cystitis Adenoviruses and polyomaviruses (i.e., JC virus and BK virus) are important causes. Uncommon in immunocompetent children Caused by E. coli , adenovirus types 11 and 21. It is self- limiting, with hematuria lasting approximately 4 days. Reference : Nelson Textbook of Pediatrics 22 nd edition , 2024

29. Rare types of cystitis – not to be confused with infection include Eosinophilic cystitis may present with hematuria whereas Interstitial cystitis may present with irritative voiding symptoms but a negative urine culture .  Reference : Nelson Textbook of Pediatrics 22 nd edition , 2024

30. Acute lobar nephronia - S ame antibiotics as pyelonephritis for 14-21 days Renal or perirenal abscess - S urgical or percutaneous drainage + antibiotic therapy( 10-14 days of IV antibiotics, followed by 2-4 wk of oral antibiotic therapy) + other supportive measures

31. POTENTIAL TREATMENT OR PREVENTION OPTIONS Probiotic therapy -which replaces urogenital flora Non-uropathogenic E. Coli called nissle1917 T hese bacteria may inhibit growth of other bacteria. Cranberry juice - Prevent bacterial adhesion and biofilm formation hypothesized to be via proanthocyanidin ( pac ).

32. APPROACH TO IMAGING AFTER AN EPISODE OF UTI

33. Recurrent UTI is defined as two episodes of febrile UTI during childhood. Abnormal ultrasound is indicated by the presence of S mall kidneys A bnormal renal echogenicity P elvi -caliceal dilatation U reteral dilatation U ro-epithelial thickening of the renal pelvis, B ladder wall thickness, and Bladder diverticulum

34. ASSESSMENT OF CHILD WITH BBD H istory I ncontinence Voiding postponement F requency U rgency P ostures of voiding postponement(Vincent’s curtsy, crossing one’s legs and bending down from the waist, pinching the glans of the penis between fingers, squatting with a heel at the perineum) Constipation (stool firmness, frequency, pain with defecation) E ncopresis

35. Clinical Assessment E xamination for a palpable fecal mass in the left iliac fossa. At least a 2-day voiding diary (< 4 and > 7 voids in a day is abnormal) and details of bowel movements over 2 weeks Q uestionnaire such as dysfunctional voiding symptom score (DVSS) – for BBD Rome IV criteria Bristol Stool Form Scale For constipation

36. Transverse rectal diameter can be used as a simple but reliable tool for documenting fecal loading in children The presence of a post-void residual volume of > 20 ml or 10% of bladder capacity in age group of 4–6 years > 10 ml or 6% of bladder capacity in age group of 7–12 years and Thickened bladder wall (> 3 mm for an empty bladder and > 5 mm for a full) On USG S/O BBD

37. Reference : Nelson Textbook of Pediatrics 22 nd edition , 2024 GRADES OF VUR

38. NICE GUIDELINES Divided children into those younger than 6 months, 6 months to 3 years, and 3 years and older. Younger than 6 months- An initial USG - For all children VCUG - A typical features (including non E. coli infection, sepsis or bacteremia, failure to respond to antibiotics within 48 hours) - Recurrent UTI - Abnormal ultrasound findings

39. For children age 6 months to 3 years USG - If UTI with atypical features or recurrent UTI VCUG - if risk factors - Dilation on ultrasound P oor urine flow N on-E.coli infection F amily history of vesicoureteral reflux

40. PROPHYLAXIS

41. PREVENTION OF RECURRENCE

42. All toilet-trained children with UTI should be evaluated for bladder bowel dysfunction

43. Primary VUR is considered an important risk factor for recurrence of febrile UTI along with BBD

44. REFERENCES Nelson Textbook of Pediatrics 22 nd edition , 2024 Pediatric Nephrology 5 th edition by RN Srivastava and Arvind bagga Hari, P., Meena, J., Kumar, M.  et al.  Evidence-based clinical practice guideline for management of urinary tract infection and primary vesicoureteric reflux.  Pediatr Nephrol   39 , 1639–1668 (2024)

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