APPROACH TO UTI.pptx education pediatrics

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1. 4/22/2020 1

2. APPROACH TO UTI MODERATOR –( UNIT 1) DR. RASHMI DWIVEDI (H.O.D MAM) DR. RASHMI VISHWAKARMA DR . SWADESH VERMA PRESENTOR – DR. RAJENDER SINGH (PGJR1)

3. REFERENCE GHAI ESSENTIAL PEDIATRICS 9 EDI. NELSON TEXTBOOK OF PEDIATRICS 21 EDI . IMAGES – SOURCE (INTERNET )

4. CONTENT

5. DEFINITION I nvasion of urinary tract by pathogen , which may involve the upper or lower tract depending upon the infection in the kidney ,bladder or urethra . Includes infection of any component of the urinary tract including Pyelonephritis Cystitis Urethritis Asymptomatic bacteriuria : a positive urine culture without any urinary symptoms, common in adolescent girls

6. PY E L O N E P H R I T I S Involvement of the renal parenchyma is termed acute pyelonephritis . Pyelonephritis is characterized by any or all of the following: abdominal, back, or flank pain; fever; malaise; nausea; vomiting; and, occasionally, diarrhea . Fever may be the only manifestation; particular consideration should occur for a temperature > 39°C without another source lasting more than 24 hr for males and more than 48 hr for females .

7. Newborns can show nonspecific symptoms, such as poor feeding, irritability and weight loss . Pyelonephritis is the most common serious bacterial infection in infants younger than 24 mo of age who have fever without an obvious focus .

8. CYSTITIS Cystitis indicates that there is only bladder involvement ; symptoms include dysuria, urgency, frequency, suprapubic pain, incontinence, and possibly malodorous urine . Cystitis does not cause high fever

9. DEFINITIONS Simple UTI : UTI with low grade fever, dysuria, frequency, and urgency; and absence of symptoms of complicated UTI Complicated UTI : Presence of fever >39ºC, systemic toxicity, persistent vomiting, dehydration, renal angle tenderness and raised creatinine. Recurrent infection : Second episode of UTI . Significant bacteriuria : Colony count of 100,000 /mL of a single species in a midstream clean catch sample. Asymptomatic bacteriuria : Significant bacteriuria in the absence of symptoms of urinary tract infection (UTI).

10. ETIOLOGY UTIs are chiefly caused by E. coli the predominant periurethral flora, others include Klebsiella, Enterobacter and Staphylococcus saprophyticus . Proteus and Pseudomons infections occur following obstruction or instrumentation . Candida infection occurs in immunocompromised children or after prolonged antimicrcbial therapy.

11. OTHER CAUSATIVE ORGANISMS Fungal infections , particularly Candida, usually in : Nosocomial Infections Complicated UTI Catheter‐associated UTI Viral infections ‐under‐recognized because of difficulties with culture and identification, but have been associated with cystitis,esp. adenovirus Cytomegalovirus frequently seen in immunocompromised patients, particularly following organ transplantation

12. PATHOGENESIS Ascending infection : Bacteria from fecal flora colonize via urethra. perineum and enter bladder In uncircumcised boys : pathogens arise from flora beneath the prepuce Rarely, bacteria causing cystitis ascend to the kidney to cause pyelonephritis Hematogenous infection‐ unusual Neonates (GBS, E. coli, Listeria) GI disease with peritonitis, sepsis Severely ill children with multi‐organ disease Presence of urinary catheter

13. PATHOGENESIS continued…………………. pathogenesis of UTI is based in part on the presence of bacterial pili or fimbriae on the bacterial surface . two types of fimbriae, type I and type II . Type I fimbriae are found in most strains of E. coli. Because attachment to target cells can be blocked by D -mannose, these fimbriae are referred to as mannose sensitive . They have no role in pyelonephritis . The attachment of type II fimbriae is not inhibited by mannose, and these are known as mannose resistant.

14. receptor for type II fimbriae is a glycosphingolipid that is present on both the uroepithelial cell membrane and red blood cells. Gal 1-4 Gal oligosaccharide fraction is the specific receptor. Because these fimbriae can agglutinate by P blood group erythrocytes, they are known as P fimbriae. Bacteria with P fimbriae are more likely to cause pyelonephritis. Between 76% and 94% of pyelonephritogenic strains of E. coli have P fimbriae, compared with 19 -23% of cystitis strains. CONTINUED………………

15. RISK FACTORS Female gender Uncircumcised male Vesicoureteral reflux Toilet training Voiding dysfunction Obstructive uropathy Urethral instrumentation Sources of external irritation(such as tight clothing, pinworm infestation ) Constipation Anatomic abnormality ( labial adhesion) Neuropathic bladder

16. PRESENTING COMPLAINTS NEONATE INFANT CHILD Usually part of septicemia and presents with fever, vomiting, lethargy, diarrhea, poor feeding , irritability , jaundice and poor weight gain . Fever , painful micturation ,Diarrhoea, foul smelling diapers, vomiting etc Fever without focus Nausea, vomiting, abdominalpain,dysuria,day time urgency‐ frequency, hesitancy, incontinence, secondary enuresis cloudy urine and Rarely‐flank pain

17. SCHOOL-AGE TO ADOLESCENCE Frequency, Urgency, Discomfort Malodorous Urine Abdominal/Flank Pain ( esp in pyelonephritis) Suprapubic tenderness Fever/Chills (esp. in pyelonephritis) Malaise Vomiting/ diarrhea (esp. in pyelonephritis)

18. HISTORY The history of the acute illness should include documentation of ; Fever, grade and duration Urinary symptoms (dysuria, frequency, urgency, incontinence ) Abdominal pain Suprapubic discomfort Back pain Vomiting Recent illnesses , antibiotics administered

19. PAST MEDICAL HISTORY: Chronic urinary symptoms – Incontinence, lack of proper stream, frequency, urgency, withholding . Chronic constipation Previous UTI Vesicoureteral reflux (VUR ) Previous undiagnosed febrile illnesses

20. Family history of frequent UTI, VUR, and other genitourinary abnormalities. Antenatally diagnosed renal abnormality Elevated blood pressure Poor growth

21. PHYSICAL EXAMINATION   Important aspects include : Documentation of blood pressure and temperature. Growth parameters (poor weight gain and/or failure to thrive may be an indication of chronic or recurrent UTI ) Abdominal examination for tenderness or mass ( eg , enlarged bladder or enlarged kidney secondary to urinary obstruction) Assessment of suprapubic and costovertebral tenderness

22. Examination of the external genitalia for anatomic abnormalities ( eg , phimosis or labial adhesions) and signs of vulvovaginitis , vaginal foreign body. Evaluation of the lower back for signs of occult myelodysplasia ( eg , midline pigmentation, lipoma , vascular lesion, sinus, tuft of hair), which may be associated with a neurogenic bladder. Evaluation for other sources of fever .

23. DIFFERENTIAL DIAGNOSIS Asymptomatic bacteriuria  — Asymptomatic bacteriuria ( ie , colonization of the urinary tract with bacteria in the absence of inflammation) occurs in 1 to 3 percent of infants and preschool age children, and approximately 1 percent of older children . Other differential diagnosis depends on the presenting symptom

24. Infants: bacteremia , meningitis Children: Vulvovaginitis , STI, Vaginal foreign body, Sexual Abuse , Abdominal Disease, Renal Calculi, dysfunctional voiding, dysuria- pyuria syndrome, appendicitis, pelvic abscess, pelvic inflammatory disease

25. Urine Blood Imaging INVESTIGATIONS

26. URINE UTI may be suspected based on symptoms or findings on urinalysis, or both; a urine culture is necessary for confirmation and appropriate therapy. In toilet-trained children, a midstream urine sample usually is satisfactory; the introitus should be cleaned before obtaining the specimen. In uncircumcised boys, the prepuce must be retracted. In children who are not toilet trained, a catheterized urine sample should be obtained.

27. Alternatively, the application of an adhesive , sealed, sterile collection bag after disinfection of the skin of the genitals can be useful only if the culture is negative or if a single uropathogen is identified . However, a positive culture can result from skin contamination, particularly in girls and uncircumcised boys . If treatment is planned immediately after obtaining the urine culture, a bagged specimen should not be the method because of a high rate of contamination often with mixed organisms . A suprapubic aspirate generally is unnecessary.

28. Pyuria (leukocytes in the urine) suggests infection, but infection can occur in the absence of pyuria; this finding is more confirmatory than diagnostic. Conversely, pyuria can be present without UTI . Sterile pyuria (positive leukocytes, negative culture) occurs in partially treated bacterial UTIs, viral infections, renal tuberculosis, renal abscess, UTI in the presence of urinary obstruction, urethritis due to a sexually transmitted infection (STI) , inflammation near the ureter or bladder (appendicitis, Crohn disease), and interstitial nephritis (eosinophils ). Diagnosis

29. Nitrites and leukocyte esterase usually are positive in infected urine. Microscopic hematuria is common in acute cystitis, but microhematuria alone does not suggest UTI. White blood cell casts in the urinary sediment suggest renal involvement, but in practice these are rarely seen. If the child is asymptomatic and the urinalysis result is normal, it is unlikely that there is a UTI. However, if the child is symptomatic, a UTI is possible, even if the urinalysis result is negative. Diagnosis

30. DIPSTICK TEST

31. Prompt plating of the urine sample for culture is important, because if the urine sits at room temperature for more than 60 min , overgrowth of a minor contaminant can suggest a UTI when the urine might not be infected . Refrigeration is a reliable method of storing the urine until it can be cultured. Diagnosis

32. Method Colony count Probability Suprapubic Any number 99% Catheter > 50 x 10 3 95% Midstream > 10 5 CFU/ml 90‐95% Bag specimen Unacceptable (lower counts significant if symptoms persistent , antibiotics, diuretics ) Note: Prompt plating of the urine sample Or refrigeration until plated URINE CULTURE - SIGNIFICANCE

33. Contamination is suspected, e.g. , mixed growth of two or more pathogens, Growth of organisms that normally constitute the periurethral flora (lactobacilli in healthy girls; enterococci in infants). UTI is strongly suspected but colony counts are equivocal. REPEAT URINE CULTURE

34. BLOOD INVESTIGATIONS With acute renal infection, leukocytosis and neutrophilia are noted on the complete blood count (CBC); an elevated serum erythrocyte sedimentation rate , C-reactive protein

35. IMAGING STUDIES IN CHILDREN WITH A FEBRILE UTI Following treatment of the first episode of UTI, plans are madefor evaluation of the urinary tract . The airm of imaging studies is to identify urologic anomalies that predispose to pyelonephritis, such as obstruction or vesicoureteric reflux, and detect evidence of renal scarring . There are two historical approaches to imaging, the traditional “bottom -up” and “top-down” approaches. The “bottom-up” method was a renal sonogram plus a voiding cystourethrogram (VCUG), which will identify upper and lower urinary tract abnormalities, including VUR, bladder–bowel dysfunction, and bladder abnormalities, such as a paraureteral diverticulum.

36. The “top-down” approach was intended to reduce the number of VCUG examinations . It begins with a dimercaptosuccinic acid (DMSA) renal scan, to identify areas of acute pyelonephritis . The DMSA scan in younger children generally requires sedation . Renal ultrasonography is useful in detecting hydronephrosis or anomalies of the urinary bladder and may be performed even during therapy for UTI. CONTINUED………………..

37. Micturating cystourethrogram is necessary for the diagnosis and grading of VUR and defines urethral and bladder anatomy This procedure may be performed 2-4 weeks after treatment of the UTI . DMSA scintigraphy detects cortical scars, which are regions of decreased uptake with loss of renal contours or presence of cortical thinning with decreased volume . In order to distinguish scars from reversible changes of pyelonephritis, this procedure is done 3-4 months after therapy for UTI. All infants (<1 year) require evaluation using ultrasonography, MCU and DMSA scan, since they are at the highest risk of UTI recurrence and scarring. Early detection of high grade VUR or obstructive uropathy allows interventions to prevent progressive kidney damage.

38. RECOMMENDATIONS OF THE INDIAN SOCIETY OF PEDIATRIC NEPHROLOGY ON EVALUATION FOLLOWING THE FIRST UTI ARE SUMMARIZEDAS:

39. WHEN TO DO ADMISSION ???????? CHILDREN WHO ARE -: D ehydrated, are vomiting, are unable to drink fluids, have complicated infection, or in whom urosepsis is a possibility should be admitted to the hospital for intravenous(IV ) rehydration and IV antibiotic therapy. Local antimicrobial sensitivity patterns should be considered when selecting empirical antibiotic treatment . For hospitalized children, parenteral treatment with ceftriaxone(50 mg/kg/24 hr , not to exceed 2 g) or cefepime (100 mg/kg/24 hrq 12 h) or cefotaxime (100-150 mg/kg/24 hr in 3-4 divided doses) ( when available ) is a reasonable choice until culture results are back to determine whether a narrower-spectrum antibiotic can be used.

40. TR E A T M E N T Once UTI is suspected, a urine specimen is sent for cultureand treatment started . I nfants below 3 months of age andchildren with complicated UTI should initially receive parenteral antibiotics . The initial choice of antibiotics is empiric and is modified once culture result is available . While a third generation cephalosporin is preferred, therapy Once oral intake improves and symptoms abate, usually after 48-72 hours, therapy is switched to an oral antibiotic. The duration of treatment for complicated UTI is 10-14 days. Older infants and patients with simple UTI should receive treatment with an oral antibiotic for 7-10 days.

41. All children with UTI are encouraged to take enough fluids and empty the bladder frequently. With appropriate therapy, fever and systemic toxicity reduce and urine culture is sterile within 24-36 hours.

42. ANTI MICROBIAL FOR TREATMENT OF UTI PARENTERAL ANTIBIOTICS CEFTRIAXONE CEFIPIME CEFOTAXIME AMIKACIN DOSE ( mg/kg/day) 75-100, 1-2 divided doses IV 100 , in 2 divided dose 100-150 , in3 divided dose 15 , single dose IV or IM

43. ORAL ANTIBIOTICS CEFIXIME CIPROFLOXACIN OFLOXACIN COAMOXICLAV DOSE (mg/kg/ day ) 10 , in 2 divided dose 10 -20 , in 2 divided dose 15-20 , in 2 divided dose 30-50of amoxicillin , in 2 divideddose

44. There is interest in probiotic therapy, which replaces pathologic urogenital flora, and Cranberry juice , which prevents bacterial adhesion and biofilm formation, but these agents have not proved beneficial in preventing UTI in children. T r e a t m e n t OTHERS

45. Infants and children in complicated UTI:10‐ 14 days. Simple UTI: 7‐10 days. Adolescents with cystitis: 3 days Following treatment prophylactic antibiotic therapy is initiated in children below 1 year of age. DURATION OF TREATMENT

46. Immediate complications Sepsis Perinephric abscess Long term sequelae Renal scar Hypertension (HT) End‐stage renal disease (ESRD) CO M PLICATIONS

47. PREVENTION OF RECURRENT UTI‐GENERAL Adequate fluid intake and frequent voiding . Constipation should be avoided . In children with VUR regular and volitional low pressure voiding with complete bladder emptying is encouraged . Double voiding . Circumcision reduces the risk of recurren t UTI in infant boys, and therefore have benefits in patients with high grade reflux.

48. At any age should undergo detailed imaging with ultrasonography, MCU and DMSA scintigraphy . RECURRENT UTI

49. PREVENTION OF RECURRENT UTI‐ANTIBIOTIC PROPYLAXIS Indications for prophylaxis UTI below 1‐yr of age , while awaiting imaging studies VUR frequent febrile UTI (3 or more episodes even if the urinary tract is normal in a year )

50. Dose, mg/kg/day Remarks Medication Cotrimoxazole 1‐2 of trimethoprim Avoid in infants <3 mo , glucose‐6‐phosphate dehydrogenase deficiency Nitrofurantoin 1‐2 May cause vomiting and nausea; avoid in infants <3 mo , G6PD deficiency, renal insufficiency ANTIMICROBIALS ‐PROPHYLAXIS OF UTI

51. M e d i c a t i on Dose, mg/kg/day Remarks Cephalexin 10 Drug of choice in first 3‐6 mo of life Cefadroxil early infancy 5 An alternative agent in ANTIMICROBIALS ‐PROPHYLAXIS OF UTI

52. PATIENT/PARENT EDUCATION Avoid bubble baths Avoid Tight fitting clothing (girls) Wipe “back to front” Don’t hold urine for long periods of time