Pyuria and urinary tract infection 2

lecture

1. Pyuria and Urinary tract infection Presented by Nancy Mohammed Alaa Assistant lecturer of Pediatrics Assiut university

2. Does Pyuria means Urinary Tract Infection ??! Does absence of Pyuria excludes Urinary tract infection ??!

3. Pyuria is a condition in which urine contains >10 WBC / hpf in in uncentrifuged sample or >5 in centrifuged sample That may or may not be asociated with UTI Sterile pyuria , is urine which contains white blood cells while appearing sterile by standard culturing of aerobic laboratory techniques (on a 5% sheep-blood agar plate and MacConkey agar plate). . Bacteriuria denotes the presence of bacteria in urine

4. True or significant bacteruria based on 1-the presence of 100,000 CFU per ml in a carefully collected sample of clean-voided or midstream urine, 2-10,000 CFU/ml in symptomatic children 3-presence of 50,000 CFU/ml by urethral catheter 4-the finding of any no of pathogens in urine obtained by suprapubic catheter

5. Causes 1- pyuria 1-acute cystitis 2-chronic cystitis 3-acute pyelonephritis PN 4-chronic pyelonephritis 5-Urethritis

6. 2-sterile pyuria A- Infection:Renal TB,anaerobe , Mycoplasma , chlamydia , virus,fungal , B-taking Antibiotics that supress growth of organism C-renal stones E -Kawasaki : F-urinary tract neoplasm ,

7. Urinary tract infection urinary tract infection 1-definition1 2-prevelance,etiology 3-defense mechanism 4-risk factors 5-Types 6-manifestations 7-TB urinary tract 8-diagnosis 9-management 10-Complications

8. Urinary tract infection (UTI ) 1-presence of symptoms + 2-significant bacteruria or 3-urine specimen with significant WBC , positive nitrite,leukocyte esterase test. .

9. Recurrent UTI is defined as two or more UTIs over a six-month period Lower urinary tract infection refers to infection at or below the level of the bladder Upper urinary tract infection refers to infection of the urinary tract above the level of the bladder; that is, the ureters , kidneys, and peri -renal tissues.This term is used mainly in reference to pyelonephritis

10. Prevelance 1-during 1 st year male :female ratio 2.8:5.4 <more in uncircumcised male> 2-age 1-2ys is 1:10 3-during adolescent sexually active male ,female at risk of urethritis 4-most common serious bacterial infection in pediatrics 5% of febrile child

11. Etiology 1-microrganism A- bacterial 1-GM – ve bacilli :most common is Ecoli ,other as proteus vaginalis,pseudomonas,klebsiella more in hospital aquired infection 2-GM+ve:strept,staph B-non bacterial ureaplasma urealyticum,trichomonas Chlamydia , Mycobacterial TB Candida more in immunosupressed <DM>,

12. Routes of entry 1-ascending < commonest >:ascend by contaminated catheter or from perineal infection 2-haematogenous:from septic focus in body ,staph and strept ,TB most common microrganism 3-lymphatic 4-direct from neighbouring organs

13. Defense mechanisms 1-acidc pH of urine , vagina 2-complete emptying of bladder 3-urethral,prostatic secretion 4-length of urethra in male 5-antegrade ureteric peristalsis 6-natural narrowing , comptent like valves : External and internal urethral meatus ,bladder neck , vesicoureteric junction

14. Risk factor 1-female short urethra, 2-uncicumcised male 3-urinary tract obstruction:stones,stricture 4-neurogenic bladder 5-congenital:vesicoureteric reflux,,bladder diverticulum,bladder exstrophy,posterior uirethral valve 6-comorbidity:DM, 7-tight clothes ,pin worms

15. 8-infrequent voiding 9-back to front wiping 10-encoporesis 11-adulthood:pregnant,sexual activity

16. Types 1-acute cystitis 2-chronic cystitis 3-acute pyelonephritis PN 4-chronic pyelonephritis 5-Urethritis

17. MANIFESTATIONS 1-asymptomatic bacteriuria Accidental finding of bacteria in urine culture without manifestation ,mostly in girls 2-acute pyelonephritis During infancy :fever,irritability poor feeding diarrhea jaundice and sepsis

18. B- childhood : FEVER , rigors,l oin pain ,t enderness ,nausea ,vomiting 3-chronic pyelonephritis The patient usually asymptomatic .may be presented by hypertension,end stage renal failure,sepsis as complications

19. 4- cystitis Urinary frequency, urgency,dysuria,bedwetting in previously dry child , , Suprapubic pain,haematuria may occur. Not usually associated with fever 5- urethritis Urethral pain,itching over urethra,urethral discharge

20. DIAGNOSIS 1-LABORATORY A-urinalysis Method to collect urine 1- MIDSTREAM URINE in toilet trained child after cleansing urethral meatus , if prepuce is not retractable in uncircumcised male ,this method unreliable 2-Adhesive bag in infant,after disinfection of genitalia 3- catheter for greater assurance

21. catheter 4- suprapubic Indications : Urethral injuries Urethral obstruction Bladder neck masses Contraindication; Absolutely: in the absence of an easily palpable or ultrasonographically localized distended urinary bladder Relative ; coagulopathy

22. HANDLING OF SAMPLE Urine should be processed within 2 hours of collection. If it cannot be processed in a timely manner, then either (1) refrigerate the specimen at 2-8°C (specimen will be stable for 24 hours) or (2) place the sample in preservative fluid and store at room temperature for up to 24-72 hours; boric acid is the most common preservative fluid used for culture.

23. Results 1-pus cells A-WBC >5/ hpf in centrfuged urine or >10 in uncentrfuged :suggest infection B-infection may occur in absence of pyuria < sterile urine > ; obstruction with infection 2- Haematuria microscopic<cystitis> 3-WBC cast 4- PH: alkaline <urea splitting bacteria lead to normal urine ph 5.5-7 ammonia formation>

24. 5-Nitrites. Bacteria that cause a urinary tract infection (UTI) make an enzyme that changes urinary nitrates to nitrite Nitrites in urine show a UTI is present. Such as :E coli,Proteus,Klebsiella 6- Leukocyte esterase (WBC esterase) B-Renal function,electrolyte level.

25. C-urine culture <gold standard> Indication 1-negative urinalysis but symptomatic 2-haematuria 3-unresolved recurrent symptoms after treatment Results : A- positive if 1-the presence of>100,000 CFU per ml in a carefully collected sample of  midstream urine, 2-10,000 colonies /ml in symptomatic child

26. 3-the finding of any bacteria in urine obtained by suprapubic catheteror catheter 4->50,000 CFU/ml collected by urethral catheter B- repeat culture if midstream culture 10,000- 50,000 colonies of gm – ve C-false negative : antibiotics,dilution from overhydration,contaminated of specimen with antiseptic soln.

27. If symptomatic . RESULTS STANDARD CULTURE URINALYSIS UTI POSITIVE PUS STERILE PYURIA <most bacterial UTI> NEGATIVE PUS LEUKOCYTE ,NITRITE +VE STERILE PYURIA NEGATIVE PUS LEUKOCYTE ,NITRITE _VE May be UTI WITH OBSTRUCTION Sterile urine POSITIVE NO PUS

28. D- CBC Leukocytosis,neutrophilia common in acute renal infection E–ESR,CRP ; Elevated in acute infection F-BLOOD CULTURES Indicated in: 1-infants 2-UTI with obstruction 3-febrile UTI as sepsis is common

29. 2-imaging 1-RENAL US ; Indications : 1-Febrile UTI in infants aged 2-24 months -2-Delayed or unsatisfactory response to treatment of a first febrile UTI 3-An abdominal mass or abnormal voiding (dribbling of urine) 4-Recurrence of febrile UTI after a satisfactory response to treatmen 5-haematuria 6-obstructive symptoms or urine retention

30. Aim 1-This to exclude acute pyelonephritis,pyonephrosis,renal or perirenal abscess 2-rule out obstructive uropathy,hydronephrosis 3- detect kidney size,renal scar 7-history of renal stones 8-raised renal functio n

31. 2-plain xray 1-To detect renal stones 2-urinary tract calcification 3-voiding cystourethrogram <VCUG> Indication 1-all children with recurrent UTI 2-Abnormality detected on abd US 3-suspect obstruction Role: Diagnosis of vesicoureteric reflux ,posterior urethral valve s .

32. Posterior urethral valve Vesico ureteric reflux stage 5

33. 4-CT KUB ,MRU INDICATION ; 1-When suspect stones or suppuration 2-Definite diagnosis of acute pyelonephritis 5-intravenousurography <IVU > INDICATION 1-haematuria 2-suspect congenital anomalies 3-suspect obstruction 4-detect renal function

34. Renal scar CT KUB

35. CT KUB CHRONIC PYELONEPHRITIS : CHRONIC PYELONEPHRITIS: CECT shows asymmetrically atrophic right kidney with scars overlying the dilated calyces, typical of chronic pyelonephritis

36. IVU ureteric stone

37. 6-renal scanning Idea DMSA, or dimercaptosuccinic acid, is a radioactive substance (called a tracer) that is injected into a vein and enters the kidneys. It is detected by special cameras and enables a scan to be taken of the inside of the kidneys. : Aim; 1-evaluate the f unctioning tissue of kidneys 2-measure the relative function of each kidney 3-diagnosis of pyelonephritis < parenchymal filling defect> 4-diagnosis of renal scar <most sesitive study to detect scar >

38. Normal Pyelonephritis

39. PREVENTION 1-if recurrence are frequent ,identify the predisposing factor 2-circumcision in male to decrease recurrence 3-Adequate fluid intake ,frequent voiding 4-urine culture should be obtained 1 week after termination of ttt of UTI to asure that urine is sterile

40. 5-antibiotic prophylaxis: indicated: 1-recurrent febrile UTI even normal urinary tract 2-Persistent vesicoureteric reflux or any structural abnormality 3-UTI in child<1y waiting imaging Duration :6mon or more Antibiotic prophylaxis not advised in: 1-obstruction,stones 2-neurogenic bladder

41. Drugs for prophylaxis remarks Dose mg/kg/d drug Avoid in infants <3 mo, glucose-6-phosphate dehydrogenase deficiency 1-2 Cotrimoxazol May cause vomiting and nausea; avoid in infants <3 mo, G6PD deficiency, renal insufficiency 1-2 Nitrofurantoin 1 Drug of choice in first 3-6 mo of life 10 Cephalexin An alternative agent in early infancy 5 Cefadroxil

42. Treatment Indication of hospitalization : 1-only functioning kidney 2-immunosupresed:DM 3-persistent vomiting 4-Failure to respond to treatment 5-age :<3 mon 6-lack of adequate outpatient follow up 7-potential sepsis 8-urinary tract obstruction or underlying disease

43. 1- acute cystitis Treatment can be delayed till results of culture are known or initiated before results if severe by using : or A-amoxicillin <50mg/kg /d> B-co trimexazole :<20mg/kg/d>for sulfamethoxazole or <4mg/kg/d>for trimethoprim C- nitrofurantoin :5-7mg/kg/d Duration :7-10d

44. 2-acute pyelonephritis Inpatient 1-parentral antibiotics A-gm + ve,-ve ; ceftriaxone 50-75mg/kg/d ,max 2gm or Cefotaxime 100mg/kg/d Or B- gm+ve;ampicillin 100mg/kg/d and gm- ve : aminoglycoside as gentamicin 3-5mg/kg/d Daily monitor of RFT, gentamicin level to avoid nephrotoxicity

45. Duration:parentral till 48 hrs after fever subside then oral 3 rd cephalosporins till end of 14 d 2-IV FLUIDS especially if vomiting,hypotension 3-symptomatic antipyretic ,antiemetic Outpatient management Oral 3 rd cephalosporins for 14 d

46. complications 1-renal abscess 2-renal scarring 3-impaired renal function 4-ACUTE LOBAR NEPHRONIA Local renal bacterial infection involve >1 lobe 5-perinephric abscess 6-urethral stricture 7-later on infertility as obstruction of ejaculatory ducts 8-epididymo orchitis < DD :acute scrotum > 9-pyonephrosis

47. Renal abscess CP :1-mostly patient with acute pyelonephritis without improvement after 3 d of medical ttt 2-chills fever local renal pain INV; 1-ABD US 2-CT SCAN MANAGEMENT 1-HOSPITALIZE ; parentral AB , antipyretic,analgesic 2-follow up : clinically,radiologically 3-drainage if A-fail medical ttt B-large abscess

48. Perinephric abscess Def :suppurative collection between renal capsule , perirenal fascia Cause ;mostly rupture of renal abscess symptoms ;fever,chills,unilateral flank pain Signs; scoliosis,bulge of renal angle with overlying skin erythema , tendrenes INV; 1-abd US 2- CT SCAN TTT ; 1-Parentral antibiotic 2-drainage

49. TB of urinary tract Pathology; 1- renal <most common site> A-acute miliary Usually bilateral , fatal,no caseation B-chronic 2-caseocavernous 1-pyelonephritis 4-autonephrectomy 3-pyonephrosis - 6-calcifications 5-fibrosis 2- ureteric Most common site is pelviureteric junction Ureter is dilated , tortous , indurated < pipe stem > 3- bladder Most common ureteric orifice

50. Diagnosis 1-tuberculin test 2- urinalysis ; 3 consecutive morning urine sample stained with Zeihl Nelsen stain 3-urine culture :Dorset egg,or Lowenstien Jensen media 4- PCR

51. Management Standard treatment of TB is rifampin , INH, pyrazinamide , and ethambutol for 2 months, then rifampin and INH for 4 more months

52. 1-Age below which UTI is admitted and treated by parentral Ab <3m/5m /1y/6m> 2-drug of choice for UTI prophylaxis in 2mon child is < nitrofurantoin / cotrimexazole / cephalexin > 3-child 3y presented with dysuria,fever inv. Show pyuria,urine culture 10,000 colony of Ecoli is A-consider UTI B-Insignificant results C-repeat urine culture 4-which of following regardind UTI prophylaxis is false A-recommended for child with urinary tract obstruction B-recurrent febrile UTI even no urinary tract abnormality C-infant awaiting urinary tract imaging

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