Urinary Tract Infection - presentation.pptx

Detailed description of uti

1. URINARY TRACT INFECTIONS IN CHILDREN - DR.CAROLINE DIVYA

2. INTRODUCTION Common bacterial infection in infants and children In young infants leads to sepsis Important to pick up UTI early -> Renal scarring and parenchymal damage  Hypertension and progressive renal damage

3. Epidemiology: 1% of all boys and 1-3 % of all girls - UTI 1 st year , Male : Female -2.8 : 5.4 Beyond 1-2 years , Male : Female – 1: 10

4. SIMPLE UTI Low grade fever , Non toxic Age > 3 months Accepting oral feeds Dysuria, frequency and urgency Absence of symptoms of Complicated UTI DEFINITION COMPLICATED UTI Age < 3 months Fever > 39 c Systemic toxicity, persistent vomiting, Dehydration,lethargy,refusal of feeds Renal angle tenderness Raised creatinine Non E.coli UTI

5. RECURRENT UTI Two episodes of febrile UTI First UTI < 6 months of age Presence of known risk factors

6. UTI FORMS CYSTITIS / LOWER UTI PYELONEPHRITIS / UPPER UTI

7. SYMPTOMS PYELONEPHRITIS High grade fever > 39 Chills and rigors Toxic look , sepsis Nausea , vomiting Abdominal pain , flank pain Diarrhoea Gross hematuria CYSTITIS Dysuria Urgency Frequency Suprapubic pain Hematuria / Foul smelling urine Usually no fever Incontinence

8. SYMPTOMS …… 0-2 Months of age - sepsis , poor feeding , lethargy ,rarely cholestasis and failure to thrive 2 months to 2 years – Fever without focus Older children – may present as secondary enuresis

9. ETIOLOGICAL ORGANISMS Uropathogens – mostly bacteria from stools – ascending infection from peri-urethral area or via bacteremia E. Coli causes 54-67 % of all UTI Klebsiella , Proteus , enterococcus, pseudomonas Staphylococcus saprophyticus , Group B streptococcus Less commonly Staphylococcus aureus, candida and salmonella Adenovirus – Hemorrhagic cystitis

10. RISK FACTORS Poor perineal hygiene Female Phimosis / Vulval synechiae Uncircumcised male VUR Toilet training Voiding dysfunction Obstructive uropathy Urethral instrumentation Anatomic abnormality Neuropathic bladder

11. BOWEL BLADDER DYSFUNCTION Voiding disorder characterised by abnormal patterns of micturition in the presence of intact neuronal pathways without congenital or anatomical abnormalities Abnormal bladder pressure and urinary stasis  UTI predisposition Usually associated with constipation Two main defects – Overactive bladder  defect in filling phase Dysfunctional voiding  defect in evacuation phase

12. MANAGEMENT Clinical diagnosis Rule out neurological causes Voiding diary by intake-output monitoring Look for Urinary stream as well as post void residue Urodynamic studies – not needed in all cases METHODS Structured voiding Management of constipation Overactive bladder – Anti-cholinergic medications( Oxybutinin ) Dysfunctional voiding – timely voiding, bladder retraining and clean intermittent catheterisation

13. DIAGNOSIS OF UTI TYPICAL SYMPTOMS – Fever, dysuria, urgency, frequency, flank pain in older children (or) fever, vomiting, diarrhoea and poor weight gain in infants PLUS Positive Dipstick test – Leukocyte esterase/ Nitrite test Pyuria or Bacteriuria as seen in Urinalysis AND Isolation of single species of organism in significant numbers in a Urine culture (Gold standard)

14. DIAGNOSTIC TESTS Microscopy For pyuria Urine dipstick test Leukocyte esterase test Nitrite test Hematuria Urine Culture

15. NITRITE TEST Urinary nitrates are reduced to nitrites by GNB (mainly E.coli) – Nitrite reductase SPECIFICITY – 98 % ( 90 – 100 ) SENSITIVITY - 53 % ( 15 – 82 ) False negative - Bacteria need 4 hours of bladder time to reduce nitrate to nitrite(Early morning samples preferred) Gram-positive uropathogens do not produce nitrite reductase and therefore when infection is due to these bacteria, the dipstick will be negative for nitrite False positive – In uncircumcised males, drops of urine may persist after urination, the skin microbes change urine nitrate to nitrite

16. LEUKOCYTE ESTERASE Leukocyte esterase is an enzyme released by neutrophils and macrophages A urine dipstick positive for this enzyme indicates pyuria (an increased number of leukocytes). SENSITIVITY - 83 % (67 – 94 ) SPECIFICITY – 78 % (64 – 92) The presence of leukocyte esterase on dipstick may also be due to non-infectious renal diseases such as glomerulonephritis. Contamination of samples by vaginal secretions may cause a false-positive result. LEUKOCYTE ESTERASE + NITRITE REDUCTASE = SENSITIVITY – 93 % (90 – 100 ) SPECIFICITY – 72 % (58 – 91 )

17. URINE MICROSCOPY To look for pyuria – presence of pus cells in urine Significant pyuria - > 10 leukocytes/mm3 in fresh uncentrifuged sample or > 5 leukocyte/HPF in centrifuged sample(Urine Micro) False positives – Febrile conditions, Glomerulonephritis, Renal stones or foreign body in the urinary tract

18. Urinanalsysis

19. URINE SAMPLE COLLECTION TECHNIQUE Sample of urine Non toilet trained – Simple urethral catheterisation or Suprapubic aspiration Toilet trained – Midstream collected urine by clean catch method. Genital area should be cleaned with soap and water before collecting sample. In uncircumcised male – prepuce must be retracted Urine sample collected for culture should be plated within an hour If not able to plate immediately, can refrigerate at 4 C till 12-24 hours Don’t use urine collecting bag sample( Minicom ) for Urine culture

20. Urine culture - GOLD STANDARD Significant bacteriuria depends on the type of collection METHOD OF COLLECTION COLONY COUNT PROBABILITY OF INFECTION SUPRAPUBIC ASPIRATION ANY NUMBER OF PATHOGENS 99 % URETHRAL CATHETERIZATION > 5 x 10000 CFU / ml 95 % MIDSTREAM CLEAN CATCH > 100000 CFU / ml 90 – 95 %

21. OTHER INVESTIGATIONS BLOOD INVESTIGATIONS - Blood counts – Neutrophilic predominant leukocytosis Increased ESR and CRP Blood culture – if positive  UROSEPSIS IMAGING - Renal and bladder ultrasound - DMSA - MCU

22. RENAL ULTRASOUND NORMAL KIDNEY RENAL CYST

23. DMSA Scan (Dimercapto succinic acid) Normal Renal scarring

24. MCU POSTERIOR URETHRAL VALVE VUR

25. GRADES OF REFLUX

26. TREATMENT OF COMPLICATED UTI: < 3 months of age and those with complicated UTI - Hospitalize, IV fluids and start empirical parenteral antibiotics Change to oral after 48 hours ,if afebrile and sensitive to the agent Duration of treatment : 10 – 14 days Do Renal and Bladder USG , DMSA and MCU Cefotaxime : 100 mg /kg /24 hr divided by 2-3 doses Ceftriaxone : 75 -100 mg / kg / 24 hr in one to two divided doses Amikacin : 10 – 15 mg /kg / 24 hr in one to two divided doses Gentamicin : 5 – 6 mg /kg /24 hr in one to two divided doses

27. Treatment for Uncomplicated first UTI Uncomplicated UTI : > 3 month old, Non toxic, tolerating orally well Start oral antibiotics If clinical improvement – give for 7-10 days (Change according to sensitivity

28. INDICATION FOR PROPHYLACTIC ANTIBIOTICS IN UTI: Pending complete radiological evaluation after 1 st episode of UTI Grade I or II VUR – till 1 year of age; restart if breakthrough UTI occurs Grade III or more VUR - till 5 years of age; consider Sx if breakthrough UTI occurs - continue beyond 5 years, if associated with BBD Bowel and bladder dysfunction in UTI No role for cyclical prophylaxis , ie changing Abx every 6-8 weeks

29. PROPHYLAXIS OF UTI Once a day Cotrimoxazole : 1-2 mg /kg/ day of trimethoprim Nitrofurantoin : 1-2 mg /kg /day Cephalexin : 10 mg / kg / day Cefadroxil : 3-5 mg /kg /day

30. FURTHER EVALUATION < 1 year - Renal and bladder ultrasound - DMSA scan after 4-6 months - MCU 1 -5 year – Renal and bladder ultrasound - DMSA scan after 4-6 months - MCU only if DMSA is abnormal >5 year – Renal and bladder ultrasound - DMSA / MCU if abnormal ultrasound

31. INDICATIONS TO REFER TO PAEDIATRIC NEPHROLOGIST Recurrent UTI UTI associated with BBD Patients with VUR Underlying urologic and renal abnormalities Children with renal scar, deranged renal function, HTN

32. FOLLOW UP SHORT TERM Document normal urine analysis at the end of treatment of current UTI Do not repeat urine culture unless there is a new UTI/breakthrough UTI LONG TERM Assess renal function once in a year in a child who had severe complicated or recurrent UTI Do urinalysis during further febrile illness, in the presence of a known riskfactors for UTI BP evaluation once in 6-12 months Periodic monitoring of growth Proteinuria after successful treatment may be associated with pyelonephritic renal scarring.

33. BIBLIOGRAPHY IAP Standard treatment guidelines 2022, UTI in children – Sudha Ekambaram etal Revised statement on management of UTI, ISPN – Dr M Vijayakumar etal , Indian Paediatrics 2011 Chapter 553, Urinary Tract Infections – Karen E Jerardi etal , Textbook of Paediatrics , Nelson 21 st edition

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