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1. Urinary tract Infections in Children Shakilu J MD UDOM

2. Urinary tract Infections in Children Learning Objectives Definition Epidemiology Etiology Risk Factors Clinical presentation Diagnosis Treatment Prognosis and Prevention

3. Urinary tract Infections in Children UTI- refers to the presence of an infectious agent (Mostly bacteria) in the urinary tract associated with variable clinical symptoms Contrary to Asymptomatic Bacteriuria -Mere presence of bacteria in the urinary tract without symptoms Very variable symptoms especially children

4. Classification of symptomatic UTI in Children Lower Urinary tract Cystis Involve the urinary bladder and urethra Prominently characterized by - Urgency -Frequency - Dysurea -Incontinence Upper urinary tract Pyelonephritis Involve the Ureter, Collecting systems and renal parenchyma Prominently characterized by - Mainly Fever - Loin pain (in older kids) This classification is only arbitrary as in most cases its not possible to distinguish the two clinically especially in young infants

5. Epidemiology Incidence vary depending on age, sex and gender About 2.4 to 2.8% of children in US annually First time symptom occurrence high in the first year of life in boys and girls declining with age Below age 3mo boys > girls (especially uncircumcised boys) One year and above the incidence of UTI is 8.1% in girls and 2.1% in circumcised boys Studies from Sweden have indicated that at least 3% of girls and 1% of boys have a symptomatic UTI by age 11 years - with slightly higher rates in sexually active teenage girls

6. Epidemiology….. High number of UTI in US are reported in White than Black children Hoberman et al J Pediatr . 1993 Jul;123(1):17-23

7. Epidemiology Ana et al, Nature Reviews Microbiology 13 , 269–284 (2015)

8. Epidemiology….. Edgar et al, Pediatrics April 2000

9. Risk factors-UTI Immune deficiency -DM Congenital urinary tract malformations -Posterior urethral valve - Vesico ureteral reflux Instrumentation -Catheterization Neurogenic bladder Young age - Infancy especially< 2 mo Prolonged antibiotic therapy Other Urinary tract obstructions - Calculi

10. Urinary tract Infections in Children-Etiology

11. Urinary tract Infections in Children Clinical Presentation Nonspecific in infants and toddlers May include -Fever -Irritability -Vomiting -Abdominal pain -Diarrhea For older children - Frequency -Abdominal - Suprapubic discomfort -Dysuria -Loin pain

12. UTI IS A DIFFERENTIAL DIAGNOSIS FOR ANY FEBRILE CHILD

13. Urinary tract Infections in Children Clinical Presentation Maintain a high index of suspicion especially for children at high risk of UTI

14. Infants and younger children with pyelonephritis usually have no localizing findings, but they are febrile and often irritable

15. Urinary tract Infections in Children Diagnosis Poses a diagnostic challenge Non specific clinical presentation Difficulties in obtaining quality urine sample Lack of highly sensitive tests

16. Urinary tract Infections in Children Diagnosis Urine collection Poses a diagnostic challenge 1. Clean catch urine sample for older and dry kids 2. Suprapubic aspiration ( Gold standard ) 3. Catheterization 4. Perineal sterile bag urine http://emedicine.medscape.com/article/969643-workup - c8

17. Urinary tract Infections in Children Diagnosis Urine dipstick LE & Nitrites Urine analysis Leukocytes (5cells/ hpf ), Bacteria,Pyuria Centirifuged sample Urine culture & sensitivity 10 3 Vs10 5 CFU/ AAP 2011-50,000CFU Other nonspecific tests Complete blood counts Serum C-reactive protein Serum Procalcitonin Urine IL-6 & 8 levels Urine protein level

18. Culture & Sensitivity

19. Urine analysis

20. Imaging studies for UTI in children Not indicated for children with first time febrile UTI episode with no obvious risk for recurrent attacks Renal and bladder ultrasonography Voiding cystourethrography Technitium 99 DMSA

21. Urinary tract Infections in Children Management Most patients with UTI do not require hospital admission -Respond well on an outpatient treatment with oral antibiotics Toxic appearing patients and those < 2mo even when not Febrile should be treated aggressively with parenteral antibiotics - At ER unstable septic patients should be stabilized as APLS protocols before admission

22. Urinary tract Infections in Children Management-Criteria for admission Toxemic or septic Urinary obstruction or significant underlying disease Unable to tolerate adequate oral fluids or medications Infants younger than 2 months with febrile UTI (presumed pyelonephritis) Infants younger than 1 month with suspected UTI, even if not febrile

23. http:// www.nps.org.au /conditions/urine-bladder-and-kidney-problems/bladder-disorders/urinary-tract-infections/for-health-professionals/key-issues

24. Complications Renal parenchyma disease Sepsis End stage renal disease

25. Any questions!