UTI in Pediatric age -How to Manage?.ppt

Recent advances in the management of UTI in Children

1. Pediatric Urinary Tract
Infections
Prof Ashwani K Sood
MD DCH FIAP

2. Objectives
Define Urinary Tract Infection (UTI)
>100,000 CFU in clean catch girls
>10,000 CFU clean catch guys
>10,000 catheter specimen
List antibiotic treatment options for UTI
Amoxicillin, Bactrim, Cephalosporins
List the workup after a first febrile UTI
Consider renal U/S and VCUG
Be familiar with the rationale for using prophylactic antibiotics
after the first febrile UTI
Prevent renal complications/scarring/pyelonephritis

3. Definition:
Presence of bacteria in urine along with symptoms of infection.
Incidence:
5% in Girls 1-2% in Boys
During the 1
st
year of life more common in boys due to higher risk of
anomalies and after age of one more in girls
Males and females are equally affected in the neonatal period.
Etiology:
Most common infecting pathogen : Escherichia Coli 80% of UTI.
Other: --Enterobacteria ( Klebsiella, Proteus, pseudomonas)
Staphylococcus & Streptococcus Species
- Occasionally Candida albicans
UTI in Children

4. Route of infection:
Neonate: Hematogenous
Later : Ascension of bacteria into the Urinary tract.
Development of UTI depend on:
1-Virulence of the invading bacteria.
2-Susceptibility of the host; some families and structural
abnormalities.
Predisposing factors:
1-Conditions leading to urinary stasis : Renal calculi, Obstructive
Uropathy, VUR, & Voiding disorders
2-Immune deficiency
3-Broad-spectrum antibiotics ( amoxicillin, cephalexin).
4-Constipation by organism moving from anus to urethra.
5-Uncircumcised male

5. Causes and course of UTI

6. Clinical Presentation:
1-Upper UTI (Pyelonephritis).
2-Lower UTI ( Cystitis).
The history & clinical coarse varies with the patient’s age & specific
diagnosis.

7. Introduction
Pediatric UTIs often signal an underlying
genitourinary tract abnormality
Can lead to renal scarring with resultant hypertension
and renal failure
Difficult to diagnose because symptoms are non-
specific in this age group and testing is often invasive

8. Epidemiology
The overall prevalence of UTI is approximately 5 percent in
febrile infants but varies widely by race and sex.
Caucasian children had a two-to fourfold higher prevalence
of UTI as compared to African-American children
Females have a two-to fourfold higher prevalence of UTI
than do circumcised males
Caucasian females with a temperature of 39 ºC have a UTI
prevalence of 16 percent

9. UTI: Classification
Classification:
Upper tract infection
Acute pyelonephritis-fever, bacteriuria, systemic
symptoms
Lower tract infection
Urethritis
Cystitis
Voiding symptoms, little or no fever, no systemic
symptoms

10. Pediatric UTIs and EBM
Up to 7% of girls and 2% of boys experience a
symptomatic culture-proven UTI prior to 6 years of
age.
Of febrile neonates, up to 7% have UTIs.
( Fever without a source guidelines)
Most UTIs in children are from ascending bacteria
E. coli (60-80%), Proteus, Klebsiella, Enterococcus, and
CoNS.

11. Organisms associated with UTI
Gram negative organisms
Escherichia coli > 80%
Klebsiella species
Proteus –common in males
Enterobacter species < 2%
Pseudomonas species < 2%
Gram positive organisms
Enterococci species
Staphylococcus saprophyticus
Staph. aureus (uncommon)
Group B strep (uncommon)

12. Risk factors for UTI in young children
Poor perineal hygiene and unnecessary use of diapers
Congenital anomalies of kidney and urinary tract (CAKUT) such as
vesicouretericreflux, pelvic ureteric junction obstruction, obstructive uropathy,
abnormal communication
between urinary tract and gastrointestinal tract, phimosis in boys, vulval synechiae in
girls,
and renal stones
Bowel bladder dysfunction (BBD) presenting with features of urinary urgency,
frequency, dysuria, voiding postponement during the toilet training age group,
incontinence, and Constipation
Almost 50% children with recurrent UTI and 10% children presenting with a single
UTI have an associated urological abnormality
Fungal UTI is more common in immunocompromised patients, intensive care unit
(ICU)setting, prolonged antibiotic usage, and in presence of indwelling catheters

13. Approximate probability of urinary tract infection
in febrile infants and young children by
demographic group
Demographic group
Prevalence
(pretest probability)
Odds
Circumcised boys >1 yr <1 percent .01 (1 in 100)
Circumcised boys <1 yr 2 percent .02 (1 in 50)
Black girls 4 percent .04 (1 in 25)
Uncircumcised boys <2 yr 8 percent .09 (1 in 12)
White girls <2 yr 16 percent .19 (1 in 5)

14. 0-2months: sepsis. Which also the presentation in premature infants
along with poor feeding
2mon-2yrs:different presentation
•Unexplained fever (low or high grade fever)
•Irritability, poor oral intake, lower abdominal pain, vomiting, loose bowel
movement (diarrhea).
•Voiding symptoms of cystitis (frequency, urgency, hesitancy)
•Crying on urination (burning urination)
•Smelly urine
•No fever or mild
2yrs :
Pyelonephritis( fever, irritability, poor appetite, abdominal flank
pain back pain, voiding symptoms, tenderness in
costovertebralangle or flank.
cystitis : voiding symptoms ( urgency, frequency, hesitancy, dysuria,
urinary incontinence)
mild or no fever, Suprapubicor abdominal pain

15. Symptoms
Classic UTI symptoms in older children
Dysuria, frequency, urgency, small-volume voids, lower
abdominal pain.
Infants with UTIs have nonspecific symptoms
Fever, irritability, vomiting, poor appetite

16. Signs and Symptoms –
Children 2 months to 2 years
Fever—usually unexplained
Vomiting and/or diarrhea
Abdominal Pain
Failure to thrive
Malodorous urine
Crying during micturation

17. Signs and Symptoms –Children >2
Fever
Vomiting and/or diarrhea
Abdominal pain
Malodorous urine
Frequency and/or urgency
Dysuria
New incontinence

18. Neonatal hematuria?
Nope, it’s uric acid crystals

19. Examination
Examination may be normal in UTI other than the presence of
fever
•Lower abdominal or loin tenderness may be present
•Non-specific findings include dehydration and lethargy
•
Assessment of severity
•Clinical distinction between lower and upper UTI can be
difficult, especially in younger children
•Cystitis is suggested by features such as dysuria, frequency,
urgency and lower abdominal discomfort
•Pyelonephritis is suggested by systemic features such as fever,
malaise, vomiting and loin tenderness

20. Evaluation
In children with a high likelihood of UTI, a urine
culture is required.
In children with a low likelihood, a negative dipstick
in a clear urine reduces the need for culture.
If the dipstick shows (+) LE and/or (+) Nitrites,
send a urine culture.
The dipstick is not sufficient to diagnose UTI’s
because false positives can occur.

21. Determining the Likelihood of UTI
Roberts KB. Am Fam Phys. 2012.
Lower likelihood of UTI
Clinically follow without testing
Higher likelihood of UTI
Obtain urinalysis and culture by catheterization OR
Obtain urinalysis by bag or catheterization
a.If urinalysis tests + for nitrites or leukocyte esterase, then obtain
culture via catheterization
b.If urinalysis tests negative, then follow clinically without antibiotic

22. Investigation
Children with suspected UTI should have a urine sample
collected; dipstick and microscopy screening can guide
initial management.
Check culture results after 24 hours to confirm or adjust
management as appropriate
Urine samples should be collected prior to starting
antibiotics (unless the child is seriously unwell and
requires immediate IV therapy)
•Older children able to void on request can provide a
midstream urine sample
•For younger pre-continent children, a clean catch is often
suitable.
•Catheter or SPA may be required for seriously unwell
infants

23. Urine Collection
The perineal/genital area should be cleaned with saline-soaked gauze for 10
seconds before collecting midstream or clean catch urine
Midstream urine (MSU):preferred method for toilet-trained children
who can void on request—contamination rate 25%
Clean catch:appropriate for pre-continent children who cannot void on
request, but are not seriously unwell (yield may be improved by gently
rubbing child’s suprapubic area with gauze soaked in cold fluid,)—
contamination rate 25%
Suprapubic aspirate(gold standard)—contamination rate 1%
In/out catheter:useful if there is little urine in the bladder, such as after
failed clean catch or SPA (discard first few drops of urine if possible to
reduce contamination)—contamination rate 10%
Bag urine:not recommended for culture due to high false positive rates—
contamination rate 50%

24. Urine dipstick
•Urine dipstick is a useful screening test to guide initial
management
•The presence of leucocytes and nitrites is suggestive
of a UTI.
•Dipstick results are less reliable in neonates and
young infants, particularly due to false negative

25. Leukocyte Esterase and Nitrites
LE is produced from the breakdown of leukocytes.
Not always indicative of infection
Vaginitis/vulvitis can lead to inflammation without
infection + LE
Nitrites are produced by bacteria that metabolize
nitrates: E. coli, Klebsiella, Proteus (GNRs)
Much more predictive of UTI
GPCs do not produce nitrites

26. >Nitrite concentrations & leukocyte estrase.
Nitrite is positive in pseudomonas mostly , klebsiella or proteus
infection.
If nitrite is positive think of structural abnormality.Nitritealone is not
diagnostic.
Pyuria and bacteruriaare not diagnostic.
-Urine analysis & dipstick: High index of suspicion
for UTI in febrile children particularly those with
unexplained fever. Lasts for 2-3days;
> 5 WBC/ hpfin centrifuged fresh urine positive
screening test.
>Bacteria in cent. & non cent. Or phase contrast
suggestible of UTI.
>Pyuria, proteinuria & Hematuria may occur with or
without UTI.

27. Urine Microscopy and Culture
•Laboratory microscopy can complement dipstick results to
guide initial management
•Bacteria and leucocytes on microscopy are suggestive of UTI.
See notes section below
•Epithelial cells (squames) suggest skin contamination and a
poorly collected sample. Consider recollection
•A positive culture with sufficient growth and pyuria confirms UTI
•Growth of a single organism at >10
8
CFU/litre(>10
5
CFU/mL)
from any collection method suggests infection
•Growth of a single organism at lower counts of 10
6-8
CFU/litre
(>10
3-5
CFU/mL) from catheter or SPA urine suggests infection,
and from clean catch or MSU may indicate early infection
•Growth of any amount from SPA suggests infection

28. POSITIVE URINE CULTURE IS ESSENTIAL
FOR DIAGNOSIS OF UTI.
Urine culture: the most diagnostic if the
patient is not receiving any antibiotics.
-Suprapubic aspiration is common in kids <1 : any
number of colonies is diagnostic.
-IN-and-out catheterization: > 10³, if more than
one year and if not possible do MSU.
-Midstream clean-catch urine collection > 10,000
-usually a single organism
-2 or more organism on the culture indicates
contamination.

29. Interpreting urine test results
•Blood and protein are not reliable markers of UTI
•Nitrites are not produced by all urinary organisms, so the
absence of nitrites on dipstick does not exclude UTI
•Pyuria (leucocytes) can occur with other febrile illnesses,
so pyuria alone on dipstick/microscopy does not confirm
UTI
•Pyuria may be absent in early infection or very young
children
•Pyuria and bacteria seen on microscopy are suggestive of
UTI, but a positive culture is required to confirm the
diagnosis
•Pure growth at low colony counts (CFU) may indicate early
infection. Consider sample recollection or empiric
treatment if the child remains unwell

30. Definition of UTI on culture
Method of urine collectionDiagnostic threshold
Clean-catch in voiding girls100,000 CFU per mL
10,000 –100,000 repeat
culture
Clean-catch in voiding boys10,000 CFU per mL
Catheter 10,000 CFU
1,000 –10,000 repeat
culture
Suprapubic aspiration Any colonies of GNRs
More than a few thousand
GPCs

31. -Blood culture : neonate & infant
-Pyelonephritis: CBC: neutrophilic leukocytosis
 high ESR
 C-reactive protein
(ESR and C-reactive protein are non-specific and are
elevated more in pyelonephritis than cystitis.
Distinction between upper & lower difficult in
children

32. Roberts, KB.
Revised AAP
guideline on UTI in
febrile infants and
young children. Am
Fam Phys.
2012;86(10):940-
946.

33. Roberts, KB.
Revised AAP
guideline on UTI
in febrile infants
and young
children. Am Fam
Phys.
2012;86(10):940-
946.

34. Ways to Obtain Urine Culture
Suprapubic aspiration
Invasive, requires expertise, painful
May be necessary in boys with phimosis and girls with
labial adhesions
Catheterization
Invasive
High sensitivity (95%), specificity (99%)
Bag applied to perineum
False positive result 88-99% of the time!

35. Imaging Modalities
Roberts KB. Am Fam Phys. 2012.
Renal & Bladder U/S
•Pros: noninvasive, no
radiation
•Cons:
•cannot reliably
demonstrate inflammation,
renal scarring
•no info on renal function
VCUG
•Pros: affects treatment
decisions that
theoretically reduce
risk of renal scarring
•Cons: radiation,
expense, discomfort

36. Urine dipsticks
In a cohort study with an 18% baseline prevalence of
UTI, negative LE and nitrates on dipstick had a
negative predictive value of 96%.
NPV = True negatives
_____________
True negative + false negative

37. Blood cultures
Blood cultures are generally unnecessary in most
children with UTI.
They are more frequently positive in children younger
than two months whose urine grows Group B strep or
Staph. Aureus.
In general, we’ll send febrile children less than two
months old to the ER for emergent evaluation/labs.

38. Treatment of UTIs
The efficacy of oral regimens is as effective as
parenteral regimens -this is great news for outpatient
therapy 
If the child is not responding the empiric treatment
within two days while awaiting culture results, repeat
the urine culture and perform a renal ultrasound.

39. Treatment
•Oral antibiotics are usually appropriate
•Any child who is seriously unwell, and most
infants under 3 months, should be admitted for
initial IV antibiotics
•3–7 day course for children with cystitis
•7–10 day course for children with pyelonephritis

40. Treatment
Use oral or parenteral antibiotic
Modify antibiotic based on sensitivities from urine
culture
Treat for 7-14 days for febrile UTI
3-7 days for afebrile UTI
Roberts KB. Am Fam Phys. 2012. Cayley WE. Am Fam Phys.2013.

41. Common antimicrobials for treatment of urinary tract infection (UTI) in
children
Antimicrobials Dose(mg/kg/day) Remarks
ORAL
Cefixime 10 in two divided doses Good effective empirical
broad spectrum agent
Amoxicillin or co-
amoxiclav
30–50 in two divided
doses
May consider for
uncomplicated UTI
Cephalexin 30–50 in three divided
doses
Parenteral
Amikacin 10–15 in one to two
divided doses
Once a day dosing is
effective
Cefotaxime
Ceftriaxone
100 in two to three
divided doses
75–100 in one to two
divided doses
Safe and effective as
monotherapy

42. Follow up
Seriously unwell children, those with renal impairment, and boys
<3 months of age should have a renal ultrasoundprior to
discharge
•Other children do not require an ultrasound for a first UTI; a
non-urgent renal ultrasound should be arranged for children
who have recurrent UTIs
•Routine antibiotic prophylaxis after simple UTI is not required
•Specialist follow-up should be arranged for children with
recurrent UTI or known renal anomalies
Consider consultation with local paediatricteam when
•Child under 6 months of age
•Child has known renal tract anomalies or not responding to
initial therapy
•Treatinganychild who is seriously unwell

43. Further testing/work-up
After the UTI resolves, what type of workup should
ensue?

44. Vesicoureteral Reflux and Treatment
Approximately 40% of children with febrile UTIs have VUR.
Approximately 8% of children with febrile UTIs demonstrate
renal scarring when studied.
Treatment recommendations are made to stop the progression
of VUR with medications/antibiotics and/or surgery.
No data/EBM demonstrate that treatment of VUR prevents
renal scarring, hypertension and CKD

45. Antibiotic prophylaxis
Children with VUR are treated prophylactically with
antibiotics to prevent potential renal scarring.
Nitrofurantoin or trimethoprim-sulfamethoxizole
Half the standard dose administered at bedtime
Family physicians would generally have a pediatric
urologist involved to assist in making treatment
decisions.

46. How long to continue Abx?
Although the evidence is not conclusive, it appears the risk of
scarring diminishes with age.
Accordingly, some experts recommend cessation of
prophylaxis after age 5 to 7 years, even if low-grade VUR
persists.
In one study of 51 low-risk (no voiding abnormalities or renal
scarring) older children (mean age 8.6 years) with grades I to
IV VUR, cessation of prophylactic antibiotics resulted in no
new renal scarring on annual DMSA

47. Indications to order radiologic studies
Children younger than 5 years of age with a febrile
UTI
Girls younger than 3 years of age with a first UTI
Males of any age with a first UTI (PUV)
Children with recurrent UTI
Children with UTI who do not respond promptly to
therapy

48. Studies to consider
Renal Ultrasound
Will evaluate for perinephric abscess in patients not
responding to antibiotics.
Can evaluate for hydronephrosis/hydroureter
Of note, dilation of the kidneys and ureters can easily be
seen on routine anatomy scans during pregnancy.
Picking up vesicoureteral reflux while asymptomatic
Does this help or hurt? Staging of VUR, antibiotics, etc...

49. Hydronephrosis

50. Studies to consider
Voiding cystourethrogram –two techniques
One involves fluoroscopic contrast –more radiation but
better delineation of anatomy for grading VUR
The other uses a radionuclide –less radiation and more
sensitive than contrast

51. Normal VCUG

52. Vesicoureteral reflux (VUR)

53. Megaureter

54. Studies to consider
Renal scintigraphy using dimercaptosuccinicacid
(DMSA)
Can detect scarring in the kidneys.
Renal cells take up the tracer.
Those cells damaged by pyelonephritis or scarring do not
take up the tracer.
Management or followupof patients does not change in
most cases.
Thus, not generally used for initial evaluation.

55. Scar in the
superior and
inferior pole of
the right kidney

56. -Breakthrough UTI:
Caused by:
1-change in the resistance pattern of organisms colonizing the
urethra.
2-noncompliance.
3-VUR
4-Voiding dysfunction.( delay in urination or structural abnormality)
-Voiding dysfunction:
Detrusor instability & incomplete bladder emptying
-Associated with daytime enuresis & constipation.
-Increase risk of UTI & VUR.
-RX: 1-Timed voiding
2-Treatment of constipation.
3-Prophylactic antibiotics.
4-Anticholinergic medications.
-Asymptomatic bacteruria:
No need for antibiotics to prevent resistance and recurrence would be
with a more virulent organism, low risk of scarring.

57. Choosing Wisely
Do not perform VCUG routinelyin first febrile UTI in
children aged 2-24 months.
The risksassociated with radiation (plus the discomfort and expense
of the procedure) outweigh the risk of delaying the detection of the
few children with correctable genitourinary abnormalities until their
second UTI.