URINARY TRACT INFECTION

MENTOR

DR.SARALA

CASE SCENARIO
4 months old/ Malay/ Boy
Was brought to casualty due to fever for 1 day

WHAT FURTHER HISTORY YOU

WOULD WANT TO ASK?

FURTHER HISTORY

Fever
any documented temperature?
rash?
bleeding tendency?
from dengue area?
contact with ill person?
child taken care by whom?
hx of recent travelling?
URTI sx?
UTI sx?
Diarrhea / Vomitting?
Irritability, Inconsolable cry?
Feeding history/Urine output?
Mother on traditional medication?
Mother applies ointment to the baby?
H/O jaundice?

4 months old malay boy

fever for 1 day
documented Temperature at home 39.5, repeated at A&E 39.9
no rash
no bleeding tendency
not from dengue area
no contact with ill person
child taken care by mother at home( mother is a housewife)
no hx of recent travelling
no URTI sx
UTI sx, foul smelling urine
no diarrhea / no vomitting
child given breast milk 2-3 hourly, tolerates well with good urine
output
mother not on traditional medication
mother not applying ointment to baby
no h/o jaundice

ANY FURTHER HISTORY

YOU WOULD WANT TO
ASK?

FURTHER HISTORY

No past medical history

No medication given before
Birth history:
born SVD/ Term/ BW 3.0kg, CW:6.0kg,
ANC : uneventful,
immunisation : up to age.
Family History :
first child in the family.
Social history :
taken care by mother
Dietary history :
child given breast milk 2-3 hourly, tolerates well
Developmental history :
according to age of patient

WHAT ASSESSMENT
YOU WOULD LIKE TO
DO?

Primary assessment
ABCDE
Secondary assessment
Head to Toe
General Condition

PRIMARY ASSESSMENT

Airway
Patent, No secretion / No foreign body
Breathing
Effort: RR 45, no SCR, ICR, no nasal flaring,
Efficacy: Not tachypneic, SpO2 98% under room air, on
auscultation: lungs clear with good air entry bilaterally
Effect: HR 142 bpm, good pulse volume, CRT < 2 sec, warm
peripheries
Circulation
Well perfused, Heart rate 142 bpm, CRT < 2 sec, good pulse
volume, BP 90/50
Disability
No abnormal posture, pupils bilateral equal and reactive,
DXT 4.8
Exposure
No skin rashes, temperature 39.9 degree celcius

SECONDARY ASSESSMENT

Alert, pink, AFNT, no recession, CRT<2sec, good pulse

volume, no jaundice.
Eyes : No conjunctivitis
Ears: No ears discharge
Throat: Normal
Lungs : Good air entry, Clear
CVS: DRNM
P/A : Soft, not distended, no hepatosplenomegaly,
Bowel sound present.
Genetalia: Normal male genetalia, bilateral testes
palpable and descended

DIFFERENTIAL DIAGNOSIS
Urinary obstruction
Nephrolithiasis
Viral fever, dengue fever

WHAT

INVESTIGATION
WOULD YOU LIKE TO
DO?

FBC
UFEME
URINE Culture and Sensitivity
BLOOD Culture and Sensitivity

UFEME (cathether in out)

INVESTIGATION RESULT

FBC

WBC
Hb
HCT
MCV
MCH
Platelet

: 27.96
: 11
: 33.1
: 61
: 18
: 433

pH
:5
Leu :500/ul
Nitrate
:negative
Pus cell
:15-20
RBC
:3-4

PROVISIONAL
DIAGNOSIS?

DS: Urinary tract infection

HOW WOULD YOU TREAT

THIS PATIENT?

IV Antibiotics
IV Cefuroxime(100mg/kg/day) TDS or
IV Cefotaxime(100mg/kg/day) TDS or
IV Gentamicin 5-7mg/kg/day) OD
Continue intravenous antibiotic until child is
afebrile for 2-3 days and then switch to
appropriate oral therapy after culture results
e.g. Cefuroxime, for total of 10-14 days.

PROGRESS OF PATIENT
IV Cefuroxime was started at Day 1 of admission
after r/v UFEME
Temperature settled after 36 hours of antibiotics
started
Urine C&S available at day 3 of admission

URINE C&S: E Coli

Sensitive to:
Cefuroxime
Cefotaxime
Cephalexin
Bactrim
Resistant to:
Gentamicin

WHAT IS THE PLAN NOW?

IV CEFUROXIME continue for total 5 days, then

change to oral Cefuroxime 15mg/kg/dose BD for
another 5 days.

PATIENTS PROGRESS
Patient was discharged at Day 5 after complete IV
Cefuroxime.

WHAT FURTHER PLANS CAN

BE DONE UPON
DISCHARGE?

Continue Oral CEFUROXIME for 5-9 days

TCA Pakar 3 3-4 weeks with repeat UFEME and
Urine C&S
Dont need for prophylaxis antibiotics
Ultrasound KUB as outpatient within 2 weeks.

WHAT IS A URINARY TRACT

INFECTION?

INTRODUCTION

The urinary tract is a common site of infection in the

pediatric population
UTI comprises 5% of febrile illnesses in early childhood
Unlike the generally benign course of UTI in the adult
population, in the pediatric population is well recognized as
a cause of acute morbidity and chronic medical conditions

Urinary tract infection is growth of bacteria in the urinary

tract or combination of clinical features and presence of
bacteria in the urine
Significant bacteriuria is defined as the presence of > 105
colony forming units (cfu) of a single organism per ml of
freshly voided urine
The urinary tract:

kidney
ureter
bladder
urethra.

A complicated UTI describes infections in urinary tracts

with structural or functional abnormalities or the presence
of foreign objects, such as an indwelling urethral catheter.

UROPATOGENS

PATOGENESIS

ASCENDING ROUTE OF UTI

Risk factors
Although all individuals are susceptible to UTI,
most remain infection free during childhood
because of the innate ability to resist uropathogen
attachment.

Neonates and infant

higher risk for UTI; incompletely developed immune
system

Uncircumcised infant boys

foreskin have been demonstrated to harbor significantly
higher concentrations of uropathogenic microbes

Fecal and perineal colonization

The flora of the colon and urogenital region is a result
of native host immunity, existing microbial ecology

Anatomic abnormalities
_ predispose children to UTI because of inadequate clearance
of uropathogens.

younger than 5 years of age.

It

is essential to identify these abnormalities early

because if uncorrected, they may serve as a reservoir
for bacterial persistence and result in recurrent UTI.

Surgical

intervention may be required to correct the

anatomic abnormality

Congenital anatomic anomalies, such as PUV

and VUR, do not predispose children to
colonization but increase the likelihood of
inadequate washout in the routine ways.
These urinary tract malformations increase the
likelihood of infections of the lower urinary tract
(ie, bladder and urethra) will ascend to the upper
tracts with possible pyelonephritis and potential
renal deterioration.

POSTERIOR URETHRAL VALVE

 Vesicoureteric reflux (VUR)

defined as the retrograde flow of urine from the bladder into
the ureter and collecting system.

divided

primary

VUR
secondary VUR ( it results from high pressure
voiding secondary to posterior urethral valve,
neuropathic bladder or voiding dysfunction)

at risk for further episodes of pyelonephritis with

potential for increasing renal scarring and renal
impairment (reflux nephropathy).

 Functional
eg;

abnormalities

neurogenic bladder
Inability to empty the bladder, frequently
results in urinary retention, urinary stasis,
and suboptimal clearance of bacteria from the
urinary tract.
Clean intermittent catheterization (CIC) is
helpful for emptying the neurogenic bladder,
but catheterization itself may introduce
bacteria to this normally sterile space.

 In older children younger

Infants younger than 60 to
THERE
BASIC FORMS
UTI: the most
90 daysARE
mayTHREE
have vague
thanOF
2 years,
PYELONEPHRITIS,
CYSTITIS, AND
ASYMPTOMATIC
and nonspecific symptoms
common
symptoms
of illness that are difficult
BACTERIURIA.
fever
to interprete
THERE
ARE VARIOUS CLINICAL
PRESENTATIONS FOR
vomiting
diarrhea
CHILDREN WITH UTI BASED
ON
AGE.
anorexia
irritability
strong-smelling urine
lethargy
malodorous urine
fever
asymptomatic jaundice
oliguria or polyuria
poor feeding
vomitting

In children between 2
and 5 years of age,the
most common
presenting symptoms
abdominal pain
fever
vomitting
strong-smelling
urine

After 5 years, the

classic lower urinary
tract symptoms
dysuria
urgency
urinary frequency
costovertebral
angle tenderness
strong-smelling
urine

Asymptomatic bacteriuria
Positive urine culture without any manifestations of
infection
Occurs almost exclusively in girls
Benign and does not cause renal injury, except in pregnant
women, in whom asymptomatic bacteriuria, if left
untreated, can result in a symptomatic UTI

PHYSICAL EXAMINATION

All children should have their sacral region examined for :

dimples
pits or a sacral fat pad

The presence of these signs is associated with neurogenic

bladder.
Hypertension should raise suspicion of hydronephrosis or
renal parenchyma disease.
Costovertebral angle (CVA) tenderness
Abdominal tenderness or mass
Palpable bladder
Dribbling, poor stream, or straining to void
Examine external genitalia for signs of irritation,
pinworms, vaginitis, trauma, sexual abuse, phimosis or
meatal stenosis

MANAGEMENT

All infants with febrile UTI should be admitted and

intravenous antibiotics started as for acute pyelonephritis.
Patients with high risk of serious illness, it is preferable that
urine sample should be obtained first; however treatment
should be started if urine sample is unobtainable.
Antibiotic prophylaxis should not be routinely recommended in
infants and children following first time UTI as antimicrobial
prophylaxis does not seem to reduce significantly the rates of
recurrence of pyelonephritis, regardless of age or degree of
reflux.
Antibiotic prophylaxis may be considered in the following:
Infants and children with recurrent symptomatic UTI.
Infants and children with vesico-ureteric reflux grades of at
least grade III.

NICE GUIDELINE:

Dehydration
-most common complication of UTI in the
pediatric population.
-IV fluid replacement is necessary in more severe
cases.
Untreated UTI may progress to renal involvement
with systemic infection (e.g., urosepsis).
Long-term complications include renal
parenchyma scarring, hypertension, decreased
renal function, and, in severe cases, renal failure.

MESSAGE:
Most cases of UTI are simple, uncomplicated, and
respond readily to outpatient antibiotic
treatments without further sequelae.
Appropriate treatment, imaging, and follow-up
prevent long-term sequelae in patients with more
severe infections or chronic infections.
Mild VUR usually resolves without permanent
damage.

All children less than 2 years of age with

unexplained fever should have urine tested for
UTI.
Greater emphasis on earlier diagnosis & prompt
treatment of UTI
Diagnosis of UTI should be unequivocally
established before a child is subjected to invasive
and expensive radiological studies
Antibiotic prophylaxis should not be routinely
recommended following first-time UTI

REFERENCE:
Paediatric protocol
Medscape
Nice guideline

THANK YOU