Urinary Tract Infection in Children

Pungky A.K.
Sub-Division of Nephrology
Department of Child Health Gadjah Mada
University Yogyakarta

1
 Introduction
Urinary tract infection is defined as the presence of
bacteria in urine along with symptoms of infection
(Syed M.A,1998). These infections can become
serious if undetected, and sometimes lead to
permanent kidney damage.

Recurrent UTI is defined as two or more UTI over a

six-month period (Ditchfield, 1994). It is useful to
determine whether recurrence is caused by
inadequate treatment of an unrecognized anatomic
site of bacterial persistence (Shortliffe ,1995). As
mentioned previously, recurrent UTI increases the risk
of subsequent renal scarring. 2
 Introduction
UTI occurs in as many as 5 % of girls and 1- 2 % of
boys (Zelikovic,1992)
The incidence of UTI in infants ranges from
approximately 0.1- 1.0 % in newborn to as high
as 10 % in low-birth-weight infants.
UTI before age one occurs more frequently in boys
than in girls. After age one, both bacteriuria and
UTI are more common in girls (Klein,1995).
In preschool-age children, the prevalence of
asymptomatic infections diagnosed by
suprapubic aspiration in girls: boys is 0.8%: 0.2%
.
In the school-age group, the incidence of
bacteriuria among girls is 30 times as much as
boys (1.2 %: 0.04%) (Travis,1996) 3
 Immunity

Ascending
Hematogenous UTI
Limphogenous

Predisposition:

(1). Obstructive: a. Congenital

b. Acquired
(2). Renal calculi
(3). VU reflux
(4). Voiding disorders
4
 Risk Factors of UTI

Urinary Tract abnormality

Sepsis
Immune deficiency
Catheterization

5
 Congenital Abnormalities

I. Non Obstructive

1. Polycystic
2. Hypoplastic
3. Ectopic vesical urinary
4. Persistent Urachus

6
II. Obstructive

1. Lower VU
Phimosis
Urethral Posterior Valve
Vesicourethral obstruction

2. Upper VU
Stricture Ureter
Vesical Ureter
/ Pelvic-Ureter stenosis

7
 Etiology

Escherichia coli is the most common infectious

pathogen in children, >80 % of UTI.
Other pathogens include Staphylococcus and
Streptococcus species, a variety of enterobacteria
(e.g., Klebsiella, Proteus) and, Candida albicans.
The virulence of the invading bacteria and the
susceptibility of the host are of primary
importance in the development of UTI
(Klein,1995).
8
Etiology ( Indonesia)
RSCM, (1982) Damanik(1990)

E. Coli 42 % 60,7 %
Proteus 20 % 10,7 %
Pseudomonas 8% 14,3 %
Aerobacter Aerogenes 8% -
Gram negative bacteria 4% 3,6 %
Difteroid 4% -
Staphylococcus 4% 10,7 %

9
 Clinical Presentation

The clinical presentation of UTI is variable.

Asymptomatic" bacteriuria, only subtle clues,
such as enuresis or squatting, may be present.
Alternatively, a systemically ill neonate may be
lethargic and hypotensive (Table 1). Although
children are often managed on the basis of
clinical symptoms and signs alone, these may be
unreliable predictors of which patients are at risk
for pyelonephritis and scarring (Majd M,1991;
Bjorvinsson, 1991).
10
Signs and Symptoms of Urinary Tract Infection in
Children
Urinary tract signs and symptoms
Dysuria
Frequency
Dripping / hesitancy
Enuresis after successful toilet training
Malodorous urine
Hematuria
Squatting
Abdominal/suprapubic pain
Systemic signs and symptoms
Fever
Vomiting/diarrhea
Flank/back pain 11
 Clinical Signs and Symptoms of UTI
Newborns Infants and School Age Children
Preschoolers
Jaundice
Sepsis Diarrhea
Failure to thrive Failure to thrive
Vomiting Vomiting Vomiting
Fever Fever Fever
Strong-smelling urine Strong-smelling urine
Abdominal or flank pain Abdominal or flank
pain
New onset urinary New onset urinary
incontinence incontinence
Frequency
Dysuria 12
Urgency
 Diagnosis
Guideline issued by the American Academy of
Pediatrics (AAP) for the evaluation of fever
>39.0C [102.2F] of unknown origin suggests
urinalysis in all cases and a urine culture in all
boys < six months of age and all girls < two years
of age (Baraff LJ, 1993).
Suprapubic aspiration, bladder catheterization and,
a clean-voided midstream specimen, perineal bags
are essential for diagnosis of UTI ( Zelikovic,
1992).
Criteria set by Dagan and colleagues : a finding of
more than 5 white blood cells per high-power field
in centrifuged fresh urine is a satisfactory positive
13
screening test ( Dagan R, 1985).
 Renal cortical scintigraphy has replaced intravenous
urography as the standard technique for detecting renal
inflammation and scarring.
Pyuria, proteinuria and hematuria may occur with or
without UTI (Zelicovic, 1992). A properly obtained
positive urine culture is essential for the diagnosis of UTI.
Any number of colonies from a suprapubic bladder
aspiration, more than 103 colonies from an intermittent
catheterization, more than 105 colonies from a midstream
clean-catch urine collection indicate UTI ( Margileth,1976
;Batisky D 1996).
Most UTI are caused by a single organism; the presence of
two or more organisms suggests contamination. A urine
culture is not mandatory in adolescent girls, particularly
with a first episode. With recurrent episodes, episodes that
fail therapy, and in girls with pyuria without bacteriuria, a
culture is recommended ( Margileth,1976). 14
Suprapubic Aspiration

15
Advantages and Disadvantages of Diagnostic
Imaging in Evaluation of Urinary Tract
Infection in Children

16
Ultrasound Measures renal size and shape
Identifies hydronephrosis,
structural or anatomic
abnormalities and renal calculi
No radiation
Not reliable to detect vesicoureteral
reflux, renal scarring or
inflammatory changes

Intravenous Precise anatomic image of the Not as reliable to detect renal

urography kidneys scarring or pyelonephritis
Estimates renal function High radiation dose
Risk of reaction to contrast medium
Poor detail in infants

Renal cortical Detects pyelonephritis and renal Does not evaluate collecting system
scintigraphy scarring even in early stages Cannot detect obstruction
Useful in neonates
Little radiation
Useful in patients with poor renal
function

Computed Provides both anatomic and Expensive

tomography functional information about the High radiation
kidney Few clinical or experimental data to
Possibly more sensitive in support its use at present
diagnosing pyelonephritis

Voiding Assesses the size and shape of Gonadal radiation

cystourethrogr bladder Catheterization
aphy Detects and grades vesicoureteral
reflux
Evaluates posterior urethral
anomalies in boys
17
 Classification of vesical reflux

I. Reflux to 1/3 of lower ureter.

II. Reflux to the pelvic without damage of calix.
III. Reflux to the pelvic with damage of calix.
IV. Reflux accompanied by hydroureter and
hydronephrosis.

18
 Treatment
In patients who appear toxic, it is reasonable to initiate
treatment with intravenous antibiotics and follow closely for
signs and symptoms of infection (fever, severe pain); these
usually resolve in three to five days (Berman S, 1991).
Antibiotic therapy should be based on age, clinical severity,
location of infection, presence of structural abnormalities, and
allergy to antibiotics. Treatment generally begins with a broad-
spectrum antibiotic, but it may need to be changed based on
the results of urine culture and sensitivity testing.
Hospitalization is suggested for symptomatic young infants
(less than three months of age) and all children with clinical
evidence of acute severe pyelonephritis (high fever, toxic
appearance, severe flank pain) (Berman S, 1991).
Although conventional therapy lasts seven to 10 days, a
three- to seven-day trial of oral antibiotics has been suggested
for uncomplicated infection of the lower urinary tract (Helwig 19
H, 1994).
 Follow-up and Chemoprophylaxis
A urine culture should be obtained three to
seven days after the completion of treatment
to exclude relapse.
Prophylaxis is recommended for children <5
years of age with vesicoureteral reflux (who
are not surgical candidates),other structural
abnormalities, in children who have had
three documented UTI in one year
(zelicovic,1992).
A prophylaxis of a single nightly dose of
nitrofurantoin 1- 2 mg/ kgbw/ day, or
trimethoprim-sulfamethoxazole 2 mg/ kg/
day, may be used for six months or more
(Eggly DF, 1993).
20
 Table Parenteral Antibiotics for treatment of UTI

Drug Dose(mg/kg/day) frequency Comments

Cefotaxime 150(mg/kg/day) Divided every 8 Monotherapy for infants > 2
(Claforance) hours months of age. If > 2 weeks
but <2 months often
combined with Ampicillin
Ampicillin 100 (mg/kg/day) Divided every 6 Ussuly in combination with
hours Gentamicin for < 2 weeks of
age or Cefotaxime for infants
2 months of age because
higher incidence of
enteroccocus
Gentamicin o 1 month old or less: 3 Veriees by age Ussually use with Ampicillin
mg/kg/dose every hours for all infants 2 weeks of age
o Between 1 to3 months 2.5 or selectivly for those
between 2-4 weeks of age
mg/kg/dose every 12 hours

Ceftriaxon 50-100 (mg/kg/day) IV or IM QD IM use ussually considered

(Rocephin) only if >2-3 mo of age
(Consesus of focal experts).
Use with caution in jaundiced
infant) (Baskin, ORourke, &21
Fleisher, 1992).
 Table Antibiotics for outpatient treatment of UTI

Drug Dose (mg/kg/day) frequency Comments

Sulfamethoxazole/Trim Trimetthonprim Oral Divided For use in children >6 weeks of age,
ethoprim (200mg/40mg 8-10 (mg/kg/day) BID not recommended for pateints with
per 5ml) (Bactrim, renal inssuficiency
Septra, Generic)
Cefixime 100 mg/5 ml 8 (mg/kg/day) Oral once daily Recommended if patients >1 month
(Suprax) of age with high likelihood of
resistant organisms or pyelonephritis
and unknown sensitivities

Cephalexin 25-50 (mg/kg/day Oral Divided Often used as an alternative choice

TID-QID pending return of cultures

Nitrofurantoin 5-7-100 (mg/kg/day) Oral Divided Not considered adequat for

QID treatment for pyelonephritis because
of poor tissue penetration. May be
useful in older children with cytitis.
Ceftriaxone (Rocephin) 50-100 (mg/kg/day) IV or IM daily Ussually recommended only if
prefered oral drugs are not tolerated.
IM use ussualy considered if > 2-3
mo of age (Consensus of local
experts). Use with caution in
jaundiced infant (Baskin, ORourke,22
& Fleisher, 1992)
 Table Prophylactic antibiotics recommended while futher evaluastion
result are pending and to limit of UTI

Drug Dose (mg/kg/day) Frequency Comments

Sulfamethoxazole 2 (mg/kg/day TMP) Daily at bedtime
(SMX)/Tremethopr (HS)
im (TMP)
(200mg/40mg per
5ml) (Bactrim,
Septra, Generic)
Nitrofuratoin or 1-2 (mg/kg/day) Daily at bedtime
Macrodantin (HS)

Cephalexin 10 (mg/kg/day) Daily at bedtime These wo choices are not

(HS) preferred but use occasionally
for selected patients.

Cefixime 4 (mg/kg/day) Daily at bedtime These wo choices are not

(HS) preferred but use occasionally
for selected patients.
Amoxicillin 10 (mg/kg/day) Daily at bedtime For young infants
(HS) 23