Urinary Tract Infection

PREVALENCE & ETIOLOGY

• 1st yr of life: Male > Female (2.8-5.4:1)
• 1-2 yr of life: Male < Female (1:10)
• More common in uncircumcised male
• Colonic bacteria
1. Escherichia coli
2. Klebsiella spp.
3. Proteus spp.
 CLASSIFICATION
• 3 basic forms of UTI
1. Pyelonephritis
2. Cystitis
3. Asymptomatic Bacteriuria
4. Focal Pyelonephritis
5. Renal abscess
 CLINICAL PYELONEPHRITIS
• Any or all of the following
– Abdominal, back or flank pain, *fever, malaise,
nausea, vomiting, diarrhea, poor feeding,
irritability, jaundice, weight loss
• Most common serious bacterial infection in
infants who have fever w/o an obvious focus
 CLINICAL PYELONEPHRITIS
• Acute Pyelonephritis: involvement of renal
parenchyma, can result in renal injury 
pyelonephritic scarring
• Pyelitis: no parenchymal involvement
• Acute Lobar Nephritis: renal mass caused by
acute focal infection w/o liquefaction; may be
an early stage in development of renal abscess
 CLINICAL NEPHRITIS
• Renal Abscess: can occur after pyelonephritic
infection
• Perinephric Abscess: can occur secondary to
contiguous infection in the perirenal area or
pyelonephritis that disects to the renal
capsule
 CYSTITIS
• Indicates bladder involement
• Dysuria, urgency, frequency, suprapubic pain,
incontinence, malodorous urine
• DOES NOT cause fever
• DOES NOT result in renal injury
 CYSTITIS
• Acute Hemorrhagic Cystitis: often caused by E.
coli
– Adenovirus Cystitis: adenovirus type 11&12, more
common in boys, self-limiting
• Eosinophilic Cystitis: rare, obscure origin,
occasionaly found in children who may have been
exposed to allergen, tx: anti-histamines & NSAIDS
• Interstitial Cystitis: sx relieved by voiding,
common in adolescent girls, idiopathic, tx:
bladder hydrodistention & laser ablation of ulcers
 ASYMPTOMATIC BACTERIURIA
• + urine culture without any manifestations of
infection
• Most common in girls
• Benign and does not cause renal injury
 PATHOGENESIS & PATHOLOGY
• Ascending bacterial infection arising from
fecal flora  colonize the perineum  enter
the bladder/kidney via the urethra
 DIAGNOSIS
• UTI Suspect: signs and symptoms or + UA
Clinical Signs and Symptoms Neonates Older Infants School Age
Adolescents
 Septic [+]
 Temperature instability [+]
 Poor feeding [+]
 Vomiting [+] [+]
 Lethargy/Irritability [+]
 Jaundice [+]
 Fever [+] [+] [+]
 Poor weight gain [+] [+] [+]
 Diarrhea [+]
 Abdominal Pain [+] [+]
 Frequency, dribbling, urgency, [+] [+]
dysuria
 Weak urinary stream [+] [+]
 Malodorous urine [+]
 Enuresis [+]
 Flank pains
 DIAGNOSIS
• Confirmatory test: urine culture
• Urine Sample: midstream urine with introitus
cleaned before collection
– if uncircumcised, prepuce retracted
– 2-24 months old: catheter, suprapubic aspirate,
wee bag after disinfection of skin
 DIAGNOSIS
• Urine Culture
– > 50 000 colonies of a single pathogen OR
– > 10 000 colonies of a single pathogen + clinical
signs and symptoms
• Renal Abscess: WBC > 20 000 – 25 000/mm3
 TREATMENT
• Acute Cystitis
– 3-5 day course of TMP-SMX or TMP [E. coli]
– Nitrofurantoin 5-7mg/kg/24hr in 3-4 divided doses [Klebsiella spp.,
Enterobacter]
– Amoxicillin 50mg/kg/24hr
• Clinical Pyelonephritis may requie admission if:
– Dehydrated, Vomiting, Unable to drink fluids, 1 month old or younger,
Complicated infection
– Ceftriaxone 50-7mg/kg/24hr not to exceed 2g/day
– Cefotaxime 100mg/kg/24hr
– Ampicillin 100mg/kg/24hr + Gentamicin 3-5mg/kg/24hr in 1-3 divided
doses
– Cefixime
– Ciprofloxacin for pt > 17y.o.
• Urine culture after 1 wk of tx is not routinely needed