URINARY TRACT INFECTION

UTI
3 5% girls

1% boys
At 1 year old, M:F ratio is 2.8 5.4:1 At 1-2 y/o, female preponderance Females: 75-90% E.coli Males: Proteus is as common as

Clinical Manifestation
3 Basic Forms:
Pyelonephritis abdominal pain/ flank pain, fever,

malaise, nausea and vomiting, and occasionally diarrhea

some newborns and infants jaundice, poor feeding, irritability and wt. loss

 Bacterial involvement of the upper urinary tract

Renal parenchyma acute pyelonephritis No parenchymal involvement pyelitis Renal injury pyelonephritis scarring

 Cystitis indicates bladder involvement

S/sx: dysuria, urgency, frequency, suprapubic pain,

incontinence, malodorous urine Does not cause fever and does not result to scarring

 Asymptomatic bacteruria
Positive urine culture without any manifestations of

infection Occurs almost exclusively in girls

CLINICAL SYMPTOMS Sepsis Temperature instability Poor feeding Vomiting Lethargy or irritability Jaundice Fever Poor weight Failure to thrive Diarrhea Abdominal pain Frequency, dribbling, urgency, dysuria Weak urinary stream Malodorous urine Enuresis Flank pain

NEONATES + + + + + + + + +

OLDER INFANTS

SCHOOL AGE ADOLESCENT

+ + + + + +

+ + + +

+ + +

History

Urinalysis (suggestive of UTI) (+) Leukocyte Esterase or Nitrite test. Bacteriuria, Gram stained specimen Pyuria > WBC/hpf or 10/mm3

Physical Examination (+) Urine c/s of a properly collected urine specimen

FEVER

ABSENT

PRESENT

Oral Antibiotics KUB, UTZ, Pre and Post void

Admit to hospital: Parenteral Antibiotics (IV, IM) KUB, UTZ, pre and post void Urology consult as needed

Poor response After 1248 hours Good response After 12-48 hours Poor response After 12-48 hours Good response After 12-48 hours

*Complete 7-14 days of treatment

*Reassess *Repeat urine c/s *Use appropriate antibiotics based on initial urine c/s * complete 7-14 days of treatment

*May shift to oral antibiotics complete 7-14 days

Renal work-up:

Voiding Cystourethrogram or nuclear cystogram When needed: Radionucleotide scan (DMS A/DTPA) IV Pyelography other imaging techniques

Urology folow-up added

Nephrology follow-up Monitor BP Urinalysis every 4-6 weeks Urine c/s GFR (Creatinine)

Pathogenesis

Risk Factors
Female Uncircumcised male Vesicoureteral reflux Toilet training

Voiding dysfunction
Obstructive uropathy Urethral instrumentation Wiping from back to front

Risk Factors
Bubble bath Tight clothing (underwear) Pinworm infestation Constipation P fimbriated bacteria

Anatomic abnormality (e.g., labial adhesion) Neuropathic bladder Sexual activity Pregnancy
* Risk increased for clinical pyelonephritis, not cystitis.

Diagnosis
Urinalysis

Proper collection of urine sample < 1 y/o : suprapubic tap Catheterized urine is a good alternative to obtain specimen Mid-stream urine collection for cooperative patients

Diagnosis
Pyuria
Males - >10 WBC (unspun), >5 WBC (centrifuged) Females - >50 WBC (unspun), >10 WBC

(centrifuged)
(+) nitrites and leukocyte esterase

Microscopic hematuria acute cystitis

WBC cast suggest renal involvement

Diagnosis
Urine culture

mid-stream urine sample

> 100,000 colonies of single pathogen 10,000 colonies + symptomatic

infants sterile collection bag after disinfection of the genital skin

(+) U/A + symptomatic + single organism cultured

with > 100,000 colonies

Diagnosis
catheterized specimen
1,000 - 10,000 CFU/ml

Imaging studies
Renal UTZ VCUG Technitium-labelled DMSA/ glucoheptonate scan

Treatment
Co-trimoxazole
DOC 5-8 mg/kg/day q12 Good coverage for gram negative

Aminoglycosides
For pseudomonas

Fluoroquinolones
Alternative for resistant organisms

Treatment
Tetracycline
Can also be used for >7 years old

Urine c/s must be requested after 1 week of

treatment