urinary tract disorder

8/10/2019 Urinary Tract Disorder

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Urinary Tract DisorderMANAGEMENT OF CHIDHOOD

URYNARY TRACT INFECTION


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A. Definition of Terms

Urinary tract infection (UTI) Presence of proliferating bacteria in theurinary tract causing tissue invasion andinflammation

Upper UTI or pylonephritis Infection involving the renalparenchymacausing systemic and local sympstoms

Lower UTI or cystitis Infection limited to the lower urinary tract(with acute volding sympstoms as the majorfeature)

Asymtomatic or covert bacteriuria Colonizationof the urinary tract by

uropatoghens without causing anysympstoms

Atypical or complicated UTI UTI associated with anatomical or functionalabnormalities of the urinary tracrt :

a) Evidence of obstructive uropathy:i. Poor urine flowii. Abdominal or bladder mass

b) Seriously ill (toxic)c) Septicemad) Raised creatiniee) Failure to respond to antibiotic treatment

within 48 hours.

Recurrent UTI a) 2 episodes of acute pyelonephritis or

b) 1 episode of acute pyelonephritis/upper UTI+ 1 episode of cytitis/lower UTI or

c 3 e isodes of c tilis/lower UTI


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B. Diagnosis of UTI

I. Guidelines for diagnosis:

1. All infants and children with unexplained fever 38.5

0c

2. Infants and children with alternative site of infection who

remained unwell.3. Infants and children wih signs and symtomps suggestive of UTI


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II. Signs and symptoms1. Signs and symptoms of UTI differ according to

age :

Infants present with non-specific signs and symptomsand there fore of UTI requires a HIGH INDEX of

suspicion


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Age group Signs and symptoms from most common to leastcommon

Infants


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Clinical Upper tract Lower tract

Age


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Leucocyte (+) Leucocyte (-)Nitrite (+) Send for urine

Treat as UTIStart antiiotics

Send for urine cultureStart antibiotics (iffreshly voided stamplewas obtained)

Nitrite (-) Send for microscopyand cultureStart antibiotics only ifwith goodEvidence of UTI

Not UTIExplore other causes offeverSend for microscopy ifwith known structuralabnormalities

III. Work-up1. Dipstik

*Dipstick (positive leucocyte esterase and nitrite) is useful torule in UTI in children2 years


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Method of collection Colony count/ml (pureculture)

Probability of infection(%)*

Suprapubic

Aspiration

Gram-negative bacilli : any

numberGram-positive cocci :>103

>99%

TransurethralCatheterization

>105

5 x 104

103-


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a.The following should be considered indeterminate and shoud berepeated :

i. Significant growth of 2 pathogensii. A predominant pathogen with a contaminantiii. Intermediate growth of a single pathogen.

b. Contamination rate of urine obtained by the following are :i. Bag specimen : 62,8 %ii. Catheterization : 9,1 %

c. Infants whose urine was obtained by bag versus catheter were 4to 5 times more likely to have unnecessary treatment andradilogical investigation, 12- fold more likely to have unnecessaryhospitalization, and were more likely to have delayed diagnosisand treatment.


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C. Imaging

I. Goals of imaging :

1. To identify those with underlying structural renal abnormalities, especially

obstructive uropathies requiring surgery

2. To identify those with factors predisposing them to increased risk of recurrent

UTI3. To identify those with renal parenchymal damage (primarity in those with

severe or bilateral disease), predisposing them to increased risk of:

a. Hypertension (38%)

b. Pre-eclampsia in pregnancy

The prevalence of structural abnormalities in the urinary tract in infantsand childreb with UTI ranges fro 1075 %

About 5-35% have significant obstruction requiring surgery


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II. Renal ultrasound: Non-invasive procedure

Gives information on :a.Renal size and shapeb.Bladder size and configuration, bladder wall thicknessc.Presence or absence of pelvicalyceal and ureteral

dilatation.

Recommendation:Renal ultrasound scan should be done as initial investigation to detct

dilatation secondary to obstruction and other abnormalities in: All children with presumptive upper tract UTI

Infants age


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III Micturating cystourethrogram (MCUG): Gives information on :

a.Bladder lesionsb.Urethral lesions especially posterior urethral valves in boysc.Competence of vesicoureteric junction and the grade of

vesicoureteric reflux (VUR) if present


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IV. 99mTecnetium Dimercaptosuccinic acid (DMSA) scan Gives information on :a.Focal areas of decreased uptake indicating:i. Acute pyelonephritis in the acute stage

ii. Established scars when DMSA done 3 months laterNote: 50% of children with scarring had normal MCUGb. Differential function of the 2 kidneys

Recommendation:DMSA scan is indicated in :

All children age


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V. Diuretic renography with 99mTecnetium Mercaptoacetyltriglycine(MAG3)

If there is delayed excretion, furosemide at1 mg/kg is given afterminutes.

Gives information on:a.Renal perfusionb.Uptake, excretion and drainage of radotracerc.Differentisl function of both kidneys

Note : To distinguish between a true mechanical obstruction andnonobstructive pelvicalyceal dilatation. T >20 minutes suggest thepresence of an underlying mechanical obstruction.

Recommendaion :MAG3 renogram is indicated when :

Pelvicalyceal dilatation 1 cm on ultrasound examination Vesicoureteric stenosis is suspected in the presence of uteric

dilatation on ultrasound examination and absence ofvesicoureteric reflux on MCUG


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VI. Algorithm for investigation of UTI1. Boys

Ultrasound of urinarytract

PC dilatation

None21 cm 0,4 to


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D. TreatmentI. Principles of treatment1. The drug of choice should be based on the resistance

patterns of the uropatogens in the hospital as well as ofrecent antibacterial treatment received by the patient.

2. The drug should have minimal adverse effects on themajor organ systems.

3. A high concentration of the drug should be preesnt in theurine after administration.

4. Oral antibiotics are efficacious in both lower and uppertract infections.

5. Second and third generation cephalosporins should beavoided as empiric therapy in non-atypical UTI to avoidincrease in antibiotic resistance.

6. Urinaru antiseptics such as nalidixic acid and

nitrofurantoin should not be the initial drug choice inupper tract UTI

Antibiotic Frequency Therapeutic dose Prophylactic dose


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Antibiotic Frequency Therapeutic dose(mg/kg/dose)

Prophylactic dose(mg/kg ON)

Ampicilin/sulbactam(Unasyn)

Q12H 15-25 (ampicilin)(maximum 2 g)

Amoxcilin Q8H 10-25 (maximum 1g) 10

Amoxycilin/Clauvulanic acid (Augmentin 7:1)

Q12H 10-25 (amoxcilin)(maximum 1g)

Cefaclor Q8H 10-15 (maximum500mg)

10

Cephalexin Q6H

Q12H

7.5 (maximum 250 mg)

15 (maximum 500mg)

7.5

Cefuroxime Q12-24H 10-15 (maximum 500mg)

Co-trimoxazole*Trimethoprim(TMP1 mg)Sulphamethoxazole(SMX 5 mg)OR Trimethoprim

Q12H

Q12H

3-4 (TMP)

3-4

2

2

Nalidixic acid*# Q6H 7.5-15 (maximum 100mg). Reduce to 7.5mg/kg/dose after 2weeks (maximum 50

15 Q12H


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II. Intranvenous antibiotics1. Intravenous antibiotics are indicated in :

a.Infants


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4. Second and third generation cephalosporins should be avoided innon-atypical UTI to avoid increase in antibiotic resistance.

5. Intravenous cefriaxone is the drug of choice in atypical or

complicated UTI. Cefriaxone should be avoided in the first 2 weeksof life as it may affect bilirubin transport in the liver.

6. In atypical or complicated UTI, if an aminoglycoside is requiredbased on antibiotic sensitivity results, amikacin is theaminoglycoside is required based on antibiotic sensitivity results,amikacin is the aminoglycoside of choice as its nephrotoxic

potential may be lower than gentamicin7. Commonly used parenteral antibiotics-intravenous (IV) and

intramuscular (IM)


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Antibiotic Route Frequency Dose (mg/kg

dose)

Comment

Amikacin IV,IM Single daily dose Term Neonate: 15

1 week to 10

years: 25 (D1),

then 18>10

years:20 (D1),

then 15

(maximum 1.5

g/day)

Monitor levels

Through level W2)

25 (Adult 1 g)

50 (maximum 2 g)

Gentamicin IV,IM Q8H

Q12H(W1)

Q8H (W2)

Q6H(>W2)

15-25 (Adult 0.5-

1g)

Severe : 50

(maximum 2 g)

Renal adjusment

Gentamicin IV,IM Q24H Term neonate to Monitor levels


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