urinary tract infection in children co. stephanie january 23. 2014
TRANSCRIPT
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Urinary Tract Infection in Children
Co. StephanieJanuary 23. 2014
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Prevalence• Occurs in 1-3% of girls, 1% of boys – Girls: usually occurs by 5 yrs of age
• peaks during infancy and toilet training
– Boys: common during the 1st year of life• more common in uncircumcised boys
• Male:Female ratio1st year of life 2.8 : 5.4
>1-2 years 1 : 10
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Etiology• Main agent: colonic bacteria – 75-90%: caused by E. coli, • followed by Klebsiella spp and Proteus spp• Proteus spp: common for boys >1 yr of age
– Other pathogens: Staph saprophytius and enteroccocus,
– Viral causes: adenovirus and other viral infections
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Risk FactorsFemale Wiping from back to
front (girls) Anatomic abnormality (labial adhesion)
Uncircumcised male Bubble bath Neuropathic bladder Toilet Training Tight
clothing/underwearSexual activity
Voiding dysfunction Pinworm infestation PregnancyObstructive uropathy Constipation Vesicoureteral reflux*Urethral instrumentation
Bacteria with P. fimbriae *increase risk for PYELONEPHRITIS
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CLASSIFICATIONS
① Pyelonephritis• Most common serious bacterial infection in infants <24 mo of age who
have fever WITHOUT an obvious focus
② Cystitis
③ Asymptomatic Bacteriuria
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PYELONEPHRITIS
a. Abdominal, back, or flank pain
b. Fever
c. Malaise
d. Nausea and vomiting
e. Occasional diarrhea
Indicative of a bacterial infection of the UPPER URINARY TRACT
ACUTE PYELONEPHRITIS: WITH renal parenchymal involvement • can result to pyelonephritic scarring
PYELITIS: NO parenchymal involvement
ACUTE LOBAR NEPHRITIS: renal mass caused by acute focal infection without liquefaction; can be an early stage of renal abscess development
XANTHOGRANULOMATOUS PYELONEPHRITIS: Rare infection characterized by granulomatous inflammation with giant cells & foamy histiocytes
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CYSTITIS
a. Dysuria
b. Frequency
c. Urgency
d. Suprapubic pain
e. Incontinence
f. Malodorous urine
• NO:✘ Fever
✘Renal Injury Acute Hemorrhagic Cystitis: often caused by E. coli and Adenovirus types 11 and 21• Adenovirus cystitis: more common in boys; self-limiting infection
Eosinophillic cystitis: rare form occasionally found in children • Usual symptoms: Hematuria, ureteral dilation with occasional
hydronephrosis, and filling defects in the bladder • May have been exposed to an allergen
Interstitial cystitis: IRRITATIVE voiding symptoms such as urgency, frequency, and dysuria, and bladder/pelvic pain • Relieved by voiding with a negative urine culture• Most likely affects adolescent girls; idiopathic
Indicative of BLADDER INVOLVEMENT
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ASYMPTOMATIC BACTERIURIA• Positive urine culture WITHOUT any manifestations of infection
• Most common in girls – <1% in pre-school and school-age
– Rare in boys
• Benign condition: does not cause renal injury EXCEPT in pregnant women
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Pathogenesis: Ascending infection
Bacteria arise from fecal flora
Colonize the
perineum
Pass the urethra
Enter the
bladder CYSTITIS
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Pathogenesis: Ascending infection
CYSTITISInfection
ascends to the kidney
ACUTE PYELONEPHRITIS
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Pathogenesis: ACUTE PYELONEPHRITIS• NORMAL kidney: Simple and compound papillae have an
antireflux mechanism that prevents urine in the renal pelvis from entering the collecting tubules– Some compound papillae (esp. upper and lower poles) allow for
INTRARENAL reflux
• Infected urine: stimulate inflammatory & immunologic response
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Diagnosis• A urine culture is necessary for
confirmation and appropriate therapy (Nelsons 19th ed)
• Urine sampling: – Toilet-trained: midstream catch
– Uncircumcised boys: retract prepuce first
– Not toilet trained: catheterized urine sample
• A positive culture can result from skin contamination
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Pyuria• Definition: positive leukocytes
• Infection CAN occur in the absence of pyuria
• Suggestive of infection; More confirmatory than diagnostic
• Pyuria can be present without UTI
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Sterile pyuria• Definition: positive leukocytes, negative culture
• Nitrites and leukocyte are usually positive in infected urine
• Microscopic hematuria is common but alone does not suggest UTI
Partially treated bacterial UTI’s Urethritis due to STI
Viral infections Inflammation near the ureter/bladder (appendicitis, Crohn’s disease)
Renal tuberculosis Interstitial nephritis (eosinophils)
Renal abscess UTI due to urinary obstruction
Asymptomatic child + normal urinalysis = Unlikely that there is UTI
Symptomatic child + negative urinalysis result = UTI is still possible
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Urine culture
• POSITIVE RESULT: >100,000 colonies of a single pathogen 10,000 colonies AND Symptomatic child
• Presumed UTI: Bag sample Positive urinalysis + Symptomatic patient + >100,000 colonies of a
single organism Confirm with a catheterized sample if any of the criteria is not met
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Other tests• CBC: leukocytosis, neutrophilia
• Serum Erythrocyte sedimentation rate: elevated
• C-reactive protein: elevated
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Imaging• Goals:
Determine anatomic abnormalities that predispose to infection Determine whether there is active renal involvement Assess renal function risk
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Imaging: DMSA renal scan• Dimercaptosuccinic acid
(DMSA) renal scan
• Involved areas are photopenic showing enlarged kidneys – Approx. 50% with febrile UTI
will have a positive DMSA scan
– 50% of those with positive DMSA scans will develop renal scarring
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Imaging: Voiding cystourethrogram Done for those with evidence
of acute pyelonephritis or renal scarring on DMSA scan
• Can help identify reflux
• Can be delayed 2-6 wks to allow for bladder inflammation to resolve
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TreatmentAcute cystitis: should be properly treated to avoid
progression to pyelonephritisSevere symptoms: presumptive treatment is started
pending results of urine cultureMild symptoms/Doubtful diagnosis: delay treatment
until culture results
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Treatment regimen: Acute Cystitis
• If treatment is initiated before culture results: a. Trimethoprim-sulfamethoxazole (TMP-SMX) or
trimethoprim (for 3-5 days): effective against most strains of E. coli
b. Nitrofurantoin (5-7mg/kg/24 hr in 3-4 divided doses): effective against Klebsiella and Enterobacter
c. Amoxicillin (50mg/kg/24hr): effective but no clear advantage
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Treatment regimen: Acute Pyelonephritis
• 10-14 day course of broad-spectrum antibiotics capable of reaching significant tissue levels is preferred
• Dehydration, vomiting, poor oral intake: signs to admit a child for IV rehydration and IV antibiotic therapy
• Ceftriaxone (50/75 mg/kg/24hr – not exceed 2g) or Cefotaxime (100mg/kg/24hr) or Ampicillin (100mg/kg/24hr) with an Aminoglycoside (ex Gentamicin 3-5mg/kg/24hr in 1-3 divided doses)
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Treatment
• Ciprofloxacin is an alternative agent for resistant microorganisms in patients >17 yr or short course treatment for young children
• Clinical use of fluoroquinolones in children should be restricted because of potential cartilage damage
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Treatment: Recurrent UTI
a. Identify predisposing factors
b. Prophylaxis against reinfection: controversial • TMP-SMX, Trimethoprim, Nitrofuratoin at 30% of the normal dose
c. Probiotic therapy: replaces pathologic urogenital flora*
d. Cranberry juice: prevents bacterial adhesion and biofilm formation*
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Complications• Renal scarring: Highest risk in
children <2 years old
• Renal insufficiency or end-stage renal disease in children
• Arterial hypertension
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Thank you.