URINARY TRACT INFECTIONS URINARY TRACT INFECTIONS IN CHILDRENIN CHILDREN

Assist. prof. dr. Magdalena StârceaAssist. prof. dr. Magdalena Stârcea

IVIVthth Pediatri Pediatric Clinicc Clinic

Background: Urinary tract infections (UTIs) are common in the pediatric age group. Early recognition and prompt

treatment of UTIs are important to prevent progression of infection to pyelonephritis or urosepsis and to avoid late

sequelae such as renal scarring or renal failure.  

Infants and young children with UTI may present with few specific symptoms. Older pediatric patients are more likely to have symptoms and findings attributable to an infection of the

urinary tract.

Differentiating cystitis from pyelonephritis in the pediatric patient is not always possible, although small children who

appear ill or who present with fever should be presumed to have pyelonephritis if they have evidence of UTI.

TERMINOLOGYTERMINOLOGY. . CLASSIFICATIONCLASSIFICATION

I. Urinary tract infectionI. Urinary tract infection - is the common term for a - is the common term for a heterogeneous group of conditions involving pathogenic heterogeneous group of conditions involving pathogenic bacterial colonization of the urinary tract at any level of the bacterial colonization of the urinary tract at any level of the urinary meatus renal cortex , followed by the elimination of urinary meatus renal cortex , followed by the elimination of germs in the urine. Colonization may be transient or germs in the urine. Colonization may be transient or permanent .permanent .

II . Asymptomatic bacteriuriaII . Asymptomatic bacteriuria: significant bacteriuria : significant bacteriuria detected by screening detected by screening in in apparently healthy population . It is apparently healthy population . It is commonly seen in girls of school age.commonly seen in girls of school age.

III . BacteriuriaIII . Bacteriuria is pathognomonic feature of urinary infection , a term is pathognomonic feature of urinary infection , a term used for the presence of bacteria in urine obtained optimally by used for the presence of bacteria in urine obtained optimally by bladder catheterizationbladder catheterization or suprapubic aspiration puncture .or suprapubic aspiration puncture .

- significant bacteriuria is defined as Kass > 10significant bacteriuria is defined as Kass > 1055CFUCFU / ml ( CFU = / ml ( CFU = colony forming units ) in urine obtained by the methods of peripheral colony forming units ) in urine obtained by the methods of peripheral collecting (urinary stream)collecting (urinary stream)

- Johnson describes more complex benchmarks with practical Johnson describes more complex benchmarks with practical applications for assessing significant bacteriuria : bacteriuria than 10 applications for assessing significant bacteriuria : bacteriuria than 10 ² CFU / ml in children catheterized bladder , or any amount of ² CFU / ml in children catheterized bladder , or any amount of colonies urine specimens collected by suprapubic aspiration .colonies urine specimens collected by suprapubic aspiration .

IV . Symptomatic UTIIV . Symptomatic UTI is defined as significant bacteriuria associated is defined as significant bacteriuria associated with suggestive symptoms (dysuria, urinary urgency, urinary with suggestive symptoms (dysuria, urinary urgency, urinary frequency, with or without fever and back pain) . frequency, with or without fever and back pain) .

It It can can manifest as:manifest as: Pyelonephritis Pyelonephritis - - bacterial infection of the renal parenchyma and bacterial infection of the renal parenchyma and intrarenal urinary intrarenal urinary way way and is accompanied by significant bacteriuria, and is accompanied by significant bacteriuria, bacteremia, pyuria, hematuria sometimes .bacteremia, pyuria, hematuria sometimes . Cystitis Cystitis : inflammation of the bladder : inflammation of the bladder, , manifested by dysuria , manifested by dysuria , urinary frequency, urinary urgency. Fever is not present .urinary frequency, urinary urgency. Fever is not present .

V. Chronic pyelonephritisV. Chronic pyelonephritis is a pathological condition which is a pathological condition which involvesinvolves renal scarringrenal scarring.. If pyelonephritis associated with If pyelonephritis associated with vesicoureteral reflux (especially intrarenal reflux ), the term used is vesicoureteral reflux (especially intrarenal reflux ), the term used is reflux nephropathy. Acute inflammatory changes are found in high reflux nephropathy. Acute inflammatory changes are found in high UUTI TI and disappear on average 6 months after and disappear on average 6 months after acute acute infectious infectious episode .episode .

VI. Response to treatmentVI. Response to treatmentReRecoverycovery is characterized by the loss of bacteriuria following is characterized by the loss of bacteriuria following treatment.treatment. RelapseRelapse : characterized by persistent bacteriuria (same bacterial : characterized by persistent bacteriuria (same bacterial species) after adequate treatment of the infection; is commonly species) after adequate treatment of the infection; is commonly associated with a structural abnormality of the urinary tract or stones associated with a structural abnormality of the urinary tract or stones .. RReinfectioneinfection: characterized by successive episodes of : characterized by successive episodes of symptomaticsymptomatic and and asymptomatic episodesasymptomatic episodes of of urinary urinary tract tract infection.infection. This This episodes are caused by different bacterial species or serotypes episodes are caused by different bacterial species or serotypes and reflects a defect in the local defense mechanisms .and reflects a defect in the local defense mechanisms .

PPersistent infectionersistent infection : characterized by the presence of significant : characterized by the presence of significant bacteriuria during and after treatment.bacteriuria during and after treatment.

EEPIDEMIOLOGYPIDEMIOLOGY:: UTI hasUTI has males predomina males predominancence in the first trimester of life (up to 3 in the first trimester of life (up to 3

months). months). Uncircumcised males have a higher incidence than Uncircumcised males have a higher incidence than circumcised males. Uncircumcised male infants have a higher circumcised males. Uncircumcised male infants have a higher incidence of UTI than female infants.incidence of UTI than female infants.

Except neonatal period, Except neonatal period, UTIs are more frequent in females than UTIs are more frequent in females than males at all agesmales at all ages..

International studies show the highest incidence peak of the first International studies show the highest incidence peak of the first episode of episode of uper uper UTI between 0 and 2 years. The peak incidence of UTI between 0 and 2 years. The peak incidence of the first the first lower lower episode of UTI (boys and girls ) is between 2-4 years. episode of UTI (boys and girls ) is between 2-4 years.

Asymptomatic bacteriuria is more common in girls of school age. Asymptomatic bacteriuria is more common in girls of school age. Nosocomial urinary infection occurs only in the case of investigating Nosocomial urinary infection occurs only in the case of investigating

urinary malformation in children substrates . urinary malformation in children substrates . After Nelson (18th edition , 2007) After Nelson (18th edition , 2007) the cthe cumulative incidence is 2.5 % umulative incidence is 2.5 %

for both sexes. ITU occurs 3-5 % of girls and 1% of boysfor both sexes. ITU occurs 3-5 % of girls and 1% of boys TThe American Academy of Pediatrics (Bergman DA , Baltz RD, he American Academy of Pediatrics (Bergman DA , Baltz RD,

2002009) recognizes a febrile urinary tract infection incidence of 6.5 % 9) recognizes a febrile urinary tract infection incidence of 6.5 % to girls and 3.3 % for boys .to girls and 3.3 % for boys .

EETIOLOGYTIOLOGY:: Escherichia coli causes 75-90 % of UTI in children. Escherichia coli causes 75-90 % of UTI in children. Other common bacterial etiology of UTI are Klebsiella pn . , Other common bacterial etiology of UTI are Klebsiella pn . ,

Proteus (30% of boys cystitis ), Staphylococcus saprophyticus Proteus (30% of boys cystitis ), Staphylococcus saprophyticus (urinary infections in adolescents of both sexes and in the (urinary infections in adolescents of both sexes and in the neonate)neonate)..

In the neonatal period, especially in premature urinary infectionsIn the neonatal period, especially in premature urinary infections areare determining determining by hematologycal wayby hematologycal way, and etiology a, and etiology arere dominated by E. coli, Salmonella , Enterobacter , Klebsiella. dominated by E. coli, Salmonella , Enterobacter , Klebsiella.

In patients with congenital abnormalitiesof renal or urinary tract In patients with congenital abnormalitiesof renal or urinary tract function may occur urinaryfunction may occur urinary infection caused by bacterial low infection caused by bacterial low virulent in normal conditions (Pseudomonas aeruginosa , virulent in normal conditions (Pseudomonas aeruginosa , Staphylococcus aureus or epidermis, Hemophilus influenzae , Staphylococcus aureus or epidermis, Hemophilus influenzae , Group B sterptococi , adenovirus ) . Group B sterptococi , adenovirus ) .

Acute cystitis may be caused by adenoviruses , especially male Acute cystitis may be caused by adenoviruses , especially male school , manifested by fever, dysuria school , manifested by fever, dysuria and and terminal hematuria .terminal hematuria .

In In adolescentsadolescents i isolated urethrsolated urethritis itis manifested manifested with with dysuria dysuria is is generated by microorganisms such as Chlamydia trachomatis , generated by microorganisms such as Chlamydia trachomatis , Neisseria gonorheae , Mycoplasma genitalium , or herpes simplex Neisseria gonorheae , Mycoplasma genitalium , or herpes simplex virus.virus.

PATHOGENESIS - UTIPATHOGENESIS - UTI is an is an interaction between interaction between                       →→ host factors host factors                       →→ invading microorganism invading microorganism

Way Way of infectionof infection

a)a) descending descending   - Common in the new born   - Common in the new born   - Unusual for   - Unusual for onotheronother age age   - Older children are involve  - Older children are involve virulent microorganismsvirulent microorganisms such such: : SS.aureus, P. aeruginosa, Serratia, .aureus, P. aeruginosa, Serratia, KBKB

b) b) aascendingscending (colonization retrograde from the urethral orifice) (colonization retrograde from the urethral orifice) - Germ involved found in - Germ involved found in bowelbowel flora flora - Serotypes with virulence special - Serotypes with virulence special for urotheliumfor urothelium - Favored by malformation- Favored by malformation

HHost ost ffactors: actors: AAnatomical abnormalitiesnatomical abnormalitiesPhysiologically - adhesion and proliferation of germs is prevented byPhysiologically - adhesion and proliferation of germs is prevented bywashing process during urination (local defense mechanism )washing process during urination (local defense mechanism )..Urinary abnormalities may interfere with defense mechanismsUrinary abnormalities may interfere with defense mechanisms  Patients with ITU - 40-50% defectsPatients with ITU - 40-50% defects detectable radiographicallydetectable radiographically - 30 % have RVU- 30 % have RVUOther malformations : - obstruction at different levels of urinaryOther malformations : - obstruction at different levels of urinary

- ureterocel- ureterocel                             -                              - uurinary stones , predispose to rinary stones , predispose to sstasistasis//infection.infection.                             -                              - fforeign bodies (catheters) facilitate infectionoreign bodies (catheters) facilitate infection

Uroepithelial aUroepithelial adherencedherence iin patients with recurrent UTIs without n patients with recurrent UTIs without malformation, urmalformation, urinaryinary cells have a high density of receptors on cells have a high density of receptors on their surface their surface →→ persistence + proliferation of germs. persistence + proliferation of germs.

Mechanisms of adhesionMechanisms of adhesion is is unclearunclear, are involved:, are involved:- some blood groupsome blood group antigens presentantigens present on cells and secreted from the on cells and secreted from the

cell surfacecell surface- ddeficiteficit of of Se Se IIggAA or or lysozyme                                   lysozyme                                  

Bacterial fBacterial factorsactors:: Virulence elements:Virulence elements:- - Bacterial outer membrane is made of - proteins, lipids ,Bacterial outer membrane is made of - proteins, lipids ,lipopolysaccharides .lipopolysaccharides .- - Bacterial endotoxin (ABacterial endotoxin (AggO, LPS structure) O, LPS structure) →→ responsible for responsible forsystemicsystemic reaction (fever, shock ) reaction (fever, shock ) - - Bacterial capsule is composed of LPS acid (K antigen Bacterial capsule is composed of LPS acid (K antigen with with importantimportantrole in bacterial virulence)role in bacterial virulence)- - Adhesion of E. coli to uroetAdhesion of E. coli to uroethheliu - essential for persistence in theeliu - essential for persistence in theurinary tract, a phenomenon mediated by receptors (pili or fimbriaeurinary tract, a phenomenon mediated by receptors (pili or fimbriae))- - Virulence of E. coli is signed by associating other bacterial factorsVirulence of E. coli is signed by associating other bacterial factors::

     - Production of hemolysin     - Production of hemolysin     - Production of aerobactină     - Production of aerobactină

CLINICAL PRESENTATIONCLINICAL PRESENTATIONUrinary tract infection in children has a wide spectrum of Urinary tract infection in children has a wide spectrum of manifestations, ranging from asymptomatic bacteriuria or subtle manifestations, ranging from asymptomatic bacteriuria or subtle manifestations, of revision (enuresis , urgency of micturition ) to manifestations, of revision (enuresis , urgency of micturition ) to the clinical picture of toxic-septic shock (in newborn and the clinical picture of toxic-septic shock (in newborn and prematurepremature..

1. 1. NeonatNeonatee: nonspecific symptoms: nonspecific symptoms such as such as weight loss, vomiting, weight loss, vomiting, flatulence, thermal instability, frequently hypothermia, flatulence, thermal instability, frequently hypothermia, poor poor feeding, respiratory distress, prolonged jaundicefeeding, respiratory distress, prolonged jaundice, , Failure to Failure to thrivethrive. May be complicated by sepsis with positive blood . May be complicated by sepsis with positive blood cultures and secondary dissemination.cultures and secondary dissemination.

2.2. Perioada infancyPerioada infancy : clinical picture : clinical picture is is nonspecificnonspecific- - ssepticeptic type type fever, fever, poor poor feedingfeeding, , vomitingvomiting

- - iirritability, rritability, pparenteral diarrhea, flatulence, jaundicearenteral diarrhea, flatulence, jaundice - s - strong-smelling urinetrong-smelling urine

3. 3. PPreschoolreschoolersers and school and schoolersers : :- Signs of cystitis ( dysuria, urinary frequency, urinary urgency)- Signs of cystitis ( dysuria, urinary frequency, urinary urgency)- Nocturnal enuresis or diurnal (recently installed)- Nocturnal enuresis or diurnal (recently installed)- Signs of acute pyelonephritis (- Signs of acute pyelonephritis (fever, vomiting, fever, vomiting, back pain or back pain or flank flank painpain, macroscopic hematuria), macroscopic hematuria)

- - Strong-smelling urine Strong-smelling urine

Acute renal failure is rarely reported in association withAcute renal failure is rarely reported in association with

first acute pyelonephritis. If therefirst acute pyelonephritis. If there happend happend betrays a betrays a malformatiomalformation.n.

Some infections with Proteus Some infections with Proteus can can generate stones (generate stones (ProteusProteus

cleaves ureacleaves urea into ammonia and CO2into ammonia and CO2, , with alkalinization with alkalinization of of urineurine

aandnd precipitation of salts, with formation of calculi) .precipitation of salts, with formation of calculi) .

DDIAGNOSISIAGNOSIS : :

Objectives: Objectives:

- - CConfirm the onfirm the UTIUTI  - Identification of malformations  - Identification of malformations  - The location of infection  - The location of infection

UUrine analysisrine analysisa) urine analysisa) urine analysis : :- Leucocyturia ( > 10- Leucocyturia ( > 10WBCWBC/ )/ )

Attention to other situations Attention to other situations with with leucocyturia without leucocyturia without UTIUTI : :- dehydration- dehydration- vaginitis- vaginitis- - uurethral irritation, stones rethral irritation, stones

- - ttubular acidosisubular acidosis- - iinterstitial nephritis, GN, polycystic kidney diseasenterstitial nephritis, GN, polycystic kidney disease

b ) screening testsb ) screening tests : :- Nitrite test- Nitrite test : bacterial nitrate reductase converts urinary : bacterial nitrate reductase converts urinary nitrates into nitrites. False negative test is if the bacteria does nitrates into nitrites. False negative test is if the bacteria does not have nitrate reductasenot have nitrate reductase or in case with or in case with polyuria polyuria

- Urinary density- Urinary density may be decreased in chronic pyelonephritis may be decreased in chronic pyelonephritis- Proteinuria- Proteinuria is found in small quantities is found in small quantities- Microscopic hematuria- Microscopic hematuria occurs frequently (sometimes occurs frequently (sometimes macroscopic)macroscopic)

c ) urine culturec ) urine culture

Method for Method for collecting urine iscollecting urine is dependent the age : dependent the age : - - Older children, teenOlder children, teenss - from medium - from medium urinary urinary jetjet,, after rigorous after rigorous

local toilet. This is the method most frequently used, but the local toilet. This is the method most frequently used, but the chance of bacterial contamination of the urine samplechance of bacterial contamination of the urine sample is great is great..

- Infants and toddlers- Infants and toddlers - by peripheral - by peripheral collecting vessels after collecting vessels after thorough cleaning of the perineal area and pasting container. It thorough cleaning of the perineal area and pasting container. It has a high risk of contamination, time being near the rectum , but has a high risk of contamination, time being near the rectum , but it isit is no no invasive . invasive .

- In infants- In infants - - by catheterby catheterisation -isation - uncontaminated urine sample uncontaminated urine sample

- In newborns and infants- In newborns and infants - suprapubic - suprapubic puncture is puncture is most simple, most simple, quick and safe method of urine collection .quick and safe method of urine collection .

Microbiological DiagnosiMicrobiological Diagnosiss Criteria Criteria

classical interpretation is classical interpretation is the Kassthe Kass criteriacriteria: significant : significant bacteriuria - over bacteriuria - over than than 101055UFC/mlUFC/ml in urine in urine obtained obtained by by peripheralperipheral method method

JohnsonJohnson describes more complex benchmarks with practical describes more complex benchmarks with practical applications for assessing significant bacteriuria :applications for assessing significant bacteriuria :

- Bacteriuria than 10 ² CFU / ml in children Bacteriuria than 10 ² CFU / ml in children with with catheterized catheterized bladder, orbladder, or

- Any colonies from urine specimens collected by suprapubic Any colonies from urine specimens collected by suprapubic aspiration, oraspiration, or

- Over 10Over 1055CFUCFU/ml in urine collected by means of peripheral/ml in urine collected by means of peripheral

B.B. B Bloodlood analyses analyses - - CBCCBC - inflammatory anemia, leukocytosis with - inflammatory anemia, leukocytosis with netrophilsnetrophils - - AAcute phase reactcute phase reactantsants: ESR, Fg; : ESR, Fg; PCRPCR (positive in (positive in

pyelonephritis )pyelonephritis )- - Nitrogen retentionNitrogen retention may occur in may occur in newborn, newborn, smallsmall infants and in infants and in cases that have a pre-existing malformation substratecases that have a pre-existing malformation substrate- - Positive blood culturesPositive blood cultures (in neonates, infants, dystrophic, (in neonates, infants, dystrophic, immunocompromised)immunocompromised)

Recently, techniques described for immunological diagnosis ofRecently, techniques described for immunological diagnosis ofrenal involvement in urinary tract infection. β2renal involvement in urinary tract infection. β2 microglobulin, IL 6,microglobulin, IL 6,procalcitonin, Tamm Horsfall protein, LDHprocalcitonin, Tamm Horsfall protein, LDH enzyme complex enzyme complex seemsseemsto to hahaveve a a important important role in the differentiation of lowrole in the differentiation of lowerer and and upperupperurinary tract urinary tract infectioninfection and to and to determin determinate ate the severity ofthe severity ofpathological lesions ofpathological lesions of UTIs UTIs..

C. ImagingC. Imaging evaluation evaluationPurpose: - discovery Purpose: - discovery malformationsmalformations                     - - ddiscovery renal scariscovery renal scarss

          -           - evaluationevaluation of renal function of renal function

Imaging evaluation is considered mandatory to:Imaging evaluation is considered mandatory to:- All children - All children less than less than 5 years with recurrent 5 years with recurrent UTIsUTIs- UTI in- UTI in infants infants- - All boys with All boys with recurrent recurrent UTIUTIss, regardless of age, regardless of age- - All cases of recurrent UTIAll cases of recurrent UTIss

a) Ultrasonographya) Ultrasonography- noninvasive- noninvasive- Reveals dimensions renal system changes pioelocaliceal , - Reveals dimensions renal system changes pioelocaliceal , stonesstones- Practice regardless of the patient's condition and GFR- Practice regardless of the patient's condition and GFR

b ) b ) VVoiding cystourethrogramoiding cystourethrogram (VCUG) (VCUG) detects detects urethral and urethral and bladder anatomybladder anatomy, UPV, UPV and and vesicoureteral reflux (VUR).vesicoureteral reflux (VUR).

- The only way (usual) for the diagnosis of - The only way (usual) for the diagnosis of VURVUR- Useful in the diagnosis of posterior urethral valve (elective - - Useful in the diagnosis of posterior urethral valve (elective - eendoscopy bladder that can be practiced valve resectionndoscopy bladder that can be practiced valve resection too too))- After at least 3 weeks after the sterilization - After at least 3 weeks after the sterilization of urineof urine

c ) Intravenous urographyc ) Intravenous urography ( (IVUIVU) view size ) view size of of kidneykidneys, s, renal renal scarring , pielocaliceal systemscarring , pielocaliceal system and and function function, , stones stones-- Is contraindicated Is contraindicated in renal failurein renal failure

d ) Exploring radionuclided ) Exploring radionuclide* Tc* Tc99 99 DTPA - provides data on renal function DTPA - provides data on renal function

* Tc* Tc9999 DM DMSA – for SA – for renal scarring renal scarring

Imaging investigations algorithm is :Imaging investigations algorithm is :• • uultrasound - first lineltrasound - first line• minimum radioisotope examination • minimum radioisotope examination at at 10-14 days 10-14 days for for diagnosisdiagnosis renal scarringrenal scarring of acute infection of acute infection

• • aat 6 months DMSA t 6 months DMSA for for chronic renal scarringchronic renal scarring

• • vvoiding cystourethrogram oiding cystourethrogram within 3-6 weeks after within 3-6 weeks after infection sterilizationinfection sterilization

TREATMENT:TREATMENT:The therapeutic measures depend on the locaThe therapeutic measures depend on the localisationlisation of the of the infectioninfection, , the age of the patienthe age of the patientt..

Acute pyelonephritisAcute pyelonephritis::- hospitalization, especially in infants andhospitalization, especially in infants and small childrensmall children- iiv antibioticsv antibiotics: : I. I. cephalosporins (IIcephalosporins (IIthth/ I/ IIIIIthth generation) generation)

- Cefamandole 50-150 mg / kg / day- Cefamandole 50-150 mg / kg / day- Ceftazidime 50-100 mg / kg / day- Ceftazidime 50-100 mg / kg / day- Cefuroxime 50-100 mg / kg / day- Cefuroxime 50-100 mg / kg / day- Ceftriaxone 50-100 mg / kg / day- Ceftriaxone 50-100 mg / kg / day

II . aminoglycosideII . aminoglycoside ( netilmicin ) 5 mg / kg / day ( netilmicin ) 5 mg / kg / day! Attention to renal toxicity! Attention to renal toxicity

FFavorable evolution occurs in 48-72 hours.avorable evolution occurs in 48-72 hours.UUrine culture rine culture ccontrol is performed in 48 - 72hours.ontrol is performed in 48 - 72hours.

After 3-5 days you can switch to oral therapy if:After 3-5 days you can switch to oral therapy if:- Toxic signs disappeared- Toxic signs disappeared- Clinical improvement occurred- Clinical improvement occurred- Germ - Germ is is sensitive to oral antibioticssensitive to oral antibiotics

The duration of the treatment The duration of the treatment == 10-14 days 10-14 daysIn case of lack of response may In case of lack of response may ssuspicion :uspicion :

- - resistance to antibioticsresistance to antibiotics- - urinary tract obstructionurinary tract obstruction- - presence of complications (renal abscess)presence of complications (renal abscess)

AAcute cystitiscute cystitis - oral therapy: - oral therapy: - Trimethoprim 5-8 mg / kg / day - Trimethoprim 5-8 mg / kg / day - - Amoxicilin+clavulanic acidAmoxicilin+clavulanic acid (40 mg / kg / day) (40 mg / kg / day) - - NitrofurantoinNitrofurantoin 5-7 mg / kg / day 5-7 mg / kg / day - Quinolones in adolescents - Quinolones in adolescents

The control urine cultures performed 48 hours The control urine cultures performed 48 hours Duration of treatment = 5-7 daysDuration of treatment = 5-7 days

UTI inUTI in newborn newborn- emergency hospitalization- emergency hospitalization (risk of sepsis)(risk of sepsis)- - iiv antibiotic therapy starts quicklyv antibiotic therapy starts quickly after hospitalisations after hospitalisations andand continued until the blood and urine normalization continued until the blood and urine normalization - - aantibiotic dosage is based on gestational age in preterm ntibiotic dosage is based on gestational age in preterm newborns and glomerular filtration rate newborns and glomerular filtration rate for newbornfor newborn

- - aafter clinic normalization malformation willfter clinic normalization malformation will fund evaluate fund evaluate - - iin the absence of malformations or complications AB stops n the absence of malformations or complications AB stops after 10-14 daysafter 10-14 days

UTI recurrence preventionUTI recurrence prevention- - Recurrence occurs in 40-50 % of cases even in the absence ofRecurrence occurs in 40-50 % of cases even in the absence ofmalformations. malformations. - - Prophylactic therapy is applied in single dose at bedtime , 1/ 4Prophylactic therapy is applied in single dose at bedtime , 1/ 4to 1 /3 of the loading dose .to 1 /3 of the loading dose .

* Nitrofurantoin 1-2 mg / kg / day * Nitrofurantoin 1-2 mg / kg / day * Trimethoprim 2 mg / kg / day * Trimethoprim 2 mg / kg / day * * Second gSecond generation cephalosporinseneration cephalosporins (Cefaclor 5-10mg/kg/zi)(Cefaclor 5-10mg/kg/zi)

Prophylactic therapy is applicableProphylactic therapy is applicable to: to:- Recurrent UTI- Recurrent UTI- - UTI withUTI with malformation malformation- - UTIUTI + urinary stones + urinary stones- - UTIUTI + neurogenic/unstable + neurogenic/unstable bladder bladder

AAsymptomatic bacteriuriasymptomatic bacteriuria- - In 40-50 % of cases sterilized In 40-50 % of cases sterilized without treatmentwithout treatment- - There is no deterioration of renal There is no deterioration of renal function function

Hygienic-dietary regime in Hygienic-dietary regime in UTI:UTI: - Rich fluid regime- Rich fluid regime

- Regular urination- Regular urination - - Emptying of the bladder Emptying of the bladder - Combating constipation- Combating constipation

References:References:1. O. Brumariu, Mihaela Munteanu, 1. O. Brumariu, Mihaela Munteanu, Infecția tractului urinarInfecția tractului urinar, în Hematologie , în Hematologie

și nefrologie pediatrică, elemente practice de diagnostic și tratament, și nefrologie pediatrică, elemente practice de diagnostic și tratament, editura Junimea, Iași, 2008, cap. 10, pag. 283 – 293.editura Junimea, Iași, 2008, cap. 10, pag. 283 – 293.

2. Brumariu O, Munteanu M, Gavrilovici C2. Brumariu O, Munteanu M, Gavrilovici C, Infecţia tractului urinar, Infecţia tractului urinar, în , în Ciofu E, Ciofu C, Ciofu E, Ciofu C, Pediatria - tratatPediatria - tratat, ediţia I, Bucureşti, 2001, cap. 11, , ediţia I, Bucureşti, 2001, cap. 11, pag. 711- 718.pag. 711- 718.

3. Nelson textbook of pediatrics - 18 ed. Behrman RE, Kliegman RM, Jenson 3. Nelson textbook of pediatrics - 18 ed. Behrman RE, Kliegman RM, Jenson HB: HB: Urinary Tract InfectionsUrinary Tract Infections, cap. 538, pag. 2223 – 2227, Saunders , cap. 538, pag. 2223 – 2227, Saunders Elsevier, 2007.Elsevier, 2007.

4. Rubin HR, Cotran RS, Tolkof – Rubin N.E. 4. Rubin HR, Cotran RS, Tolkof – Rubin N.E. Urinary Tract Infection, Urinary Tract Infection, Pyelonephritis, and Reflux NephropathyPyelonephritis, and Reflux Nephropathy, BRENNER & RECTOR’S THE , BRENNER & RECTOR’S THE KIDNEY, ediția 9, Saunders Elsevier, 2012; cap. 34:1203 – 1238.KIDNEY, ediția 9, Saunders Elsevier, 2012; cap. 34:1203 – 1238.

5. Rees L., Brogan P., Bockenhauer D., Webb N., 5. Rees L., Brogan P., Bockenhauer D., Webb N., Urinary Tract InfectionsUrinary Tract Infections, , în Pediatric Nephrology, Oxford Specialist Handbooks in Pediatrics, în Pediatric Nephrology, Oxford Specialist Handbooks in Pediatrics, second edition, cap. 4, pag. 75 - 90.second edition, cap. 4, pag. 75 - 90.

6. Stârcea (Buhuș) Iuliana, Infecția de tract urinar la copil. Probleme de 6. Stârcea (Buhuș) Iuliana, Infecția de tract urinar la copil. Probleme de diagnostic și tratament, teză de doctorat, Iași, 2011. diagnostic și tratament, teză de doctorat, Iași, 2011.

7. Stârcea Magdalena, Mihaela Munteanu, Gabriela Coman, Cristiana 7. Stârcea Magdalena, Mihaela Munteanu, Gabriela Coman, Cristiana Dragomir, O. Brumariu: Dragomir, O. Brumariu: Infecția urinară la copil. Aspecte ale Infecția urinară la copil. Aspecte ale diagnosticului bacteriologicdiagnosticului bacteriologic, Rev. Med. Chir, Iași, 2008; 112(4):932-937. , Rev. Med. Chir, Iași, 2008; 112(4):932-937.

8. 8. Svanborg C., Godaly G., Svanborg C., Godaly G., Urinary tract infections revisitedUrinary tract infections revisited, Kidney , Kidney International (2007) 71, 721–723.International (2007) 71, 721–723.