URINARY TRACT
INFECTION in
CHILDREN
CC MAGBANUA
PREVALENCE
▰ 1% OF BOYS ▰ 1-3% OF GIRLS
▰ 1st YEAR OF LIFE (2.8-5.4:1) ▰ BEYOND 1-2 YEARS OLD (1:10)
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ETIOLOGY
BACTERIAL NON-BACTERIAL
• Escherichia coli • Adenovirus
• Klebsiella • Candida sp.
• Proteus
• Enterobacter
• Pseudomonas
• Serratia
• Group B Streptococci
• Enterococcus
• Staphylococcus
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CLASSIFICATIONS
Pyelonephritis
Cystitis
Asymptomatic Bacteriuria
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PYELONEPHRITIS
The most common serious bacterial infection in
infants younger than 24 months of age who
have fever without an obvious focus
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PYELONEPHRITIS
• Abdominal, back or flank pain
• Fever
• Nausea
• Malaise
• Vomiting
• Diarrhea
• Poor feeding
• Irritability
• Weight loss or failure to thrive
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PYELONEPHRITIS
ACUTE PYELONEPHRITIS • Involvement of the renal parenchyma
PYELITIS • No parenchymal involvement
PYELONEPHRITIC
• Result due to renal injury
SCARRING
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PYELONEPHRITIS
• Renal mass due to acute focal infection without liquefaction. It may be an early
ACUTE LOBAR NEPHRONIA stage in the development of a renal abscess
• Can occur secondary to contiguous infection in the perirenal area or pyelonephritis
PERINEPHRIC ABSCESS that dissects the renal capsule
XANTHOGRANULOMATHOUS • Granulomatous inflammation with giant cells and foamy histiocytes. It may
manifest as a renal mass or an acute or chronic infection and usually requires
PYELONEPHRITIS partial or total nephrectomy.
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CYSTITIS
Involvement of the bladder
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CYSTITIS
• Dysuria
• Urgency Acute Hemorrhagic Cystitis
• Frequency
• Suprapubic pain Eosinophilic Cystitis
• Incontinence
• Malodorous urine
Interstitial Cystitis
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ACUTE HEMORRHAGIC CYSTITIS
▻ E. coli, Adenovirus types 11 and 21
▻ Adenovirus cystitis is more common in
boys, self- limiting and manifests as
hematuria
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EOSINOPHILIC CYSTITIS
▻ Rare, may be due to allergen exposure
▻ Imaging: multiple solid bladder masses that
consists of inflammatory infiltrates and eosinophils
▻ Ureteral dilatation and hydronephrosis are common
▻ Treatment: antihistamines and NSAIDs
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INTERSTITIAL CYSTITIS
▻ Characterized by irritative symptoms relieved
by voiding with a negative urine culture
▻ Usually in adolescent girls
▻ Idiopathic
▻ Diagnosis: cytoscopic observation of mucosal
ulcers with bladder distention
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What is the clinical differentiation between
acute pyelonephritis/upper UTI and
cystitis/lower UTI?
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“ Infants and children who have bacteriuria and
fever of 38°C or higher or presenting with
fever lower than 38°C with loin
pain/tenderness and bacteriuria should be
considered to have acute
pyelonephritis/upper UTI
NICE Guidelines
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ASYMPTOMATIC
BACTERIURIA
Positive urine culture without any manifestation
of infection
Most common in girls
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PATHOGENESIS
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DIAGNOSIS
Signs and Symptoms
Urinalysis
Urine culture
Imaging Studies
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“ Infants and children presenting
with unexplained fever of 38 °C
or higher should have a urine
sample tested after 24 hours at
the latest.
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SIGNS and SYMPTOMS
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URINALYSIS and URINE CULTURE
▰ Presence of pyuria and/or bacteriuria on urinalysis
Pyuria - >5 WBC/hpf of freshly voided spun urine OR >10 WBC/hpf of voided unspun urine
▰ Presence of at least 50,000 colony-forming units (CFU) per mL of a uropathogen
from the quantitative culture of a properly collected urine specimen (suprapubic or
urine catheter sample) OR >10,000 CFU per mL in a symptomatic child OR there is
a single organism colony count of >100,000 CFU per mL in asymptomatic child
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“ Urine dipstick testing may
provide an adequate initial UTI
screen
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NITRITE TEST
▻ Due to bacterial conversion of nitrate to nitrite in urine
▻ Specific but not highly sensitive
▻ Positive test indicates infection with significant
bacterial load
▻ Negative result cannot rule out UTI
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LEUKOCYTE ESTERASE TEST
▻ Esterase reaction by enzyme release from lysed
granulocytes in urine
▻ Semi-quantitative measure
1+ 10-25 WBC/mm3
2+ >75 WBC/mm3
3+ >500 WBC/mm3
TNT Too numerous to count
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RAPID SCREENING TESTS
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RAPID SCREENING TESTS
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URINE COLLECTION
▰ A mid stream clean catch urine sample is the recommended
method for urine collection.
▰ When it is not possible or practical to collect urine by non
invasive methods, catheter samples or suprapubic aspiration
(SPA) should be used.
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URINE COLLECTION
SUPRAPUBIC TAP URINE
• Any growth of Gram negative bacilli indicates UTI
• 99% sensitivity
• More than a few thousand CFU’s per ml for gram
positive cocci
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URINE COLLECTION
CATHETERIZED URINE
• Single catheterized urine or from Foley’s catheter
• >100,000 CFU’s/ml urine diagnostic of UTI (95%
sensitivity)
• 10,000-100,000 CFU’s/ml urine indicates likely infection
• May introduce infection or trauma to urethra and bladder
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URINE COLLECTION
CLEAN CATCH URINE
• >10,000 CFU’s/ml urine indicates likely infection for boys
• >100,000 CFU’s/ml urine indicates infection in girls
• 95% sensitivity
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“ If the culture shows >50,000
colonies of a single pathogen
(supra- pubic or catheter sample),
or if there are 10,000 colonies and
the child is symptomatic, the child
is considered to have a UTI
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IMAGING STUDIES
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BOTTOM-UP METHOD
▰ Renal sonogram plus voiding
cystourethrogram
▰ This approach will identify upper and lower
urinary tract abnormalities, including
vesicoureteral reflux, bladder–bowel
dysfunction, and bladder abnormalities
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TOP DOWN METHOD
▰ Begins with a DMSA renal scan, to identify
areas of acute pyelonephritis
▰ On DMSA, involved areas of the kidney are
photopenic and the kidney is enlarged
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RECOMMENDATIONS BY AAP
▰ In a typical first-episode of UTI, initial
imaging should be ultrasonography of the
kidneys, ureters, and bladder.
▰ VCUG is indicated if the ultrasound study is
abnormal, the patient has atypical features,
or after a recurrent febrile UTI
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RECOMMENDATIONS BY AAP
▰ In children with a history of cystitis, (dysuria,
urgency, frequency, suprapubic pain),
imaging is usually unnecessary. Instead,
assessment and treatment of bladder and
bowel dysfunction is important.
▰ If there are numerous lower UTIs, then a renal
sonogram is appropriate, but a VCUG rarely
adds useful information.
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TREATMENT
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ACUTE CYSTITIS
▻ Treated promptly to prevent possible progression to pyelonephritis
▻ Severe symptoms awaiting culture results -> presumptive treatment with
3-5 day course of:
▻ Trimethoprim-Sulfamethoxazole against E. coli
▻ Nitrofurantoin (5-7mg/kg/hr in 3-4 divided doses) against Klebsiella
and Enterobacter
▻ Amoxicillin (50mg/kg/24hours) effective as initial treatment but has
a high rate of bacterial resistance
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PYELONEPHRITIS
▻ 7-14 day course of broad spectrum antibiotics
▻ children with dehydration, vomiting, unable to drink fluids or <1
month old -> IV rehydration and IV antibiotic therapy with:
▻ Ceftriaxone (50-75mg/kg/24hr)
▻ OR Cefotaxime (100mg/kg/24hr)
▻ OR Ampicillin (100mg/kg/24hr)
▻ WITH Gentamycin (3-5mg/kg/24hr in 2-3 divided doses)
against Pseudomonas spp.
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ASYMPTOMATIC BACTERIURIA
▻ Should not be treated
▻ Treatment increases the risk of pyelonephritis
in these patients
▻ Despite not being treated, patients do not
have an increased prevalence of renal
scarring
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PREVENTION OF RECURRENCE
▰ Dysfunctional elimination syndromes and
constipation should be addressed in infants and
children who have had a UTI
▰ Asymptomatic bacteriuria in infants and children
should not be treated with prophylactic
antibiotics
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PREVENTION OF RECURRENCE
▰ Prophylaxis with TMP-SMZ, amoxicillin, or
cephalexin can also be effective, but the risk
of breakthrough UTI may be higher because
bacterial resistance may be induced.
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SUMMARY
▰ Diagnosing UTI entails a high index of suspicion
▰ Routine dipstick is a good screening test, but not all pyuria is considered
UTI
▰ Urine culture is still the gold standard for diagnosing UTI.
▰ A negative urine culture does not necessarily rule out UTI. Likewise, a
growth in urine culture may be a contaminant.
▰ Risk factors like voiding dysfunction, constipation, and phimosis must be
identified and managed accordingly, to avoid unnecessary workups
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