GU - UTI

Question 1

Defintion

Answer 1

UTIs in children usually result of bacteria ascending to the bladder via the urethra -> cystitis.
From the bladder, infection can ascend to the kidneys resulting in pyelonephritis

Question 2

Epidemiology

Answer 2

Age: children <12
Male < 3 months due to increased risk of congenital urinary abnormalities
Female > 3 months
White

Question 3

Risk factors

Answer 3

• Previous UTI
• Voiding dysfunction: inability to empty the bladder increases the risk of UTI. This includes structural abnormalities, voluntary withholding of urine and chronic constipation
• Vesicourecteric reflux (VUR): reflux of urine from the bladder into the ureter during voiding. It can be unilateral or bilateral, and increases the risk of pyelonephritis and renal scarring
• Immunosuppression

Question 4

Aetiology

Answer 4

Escherichia coli (MC)
Klebsiella
Proteus,
Pseudomonas
Streopoccocus faecalis

Question 5

Classification of UTIs

Answer 5

Lower UTI: Involves the bladder (cystitis) and urethra (uthethritis)
Upper UTI: ureters and kidneys (pyelonephritis)
Uncomplicated UTIs: occuring in a structurally and neurologically normal urinary tract
Complicated UTIs: associated with structural and neurological abnormality

Question 6

Atypical UTI

Answer 6

defined by the presence of any of the following features (remembered by the mnemonic “CATFISH”):
- Creatinine raised
- Abdominal or bladder mass
- Terribly ill
- Flow of urine poor
- Infection non-E.coli
- Sepsis
- Halted response to Abx >48 hours

Question 7

Recurrent UTIs

Answer 7

2 or more episodes of upper UTIs
OR
1 episode of upper UTI and 1 or more episdoes of lower UTI
OR
3 episodes of lower UTIs

Question 8

Signs

Answer 8

Fever
Suprapubic tenderness
Flank tenderness (in pyelonephritis)

Question 9

Symptoms

Answer 9

Younger children:
- Lethargy
- Irritability
- Poor feeding + vomiting
- Urinary frequency
Older children:
- Dysuria
- Frequency
- Lower abdominal pain
- New onset bedwetting
- Vomiting
- Loss of appetite

Question 10

Diagnosis

Answer 10

FIRST LINE =
- Urinalysis: useful screening tool in children > 3 months
- If nitrates and leukocytes +ve: treat as UTI
- If nitrates and leukocytes are -ve : UTI is unlikely
- If nitrates +ve but leukocytes -ve: treat as UTI and send urine for microscopy and culture
- If nitrates -ve but leukocytes +ve: send urine for microscopy and culture. Treat as UTI in children < 3 year or if there is clinical evidence of a UTI

GOLD STANDARD = Urine MC+S
- Identify causative organism
- In children wearing nappies, clean catch urine (CCU) is preferable however this must not delay treatment

• USS KUB = Any child with first presentation of UTI under 6 months or any age with recurrent or atypical UTIs to check for nephroagenesis or VUR
  Consider doing:
• Micturating cystourethrogram (MCUG): indicated in children with vesicoureteric reflux
• Dimercaptosuccinic (DMSA) acid renal scan:
  = children >3 with recurrent UTI
  = children < 3 with atypical UTI

Question 11

Treatment

Answer 11

Antibiotic therapy: children <3 months are admitted to hospital for IV antibiotics. Older children that do not otherwise require hospital admission can be treated with oral antibiotics:
Upper UTI:
FIRST LINE = CO-AMOXICLAV or CEFALEXIN, pending culture results.
Lower UTI:
FIRST LINE = IV CEFUROXIME
Infants and children on prophylactic antibiotics should be treated with an alternative antibiotic.

Analgesia: regular paracetamol for pain relief
Fluids: encourage fluid intake to promote urinary output

Question 12

Complications

Answer 12

Recurrent UTIs
Renal scarring
Sepsis

Question 13

Extended-spectrum beta-lactamases (ESBLs)

Answer 13

Enzymes that confer resistance to most beta-lactam antibiotics, including penicillins, cephalosporins
- TREATMENT: MEROPENAM