Paeds: UTI Flashcards
Symptoms and Signs
Fever
Vomiting
Lethargy
Irritability
Symptoms and Signs
- Poor feeding
Failure to thrive
Symptoms and Signs
Abdominal pain
Jaundice
Haematuria
Offensive urine
Infants and children >3 months (preverbal)
Most common
Fever
Infants and children >3 months (preverbal) Less common
- Abdominal pain
- Loin tenderness
- Vomiting
Poor feeding
Infants and children >3 months (preverbal) Least common
- Lethargy
- Irritability
- Haematuria
- Offensive urine
Failure to thrive
Infant and children >3 months verbal;
Most common
Fever
Dysuria
Infant and children >3 months verbal;
Less common
- Dysfunctional voiding
- Changes in continence
- Abdominal pain
Loin tenderness
Infant and children >3 months verbal; Least common
- Fever
- Malaise
- Vomiting
- Haematuria
- Offensive urine
Cloudy urine
Infants symptoms of UTI
- Fever
- Vomiting
- Lethargy or irritability
- Poor feeding/failure to thrive
- Jaundice
- Septicaemia
- Offensive urine
Febrile convulsion (>6 months)
Children
symptoms of UTI
- Dysuria and frequency
- Abdominal pain or loin tenderness
- Fever with or without rigors (exaggerated shivering)
- Lethargy and anorexia
- Vomiting, diarrhoea
- Haematuria
- Offensive/cloudy urine
- Febrile convulsion
Recurrence of enuresis
Collection of samples:
Child in nappies:
- Clean catch (recommended method)
- An adhesive plastic bag applied to the perineum after careful washing – may be contamination from the skin
- A urethral catheter (urgency in obtaining sample)
- Suprapubic aspiration – in severely ill infants requiring urgent diagnosis and treatment
Older children:
collection of samples
Mid stream urine may be possible
Note: Cleaning of area needed as contamination high in boys due to foreskin and reflux into the vagina.
Leucocyte esterase and nitrite positive
Regard as UTI
Leucocyte esterase negative and nitrite positive
Start antibiotic treatment
Leucocyte esterase positive and nitrite negative
Only start antibiotic treatment if clinical evidence of UTI
Diagnosis depends on urine culture
Leucocyte esterase and nitrite negative
UTI unlikely. Repeat or send urine for culture if clinical hx suggests
UTI
Blood, protein and glucose present on stick testing
Useful in any unwell child to identify other diseases e.g. nephritis, DM but will not discriminate between children with and without UTIs
Bacterial and host factors that predispose to infection:
Causative organism:
- E.coli
- Klebsiella
- Proteus
- Pseudomonas
- Strep. faecalis
- Newborn: likely to be haematogenous
Proteus organism more common in
(more common in boys – potentially due to presence under prepuce)
Pseudomonas may indicate
may indicate the presence of some structural abnormality in the urinary tract affecting drainage.
Predisposing Factors:
- Infecting organism
- Antenatally diagnosed renal or urinary tract abnormality
- Incomplete bladder emptying
- Vesicoureteric reflex
Incomplete bladder emptying
- Infrequent voiding, resulting in bladder enlargement
- Vulvitis
- Incomplete micturition with residual post-micturition bladder volumes
- Obstruction by a loaded rectum from constipation
- Neuropathic bladder
Vesicoureteric reflux
Vesicoureteric reflux: Definition
A developmental anomaly of the vesicoureteric junctions
Displaced laterally and enter directly into the bladder
Vesicoureteric reflux:
Cause
Familial with a 30-50% chance of occurring in first-degree relative.
May also occur with bladder pathology e.g. neuropathic bladder or urethral obstruction or temporarily after a UTI
Vesicoureteric reflux:
Presentation
Mild (reflux into ureter only) to Severe (Gross dilatation o ureter, renal pelvis and calyces)
Vesicoureteric reflux:
Severe reflux leads to
Predisposes to intrarenal reflux and renal scarring with UTI via
Backflow of urine from the renal pelvis into the papillary collecting ducts; intrarenal reflux
Vesicoureteric reflux:
Reflux with associated ureteric dilatation is important, as:
- Urine returning to the bladder from the ureters after voiding results in incomplete bladder emptying, which encourages infection
- The kidneys may become infected (pyelonephritis), particularily if there is intrarenal reflux
Bladder voiding pressure is transmitted to the renal papillae; this may contribute to renal damage if voiding pressure are high
Vesicoureteric reflux:
Consequence
Chronic renal failure due to scarring leading to hypertension in childhood or early adult life (10%)
Vesicoureteric reflux:
Outcome
Mild – resolves spontaneously
Investigation:
NICE recommendation
NICE don’t recommend an ultrasound for first UTI if there was response to antibiotic treatment within 48h, unless
Paediatrician protocol
- First proven urinary tract infection
- Antibiotic therapy + ultrasound of kidneys and urinary tract
Ultrasound
After ultrasound in
MCUG and DMSA
After ultrasound in >1 year and
DMSA
Atypical UTI symtpoms
- Seriously ill or septicaemia
- Poor urine flow
- Abdominal or bladder mass
- Raise creatinine
- Failure to respond to suitable antibiotics within 48h
- Infection with non-E.coli organism
Ultrasound with reveal:
- Serious structural abnormalities and urinary obstruction
- Renal defects (but poor at identifying renal scars).
MSUG: for
micturating cystorethrogram – useful for reflux but INVASIVE
DMSA scan
radionuclidescan – for scarring
Plain abdo X-ray:
if haematuria look for stones
Management All infants
- Referral to hospital
IV antibiotics e.g. cefotaxime until temp reduced
Management Infants >3 months and children with acute pyelonephritis/upper urinary tract infection (bacteruria and fever > 38oC) or bacteruria and loin pain/tenderness even if fever is
- Oral antibiotics with low resistance patterns (e.g. co-amoxiclav for 7-10 days) or
IV antibiotics cefotaxime 2-4 days followed by oral antibiotics for 7-10 days total
Management Children with cystitis/lower UTI infection (dysuria but no systemic symptoms or signs)
Oral antibiotics for 3 days
Medical measures for the prevention of UTI:
Ensure washout of organisms that ascend into the bladder from the perineum, and to reduce the presence ofaggressive organisms in the stool, perineum and under the foreskin.
Prevention and advice for parents
- High fluid intake to produce a high urine output
- Regular voiding
- Ensuring complete bladder emptying by encouraging the child to try a second time to empty his bladder after a minute or two, commonly know as double micturition, this empties any urine residue or refluxed urine returing to the bladder
- Prevention or treatment of constipation
- Good perineal hygiene
- Lactobacillus acidophilus, a probiotic to encourage colonization of the gut by this organism that might potentially cause invasive disease
Antibiotic prophylaxis:
Antibiotics prophylaxis
- often used in the under 2 with a congenital abnormality: trimethoprim (2mg/kg at night), but nitrofurantoin or cephalexin may be given
Follow-up
- Urine culture in nonspecific illness
- Low-dose prophylaxis can be used
- Circumcision considered
- Anti-reflux surgery with evidence of progression
- Blood pressure checked if renal disease present
- Regular assessment of renal growth and function if bilateral defects present
