Urinary tract infection Flashcards
Epidemiology of UTIs?
3-7% of girls and 1-2% of boys will have at least one symptomatic UTI before 6 years
12-30% will have a recurrence within a year
Difference of symptoms between cystitis and pyelonephritis?
Pyelonephritis is usually associated with fever and systemic involvement, where as cystitis there may be no fever
Why is UTI important in childhood?
- up to 50% of pts have a structural abnormality of their urinary tract
- pyelonephritis may scar and damage the growing kidney, predisposing to hypertension and leading to progressive CKD if scarring is bilateral
Clinical presentation of UTI in infants
symptoms are usually non specific
- fever
- vomiting
- lethargy or irritability
- poor feeding/faltering growth
- jaundice
- septicaemia
- offensive urine
- febrile seizure (>6 months)
Clinical presentation of UTI in children
- dysuria, frequency and urgency
- abdominal pain/ loin tenderness
- fever with/without rigors
- lethargy and anorexia
- vomiting and diarrhoea
- haematuria
- offensive/cloudy urine
- febrile seizure
- recurrence of enuresis
What is dysuria alone usually due to?
Cystitis
Vulvitis in girls
Balantitis in uncircumcised boys
Safeguarding thing to consider??
Symptoms suggestive of a UTI may also occur following sexual abuse
Methods of collecting urine samples in child in nappies
- clean catch sample when nappy is removed (recommended)
- urethral catheter
- suprapubic aspiration
Investigations?
Urine sample should be observed under microscope and cultured straight away (indicated in all infants and children <3y with suspected UTI)
When else may urinary white cells be present?
- febrile without UTI
- balantitis
- vulvovaginitis
When should urine culture be performed?
Always, unless both leucocyte esterase and nitrate are negative, or clinical symptoms and dipstick tests do not correlate
Methods of dipstick testing?
Nitrite stick testing
- +ve result very likely to indicate true UTI
- some children with UTI are nitrite -ve
Leucocyte esterase stick testing (for WBC)
- may be present in children with UTI, or negative
- present in children with febrile illness w/o UTIs
- +ve in balantits and vulvovaginitis
Leucocyte esterase and nitrite +ve?
regard as UTI
Leucocyte esterase -ve and nitrite +ve?
start abx treatment if clinical evidence of UTI. Diagnosis depends on urine culture
Leucocyte esterase +ve and nitrite -ve?
only start abx treatment if clinical evidence of UTI. diagnosis depends on urine culture
Leucocyte esterase and nitrite -ve?
UTI unlikely. Repeat or send urine for culture if clinical Hx suggests UTI
Blood, protein and glucose present on stick testing?
Useful for other diseases but will not discriminate between child with/without UTI
Infecting organisms?
Escherichia coli (Most common) Klebsiella Proteus Pseudomonas Streptococcus faecalis
Risk factors?
Renal/urinary tract abnormality
Incomplete bladder emptying
Vesicoureteric reflux
Contributing factors to incomplete bladder emptying?
- infrequent voiding, resulting in bladder enlargement
- vulvitis
- incomplete micturition with residual postmicturition bladder volumes
- obstruction by a loaded rectum from constipation
- neuropathic bladder
- vesicoureteric reflux
What is vesicoureteric reflux (VUR)?
Developmental anomaly of the vesicoureteric junctions. Ureters are displaced laterally and enter directly into the bladder rather than at an angle, with a shortened or absent intramural course. Severe cases may be associated with renal dysplasia
Risk factors for VUR?
- Familial (30-50% chance of occurring in 1st degree relatives)
- Secondary to bladder pathology
- Temporarily after a UTI
When do you extensively investigate?
Atypical or recurrent UTI
Atypical UTI
- seriously ill or septicaemia
- poor urine flow
- abdominal or bladder mass
- raised creatinine
- failure to respond to suitable antibiotics within 48 hours
- infection with atypical (non-E.coli) organisms
Investigation of atypical UTI
Initial ultrasound to identify structural abnormalities/ urinary obstruction/ renal defects
Subsequent Ix depend on USS results
- MCUG if urethral obstruction is suspected (abnormal bladder in boy)
- Functional scans should be deferred for 3 months post UTI, unless USS is suggestive of obstruction
Management for all infants under 3 months of age
Refer to hospital immediately if suspicion of UTI or seriously ill.
- require IV abx (e.g. coamoxiclav) for at least 5-7 days) then oral prophylaxis
Management for infants over 3 months and children with acute pyelonephritis/upper UTI
Bacteria + fever >38 and loin pain/tenderness with fever <38 is usually treated with
- oral abx (e.g. trimethoprim for 7 days)
- IV abx (e.g. co-amoxiclav) for 2-4 days followed by oral abx for a total of 7-10 days
Choice of abx is adjusted according to sensitivity on urine culture.
Management of children with cystitis/lower UTI
dysuria with no systemic symptoms or signs can be treated with oral abx such as trimethoprim or nitrofurantoin for 3 days
Medical measures for prevention of UTI
- high fluid intake to produce high urine output
- regular voiding
- ensure complete bladder emptying “double voiding” by encouraging child to try again after a minute or two
- treatment and/or prevention of constipation
- good perineal hygiene
- Lactobacillus acidophilus, probiotic to encourage colonisation of gut to reduce number of pathogenic organisms
- Antibiotic prophylaxis (controversial). Often used in those under 2 years - 3 years with congenital abnormality of kidneys/ severe reflux and upper UTI. Trimethoprim (2mg/kg per nocte). Can use nitrofurantoin or cephalexin. Avoid amoxicillin.
Diagnostic tests for VUR
MCUG - micturating cystourethrogram
DMSA scan?
Follow up of children with recurrent UTIs, renal scarring or reflux
- urine dip any non-specific illness
- long-term, low-dose abx prophylaxis can be used
- circumcision in boys
- anti-VUR surgery
- BP monitoring annually if renal defects are present
- urinalysis to check for proteinuria (CKD)
- regular assessment of renal grown and function if bilateral defects (CKD)
