Urinary tract infection

Question 1

Epidemiology of UTIs?

Answer 1

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

Question 2

Difference of symptoms between cystitis and pyelonephritis?

Answer 2

Pyelonephritis is usually associated with fever and systemic involvement, where as cystitis there may be no fever

Question 3

Why is UTI important in childhood?

Answer 3

• 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

Question 4

Clinical presentation of UTI in infants

Answer 4

symptoms are usually non specific

• fever
• vomiting
• lethargy or irritability
• poor feeding/faltering growth
• jaundice
• septicaemia
• offensive urine
• febrile seizure (>6 months)

Question 5

Clinical presentation of UTI in children

Answer 5

• 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

Question 6

What is dysuria alone usually due to?

Answer 6

Cystitis
Vulvitis in girls
Balantitis in uncircumcised boys

Question 7

Safeguarding thing to consider??

Answer 7

Symptoms suggestive of a UTI may also occur following sexual abuse

Question 8

Methods of collecting urine samples in child in nappies

Answer 8

• clean catch sample when nappy is removed (recommended)
• urethral catheter
• suprapubic aspiration

Question 9

Investigations?

Answer 9

Urine sample should be observed under microscope and cultured straight away (indicated in all infants and children <3y with suspected UTI)

Question 10

When else may urinary white cells be present?

Answer 10

• febrile without UTI
• balantitis
• vulvovaginitis

Question 11

When should urine culture be performed?

Answer 11

Always, unless both leucocyte esterase and nitrate are negative, or clinical symptoms and dipstick tests do not correlate

Question 12

Methods of dipstick testing?

Answer 12

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

Question 13

Leucocyte esterase and nitrite +ve?

Answer 13

regard as UTI

Question 14

Leucocyte esterase -ve and nitrite +ve?

Answer 14

start abx treatment if clinical evidence of UTI. Diagnosis depends on urine culture

Question 15

Leucocyte esterase +ve and nitrite -ve?

Answer 15

only start abx treatment if clinical evidence of UTI. diagnosis depends on urine culture

Question 16

Leucocyte esterase and nitrite -ve?

Answer 16

UTI unlikely. Repeat or send urine for culture if clinical Hx suggests UTI

Question 17

Blood, protein and glucose present on stick testing?

Answer 17

Useful for other diseases but will not discriminate between child with/without UTI

Question 18

Infecting organisms?

Answer 18

Escherichia coli (Most common)
Klebsiella
Proteus
Pseudomonas
Streptococcus faecalis

Question 19

Risk factors?

Answer 19

Renal/urinary tract abnormality
Incomplete bladder emptying
Vesicoureteric reflux

Question 20

Contributing factors to incomplete bladder emptying?

Answer 20

• 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

Question 21

What is vesicoureteric reflux (VUR)?

Answer 21

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

Question 22

Risk factors for VUR?

Answer 22

• Familial (30-50% chance of occurring in 1st degree relatives)
• Secondary to bladder pathology
• Temporarily after a UTI

Question 23

When do you extensively investigate?

Answer 23

Atypical or recurrent UTI

Question 24

Atypical UTI

Answer 24

• 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

Question 25

Investigation of atypical UTI

Answer 25

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

Question 26

Management for all infants under 3 months of age

Answer 26

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

Question 27

Management for infants over 3 months and children with acute pyelonephritis/upper UTI

Answer 27

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.

Question 28

Management of children with cystitis/lower UTI

Answer 28

dysuria with no systemic symptoms or signs can be treated with oral abx such as trimethoprim or nitrofurantoin for 3 days

Question 29

Medical measures for prevention of UTI

Answer 29

- 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.

Question 30

Diagnostic tests for VUR

Answer 30

MCUG - micturating cystourethrogram | DMSA scan?

Question 31

Follow up of children with recurrent UTIs, renal scarring or reflux

Answer 31

- 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)