Urinary tract infection in a child Flashcards
What is a common presentation of UTI and indication for urine dip?
If there is an unexplained fever of 38’C or higher
NOT if there is an alternative site of infection
What are the signs and symptoms of UTI in an infant <3 months?
Most to least common:
- fever, vomiting, lethargy, irritability
- poor feeding, failure to thrive
- abdominal pain, jaundice, haematuria, offensive urine
What are the signs and symptoms of UTI in a preverbal child >3 months?
Most to least common:
- fever
- abdominal pain, loin tenderness, vomiting, poor feeding
- lethargy, irritability, haematuria, offensive urine, failure to thrive
What are the signs and symptoms of UTI in a verbal child?
Most to least common:
- frequency, dysuria
- dysfunctional voiding, changes to continence, abdominal pain, loin tenderness
- fever, malaise, vomiting, haematuria, offensive urine, cloudy urine
What alternative to MSU can be used in children?
- Urine collection pads
- If all other methods fail, catheter samples of suprapubic aspiration
Cotton wool balls, gauze and sanitary towels are n_ot suitable_
Should you start antibiotics in these clinical situations for a UTI?
- If both leukocyte esterase and nitrite are positive
- If leukocyte esterase is negative and nitrite is positive
- If leukocyte esterase is positive and nitrite is negative
- If both leukocyte esterase and nitrite are negative
- If both leukocyte esterase and nitrite are positive - start antibitics, send for MSC only if risk factors
- If leukocyte esterase is negative and nitrite is positive - start antibiotics only if the sample was fresh
- If leukocyte esterase is positive and nitrite is negative - send for MSC and only start antibiotics if there is good clinical evidence of UTI
- If both leukocyte esterase and nitrite are negative - do not start antibiotics and do not send urine for MSC
How do you differentiate between acute pyelonephritis/upper UTI and cystitis/lower UTI clinically?
Pyelonephritis = fever of 38’C+bacteruria OR loin pain+bacteruria
Cystitis = bacteruria but no systemic symptoms
Define pyuria.
white cells in the urine
What is an atypical UTI?
Atypical UTI includes:
- Seriously ill
- Poor urine flow
- Abdominal or bladder mass
- Rasied Cr
- Septicaemia
- Failure to respond to Abx within 48 hours with suitable treatment
- Non-E. coli organism
What defines a recurrent UTI?
- _>_2 episodes of UTI with acute pyelonephritis
OR
- 1 episode of UTI with acute pyelonephritis AND _>_1 episodes of UTI with cystitis
OR
- _>_3 episodes of UTI with cystitis
When is an ultrasound of the urinary tract recommended?
- atypical UTI
- infants <6 months (within 6 weeks)
What can US urinary tract be used to detect?
US shows:
- hydronephrosis,
- duplex renal system,
- ureterocele
- hydroureter,
- abscess,
- trabeculation or thickening of bladder wall
BUT has a low sensitivity for detecting vesicoureteral reflux or renal scarring.
What is the issue with using pyruia without bacteruria to diagnose UTI?
Other inflammatory conditions, or the presence of renal stones, may cause pyuria in the absence of UTI
What are the uses of DMSA scanning in UTI?
DMSA = dimercaptosuccinic acid
Done in recurrent/atypical UTIs in children 4–6 months after the acute infection should be used to detect:
- renal parenchymal defects,
- scarring,
- pyelonephritis
What are the uses of MCUG?
MCUG = micturating cystourethrogram
Uses:
- vesicoureteral reflux,
- posterior urethral valves in males,
- evaluation of bladder anatomy (to exclude ureterocele, polyps, and diverticulae),
- post-void residual volume
What are the most common causative organisms of UTI in children?
- E. coli (responsible for around 80% of cases)
- Proteus
- Pseudomonas
What are the predisposing factors for UTI?
Incomplete bladder emptying
- infrequent voiding
- hurried micturition
- obstruction by full rectum due to constipation
- neuropathic bladder
Vesicoureteric reflux - a developmental anomaly found in around 35% of children who present with a UTI
Poor hygiene e.g. not wiping from front to back in girls
Are UTIs more common in boys or girls? How common are UTI in childhood?
More common in boys until 3 months of age (due to more congenital abnormalities)
After this the incidence is substantially higher in girls.
At least 8% of girls and 2% of boys will have a UTI in childhood
What is the management of UTI in neonates and infants <6 weeks?
What is the management of UTI in >6 weeks to <2years?
When should you consider antibiotic prophylaxis for UTI?
antibiotic prophylaxis is not given after the first UTI but should be considered with recurrent UTIs
Urine culture is reported as positive for growth of proteus species >10⁵ cfu/mL sensitive to cephalexin, trimethoprim and nitrofurantoin. Is this result significant?
Yes, growth >10^5 is significant
Isolation of proteus from the urine often indicates underlying renal tract abnormalities and predisposes to renal calculi which can be radio-opaque.
What is shown by the labels on this US of the left kidney in a 5 month old?
- A – renal cortex
- B – renal sinus fat-bright
- C – dilated renal pelvis
- D – dilated upper ureter
- E – dilated calyces
Ultrasound shows dilatation of the left pelvicalyceal system and also the upper left ureter.
Is DMSA or MCUG better for detecting VU reflux?
MCUG = VU reflux
DMSA = scarring (3-4 months after acute episode)
Is surgical correction of VU reflux necessary?
VU Reflux often improves with time, and urgent surgical intervention is not indicated by NICE
What is the pathophysiology of VUR?
During micrturition the VU valves do not close so while urine is flowing into urethra, it is also going up the ureters towards the kidneys. MCUG needed for confirmation.
What is the consequence of scarring in the kidney seen on DMSA scan?
Hypertension in adulthood
