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Paediatrics Y5 > Urinary tract infection in a child > Flashcards

Urinary tract infection in a child Flashcards

1
Q

Define symptomatic bacteriuria.

A

Presence of urine bacteria which is not contaminant of urethral flora with concomitant pyuria.

Broad clinical categories: Upper UTI (acute polynephritis) and lower UTI (cystitis, urethritis).

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2
Q

Define asymptomatic bacteriuria.

A

Detection of incidental bacteriuria is an asymptomatic child.

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3
Q

Explain the general aetiology of UTI in a child.

A

Proliferation of bacteria in the urinary tract, ascending infection secondary to bacteria in the periurethral flora and distal urethra.

F>M as short urethra and closer proximity of perianal colonic organisms.

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4
Q

Explain the aetiology of UTI in neonates.

A

70% ascending infection, 30% are of haematogenous origin.

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5
Q

Explain the aetiology of UTIs in infants, children and adolescents.

A

Majority are ascending infections.

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6
Q

What organisms cause UTIs?

A

Gram-negative bacteria: E.coli (90%), Streptococcus faecalis and Klebsiella

Proteus: Males; present under the prepuce

Staphylococcus saprophyticus: Common in adolescent girls.

Pseudomonas: Usually in children with congenital urinary tract anomalies or acquired renal problems, e.g. stones

Adenovirus 11 and 12 in haemorrhagic cystitis

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7
Q

What is an atypical UTI?

A
  • Seriously ill child
  • Poor urine flow
  • Abdominal/bladder mass
  • Increased creatinine
  • Septicaemia
  • Failure to respond to treatment <48 degrees
  • Non-E.coli infections
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8
Q

What is a recurrent UTI?

A
  • 2+ acute pyelonephritis/upper UTIs
  • 1 upper with 1+ lower UTI episode
  • 3+ lower UTI episodes
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9
Q

What are risk factors for UTIs?

A

Congenital GU malformations and urinary obstructions (posterior urethral valves, PUJ obstruction).

Vesicoureteric reflux

Chronic constipation

Voiding dysfunction

Neuropathic bladder

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10
Q

What is the pathophysiology of acute pyelonephritis?

A

Renal parenchymal infection with neutrophil infiltration secondary to ascending ureteric infection or haematogenous spread (bacteraemia)

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11
Q

What is the pathophysiology of chronic pyelonephritis?

A

Reflux nephropathy shows cortical scarring and clubbing of calyces

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12
Q

Summarise the epidemiology of UTIs.

A

General: F>M (F 3-8%, M 0.5-1%)

Specific: Increased upper UTIs < 1 year (M>F)< increased lower UTI > 2 years (F>M)

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13
Q

What are signs and symptoms of an upper UTI?

A

Bacteriuria and pyrexia >38C or loin pain with pyrexia <38C.

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14
Q

What are signs and symptoms of a lower UTI?

A

Bacteriuria with no systemic symptoms.

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15
Q

What are the signs and symptoms of a UTI in infants <3/12?

A

Common:

  • Pyrexia
  • Vomiting
  • Lethargy
  • Irritability
  • Poor feeding
  • Failure to thrive

Less common:

  • Abdominal pain
  • Jaundice
  • Haematuria
  • Offensive urine
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16
Q

What are the signs and symptoms of a UTI in a preverbal infant/child >3/12?

A

Common:

  • Pyrexia
  • Abdmonial pain
  • Loin tenderness
  • Vomiting
  • Poor feeding

Less common:

  • Lethargy
  • Irritability
  • Haematuria
  • Offensive urine
  • Failure to thrive
17
Q

What are the signs and symptoms of a UTI in a verbal infant/child >3/12?

A

Common:

  • Frequency
  • Dysuria
  • Dysfunctional voiding
  • Continence changes
  • Abdominal pain
  • Loin tenderness

Less common:

  • Malaise
  • Vomiting
  • Haematuria
  • Offensive urine
  • Cloudy urine
18
Q

What are appropriate bedside investigations for a UTI?

A

Urine collection: All infants and children presenting with an unexplained pyrexia > 38 degrees should have a urine sample tested < 24 hours. ‘Clean catch’ sample/urine collection pads/suprapubic aspiration/mid-stream urine sample (MSU) dependent on age. Adhesive plastic bags/cotton wool balls may be contaminated with faecal +/- genital flora and are therefore not used.

Urine dispstick: May be diagnostic leucocyte esterase +ve/nitrite +ve (UTI). Leucocyte esterase –ve/ nitrite +ve (suspected- treat as UTI). Lecuocyte esterase +ve/nitrite –ve (suspected- await MC&S unless clinically apparent). Leucocyte esterase –ve/nitrite –ve (no UTI).

Urine MC&S: Pyuria +ve/ bacteriuria +ve (UTI). Pyuria +ve/bateriuria –ve and pyuria –ve/bacteriuria +ve (suspected- treat as UTI). Pyuria –ve/bacteriuria –ve (no UTI). Bloods: Increased WCC, increased CRP, U&Es

19
Q

What are appropriate radiological investigations for a UTI?

A

USS: Quick, non-invasive and no radiation. Identifies structural anomalies, scars or hydronephrosis, low sensitivity for detecting VUR.

Radio-isotope scanning (DMSA): IV radio-labelled DMSA taken up and binds to the cortical tubular cells, allows visualisation of the renal parenchyma, independent of activity in the pelvicalyceal system. Distinguishes areas of acute inflammation from normal renal parenchyma and degree of renal involvement.

MCUG: Bladder filled with contrast via urethral catheter. Voiding XRs. Significant radiation but is very sensitive/specific for detecting VUR. Performed once the urine is sterile so as not to precipitate septicaemia. May be an unpleasant and traumatic investigation. 3/7 prophylactic antibiotics with procedure.

MAG 3 indirect cystogram: IV MAG3 which has renal excretion. Once all the tracer is visualised in the bladder on screening, the child voids detecting VUR.

20
Q

At what ages should radiological investigations be appropriate?

A

<6/12: Atypical/recurrent UTIs should have immediate USS and follow-up DMSA (4-6/12) and MCUG. Followup USS only, withing 6/52, if response to therapy is < 48 degrees

6/12–3 years: Atypical UTIs should have immediate USS and follow-up DMSA. Recurrent UTIs have USS within 6/52 and DMSA at 4–6/12

>3 years: Atypical UTIs should have immediate USS. Recurrent UTIs have USS within 6/52 and DMSA at 4– 6/12. MCUG not indicated and no investigations if responds <48degrees.

21
Q

What is the management for a UTI?

A

Prompt treatment is important as risk of irreversible renal damage is high, especially in infants.

Treatment: PO cephalosporin or co-amoxiclav. In infants and severely ill children IV cefotaxime or gentamicin may be required. Ensure good oral intake.

Prevention: Regular and complete voiding, good hygiene, avoidance of constipation and long-term-low-dose antibiotic prophylaxis (trimethoprim) for children with recurrent UTIs, reflux, scarring, and whilst awaiting investigations.

22
Q

What are complications associated with UTIs?

A

Chronic pyelonephritis

Chronic renal failure (CRF)

Hypertension (3%).

VUR accounts for CRF in 20% of children and 5–10% in adults.

23
Q

What is the prognosis of UTIs?

A

Infants who present with first symptomatic UTI aged <1 year are significantly more at risk of having recurrence (30% risk).

Preschool presentation of a UTI has a recurrence of 12%.

Paediatrics Y5 (112 decks)

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