Urinary tract infections and renal disease in children

Question 1

What is the most common presentation for UTI is infants?

Answer 1

Undiagnosed fever. Lethargy, irritability and vomiting may also occur in children younger than 3 months.

Question 2

What are the most common symptoms of UTI in children older than 2 years?

Answer 2

Dysuria.

Frequency.

Question 3

What does the diagnosis of UTI require?

Answer 3

Symptoms.
Pyuria (leukocutes in the urine).
Significant bacteriuria.

Question 4

How is recurrent UTI defined?

Answer 4

Two or more episodes with pyelonephritis.
One episode of pyelonephritis and one or more episodes of cystitis.
Three or more episodes of cystitis.

Question 5

How is atypical UTI defined?

Answer 5

Severe illness.
Septicemia.
Raised creatinine. 
Abdominal or bladder masses.
Poor urine flow.
Pathogen other than E. coli. 
No effect of suitable  antibiotic treatment after 48 hours.

Question 6

True or false: A urine bag sample is reliable if positive.

Answer 6

False. A urine bag sample is reliable if negative. (Two samples should be taken before starting treatment with antibiotics.)

Question 7

What are optional methods of collecting urine samples in children?

Answer 7

Clean catch.
Urine bag sample.
Urine catheter sample.
Supra-pubic aspiration (ultrasound guided).

Question 8

What is defined as low-grade pyuria in dipstick tests? What does low-grade pyuria indicate?

Answer 8

1-2+.

Low-grade pyuria is unspecific.

Question 9

What kind of bacteria produce nitrite?

Answer 9

Gram negative bacteria.

Question 10

True or false: Even if the nitrite-test is negative the possibility of an UTI cannot be excluded in small children.

Answer 10

True. Nitrite-test has a 40-50 % sensitivity for UTI in children under the age of 2 years. In other words, only up to 50 % of children with a UTI will have a positive test.

Question 11

True or false: Isolated hematuria and/or proteinuria

are not signs of UTI.

Answer 11

True.

Question 12

What are advantages of urine microscopy compared to urine dipstick test?

Answer 12

In urine microscopy casts (sign of upper UTI), bacteria and leukocytes (and morphology) can be seen. (Has a higher sensitivity as well.)

Question 13

What are disadvantages of urine microscopy compared to urine dipstick test?

Answer 13

Urine microscopy requires experience and is time consuming. (Has a lower specificity as well.)

Question 14

What should you ideally do if a dipstick test gives unclear findings?

Answer 14

A urine microscopy to confirm/disprove the diagnosis.

Question 15

What is likely if there is growth of more than one bacterial species in a urine sample?

Answer 15

Contamination of the sample.

Question 16

What are some main differences between upper and lower UTIs?

Answer 16

Lower UTI are also known as cystitis, and can be referred to as non-febrile UTI. It gives no renal scarring or effects in renal function as opposed to upper UIT.

Upper UTI are also known as pyelonephritis, and can be referred to as febrile UTI. It causes renal scarring, especially in young children

Question 17

What findings/factors increase the chance of an upper UTI?

Answer 17

Age < 1 year.
CRP > 50 (high).
Temp. > 38 (fever).

Question 18

What is it important to remember about children with malformations in the urinary tract or vesicoureteral reflux?

Answer 18

These children are at high of UTIs. Their parents should be informed of this, of symptoms and when to seek medical help.

Question 19

What can be long term complications of recurrent UTIs?

Answer 19

Decreased renal function, hypertension and complications in pregnancy.

Question 20

Which children with UTIs should be followed up with further testing and how?

Answer 20

All children < 3 years should be followed up with an ultrasound scan.
Children > 3 years with recurrent UTIs should be followed up with bladder scan or flowmetry, especially if patient history is suggestive of voiding.

Question 21

What are indications for antibiotic prophylaxis in children with UITs? What antibiotics should be used?

Answer 21

Recurrent infection only. Use either nitrofurantoin or trimethoprim.

Question 22

Besides antibiotic prophylaxis, what are other preventative measures against UTIs in children?

Answer 22

Urotherapy, e.g. completely emptying the bladder, fluid intake, voiding frequency.
Anti-reflux surgery.

Question 23

What is characteristic of nephritic syndrome?

Answer 23

Hematuria and proteinuria.
Hypertension.
Reduced GFR / Increased creatinine.

Question 24

What is characteristic of nephrotic syndrome?

Answer 24

Proteinuria.
Edema (often periorbital).
Decreased albumin.

Question 25

What are examples of “good” forms of nephritis syndrome?

Answer 25

Post-streptococcal glomerulonephritis.

Henoch-Schoenlein glomerulonephritis.

Question 26

What is the most common cause of nephrotic syndrome in children? What are the characteristics of this disease?

Answer 26

Minimal change glomerulonephrtitis / Minimal change disease.
More common in boys < 10 years. Responds to steroid. Often a “pure” nephrotic syndrome - hematuria or decreased GFR. Often relapses, but “everyone” eventually becomes healthy.

Question 27

What is the characteristics of minimal change disease under the light microscope and electron microscope?

Answer 27

Light microscope: No obvious pathological changes.

Electron microscope: Fusion of foot processes.

Question 28

True or false: Hematuria in children is very uncommon. A positive urine dipstick test for blood usually indicates significant renal disease.

Answer 28

False. Hematuria (microscopic) is common in children. Urin dipstick is very sensitive for blood and ”traces of blood” or ”1+” is often not significant.

Question 29

How should an accidental finding in asymptomatic child with no fever or signs of UTI be followed up?

Answer 29

Repeat controls twice with 3-4 weeks interval.