UTI

Question 1

Acute cystitis

Answer 1

Inflammation of bladder mucosa ass.
with clinical sympt. of lower UTI
(Urgency, dysuria, frequency) – No fever

Question 2

Acute pyelonephritis

Answer 2

Bact. Infection of renal parenchyma
with fever, flank pain,
vomiting + CF of lower UTI

Question 3

Asymptomatic bacteriuria (ABU):
Recurrent UTI
Relapse of UTI

Answer 3

Asymptomatic bacteriuria (ABU):
Significant bacteria in healthy child without any
sympt. Of UT (common in school age girls)

Recurrent UTI
Repeated symptomatic episodes of UTI in sympt. In
free intervals

v Persistence of the same bact. Species and strain
within the urinary tract despite appropriate antibiotics therapy .
vUsually associated with underlying structural abn.
Of UT and with renal calculi.

Question 4

Epi

Answer 4

¥ The commonest age for 1st symptomatic
UTI is the 1st yr. of life in both sexes.
¥In neonatal period & early infancy (1st 3
mo. of life): Males > females.
¥Peak incidence of first episode of acute
pyelonephritis : 1st 2 years of life.

In boys most UTI ’s occur during the first year of life
More common in uncircumcised boys

Question 5

Organisms

Answer 5

E. coli : 80 -90% of first UTI in
children
- Klebsiella, proteus, pseudomonas - Staph. Saprophyticus - Staphylococci, streptococcus
¥ Proteus : Boys with obstructive uropathy
¥ S. saprophyticus
30% sexually active adolescents
¥ Candida : Preterm
¥ Viral

—-Route of infection
- Hematogenous – Uncommon (Neonates)
- Ascending – almost all J 
Urosepsis : bactremia developing from
a primary focus of infection within the urinary tract.

Question 6

Risk factors for UTI

Answer 6

Female, uncircumcised male, VUR
Toilet training, voiding dysfunction
Obstructive uropathy, urethral instrument
Wiping from back to front in females
Tight clothing, constipation, pregnancy,
Pinworm,
anatomic abn. (Labial adhesion),
Neuropathic bladder, sexual activity

Question 7

Clinical presentation

Answer 7

Neonatal period
¯ Non-specific
¯ Sepsis is common
¯ +ve Blood culture in 30% of cases
infancy
Non-specific
Pre-school & school-ages children :
Dysuria, urgency, ↑ frequency
Urinary incontinence
Fever, flank pain, chills
Costovertebral tenderness
Hematuria : Hypertension : uncommon Acute renal failure : rare Urinary stones : proteus

Question 8

∆∆ / Dysuria

Answer 8

' UTI
' Vaginitis
' Urethritis
' Pinworm infection
' Hypercalciuria

Question 9

Investigators

Answer 9

Urine analysis
Pyuria : > 10 WBC/high
power field
Pyuria is presnt in 80-90%
of episodes of symptomatic UTI
-ve test doesn’t exclude UTI

Urine collection: Bag specimens should be avoided Older children: mid-stream urine Infants : clean-catch urine
catheter sample SPA

The urine specimen should be fresh (within one hour)
If not possible, then keep in the refrigerator @ 4c temp.

Leukocyte esterase dipstick test Nitrite test:
need 4 hrs
Clin Microbiol Rev 1,1988
Low urine SG in first morning sample is presumptive of acute PN.
early morning sample false –ve with : frequent voiding streptococcal species
Combining both tests icreased sensitivity & specifity

Question 10

Labs in PN

Answer 10

{ ↑ ESR { ↑ CRP { ↓Urinary concentrating ability { Pyuria with WBC casts { DMSA scan

Question 11

Diagnosis of UTI

Answer 11

Toilet-trained children : midstream urine >100,000 colonies, single pathogen
Or ≥ 10,000 colonies in symptomatic

Question 12

Radiology

Answer 12

Who needs it ?
{ All neonates with first UTI
{ All males with first UTI at any age
{ All patients with recurrent UTI
{ All patients with pyelonephritis

Question 13

Who need admission .

?

Answer 13

{ Children of any age who are

suspected to have PN { Complicated UTI with UTO { Severe cystitis with vomiting { Neonates, infants

Question 14

Tt

Answer 14

c cases antibiotics are promptly started without Waiting for the result of urine culture.
Asses degree of toxicity, dehydration, ability to take oral intake.
Amoxil, Cefaclor, Bactrim
Avoid nalidoxic acid & Nitrofurantoin in pt with PN
Parenteral therapy:
Ampicillin + Gent. or 3rd Gen. cephalosporines Oral therapy:

Duration of treatmen :
Infants & complicated UTI:10-14 days
uncomplicated UTI: 7-10 days short course : 1-3 days
Failure to respond to Rx (2 days):
drug resist. complicated UTI noncompliance
repeat urine culture & U/S

Question 15

Fungal UTI

Answer 15

Treatment ü remove bladder catheter/stents ü If no systemic mainfestation and fungal culture
from other body fluid &tissues is –ve:
bladder irrigation w ampho B
Candida cystitis:
fluconazole oral
Systemic mainfestation :
Ampho. B or fluconazole iv for 3-4 wks

Question 16

Risk factors for development of renal damage

Answer 16

• Obstruction
• Degree of reflux
• Young age
• Delay of treatment
• Number of PN attacks
• Unusual bacteria

Question 17

Asymptomatic bacteruria

Answer 17

{ More common in school-aged girls
{ E. coli most prevalent org. but less virulent
{ ABU should not be treated with antibiotics
{ Long-term follow-up of children in ABU shows 40-
50% become culture –ve over 2-5 years without
Rx.
{ ABU in infants <1 yr. of age follow the same
course

Question 18

VUR

Answer 18

VUR
Retrograde flow of urine from the bladder to the ureter and renal pelvis
1% of children
Reflux nephropathy
15-20% of ESRD in children, young adults
One of the most common cause of HTN in
children Reflux in the absence of infection or elevated bladder pressure does not cause renal injury

Goal:
ü Protect the kidney from scarring
ü Allow max. renal parenchymal growth
ü Preserve renal function
ü Major problem is noncompliance
Smyth A. et al
Arch. Dis Child 1993,68
Endoscopic subureteric injecion
success rate= 70-90% recurrence rate= 5-10%
Reimplantation
success rate=>95% over all