UTI Flashcards
Epidemiology of UTIs?
- Occurs in 5% of infants and young children with fever and no apparent source
- Highest risk in uncircumcised boys < 3 mo and girls <12 mo
Note: Most common bacterial infection in children < 2 years old
Untreated UTIs can lead to?
renal scarring
Overdiagnosis of UTIs can lead to?
- misuse of antibiotics
- unnecessary imaging
Signs and symptoms of UTIs?
- fever
- abdominal pain
- vomiting
- diarrhea
- new onset of urinary incontinence
- strong-smelling urine
Contributing factors in incomplete bladder emptying?
1, infrequent voiding - bladder enlargement
2. vulvitis
3. incomplete micturition with residual postmicturition bladder volumes
4. obstruction by a loaded rectum in constipation
5. neuropathic bladder
6. vesicoureteric reflux
Important question to ask in family history?
Ask about history of vesicoureteral reflux in parents and siblings
Clinical features in infants?
- fever
- vomiting
- lethargy/irritability
- poor feeding/faltering growth
- jaundice
- septicemia
- offensive urine
- febrile seizures (>6 months)
Clinical features of UTI in children?
- dysuria, frequency, urgency
- abdominal pain/loin tenderness
- fever
- lethargy and anorexia
- vomiting, diarrhea
- haematuria
- offensive/cloudy urine
- febrile seizure
- recurrence of enuresis
Methods of dipstick testing?
- nitrite stick testing
- leukocyte esterase stick testing (WBC)
Interpretation of nitrite stick testing?
+ result is likely indicative of a true UTI
- but some children with UTI may be nitrite -
Interpretation of leucocyte esterase stick testing?
- may be present in child with UTI
- may also not be present - present in febrile illness without UTI
- in balanitis and vulvovaginitis
Diagnostic criteria of UTIs?
- urinalyis shows pyuria and/or bacteriuria
- urine culture grows >50,000 CFU/ml of bacteria
Note: obtain urine specimen before giving antibiotics
3 ways to obtain urine culture?
- Suprapubic aspiration
- Invasive, requires expertise, painful
- May be necessary in boys with phimosis and girls with labial adhesions - Catheterization
- Invasive
- High sensitivity (95%), specificity (99%) - Bag applied to perineum
- False positive result 88-99% of the time!
Risk factors for UTIs in girls?
- white race
- temp. >39 degrees
- fever lasting >2days
- no other source of infection
- age<12 months
Risk factors for UTI in boys?
- non black race
- temp. >39 degrees
- fever lasting >24 hours
- no other source of infection
In the lower likelihood of UTI what do you do?
clinically follow without testing
In the event of higher likelihood of UTI what do you do?
- Obtain urinalysis and culture by catheterization OR
- Obtain urinalysis by bag or catheterization
1. If urinalysis tests + for nitrites or leukocyte esterase, then obtain culture via catheterization
2. If urinalysis tests negative, then follow clinically without antibiotic
Treatment of UTIs?
- Use oral or parenteral antibiotic
- Adjust the antibiotic based on sensitivities from urine culture
- Treat for 7-14 days for febrile UTI, 3-7 days for afebrile UTI
Pathophysiology of UTI?
ascending infection
normal anatomy
1. E.coli
abnormal anatomy
1. vesicoureteral obstruction
2. uretropelvic junction obstruction
- citrobacter and enterococcus
Note: pyelonephritis - if infection gets to the kidney
Examples of treatment regimens?
- Amoxicillin/clavulanate (Augmentin)
- 20-40 mg/kg/day, divided q 8 hrs - Ceftriaxone
- 50-100/kg/day. Once a day
Grading of vesicoureteral reflux?
Grade 1: reflux into the non-dilated ureter
Grade 2: reflux into the ureter and renal pelvis
Grade 3: reflux with mildly dilated ureter and pyelocalyceal system
Grade 4: reflux with the tortuous and moderately dilated ureter with with blunting renal fornices
Common organisms that affect newborns (<30 days) and their treatment?
Organisms: GBS,Listeria Monocytogens Ecoli, Kelbsiella, Entrobactor, Coag Neg Staph, Enterococcus
Treatment: Amp (Xpen) and Gent
Common organisms that affect young infants (30 to 60 days)?
Organisms: E.coli, Enterococcus Klebsiella
Treatment: Augumentin , Ceftriaxone
Organisms that affect children over (60 days) and their treatment?
Organisms: E.coli, Kelbsiella, Proteus,Enterobactor, Pseudomonus Candida
Treatment: Cephalexin, Bactrim, Ceftriaxone, Nystatin
Imaging modalities to confirm for UTI?
- renal and bladder ultrasound
- VCUG (voiding cystourethrogram)
Pros and cons of renal and bladder ultrasound?
Pros: noninvasive, no radiation, can identify congenital anomalies of kidney, ureter and bladder; renal calculi, and hydronephrosis
Cons: cannot reliably demonstrate inflammation, renal scarring; no info on renal function
Pros and cons of VCUG?
Pros: affects treatment decisions that theoretically reduce risk of renal scarring, is used primarily to diagnose and grade vesicoureteral reflux
Cons: radiation, expense, discomfort
Imaging recommendations?
- Order renal and bladder U/S in febrile infants with confirmed UTI
- Order a VCUG if the U/S shows:
- Hydronephrosis
- Scarring
- Other findings to suggest high-grade VUR or obstruction - Perform a VCUG if a child develops a 2nd UTI
Prevention of recurrent UTIs?
- Breastfeed
- Treat constipation
- Routine circumcision not recommended
- Use of daily prophylactic antibiotic is controversial
- high fluid intake to produce a high urine output
- regular voiding
- good perineal hygiene
- ensure complete bladder emptying - double voiding
