URINARY TRACT INFECTION

MENTOR
DR.SARALA
CASE SCENARIO
5 years old/ Malay/ Boy
Was brought to casualty due to fever for 1 day

WHAT FURTHER HISTORY YOU

WOULD WANT TO ASK?
FURTHER HISTORY
Fever
any documented temperature?
Warm to touch ?
rash?
bleeding tendency?
from dengue area?
contact with ill person?
child taken care by whom?
hx of recent travelling?
URTI sx?
UTI sx?
Diarrhea / Vomitting?
Irritability?
Feeding history/Urine output?
 5 years old malay boy
fever for 1 day
documented Temperature at home 39.5, repeated at A&E 39.9
no rash
no bleeding tendency
not from dengue area
no contact with ill person
child taken care by mother at home( mother is a housewife)
no hx of recent travelling recent water based activity
no URTI sx
UTI sx, foul smelling urine, dysuria, increase in frequency
Associated with pain at suprapubic region (unable to rate)
Claims have to strain during PU, poor stream, dribbling
Denied passing any sandy urine
Denied any hematuria
no diarrhea / no vomitting
ANY FURTHER HISTORY
YOU WOULD WANT TO
ASK?
FURTHER HISTORY
No past medical history
No medication given before
Birth history:
born SVD/ Term/ BW 3.0kg, CW:6.0kg,
ANC : uneventful,
immunisation : up to age.
Family History :
first child in the family.
Social history :
taken care by mother
Dietary history :
usually eats vegetables
eats 3 times a day with snack at 9am and 3pm , tolerates
well , no known of food allergies
Developmental history :
according to age of patient
WHAT ASSESSMENT
YOU WOULD LIKE TO
DO?
 Primary assessment
ABCDE

Secondary assessment

Head to Toe

General Condition
PRIMARY ASSESSMENT
Airway
Patent, No secretion / No foreign body
Breathing
Effort: RR 28, no SCR, ICR, no nasal flaring,
Efficacy: Not tachypneic, SpO2 98% under room air, on
auscultation: lungs clear with good air entry bilaterally
Effect: HR 100 bpm, good pulse volume, CRT < 2 sec, warm
peripheries
Circulation
Well perfused, Heart rate 100 bpm, CRT < 2 sec, good pulse
volume, BP 90/50
Disability
No abnormal posture, pupils bilateral equal and reactive,
DXT 4.8
Exposure
No skin rashes, temperature 39.9 degree celcius
SECONDARY ASSESSMENT
Alert, pink, no recession, CRT<2sec, good pulse volume, no
jaundice.
Eyes : No conjunctivitis
Ears: No ears discharge
Throat: Normal
Lungs : Good air entry, Clear
CVS: DRNM
P/A : Soft, palpable bladder, no hepatosplenomegaly,
Bowel sound present.
costovertebral angle tenderness
Genetalia: Normal male genetalia, no phimosis, no
irritation, uncircumcised
Sacral area : no dimples, no pits sacral pad
DIFFERENTIAL DIAGNOSIS
Urinary obstruction
Nephrolithiasis

Viral fever, dengue fever

WHAT
INVESTIGATION
WOULD YOU LIKE TO
DO?
 FBC
UFEME

URINE Culture and Sensitivity

BLOOD Culture and Sensitivity

 INVESTIGATION RESULT
FBC UFEME

WBC : 17.5
Hb : 11
HCT : 33.1
pH :5
Leu :500/ul
MCV : 61
Nitrate :negative
MCH : 18
Pus cell :15-20
Platelet : 433
RBC :3-4
PROVISIONAL
DIAGNOSIS?
DS: Urinary tract infection
HOW WOULD YOU TREAT
THIS PATIENT?
 IV Antibiotics
IV Cefuroxime(100mg/kg/day) TDS or
IV Cefotaxime(100mg/kg/day) TDS or
IV Gentamicin 5-7mg/kg/day) OD
Continue intravenous antibiotic until child is
afebrile for 2-3 days and then switch to
appropriate oral therapy after culture results
e.g. Cefuroxime, for total of 10-14 days.
PROGRESS OF PATIENT
IV Cefuroxime was started at Day 1 of admission
after r/v UFEME
Temperature settled after 36 hours of antibiotics
started
Urine C&S available at day 3 of admission
 URINE C&S: E Coli
Sensitive to:
Cefuroxime

Cefotaxime

Cephalexin

Bactrim

Resistant to:
Gentamicin
WHAT IS THE PLAN NOW?

IV CEFUROXIME continue for total 5 days, then

change to oral Cefuroxime 15mg/kg/dose BD for
another 5 days.
PATIENTS PROGRESS

Patient was discharged at Day 5 after complete IV

Cefuroxime.
WHAT FURTHER PLANS CAN
BE DONE UPON
DISCHARGE?
 Continue Oral CEFUROXIME for 5-9 days
TCA Pakar 3 3-4 weeks with repeat UFEME and
Urine C&S
Dont need for prophylaxis antibiotics

Ultrasound KUB as outpatient within 2 weeks.

WHAT IS A URINARY TRACT
INFECTION?
INTRODUCTION

The urinary tract is a common site of infection in the

pediatric population

UTI comprises 5% of febrile illnesses in early childhood

Unlike the generally benign course of UTI in the adult

population, in the pediatric population is well recognized as
a cause of acute morbidity and chronic medical conditions
 Urinary tract infection is growth of bacteria in the urinary
tract or combination of clinical features and presence of
bacteria in the urine
Significant bacteriuria is defined as the presence of > 105
colony forming units (cfu) of a single organism per ml of
freshly voided urine

The urinary tract:

kidney
ureter
bladder
urethra.

A complicated UTI describes infections in urinary tracts

with structural or functional abnormalities or the presence
of foreign objects, such as an indwelling urethral catheter.
UROPATOGENS
PATOGENESIS
ASCENDING ROUTE OF UTI
 Risk factors
Although all individuals are susceptible to UTI,
most remain infection free during childhood
because of the innate ability to resist uropathogen
attachment.
 Neonates and infant
higher risk for UTI; incompletely developed immune
system

Uncircumcised infant boys

foreskin have been demonstrated to harbor significantly
higher concentrations of uropathogenic microbes

Fecal and perineal colonization

The flora of the colon and urogenital region is a result
of native host immunity, existing microbial ecology
 Anatomic abnormalities
_ predispose children to UTI because of inadequate clearance
of uropathogens.
younger than 5 years of age.
It is essential to identify these abnormalities early
because if uncorrected, they may serve as a reservoir
for bacterial persistence and result in recurrent UTI.
Surgical intervention may be required to correct the
anatomic abnormality
 Congenital anatomic anomalies, such as PUV
and VUR, do not predispose children to
colonization but increase the likelihood of
inadequate washout in the routine ways.

These urinary tract malformations increase the

likelihood of infections of the lower urinary tract
(ie, bladder and urethra) will ascend to the upper
tracts with possible pyelonephritis and potential
renal deterioration.
POSTERIOR URETHRAL VALVE
 Vesicoureteric reflux (VUR)
defined as the retrograde flow of urine from the bladder into
the ureter and collecting system.
divided
primary VUR
secondary VUR ( it results from high pressure
voiding secondary to posterior urethral valve,
neuropathic bladder or voiding dysfunction)

at risk for further episodes of pyelonephritis with

potential for increasing renal scarring and renal
impairment (reflux nephropathy).
 Functional abnormalities
eg;neurogenic bladder
Inability to empty the bladder, frequently
results in urinary retention, urinary stasis,
and suboptimal clearance of bacteria from the
urinary tract.
Clean intermittent catheterization (CIC) is
helpful for emptying the neurogenic bladder,
but catheterization itself may introduce
bacteria to this normally sterile space.
 Infants younger than 60 to In older children younger
THERE
90 daysARE
mayTHREE BASIC FORMS
have vague thanOF UTI: the most
2 years,
PYELONEPHRITIS, CYSTITIS, AND
and nonspecific symptoms ASYMPTOMATIC
common symptoms
of illness that are difficult
BACTERIURIA. fever
to interprete
THERE ARE VARIOUS CLINICAL PRESENTATIONS FOR
vomiting
diarrhea
CHILDREN WITH UTI BASED ON AGE.
anorexia
irritability
strong-smelling urine
lethargy
malodorous urine
fever
asymptomatic jaundice
oliguria or polyuria
poor feeding
vomitting
 In children between 2 After 5 years, the
and 5 years of age,the classic lower urinary
most common tract symptoms
presenting symptoms dysuria
abdominal pain urgency
fever urinary frequency
vomitting costovertebral
strong-smelling angle tenderness
urine strong-smelling
urine
 Asymptomatic bacteriuria
Positive urine culture without any manifestations of
infection
Occurs almost exclusively in girls
Benign and does not cause renal injury, except in pregnant
women, in whom asymptomatic bacteriuria, if left
untreated, can result in a symptomatic UTI
PHYSICAL EXAMINATION
All children should have their sacral region examined for :
dimples
pits or a sacral fat pad
The presence of these signs is associated with neurogenic
bladder.
Hypertension should raise suspicion of hydronephrosis or
renal parenchyma disease.
Costovertebral angle (CVA) tenderness
Abdominal tenderness or mass
Palpable bladder
Dribbling, poor stream, or straining to void
Examine external genitalia for signs of irritation,
pinworms, vaginitis, trauma, sexual abuse, phimosis or
meatal stenosis
MANAGEMENT

All infants with febrile UTI should be admitted and

intravenous antibiotics started as for acute pyelonephritis.

Patients with high risk of serious illness, it is preferable that

urine sample should be obtained first; however treatment
should be started if urine sample is unobtainable.

Antibiotic prophylaxis should not be routinely recommended in

infants and children following first time UTI as antimicrobial
prophylaxis does not seem to reduce significantly the rates of
recurrence of pyelonephritis, regardless of age or degree of
reflux.

Antibiotic prophylaxis may be considered in the following:

Infants and children with recurrent symptomatic UTI.
Infants and children with vesico-ureteric reflux grades of at
least grade III.
NICE GUIDELINE:
Dehydration
-most common complication of UTI in the
pediatric population.
-IV fluid replacement is necessary in more severe
cases.

Untreated UTI may progress to renal involvement

with systemic infection (e.g., urosepsis).

Long-term complications include renal

parenchyma scarring, hypertension, decreased
renal function, and, in severe cases, renal failure.
MESSAGE:
Most cases of UTI are simple, uncomplicated, and
respond readily to outpatient antibiotic
treatments without further sequelae.
Appropriate treatment, imaging, and follow-up
prevent long-term sequelae in patients with more
severe infections or chronic infections.
Mild VUR usually resolves without permanent
damage.
All children less than 2 years of age with
unexplained fever should have urine tested for
UTI.
Greater emphasis on earlier diagnosis & prompt
treatment of UTI
Diagnosis of UTI should be unequivocally
established before a child is subjected to invasive
and expensive radiological studies
Antibiotic prophylaxis should not be routinely
recommended following first-time UTI
REFERENCE:
Paediatric protocol
Medscape

Nice guideline
THANK YOU