URINARY TRACT INFECTION IN CHILDREN

MIHAI CRAIU MD PhD IOMC ALFRED RUSESCU

URINARY TRACT INFECTION

A UTI is an infection in the urinary tract.

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Urinary tract infections affect about 3 percent of children in the United States every year. UTIs account for more than 1 million visits to pediatricians offices every year*.
*Freedman, AL. Urinary tract infections in children. In: Litwin MS, Saigal CS, eds. Urologic Diseases in America. U.S. Department of Health and Human Services, National Institute of Diabetes and Digestive and Kidney Diseases. Washington, D.C; 2007. NIH publication 075512:439458.

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UTI prevalence is 5% among children 2 to 24 months of age with a fever without obvious source*.

*Hoberman A et al Is urine culture necessary to rule out urinary tract infection in young febrile children? Pediatr Infect Dis J. 1996 Apr ;15(4):304-9.

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UTI can be divided in upper tract UTI and lower tract UTI

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Infections are caused by microorganisms including fungi, viruses and bacteria.
Bacteria are the most common cause of UTIs.

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The tests used to check for a UTI are urinalysis and urine culture.

A urinalysis is a preliminary test that indicates whether there is any likelihood of a UTI.
Sometimes gross-aspect of urine can suggest UTI [pyuria]

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It can be done in a laboratory or using a simple dipstick method in a doctors office. It takes only a few minutes and can suggest the presence of an infection. A piece of paper (or dipstick) is submersed into the urine and then removed.

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After two to three minutes, the paper changes color to signify what components have been found in the urine. A positive urinalysis, suggesting UTI, shows that there are leukocytes or nitrites.

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URINARY TRACT INFECTION

URINARY TRACT INFECTION

If the test is positive (or if it is negative but the childs symptoms really seem to indicate a UTI), a urine culture will be done.

Updated guidelines from the American Academy of Pediatrics (AAP) recommend urinalysis and culture when a urinary tract infection (UTI) is suspected or when antibiotic treatment will be started empirically in children 2-24 months.

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A small amount of urine is transferred onto a special plate and left in an incubator for 24 to 48 hours. If bacteria grow on the plate doctor will identify the bacteria and prescribe an antibiotic that is effective.

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A urinalysis and a urine culture can be collected at the same time, as long as a sterile cup is used during the collection. A non-sterile cup can contaminate the urine culture, leading to falsepositive results.

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SAMPLING

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Whenever possible, the urine specimen should be obtained by catheterization or suprapubic aspiration, as bagcollected specimens are unreliable. Preliminary diagnosis by bag-collected specimens should be confirmed by one of the other methods, members of an AAP committee on UTIs recommended

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With a prevalence of 5% and specificity of 70%, the positive predictive value of a positive culture result for urine obtained in a bag would be 15%. This means that, of all positive culture results for urine obtained in a bag, 85% would be false-positive results*.
* Perlhagen M et al Evaluating the specificity of a new type of urine collection bag for infants. J Pediatr Urol 2007;3(5):378-81

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Roberts KB, et al "Urinary tract infection: Clinical practice guideline for the diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months" Pediatrics 2011; 128: 595-610.

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Diagnosis now requires evidence of infection from both abnormal urinalysis results AND positive urine culture results. The criterion for a positive culture has been reduced from at least 100,000 colony-forming units per mL to at least 50,000 colony-forming units per mL.
* Roberts KB Revised AAP Guideline on UTI in Febrile Infants and Young Children. Am Fam Physician. 2012;86(10):940-6.

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Urine culture should show the presence of: at least 50,000 colony-forming units (CFUs) per mL of a single uropathogen to confirm clinical suspicion arising from
pyuria, positive nitrates, bacteriuria.

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Most UTIs are caused by bacteria that live in the bowel. The bacterium Escherichia coli (E. coli) causes the vast majority of UTIs.

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RISK FACTORS Male infants and children have < risk For uncircumcised boys, the risk of UTI never decreases below 2%. For circumcised boys, the probability exceeds 1% if there are 2 or more risk factors.

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RISK FACTORS
presence of another, clinically obvious source of infection*, particularly documented viral infections**, such as respiratory syncytial virus infections***, reduces the risk of UTI by onehalf.
*

Pantell RH et al Management and outcomes of care of fever in early infancy. JAMA 2004;291(10):1203-12. ** Byington CL et al Serious bacterial infections in febrile infants 1 to 90 days old with and without viral infections. Pediatrics 2004;113(6):1662-6 *** Levine DA et al - Risk of serious bacterial infections in young febrile infants with respiratory syncytial virus infections. Pediatrics 2004;113(6):1728-34.

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SIGNS AND SYMPTOMS Frequent and painful voiding of small amounts of cloudy urine Foul-smelling urine Fever and shivering Abdominal and lumbar pain Nausea and vomiting
Finnell SM et al Technical reportDiagnosis and management of an initial UTI in febrile infants and young children. Pediatrics. 2011 Sep;128(3):e749-70.

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PATHOGENETIC ASPECTS IN UTIs

AFTER DIAGNOSIN UTIs

In a child with documented UTI a renal ultrasound should be performed
Echo replaces iv pyelography for screening of renal abnormalities

RENAL ULTRASOUND

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Febrile UTIs in children less than 2 years of age are associated with bacterial sepsis in 10% of cases. Renal scarring is common among children who have febrile UTIs. The risk is higher among those with higher grades of VUR but occurs with all grades, even when there is no VUR.

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Increased risk of scarring is associated with delayed treatment * Children whose treatment is delayed more than 48 hours after onset of fever may have a more than 50% higher risk of acquiring a renal scar.
Fernandez-Mendez JM et al Risk factors in the development of early technetium-99m dimercaptosuccinic acid renal scintigraphy lesions during first urinary tract infection in children. Acta Paediatr. 2003 ;92(1):21-6.

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TDT (therapeutic delay time) > or = 48 h, bacteria other than E. coli, percentage of polymorphonuclear cells > or = 60% CRP > or = 30 mg l(-1)

influence the findings detected in the DMSA scintigraphy performed in the acute phase of a first episode of UTI

Fernandez-Mendez JM et al Risk factors in the development of early technetium-99m dimercaptosuccinic acid renal scintigraphy lesions during first urinary tract infection in children. Acta Paediatr. 2003 ;92(1):21-6.

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TREATMENT
Curativ Profilactic

Combined estimates of the effect of antimicrobial prophylaxis on prevention of pyelonephritis in children with VUR, from random-effects modeling.

Finnell S M E et al. Pediatrics 2011;128:e749-e770

2011 by American Academy of Pediatrics

Combined estimates of the effect of antimicrobial prophylaxis on prevention of pyelonephritis in children without VUR, from random-effects modeling.

Finnell S M E et al. Pediatrics 2011;128:e749-e770

2011 by American Academy of Pediatrics

Combined estimates of the effect of antimicrobial prophylaxis on prevention of pyelonephritis in children 2 to 24 months of age with any grade of VUR, from random-effects modeling.

Finnell S M E et al. Pediatrics 2011;128:e749-e770

2011 by American Academy of Pediatrics

Combined estimates of the effect of antimicrobial prophylaxis on prevention of pyelonephritis in children 2 to 24 months of age without VUR, from random-effects modeling.

Finnell S M E et al. Pediatrics 2011;128:e749-e770

2011 by American Academy of Pediatrics

Combined estimates of the effect of antimicrobial prophylaxis on prevention of any UTI in children with any grade of VUR, from random-effects modeling.

Finnell S M E et al. Pediatrics 2011;128:e749-e770

2011 by American Academy of Pediatrics

Combined estimates of the effect of antimicrobial prophylaxis on prevention of any UTI in children without VUR, from randomeffects modeling.

Finnell S M E et al. Pediatrics 2011;128:e749-e770

2011 by American Academy of Pediatrics

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vesicoureteral reflux by retrograde Voiding Cystourethrography

Grading of vesicoureteral reflux with the International Reflux System

Fernbach S K et al. Radiographics 2000;20:155-168

2000 by Radiological Society of North America

ANATOMIC ABNORMALITIES

ANATOMIC ABNORMALITIES

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American Academy of Pediatrics* committee also no longer recommends voiding cystourethrograms following a first UTI but rather reserves this test for children with an abnormal renal/bladder ultrasound or recurrent UTI
* Roberts KB Revised AAP Guideline on UTI in Febrile Infants and Young Children. Am Fam Physician. 2012;86(10):940-6.

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The choice of medication and length of treatment depend on the childs history and the type of bacteria causing the infection. In severe cases the antibiotic may need to be put directly into the bloodstream through a vein or be given as an IM injection. Otherwise, the medication may be given by mouth. The medication is given for at least 3 to 5 days and possibly for as long as several weeks. The daily treatment schedule recommended depends on the specific medication prescribed: the schedule may call for a single dose each day or up to four doses each day.

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Antibiotic treatment in UTI
To concentrate in urine Urine levels >> blood levels [PK] To excrete in urine as active form To act efficiently in an acidic pH

Points to Remember
Urinary tract infections (UTIs) usually occur when the body fails to remove bacteria rapidly from the urinary tract. UTIs affect about 3% of children in the United States every year. Most UTIs are not serious but chronic kidney infections can cause permanent damage [renal scars and renal failure].

Points to Remember
A UTI in a young child may be a sign of an abnormality in the urinary tract that could lead to repeated problems. Symptoms of a UTI range from slight burning with urination or unusualsmelling urine to severe pain and high fever. A child with a UTI may also have no symptoms, but fever.