Urinary Tract Infection (UTI)

UTI : Is growth of bacteria in the urinary tract.

Bacteriuria : Growth of 100.000 colony-forming unit (CFU)/ml in freshly voided urine Symptomatic UTI : Acute pyelonephritis is infection involving the renal parenchyma Acute cystitis is infection limited to the lower urinary tract. Asymptomatic(covert) bacteriuria (ABU) : Repeated bacteriuria in a child without any symptoms. Causes : E. Coli, Proteus species, Klebsiella, Enterococci Staph. Saprophyticus,, Pseudomonas, Staph. Aureus or epidermidis.

Bowel flora
Emergence of uropathogenic strains Perineal and anterior urethral colonization (Vaginal colonization in females) Normal Mucosal Defence Barriers BACTERIAL VIRULENCE HOST FACTORS 1. Enhanced uroepithelial Cystitis Adherence 2. VUR Acute 3. Intrarenal reflux pyelonephritis 4. Obstructed urinary tract 5. Foreign body (urinary catheter) Renal scarring Urosepsis

Pathogenesis of ascending UTI

PATHOGENESIS OF ACUTE PYELONEPHRITIS CHAIN OF EVENTS

Bacterial inoculation of renal parencyma Complement activation Immune respon Chemotaxis-Opsonization Phagocytosis Superoxide Release Tubular cell death Interstitial invasion RENAL SCAR Hypothesis for the renal pathogenetic chain of event in acute pyelonephritis

Bacterial killing

Intravascular granulocyte aggregation

Lysosyme release Focal Ischemia

Long-term Consequence
UTI causes = Significant morbidity & suffering for children = Inconvinience and anxiety for families = Considerable consumption of medical resources Most children with UTIs have an exelent prognosis The process of scarring after acute pyelonephritis is low Hypertension has been shown in 10% of children & young adult Women who had a tendency to recurrent UTIs as girl have an increased risk of new infections during pregnancy

Diagnosis
The diagnosis procedure is based on urinalysis, with culture as the most important investigation Methods of urine collection 1. Meadstream specimen 2. Bag urine sample 3. Suprapubic aspiration urine 4. Bladder catheterization

Culture of Urine
Urine should be refrigerated at 40 C Diagnosis of ABU : requires repeated samples

Urine interpretation in diagnosis of UTI

Method of collection Suprapubic aspiration Catheterization Quantitative culture :UTI present Growth of urinary pathogens in any number Febrile infants or children usually have > 50 x103 CFU/ml of a single urinary pathogen, but infection may be present with counts from 10 x 103 to 50 x 103 CFU/ml Symptomatic patient usually have > 105 CFU/ml of a single urinary tract pathogen

Midstream clean-void

Midstream clean-void

Asymptomatic patiens : at least two specimens on different days with > 105 CFU/ml of the same organism

Other urine findings

Pyuria : is the presence of > 10 WBCs per high power field by light microscopy in a centrifuged urinary sediment. Nitrite test : the ability of most uropathogens to reduce nitrate to nitrite (pink azo) Microscopic hematuria : is more than 5 red cells per mm3 in urine in a Fuchs-Rosenthal counting chamber. Macroscopic hematuria : is found in 2030% of acute cystitis

Site of infection
Localization of bacteria Measurement of host reactions to renal inflamation : Renal imaging

Antibiotic treatment Symtomatic UTIs should be given antibiotic without delay The drug is depend on the resistance pattern of urophatogens
Antibiotic prophylaxis Is indicated at high risk for developing renal scarring Monitoring Acute situation Previous UTIs, recent episodes of high fever, bladder and bowel emptying habits Essential full physical examination Urinalysis, urine culture, serum creatinine Follow up : Within 24 hours, after 4-5 days and 3-4 weeks, after 6 monts and 1 year

Antibacterial drug in chilhood UTI

Frequency of resistant in Children with primary UTI in Goteborg 1992-1995 (%) E.coli Non E.coli All Serious adverse rection
27 1 1 10 1 1 61 39 29 13 61 15 31 5 4 10 7 2 Bone marrow depresion, mucocuutaneus Syndromes Pulmonary Cartilage (before puberty) Ototoxicity, renal toxicity

Drug
Ampicillin derivates Pivmecillinam Cephalosporins Trimethoprim (with or Without sulfanamide) Nitrofurantoin Ciprofloxacine

Aminoglucosides

Asymptomatic Bacteriuria (ABU)

Symptoms in school girls with ABU

History of urgency, urge incontinence, difficult micturation Untreated symptomatiic UTI may deal spontaneously or the may turn into ABU ABU may develop into symptomatic UTI Screening for bacteriuria in healhty children should be discontinued Follow up includes bladder and bowel history, physical examination as in symptomatic UTI Avoid the of antibiotics in ABU

Relationship between symptomatic and asymptomatic bacteriuria

Treatmen of children with ABU