URINARY TRACT INFECTION AMANINA ZAHRAA ZAINOL

M121125934
 DEFINITION
Urinary tract infection is growth of bacteria in the urinary tract or combination of clinical
features and presence of bacteria in the urine
 PREVALENCE
Urinary tract infection (UTI) comprises 5% of febrile illnesses in early childhood.
occur in 1% of boys and 1-3% of girls.
The prevalence of UTIs varies with age.
1st yr of life, the male : female ratio is 2.8-5.4 : 1 (boy> girl)
Beyond 1-2 yr, male : female ratio of 1 : 10. (girl>boy)
In boys, most UTIs occur during the 1st yr of life.
common in uncircumcised boys, especially in the 1st yr of life.
In girls, the first UTI usually - age of 5 yr, with peaks during infancy and toilet training.
UTI is an important risk factor for the development of hypertension, renal failure and end
stage renal disease.
 ETIOLOGY
90% of first symptomatic UTI and 70% of recurrent UTI are due to E.coli

GIRLS BOTH
BOYS
E.coli- 75-90% Staphylococcus
E.coli, Proteus
Klebsiella saprophyticus and
proteus enterococcus
Recurrent UTI- proteus and pseudomonas ( also in instrumentation and nosocomial infections)
Fungi in immunocompromised
Candida albicans- in preterms
AN OUTLINE OF PATHOGENESIS FOR UTI
Ascending infections Hematogenous Local spread of infection

FACTORS
BACTERIAL
Bacterial virulence COLONIZATION
Female factors
Male factors
Medical devices
Infection and inflammation

UTI
Infect Dis Clin North Am.1987 Dec;1(4):751-72
N Engl J Med. 2012 Mar 15;366(11):1028-37.Lancet Infect Dis. 2004 Oct;4(10):631-5.
PATHOGENESIS
Neonatal period- hematogenous spread
Other ages- through ascending route and ureters and kidney through VUR
Predisposing factors
 CLASSIFICATION
The 3 basic forms of UTI
1. Acute Pyelonephritis
bacteriuria presenting clinically with fever > 38C and/or loin pain and tenderness. It
carries a higher risk of renal scarring
2. Acute Cystitis
infection limited to the lower urinary tract presenting clinically with acute voiding
symptoms: dysuria, urgency, frequency, suprapubic pain or incontinence.
3. Asymptomatic bacteriuria
presence of bacteriuria in the urine in an otherwise asymptomatic child.

Significant bacteriuria is defined as the presence of > 105 colony forming units (cfu) of a
single organism per ml of freshly voided urine.
 ACUTE PYELONEPHRITIS (UPPER UTI)
Involvement of the renal parenchyma is termed acute pyelonephritis
Clinical features:
Abdominal back or flank pain, fever (> 38C), malaise , nausea, vomiting
Newborns: poor feeding, irritability, jaundice weight loss
Most common in <24 months
can lead to renal injury: pyelonephritic scarring
Acute lobar nephronia (acute lobar nephritis) -renal mass caused by acute focal infection
Early development of a renal abscess. Manifestations are identical to pyelonephritis

Renal abscess - after pyelonephritic infection caused by the usual uropathogens or may be
secondary to hematogenous infection (Staphylococcus aureus).
Perinephric abscess - occur secondary to contiguous infection in the perirenal
area (e.g., vertebral osteomyelitis, psoas abscess)
Xanthogranulomatous pyelonephritis (rare)- granulomatous inflammation with giant
cells and foamy histiocytes.
caused by renal calculi, obstruction and proteus / E. coli infection
Tx: total and partial nephrectomy
 ACUTE CYSTITIS
Cystitis indicates that there is bladder involvement
Clinical Features:
Dysuria, urgency, frequency, suprapubic pain, incontinence and malodorous urine
No fever and does not result in renal injury.
Acute hemorrhagic cystitis- by E.coli
Also assoc. with adenovirus 11 and 21
Adenovirus cystitis is more common in boys, self-limiting with hematuria lasting ~4 days.
Eosinophilic cystitis (rare)- hematuria, ureteral dilatation and ocassional hydronephrosis,
filling defects.
Dx: USS bladder (multiple solid bladder masses), Bladder biopsy
Tx: antihistamines and NSAIDS, intravesical dimethyl sulfoxide
Interstitial cystitis- irritative voiding symptoms such as urgency,
frequency, and dysuria, and bladder and pelvic pain relieved by
voiding
Adolescent girls
negative urine culture.
Dx: Cystoscopic observation of mucosal ulcers with bladder distention
Tx: Bladder hydrodistention and laser ablation of ulcerated areas, but no
treatment provides sustained relief.
ASYMPTOMATIC BACTERIURIA
Asymptomatic bacteriuria refers to a condition in which there is a
positive urine culture without any manifestations of infection.
Most common in girls.
The incidence is <1% in preschool and school age girls and is rare
in boys.
Benign and does not cause renal injury.
Some girls are mistakenly identified as having asymptomatic
bacteriuria, while they actually are experiencing day or night
incontinence or perineal discomfort secondary to UTI.
PHYSICAL EXAMINATION
General examination, growth, blood pressure.
Abdominal examination for distended bladder, ballotable kidneys, other
masses, genitalia, and anal tone.
Examine the back for any spinal lesion.
Look for lower limb deformities or wasting (suggests a neurogenic bladder).
DIAGNOSIS: INVESTIGATION
1. Urinalysis: bacteria, pyuria, +ve nitrite
2. Urine CnS
3. USS KUB & DMSA scan
Recommendation: < 3 years, >3 years with poor
urinary stream, seriously ill with UTI, abd. mass,
raised creatinine, non E.coli UTI, fever after 48 hours
antibiotic therapy/ recurrent UTI

4. Micturition Cystourethrogram(MCUG)
Recommendation: Dilatation on ultrasound, poor urine
flow, non E. coli infection, family history of VUR.