Nylon panties (also biker shorts, leotards, bathing suits

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Uti in children
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Introduction

• Pediatric UTIs often signal an underlying
  genitourinary tract abnormality
• Can lead to renal scarring with resultant
  hypertension and renal failure
• Difficult to diagnose because symptoms are
  non-specific in this age group and testing is
  often invasive

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Pediatric UTIs Epidemiology

• Prevalence
• Girls6.5-8
• Boys2-3
• Uncircumcised boys have a 5-20 X increase in UTIs
  vs circumcised boys
• Occurs in about 7 of children lt2 who present
  with fever without a source

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Epidemiology (continued)

• Incidence of vesicoureteral reflux (VUR) is 1 in
  children lt 2 yoa.
• 50 of kids lt1 yoa with UTI have VUR
• Early renal scarring is nearly twice as common in
  this age group.
• Incidence of scarring increases with each
  subsequent UTI
• Scarring occurs in 5-38 of febrile UTIs.

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Figure 1Prevalence of VUR by age. Plotted are
the prevalencesreported in 54 studies of urinary
tract infections inchildren (references in
Technical Report).
Pediatrics 1999 103 843-852
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Figure 2Relationship between renal scarring and
number ofurinary tract infections.16
Pediatrics 1999 103 843-852
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UTI Classiffication

• Classification
• Upper tract infection
• Acute pyelonephritis- fever, bacteriuria,
  systemic symptoms
• Lower tract infection
• Urethritis
• Cystitis
• Voiding symptoms, little or no fever, no systemic
  symptoms

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Clinical Presentation

• Age and gender dependent
• 0 - 2 months
• Fever
• 2 mo. 2 y/o
• Fever (gt38 C)
• Irritability
• Vomiting and Diarrhea
• Decrease appetite
• Between 1-2 y/o crying on urination, foul
  smelling odor

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Clinical Presentation

• 2 y/o 6 y/o
• Systemic symptoms
• Fever
• Flank or back pain
• Urgency, urinary incontinence, dysuria
• Suprapubic or abdominal pain
• Foul smelling odor
• gt 6 y/o and adolescents
• Same as above

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Urethritis

• In female infants
• Part of a diaper dermatitis
• In adolescent girls and boys
• Presenting sign of STD

• In pre-school and school age girls
• Part of non-specific vulvovaginitis
• Generally environmental
• Bubble bath
• Nylon panties (also biker shorts, leotards,
  bathing suits)
• Poor hygiene (not wiping, wiping back to front)
• Overzealous hygiene
• Use of baby powder, perfumes

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Symptoms of urethritis

• Dysuria
• Reluctance to void
• Perineal discomfort, erythema
• May be associated with vaginal irritation and
  erythema in girls
• In older boys, urethral discharge
• In adolescent girls associated with PID symptoms

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Cystitis

• Afebrile usually
• Frequency
• Enuresis
• Dysuria
• Reluctance to void

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Pyelonephritis

• Usually associated with fever and systemic signs
  2 renal parenchymal inflammation
• Older children
• Flank pain or abdominal pain
• Younger children
• Fever, irritability, vomiting, poor feeding

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Pyelonephritis - Significance

• EACH infection results in scar formation and
  reduced renal function
• After diabetes mellitus and collagen vascular
  disease, undetected renal disease and untreated
  childhood UTI may be responsible for
• A large of portion of ESRD in adults
• A huge need for dialysis and transplantation

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Pyelonephritis - Significance

• Untreated childhood UTI responsible for
• Hypertension
• Impaired kidney function
• Complications of pregnancy

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Causes and course of UTI
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Risk Factors

• Age lt1 year
• Female gender
• Uncircumcised males
• Constipation
• Voiding dysfunction

• Improper wiping
• Genitourinary abnormalities
• Vesicoureteral reflux
• Obstruction
• Colonization with virulent E. Coli

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Signs and Symptoms Children 2 months to 2 years

• Feverusually unexplained
• Vomiting and/or diarrhea
• Abdominal Pain
• Failure to thrive
• Malodorous urine
• Crying on urination

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Signs and Symptoms Children gt2

• Fever
• Vomiting and/or diarrhea
• Abdominal pain
• Malodorous urine
• Frequency and/or urgency
• Dysuria
• New incontinence

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Summary

• Urinary tract infections are a common cause of
  fever without a source in children lt2 and can
  lead to renal scarring, HTN or ESRD. Rapid
  treatment is essential.
• Symptoms are non-specific and thus a high level
  of suspicion is required
• Urine culture is required for diagnosis, and
  should be obtained by catheterization or SPA when
  child is ill or infection is suspected
• Treatment requires a 7-14d course of antibiotics
• Prophylactic abx are required after initial
  treatment
• All Children lt2 require 2 imaging studies after
  initial UTI

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References

• Committee on Quality Improvement, Subcommittee on
  Urinary Tract Infection. The diagnosis,
  treatment, and evaluation of the initial urinary
  tract infection in febrile infants and young
  children. Pediatrics 1999 103843-852
• Layton, KL. Diagnosis and Management of Pediatric
  Urinary Tract Infections. Clinics in Family
  Practice 2003 5 2
• Chon DH, Frank CL, Shortliffe LM. Pediatric
  Urinary Tract Infections. Pediatric Clinics of
  North America 2001 48 1441-1459
• Linderd KA, Shortliffe LM. Evaluation and
  management of pediatric urinary tract infections.
  Urologic Clinics of North America 1999 26
  719-728
• McCollough M, Sharieff G. Marx Rosens Emergency
  Medicine Concepts and Clinical Practice, 5th
  ed.2002 2327-2334
• Acute Urinary Tract Infections Clinical Effective
  Committee. Evidence based clinical practice
  guideline for patients 6 years of age or less
  with a first time acute urinary tract infection.
  Cincinnati (OH) Childrens Hospital Medical
  Center 1999 1-14

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long-term antibiotic treatment for preventing
recurrent urinary tract infections (UTI) in
children

• Patient groups
• Infants of 1 year
• Girls and boys
• Recurrent UTI (no abnormalities)
• Mild VUR (grade I and II)
• Options
• Long-term low dose antibiotics (Cochrane review)
• (Trimethoprim, Nitrofurantoin, Cotrimoxazole)
• Intermittent treatment of UTIs
• Time horizon
• 3 years of long-term antibiotics and follow-up to
  end stage renal disease
• NHS perspective

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Model Structure for UTI
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The evidence

• Effectiveness
• Existing reviews (variable quality)
• Meta analysis, Multiple parameter synthesis
• Probabilistic trial based model
• Natural history
• Epidemiological studies
• Pooled trial baselines
• Registry studies
• Clinical judgement
• Quality of life
• Published studies
• Survey
• Costs
• Published studies
• Published unit costs and dosage (BNF, PSSRU,
  CIPFA)

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Antenatal Period

• The most common cause is physiologic dilation.
• Metanephric urine production begins at 8 weeks,
  even before ureteral canalization is complete.
• Transient obstruction with hydronephrosis occurs.

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Embryology
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Pathophysiology

• Anatomic and functional processes interrupts the
  flow of urine.
• There is a rise in ureteral pressure causing
  stretching and dilation if pressures continue to
  rise, leads to decline in renal blood flow and
  GFR.
• When significant obstruction is persistent, it
  affects nephrogenic tissue and results in varying
  degrees of cystic dysplasia and renal impairment.

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Grading of Severity of Hydronephrosis
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Most Common Causes in Neonates

• Ureteropelvic Junction Obstruction
• Ureterovesical Junction Obstruction
• Posterior Urethral Valves
• Eagle-Barrett Syndrome (a.k.a. Prune Belly
  Syndrome)
• Vesicoureteral Reflux
• Ureterocele

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Treatment for UPJ Pyeloplasty
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Diagnosis
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Urine Collection

• Clean Catch acceptable for toilet trained
  children (wearing underwear or pull-ups)
• Ensure cleansing with antiseptic towelette
• Catheterized specimen in diapered children
• Suprapubic bladder tap in lt6 month old child is
  guaranteed sterile

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Leukocyte Esterase

• Has to accumulate in urine
• Insufficient accumulation possible in small
  infants who void frequently
• Infants lt3 months old may not have mature enough
  immune system to induce leukocytes in urine
  (beware neutropenia on CBC)

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Nitrites

• By-products of E. coli and other lactose
  fermenters (glucose digestion)
• Insufficient accumulation possible in small
  infants who void frequently
• Insufficient accumulation possible in older child
  during the day and in older patient who has
  significant frequency
• If positive, highly suggestive of UTI (high
  specificity)

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Microscopy

• gt10 WBC/hpf on spun urine
• Bacteria on unspun urine are common unless
  catheterized specimen
• Gram stain is very helpful on spun urine
• Standard UA plus gram stain is enhanced UA

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Urine Culture

• gt100,000 cfu per mL on any culture
• gt10,000 cfu per mL on cath specimen
• ANY bacterial growth on bladder tap (at least
  1,000 cfu/mL)

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Sensitivity and Specificity of Components of the
UA
Sensitivity (Range)
Specificity (Range)
Test
Leukocyte esterase Nitrite Leukocyte esterase
or nitrite positive Microscopy white blood
cells Microscopy bacteria Leukocyte esterase
or nitrite or Microscopy positive
83 (67.94) 53 (15-82) 93 (90-100) 73
(32-100) 81 (16-99) 99.8 (99.100)
78 (64-92) 98 (90-100) 72 (58-91) 81
(45-98) 83 (11-100) 70 (60-92)
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Urine Cultures

• Held for 48 h but usually positive at 24 h for
  true UTI
• Requires another day for ID of organism
• May require another day for sensitivities
• If contains skin flora (S. epi., S. aureus or
  a-strep.) considered contamination secondary to
  poor specimen collection

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Diagnosis

• Urinalysis
• Can be obtained by most convenient means if
  infant is not ill
• UTI CANNOT be diagnosed with UA alone
• If suspicious UA, the Urine Culture must be
  obtained via SPA or catheter specimen
• If UA does not suggest UTI, it is reasonable to
  follow child clinically

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Pediatrics 1999 103 843-852
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Diagnosis

• Urine Culture
• MUST be collected via catheter or SPA
• UTI CANNOT be diagnosed from a bag specimen
• Diagnosis of UTI requires Urine Culture
• LOE--Strong

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Urine Collection Suprapubic Aspirate

• Gold standard - gt99 specificity
• Positive culture any number of g- bacilli or
  gt3000 CFU of g cocci

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Urine Collection Transuretheral Catherization

• gt105 CFU - 95 specificity
• 104 105 CFU infection is likely
• 103 104 CFU Suspicious
• lt103 CFU infection unlikely

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treatment
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Treatment

• May initiate treatment either orally or
  parenterally
• Admit and use parenteral antibiotics if toxic,
  dehydrated or unable to take PO
• Choices
• TMP/SMX
• Cephalosporin
• Amoxicillin (check local resistance)

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Treatment--continued

• Improvement should be seen in 24-48 hours
• If not having expected clinical response in 2
  days, re-culture, consider changing antibiotics
  and do imaging studies
• Complete 7-14 day course of antibiotics
• 14 days should be given for those that were ill
  with clinical evidence of pyelonephritis

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Prophylaxis

• After completion of initial antibiotics, children
  should be give a prophylactic dose of antibiotics
  until imaging studies complete
• Antibiotic should have high urinary excretion and
  low serum and fecal levels, thus minimizing the
  development of resistance.

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Imaging

• Needs to be performed in ALL children lt2 years
  old with initial UTI
• Need to perform at least 2 studies to image the
  upper and lower urinary tracts
• Acute imaging only necessary when appropriate
  clinical response is not achieved within 2 days

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Ultrasound

• Should be done on all infants lt 2yoa after their
  initial UTI
• Helps to detect hydronephrosis and ureteral
  dilation
• Has replaced IVP
• Need additional study to evalute VUR
• Is not as sensitive as renal cortical
  scintigraphy (DMSA) for detecting inflamation and
  scarring

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Voiding Cystourethrography (VCUG)

• Used to identify and grade reflux
• Also evaluates the urethra and bladder for
  abnormalities important for boys who may have
  posterior urethral valves and girls with voiding
  dysfunction
• Radionuclide cystography (RNC) can also
  evaluate reflux, but does not delineate the lower
  tract anatomy well. Can be used for follow-up
  exams as has low ratiation dose

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Renal Cortical Scintigraphy (DMSA)

• Very sensitive for evaluating acute inflammation
  from pyelonephritis as well as renal scarring
• Role in clinical management is still unclear

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Treatment

• No short course therapy for small children
• No short course therapy for males
• Empiric therapy is directed at organisms and
  adjusted for age.
• Choose narrowest spectrum allowable considering
  host factors
• Adjust therapy when sensitivities available

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IV antibiotics-Indications

• Any person of any age who appears clinically
  toxic or who has neutropenia
• Infants lt1 mo until bacteremia, sepsis,
  meningitis ruled out
• Children unable to tolerate oral antibiotics
• Immunocompromised patients

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Antibiotic choice

• Neonates
• Ampicillin plus a second antibiotic (usually
  gentamycin or cefotaxime) to cover for GBS,
  Listeria, as well as gram negative organisms
• S. aureus and S. epi. can cause hematogenous
  pyelonephritis (in children instrumented ET
  tube,central lines, etc)
• Vancomycin may be indicated for toxic patients or
  those unresponsive to initial therapy

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Therapy

• Cefixime (Suprax) oral is as effective as
  parenteral ceftriaxone
• Cefpodoxime (Vantin)
• Bad tasting
• 10 mg/kg/day
• Fluoroquinolones are expensive and off label in
  pedi

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Bacterial virulence Bacterial spectrum at the
Ist Dept. of Pediatrics, in 2002-2003

• N7850 ()
• E. coli 49
• Enterococcus faecalis 13
• Proteus indol neg. 10
• Klebsiella 7
• Pseudomonas spp 7
• Enterobacter spp 6
• Proteus indol pos 3
• Staphylococcus 3
• Other 2

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Sensitive host

• Age related factors
• Anatomy (short urethra, phymosis and adhesio
  cellularis preputii et labia minora, diaper)
• colonization
• Immunological susceptibility
• Mucosal barrier
• Inherited/acquired
• immunresponse
• Inherited/acquired
• Ex IgA deficiency, P1 blood group

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Sensitive host

• Anatomical malformations
• obstruction
• VUR
• meningomyelokele
• prune-belly syndrome
• Stone disease, etc

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Age-related incidence of UTI
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Management of UTI
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Prognosis
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UTI Controversy 1Antibiotic Prophylaxis

• Indications
• ? grade 1 VUR
• frequent UTI recurrences
• Problems
• Pt Rxd with antibiotic prophylaxis
• Increased infection with Proteus and Enterobacter
• pseudomonas and Candida increased in children
  with urogenital abnormalities
• Drug toxicity and sensitivities
• Antimicrobial choices (qhs better)
• TMP-SMX or Nitrofurantoin (GI disturbance)
• Keflex if lt 3 months
• Quinolones in some circumstances

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Posterior Urethral Valves

• Abnormal congenital mucosal folds that are thin
  membranes impeding bladder drainage.
• Most common obstructive urethral lesion in male
  newborns found at the distal prostatic urethra.
• Incidence is approxly 1 in 8,000 males.
• Approxly 50 have reflux.
• VCUG is the modality of choice.

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Radiographic signs of PUV

• distended prostatic urethra
• valve leaflets
• bladder and/or bladder neck hypertrophy
• diverticula
• narrow stream in the penile urethra
• incomplete emptying of the bladder

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Treatment of PUV

• Transurethral valve ablation, vesicostomy or
  upper tract diversion
• Urethral stricture is a common complication
• Fetal intervention carries a high risk with
  mortality rate of 43
• ESRD, renal insufficiency and chronic renal
  failure are long-term consequences

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• 30 of boys with posterior urethral valves whose
  symptoms present in infancy are at risk for
  progressive renal insufficiency.

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PUV, 2 months , MCU
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PUV, 2months
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• Mcu done for suspected PUV

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• 9 months old child with dribbling of urine and
  difficulty in passing urine
• ?PUV
• MCU done
• Uroprophylaxis suggested
• Told by another Doc not necessary
• Came with high grade fever after 1 month
• UTI

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Vesicoureteral Reflux

• Retrograde propulsion of urine into the upper
  urinary tract during bladder contraction.
• Primary reflux is caused by attenuation of the
  trigone and the contiguous intravesical ureteral
  musculature.
• May be caused by the ectopic insertion of the
  ureter into the bladder wall resulting in a
  shorter intravesicular ureter, which acts as an
  incompetent valve during urination.

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• The ratio of the submucosal tunnel length to the
  ureteral diameter is the primary factor
  determining the effectiveness of the normal valve
  mechanism.
• It is normally 51, and in those with reflux it
  is 1.41.
• The intramural length increases from 0.5 cm at
  birth to 1.3 cm by 12 years of age.
• Duplication of the collecting system and
  ureteroceles should also be considered.

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Some clinical facts about VUR

• It is genetic.
• Occurs in about 30 of first-degree relatives.
• 1/3 of children with a urinary tract infection
  has reflux on VCUG.
• Primary reflux tends to resolve over time as
  intravesical segment elongates with growth.

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Grading of Vesicoureteral Reflux
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VUR Grading
Grade I
Grade III
Grade II
Prognosis - 5 adults Scarring -
5-50 Screening UTI
Grade IV
Grade V
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Prognosis

• Kidney is most susceptible to scarring in the
  first year of life and at the time of first upper
  tract infection.
• Scars less frequently develop after the age of 5.
• VUR and scarring lead to hypertension,
  progressive renal insufficiency and failure.

• Resolves spontaneously before adolescence in
• 90 of Gr. 1 reflux
• 80 of Gr. 2
• 50 of Gr. 3
• 10 of Gr. 4
• 0 in Grade 5 reflux

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Treatment

• Observation
• Medical treatment of infections
• Surgical treatment
• significant hydroureteronephrosis
• indicated if impossible to keep urine sterile and
  reflux persists
• acute pyelonephritis occurs
• evidence of increasing renal damage

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VUR
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MCU

• C/o Recurrent UTI

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Endoscopic submucosal injection
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Endoscopic submucosal injection

• Teflon
• Silicon
• Collagen

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Bacterial virulence

• Virulencefactors that enable bacteria to invade
  the urinary tract
• Surface antigenes
• O lipopolysacharides with endotoxin properties.
  Induces fever, local inflammation
• K, (capsular) antigene, prevents phagocytosis
• P fimbriae bind to glycolipid receptors of the
  P blood group family
• A number of further factors not routinely checked
  

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Bacterial virulence

• Pyelonephritis 3-4 (known) virulence factors
• Cystitis 0-2 factors
• CAVE OBSTURCTION !! MALFORMATION !!