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diagnosis and treatment of UTI

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Diagnosis and Treatment of UTI in children

Novina Firlia 0961050083

TABLE OF CONTENTS

Table of content.......................................................................................................................1 List of table and figure..............................................................................................................2 Chapter I..................................................................................................................................3 Prelude.........................................................................................................................3 Chapter II.................................................................................................................................5 Diagnosis and Treatment of Urinary tract infection in

children........................................................................................................................5 2.1 Definition and Epidemiolog........................................................................5 2.2 Etiology and Pathogenesis..........................................................................6 2.3 Signs and Symptoms...................................................................................8 2.4 Diagnosis of UTI.........................................................................................9 2.5 Treatments of UTI.......................................................................................13 Chapter III..............................................................................................................................16 Conclusion...................................................................................................................16 Reference.................................................................................................................................17

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LIST OF TABLES
Table 1. etiology of UTIs.........................................................................................................6 Table 2. Signs and Symptoms..................................................................................................8 Table 3. Treatment of UTIs.....................................................................................................14

LIST OF FIGURES
Figure 1. Algorithm for urine testing in children with suspected urinary tract infection (UTI).........11 Figure 2. Algorithm for imaging decisions in children with urinary tract infection...........................13

Chapter I
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Prelude

Urinary tract infections (UTIs) are common in kids. By the time they're 5 years old, about 8% of girls and about 1-2% of boys have had at least one. In older kids, UTIs may cause obvious symptoms such as burning or pain with urination (peeing). In infants and young children, UTIs may be harder to detect because symptoms are less specific. In fact, fever is sometimes the only sign.1 The most common pathogen is Escherichia coli, accounting for approximately 85 percent of urinary tract infections in children. Renal parenchymal defects are present in 3 to 15 percent of children within one to two years of their first diagnosed urinary tract infection.1 In a study of infants presenting to pediatric emergency departments, the prevalence of UTI in infants younger than 60 days with a temperature greater than 100.4°F (38°C) was 9 percent. Clinical signs and symptoms of a UTI depend on the age of the child. Newborns with UTI may present with jaundice, sepsis, failure to thrive, vomiting, or fever. In infants and young children, typical signs and symptoms include fever, strong-smelling urine, hematuria, abdominal or flank pain, and new-onset urinary incontinence. School-aged children may have symptoms similar to adults, including dysuria, frequency, or urgency. Boys are at increased risk of UTI if younger than six months, or if younger than 12 months and uncircumcised. Girls are generally at an increased risk of UTI, particularly if younger than one year. Physical examination findings can be nonspecific but may include suprapubic tenderness or costovertebral angle tenderness.1 Evaluation of older children may depend on the clinical presentation and symptoms that point toward a urinary source (e.g., leukocyte esterase or nitrite present on dipstick testing; pyuria of at least 10 white blood cells per high-power field and bacteriuria on microscopy). Increased rates of E. coli resistance have made amoxicillin a less acceptable choice for treatment, and studies have found higher cure rates with trimethoprim/sulfamethoxazole. Other treatment options include amoxicillin/clavulanate and
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cephalosporins. Prophylactic antibiotics do not reduce the risk of subsequent urinary tract infections, even in children with mild to moderate vesicoureteral reflux. Constipation should be avoided to help prevent urinary tract infections. Ultrasonography, cystography, and a renal cortical scan should be considered in children with urinary tract infections.2 Adequate treatment of acute UTI depends on knowledge of the local pattern of causative pathogens, their antimicrobial resistance and the associated underlying risk factors. The changing pattern of antimicrobial susceptibility of bacterial pathogens causing acute UTI is a growing problem. Consequently, many organisms including those causing acute UTI may ultimately develop high resistance to many antibiotics in current use. Moreover, organisms not known to be common in causing acute UTI may emerge as important causative pathogens. Therefore, the knowledge of the local pattern of urinary pathogens and their susceptibility to various antimicrobials are essential for selection of the appropriate empiric therapy for children with acute UTI.3

Chapter II Diagnosis and Treatments of UTI in children
2.1 Definition and Epidemiology Urinary tract infection (UTI) is defined by the presence of microorganisms within the urinary tract, which is usually sterile. Since asymptomatic colonization of the urinary tract can occur, definitive diagnosis often relies upon a constellation of features that might include history and examination findings, elevated inflammatory markers, and repeat urine cultures.
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UTIs are typically divided into lower tract disease, where infection is localized to the bladder and urethra (cystitis and urethritis), and upper tract disease, where it extends to the ureter and kidney (pyelonephritis). Although both upper and lower tract disease may result in significant morbidity, pyelonephritis in particular is associated with renal scarring and subsequent hypertension, chronic renal disease, and preeclampsia.3 UTIs are the most common serious bacterial infections affecting infants and young children. In recent decades, UTI has been increasingly recognized as an important occult cause of fever in young children. Rates of UTI vary widely with respect to age, gender, race, and other factors. Screening studies performed in emergency departments suggest an overall prevalence of UTI of up to 5% in febrile children younger than 2 years. Peak incidence of UTI occurs in the first year of life for all children, with a second peak occurring among female adolescents. After infancy, females are far more likely than males to have a UTI.1,3 A population-based European study reported a cumulative UTI incidence of 7.8% for girls by age 7 years. One factor influencing the relatively higher rates of UTI in male infants is circumcision status; uncircumcised males younger than a year are approximately 10 times more likely to develop UTI than their circumcised counterparts. In young children, race appears to be an independent risk factor for UTI. In an emergency department study, Caucasian females younger than 2 years with fever 39 oC have a UTI prevalence of 16% compared to a 2.7% prevalence among nonwhite girls.3

2.2 Etiology and Pathogenesis The normal urinary tract is sterile. Contamination by bowel flora may result in urinary infection if a virulent organism is involved or if the child is immunosuppressed. In neonates, infection may originate from other sources. Escherichia coli accounts for about 75 percent of all pathogens. Proteus is more common in boys (one study found that proteus caused 33 percent of UTI infections in boys one to 16 years of age, compared with 0 percent of UTI infections in girls of the same age). Obstructive anomalies are found in up to 4 percent and vesicoureteric reflux in 8 to 40 percent of children being evaluated for their first UTI.
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Although vesicoureteric reflux is a major risk factor for adverse outcome, other factors, some of which have not yet been identified, are also important.4

Table 1 etiology of UTIs in children3

Almost all clinically significant urinary infections are monomicrobial rather than polymicrobial. Most uncomplicated UTIs are caused by the gram-negative Enterobacteriaceae family. causes the vast majority of acute infections. Organisms such as Proteus, Enterobacter, Citrobacter, and Klebsiella spp. are more commonly encountered in cases of recurrent UTI, particularly in cases of urinary anomalies. Pseudomonas sp., while not usually a cause of UTI in healthy children, is a significant pathogen for hospitalized children, immunocompromised children, and children with indwelling catheters or frequent bladder instrumentation.Gram-positive organisms account for a minority of uncomplicated UTIs (approximately 5–10%); those most commonly encountered include Enterococcus sp., Staphylococcus saprophyticus, and group B streptococci. S. saprophyticus tends to infect sexually active adolescent females. Candidal UTIs typically occur in children with indwelling catheters who are receiving broad-spectrum antibiotics or in children in the neonatal intensive care unit.3,4

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Risk factors — Some children have a higher chance of developing a UTI. The following are some risk factors for UTI5 :


Young age; boys younger than one year old, and girls younger than four years of age are at highest risk. Being uncircumcised; there is a four to 10 times higher risk of UTIs in uncircumcised boys. Still, most uncircumcised boys do NOT develop UTIs. (See "Patient information: Circumcision in baby boys (Beyond the Basics)".)



   

Having a bladder catheter for a prolonged period of time. Having parts of the urinary tract that did not form correctly before birth. Having a bladder that does not work properly. Having one UTI slightly increases the chance of getting another UTI.

2.2 Signs and Symptoms Symptoms of a UTI range from slight burning with urination or unusual-smelling urine to severe pain and high fever. A child with a UTI may also have no symptoms. A UTI causes irritation of the lining of the bladder, urethra, ureters, and kidneys, just as the inside of the nose or the throat becomes irritated with a cold. In infants or children who are only a few years old, the signs of a UTI may not be clear because children that young cannot express exactly how they feel. Children may have a high fever, be irritable, or not eat.7

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Table 2 Signs and Symptom6

On the other hand, children may have only a low-grade fever; experience nausea, vomiting, and diarrhea; or just not seem healthy. Children who have a high fever and appear sick for more than a day without signs of a runny nose or other obvious cause for discomfort should be checked for a UTI. Older children with UTIs may complain of pain in the middle and lower abdomen. They may urinate often. Crying or complaining that it hurts to urinate and producing only a few drops of urine at a time are other signs of a UTI. Children may leak urine into clothing or bedsheets. The urine may look cloudy or bloody. If a kidney is infected, children may complain of pain in the back or side below the ribs.6,7 2.3 Diagnosis of UTI The physical examination of a child with suspected urinary tract infection should start with the vital signs (temperature, pulse, breathing rate, and blood pressure, which is often measured with the vital signs). The presence of fever (especially over 102.2 F or 39 C) is highly correlated with the presence of a UTI. 10 All febrile children between two and 24 months of age with no obvious cause of infection should be evaluated for UTI, with the exception of circumcised boys older than 12 months. Older children should be evaluated if the clinical presentation points toward a urinary source.9 Blood pressure and assessment of height and weight provide helpful reassurance if normal or stable long-term renal function. Visual examination of the abdomen for enlargement related to potentially oversized kidney(s) or bladder is important. Tenderness during palpation of the abdomen (especially the suprapubic region containing the bladder) or the flank area (where the kidneys are situated) is very helpful in establishing the diagnosis. Examination of the genitalia is also very important to see if there is evidence of vaginal irritation (redness, discharge, evidence of trauma or foreign body). An uncircumcised male (especially with a foreskin which is difficult to retract) is more likely to experience a
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UTI when compared to a population of similar infant boys who have been circumcised. Lastly, consideration of other conditions that might be responsible for fever and abdominal pain is important.10 The National Institute for Health and Clinical Excellence in the United Kingdom endorses incorporating specific strategies for urine testing based on the child's age. In this model, microscopy and urine culture should be performed in children younger than three years instead of dipstick testing.1 The presence of pyuria of at least 10 white blood cells per high-power field and bacteriuria are recommended as the criteria for diagnosing UTI with microscopy. In young children, urine samples collected with a bag are unreliable compared with samples collected with a catheter. Therefore, in a child who is unable to provide a cleancatch specimen, catheterization should be considered.1,7 Urine culture is the gold standard for diagnosis of UTI, but results are unavailable for 24–48 hours. As such, several rapid diagnostic tests are available for faster UTI detection. These include: Urine dipstick testing for leukocyte esterase (LE) and nitrites; traditional urinalysis, which is typically done by microscopy on a centrifuged specimen; and enhanced urinalysis, using a hemocytometer cell count and Gram stain of unspun urine. Urine Culture -- Although growth of pathogenic bacteria from the normally sterile urine is the gold standard for diagnosis of UTI, what constitutes a significant colony count varies by collection method. Children who are toilet trained can use the clean-catch method, which is susceptible to urethral contamination. Using this modality, UTI is often defined as >105 colony-forming units (CFU) of a single pathogen. Diagnostic Test -- Dipstick tests for UTI include leukocyte esterase, nitrite, blood, and protein. Leukocyte esterase is the most sensitive single test in children with a suspected UTI. The test for nitrite is more specific but less sensitive. A negative leukocyte esterase result greatly reduces the likelihood of UTI, whereas a positive nitrite result makes it much more likely; the converse is not true, however. Dipstick tests for blood and protein have poor sensitivity and specificity in the detection of UTI and may be misleading. Accuracy of positive findings is as follows (assumes a 10 percent pretest probability):  Nitrite: 53 percent sensitivity, 98 percent specificity, 75 percent probability of UTI
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Bacteria on microscopy: 81 percent sensitivity, 83 percent specificity, 35 percent probability of UTI



Leukocytes on microscopy: 73 percent sensitivity, 81 percent specificity, 30 percent probability of UTI



Leukocyte esterase: 83 percent sensitivity, 78 percent specificity, 30 percent probability of UTI



Leukocyte esterase or nitrite: 93 percent sensitivity, 72 percent specificity, 27 percent probability of UTI

 

Blood: 47 percent sensitivity, 78 percent specificity, 19 percent probability of UTI Protein: 50 percent sensitivity, 76 percent specificity, 19 percent probability of UTI

Figure 1. Algorithm for urine testing in children with suspected urinary tract infection (UTI). 1

Laboratory Testing -- A few laboratory parameters have been examined to help determine not only whether bacteriuria is consistent with acute infection, but also the location of the infection within the urinary tract. Commonly used markers of inflammation such as
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white blood cell count, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) cannot reliably distinguish pyelonephritis and cystitis.While CRP is the best among these and has a sensitivity of greater than 92% for pyelonephritis, it has a low specificity, which limits its applicability. Although not as widely available (although a rapid test exists in some centers), multiple studies35–38 have found that an elevated serum procalcitonin level appears to be more highly correlated with renal involvement than an elevated CRP. If made more available, this test could potentially alter the management and disposition of febrile patients with UTI. 3,11 A blood culture should be performed in young infants with UTI since they are at higher risk of bacteremia. Febrile infants older than 2 months with UTI do not routinely require lumbar puncture. Concomitant invasive meningitis appears to be rare; an association of UTI with aseptic meningitis has been reported but is controversial and may represent coincidental CSF infection and bacteruria.3 Imaging procedures with the highest ratings from the American College of Radiology Appropriateness Criteria for further evaluation of select children with UTIs are renal and bladder ultrasonography, radionuclide cystography or voiding cystourethrography, and renal cortical scan.12 Renal and bladder ultrasonography is effective for evaluating anatomy, but is unreliable for detecting vesicoureteral reflux. Radionuclide cystography or voiding cystourethrography is effective for screening and grading vesicoureteral reflux, but involves radiation exposure and catheterization. Although voiding cystourethrography is suggested for either girls or boys, radionuclide cystography is suggested only for girls because voiding cystourethrography is needed for adequate anatomic imaging of the urethra and bladder in boys. A renal cortical scan (also called scintigraphy or DMSA scan) uses technetium and is effective for assessing renal scarring, but requires intravenous injection of radioisotope.1 Long-term outcome studies have not been performed to determine the best initial imaging study in children diagnosed with UTI. Guidelines based on observational studies and expert opinion recommend that all boys, girls younger than three years, and girls three to seven years of age with a temperature of 101.3°F (38.5°C) or greater receive cystography and ultrasonography with a first-time UTI.1,13 An optional imaging strategy for febrile children with UTI, especially those older than three years, is to first perform ultrasonography and a renal cortical scan. This strategy avoids bladder catheterization with cystography and minimizes radiation exposure if the results of the scan are normal. However, if pyelonephritis
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or cortical scarring is found on the renal cortical scan, cystography is indicated. Observation without imaging should be considered in girls three years or older with a temperature less than 101.3° F and in all girls older than seven years.13

Figure 2. Algorithm for imaging decisions in children with urinary tract infection .1

2.3 Treatments of UTI

Although amoxicillin has traditionally been a first-line antibiotic for UTI, increased rates of E. coliresistance have made it a less acceptable choice, and studies have found higher cure rates with trimethoprim/sulfamethoxazole (Bactrim, Septra). Other choices include amoxicillin/clavulanate (Augmentin) or cephalosporins, such as cefixime (Suprax), cefpodoxime, cefprozil (Cefzil), or cephalexin (Keflex). There was no significant difference between short- and standard-duration therapies in the development of resistant organisms at the end of treatment.1 Thus, a two- to four-day course of oral antibiotics appears to be as effective as a seven- to 14-day course in children with lower UTIs. A single-dose or singleday course may be less effective than longer courses of oral antibiotics and is not recommended.1,2 When the presenting symptoms are nonspecific for a UTI or the urine dipstick test is nondiagnostic, there may be a delay in treatment while culture results are pending. Parents can be reassured that antibiotics initiated 24 hours after the onset of fever are not associated with a higher risk of parenchymal defects than immediate antibiotics in children younger than
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two years.5 However, delaying antibiotics by four days or more may increase the risk of renal scarring.1

Table 3 Antibiotics Commonly Used to Treat Urinary Tract Infections in Children 1 COMMON ADVERSE EFFECTS Diarrhea, nausea/vomiting, rash

ANTIBIOTIC Amoxicillin/clavulanate (Augmentin)

DOSING 25 to 45 mg per kg per day, divided every 12 hours

Cefixime (Suprax)

8 mg per kg every 24 Abdominal pain, diarrhea, hours or divided flatulence, rash every 12 hours

Cefpodoxime

10 mg per kg per Abdominal pain, diarrhea, day, divided every 12 nausea, rash hours 30 mg per kg per Abdominal pain, diarrhea, day, divided every 12 elevated results on liver hours function tests, nausea

Cefprozil (Cefzil)

Cephalexin (Keflex)

25 to 50 mg per kg per day, divided every 6 to 12 hours

Diarrhea, headache, nausea/vomiting, rash

Trimethoprim/sulfamethoxazole (Bactrim, Septra)

8 to 10 mg per kg per Diarrhea, nausea/vomiting, day, divided every 12 photosensitivity, rash hours

Follow-up assessment to confirm an appropriate clinical response should be performed 48 to 72 hours after initiating antimicrobial therapy in all children with UTI. Culture and susceptibility results may indicate that a change of antibiotic is necessary. If
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expected clinical improvement does not occur, consider further evaluation (e.g., laboratory studies, imaging, consultation with subspecialists). Referral to a subspecialist is indicated if vesicoureteral reflux, renal scarring, anatomic abnormalities, or renal calculi are discovered, or if invasive imaging procedures are considered.1

Chapter III Conclusion
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In conclusion, increased vigilance on the part of practitioners and screening for UTI in febrile young children has dramatically reduced the morbidity associated with this diagnosis. Although there are several areas that remain ripe for further study, there is good evidence about the epidemiology, diagnosis, and treatment of UTI in children. Key principles of improving outcomes for pediatric UTI include maintaining a high index of suspicion, particularly in young children with fever; understanding the strengths and limitations of screening tests for UTI; and using evidence-based guidelines to approach further anatomic work-up of UTI, while recognizing the limitations of current knowledge in this area.

REFERENCES

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1.

BRETT WHITE, MD, Oregon Health and Science University, Portland, Oregon Am Fam Physician. 2011 Feb 15;83(4):409-415.

2. Giovanni Montini, M.D., Kjell Tullus, M.D., Ph.D., and Ian Hewitt, M.B., B.S.N Engl J Med 2011; 365:239-250July 21, 2011DOI: 10.1056/NEJMra1007755

3.

S. Shah, MD, MSCE. Pediatrics Practice Infectious Disease . In : Mercedes M.

Blackstone and Joseph J Zorc. Urinary Tract Infection. Pennsylvania : Me Graw Hill, 2009; Page; 408 - 419 4. Larcombe James, Urinary Tract Infection in Children, Clinical Handbook.

Am Fam Physician. England National Health Services Nothern and Yorksire, Sedgefield,UK. November 2010. 15:82 (10) Page; 1252 – 1254 5. Subcommittee on Urinary Tract Infection, Steering Committee on Quality

Improvement and Management, Roberts KB. 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. 6. Bragoinier R, J Rudley, MD. Urinary Tract Infection (UTI) in Children –

Management and Refferal, In : Local Practice Guidelines. Bristol – UK : University Hospital Bristol, March 2010; Page 01-06, NHS-Journal. 7. 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, Public Health Service, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. Washington, D.C.: U.S. Government Printing Office; 2009. NIH publication 07–5512:439–458. 8. Finnell SM, Carroll AE,DownsSM, et al. Technical report: diagnosis and

management of an initial urinary tract infection in febrile infants and young children. Pediatrics. 2011;128(3):e749 9. Clinical Knowledge Summaries (CKS). Urinary tract infection - children. CKS; 2009. Available from: www.cks.nhs.uk (Accessed August, 2013).

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10.

Mersch J, MD , FAAP. Melissa C, S, MD . Urinary Tract Infection in

Children, In ; MedicineNet.com , Article, August 2013; Page 2 -3 11. Febrile urinary tract infections in children: recommendations for the diagnosis, treatment and follow up. Acta Pediatr 2012; 101:451-457. 12. American College of Radiology. ACR Appropriateness Criteria: urinary tract

infection child.http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/ pdf/ExpertPanelonPediatricImaging/UrinaryTractInfectionChildDoc10.aspx. Accessed in August 2013-08-12 13. in UTI Guideline Team, Cincinnati Children's Hospital Medical Center. children 12 years of age or 2010. 2010.

Evidence-based care guideline for medical management of first urinary tract infection less.http://www.cincinnatichildrens.org/svc/alpha/h/health-policy/uti.htm. Accessed in August 2013

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