Urinary Tract Infections in Children

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Urinary Tract Infections in Children

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Urinary Tract Infections in Children Epidemiology Female predominance Complications Permanent scarring of kidney Sepsis Hypertension Renal failure Bacteriology Enterobacteriaceae E coli Klebsiella, Enterobacter, Citrobacter, Proteus, Providencia, Morgenella, Serratia, Salmonella Pseudomona s species Pseudomonas Gram +ve species Staphylococcus Enterococcus Virulence Factors Enhance colonisation Aid in persistence in urinary tract Capacity for inflammation Adherence (Hydrophobic, Electrostatic, Receptors ) Motility (Flagellae) Bacterial survival enhanced (K-antigen, Proteins enhancing Fe uptake, Complement resistance) Damage to tissues (Haemolysins, Colicine) Host Defence Factors Mechanical Hydrodynamic Anti-adherent Receptor dependant Immunologic Pathogenesis Ascending

jslum.com | Medicine

Urine samping Midstream Clean catch Catheterisation Bag samples (contamination rate ↑ with longer application) Investigations Urine microscopy (gram stain) Pyuria No Pyuria Phimosis wash out Still can be UTI Vaginal wash out Leukopaenia Glomerulonephritis Febrile illnesses Dip sticks Leukocyte esterase – 88-95% sensitivity pyuria Nitrites – less sensitive, less specific Cultures Positive (> CFU/mL) Positive (< CFU/mL) UTI/ (contamination) Contamination UTI Frequent voiding ↓ Urinary pH ↑ Fluid intake Mixed Growth No Growth Contamination No infection UTI may present/ not present Infection but organism has not UTI with > 1 organism (rare) grown Therapy Normal Hygiene Normal Voiding Habits Treat Constipation Treat Worm Infestation Drinking Habits Antibiotic Therapy IV or Oral Duration 1 dose for Cystitis Longer for PN, Infants, Pregnant Antibiotic of Choice Trimetoprim Cotrimoxazole Nitrofurantoin (Nalidixic acid) 2nd or 3rd generation Cephalosporins (Not ampi- or amoxicillin)

Descending Infants Perinephric abscess

Perineal/ Urethral Factors Phimosis/ non -circu mcision Short urethra (Female) Bubble bath, Wiping techniques Hygiene Pinworms Bladder Factors Infrequent voiding Incomplete voiding Neurogenic bladder Constipation, Encopresis Upper Urinary Tract Vesico-ureteral Reflux 50% of children with UTI Residual urine post micturition

Obstruction Pelvi-Ureteric Junction Vesico-Ureteric Junction Posterior Urethral Valves Ectopic ureters +/- Ureterocoeles

Clinical Presentation Infants Irritability Poor feeding Failure to gain weight Vomiting, Diarrhoea Jaundice (late onset) Fever

Asymptomatic

Cystitis

Lower tract symptoms Urgency Frequency Enuresis Dysuria Vulvitis Bubble bath irritation Urethritis Voiding dysfunction Pyelonephritis ↑ grade Fever Flank pain/ tenderness ↑ WBC, ESR, CRP

Investigations Ultrasound VUR (Not most reliable method) Presence of 2 kidneys Exclude obstruction Measure kidneys Bladder residual volume post micturation 1st UTI at 0-2 y/o Prophylaxis antibiotics Ultrasound +/- 6 weeks after infection MCU (Boys) Isotope Cystography (Girls) DMSA 1st UTI at 2-7 y/o VUR a bit ↓ common Ultrasound MCU might be traumatic DMSA If 1st UTI no scar, unlikely for next UTI If abnormal, MCU/ Isotope to scar cystography 1st UTI > 7 y/o Ultrasound (Urodynamics on indi cation) If all Investigations –ve Stop antibiotic prophylaxis Examine urine (at every febrile episode, whenever child unwell) Quick response to eventual new UTI If VUR present Depend on • Degree of reflux • Presence & extend of renal scarring • Discuss with surgeon • Expected compliance Conservative treatment Surgery

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