Urinary Tract Infection (UTI) PDF
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University of Wasit/College of Medicine
Prof. Dr.Qasim Dawood Altameemi
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Summary
This document provides an overview of urinary tract infections (UTIs), specifically focusing on childhood UTIs. It discusses diagnostic methods, common causes, and potential complications, such as Vesicoureteric Reflux (VUR) and Hemolytic-Uremic Syndrome (HUS). The document details treatment strategies and management.
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Uni versi tyofWasi t–CollegeofMedi cine Depart mentofPedi...
Uni versi tyofWasi t–CollegeofMedi cine Depart mentofPedi atr ics2022–2023 By :-Pr of.Dr.Qasi m DawoodAl tameemi Ur inar ytr acti nfect ion( UTI )isoneof t hecommonestbact eri aldi seasesi nchi l dhood, aff ect ing8%ofal lgi rl sand1%ofal lboy s wi thi nthef ir st10y ear sofl i feandassoci atedwi thf everi n50%. Ther eisasi gni fi cant f emal epr edomi nanceexceptwi thi nthef irstsi xmont hsofl i fe andt her ecur rencer ate i s50%i ngi rl sand15%i nboy s. Thedi agnosi sisbasedonur inemi crobi ology.Mi d-st ream ur inesampl e(MSSU)orcl ean - cat ch ur ine ( ≥105 col CCU)( ony -for ming uni ts( CFU) /mL)i sthe pr efer red sampl i ng met hodunl ess, inv iewofcl i nicalur gency ,supr apubi caspi rat ion( anyGr am- negat iveor >103 Gr am- posi ti veor gani sms)orur ethr alcat het eri za¬t i >103 CFU/ on( ml)i srequi red si nceur inecol lect edi nst eri leadhesi vebagsandur inar ypadsar eassoci atedwi tha hi ghr ateofcont ami nat ion. Thef indi ngofpy uri aonur inemi croscopy( >10whi tebl oodcel ls( WBC) /mm3 i nboy s mm3 i and>50/ ngi rl s)i sahel pfulr api dinv est igat ioni nachi l dsuspect edofUTIsi nce py uri aispr esenti npr act ical l yal lepi sodesoff ir stsy mpt omat icUTI.Inr ecur rentUTI , howev er,si gni fi cantpy uri amaybeabsenti n25%ofcases.I naddi ti on,py uri adoesnot al way sindi cat ethepr esenceofsi gni fi ¬cantbact erur ia. Combi nat iondi pst ickur inal ysi smeasur ingl eucocy teest eraseact ivi tyand ur inar y ni tri tei sfast erandl essexpensi vet hanur inemi croscopy.Ur inecul tur emaybeav oidabl e i fleucocy teest eraseandni tr it ear eabsenti nchi ldr enovert heageof2year s,si nce ur inar ytr actsy mpt omsar emor erel i abl eev idenceofi nfect ionbutt het echni quehasa l owersensi ti vi tyi ninf ant s. Themai nof fendi ngor gani sm i ncommuni tyacqui r sEscher edUTIi ichi acol i,whi ch account sforupt o75% ofcasesi nchi l dhood.Ther emai ning25% ar ecausedbya combi nat ionofent erococci ,Kl ebsi ell a,Pr oteus, Ser rat iaandot her s. I tisgener all yassumedt hatal mostal lbact eri alUTIoccurv iat heascendi ngr out e. Ur inar yst asi sist her efor eofi mpor tance, bei tasar esul tofanat omi calobst ruct ion, VUR, i ncompl eteori nef fi cientv oidi nghabi ts,l ow f lui dint akeorconst ipat ion.However ,a numberofpat ient shav enoneoft hef oregoi ngr iskf act orsandot hermechani smsar e 1 l i kel ytobei nvol vedsuchasper iur ethr alcol oni zat ionbyur opat hogeni cbact eri aaswel las i mpai r¬mentofl owerur inar ytr actdef ensemechani sms. Ear lydi agnosi sandpr omptt reat mentofUTIi sespe¬ci all yimpor tantdur ingt he f irstyear sofl if eandal linf ant sandchi l drenwi that emper atur e>38° Cwi thnodef ini te causef oundshoul dhaveaur inesampl eexam¬i ned.Ot heri ndi cat ionsf orexami ning ur inear eunex¬pl ainedv omi ti ngorabdomi nalpai n,f ail uret othr ive,pr olongedj aundi ce i ntheneonat e,haemat uri a,hyper ¬tensi onandsuspect edchi l dsexual abuse. Whenconsi der ingur inar ytr acti magi ng, iti susef ult odi sti ngui sht hosesy mpt omst hat ar eli kel ytobeconsi st¬entwi thacut epy elonephr it is( 'uppert ract ')f rom t hosemor e consi stentwi thacut ecy sto- uret hri ti s(' l owert ract '). Uppert ractFev er, Let har gy, Gener almal aise, Vomi ti ng, Loi npai n. Lowert ract Dy sur ia,Ur gency ,fr equency,Wet ti ng,Fr ankhaemat uri a,Non- speci fi c abdomi nal pai n. 99m I magi nggui del i nesf orUTI: -Ul tr asound, Tc- DMSAandMCUG Management Thechoi ceofant ibi oti csshoul dbebasedona" bestguess"pol i cyunt ilt hesensi ti vi tyof t heor gani sm i sav ail abl e.Howev er, ift her eisnocl i nicalr esponsewi thi n24- 48hour sthe ant ibi oti cshoul dbechanged. Thef oll owi ngant ibi oti csar esui tabl eforor aladmi nist rat ion: Tr imet hopr im, Co- amoxi clav, Nit rof urant oin, Cephr adi ne I ntr avenoust her apyshoul dbeconsi der edi nthei nfantandy oungchi ldandi nal l pat ient s who ar e suf fi cient lyi l lto war ranthospi taladmi ssi on.Thi rd gener ati on cephal ospor ins,e. g.cef otax ime,cef taz idi me or cef tr iax one ora combi nat ion of ami nogl ycosi deandamoxi cil li nwoul dbeappr opr iat e.Thecur rentev idence:2- 4day s cour sei ssuf fi cientf orl owert ract&uppert racti nfect ionsa7- 10daycour sei sef fect iv e. Pr ophy lax is shoul d be consi der ed unt ili nvest igat ions oft he ur inar ytr acthas been compl eted.Theagent scommonl yusedf orpr ophy laxi s Tr imet hopr im 1- 2mg/ kgperday, Nit rof urant oin1mg/ kgperday, Co- amoxi clav 2 Vesi cour eter icRef lux Thi sisdef inedasar etr ogr adef low ofur inef rom t hebl addert otheur eter sandi sa commonf indi ng( 30percent )inpat ient swi thUTI.Ear lydat asuggest edt hatpr imar yVUR i nappr oxi mat ely1percentofheal thyneonat es. VURmayal sooccurasasecondar yphenomenoni nthecont extofur ethr alobst ruct ion, neur opat hicbl adderdysf unct ionorsever edysf unct ionalvoi ding. Thepat hogenesi sofr enal scar ri ngi npat ient swi thVUR, par ti cul arl yhi ghgr ade, issex depend¬ent.Inboy s,pr enat aldy spl asi aismor eli kel ywher easi ngi rl s,acqui redpost - i nfect ivescar ri ngi smor eli kel y.Ot herr elev antf act orspar ti cul arl yinpat ient swhohav eno demonst rabl eVUR, aredy sfunct ional voi ding, bact eri alv ir¬ul encef act orsandt hehost i nfl ammat oryr esponse. Out come Al thoughmostchi l drenwi thUTIhav eex cel l entpr ognosi s,t her emaybel ong- ter m i mpl icat ionsi nasmal lgr oupespeci all ythosewi thobst ruct ivemal for mat ionsand hi gh- grade VUR wi th scar ri ng.Long- ter m f oll ow- up ofwomen who pr esent ed i n chi ldhoodwi thsympt omat icorcov ertbact eri uri ahav eat hreet imesgr eat eri nci dence ofacut epy elonephr it iscompar edwi thcont rol s.I naddi ¬ti on,t her eisani ncr eased i nci denceofpr e-ecl ampsi aint hosewomenwhohav erenal scar ri ng. Al thoughhy per tensi onandchr oni crenali nsuf fi ciencyar erecogni zedl ong- ter mri sk f act orsi npat ient swi thbi l ater alr enal scar ri ng, for tunat elyr ecentpr ospect ivedat a suggestt her iski ssmal landpr obabl yrest ri ctedt othosewi thr enal dyspl asi a. KEYLEARNI NGPOI NTS ·Cl i nical feat uresofUTIar eof tennon- speci fi candev eryy oungchi l dwi thanunexpl ained f evershoul dhav eaur inecul tur e. ·Anegat ivecombi nat iondi pst ickur inal ysi sresul tdoesnotexcl udeUTIpar ti cul arl yin i nfant s. ·Al lchi l drenshoul dhav eaur inar ytr actul tr asoundaf teraf ir stpr ovedUTI.Subsequent 3 i nvest igat ionshoul dbedi ctat edbyage, present ingsy mpt omsandf ami l yhi stor y. ·VURi sfoundi nupt o30percentofchi l drenwi thahi stor yofUTIbutr enal scar ri ngmay occuri ntheabsenceofVUR. ·Thepat hogenesi sofr enal scar ri ngi nassoci ati onwi thVURi ssex -speci fi cwi thpr enat al dy spl asi abei ngpr omi nenti nboy sandpost -i nfect ivescar ri ngi ngi rl s. ·Thel ong- ter mri skofhy per tensi oni npat ient swi thuni l ater alr enal scar ri ngi sver ysmal l butpat ient swi thbi l ater alr enal scar ri ngr equi rel i fel ongr evi ew. TheHEMOLYTI C–UREMI CSYNDROME( HUS) Thehemol yti c-ur emi csy ndr ome( HUS)i sthemostcommoncauseofacut erenal fai l ure i nyoungchi l dren.I tiscl assi cal l ychar act eri zedbyt het ri adofmi croangi opat hichemol yti c anemi a,t hrombocy topeni a,andur emi a.HUShasf eat urescommont othr ombot ic t hrombocy topeni cpur pur a,exceptt hatt hel atert endst ooccuri nyoungwomenasa r elapsi ngi l lnesswi thf ever ,ser iouscent ral ner voussy stem i nvol vement ,andt hrombo- cy topeni a. ETI OLOGY Thedi seasef oll owsanepi sodeofgast roent eri ti scausedbyanent erohemor rhagi cst rai n ofEscher ichi acol i.Theor gani sm pr oducesaShi gal i kev erot oxi nthati sabsor bedf rom t hei ntest inesandi nit iat esendot hel i alcel li njur y.HUSi sal soassoci atedwi thShi gel l aand l esscommonl ywi thot herbact eri al( Sal monel l a,Campy lobact er, Str ept ococcus pneumoni ae), Bar tonel l aandv iral( coxsacki evi rus, echov irus, inf luenza, var icel l a,HI V, Epst ein- Bar r)i nfect ions.Fami l ial occur rencesar eusual l ynotassoci atedwi thdi arr heaand maybeaut osomal recessi veordomi nantdi sor der s. PATHOGENESI S Thepr imar yev enti stheendot hel i alcel li njur y,Capi l lar yandar ter iol arendot hel i al i njur yint heki dneyl eadst olocal i zedcl ott ing.Mi croangi opat hicanemi aresul tsf rom 4 mechani cal damaget o(RBCs)ast heypasst hrought heal ter edv ascul atur e. Thr ombocy topeni aiscausedbyi ntr arenal anddi ff usemi crov ascul arpl atel etadhesi onor damage.DamagedRBCsandpl atel etsar eremov edf rom ci rcul ati onbyt hel i verand spl een.Nondi arr heal andspor adi crecur rentf ami l ial casesofHUSar eassoci atedwi thl ow compl ement( C3)l evel sduet ocompl ementdy sregul ati onandact ivat ionf oll owi ngi njur y t otheendot hel i alcel l. CLI NlCALMANI FESTATI ONS. Mostcommoni nchi l dreny oungert han4y rofage.Theonseti susual l ypr ecededby gast roent eri ti s(f ever ,vomi ti ng, abdomi nal pai n,anddi arr heat hati sini ti all ywat erybutt hen becomesbl oody ).Lesscommonl y,pat ient smaypr esentaf teranupperr espi rat oryt ract i nfect ion.Suddenonsetofpal l or, irr it abi l ity ,weakness, let har gy, andol i gur iausual l y occur s5- 10day saf tert hei nit ial gast roi ntest inal orr espi rat oryi l lness.Phy sical exami nat ionmayr eveal dehy drat ion, edema, pet echi ae, hepat ospl enomegal yandmar ked i rr it abi l ity. DI AGNOSI ASANDDI FFERENTI ALDI AGNOSI S Thedi agnosi sissuppor tedbyt hef indi ngsofmi croangi opat hichemol yti canemi a, Thr ombocy topeni aandacut erenal fai l ure.Thehemogl obi nval uei scommonl yint he5- 9 g/ dlr ange.Thebl oodper ipher alsmearr eveal shel metcel l s,bur rcel l s,andf ragment ed RBCs.Ther eti cul ocy tecounti smoder atel yel evat ed, andt heCoombst estr esul tis negat ive.Leukocy tosi sissi gni fi cant ,andcommonl ythel eukocy tecountmayexceed 30, 000/ mm3, Thr ombocy topeni a(20, 000- 100, 000/ mm3)occur sinmor ethan90%of pat ient s.Fi ndi ngsonur inal ysi sar esur pri si ngl ymi l dandusual l yconsi stofl ow- grade mi croscopi chemat uri aandpr otei nur ia.HUSshoul dal way sbeconsi der edi nthechi l dwi th asuddenonsetofacut erenal fai l ure.Thet ypi cal hist ory ,cl i nical pict ure, andl abor ator y f indi ngsconf ir mthedi agnosi sinmostpat ient s.Ar enal biopsyi srar elyi ndi cat ed. Pat ient swi thbi l ater alr enal vei nthr ombosi smaybedi ff icul ttodi sti ngui shf rom t hose wi thHUS. 5 COMPLl CATI ONS Anemi a,aci dosi s,hy per kal emi a,f lui dov erl oad, hear tfai l ure, hyper tensi on,andur emi a. Ext rar enal mani fest ati onsi ncl udei ntest inal hemor rhageandper for ati on, CNS( ir ri tabi l ity , sei zur es, inf arct s,coma), D.M. TREATMENANDPROGNOSI S Suppor ti ve1-Cont rol off lui dandel ect rol ytebal ance, cor rect ionofdehy drat ion. 2-Pl asmaphar esi sorf reshf rozenpl asma 3-Car eful managementofhemat ologi candr enal mani fest ati ons, wit hear lyandf requent per it oneal dial ysi s(t hemosti mpor tant ). 4-Wi thaggr essi vemanagement, mor ethan90%sur viv etheacut ephase, andt he maj ori tyr ecov ernor mal renal funct ion 5-Long- ter m obser vat ioni snecessar ytowat chf orl atedev elopmentofhy per tensi onor chr oni cki dneydi sease.Recur rencei srar e. POSTERI ORURETHRALVALVES I sthemostcommoncauseofsev ereobst ruct iveur opat hyi nchi l dren, aff ect ing1i n 8000boy s.I tref erst oti ssuel eaf let sfanni ngdi stal l yfr om t hepr ost ati cur ethr atot he ext ernal uri nar ysphi nct er.About30%ofpat ient sexper ienceend- stager enal diseaseor chr oni crenal insuf fi ciency.VURoccur sin50%ofpat ient s,anddi stal uret eral obst ruct ion mayr esul tfr om achr oni cal l ydi stendedbl adderorbl addermuscl ehy per trophy.Ther anal changesr angef rom mi l dhy dronephr osi stosev erer enal dyspl asi a(t her emaybe ol i gohy damni osandpul monar yhy popl asi a). Prenat all ydi agnosedPUVs, par ti cul arl yint he secondt ri mest er, car ryapoorpr ognosi sthant hosedet ect edatbi rt h.PUVsar e suspect edi naneonat ewi thapal pabl ydi stendedbl adderandt heur inar yst ream i sweak. I fsev ereobst ruct ionunr ecogni zeddur ingneonat alper iod,i tmaypr esentl ateri nli fewi th f ail uret othr iveduet our emi aorsepsi scausedbyi nfect ioni ntheobst ruct edur inar ytr act. Wi thl esserdegr eesofobst ruct ion, chi l drenpr esentl ateri nli fewi thdi ff icul tyi nachi evi ng 6 di urnal uri nar ycont inenceorwi thUTI.Thedi agnosi sisest abl i shedwi thaVCUGorby per ineal ult rasonogr aphy.I nheal thyneonat es, asmal lfeedi ngt ubei sinser tedi nthe bl adderandl eftf orsev eral day s,aFol ey( bal l oon)cat het ershoul dnotbeusedasi tmay causesev erebl adderspasm andsev ereur eter alobst ruct ion.Whenser um cr eat ini nei s nor mal ,tr eat mentconsi stsoft ransur ethr alabl ati onoft hev alv eleaf let sendoscopi cal l y UGA, andi ftheur ethr aist oosmal l,t empor aryv esi cot omyi spr eff ered.Cont rolof i nfect ionbyant ibi oti cswi thpr ophy laxi s. 7