Urinary Tract Infection (UTI) Presentation PDF

URINARY TRACT INFECTION (UTI)  DR AJITE AB MBChB, FMCPaed  INTRODUCTION   Urinary tract infection is among the most common bacterial infections in children  It occurs in approximately 1% of boys and 3% of girls during childhood.  Urine is an excellent cult...

URINARY TRACT INFECTION (UTI)  DR AJITE AB MBChB, FMCPaed  INTRODUCTION   Urinary tract infection is among the most common bacterial infections in children  It occurs in approximately 1% of boys and 3% of girls during childhood.  Urine is an excellent culture medium and if there is residual urine after voiding, there is a significant risk for developing UTI which can occur at any age  EPIDEMIOLOGY   In neonates, boys are more likely to have UTI than girls owing to the higher incidence of congenital urinary tract abnormalities in males.  The prevalence of UTIs varies with age. During the 1st yr of life, the male : female ratio is 2.8–5.4 : 1. Beyond 1–2 yr, there is a striking female preponderance, with a male : female ratio of 1 : 10.    Female infants and children have a higher incidence of UTI than males because they have shorter urethras, a greater predisposition to dysfunctional voiding and a higher prevalence of vesicoureteral reflux.  Females are more prone to UTI when they become sexually active  AETIOLOGY   75–90% of all UTI are caused by Escherichia coli, followed by Klebsiella spp. and Proteus spp.  Klebsiella, Enterobacter, Proteus, Pseudomonas, Enteroccocus and Candida are encountered in the presence of obstruction, instrumentation and poor immune state  Klebsiella is a common aetiology in neonates  PATHOGENESIS   Virtually all UTIs are ascending infections, rarely, renal infection may occur by hematogenous spread, as in endocarditis or in some neonates.  The bacteria arise from the fecal flora, colonize the perineum, and enter the bladder via the urethra.  In uncircumcised boys, the bacterial pathogens arise from the flora beneath the prepuce.  The bacteria causing cystitis may ascend to the kidney to cause pyelonephritis.    The pathogenesis of UTI is based in part on the presence of bacterial pili or fimbriae on the bacterial surface with which they adhere to the epithelial cells  Some E. coli possess invasive toxins and hemolysins and are more pathogenic  RISK FACTORS FOR UTI   Female gender  Obstructive uropathy  Vesicoureteral reflux  Neurogenic bladder  Uncircumcised male  Urethra instrumentation  Wiping from back to the front in female after defaecation  Constipation  Immunosuppression  CLINICAL FEATURES   The 3 basic forms of UTI are pyelonephritis, cystitis, and asymptomatic bacteriuria  Clinical pyelonephritis is characterized by any or all of the following: abdominal or flank pain, fever, malaise, nausea, vomiting, and, occasionally, diarrhea.  Newborns may show nonspecific symptoms such as poor feeding, irritability, and weight loss    In younger children it is non-specific and may include fever, vomiting,poor feeding, diarrhoea, failure to thrive, micturitional cry  In older children there is dysuria, frequency and urgency of micturition, haematuria, loin pain (Renal angle tenderness)    Cystitis indicates that there is bladder involvement; symptoms include dysuria, urgency, frequency, suprapubic pain, incontinence, and malodorous urine  Asymptomatic bacteriuria refers to a condition that results in a positive urine culture without any manifestations of infection  INVESTIGATION  Urine sample is obtained by ;  Clean catch  Suprapubic aspiration  Urethra catheterization Appearance of the urine may be turbid Presence of WBC cast on urine microscopy  INVESTIGATIONS   Diagnosis is confirmed by urine culture when it is 105 or more bacterial per ml  Any colony growth obtained by suprapubic aspiration is significant  Dipstick examination- detection of leucocyte esterase and nitrite  Microscopy of an uncentrifuged urine showing more than 10WBC/cu mm is abnormal   . If the culture shows >100,000 colonies of a single pathogen, or if there are 10,000 colonies and the child is symptomatic, the child is considered to have a UTI.    FBC  Blood culture  E/U/Cr  Plain abdominal X-ray  Abdominopelvic USS  Intravenous urography  TREATMENT  General measures;  Encourage liberal fluid intake  Regular bladder emptying to prevent stasis Specific measures; UTI in early infancy is often associated with sepsis, treatment should be with a combination of parenteral ampicillin with an aminoglycoside for 10-14 days. Alternatively a third generation cephalosporin can be used    UTI in older children; the management depends on the severity, if pyelonephritis is suspected antibiotics are given parenteral initially as above and antibiotics are changed to oral once toxicity resolves  In patients who are not toxic and are tolerating orally, amoxicillin, co-amoxiclav, cephalexin or cefixime for 10days  Patients are followed up with repeat urine m/c/ s  Surgical intervention in cases of obstruction    Long term prophylaxis in UTI  Age 3yrs being investigated for the underlying cause of UTI  Recurrent UTI of ≥3episodes in one year being investigated for the underlying cause  UTI with VUR e.g. of drugs used as prophylaxis are; cotrimoxazole,nitrofurantoin,  DIFFERENTIAL DIAGNOSIS   Malaria  Respiratory tract infection  Gastroenteritis  COMPLICATIONS OF UTI   UTI involving the kidney can lead to parenchymal injury and scar formation.  Hypertension-Renal scars can lead to distortion of the renal parenchyma and vessels causing hyperreninemic hypertension.  CKD- rarely, chronic urinary tract infections can be the cause of progressive renal injury leading to chronic renal failure and end-stage renal disease.  PROBLEM BASED LERNINGSESSION  A 6yr old boy was brought to the CEW with 3days history of fever, vomiting, loin pain 1. What relevant question will you ask the parent 2. What investigation will you request for 3. What is your diagnosis 4. What are the likely complications of your diagnosis