URINARY TRACK INFECTION (UTI)

urinary tract infection, or UTI, is an infection in any part of the urinary system, which includes:
kidneys, bladder, ureters, and urethra. Or it can be defined as an infection of one or more
structures of the urinary track and can be classified as lower urinary track infection ( cystitis ie
inflammation of the bladder or urethritis ie infection of the urethra).
It can be upper urinary track infection eg Pyelonephritis ie infection of the kidney.
Identification of the site of infection is very important in determining the treatment.
INCIDENCE
- Each year, about 3 in 100 children develop a UTI and most of these infections are
bladder infections.
- Babies under 12 months of age are more likely to have a UTI than older children, but
uncommon in neonate. At this age they are more common in boys than girls. This is so
because bacteria and other infection-causing microbes may enter the urinary tract when
an infant has a dirty diaper or when babies are wiped from back to front.
- UTI in neonate is approximately 1% with a greater frequency in males. However, after
the first year of life, the incidence is more common in girls than boys which is about 3%
this is so because of girls anatomical position ie short female urethra.
- Boys who are uncircumcised are more likely to have UTI than those who are
circumcised.

TYPES OF UTI
An infection can happen in different parts of your urinary tract. Each type has a different name,
based on where it is.

1) Cystitis – infection of the bladder.

2) Pyelonephritis infection of the kidneys.
3) Urethritis infection of the urethra
CAUSES OF UTI IN CHILDREN
The most common bacterial causing UTI infection are:-
In full- term neonate the common organism causing UTI is Escherichia coli ( E. Coli)
In preterm babies are Kleibsiella and enterobacterial
In newborn is Candida species.
Other organisms includes :-
Enterobacter
Proteus species
Staphylococcus
Enterococus
Aerobacter aerogenosa
THE RISK OR CONTRIBUTING FACTOR CAUSING UTI INCLUDES:-
 A structural deformity or blockage in one of the organs of the urinary tract

 Abnormal function of the urinary tract

 Vesicoureteral reflux, (a birth defect that results in the abnormal backward flow of
urine)

 The use of bubbles in baths

 Tight-fitting clothes (for girls)

 Wiping from back to front after a bowel movement

 Poor toilet and hygiene habits

 Urinary retention for any reason

 UTIs are most common in immunosuppressed children (kids who have a weaker
immune system)

 Children who have been on antibiotics for a long period of time for other issues.

 Child who recently went through an organ transplantation

 Renal scarring from previous UTurogenic bladder and urethra valve

 Short female urethra and proximity to the anus

 Urinary catherization or instrumentation

 Local inflammation

 Infection of the skin may act as a focus for haematogenous spread of bacteria to urinary
track

 Presence of renal/ urinary calculi

 infrequent urination or delaying urination for long periods of time

 Type 1 diabetes.

CLINICAL FEATURES OF UTI IN CHILDREN

Symptoms of a UTI can vary depending on the degree of infection and child’s age. Infants and
very young children may or may not experience any symptoms. The onset of symptoms may be
sudden or gradual.

The common age at presentation of UTI in term neonates is the second week of life.

About 25% of premature infant after first week of life with features of sepsis have UTI.

When they do occur in younger children, the general symptoms may include:

 fever

 poor appetite

 vomiting

 diarrhea

 irritability

 overall feeling of illness

Additional symptoms vary depending on the part of the urinary tract that is infected. If the child
has a bladder infection, symptoms may include:

 blood in the urine

 cloudy urine

 foul-smelling urine

 pain, stinging, or burning with urination

 pressure or pain in the lower pelvis or lower back, below the navel

 frequent urination

 feeling the need to urinate with minimal urine output

 urine accidents after the age of toilet training

If the infection has traveled to the kidneys, the condition is more serious. Thel child may
experience more serious symptoms, such as:

 irritability

 chills with rigor

 high fever

  flushed or warm skin

 nausea and vomiting

 side or back pain

 severe abdominal pain

 severe fatigue

There is association of in conjuncted jaundice in neonates. Convulsion, anorexia, malaise,

lethargy, diarrhea, poor weight gain.

Urinary symptoms include:-

Frequency and urgency, dysuria, dribbling and bed wetting etc.

DIAGNOSIS
Urine sample is the first thing to obtain
 Collecting a clean urine sample can be a challenge for children who has not started toilet
trained, because urine sample can not be obtained from a wet diaper. For this reason,
doctor may use one of the following techniques to obtain urine sample:
 Urine collection bag. A plastic bag is taped over the child’s genitals to collect the urine.

 Catheterized urine collection. A catheter is inserted into the tip of a boy’s penis or into
a girl’s urethra and into the bladder to collect urine. This is the most accurate method.

 Suprapubic aspiration. It can be performed safely using a 21guage needle 1-2cm above
the symphysis pubis.

 Urinalysis. Urine is tested with a special test strip to look for signs of infection such as
red blood and white blood cells. In addition, a microscope may be used to examine the
sample for bacteria or pus.
  Urine culture. This laboratory test usually takes 24 to 48 hours. The sample is analyzed
to identify the type of bacteria causing the UTI, the number of bacteria and appropriate
antibiotic treatment to be used.

The following imaging tests may be used:

 Kidney and bladder ultrasound

 Full blood count (FBC) this revealed an elevated WBC

 Radiological study may be performed to detect structural abnormalities.

 Glucoheptonates scan after 4 months to detect renal scarring

 Voiding cystourethrogram (VCUG)

 Nuclear medicine renal scan (DMSA)

 CT scan or MRI of the kidneys and bladder

 Cystoscopy - to look inside your urethra and bladder.

A VCUG is an X-ray that’s taken while your child’s bladder is full. The doctor will inject a contrast
dye into the bladder and then have your child urinate — typically through a catheter to observe
how the urine flows out of the body. This test can help detect any structural abnormalities that
may be causing a UTI, and whether vesicoureteral reflux occurs.

A DMSA is a nuclear test in which pictures of the kidneys are taken after the intravenous (IV)
injection of a radioactive material called an isotope.

TREATMENT

A child with UTI will require prompt antibiotic treatment to prevent kidney damage after the
sample have been collected.

The most common antibiotics used for treatment of UTIs in children are:

 amoxicillin

 amoxicillin and clavulanic acid

 cephalosporin

 doxycycline, but only in children over age 8

 nitrofurantoin

 sulfamethoxazole-trimethoprim.

Antibiotic are selected based upon:-

 The age of the child.

 The signs and symptoms the child presented
 The type of bacteria causing UTI and the severity of infection will determine the type
of antibiotic to be used and the length of treatment.
 The antibiotics is changed if necessary after culture and sensitivity results is
determined.
 All newborn with suspected UTI should be treated with parenteral antibiotics
 A third generation cephalosporin eg Ceftriaxone is preferred and it can be combined
with aminoglycoside such as Gentamycin in severe cases. The treatment should be
continued for at least 14 days.
 Nitrofuradantoin, Amoxycillin, Ampicillin and Contrimoxazole is commonly usedin
older children but are avoided in neonates
 Follow- up culture may be obtained 48-72 hours after drugs therapy has commenced
if the child is still febrile.
 If correctable surgical lesions are present, this require repair.
 For frequently recurring UTI, a prolonged prophylactic therapy for a year even more
may be given in half (1/2 ) doses of the recommended doses for active infection.
 Prescribed Antipyretic and Analgesic should be administered to reduce fever and
pain.

NURSING MANAGEMENT

Initial assessment includes:-

 Interviewing the care giver and or the child (appropriate) regarding changes in
urine elimination such as:
  Pattern of elimination, frequency, hesitancy, dysuria, urgency and bed wetting in
a child who has already established night time control are symptoms of UTI
 Determine if there is an history of recurring UTI
 Evaluate the fluid intake
 Assess for quality, quantity and frequency of voiding
 Assess the vital signs including BP, this is very important in infant and toddler
who can not communicate
 A careful history can assist health care practitioners in determining the diagnosis
of UTI if possible perform urinalysis including specific gravity
 Rehydration is required to maintain renal blood flow and flush out bacterial and
debris
 To assess for dehydration, the nurse should observe for signs of tachycardia,
poor skin turgor, dry mucus membrane sunken eyes and fontanel.
 Lastly, assess the child level of comfort to determine need for analgesics and/ or
teaching distraction techniques.

COMPLICATIONS OF UTI

 Recurrent infection
 Irreversible Renal damage
 Severe vesicoureteric reflux (VUR)
 Chronic renal Failure
 Uremia
 Mental confusion
 Infertility in adult
 Kidney abscess
 Renal vein thrombosis
 Emphysematous pyelonephritis (EPN): This is a very rare, potentially fatal
complication. EPN is a severe infection in which necrotizing
bacteria destroy kidney tissue.

PREVENTION OF UTI IN CHILDREN

Prevention of urinary track infection include the following:

 1. Drinking Fluids. Encourage children to drink 8–10 glasses of water and other fluids
everyday.
2. Increasing vitamin C intake may decrease the risk of UTIs by making the urine more
acidic, thus killing infection-causing bacteria.
3. Use of probiotic eg Yogurt- Probiotics could help prevent UTIs and are beneficial for
restoring gut bacterial
4. Urination: Urinate whenever there is an urge. Do not wait.
5. Sexual intercourse: Urinate after sexual intercourse. Wash the genitals before and after
intercourse.

6. Hygiene: Wash the genitals every day. Do not use deodorant sprays or a douche on the
genitals.

7. Toilet hygiene: After passing stools, wipe the anus from front to back. This reduces the
risk of spreading bacteria to the genitals.

8. Fiber: Eat plenty of fiber so that stools come out easily and do not cause irritation or
skin lesions. Constipation increases the risk of developing a kidney infection, and a lack
of fiber has links with kidney stones.
9. Good Bathroom Habits.
10. No Bubble Baths.
11. Frequent Diaper Changes.
12. Proper Wiping.
13. Cotton Underwear.
14. Regular empty of bladder.