==================================================================UTI in children

**c/o: fever (ddx)***

=======================intro, df
- febrile illness , comm any age BUT <2y
- All children <2 years of age with unexplained fever should have urine tested for UTI.
- Compli: - imp RF to develop--> HTN, renal failure , ESRD (end stage renal dis)

- df [pp]:
• uti is growth of bacteria in the urinary tract /or combination of clinical features + bacteriuia
-[prof] : presence of inf (usually bacterial) in normal sterile posterior urethra, bladder, ureters, renal pelvis or parenchyma
- urine contaminated by bacteria presence in the anterior urethra and skin

• Significant bacteriuria is defined as the presence of > 105 colony forming units (cfu) of a single organism per ml of freshly voided
urine (Kass).
• Acute pyelonephritis is bacteriuria presenting clinically with fever > 38⁰C and/or loin pain and tenderness. It carries a higher risk of
renal scarring
• Acute cystitis is infection limited to lower urinary tract presenting clinically with acute voiding symptoms: dysuria, urgency,
frequency, suprapubic pain or incontinence.
• Asymptomatic bacteriuria is presence of bacteriuria in the urine in an otherwise asymptomatic child.

=====================epid
- vary w age & sex
• High in first 6 months and more in boys ; • School age UTI is far more common in girls
– 1% of boys and 3% of girls have UTI in the first decade
– 40% of girls suffer recurrent UTI
• 0.3 % --> hv significant UT abnormalities confirmed postnatally
- 1/3 : pelvi-ureteric junction obstruction. --> can cause VUR (vesico-ureteric reflux)
- Others: – multicystic dysplastic kidney – Vesico-ureteric junction obstruction – Duplex system – VUR

====================MB
- E. coli (80%), proteus spp , klebsiella, pseudomonas, enterococcis, staphylococcus , serratia…

----------------pathog (E.coli)
Bacteria Factors associated with Uropathogenic virulence of E. coli:
1.Have P-fimbriae 2.Adhere to uroepithelium 3.Produce hemolysin 4.Produce colistin V 5.Resistant to bactericidal action

====================RF (ask in h/o*) #

- male: uncircumcised , anatomical problem
- female: gender , wipe back to front?

- home: toilet training , bubble bath, tight clothing (underwear), hygiene

- instrument: urethral instrum
- patho: UT anomaly# discussed below in mx too: VUR, bladder/voiding dysf, … ; GIT: pinworm inf, constipation
-[prof] bladder dysf: s/s: daytime wetting; compli: aquired VUR, renal damage
-[p] VUR : high grade UTI symp
-[p] obstruction (at pelvi-ureteric/vesico-ureteric junction, & in male: post urethral valve…)
- ureteric duplication: duplex kidney
- renal scarring
- adolesc: sexual actvt, pregnancy

====================CF, PE:
• Symp depend on age & site of inf.
AGE• infants, toddlers: s/s r non-specific e.g. fever, irritability, prolonged neonatal jaundice, poor feeding/ failure to thrive,
vomiting/diarrhea
• if unexplained fever (esp <2y) ---> UTI should be considered in children
SITE• lower UTI : eg pain with micturition and frequency are often not recognized <2y
PE
• General examination, growth, bp.
• Abd exam for distended bladder, ballotable kidneys, other masses, genitalia, and anal tone. {genitalia--> for congenital anomalies)
• Examine the back for any spinal lesion. {spine for congenital ano} ??? eg??--> neurogenic bladder
• Look for lower limb deformities or wasting (suggests a neurogenic bladder).

=======================dx
• Accurate diagnosis is extremely important as false diagnosis of UTI would lead to unnecessary interventions that are costly and potentially harmful.
• dx is best made with-->
- urinalysis + (rapid dx by urine dipstick & microscopy = UFEME
- culture&S (where possible C&S)
• The quality of the urine sample is of crucial importance.
• Urine specimen transport
• If collected urine cannot be cultured within 4 hours; refrigerate specimen at 4 oC or add a bacteriostatic agent e.g. boric acid (1.8%)
• Use container pre-filled with boric acid and fill urine to required level.
?-*[prof] Positive urine culture does not mean UTI
-----------------collection of urine by:
- Bag urine specimen ; Clean catch specimen (child w bladder trained);
- When it is not possible to collect urine by non-invasive methods, ---> catheterization or SPA(Suprapubic aspiration)
- Catheterisation • Sensitivity 95%, specificity 99%, as compared to SPA.
• Low risk of introducing infection but have higher success rates and the procedure is less painful compared to SPA.
- SPA • Best technique (“gold standard”) of obtaining an uncontaminated urine sample.
• Any gram-negative growth is significant.

-[prof]
--------------------the components in test
- Leucocyte esterase (LE); Nitrite; pyuria; bacteria
-LE: an enzyme prod by leukocytes …so test for presence of wbc = inf
- nitrite: normal urine has nitrates; bacteria in UT turn it into nitrites = sign of uti

------------------imaging (now only recomm for specific indication, for high-risk pt:)
--u/s (**all boys w uti need u/s)
-HIGH RISK PT: all childr <3y (prof <2y);
for>3y: seriously ill (s/s of pyelonephritis/septicemia),
recurrent uti
palpable abdominal masses,
^sr Cr, non E coli UTI,
febrile after 48h of abx tx,
-voiding d/o
-clinical f suggestive of UT anomalies
**LOW-RISK PT: if not fit the above…no Ix needed**
**below can be done if u/s result is abnormal**:
--DMSA scan
-similar to above#
--Micturating cystourethogram (MCUG)
 -similar#
- isotope renogram
-#pic in slide at end

==========================Mx
• All infants with febrile UTI should be admitted and intravenous antibiotics started as for acute pyelonephritis.
• In patients with high risk of serious illness, it is preferable that the urine sample should be obtained first; however treatment should be
started if urine sample is unobtainable.

--------------Abx Tx for uti : (just remember some names, also from the prof one)
-(( ([p]<3m old OR any age with toxic/unwell/not tolerate orally:
- ampicillin & gentamicin OR cefotaxime & ampicillin (IV) ))

- ([p]>3m old +) Upper Tract UTI (Acute pyelonephritis) with E.coli., Proteus spp.
- Preferred Treatment : IV Cefotaxime 100mg/kg/day q8h for 10-14 days
- Alternative Treatment IV Cefuroxime 100mg/kg/day q8h or IV Gentamicin 5-7mg/kg/day daily
- *Note:
• Repeat culture within 48hours if poor response.
• Antibiotic may need to be changed according to sensitivity.
• Suggest to continue intravenous antibiotic until child is afebrile for 2-3 days and then switch to appropriate oral therapy after culture results e.g. Cefuroxime, for total of 10-14 days.

- ([p]>3m old +) lower UTI (Acute cystitis) with E.coli., Proteus spp.
- Preferred Tx: PO Trimethoprim 4mg/kg/dose bd (max 300mg daily) for 1 week
- Alternative Treatment : PO Trimethoprim/Sulphamethazole 4mg/kg/dose (TMP) bd for 1 week
-*Note:
• Cephalexin, cefuroxime can also be used especially in children who had prior antibiotics.
• A single dose of antibiotic therapy is not recommended.

- Asymptomatic bacteriuria : none recommended

---------------uti Antibiotic prophylaxis

• should not be routinely recommended for infants and children following a first ep of UTI except for certain indications as listed below
• Recent evidence has shown that antimicrobial prophylaxis does reduced the risk of febrile or symptomatic UTI in children with VUR III or IV but has no significant effect on the incidence of renal scarring

• indication:
• Infants and children with recurrent symptomatic UTI or/and   VUR >=grade III
- Preferred Treatment : PO Trimethoprim 1-2mg/kg ON
- Alternative Treatment : PO Nitrofurantoin 1-2mg/kg ON or PO Cephalexin 5mg/kg ON #

===========prevention
- ^fluid intake

- change diapers freq

-wipe from ant to post (esp girl)

- encourage child to pee when needed

- provide proper toilet training

- give probiotic yogurt

- drink cranberry juice

==========further Mx [pp] #
- NO VESICOURETERIC REFLUX BUT RENAL SCARRING PRESENT
- • Shrunken/scarred kidneys --> ^risk of hypertension in the long term
• If bilateral involvement- risk of progressive renal failure
- pathog#prof

- Mx invasive:
- VESICOURETERIC REFLUX
-df: retrograde flow of urine from the bladder into the ureter and collecting system
- mostly VUR results from--> a congenital anomaly of ureterovesical junction (primary VUR),
others from--> high pressure voiding secondary to posterior urethral valve, neuropathic bladder or voiding dysfunction
(secondary VUR).

- Signif:
• Commonest radiological abnormality in children with UTI (30 – 40%).
• compli: risk for further eps of pyelonephritis with potential for ^ renal scarring and renal impairment (reflux
nephropathy).

- compli:
- Mx: • Antibiotic prophylaxis: #as above.
• Surgical Mx/ endoscopic Tx is considered if the child has recurrent breakthrough febrile UTI.

- POSTERIOR URETHRAL VALVE #

- RENAL DYSPLASIA, HYPOPLASIA OR MODERATE TO SEVERE HYDRONEPHROSIS # - mx: surgery

<>>>>>>>>>>>>
=======================epid
- boy (if get uti, more likely RT abnormality
- girl (more chance later)

- <1% --> UT abnormality confirmed postnatally

- 1/3 --> pelvi-ureteric j obstr

-***post urethral valve (dribbling, not continuous)

=====================etio
-1) E. coli (80-90%) (70% of recurrence)
- r resistant to most Abx

--------host factors
-
- VUR
- intrarenal reflux
- obstr UT (also constip)
- foreign body (by themselve, or sexual abuse)

- inborn metabolism --> fenal-ketonuria (sweet smell; UTI (more awful smell)

-----------------pylonephritis
- classic symptom

Urosepsis, septicemia

-----------------prevent
- in school, toilet dirty so hold pee

- wipe the anal area cleanly first** --> don’t touch genitalia until anas clean

------clean catch urine --> but need to wait 30min

------needle aspiration (in neonate, icu, suspect urosepsis, septicemia) --> send immediately within 30min…any growth (emergency) …
not painful

--------uti is imp, coz suspicion of RT abnormality (so don’t just give abx like in adult)

------bladder dysf (daytime wetting…..risk of uti )

- when there is residual of 5ml, risk of uti

- vur (holf pee at school)

-if uti, <2y……..make sure it is not anatomical abnormality ****

- microbe can metabolise nitrate to nitrite

-----compli
- can lead to renal scarring--> Renal failure, htn, ……. (u/s to look at kidney size)

- incontinence / voiding ---> bladder dysf

-1-u/s
- DMSA scan
- MCUG (to dx reflux)
<5y: pyelonephritis, u/s for anatomical banormality

- need to put on prophylaxis

- 2 main area of interest

-any relux? --> scarring/damage more

---------VUR
- grade 4, 5 (paed urologist has to do)--> surgery req
- grade 3: give abx?

- image: intestine like ureter, clubbing

- 17% function, smaller, scarring

-

--------abx
- given at night…coz bladder get distended at night so more relux risk…so abx from jidney excreted--> kill

-----------vur
- rare
- <2y

--------------symp
-lower moity (bladder downward
- dysuria, urgency, freq ---> urine color change, odor (normally, odorless), pass urine freq (small amount ), rigor, fever (high), urine
color look dirty/blood , tenderness at back
- recurrence high
- send urine for culture
- do u/s--> smaller? Why? Scarring?

- renal punch --> if <2y = just press

-------------urosepsis
- cloudy urine?
=========================================================HTN (as complication, more comm..nephritic)
============df

===**dx:
• made if a child or adolescent has auscultatory-confirmed BP readings ≥ 95th percentiles on 3 different visits.

===how to find out?:

- 1-know the height of pt --> plot in growth chart to find out his percentile (if in bw 2 percentiles, choose the higher one eg: bw 90 & 95,
choose 95) --> then use the bp table

====bp measurement/check
- who?: all >=7y (whenever visit clinic..); for <7y those w risk (f/o, 2ry causes)

-
• Choose appropriately sized cuff. (Cuff width covers ≥ 40% of upper arm and cuff length covers 80%- 100% of circumference of arm.)
• Measure BP with the child in a seated position and their arm supported, after he or she has been sitting quietly for 3-5 minutes (for an
infant, lying supine). ….do both hands
• Perform a manual BP reading using auscultation if any BP level >90 percentile on oscillometric devices.
• BP should be measured preferably 3 times at each visit and the average of measurement should be used.

===terms: #
------white coat htn
- office bp >=95th p but outside office bp is normal

-------1ry htn = essential htn (RARE…<1%)

- if >=6y + fullfill >=1 of factors below ==> no need further ix for 2ry cause
- +ve f/o of htn; overweight/obese; X s/s suggestive of 2ry cause
------- 2ry htn (comm in infant, younger children)
Most comm cause:
- kidney disease 75%
- vascular abnormality 15%
 - endocrinological d/o 5%
- CNS
- other …eg

================pathog ###
- bp = CO x PR

================h/o, PE ###
- check for 2ry causes

===================Ix

===================Mx
- treatment goal --> reduction of SBP and DBP to <90th percentile and <130/80 mmHg in adolescents ≥13 years old.

- non-pharma
- exercise, weight loss, low-salt/added-salt diet , smoke
- pharma (if non-pharma failed, sympt pt, not modifiable , a/w CKD/DM, red-flags…#)
- in KB: Ca channel blocker …eg: amlodipine, nifedipine
- if renal disease, give ACEi or ARBs ??
- * start with 1 medication type only --> increase dose until max if not respond--> after that can add another drug
==============================================================================================AKI
===============df =prev called AKF
- sudden ^ sr Cr & v GFR --> r/I n inability of the kidneys to regulate fluid and electrolyte balance

==============causes

==============CF
• Of underlying cause.
• Oliguria (< 300 ml/m²/day in children; < 1 ml/kg/hour in neonates)
• Non-oliguria.

• Clinical features arising from complications of AKI e.g. seizures, acute pulmonary oedema

• Important to consider pre-renal failure as a cause of oliguria.

• In pre-renal failure, the kidney is intrinsically normal and the tubules are working to conserve water and sodium appropriately.
• In acute tubular necrosis (ATN) the damaged tubules are unable to conserve sodium appropriately

==============Ix
BLOOD
-fbc
-RFT (urea, Cr)+
- sreum electrolyte (Na, K, Ca, P)
- serum albumin
- blood gas (VBG)
URINE
- biochemistry and microscopy.

• Imaging: renal ultrasound scan (urgent if cause unknown).

• Other investigations as determined by cause

==============Mx
-----Fluid balance
In Hypovolaemia
• Fluid resuscitation regardless of oliguric / anuric state
• Give crystalloids e.g. isotonic 0.9% saline / Ringer’s lactate

In Hypervolaemia / Fluid overload …CF: HTN, ^JVP, displaced apex bat, basal crepts, hepatomegaly, SOB
-
- diuretic
- dialysis (if no response/sever)

HTN mx:#

Metabolic acidosis
- if pH < 7.2 or symptomatic or contributing to hyperkalaemia
- HCO3

Electrolyte abnormalities
Hyperkalaemia (K)
• Definition: serum K⁺ > 6.0 mmol/l (neonates) and > 5.5 mmol/l (children).
• Cardiac toxicity generally develops when plasma potassium > 7 mmol/l.
- mx started if ECG anormality:
• Tall, tented T waves • Prolonged PR interval
• Widened QRS complex
• Flattened P wave
• Sine wave (QRS complex merges with peaked T waves)
• VF or asystole
-Mx #

Hyponatraemia (Na)
• Usually dilutional from fluid overload.
• If asymptomatic, fluid restrict.
• Dialyse if symptomatic or the above measures fail.

Hypocalcaemia (Ca)
• Treat if symptomatic (usually serum Ca²⁺ < 1.8 mmol/L), and if Sodium bicarbonate is required for hyperkalaemia, with IV 10% Calcium
gluconate 0.5 ml/kg, given over 10 – 20 minutes, with ECG monitoring.

Hyperphosphataemia (P)
•  Phosphate binders e.g. calcium carbonate orally with main meals.

===============================================================CKD
Most are asymptomatic until approaching CKD stage 4 (see Table 11.7). CKD should be suspected if:
• failure to thrive;
• polyuria and polydipsia;
• lethargy, lack of energy, poor school concentration;
• other abnormalities such as rickets.
- avoid nephrotoxic drugs
- renal transplant: definitive goal for child
- if not, maintenance dialysis (peritoneal dialysis--> at home can; hemodialysis--> done 3x/week at facility)

---------complic Tx:
- poor growth: ^ calorie intake
- anemia: Fe supplem, erythropoietin
- mineral bone d/o / hyperparathyroidism: 1,25 dihydroxyvitamin D supplement, Ca supplement, P diet restriction/P binder
- HTn: ACEi, ARB ..
- HyperK: low K diet, furosemide, Na polystyrene sulfonate
- hypoNa: Na supp
- metabolic acidosis: alkali replacement HCO3