Urinary Tract Infection

in Children

Dr Sri Riyanti SpA

Definition

■ Condition in which there is growth of bacteria/microbe within the urinary

tract in significant number

■ Renal parenchymal infection

■ Infection of urinary bladder
 UTI in children
■ A common health problem
– Cumulative incidence: 2%-8% < 10 years of age
– UTI: sign of urinary tract abnormalities (RVU, obstructive uropathies)
– Cause ESRD
– Uncomfort symptoms (fever, flank pain, dysuria)

■ Unexplained fever in neonates

Etiology

■ Escherichia coli : 60-85%

■ Enterobacter aerogenes
■ Enterococcus
■ Klebsiella, Proteus
■ Pseudomonas
■ Acinetobacter
■ Streptococcus faecalis
■ Staphylococcus aureus and epidermidis
■ Staphylococcus saprophyticus
■ Haemophylus influenzae
 Route of infection

■ Hematogenous route (neonates)

■ Ascending from urethral orifice  bladder
 Risk factors for UTI
■ Systemic or immunologic diseases
■ Condition that cause urinary stasis:
- VUR, calculi, voiding disorders
- Anatomic abnormalities
■ Previous UTI
■ History of VUR or UTI in siblings/parents
■ Constipations or encoporesis
■ Prematurity
■ Uncircumsised
 Clinical manifestations
■ Vary depends on age, site of infection, severity
■ Neonate:
■ Non specific
■ Slow weight gain
■ Temperature instability
■ Feeding difficulties
■ Irritability
■ Vomiting
■ Diarrhea
■ Abdominal distention
■ Jaundice
■ Sepsis : 30%
■ < 1 years:
■ Fever
■ Irritability
■ Sickly appearance
■ Refusal of food
■ Vomiting
■ Diarrhea
■ Abdominal distention
■ Jaundice
■ Preschool and school aged
■ Dysuria
■ Urgency
■ Increased frequency
■ Enuresis
■ Flank pain
■ Fever, chills
■ Costovertebral tenderness
■ Macroscopic hematuria: 26%
Laboratory investigation

a. Urinalysis:
■ Leucocyturia:
– 80-90% in symptomatic UTI

■ Leucocyte esterase test

■ Nitrite stick tests

– Most bacteria that cause UTI produce nitrite
■ Bacteria take time to produce nitrite
■ UTI: tends to void more frequent

■ Hematuria and proteinuria: sensitivity and specificity: low

■ Phase-contrast microscopy: bacteria

Lambert H, Coulthard M. Clinical Paediatric Nephrology, 3 rd ed., 2003,p.197-226

Table : Sensitivity and specificity or components of the
urinalysis alone and combination

Test Sensitivity % Specificity %

(Range) (Range)
Leukocyte esterase 83 (67-94) 78 (64-92)
Nitrite 53 (15-82) 98 (90-100)
Leukocyte esterase or 93 (90-100) 72 (58-91)
nitrite positive
Microscopy: WBCs 73 (32-100) 81 (45-98)
Microscopy: bacteria 81 (16-99) 83 (11-100)
Leukocyte esterase or 99.8 (99-100) 70 (60-92)
nitrite or microscopy
positive
Laboratory investigation…..

b. Blood examinations:

■ Differentiate upper UTI and lower UTI

■ Leukocytosis
■ Absolute neutrophil count 
■ ESR 
■ C-reactive protein
■ Procalcitonin 

Lambert H, Coulthard M. Clinical Paediatric Nephrology, 3 rd ed., 2003,p.197-226

Laboratory investigation….

c. Urine culture: gold standard

1. Methods of urine collection
2. Interpretation

 If urine is not directly culture: temperature 40C

 Media culture: McConkey
 Some bacteria require specific culture media

Lambert H, Coulthard M. Clinical Paediatric Nephrology, 3 rd ed., 2003,p.197-226

1. Methods of urine collection

a. Suprapubic aspiration: gold standard

b. Catheterization
c. Mid-stream specimen
d. Urine collector/bag sample: high false positive
2. Interpretation of culture

■ Depends of method of urine collections and clinical manifestations

■ Kass criteria:
– Urine catheterization and mid stream:  100.000 cfu/mL urine
– Supra-pubic aspiration: any bacteria
■ Others: urine catheterization: > 50.000 cfu/mL
■ Practically: if bacteria:
– > 100.000 cfu/mL : siginificant
– 10.000 – 100.000 cfu/mL : doubtfull, must be repeated
– 1.000 – 10.000 cfu/mL : contamination
– < 1.000 cfu/mL : negative.
• Usually: one strain bacteria.
• If bacteria > 1 strain: contamination
 Classification of UTI
■ Symptomatic
■ Symptomatic UTI
■ Asymptomatic UTI
■ Type of UTI
■ Simplex UTI = uncomplicated UTI
■ Complex UTI = complicated UTI
■ Site of infection
■ Lower UTI
■ Upper UTI
■ Atypical or recurrent
■ Atypical UTI
■ Recurrent UTI
■ Symptomatic UTI:
– UTI with symptoms, such as fever, dysuria

■ Asymptomatic UTI:
– UTI without symptoms

■ Simplex UTI
– UTI without anatomical and functional urinary tract
abnormalities which cause stasis of urine
■ Complex UTI:
– UTI with anatomical and functional urinary tract
abnormalities which cause stasis of urine:
■ Vesico-uretero reflux (VUR)
■ Hydronephrosis
■ Urolithiasis
■ Neurogenic bladder, etc)

– Acute pyelonephritis
– UTI in neonate
■ Lower UTI = Cystitis:
■ Dysuria
■ Frequency
■ Urgency of micturition

■ Upper UTI = Pyelonephritis:

■ Fever
■ Tenderness
■ ESR 
■ Urine concentrating ability 
■ White blood cell cast
■ C-reactive protein (CRP) 
■ Urinary beta-2 microglobulin 
■ Antibody coated bacteria (ACB)
■ Scar (DMSA)
Atypical UTI and recurrent UTI

Atypical UTI Recurrent UTI

■ Seriously ill
■ 2 or more episode of UTI with
■ Poor urine flow acute pyelonephritis or
■ Abdominal or bladder mass ■ 1 episode of UTI with acute
■  creatinine pyelonephritis plus 1 or more
episode of cystitis or
■ Septicaemia
■ 3 or more episode of UTI with
■ Failure to respond to treat with cystitis
suitable AB within 48 hours
■ Infection with non E. coli
organisms

National Institute for Health and Clinical Excellence. (2007):

 Management

1. Eradication of acute infection

2. Detection and treatment (surgery) of functional or
anatomical urinary tract abnormalities
3. Detection, prevention, and treatment of recurrent
infection
1. Eradication of acute infection

■ Elimination of acute infection

■ Prevent urosepsis
■ Reduce/prevent renal parenchyme damage

Lambert H, Coulthard M. Clinical Paediatric Nephrology, 3 rd ed., 2003,p.197-226

Table : Some antimicrobials for oral
treatment of UTI
Antimicrobial Dosage

Amoxicillin 20-40 mg/kg/d in 3 doses

Sulfonamide
TMP in combination 6-12 mg TMP, 30-60 mg
with SMX SMX per kg per d in 2 doses
Sulfisoxazole 120-150 mg/kg/d in 4 doses
Cephalosporin
Cephalexin 50-100 mg/kg/d in 3 doses
Cefixime 8 mg/kg/d in 2 doses
Cefpodixime 10 mg/kg/d in 2 doses
Cefprozil 30 mg/kg/d in 2 doses
Table: Some antimicrobials for parenteral
treatment of UTI

Antimicrobial Daily dosage

Ceftriaxone 75 mg/kg/d
Cefotaxime 150 mg/kg/d
Ceftazidime 150 mg/kg/d
Cefazolin 50 mg/kg/d
Gentamycin 7.5 mg/kg/d
Tobramycin 5 mg/kg/d
Ticarcillin 300 mg/kg/d
Ampicillin 100 mg/kg/d
Symptomatic treatment

■ Therapy of fever, vomiting

■ Adequate fluid intake
■ Perineum hygiene
■ Hospitalization:
– Severe illness, high fever, vomiting, abdominal
pain
Indications for hospitalized

■ Severe systemic symptoms:

■ Dehydrated
■ Toxic
■ Oral intake difficulties
■ Acute pyelonephritis
■ Hypertension
■ Renal failure
■ Neonates

Smellie JM. Clinical Paediatric Nephrology, 1994, p.160-74

Lamber H, Coulthard M. Cilical Paediatric Nephrology, 2003,197-226
Wong SN. Practical Paediatric Nephrology, 2005, 160-7.
 Acute pyelonephritis

■ Hospitalization
■ Broad antibiotic, parenteral (intravenous)
■ Nitrofurantoin should not used
■ 10 – 14 days
■ Parenteral AB maybe replaced by oral AB
■ Low dose AB prophylaxis for prolonged period
 Cystitis
■ Oral antibiotics
■ Do not require hospitalization
■ Severe cystitis (pain, vomiting, dehydration):
hospitalization
■ 7-10 days (3-5 days)
■ Trimetoprim-sulfametokszol, nitrofurantoin,
amoxicillin, amoxicillin-clavulanic, cefixime
■ If possible, avoid cephalosporine
 UTI in neonate

■ Commonly associated with sepsis

■ IV antibiotics
■ AB: 10 – 14 days
2. Detection and treatment
(surgery) of functional/anatomical
urinary tract abnormalities

■ Physical examinations
■ Radiological examinations
 Technique
1. Renal US
2. IVP
3. Mictiocystourethrogram (MCU)
4. Scintigraphy: 99m-Tc Dimercapto- succinic acid (DMSA)

William G, Craig JC. Diagnosis and management of urinary tract infections. Comprehensive Pediatric
Nephrology, Mosby Elseviar, Philadelphia, 2008,p.539-47.
Fig: Vesicolithiasis
Normal flow vs VUR
 GRADE OF REFLUX

I. Ureter only
II. Ureter, pelvis and calyces : no dilatation, normal fornices
III. Mild or moderate dilatation of renal pelvis, no or slight bunting of fornices
IV. Moderate dilatation and or turtuosity of ureter, moderate dilatation of pelvis
and calyces
V. Gross dilatation and turtuosity of ureter gross dilatation of pelvis and calyces
■ Surgery treatment: Complex UTI:

– Obstruction
– Posterior uretheral valve
– Ureterocele
– Duplex ureter
 3. Detection, prevention, and
treatment of recurrent
infection
■ Urine culture
■ Treat predisposing factors
■ Prophylaxis
■ antibiotics
■ probiotics
■ Recurrent UTI: in 40 – 50% of symptomatic UTI in 2 years observations
Prophylaxis treatment
■ Indications:
– Children with high risk: obstructive uropathy
– High grade VUR
– Recurrent UTI
– Acute pyelonephritis

■ Not recommended:
– first febrile UTI without VUR or with grade I-II VUR
– routinely for the first UTI

■ Complex UTI: prophylaxis for 3 - 4 months

National Institute for Health and Clinical Excellence. (2007):

Montini and Hewitt, Pediatr Nephrol 2009;24:1605-9.
The International VUR Study of Children
Table: Antibacterial prophylaxis for UTI

■ Trimetoprim :1-2 mg/kgbw/d

■ Co-trimoxazole
■ Trimetoprim : 1-2 mg/kgbw/d
■ Sulphamethoxazole : 5-10 mg/kgbw/d
■ Cephalexin : 10-15 mg/kgbw/d
■ Nitrofurantoin : 1 mg/kgbw/d
■ Nalidixic : 15-20 mg/kgbw/d
■ Cefaclor : 15-17 mg/kgbw/d
■ Cefixime : 1-2 mg/kgbw/d

Smellie JM. Clinical Paediatric Nephrology, 1994, p.160-74

Lamber H, Coulthard M. Cilical Paediatric Nephrology, 2003,197-226
Wong SN. Practical Paediatric Nephrology, 2005, 160-7.
Long-term problems

■ Renal scarring
■ Hypertension
■ Renal failure

Smellie JM. Clinical Paediatric Nephrology, 1994, p.160-74

Lamber H, Coulthard M. Cilical Paediatric Nephrology, 2003,197-226
Wong SN. Practical Paediatric Nephrology, 2005, 160-7.
Congenital Anomaly of Kidney
and Urinary Tract
1. Bilateral renal agenesis
2. Super numery right kidney
3. Unilateral renal agenesis . Left kidney and ureter are absent
1. Left unilateral hypoplasia of the
kidney
2. Persistent fetal lobulation
3. Bilateral renal hypoplasia
1. Palpable mass in abdomen: hydronephrosis, neuronlastoma, Wilm’s tumor
2. Multicystic kidney
3. Multicystic kidney with duplication of ureter
4. Cystic mass sectioned: loosely agglomerulated large cysts
1. Polycystic kidney: surface aspect
2. Intravenous pyelogram: bilateral polycystic disease
3. Polycystic kidney: Kidney sectioned
1. Right pelvic kidney
2. Thoracic kidney
3. Crossed ectopia of the right kidney
1. Simple crossed ectopia with
fusion
2. S-shaped or sigmid kidney
3. Pelvic cake or lump kidney
4. Horsehoe kidney
1. Duplicated renal pelvis
2. Unusual configuration: elongation and spread of calyces
3. Calyceal cyst
4. Congenital uretropelvic obstruction with hydronephrosis
5. Aberrant vessel apparent cause of obstruction
Fig. Complete duplication of the ureter
Fig. Incomplete duplication of urete
Ureterocele:
1.Bilateral ureterocele
2.Ureterocele at ectopic orifice of a duplicated ureter:
ureterocele so placed may pbstruct bladder outlet
1. Prune belly syndrome
2. Voiding cystogram: reflux into massively dilated urinary tract
3. Enlarged bladder, dilated, turtuous ureters and bilateral hydronephrosis
4. Abdominal laxity becomes less apparent with age
1. Completely patent urachus
2. Partially patent urachus, opening external, blind internally
3. Partially patent urachus, opening internally, blind external
4. Cyst of urachus
Fig. Megacystic (megaureter syndrome)
Congenital bladder outlet obstruction:
1.Posterior urethral valve: hypertrophy and trabecula tion of bladder,
dilatation of ureters, renal pelvis
2. Fibroblastosis of prostate
Duplication and septa of the bladder:
1.Complete duplication of bladder and urethra
2.Incomplete duplication of bladder
3.Complete sagital septum of bladder
4.Incomplete septum of bladder
5.Hourglass bladder
 Vesico-ureteral reflux
■ Regurgitation of urine from the bladder into ureter and potentially to renal
parenchym
■ Diagnosis: VCUG (radio-contrast or radio-isotop)
Normal flow vs VUR
 GRADE OF REFLUX

I. Ureter only
II. Ureter, pelvis and calyces : no dilatation, normal fornices
III. Mild or moderate dilatation of renal pelvis, no or slight bunting of fornices
IV. Moderate dilatation and or turtuosity of ureter, moderate dilatation of pelvis
and calyces
V. Gross dilatation and turtuosity of ureter gross dilatation of pelvis and calyces