Urinary Tract Infections in

Children

BY
Daniel Ghossein
 Introduction
• Most UTIs are caused when bacteria infect
the urinary tract, which is made up of the kidneys,
ureters, bladder, and urethra.
• An infection can occur anywhere along this tract,
but the lower part — the urethra and bladder — is
most commonly involved. This is called cystitis.
• If the infection travels up the ureters to the
kidneys, it's called pyelonephritis and is usually
more serious.
Introduction
• Urinary tract infections (UTI) are a common and
important clinical problem in childhood.
• Upper urinary tract infections (ie, acute
pyelonephritis) may lead to renal scarring,
hypertension, and end-stage renal disease.
• Difficult on clinical grounds to distinguish cystitis
from pyelonephritis, particularly in young children
(those younger than 2 years)
Prevalence
• The overall prevalence of UTI is approximately 7
percent in febrile infants.
• White children have a two- to four-fold higher
prevalence of UTI than do black children.
• Girls have a two- to four-fold higher prevalence of
UTI than do circumcised boys.
• White girls with a temperature of ≥39ºC have a UTI
prevalence of 16 percent.
Prevalence
• Older children are more likely to present with
urinary symptoms in association with a UTI than
younger children.
Microbiology
• Escherichia coli is the most common bacterial cause
of UTI (80%)
• Other gram-negative bacterial pathogens include
Klebsiella, Proteus, Enterobacter, and Citrobacter.
• Gram-positive bacterial pathogens include
Staphylococcus saprophyticus, Enterococcus, and,
rarely, Staphylococcus aureus.
Microbiology
• Viruses (eg, adenovirus, enteroviruses) and fungi
(eg, Candida spp, Aspergillus spp, Cryptococcus
neoformans, endemic mycoses) are less common
causes of UTI in children
• Viral UTI are usually limited to the lower urinary
tract.
• Risk factors for fungal UTI include
immunosuppression and long-term use of broad-
spectrum antibiotic therapy, and indwelling urinary
catheter
Pathogenesis
• The result of ascending infection.
• Colonization of the periurethral area by
uropathogenic enteric pathogens is the first step in
the development of a UTI.
• In E. Coli: pili, hair-like appendages on the cell
surface aid in attaching to epithelium.
• In the kidney, the bacterial inoculum generates an
intense inflammatory response, which may
ultimately lead to renal scarring.
Risk Factors
• Boys < 1, Girls < 4 (Short urethra)
• Uncircumcised boys
• White children x4 > black children
• Family history of UTI: Genetic factors
• Urinary Obstruction: PUV, UPJ, myelomeningocele,
neurogenic bladder
• Vesicoureteral reflux (VUR)
• Sexual activity
• Bladder catheterization.
VUR
• Vesicoureteral reflux (VUR) is the retrograde
passage of urine from the bladder into the upper
urinary tract.
• It is the most common urologic anomaly in
children, occurring in approximately 1 percent of
newborns, and as high as 30 to 45 percent of young
children with UTI.
 Pathogenesis
• Primary VUR, the most
common form of reflux, is due
to incompetent or inadequate
closure of the ureterovesical
junction (UVJ).

• Secondary VUR is a result of

abnormally high pressure in
the bladder that results in
failure of the closure of the
UVJ during bladder
contraction. Secondary VUR is
often associated with
anatomic (eg, posterior
urethral valves) or functional
bladder obstruction
Grading
• Grade I — Reflux only fills the ureter without dilation.
• Grade II — Reflux fills the ureter and the collecting
system without dilation.
• Grade III — Reflux fills and mildly dilates the ureter and
the collecting system with mild blunting of the calyces.
• Grade IV — Reflux fills and grossly dilates the ureter
and the collecting system with blunting of the calyces.
Some tortunsity of the ureter is also present.
• Grade V — Massive reflux grossly dilates the collecting
system. All the calyces are blunted with a loss of
papillary impression and intrarenal reflux may be
present. There is significant ureteral dilation and
tortuosity.
Grading

Mild Moderate Severe

Risk Factors for Renal Scarring

•Recurrent febrile UTI

•Delay in treatment of acute
infection
•Dysfunctional elimination
•Obstructive malformations
•VUR
Clinical Presentation
• In young children (<2 yrs): Fever, vomiting,
poor feeding, abdominal tenderness,
irritability.
• Older Children: fever, urinary symptoms
(dysuria, urgency, frequency, incontinence,
macroscopic haematuria), and abdominal
pain
• The constellation of fever, chills, and flank
pain is suggestive of pyelonephritis in older
children
 History
• Chronic urinary symptoms — Incontinence, lack of proper
stream, frequency, urgency, withholding maneuvers
• Chronic constipation
• Previous UTI
• Vesicoureteral reflux (VUR)
• Previous undiagnosed febrile illnesses
• Family history of frequent UTI, VUR, and other genitourinary
abnormalities
• Antenatally diagnosed renal abnormality
• Elevated blood pressure
• Poor growth
 Clinical Examination
• Documentation of blood pressure and temperature.
• Growth parameters
• Abdominal examination for tenderness or mass
• Assessment of suprapubic and costovertebral
tenderness.
• Examination of the external genitalia for anatomic
abnormalities (eg, phimosis or labial adhesions) and
signs of vulvovaginitis, vaginal foreign body, sexually
transmitted diseases (STDs)
• Evaluation of the lower back for signs of occult
myelodysplasia (eg, midline pigmentation, lipoma,
vascular lesion, sinus, tuft of hair), which may be
associated with a neurogenic bladder.
• Evaluation for other sources of fever.
Laboratory Investigations
• Urinalysis: Clean catch or suprapubic aspirate
• WCC, RCC, Nitrites (E Coli): Sensitivity of 80%.
• Urine Microscopy
• Urine Culture
• FBC, U/E, CRP
• Blood Culture
• Lumbar Puncture in a febrile child < 3 months
 Management
• Elimination of infection and prevention of
urosepsis
• Prevention of recurrence and long-term
complications including hypertension, renal
scarring, and impaired renal growth and function
• Relief of acute symptoms (eg, fever, dysuria,
frequency)
Hospitalization
• Age <3 months
• Clinical urosepsis or potential bacteremia
• Immunocompromised patient
• Vomiting or inability to tolerate oral medication
• Lack of adequate outpatient follow-up (eg, no
telephone, live far from hospital, etc.)
• Failure to respond to outpatient therapy
Antibiotics
• Amoxicillin ( or Co-amoxiclav)
• Gentamycin
• Cefotaxime
Duration of Therapy
• Children younger than 2 years and children with febrile or
recurrent UTI are usually treated for 10 days

• TMP-SMX or nitrofurantoin may be initiated after

completion of treatment and continued until the results of
the imaging tests are available

• Children older than 2 years who are afebrile, and without

abnormalities of the urinary tract or previous episodes of
UTI are usually treated for 5 to 7 days; such children have a
low risk of recurrence or complications
Imaging Studies
Routine imaging (RUS and MCUG) for:
• Girls younger than 3 years of age with a first UTI
(children older than 3 years are more reliably able
to verbalize urinary symptoms)
• Boys of any age with a first UTI
• Children of any age with a febrile UTI
• Children with recurrent UTI (if they have not been
imaged previously)
• First UTI in a child of any age with a family history
of renal disease, abnormal voiding pattern, poor
growth, hypertension
DMSA scan
• Renal scintigraphy using dimercaptosuccinic acid (DMSA)
can be used to detect acute pyelonephritis and renal
scarring in the acute and chronic settings, respectively
• DMSA is injected intravenously, and uptake by the kidney is
measured two to four hours later. Areas of decreased
uptake represent pyelonephritis or scarring.
• Scintigraphy at the time of an acute UTI provides
information about the extent of renal parenchymal
involvement.
• Most (>80 percent) children with moderate to severe VUR
(grade III or higher) will have a positive DMSA scan.
• Some have advocated DMSA be used instead of a MCUG to
identify children at higher risk for renal scarring.
MCUG
DMSA
Prognosis
• Recurrent UTI — Approximately 14 percent of children younger than 6
years with UTI have a subsequent UTI.

• Long-term sequelae :
• Approximately 40 percent have VUR: 96 percent had VUR of grade I, II,
or III, which typically resolves spontaneously over time.
• Renal scars (identified by DMSA scan) develop in approximately 8
percent of patients overall, 15 percent of those who had abnormal
DMSA scan at the time of diagnosis, and none of the children who had
normal renal scans at the time of diagnosis.
• The long-term significance of scarring, as identified by DMSA, remains
to be determined.
• Predicting which children with UTI will develop long-term sequelae
remains difficult. The large majority of children with UTI have no long-
term sequelae.
Thank you