Urinary tract infection resident survival guide (pediatrics)

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Rana aljebzi, M.D.[2]

Synonyms and keywords: Urinary tract infection in kids, UTI in kids, UTI in pediatrics, pedicatrics urinary tract infection

Urinary tract infection resident survival guide (pediatrics) Microchapters
Overview
Causes
FIRE
Diagnosis
Treatment
Do's
Don'ts

Overview

Urinary tract infections (UTIs) are common in kids. it occurs when bacteria (germs) get into the bladder(lower tract infection) or kidneys(upper tract).abdominal pain and loin tenderness, with systemic features fever, anorexia, vomiting, lethargy and malaise is the signs of upper tract infection while lower abdominal or suprapubic pain, dysuria, urinary frequency and urgency is lower tract infections signs.in younger children the typical signs are not clear and it is difficult to differentiation between upper and lower tract infection, Up to 8% of girls and 2% of boys will get a UTI by age 5 Prompt diagnosis and appropriate treatment are very important to reduce the morbidity associated with this condition,usually With the right treatment, your child should start to feel better in just a few days.

Causes

Life Threatening Causes

Urinary tract infections has two basic types, bladder infection and kidney infection. if the infection is in the bladder it is called cystitis and it causes pain and swelling in bladder, while if the infection traveled up to the kidneys in this condition ,it is called pyelonephritis and it is serious and it might harm the kidneys.

infection

• E.coli ,is the most common cause of UTI in children of all age.
• Klebsiella, is the second common cause.
• Proteus
• Enterobacter and Enterococcus
• Citrobacter
• Staphylococcus saprophyticus
• Candida albicans.

Mechanical

• vesicoureteral reflux , is the most common predisposing factor in recurrent UTI.
• urinary obstruction.

FIRE: Focused Initial Rapid Evaluation

UTI should be considered in any infant or child presenting with fever without an identifiable source of infection.because it can be associated with acute mortality (i.e. urosepsis) and/or chronic medical problems like renal scarring, hypertension, and chronic renal insufficiency,that is why urinalysis and urine culture should be done.The AAP (American Academy of pediatrics) recommendations for imaging after an initial febrile UTI were extensive and included renal and bladder ultrasound, voiding cystourethrography (VCUG) or radionuclide cystography in all children younger than two years of age

Complete Diagnostic Approach

Shown below is an algorithm summarizing the diagnosis of UTI in children according to the AAP [American Academy of Pediatrics] guidelines.

Child with fever and symptoms of UTI

Unstable/Septic

Stable

Admit + IV antibiotics + Consider specialist consult

Urine culture and urianalysis

First UTI

Recurrent UTI

<2years old

>2years old

Ultrasound

Ultrasound

Normal

Abnormal

Normal

Abnormal

DMSA scan if appropriate

Further management

Antibiotic for 7-14 days according to sensitivity

Further management according to findings

• MAG3 renography • MR urography • Delayed DMSA scan

Obstruction

Vesicoureteral reflux

MAC3 renography

MCV

Treatment

Shown below is an algorithm summarizing the treatment of UTI in children according to the AAP [American Academy of pediatrics] guidelines.

Treatment of febrile children with UTI

Stable

Toxic

Oral antibiotic 7-14 days

Parenteral antibiotic, once improved shift to oral antibiotic

• The goals of treatment are:
  • Elimination of the acute infection.
  • Prevent the complication.
  • Reduce the renal damage.

Table1

Some Empiric Antimicrobial Agents for Oral Treatment of UTI.

Antimicrobial Agent	Dosage
Amoxicillin-clavulanate	20–40 mg/kg per d in 3 doses
Sulfonamide
Trimethoprim-sulfamethoxazole	6–12 mg/kg trimethoprim and 30-60 mg/kg sulfamethoxazole per d in 2 doses
Sulfisoxazole	120–150 mg/kg per d in 4 doses
Cephalosporin
Cefixime	8 mg/kg per d in 1 dose
Cefpodoxime	10 mg/kg per d in 2 doses
Cefprozil	30 mg/kg per d in 2 doses
Cefuroxime axetil	20–30 mg/kg per d in 2 doses
Cephalexin	50–100 mg/kg per d in 4 doses

Table2

Empiric Antimicrobial Agents for Parenteral Treatment of UTI

Antimicrobial Agent	Dosage
Ceftriaxone	75 mg/kg, every 24 h
Cefotaxime	150 mg/kg per d, divided every 6–8 h
Ceftazidime	100–150 mg/kg per d, divided every 8 h
Gentamicin	7.5 mg/kg per d, divided every 8 h
Tobramycin	5 mg/kg per d, divided every 8 h
Piperacillin	300 mg/kg per d, divided every 6–8 h

Do's

• Immediate empirical antimirobial.
• Diagnostic ultrasonography for kidney and bladder to detect anatomical abnormalities.
• Voiding cystourethrogram VCUG ,indicated if US(ultrasonography) shows Hydronephrosis ,scarring,high grade Vesicoureteral Reflux.

Don'ts

• Delay treatment while waiting results of microscopy or culture,that would be harmful.
• Routine diagnostic imaging in all children with first infection.
• Giving prophylaxis antimicrobial to prevent febrile recurrent UTI.
• Surgical correction of minor functional abnormalities, moderate VUR.