Diagnosis- Infants and children with unexplained fever- of 38° or higher- check urine to r/o UTI within 24 hrs Check urine in cases of unexplained fever Infants and children – UTI is suspected check urine UTI can be difficult to diagnose particularly in children < 2-3 yrs Presentation can be non specific and – use below as a guide to presentation of UTI in children
Urine sampling –For a definitive diagnosis – a positive result from urine culture is required which can be – invasive and non-invasive ♦ suprapubic aspirate ( SPA ) ♦ bladder catheterization ♦ bag applied to perineum ♦ clean catch midstream specimen ( CCM ) Urine collection pads can be used for infants Refrigerate the sample in a boric acid container if it cannot be cultured within 4 hrs
Urine culture-acute pyelonephritis / upper UrTr infection high to intermediate risk of serious illness younger than 3 yrs of age a single + ve result for leucocyte esterase or nitrite recurrent UTI an infection that does not respond to treatment within 24-48 hrs when clinical symptoms and dipstick do not correlate
Definitions –UTI is an illness caused by micro-organisms in the UrTr ◘ lower UTI – is cystitis which affects bladder and urethra ◘ upper UTI is pyelonephritis which affects the renal pelvis and kidneys Atypical UTI – this includes ◘ seriously ill patients ◘ poor urine flow ◘ abdominal or bladder mass ◘ raised creatinine ◘ septicaemia ◘ no response to treatment with suitable antibiotics within 48 hrs ◘ non E Coli infection Recurrent UTI ◘ 2 or more episodes of UTI with acute pyelonephritis /upper UrTr infection or ◘ 1 episode of UTI with acute pyelonephritis /upper UrTr infection plus one or more episode UTI with cystitis/ lower UrTr infection or ◘ 3 or more episodes of UTI with cystitis / lower urinary tract infection
Risk factors- serious underlying pathology-Poor urine flow History suggesting previous UTI or confirmed previous UTI Recurrent fever of uncertain origin Antenatally- diagnosed renal abnormality Family h/o VUR or renal disease Constipation Dysfunctional voiding Enlarged bladder Abdominal mass Evidence of spinal lesion
Whys is it important –a UTI may be the first symptom of congenital abnormality of the kidneys and UrTr with VUR (vesicouretral reflux ) being the most prevalent that recurrent UTI in patients with VUR will lead to renal scarring and consecutively CKD – has been the basis of aggressive management with accurate diagnosis imaging follow up it is thought that failing to treat would lead to damage to the upper UrTr- however identifying children at risk of renal paranchymal damage and f/u imaging after UTI is controversial It has also been noted that that damage to the kidney tissue , which was previously attributed to UTIs or reflux – is congenital in nature Risk of recurrent infection is 12-30 % in the 1st 6-12 months after the 1st UTI and is increases in the presence of urological abnormalities Prognosis is good in absence of any structural or functional obstruction or severe VUR Renal scarring – associated with reflux is called reflux nephropathy
Diagnostic tests –Imaging in children with UTI is controversial Prenatal US is increasingly available and will detect significant abnormalities Imaging is restricted to those children who are at highest risk of kidney damage and underlying abnormalities NICE recommends that children with cystitis / lower UrTr infection should undergo US- within 6 wks only if they are younger than 6 months or have had recurrent infection For a full recommendations please see the NICE guidance – UTI in children under 16-diagnosis and management Imaging is associated with ○ radiation exposure ○ risk of catheter induced UTIs ○ stress – parents and child ○ cost Abdominal US- least invasive and cheap good for showing hydronephrosis ,hydroureters , bladder wall abnormalities and acute UTI complications asrenal or parenchymal abscess Limitation-VUR detection VCUG-voiding urethrocystography is the gold standard for VUR diagnosis and grading DMSA – dimercaptosuccinic acid scintigraphy – can detect reliably both acute pyelonephritis and late parencyhmal scarring . Costly test , sig radiation -indications vary between guidelines.
BMJ Best Practice Urinary Tract Infection in children Urinary tract infection in under 16s : diagnosis and management Urinary tract infection in children ; Diagnosis , treatment , imaging- Comparison of current guidelines Journal of Pediatric Urology- September 2017 Management of UTIs in children in Primary Care NHS Oxfordshrie Clinical Commissioning Group Urinary Tract Infections in Children : EAU/ ESPU Guidlines Raimund Stein et al European Association of Urology March 2015 , Volume 67 , Issue 3 , Pages 546-558 Urinary Tract Infection in Children Mandell , Douglas and Bennett’s Principles and Practices of Infectious Diseases, Updated Edition Jan 2015 CKS – Urinary tract infection- children revised Feb 2019