Urinary tract infection in children: Difference between revisions
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A health care professional will look at the sample under a microscope for bacteria and white blood cells, which the body produces to fight infection. Bacteria also can be found in the urine of healthy children, so a bladder infection is diagnosed based on both your child’s symptoms and lab test results. | A health care professional will look at the sample under a microscope for bacteria and white blood cells, which the body produces to fight infection. Bacteria also can be found in the urine of healthy children, so a bladder infection is diagnosed based on both your child’s symptoms and lab test results. | ||
*Urine culture. | *Urine culture. This laboratory test usually takes 24 to 48 hours. The sample is analyzed to identify the type of bacteria causing the UTI, how much of it exists, and appropriate antibiotic treatment. | ||
===Imaging tests=== | ===Imaging tests=== | ||
Revision as of 19:16, 7 December 2020
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
Overview
Historical Perspective
- [Disease name] was first discovered by [scientist name], a [nationality + occupation], in [year] during/following [event].
- In [year], [gene] mutations were first identified in the pathogenesis of [disease name].
- In [year], the first [discovery] was developed by [scientist] to treat/diagnose [disease name].
Classification
Urinary tract infection in children may be classified to:[1]
| UTI classification | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| level of the infection | Severity | Recurrency | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Cystitis:infection in the bladder | Pyelonephritis:infetion of the renal pelvis and kidney | Urethritis:infection of the urethra | Complicated | Uncomplicated | First time of infection | recurrent infection | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
UTI can be classified by the sites of infection (bladder [cystitis], kidney [pyelonephritis], urethra [Urethritis]), or by severity (complicated versus uncomplicated). For practical purposes, pediatric UTI categorized as either first or recurrent based on the natural history because this may affect clinical management.The first infection is the initially diagnosed UTI. In infants and children the first infection is complicated because of the potential association with anatomic anomalies. Unresolved infection may result from subtherapeutic level of antimicrobial agent,or the presence of resistant pathogens unresponsive to current treatment.In these situations, correcting antimicrobial dose or switching to a more appropriate drug cures the UTI.
Pathophysiology
The urinary tract in healthy children is usually sterile. The urethra on the other hand is colonized with bacteria. UTI occurs with the entrance of pathogens into the urinary tract and subsequent adherence to it. Although normal voiding with intermittent urinary outflow usually clears pathogens within the bladder. that is why the pathogenesis of UTI in Urinary malformation, urine stasis, impaired urine flow increased reservoir, and giving more time to establish infection and adherence of bacteria to the uroepithelial mucosa being the main predisposing factors for the development of UTI. Congenital obstructive uropathy, "detrusor sphincter" dyssynergia syndrome is an infrequent bladder emptying and stasis, which are also causes of UTI. The second mechanism is the introduction of pathogens by way of a foreign body or instrument. Urinary infection is the third most common nosocomial infection after primary bloodstream infections and pneumonia in intensive care units. A recent prospective study estimates the incidence of nosocomial UTI as 0.6 case/1000 patient/day and newborns and infants are affected disproportionately. The infection is associated frequently with urethral catheterization. Escherichia coli accounts for 80 to 90% of UTI in children. Among febrile infants, unwell children in general practice, and older children with urinary symptoms, 6%–8% will have a UTI, symptoms and signs of pyelonephritis include fever, chills, rigor, flank pain, and costovertebral angle tenderness. Lower tract symptoms and signs include suprapubic pain, dysuria, urinary frequency, urgency, cloudy urine, malodorous urine, and suprapubic tenderness. A urinalysis and urine culture should be performed when UTI is suspected. In the work-up of children with UTI, physicians must judiciously utilize imaging studies to minimize exposure of children to radiation. While waiting for the culture results, prompt antibiotic therapy is indicated for symptomatic UTI based on clinical findings and positive urinalysis to eradicate the infection and improve clinical outcomes. The prevalence varies with age, peaking in young infants, toddlers, and older adolescents. UTI is more common in female and uncircumcised male infants. During toddler years, toilet training can lead to volitional holding and bladder stasis, promoting UTIs. Over 30% of children with UTI will have recurrent UTI. Common risk factors for recurrence include vesicoureteric reflux (VUR) and bladder–bowel dysfunction. Older non-continent children (eg, developmental delay) also have more recurrent UTIs.[2][3]
Causes
The common pathogenic sources of UTI are bacteria of enteric origin, although other pathogens (fungi, mycobacteria, and viruses) also are encountered. Escherichia coli is responsible for over 80% of all mechanisms of UTIs. pathogens in the urinary tract of a healthy child is usually the result of retrograde migration of enteric bacteria colonizing the periurethral area and reflects this flora. Other common gram-negative organisms include Klebsiella, Proteus, Enterobacter, and occasionally Pseudomonas. Proteus mirabilis is a common pathogen in males and in children with kidney stones. Gram-positive pathogens include group B Streptococcus and Enterococcus in neonates and infants reflecting the colonization status of the mothers, and Staphylococcus saprophyticus in adolescent girls. Fungal infections are much less common and are usually to those who are immune-compromised or diabetic, on long-term antibiotics or have a long-term indwelling catheter. Viral UTI is more common in immunocompromised patients, particularly those receiving immunosuppressants, than in otherwise healthy children. Adenovirus and BK virus are viral pathogens that may cause hemorrhagic cystitis Often urine is contaminated by Lactobacillus species, Corynebacterium spp., coagulase-negative staphylococci, and α hemolytic streptococci, and not considered pathogens in otherwise healthy children 2 months to 2 years of age.[4][5]
Differentiating Urinary tract infection in children from other Diseases
Although fever may be the sole presenting symptom in children younger than 24 months, physical examination findings may point toward an alternative diagnosis, including:
- Otitis media.
- Gastroenteritis.
- Upper respiratory tract infection.
Occult bacteremia should always be considered, although the probability of this diagnosis is much lower than UTI (less than 1 versus 7 percent) in fully immunized children with no other identifiable potential source for fever on physical examination. Urinary calculi, urethritis (including a sexually transmitted infection), dysfunctional elimination, and diabetes mellitus must be considered in verbal children with urinary tract problems.
Epidemiology and Demographics
Factors that seem to affect the incidence of UTI are associated with gender, age, race, circumcision status, and general health or immune status. Host factors that contribute to increased bacterial adherence seems to be associated with age, gender, and colonization.
Age ,Gender and race
- Neonates and infants are at higher risk for UTI, which coincides with their incompletely developed immunity. In males, it is more common during the neonatal period and early infancy and it declines afterward. Breast milk seems to protect children from UTI and other infections, which have higher IgA levels than nonbreastfed children.
- Usually associated with anatomical abnormalities and outlet obstruction. About 8% of girls and 2% of boys experience at least one episode of UTI up to the age of 7. It occurs in 0.1–0.4% of infant girls and increases up to 1.4% during 1–5 years and 0.7–2.3% in school age. The incidence is greater in girls in this age group and is likely due to short urethra and translocation of fecal bacteria. uncircumcised infant boys are more at risk, which reaches to 0.1-0.2 during 1–5 years and 0.04–0.2 in school age. UTI may lead to transient renal damage and permanent renal scarring. Structural abnormalities, neurologic deficiency, or behavioral voiding dysfunction resulting in residual urine in any part of the urinary tract also may influence the persistence of bacteriuria once established.
the incidences of UTI in boys and girls younger than 2 years of age are the same. In older children, particularly in sexually active teenagers, there is a female predominance of UTI. Race seems to affect the incidence of UTI. In developed countries with adequate medical resources, UTI is more common in white girls than girls of other races. Although UTI occurs in children of all races and ethnicities, the incidence is low in African-American children. Diabetes mellitus increases the risk of UTI in patients of all ages. In immunocompromised patients, UTI is more common and has more severe sequelae.in pediatric HIVpositive patients, UTI is the second most common cause of bacteremia after pneumonia. Many children have recurrent UTI after the initial infection, The rate of recurrence increases to 32% in boys older than 1 year of age. In girls older than 1 year of age, the risk for recurrence is proportional to the number of previous infections.[6]
Risk Factors
- UTIs occur more often in girls, especially when toilet training begins. Girls are more susceptible because their urethras are shorter and closer to the anus. This makes it easier for bacteria to enter the urethra. Uncircumcised boys under 1-year-old also have a slightly higher risk of UTIs.
- The urethra doesn’t normally harbor bacteria. But certain circumstances can make it easier for bacteria to enter or remain in your child’s urinary tract. The following factors can put your child at a higher risk for a UTI:
- Structural deformity or blockage in one of the organs of the urinary tract.
- Vesicoureteral reflux, a birth defect that results in the abnormal backward flow of urine.
- The use of bubbles in baths (for girls).
- Tight-fitting clothes (for girls).
- Wiping from back to front after a bowel movement.
- Poor toilet and hygiene habits.
- Infrequent urination or delaying urination for long periods of time.
Natural History, Complications and Prognosis
- The majority of patients with [disease name] remain asymptomatic for [duration/years].
- Early clinical features include [manifestation 1], [manifestation 2], and [manifestation 3].
- If left untreated, [#%] of patients with [disease name] may progress to develop [manifestation 1], [manifestation 2], and [manifestation 3].
- Common complications of [disease name] include [complication 1], [complication 2], and [complication 3].
- Prognosis is generally [excellent/good/poor], and the [1/5/10year mortality/survival rate] of patients with [disease name] is approximately [#%].
Diagnosis
Fever is the most common presentation of UTI in young children, for this reason, the American Academy of Pediatrics (AAP) recommends UTI be ruled out in any child 2 months to 2 years of age with unexplained fever.
- In younger children, the presence of upper respiratory infections, otitis media, or gastroenteritis does not eliminate the possibility of a UTI. In this age group, recurrent abdominal pain could be a symptom of recurrent UTI and should be evaluated promptly.
- In older children, fever is usually the presenting symptom of UTI. Besides fever, children may have vomiting, loose stools, and abdominal pain. This age group could present with more specific symptoms of either cystitis or pyelonephritis. These may include dysuria, frequency, new onset incontinence flank pain, and fever.
- Adolescent girls may have urethritis from an STD. Hence, for proper diagnosis, laboratory evaluation is mandatory.[7]
Diagnostic Criteria
- The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met:
- [criterion 1]
- [criterion 2]
- [criterion 3]
- [criterion 4]
Symptoms
The classic presentations of dysuria, frequency, hesitancy, and flank pain in adults are unreliable when applied to pediatric UTI, particularly in infants.
- Consider a diagnosis of urinary tract infection in all infants and children with:
-unexplained fever of 100.4°F (38°C) or higher after 24 hours.
-symptoms and signs suggestive of urinary tract infection, including.
- fever
- non-specific symptoms, such as lethargy, irritability, malaise, failure to thrive, vomiting, poor feeding, abdominal pain.
- specific symptoms, such as frequency, dysuria, loin tenderness, dysfunctional voiding, changes to continence, haematuria, and offensive or cloudy urine.[7]
Physical Examination
The physical examination of children with UTI can be nonspecific. With the advent of ultrasonography, occasionally an anatomically abnormal genitourinary organ may be found during the initial evaluation (eg, hydronephrosis, xanthogranulomatous kidney, protruding ureterocele). An old-fashioned examination, however, still may reveal subtle information suggestive of neurogenic bladder (eg, spinal anomalies, sacral dimples/pits/fat pads)
Laboratory Findings
- Urinalysis. A small amount of the child’s urine must be collected for this test. Babies and small children who are not toilet trained will have a small, thin, flexible tube called a catheter placed into the urethra to get a urine sample. This is needed because urine from collection bags, which can be taped around a baby’s diaper area, is often contaminated, or mixed, with germs and other substances found on the baby’s skin. If urine is contaminated, test results will not be accurate.
Parents may help preschoolers catch a clean urine sample in a special container, and older children and teens can do it by themselves.
A health care professional will look at the sample under a microscope for bacteria and white blood cells, which the body produces to fight infection. Bacteria also can be found in the urine of healthy children, so a bladder infection is diagnosed based on both your child’s symptoms and lab test results.
- Urine culture. This laboratory test usually takes 24 to 48 hours. The sample is analyzed to identify the type of bacteria causing the UTI, how much of it exists, and appropriate antibiotic treatment.
Imaging tests
- Ultrasound is recommended if the child
- Is younger than age 2 and has a bladder infection with a fever.
- Has had repeated bladder infections at any age.
- Has high blood pressure, poor growth, or a family history of kidney or bladder problems doesn’t get better with treatment.
- Voiding cystourethrogram (VCUG). Voiding cystourethrogram uses x-rays of the bladder and urethra to show how urine flows. A catheter is used to fill the child’s bladder with a special dye. Then x-ray pictures are taken before and after your child urinates. A VCUG can show if urine flows backward from the bladder into the ureters or kidneys, a condition called vesicoureteral reflux (VUR).
Other Diagnostic Studies
- Urinary tract infection may also be diagnosed using DMSA is a nuclear test in which pictures of the kidneys are taken after the intravenous (IV) injection of radioactive material called an isotope.
- CT scan and MRI of the kidney and the bladder.
Treatment
Medical Therapy
The recommended initial antibiotic for most children with UTI is trimethoprim/sulfamethoxazole (Bactrim, Septra). Alternative antibiotics include amoxicillin/clavulanate (Augmentin) or cephalosporins, such as cefixime (Suprax), cefpodoxime, cefprozil (Cefzil), or cephalexin (Keflex). two- to four-day course of oral antibiotics is as effective as a seven- to 14-day course in children with a lower UTI. A single-dose or single-day course is not recommended. Children with acute pyelonephritis can be treated effectively with oral antibiotics (e.g., amoxicillin/clavulanate, cefixime, ceftibuten [Cedax]) for 10 to 14 days or with short courses (two to four days) of intravenous therapy followed by oral therapy. Prophylactic antibiotics do not reduce the risk of recurrent UTIs, even in children with mild to moderate vesicoureteral reflux.
- The length of treatment depends on
- How severe the infection is.
- Whether a child’s symptoms and infection go away.
- Whether a child has repeated bladder infections.
- Whether the child has vesicoureteral reflux or another problem in the urinary tract.
Surgery
The surgical opinion is sought only when medical management has failed. Failure is defined as either recurrent infections and pyelonephritis or poor renal growth.
Prevention
- Drinking enough liquids.
- Following good bathroom and diapering habits.
- Wearing loose-fitting clothes.
- Avoid constipation.
Getting treated for related health problems may help prevent a UTI .
References
- ↑ Chang, Steven L.; Shortliffe, Linda D. (2006). "Pediatric Urinary Tract Infections". Pediatric Clinics of North America. 53 (3): 379–400. doi:10.1016/j.pcl.2006.02.011. ISSN 0031-3955.
- ↑ Habib S (2012). "Highlights for management of a child with a urinary tract infection". Int J Pediatr. 2012: 943653. doi:10.1155/2012/943653. PMC 3408663. PMID 22888360.
- ↑ Kaufman J, Temple-Smith M, Sanci L (2019). "Urinary tract infections in children: an overview of diagnosis and management". BMJ Paediatr Open. 3 (1): e000487. doi:10.1136/bmjpo-2019-000487. PMC 6782125 Check
|pmc=value (help). PMID 31646191. - ↑ Ma, Jian F; Shortliffe, Linda M.Dairiki (2004). "Urinary tract infection in children: etiology and epidemiology". Urologic Clinics of North America. 31 (3): 517–526. doi:10.1016/j.ucl.2004.04.016. ISSN 0094-0143.
- ↑ Sobel, J. D.; Vazquez, J. A. (1999). "Fungal infections of the urinary tract". World Journal of Urology. 17 (6): 410–414. doi:10.1007/s003450050167. ISSN 0724-4983.
- ↑ Shaikh, Nader; Morone, Natalia E.; Bost, James E.; Farrell, Max H. (2008). "Prevalence of Urinary Tract Infection in Childhood". The Pediatric Infectious Disease Journal. 27 (4): 302–308. doi:10.1097/INF.0b013e31815e4122. ISSN 0891-3668.
- ↑ 7.0 7.1 Habib, Sabeen (2012). "Highlights for Management of a Child with a Urinary Tract Infection". International Journal of Pediatrics. 2012: 1–6. doi:10.1155/2012/943653. ISSN 1687-9740.