UTI

Question 1

Epidemiology of UTIs?

Answer 1

• Occurs in 5% of infants and young children with fever and no apparent source
• Highest risk in uncircumcised boys < 3 mo and girls <12 mo
  Note: Most common bacterial infection in children < 2 years old

Question 2

Untreated UTIs can lead to?

Answer 2

renal scarring

Question 3

Overdiagnosis of UTIs can lead to?

Answer 3

1. misuse of antibiotics
2. unnecessary imaging

Question 4

Signs and symptoms of UTIs?

Answer 4

1. fever
2. abdominal pain
3. vomiting
4. diarrhea
5. new onset of urinary incontinence
6. strong-smelling urine

Question 5

Contributing factors in incomplete bladder emptying?

Answer 5

1, infrequent voiding - bladder enlargement
2. vulvitis
3. incomplete micturition with residual postmicturition bladder volumes
4. obstruction by a loaded rectum in constipation
5. neuropathic bladder
6. vesicoureteric reflux

Question 6

Important question to ask in family history?

Answer 6

Ask about history of vesicoureteral reflux in parents and siblings

Question 7

Clinical features in infants?

Answer 7

1. fever
2. vomiting
3. lethargy/irritability
4. poor feeding/faltering growth
5. jaundice
6. septicemia
7. offensive urine
8. febrile seizures (>6 months)

Question 8

Clinical features of UTI in children?

Answer 8

1. dysuria, frequency, urgency
2. abdominal pain/loin tenderness
3. fever
4. lethargy and anorexia
5. vomiting, diarrhea
6. haematuria
7. offensive/cloudy urine
8. febrile seizure
9. recurrence of enuresis

Question 9

Methods of dipstick testing?

Answer 9

1. nitrite stick testing
2. leukocyte esterase stick testing (WBC)

Question 10

Interpretation of nitrite stick testing?

Answer 10

+ result is likely indicative of a true UTI
- but some children with UTI may be nitrite -

Question 11

Interpretation of leucocyte esterase stick testing?

Answer 11

1. may be present in child with UTI
   - may also not be present
2. present in febrile illness without UTI
3. in balanitis and vulvovaginitis

Question 12

Diagnostic criteria of UTIs?

Answer 12

1. urinalyis shows pyuria and/or bacteriuria
2. urine culture grows >50,000 CFU/ml of bacteria
   Note: obtain urine specimen before giving antibiotics

Question 13

3 ways to obtain urine culture?

Answer 13

1. Suprapubic aspiration
   - Invasive, requires expertise, painful
   - May be necessary in boys with phimosis and girls with labial adhesions
2. Catheterization
   - Invasive
   - High sensitivity (95%), specificity (99%)
3. Bag applied to perineum
   - False positive result 88-99% of the time!

Question 14

Risk factors for UTIs in girls?

Answer 14

1. white race
2. temp. >39 degrees
3. fever lasting >2days
4. no other source of infection
5. age<12 months

Question 15

Risk factors for UTI in boys?

Answer 15

1. non black race
2. temp. >39 degrees
3. fever lasting >24 hours
4. no other source of infection

Question 16

In the lower likelihood of UTI what do you do?

Answer 16

clinically follow without testing

Question 17

In the event of higher likelihood of UTI what do you do?

Answer 17

• Obtain urinalysis and culture by catheterization OR
• Obtain urinalysis by bag or catheterization
  1. If urinalysis tests + for nitrites or leukocyte esterase, then obtain culture via catheterization
  2. If urinalysis tests negative, then follow clinically without antibiotic

Question 18

Treatment of UTIs?

Answer 18

• Use oral or parenteral antibiotic
• Adjust the antibiotic based on sensitivities from urine culture
• Treat for 7-14 days for febrile UTI, 3-7 days for afebrile UTI

Question 19

Pathophysiology of UTI?

Answer 19

ascending infection
normal anatomy
1. E.coli
abnormal anatomy
1. vesicoureteral obstruction
2. uretropelvic junction obstruction
- citrobacter and enterococcus
Note: pyelonephritis - if infection gets to the kidney

Question 20

Examples of treatment regimens?

Answer 20

1. Amoxicillin/clavulanate (Augmentin)
   - 20-40 mg/kg/day, divided q 8 hrs
2. Ceftriaxone
   - 50-100/kg/day. Once a day

Question 21

Grading of vesicoureteral reflux?

Answer 21

Grade 1: reflux into the non-dilated ureter
Grade 2: reflux into the ureter and renal pelvis
Grade 3: reflux with mildly dilated ureter and pyelocalyceal system
Grade 4: reflux with the tortuous and moderately dilated ureter with with blunting renal fornices

Question 22

Common organisms that affect newborns (<30 days) and their treatment?

Answer 22

Organisms: GBS,Listeria Monocytogens Ecoli, Kelbsiella, Entrobactor, Coag Neg Staph, Enterococcus
Treatment: Amp (Xpen) and Gent

Question 23

Common organisms that affect young infants (30 to 60 days)?

Answer 23

Organisms: E.coli, Enterococcus Klebsiella
Treatment: Augumentin , Ceftriaxone

Question 24

Organisms that affect children over (60 days) and their treatment?

Answer 24

Organisms: E.coli, Kelbsiella, Proteus,Enterobactor, Pseudomonus Candida
Treatment: Cephalexin, Bactrim, Ceftriaxone, Nystatin

Question 25

Imaging modalities to confirm for UTI?

Answer 25

1. renal and bladder ultrasound 2. VCUG (voiding cystourethrogram)

Question 26

Pros and cons of renal and bladder ultrasound?

Answer 26

Pros: noninvasive, no radiation, can identify congenital anomalies of kidney, ureter and bladder; renal calculi, and hydronephrosis Cons: cannot reliably demonstrate inflammation, renal scarring; no info on renal function

Question 27

Pros and cons of VCUG?

Answer 27

Pros: affects treatment decisions that theoretically reduce risk of renal scarring, is used primarily to diagnose and grade vesicoureteral reflux Cons: radiation, expense, discomfort

Question 28

Imaging recommendations?

Answer 28

1. Order renal and bladder U/S in febrile infants with confirmed UTI 2. Order a VCUG if the U/S shows: - Hydronephrosis - Scarring - Other findings to suggest high-grade VUR or obstruction 3. Perform a VCUG if a child develops a 2nd UTI

Question 29

Prevention of recurrent UTIs?

Answer 29

1. Breastfeed 2. Treat constipation 3. Routine circumcision not recommended 4. Use of daily prophylactic antibiotic is controversial 5. high fluid intake to produce a high urine output 6. regular voiding 7. good perineal hygiene 8. ensure complete bladder emptying - double voiding