Related Review of Literature

Definition

Urinary tract infections (UTIs) are common in childhood. Nearly all UTIs are caused by
bacteria that enter the opening of the urethra (the tube that drains urine from the bladder out of
the body) and move upward to the urinary bladder and sometimes the kidneys. Rarely, in severe
infections, bacteria may enter the bloodstream from the kidneys and cause infection of the
bloodstream (sepsis) or of other organs.

During infancy, boys are more likely to develop urinary tract infections. After infancy,
girls are much more likely to develop them. UTIs are more common among girls because their
short urethras make it easier for bacteria to move up the urinary tract. Uncircumcised infant boys
(because bacteria tend to accumulate under the foreskin) and young children with severe
constipation (because severe constipation also interferes with normal passage of urine) also are
more prone to UTIs.

Etiology

A variety of organisms can be responsible for UTI. Escherichia coli (80% of cases) and
other gram-negative enteric organisms are most commonly implicated; all are common to the
anal, perineal, and perianal region. Other organisms associated with UTI include proteus,
Pseudomonas, klebsiella, Staphylococcus aureus, Haemophilus, and coagulase-negative
staphylococci. A number of factors contribute to the development of UTI, including anatomic,
physical, and chemical conditions or properties of the host’s urinary tract.

Clinical Manifestation

 fever
 Irritability
 vomiting
 frequent urination
 wetting during day and or night
 poor feeding
Risk factor

Predisposing factor

Age

Gender

Females are more prone to urinary tract infections than are males. This is because the
urethra is shorter which cuts down the distance that bacteria have to travel to reach the bladder.
The urethral opening is also much closer to the anus and can come into contact with bacteria
more readily. Females lack the prostatic secretions which are present in males.

Precipitating factor

Pathogenesis

Bacterial clonal studies strongly support entry into the urinary tract by the fecal-
perineal-urethral route with subsequent retrograde ascent into the bladder. Because of
differences in anatomy, girls are at a higher risk of UTI than boys beyond the first year of
life. In girls, the moist periurethral and vaginal areas the growth of uropathogens. The shorter
urethral length increases the chance for ascending infection into the urinary tract. Once the
uropathogen reaches the bladder, it may ascend to the ureters and then to the kidneys by
some as-yet undefined mechanism. Additional pathways of infection include nosoco-mial
infection through instrumentation, hematogenous seeding in the setting of systemic infection
or a compromised immune system, and direct extension caused by the presence of fistulae
from the bowel or vagina. The urinary tract (ie, kidney, ureter, bladder, and urethra) is a
closed, normally sterile space lined with mucosa composed of epithelium known as
transitional cells. The main defense mechanism against UTI is constant ante grade flow of
urine from the kidneys to the bladder with intermittent complete emptying of the bladder via
the urethra. This washout effect of the urinary flow usually clears the urinary tract of
pathogens. The urine itself also has specific antimicrobial characteristics, including low urine
pH, polymorphonu clear cells, and Tamm-Horsfall glycoprotein, which inhibits bacterial
adherence to the bladder mucosal wall.
Epidemiology

Urinary tract infection (UTI) is one of the most frequent bacterial infections in infants
and young children. Its incidence is influenced by age and sex, and it is difficult to estimate, as
the existing epidemiological studies are very heterogeneous, with varying definitions of UTI,
populations studied and methodologies used for collecting urine specimens. In addition, children
with UTI, especially smaller children, have non-specific symptoms, which means UTI
sometimes goes unnoticed. (Winberg J, 2007)

This situation is further complicated by the fact that accurate diagnosis depends on both
the presence of symptoms and a positive urine culture, although in most outpatient settings this
diagnosis is made without the benefit of culture. Women are significantly more likely to
experience UTI than men. Urinary tract infections (UTIs) are considered to be the most common
bacterial infection. According to the 1997 National Ambulatory Medical Care Survey and
National Hospital Ambulatory Medical Care Survey, UTI accounted for nearly 7 million office
visits and 1 million emergency department visits, resulting in 100,000 hospitalizations . (Foxman
B. 2002).

Therapeutic Management

The objectives of treatment of children with UTI are two (1) eliminate the current
infection , (2) identify contributing factors to reduce the risk recurrence. (3) prevent urosepsis,
and (4) preserve renal function. Nonetheless, empiric therapy on the basis of the child’s history
and presenting symptoms may be necessary when fever or systemic illness complicates. UTI.
Common antiinfective agents used for UTI include the penicillins, sulfonamide (including
trimethoprim and sulfamethoxazole in combination , the cephalospirirns, nitrofurantoin, and the
tertracyclines. All antibiotics may cause side effects or prove ineffective because of bacterial
resistance. Children with suspected pyelonehritis and fever are admitted to the hospital and given
appropriate intravenously for a minimum of 48hrs. Blood and urine cultures are obtained on
admission and after therapy. Urine cultures are usually repeated are monthly intervals for 3
months and at 3-months intervals for another 6 months.

Nursing Care Management:

 Objectives of nursing care include identification of children with UTI and education of
parents and children regarding prevention and treatment of infection. Aside from the influence of
renal abnormalities, girls between the ages of 2 and 6 years are in the general high-risk group.
Because they are not a captive population, mass screening is difficult. However, the annual
health examination should include a routine urinalysis. In addition, nurses should instruct parents
to observe regularly for clues that suggest UTI. Unfortunately, the signs of UTI are not as
evident as those of upper respiratory tract infection. Therefore many cases go undetected because
no one thought to investigate this common problem.

Diagnostic Evaluation

The diagnostic of UTI depends on high degree of suspicion, evaluation of the history and
physical examination and urinalysis and culture. Urine with a possible infection appears cloudy,
hazy, or thick with noticeable strands of mucos and pus; it also smells unpleasant, even when
fresh. a presumptive UTI diagnosis can be made on the basis of microscopic examination of the
urine, which often reveal pyuria (5 to 8 white blood cells0ml of uncentrifuged urine) and the
presence of at least one bacterium in a Gram stain. However, a normal urinalysis may also be
present of asymptomatic bacteriuria.

The diagnosis of UTI is confirmed by the detection of bacteria in the urine culture, but
urine collection is often difficult, especially in infants and very small children. Several factors
may alter a urine specimen. Contamination of a specimen by organism from sources other than
the urine is the most common cause of false-positive results. Bag urine specimen are commonly
contaminated by perineal and perianal flora and are usually considered inadequate for a
definitive diagnosis. The American of Pediatrics recommends that urine collected by the bag be
used to determine whether it is necessary to obtain a catherized urine specimen for culture.

Unless the specimen is a first morning sample, a recent high fluid intake may indicate a
falsely low organism count. Therefore children should not to be encouraged to drink large
volumes of water an attempt to obtain a specimen quickly.

Medical treatment
 Children with uncomplicated UTI are likely to respond to amoxycillin, sulphonamides,
trimethoprim-sulfamethoxazole (cotrimoxazole) or cephalosporins, as these antibiotics are
concentrated in the lower urinary tract. Parenteral antibiotics should be considered in children
who are toxic, vomiting or dehydrated, or who have an abnormal urinary tract (Riccabona 2003).
The authors state that oral antibiotics, chosen to cover local uropathogens are as safe and
effective as intravenous antibiotics in children with a clinical diagnosis of acute pyelonephritis
and intravenous antibiotics should be reserved for those who are seriously ill or have persistent
vomiting (Craig and Hodson 2004).

Prognosis

UTI in young children may be a marker for abnormalities of the urinary tract including
vesico-ureteric reflux (VUR) and reflux nephropathy (renal scarring). VUR is the commonest
abnormality with a prevalence of 1% in all children and 35% in children following first UTI.
Data in both humans and animals have demonstrated that UTI in the presence of VUR may lead
to acute pyelonephritis and renal scarring. Renal scarring is associated with subsequent renal
damage, hypertension and end stage renal disease (ESRD). Reflux nephropathy has been
estimated to account for 7-17% of ESRD (Craig, Irwig et al. 2000). Until recently, standard
practice after diagnosing UTI has been to image the urinary tract of children for abnormalities by
performing a renal ultrasound and micturating cystourethrography (MCU). This was on the
assumption that prevention of UTI recurrence through administering prophylactic antibiotics
would reduce the risk of developing renal scarring and thus ESRD. A systematic review of long-
term antibiotics for preventing recurrent UTI in children, has suggested problems with the
existing published trials and that further research is required (Williams, Lee et al. 2001;
Williams, Lee et al. 2004).