Urinary Tract Infections in

Children
 Introduction
• Urinary tract infections (UTI) are a common
and important clinical problem in childhood.
• Upper urinary tract infections (ie, acute
pyelonephritis) may lead to renal scarring,
hypertension, and end-stage renal disease.
• Difficult on clinical grounds to distinguish
cystitis from pyelonephritis, particularly in
young children (those younger than 2 years)
UTI
 Microbiology
• Escherichia coli is the most common bacterial
cause of UTI (80%)
• Other gram-negative bacterial pathogens
include Klebsiella, Proteus, Enterobacter, and
Citrobacter.
• Gram-positive bacterial pathogens include
Staphylococcus saprophyticus, Enterococcus,
and, rarely, Staphylococcus aureus.
 Microbiology
• Viruses (eg, adenovirus, enteroviruses) and fungi
(eg, Candida spp, Aspergillus spp, Cryptococcus
neoformans, endemic mycoses) are less common
causes of UTI in children
• Viral UTI are usually limited to the lower urinary
tract.
• Risk factors for fungal UTI include
immunosuppression and long-term use of broad-
spectrum antibiotic therapy, and indwelling
urinary catheter
 Risk Factors
• Boys < 1, Girls < 4 (Short urethra)
• Uncircumcised boys
• White children x4 > black children
• Family history of UTI: Genetic factors
• Urinary Obstruction
• myelomeningocele, neurogenic bladder
• Vesicoureteral reflux (VUR)
• Sexual activity
• Bladder catheterization.
 VUR
• Vesicoureteral reflux (VUR) is the retrograde
passage of urine from the bladder into the
upper urinary tract.
• It is the most common urologic anomaly in
children, occurring in approximately 1 percent
of newborns, and as high as 30 to 45 percent
of young children with UTI.
 Pathogenesis
• Primary VUR, the most
common form of reflux, is due
to incompetent or inadequate
closure of the ureterovesical
junction (UVJ).
• Secondary VUR is a result of
abnormally high pressure in
the bladder that results in
failure of the closure of the
UVJ during bladder
contraction. Secondary VUR is
often associated with
anatomic (eg, posterior
urethral valves) or functional
bladder obstruction
 Grading
• Grade I — Reflux only fills the ureter without dilation.
• Grade II — Reflux fills the ureter and the collecting system
without dilation.
• Grade III — Reflux fills and mildly dilates the ureter and the
collecting system with mild blunting of the calyces.
• Grade IV — Reflux fills and grossly dilates the ureter and
the collecting system with blunting of the calyces. Some
tortunsity of the ureter is also present.
• Grade V — Massive reflux grossly dilates the collecting
system. All the calyces are blunted with a loss of papillary
impression and intrarenal reflux may be present. There is
significant ureteral dilation and tortuosity.
 Grading

Mild Moderate Severe

 Risk Factors for Renal Scarring

• Recurrent febrile UTI

• Delay in treatment of acute
infection
• Dysfunctional elimination
• Obstructive malformations
• VUR
 Clinical Presentation
• In young children (<2 yrs): Fever, vomiting,
poor feeding, abdominal tenderness,
irritability.
• Older Children: fever, urinary symptoms
(dysuria, urgency, frequency, incontinence,
macroscopic haematuria), and abdominal pain
• The constellation of fever, chills, and flank pain
is suggestive of pyelonephritis in older
children
 History
• Chronic urinary symptoms — Incontinence, lack of proper
stream, frequency, urgency, withholding maneuvers
• Chronic constipation
• Previous UTI
• Vesicoureteral reflux (VUR)
• Previous undiagnosed febrile illnesses
• Family history of frequent UTI, VUR, and other genitourinary
abnormalities
• Antenatally diagnosed renal abnormality
• Elevated blood pressure
• Poor growth
 Clinical Examination
• Documentation of blood pressure and temperature.
• Growth parameters
• Abdominal examination for tenderness or mass
• Assessment of suprapubic and costovertebral tenderness.
• Examination of the external genitalia for anatomic abnormalities
(eg, phimosis or labial adhesions) and signs of vulvovaginitis, vaginal
foreign body, sexually transmitted diseases (STDs
• Evaluation of the lower back for signs of occult myelodysplasia (eg,
midline pigmentation, lipoma, vascular lesion, sinus, tuft of hair),
which may be associated with a neurogenic bladder.
• Evaluation for other sources of fever.
• Urinalysis
 Laboratory Investigations
• Urinalysis: Clean catch or suprapubic aspirate
– WCC, RCC, Nitrites (E Coli): Sensitivity of 80%.
– Urine Microscopy
• Urine Culture
• FBC, U/E, CRP
• Blood Culture
• Lumbar Puncture in a febrile child < 3 months
 Management
The goals of Treatment
• Elimination of infection and prevention of
urosepsis
• Prevention of recurrence and long-term
complications including hypertension, renal
scarring, and impaired renal growth and function
• Relief of acute symptoms (eg, fever, dysuria,
frequency)
 Hospitalization
• Age <3 months
• Clinical urosepsis or potential bacteremia
• Immunocompromised patient
• Vomiting or inability to tolerate oral
medication
• Lack of adequate outpatient follow-up (eg, no
telephone, live far from hospital, etc.)
• Failure to respond to outpatient therapy
 Antibiotics
• Amoxicillin ( or Co-amoxiclav)
• Gentamycin
• Cefotaxime

• Children younger than 2 years and children

with febrile or recurrent UTI are usually
treated for 10 days
 Duration of Therapy
• Children younger than 2 years and children with febrile
or recurrent UTI are usually treated for 10 days

• TMP-SMX or nitrofurantoin may be initiated after

completion of treatment and continued until the
results of the imaging tests are available

• Children older than 2 years who are afebrile, and

without abnormalities of the urinary tract or previous
episodes of UTI are usually treated for 5 to 7 days; such
children have a low risk of recurrence or complications
 Imaging Studies
Routine imaging (RUS and MCUG) for:
• Girls younger than 3 years of age with a first UTI
(children older than 3 years are more reliably able to
verbalize urinary symptoms)
• Boys of any age with a first UTI
• Children of any age with a febrile UTI
• Children with recurrent UTI (if they have not been
imaged previously)
• First UTI in a child of any age with a family history of
renal disease, abnormal voiding pattern, poor growth,
hypertension
 DMSA scan
• Renal scintigraphy using dimercaptosuccinic acid (DMSA)
can be used to detect acute pyelonephritis and renal
scarring in the acute and chronic settings, respectively
• DMSA is injected intravenously, and uptake by the kidney is
measured two to four hours later. Areas of decreased
uptake represent pyelonephritis or scarring.
• Scintigraphy at the time of an acute UTI provides
information about the extent of renal parenchymal
involvement.
• Most (>80 percent) children with moderate to severe VUR
(grade III or higher) will have a positive DMSA scan.
• Some have advocated DMSA be used instead of a MCUG to
identify children at higher risk for renal scarring.
MCUG
DMSA
 Prognosis
• Recurrent UTI — Approximately 14 percent of children younger
than 6 years with UTI have a subsequent UTI.

• Long-term sequelae :
• Approximately 40 percent have VUR: 96 percent had VUR of grade
I, II, or III, which typically resolves spontaneously over time.
• Renal scars (identified by DMSA scan) develop in approximately 8
percent of patients overall, 15 percent of those who had abnormal
DMSA scan at the time of diagnosis, and none of the children who
had normal renal scans at the time of diagnosis.
• The long-term significance of scarring, as identified by DMSA,
remains to be determined.
• Predicting which children with UTI will develop long-term sequelae
remains difficult. The large majority of children with UTI have no
long-term sequelae.