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
In healthy people, urine in the bladder is sterile, no bacteria or other infectious organisms are present. The urethra that carries urine from the bladder out of the body contains no bacteria or too few to cause an infection. However, any part of the urinary tract can become infected. That is why any growth of typical urinary pathogens is considered clinically important if obtained by suprapubic aspiration. An infection anywhere along the urinary tract is called a urinary tract infection (UTI) and it is the 2nd most common infection in children. UTIs are caused by bacteria that enter the opening of the urethra 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 infection of other organs. During infancy, boys are more likely to develop urinary tract infections. After infancy, girls are much more likely to develop them. children who have UTIs, however, more commonly have various structural abnormalities of their urinary system that make them more susceptible to urinary infection. These abnormalities include vesicoureteral reflux (VUR), which is an abnormality of the ureters that allows urine to pass backward from the bladder up to the kidney, and a number of conditions that block the flow of urine. The risk of renal scarring is greatest in infants and may be progressive if there is a delay in diagnosis and management of urinary tract infections in children. The aims of urinary tract infection management are to provide symptomatic relief and to prevent renal damage. In the meantime to be able to prevent the recurrences of urinary tract infection, evaluation and looking for any structural or functional predisposing factors. Treatment of underlying voiding dysfunction and constipation is important for the successful management of urinary tract infections in children.[1]
Since the early 1970s, occult bacteremia has been the major focus of concern for clinicians evaluating febrile infants who have no recognizable source of infection. With the introduction of effective conjugate vaccines against Haemophilus influenza type b and Streptococcus pneumoniae (which have resulted in dramatic decreases in bacteremia and meningitis), there has been increasing appreciation of the urinary tract as the most frequent site of the occult and serious bacterial infections. Because the clinical presentation tends to be nonspecific in infants and reliable urine specimens for culture cannot be obtained without invasive methods (urethral catheterization or suprapubic aspiration [SPA]), diagnosis and treatment may be delayed. Most experimental and clinical data support the concept that delays in the institution of appropriate treatment of pyelonephritis increase the risk of renal damage
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:
1- The sites of infection bladder [cystitis], kidney [pyelonephritis], urethra [Urethritis].
2- Severity (complicated versus uncomplicated).
3- Recurrency either first or recurrent based on natural history. That may affect clinical management.
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. In conditions with Urinary malformation, urine stasis, impaired urine flow lead to increase reservoir and gives more time to establish the infection and the 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 that is also a cause 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, 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. 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 vesicoureteral reflux (VUR) and the bladder–bowel dysfunction. Older non-continent children (eg, developmental delay) also have more recurrent UTIs.[3][4]
The common pathogenic sources of UTI are bacteria of enteric origin, although other pathogens (fungi, mycobacteria, and viruses) also are encountered.
Bacterial infection:
Fungal infections:
Viral infection:
Although fever may be the sole presenting symptom in children younger than 24 months, physical examination findings may point toward an alternative diagnosis, including:
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.
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. 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. the risk for recurrence is proportional to the number of previous infections.[7]
Long-term antibiotic treatment is more likely if the child receives a diagnosis of vesicoureteral reflux or VUR. This birth defect results in the abnormal backward flow of urine from the bladder up the ureters, moving urine toward the kidneys instead of out the urethra. This disorder should be suspected in young children with recurring UTIs or any infant with more than one UTI with fever. Children with VUR have a higher risk of kidney infection. It creates an increased risk of kidney damage and, ultimately, kidney failure. Surgery is an option used in severe cases. Typically, children with mild or moderate VUR outgrow the condition. However, kidney damage or kidney failure may occur into adulthood.
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.
-unexplained fever of 100.4°F (38°C) or higher after 24 hours.
-symptoms and signs suggestive of urinary tract infection, including.
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 the neurogenic bladder (eg, spinal anomalies, sacral dimples/pits/fat pads).
Urinalysis
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
Currently, a second or third-generation cephalosporin and amoxicillin-clavulanate are drugs of choice in the treatment of acute uncomplicated UTI. Parenteral antibiotic therapy is recommended for infants ≤ 2 months and any child who is toxic-looking, hemodynamically unstable, immunocompromised, unable to tolerate oral medication, or not responding to oral medication. A combination of intravenous ampicillin and intravenous/intramuscular gentamycin or a third-generation cephalosporin can be used in those situations. Routine antimicrobial prophylaxis is rarely justified, but continuous antimicrobial prophylaxis should be considered for children with frequent febrile UTI.[9]
Prophylactic antibiotics do not reduce the risk of recurrent UTIs, even in children with mild to moderate vesicoureteral reflux.
The surgical opinion is sought only when medical management has failed. Failure is defined as either recurrent infections and pyelonephritis or poor renal growth.
Getting treated for related health problems may help prevent a UTI.
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