Paeds: UTI

Question 1

Symptoms and Signs

Answer 1

Fever
Vomiting
Lethargy
Irritability

Question 2

Symptoms and Signs

Answer 2

• Poor feeding

Failure to thrive

Question 3

Symptoms and Signs

Answer 3

Abdominal pain
Jaundice
Haematuria
Offensive urine

Question 4

Infants and children >3 months (preverbal)

Most common

Answer 4

Fever

Question 5

Infants and children >3 months (preverbal) Less common

Answer 5

• Abdominal pain
• Loin tenderness
• Vomiting
  Poor feeding

Question 6

Infants and children >3 months (preverbal) Least common

Answer 6

• Lethargy
• Irritability
• Haematuria
• Offensive urine
  Failure to thrive

Question 7

Infant and children >3 months verbal;

Most common

Answer 7

Fever

Dysuria

Question 8

Infant and children >3 months verbal;

Less common

Answer 8

• Dysfunctional voiding
• Changes in continence
• Abdominal pain
  Loin tenderness

Question 9

Infant and children >3 months verbal; Least common

Answer 9

• Fever
• Malaise
• Vomiting
• Haematuria
• Offensive urine
  Cloudy urine

Question 10

Infants symptoms of UTI

Answer 10

• Fever
• Vomiting
• Lethargy or irritability
• Poor feeding/failure to thrive
• Jaundice
• Septicaemia
• Offensive urine
  Febrile convulsion (>6 months)

Question 11

Children

symptoms of UTI

Answer 11

• Dysuria and frequency
• Abdominal pain or loin tenderness
• Fever with or without rigors (exaggerated shivering)
• Lethargy and anorexia
• Vomiting, diarrhoea
• Haematuria
• Offensive/cloudy urine
• Febrile convulsion
  Recurrence of enuresis

Question 12

Collection of samples:

Child in nappies:

Answer 12

1. Clean catch (recommended method)
2. An adhesive plastic bag applied to the perineum after careful washing – may be contamination from the skin
3. A urethral catheter (urgency in obtaining sample)
4. Suprapubic aspiration – in severely ill infants requiring urgent diagnosis and treatment

Question 13

Older children:

collection of samples

Answer 13

Mid stream urine may be possible

Note: Cleaning of area needed as contamination high in boys due to foreskin and reflux into the vagina.

Question 14

Leucocyte esterase and nitrite positive

Answer 14

Regard as UTI

Question 15

Leucocyte esterase negative and nitrite positive

Answer 15

Start antibiotic treatment

Question 16

Leucocyte esterase positive and nitrite negative

Answer 16

Only start antibiotic treatment if clinical evidence of UTI

Diagnosis depends on urine culture

Question 17

Leucocyte esterase and nitrite negative

Answer 17

UTI unlikely. Repeat or send urine for culture if clinical hx suggests
UTI

Question 18

Blood, protein and glucose present on stick testing

Answer 18

Useful in any unwell child to identify other diseases e.g. nephritis, DM but will not discriminate between children with and without UTIs

Question 19

Bacterial and host factors that predispose to infection:

Causative organism:

Answer 19

• E.coli
• Klebsiella
• Proteus
• Pseudomonas
• Strep. faecalis
• Newborn: likely to be haematogenous

Question 20

Proteus organism more common in

Answer 20

(more common in boys – potentially due to presence under prepuce)

Question 21

Pseudomonas may indicate

Answer 21

may indicate the presence of some structural abnormality in the urinary tract affecting drainage.

Question 22

Predisposing Factors:

Answer 22

1. Infecting organism
2. Antenatally diagnosed renal or urinary tract abnormality
3. Incomplete bladder emptying
4. Vesicoureteric reflex

Question 23

Incomplete bladder emptying

Answer 23

• Infrequent voiding, resulting in bladder enlargement
• Vulvitis
• Incomplete micturition with residual post-micturition bladder volumes
• Obstruction by a loaded rectum from constipation
• Neuropathic bladder
  Vesicoureteric reflux

Question 24

Vesicoureteric reflux: Definition

Answer 24

A developmental anomaly of the vesicoureteric junctions

Displaced laterally and enter directly into the bladder

Question 25

Vesicoureteric reflux: | Cause

Answer 25

Familial with a 30-50% chance of occurring in first-degree relative. May also occur with bladder pathology e.g. neuropathic bladder or urethral obstruction or temporarily after a UTI

Question 26

Vesicoureteric reflux: | Presentation

Answer 26

Mild (reflux into ureter only) to Severe (Gross dilatation o ureter, renal pelvis and calyces)

Question 27

Vesicoureteric reflux: | Severe reflux leads to

Answer 27

Predisposes to intrarenal reflux and renal scarring with UTI via Backflow of urine from the renal pelvis into the papillary collecting ducts; intrarenal reflux

Question 28

Vesicoureteric reflux: | Reflux with associated ureteric dilatation is important, as:

Answer 28

- Urine returning to the bladder from the ureters after voiding results in incomplete bladder emptying, which encourages infection - The kidneys may become infected (pyelonephritis), particularily if there is intrarenal reflux Bladder voiding pressure is transmitted to the renal papillae; this may contribute to renal damage if voiding pressure are high

Question 29

Vesicoureteric reflux: | Consequence

Answer 29

Chronic renal failure due to scarring leading to hypertension in childhood or early adult life (10%)

Question 30

Vesicoureteric reflux: | Outcome

Answer 30

Mild – resolves spontaneously

Question 31

Investigation: | NICE recommendation

Answer 31

NICE don’t recommend an ultrasound for first UTI if there was response to antibiotic treatment within 48h, unless

Question 32

Paediatrician protocol

Answer 32

1. First proven urinary tract infection 2. Antibiotic therapy + ultrasound of kidneys and urinary tract Ultrasound

Question 33

After ultrasound in

Answer 33

MCUG and DMSA

Question 34

After ultrasound in >1 year and

Answer 34

DMSA

Question 35

Atypical UTI symtpoms

Answer 35

- Seriously ill or septicaemia - Poor urine flow - Abdominal or bladder mass - Raise creatinine - Failure to respond to suitable antibiotics within 48h - Infection with non-E.coli organism

Question 36

Ultrasound with reveal:

Answer 36

- Serious structural abnormalities and urinary obstruction | - Renal defects (but poor at identifying renal scars).

Question 37

MSUG: for

Answer 37

micturating cystorethrogram – useful for reflux but INVASIVE

Question 38

DMSA scan

Answer 38

radionuclide scan – for scarring

Question 39

Plain abdo X-ray:

Answer 39

if haematuria look for stones

Question 40

Management All infants

Answer 40

- Referral to hospital | IV antibiotics e.g. cefotaxime until temp reduced

Question 41

Management Infants >3 months and children with acute pyelonephritis/upper urinary tract infection (bacteruria and fever > 38oC) or bacteruria and loin pain/tenderness even if fever is

Answer 41

- Oral antibiotics with low resistance patterns (e.g. co-amoxiclav for 7-10 days) or IV antibiotics cefotaxime 2-4 days followed by oral antibiotics for 7-10 days total

Question 42

Management Children with cystitis/lower UTI infection (dysuria but no systemic symptoms or signs)

Answer 42

Oral antibiotics for 3 days

Question 43

Medical measures for the prevention of UTI:

Answer 43

Ensure washout of organisms that ascend into the bladder from the perineum, and to reduce the presence ofaggressive organisms in the stool, perineum and under the foreskin.

Question 44

Prevention and advice for parents

Answer 44

- High fluid intake to produce a high urine output - Regular voiding - Ensuring complete bladder emptying by encouraging the child to try a second time to empty his bladder after a minute or two, commonly know as double micturition, this empties any urine residue or refluxed urine returing to the bladder - Prevention or treatment of constipation - Good perineal hygiene - Lactobacillus acidophilus, a probiotic to encourage colonization of the gut by this organism that might potentially cause invasive disease Antibiotic prophylaxis:

Question 45

Antibiotics prophylaxis

Answer 45

- often used in the under 2 with a congenital abnormality: trimethoprim (2mg/kg at night), but nitrofurantoin or cephalexin may be given

Question 46

Follow-up

Answer 46

- Urine culture in nonspecific illness - Low-dose prophylaxis can be used - Circumcision considered - Anti-reflux surgery with evidence of progression - Blood pressure checked if renal disease present - Regular assessment of renal growth and function if bilateral defects present