UTI Final

Presenter: Dr Vijayalaxmi
yeresheeme
Junior Resident
Moderator:Dr Borra Ranganath

Senior Resident
URINARY TRACT INFECTIONS
Overview of the topic
1.Anatomy of urinary tract
2.Definitions
3.Initial evaluation
4.How to collect sample
5.Treatment
6.Evaluation after 1st UTI
7.Take home points
Anatomy of urinary tracts
Upper urinary tract includes kidneys
and ureters
Lower urinary tract includes bladder
and urethra
Definition
 Infection of the urinary tract is identified by
growth of a significant number of organisms of
a single species in the urine, in the presence of
symptoms.
 The diagnosis of UTI should be made only in

patients with a positive urine culture.
Recurrent UTI
 Recurrent UTI, defined as the recurrence of
symptoms with significant bacteriuria in
patients who have recovered clinically
following treatment.
 Recurrent UTI is common in girls.

Clinical features
Infants and younger children present with
Fever
Diarrhea
Vomiting
Abdominal pain
Poor weight gain
Older children present with
Fever
Dysuria
Urgency
Frequency
Abdominal and flank pain
Important definitions
Complicated UTI: Patients with features of
systemic toxicity are considered as having
complicated UTI.
Presence of fever >39ºC, systemic toxicity,
persistent vomiting, dehydration, renal angle
tenderness and raised creatinine.
Simple UTI: UTI with low grade fever, dysuria,
frequency, and urgency; and absence of
symptoms of complicated UTI
 Significant bacteriuria Colony count of
>10ˆ5/mL of a single species in a midstream
clean catch sample.
 Asymptomatic bacteriuria Significant

bacteriuria in the absence of symptoms of
urinary tract infection (UTI).
 Recurrent infection Second episode of UTI

Diagnosis
 The diagnosis of UTI is based on positive

culture of a properly collected specimen of
urine while urinalysis is helpful in making
presumptive diagnosis
1.Urine microscopy
2.Dipstick Tests
3.Urine culture
Urine microscopy:
should be performed on any freshly voided urine

specimen(<1 hour after voiding) or a refrigerated
specimen <4 hours after voiding
. Febrile UTI is usually associated with pyuria (>5
white cells/high power field in a centrifuged urine
sample or more than 10 white cells/ cu mm in
uncentrifuged urine)
White cell casts in urine indicate renal parenchymal
involvement
Dipstick tests
 Urinary bacteria convert nitrate to nitrite, which
can be detected as a color change on chemically
coated paper strips. The intensity of color change
is proportional to the number of bacteria in the
urine
 Similarly, production of esterase by neutrophils
in the urine can be detected by chemical methods
 Simultaneous detection of both is highly
suggestive of UTI
Urine culture
Collection of specimen
 A clean-catch midstream specimen is used to minimize
contamination by periurethral flora.
 Contamination can be minimized by washing the genitalia with

soap and water.
 In neonates and infants, urine sample is obtained by either

suprapubic aspiration or transurethral bladder catheterization.
 The urine specimen should be promptly plated within one hour

of collection. If delay is anticipated, the sample can be stored in
a refrigerator at 4ºC for up to 12-24 hours.
Repeat urine culture?
 Contamination
 UTI is strongly suspected but colony counts

are equivocal.
 persistence of fever and toxicity despite 72

hours of adequate antibiotic therapy
Management
 Initial evaluation
 Degree of toxicity
 Dehydration
 Ability to retain oral intake
 Blood pressure
 Bowel and bladder habits

Whom to hospitalize?
 Children < 3 months of age
 Children with complicated uti
 Parenteral antibiotics
 Third generation cephalosporins preferred
 Children >3months and those with simple uti can be treated with oral antibiotics
 The duration of therapy is 10-14 days for infants and children with complicated
UTI, and 7-10 days for uncomplicated UTI
 Along with antibiotics: adequate hydration,antipyretics

Evaluation after the first uti
INCLUDES
 Ultrasonography
 DMSA(dimercaptosuccinic acid renal scan)
 MCU(micturating cystourethrography )
 An ultrasonogram :kidney size, number and
location, presence of hydronephrosis, urinary
bladder anomalies and post-void residual urine.
 DMSA :renal parenchymal infection and
cortical scarring.
 MCU: detects VUR and provides anatomical
details regarding the bladder and the
Ultrasonography should be done soon after the
diagnosis of UTI. The MCU is recommended
2-3 weeks later, while the DMSA scan is
carried out 2-3 months after treatment.
Prevention of recurrent uti
 Adequate hydration
 Frequent voiding
 In children with VUR who are toilet trained, regular

and volitional low pressure voiding with complete
bladder emptying is encouraged.
 Double voiding ensures emptying of the bladder of

post void residual urine.
Antibiotic prophylaxis
 Long-term, low dose, antibacterial prophylaxis is used to prevent
recurrent, febrile UTI
 Indications
 (i) UTI below 1-yr of age, while awaiting imaging studies
 (ii) VUR
 (iii) frequent febrile UTI (3 or more episodes in a year) even if the

urinary tract is normal
 Antibiotic prophylaxis is not advised in patients with urinary tract

obstruction (e.g., posterior urethral valves), urolithiasis and neurogenic
bladder, and in patients on clean intermittent catheterization.
Asymptomatic bacteruria
 Asymptomatic bacteruria is the presence of significant bacteruria in the
absence of symptoms of UTI.
 Its frequency is 1-2% in girls and 0.2% in boys . Asymptomatic bacteruria is a

benign condition, which does not cause renal injury and requires no treatment.
 The organism : E. coli, which is of low virulence. Eradication of these

organisms is often followed by symptomatic infection with more virulent
strains.
 Therapy of asymptomatic bacteruria or antibiotic prophylaxis is not required .
 The presence of asymptomatic bacteruria in a patient previously treated for

UTI should not be considered as recurrent UTI
VUR
 VUR grade Management
 Grades I and II :Antibiotic prophylaxis until 1 yr
old. Restart antibiotic prophylaxis if breakthrough
febrile UTI.
 Grades III to V: Antibiotic prophylaxis up to 5 yr of

age. Consider surgery if breakthrough febrile UTI.
 Beyond 5 yr: Prophylaxis continued if there is bowel

bladder dysfunction
Take home messages
 Rapid evaluation and treatment of UTI is important to prevent renal
parenchymal damage and renal scarring that can cause hypertension and
progressive renal damage
 Aim for symptomatic improvement, complete and sustained resolution of fever,

and return of normal well being
 It is important to start on prophylactic antibiotics to prevent recurrent uti
 Patients with UTI should be evaluated for the presence of complications,

underlying anomalies or voiding dysfunction.
 Periodic monitoring of growth
 Blood pressure evaluation once in 6–12 months

References
 RN Srivastava ,Arvind Bagga
 Indian society of pediatric nephrology

Thank you

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Presenter: Dr Vijayalaxmi

Moderator:Dr Borra Ranganath

 The diagnosis of UTI should be made only in

 Recurrent UTI is common in girls.

 Asymptomatic bacteriuria Significant

 Recurrent infection Second episode of UTI

 The diagnosis of UTI is based on positive

should be performed on any freshly voided urine

 Contamination can be minimized by washing the genitalia with

 In neonates and infants, urine sample is obtained by either

 The urine specimen should be promptly plated within one hour

 UTI is strongly suspected but colony counts

 persistence of fever and toxicity despite 72

 Ability to retain oral intake

 Bowel and bladder habits

 Children with complicated uti

 Third generation cephalosporins preferred

 Along with antibiotics: adequate hydration,antipyretics

 DMSA(dimercaptosuccinic acid renal scan)

 In children with VUR who are toilet trained, regular

 Double voiding ensures emptying of the bladder of

 (iii) frequent febrile UTI (3 or more episodes in a year) even if the

 Antibiotic prophylaxis is not advised in patients with urinary tract

 Its frequency is 1-2% in girls and 0.2% in boys . Asymptomatic bacteruria is a

 The organism : E. coli, which is of low virulence. Eradication of these

 Therapy of asymptomatic bacteruria or antibiotic prophylaxis is not required .

 The presence of asymptomatic bacteruria in a patient previously treated for

 Grades III to V: Antibiotic prophylaxis up to 5 yr of

 Beyond 5 yr: Prophylaxis continued if there is bowel

 Aim for symptomatic improvement, complete and sustained resolution of fever,

 It is important to start on prophylactic antibiotics to prevent recurrent uti

 Patients with UTI should be evaluated for the presence of complications,

 Periodic monitoring of growth

 Blood pressure evaluation once in 6–12 months

 Indian society of pediatric nephrology

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