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    Add as FriendUrinary Tract Infection in children

    by: Shashank Ranjan Ojha

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    1 : Urinary Tract Infection guidelines Dr. Shashank Ranjan Ojha SAIMS Indore, India
    2 : NICE, UK : Aug 2007 AAP : Aug 2011 IAP : September 2011
    3 : IAP Indian Society of Pediatric Nephrology Meeting held in November 2010, Kolkata Published in Indian Pediatrics Volume 48 September, 2011
    4 : Why this guideline matters ? Urinary tract infection (UTI) is common in infants and children UTI is difficult to recognise Collecting urine and interpreting laboratory results is not easy Diagnosis is not always confirmed UTI in infants and children may have long term sequelae
    5 : UTI is simply defined as infection of the urinary tract. Pyelonephritis Cystitis Asymptomatic bacteriuria
    6 : Clinical features Fever without focus Neonates : A part of septicemia - Fever - Vomiting - Lethargy - Jaundice - Seizures
    7 : Infants and Young Children : Recurrent fever, Diarrhea, Vomiting Abdominal pain, Poor weight gain Older children: Fever, Dysuria, urgency, frequency, Abdominal or flank pain Adolescents : Symtoms restricted to lower tract and fever may not be present.
    8 : Definitions Significant bacteriuria : Colony count of >105/ml of a single species in a midstream clean catch sample. Asymtomatic bacteriuria : Significant bacteriuria in the absence of sumptoms of UTI Simple UTI : UTI with low grade fever, dysuria, frequency, and urgency; and absence of symptoms of complicated UTI.
    9 : Complicated UTI: Presence of fever > 39 0 C, Systemic toxicity, persistent vomiting, dehydration, renal angle tenderness and raised creatinine. Recurrent infection: Second episode of UTI
    10 : Diagnosis Based on positive culture of a properly collected specimen of urine Urinalysis enables a provisional diagnosis of UTI AAP – Both culture and urinalysis
    11 : Significant pyuria: >10 leukocytes per mm3 in a fresh uncentrifuged sample, or >5 lekocytes per HPF in a centrifuged sample. Leukocytouria in absence of significant bacteriuria – not sufficient to diagnose a UTI Leukocyte esterase and Nitrites
    12 : Sensitivity and specificity of Urinalysis Source : AAP
    13 : Collection of urine for culture 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. Antiseptic washes and forced retraction of the prepuce are not advised. In neonates and infants, urine sample is obtained by either suprapubic aspiration or transurethral bladder catheterization.
    14 : Clean catch midstream specimen – IAP , NICE Bladder catheterization Suprapubic aspiration (SPA) - AAP
    15 : Urine specimen should be promptly plated within 1 hour of collection If delay, store sample at 40 C for up to 12 – 24 hours. Repeat urine culture in case contamination is suspected e.g. mixed growth of two or more pathogens, or growth of organisms that normally constitute the periurethral flora The number of bacteria required for defining UTI depends on the method of collection of sample
    16 : Criteria for the diagnosis of UTI AAP - >5 × 104 CFU/ml by suprapubic aspiration or catheterization
    17 : Initial evaluation Patient is examined for the degree of toxicity, dehydration and ability to retain oral intake Examined for underlying functional or urological abnormalities
    18 : Features suggesting underlying structural abnormality Distended bladder Palpable, enlarged kidneys Tight phimosis; vulval synechiae Palpable fecal mass in the colon Patulous anus; neurological deficits in LL Urinary incontinence Previous Sx of the urinary tract, anorectal malformation or meningomyelocoel
    19 : Features suggestive of bowel bladder dysfunction Recurrent UTI Persistent high grade VUR Constipation, impacted stools Holding maneuvers to postpone voiding Voiding <3 or >8 times/day Straining or poor urinary stream Thickened bladder wall (>2 mm) Post void residue > 20 ml
    20 : Immediate treatment Decide hospitalization Children < 3 months Hospitalize Complicated UTI Parental antibiotics Children > 3 months Simple UTI Oral antibiotics Therapy to reduce the morbidity of infection, minimize renal damage and subsequent complications
    21 : Antibiotics for treatment of UTI
    22 : Choice of antibiotic should be guided by local sensitivity pattern 3rd generation cephalosporin is preferable Single daily dose of aminoglycoside in children with normal renal function Intravenous therapy for the first 2-3days followed by oral antibiotics once the general condition improves Re-evaluate
    23 : Duration of treatment Complicated UTI – 10 – 14 days Simple UTI – 7-10 days
    24 : Supportive therapy Maintain adequate hydration Routine alkalization of urine is not necessary Paracetamol Repeat urine culture not required unless there is persistence of fever and toxicity despite 72 hours of adequate antibiotic therapy
    25 : Evaluation after the 1st UTI USG : kidney size, no. & location, hydronephrosis, urinary bladder anomalies and post voidal residual urine DMSA scintigraphy : Renal parenchymal infection and cortical scarring MCU : VUR, anatomical details of the bladder and urethra
    26 : First Urinary Tract Infection Age 1-5 years USG DMSA MCU if USG or DMSA scan is abnormal Age <1 yr Ultrasound MCU DMSA renal scan Age = 5 years USG MCU, DMSA Scan ( If USG abnormal ) AAP: 1st episode only USG, if ab do VCUG
    27 : USG : soon after the diagnosis of UTI MCU : 2-3 weeks later DMSA Scan : 2-3 months after treatment Note: Recurrent UTI at any age should undergo detailed imaging with USG, MCU & DMSA scintigraphy
    28 : Prevention of Recurrent UTI General : . Adequate fluid intake & frequent voiding . Constipation should be avoided . In children with VUR who are toilet trained, regular & volitional low pressure voiding with complete bladder emptying is encouraged . Double voiding . Circumcision
    29 : Antibiotic prophylaxis UTI below 1 yr of age, while awaiting imaging studies VUR Frequent febrile UTI ( 3 or more episodes in a year) Nb: Antibiotic prophylaxis is not recommended in pts with urinary tract obstruction ( e.g. post urethral valves ), urolithiasis and neurogenic bladder, & in pts on clean intermittent catheterization.
    30 : Antimicrobials for prophylaxis of UTI
    31 : Breakthrough UTI on prophylactic antibiotics results either from poor compliance or associated voiding dysfunction Should be treated with appropriate antibiotics Change of medication is not necessary No role of cyclic therapy.
    32 : Asymptomatic bacteriuria Significant bacteriuria in the absence of symptoms of UTI Benign condition No therapy or antibiotic prophylaxis required
    33 : Vesicoureteric Reflux
    34 : VUR (Antibiotic prophylaxis)
    35 : VUR ( continued ) Patients with grade III to V may be offered surgical repair breakthrough febrile UTI if parents prefer surgical interventions to prophylaxis who show deterioration of renal function Antibiotic prophylaxis is continued for 6 months after surgical repair Screening of siblings and offspring
    36 : Long Term Follow-up Patients with a renal scar (reflux nephropathy) are counseled regarding the need for early diagnosis and therapy of UTI and regular follow up. Physical growth and blood pressure monitored every 6-12 months, through adolescence. Investigations - urinalysis for proteinuria and serum creatinine. Annual ultrasound examinations are done to monitor renal growth.
    37 : Referral to Nephrologist Recurrent urinary tract infections Urinary tract infections in association with bowel bladder dysfunction Patients with vesicoureteric reflux Underlying urologic or renal abnormalities Children with renal scar, deranged renal functions, hypertension
    38 :
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