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Slide 1 :
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Urinary Tract Infection guidelines Dr. Shashank Ranjan Ojha
SAIMS
Indore, India |
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Slide 2 :
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NICE, UK : Aug 2007
AAP : Aug 2011
IAP : September 2011 |
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Slide 3 :
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IAP Indian Society of Pediatric Nephrology
Meeting held in November 2010, Kolkata
Published in Indian Pediatrics Volume 48 September, 2011 |
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Slide 4 :
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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 |
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Slide 5 :
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UTI is simply defined as infection of the urinary tract.
Pyelonephritis
Cystitis
Asymptomatic bacteriuria
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Clinical features Fever without focus
Neonates :
A part of septicemia - Fever
- Vomiting
- Lethargy
- Jaundice
- Seizures
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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. |
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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. |
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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 |
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Diagnosis Based on positive culture of a properly collected specimen of urine
Urinalysis enables a provisional diagnosis of UTI
AAP – Both culture and urinalysis |
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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
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Sensitivity and specificity of Urinalysis Source : AAP |
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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. |
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Clean catch midstream specimen – IAP , NICE
Bladder catheterization
Suprapubic aspiration (SPA) - AAP |
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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 |
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Criteria for the diagnosis of UTI AAP - >5 × 104 CFU/ml by suprapubic aspiration or catheterization |
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Initial evaluation Patient is examined for the degree of toxicity, dehydration and ability to retain oral intake
Examined for underlying functional or urological abnormalities
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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 |
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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 |
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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
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Antibiotics for treatment of UTI |
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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 |
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Duration of treatment Complicated UTI – 10 – 14 days
Simple UTI – 7-10 days
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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
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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 |
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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 |
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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 |
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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
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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.
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Antimicrobials for prophylaxis of UTI |
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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. |
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Asymptomatic bacteriuria Significant bacteriuria in the absence of symptoms of UTI
Benign condition
No therapy or antibiotic prophylaxis required |
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Vesicoureteric Reflux |
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VUR (Antibiotic prophylaxis) |
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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 |
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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. |
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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 |
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