Urinary Tract Infections



Urinary Tract Infections


Dennis Scolnik



Introduction



  • Urinary tract infections (UTIs) occur frequently throughout childhood


  • Prevalence in first year of life: 6.5% (girls), 3.3% (boys)


  • Prevalence in children: 8.1% (girls), 1.9% (boys)


  • Rate of UTIs is 5-20 × higher in uncircumcised boys


  • Less common in African American children


  • Prevalence in febrile children 2 months to 2 years of age: ˜ 5%


  • Upper respiratory tract infection or otitis media does not preclude UTI


  • Other risk factors: fever > 24 hours, fever > 38.9°C and prior UTIs


Clinical Presentation

Different presentations through childhood:


Infants



  • Nonspecific feeding difficulty, anorexia, irritability, vomiting, diarrhea


  • 2/3 have fever, few present with sepsis syndrome or shock


  • Late onset jaundice, with elevation of both direct and indirect bilirubin may be the only indication of infantile UTI


Toddlers and Preschool Children



  • Nonspecific presentation


  • May notice a change in urine smell, color, or pattern of urination



Schoolchildren



  • More likely to present with “classic” adult symptoms and signs


  • Frequency, dysuria, and urgency are common but not pathognomonic


  • May report changed behavior, vomiting, anorexia, fever, abdominal pain, or secondary enuresis


  • If untreated, symptoms may subside over 1-3 weeks, although the urine culture remains positive


  • In recurrent UTIs, symptoms may be minimal


UTI vs Pyelonephritis



  • Not possible to clinically distinguish lower UTIs from pyelonephritis in young children; therefore must maintain a high index of suspicion


  • 75% of children < 5 years with febrile UTIs have upper tract involvement


  • Costovertebral angle tenderness, rigors, and toxicity suggest upper tract involvement


  • Up to 50% of children with febrile UTIs develop renal scarring—may be associated with development of hypertension and end stage renal disease


  • Most scars develop in first five years of initial diagnosis


When to Send a Urine Culture?



  • Febrile infants < 1 year


  • Symptoms/signs suggestive of UTI


  • Toxic/septic/shock without obvious cause


  • History of recurrent UTI, regular catheterization, or known urinary tract anomaly


  • Unexplained fever or symptoms


Obtaining a Urine Sample



  • Four methods: midstream/clean catch sample, urine bag, catheterization, and suprapubic aspiration


  • Urine must be promptly analyzed and plated



  • Refrigerate specimen if > 30-min delay between collection and plating


Midstream/Clean Catch Sample



  • Least traumatic method


  • Can be used in all children without obvious infection or anomaly of external genitalia


  • In infants the parent may prefer to wait with a sterile container and catch urine


Catheterization



  • Method of choice for febrile infants, toxic/septic/shock, and in all age groups with an urgent clinical indication to start antibiotic treatment


  • Genitalia must be carefully cleansed and strict aseptic technique followed to avoid iatrogenic infection


  • Contraindications: gross infection of genital area, labial adhesions, and uncircumcised boys whose urethral opening cannot be visualized


  • Foreskin should not be forcibly retracted as predisposes to paraphimosis

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Jun 22, 2016 | Posted by in EMERGENCY MEDICINE | Comments Off on Urinary Tract Infections

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