Urinary Tract Infection (UTI)

UTI : Is growth of bacteria in the urinary tract.

Bacteriuria : Growth of 100.000 colony-forming unit (CFU)/ml
in freshly voided urine
Symptomatic UTI :
Acute pyelonephritis is infection involving the renal
parenchyma
Acute cystitis is infection limited to the lower urinary tract.
Asymptomatic(covert) bacteriuria (ABU) :
Repeated bacteriuria in a child without any symptoms.
Causes : E. Coli, Proteus species, Klebsiella, Enterococci
Staph. Saprophyticus,, Pseudomonas, Staph. Aureus or
epidermidis.
 Bowel flora

Emergence of uropathogenic strains

Perineal and anterior urethral colonization

(Vaginal colonization in females)

Normal Mucosal Defence Barriers

BACTERIAL HOST FACTORS

VIRULENCE 1. Enhanced uroepithelial
Cystitis Adherence
2. VUR
Acute 3. Intrarenal reflux
pyelonephritis 4. Obstructed urinary
tract
5. Foreign body
(urinary catheter)
Renal scarring Urosepsis

Pathogenesis of ascending UTI

 PATHOGENESIS OF ACUTE PYELONEPHRITIS
CHAIN OF EVENTS
Bacterial inoculation of renal parencyma

Complement activation

Immune respon
Chemotaxis-Opsonization
Intravascular
Phagocytosis granulocyte
Bacterial killing aggregation

Superoxide Release
Lysosyme
release
Tubular cell death
Focal
Ischemia
Interstitial invasion

RENAL SCAR

Hypothesis for the renal pathogenetic chain of event in

acute pyelonephritis
 Long-term Consequence

UTI causes = Significant morbidity & suffering for children

= Inconvinience and anxiety for families
= Considerable consumption of medical resources
Most children with UTIs have an exelent prognosis
The process of scarring after acute pyelonephritis is low
Hypertension has been shown in 10% of children &
young adult
Women who had a tendency to recurrent UTIs as girl have
an increased risk of new infections during pregnancy
Diagnosis
The diagnosis procedure is based on urinalysis, with
culture as the most important investigation
Methods of urine collection
1. Meadstream specimen
2. Bag urine sample
3. Suprapubic aspiration urine
4. Bladder catheterization
Culture of Urine
Urine should be refrigerated at 40 C
Diagnosis of ABU : requires repeated samples
Urine interpretation in diagnosis of UTI
Method of collection Quantitative culture :UTI present
Suprapubic aspiration Growth of urinary pathogens in any
number
Catheterization Febrile infants or children usually have >
50 x103 CFU/ml of a single urinary
pathogen, but infection may be present
with counts from 10 x 103 to 50 x 103
CFU/ml
Midstream clean-void Symptomatic patient usually have > 105
CFU/ml of a single urinary tract pathogen
Midstream clean-void Asymptomatic patiens : at least two
specimens on different days with > 105
CFU/ml of the same organism
 Other urine findings
Pyuria : is the presence of > 10 WBCs per high power
field by light microscopy in a centrifuged
urinary sediment.
Nitrite test : the ability of most uropathogens to reduce
nitrate to nitrite (pink azo)
Microscopic hematuria : is more than 5 red cells per mm3
in urine in a Fuchs-Rosenthal counting
chamber.
Macroscopic hematuria : is found in 2030% of acute
cystitis
Site of infection
Localization of bacteria
Measurement of host reactions to renal inflamation :
Renal imaging
Antibiotic treatment
Symtomatic UTIs should be given antibiotic without delay
The drug is depend on the resistance pattern of
urophatogens
Antibiotic prophylaxis
Is indicated at high risk for developing renal scarring
Monitoring
Acute situation
Previous UTIs, recent episodes of high fever, bladder
and bowel emptying habits
Essential full physical examination
Urinalysis, urine culture, serum creatinine

Follow up : Within 24 hours, after 4-5 days and 3-4 weeks,

after 6 monts and 1 year
 Antibacterial drug in chilhood UTI
Frequency of resistant in
Children with primary UTI in
Goteborg 1992-1995 (%)
Drug E.coli Non E.coli All Serious adverse rection

Ampicillin derivates 27 61 31 -
Pivmecillinam 1 39 5 -
Cephalosporins 1 29 4 -
Trimethoprim (with or Bone marrow depre-
Without sulfanamide) 10 13 10 sion, mucocuutaneus
Syndromes
Nitrofurantoin 1 61 7 Pulmonary
Ciprofloxacine 1 15 2 Cartilage (before
puberty)
Aminoglucosides 1 1 1 Ototoxicity, renal
toxicity
 Asymptomatic Bacteriuria (ABU)

Symptoms in school girls with ABU

History of urgency, urge incontinence, difficult micturation
Relationship between symptomatic and asymptomatic bacteriuria
Untreated symptomatiic UTI may deal spontaneously or the may
turn into ABU
ABU may develop into symptomatic UTI
Treatmen of children with ABU
Screening for bacteriuria in healhty children should be discontinued
Follow up includes bladder and bowel history, physical examination
as in symptomatic UTI
Avoid the of antibiotics in ABU