1. Presented by Nancy Mohammed Alaa
Assistant lecturer of Pediatrics
Assiut university
2. Does Pyuria means Urinary Tract
Infection ??!
Does absence of Pyuria excludes
Urinary tract infection ??!
3. Pyuria is a condition in which urine contains >10 WBC
/hpf inin uncentrifuged sample or >5 in centrifuged
sample
That may or may not be asociated with UTI
Sterile pyuria, is urine which contains white blood cells
while appearing sterile by standard culturing of
aerobic laboratory techniques (on a 5% sheep-blood
agar plate and MacConkey agar plate)..
Bacteriuria denotes the presence of bacteria
in urine
4. True or significant bacteruria based on
1-the presence of 100,000
CFU per ml in a carefully collected sample of
clean-voided or midstream urine,
2-10,000 CFU/ml in symptomatic children
3-presence of 50,000 CFU/ml by urethral catheter
4-the finding of any no of pathogens in urine obtained
by suprapubic catheter
8. Urinary tract infection (UTI)
1-presence of symptoms +
2-significant bacteruria or
3-urine specimen with significant WBC , positive
nitrite,leukocyte esterase test.
.
9. Recurrent UTI
is defined as two or more UTIs over a six-month period
Lower urinary tract infection
refers to infection at or below the level of the bladder
Upper urinary tract infection
refers to infection of the urinary tract above the level of the
bladder; that is, the ureters, kidneys, and peri-renal
tissues.This term is used mainly in reference to
pyelonephritis
10. Prevelance
1-during 1st year male :female ratio 2.8:5.4 <more in
uncircumcised male>
2-age 1-2ys is 1:10
3-during adolescent sexually active male ,female at risk
of urethritis
4-most common serious bacterial infection in pediatrics
5% of febrile child
11. Etiology
1-microrganism
A-bacterial
1-GM –ve bacilli :most common is Ecoli ,other as
proteus vaginalis,pseudomonas,klebsiella more in
hospital aquired infection
2-GM+ve:strept,staph
B-non bacterial
ureaplasma urealyticum,trichomonas Chlamydia
,Mycobacterial TB
Candida more in immunosupressed <DM>,
12. Routes of entry
1-ascending <commonest>:ascend by contaminated
catheter or from perineal infection
2-haematogenous:from septic focus in body ,staph and
strept ,TB most common microrganism
3-lymphatic
4-direct from neighbouring organs
13. Defense mechanisms
1-acidc pH of urine , vagina
2-complete emptying of bladder
3-urethral,prostatic secretion
4-length of urethra in male
5-antegrade ureteric peristalsis
6-natural narrowing ,comptent like valves :
External and internal urethral meatus ,bladder neck
,vesicoureteric junction
20. DIAGNOSIS
1-LABORATORY
A-urinalysis
Method to collect urine
1- MIDSTREAM URINE in toilet trained child
after cleansing urethral meatus ,
if prepuce is not retractable in uncircumcised
male ,this method unreliable
2-Adhesive bag in infant,after disinfection of genitalia
3-catheter for greater assurance
23. HANDLING OF SAMPLE
Urine should be processed within 2 hours of collection.
If it cannot be processed in a timely manner, then either
(1) refrigerate the specimen at 2-8°C (specimen will
be stable for 24 hours) or
(2) place the sample in preservative fluid and store at
room temperature for up to 24-72 hours; boric acid is
the most common preservative fluid used for culture.
24. Results
1-pus cells
A-WBC >5/hpf in centrfuged urine or >10 in
uncentrfuged :suggest infection
B-infection may occur in absence of pyuria <sterile
urine> ; obstruction with infection
2-Haematuria microscopic<cystitis>
3-WBC cast
4-PH:alkaline <urea splitting bacteria lead to
normal urine ph 5.5-7ammonia formation>
25. 5-Nitrites. Bacteria that cause a urinary tract infection
(UTI) make an enzyme that changes urinary nitrates to
nitrite
Nitrites in urine show a UTI is present.
Such as :E coli,Proteus,Klebsiella
6-Leukocyte esterase (WBC esterase)
B-Renal function,electrolyte level.
26. C-urine culture <gold standard>
Indication
1-negative urinalysis but symptomatic
2-haematuria
3-unresolved recurrent symptoms after treatment
Results:
A- positive if
1-the presence of>100,000
CFU per ml in a carefully collected sample of
midstream urine,
2-10,000 colonies /ml in symptomatic child
27. 3-the finding of any bacteria in urine obtained by
suprapubic catheteror catheter
4->50,000 CFU/ml collected by urethral catheter
B-repeat culture if midstream culture 10,000-
50,000 colonies of gm –ve
C-false negative :antibiotics,dilution from
overhydration,contaminated of specimen with
antiseptic soln.
29. D- CBC
Leukocytosis,neutrophilia common in acute renal
infection
E–ESR,CRP ;Elevated in acute infection
F-BLOOD CULTURES
Indicated in:
1-infants
2-UTI with obstruction
3-febrile UTI as sepsis is common
30. 2-imaging
1-RENAL US;
Indications:
1-Febrile UTI in infants aged 2-24 months
-2-Delayed or unsatisfactory response to treatment of a first
febrile UTI
3-An abdominal mass or abnormal voiding (dribbling of
urine)
4-Recurrence of febrile UTI after a satisfactory response to
treatmen
5-haematuria
6-obstructive symptoms or urine retention
31. Aim
1-This to exclude acute
pyelonephritis,pyonephrosis,renal or perirenal
abscess
2-rule out obstructive uropathy,hydronephrosis
3- detect kidney size,renal scar
7-history of renal stones
8-raised renal function
32.
33. 2-plain xray
1-To detect renal stones
2-urinary tract calcification
3-voiding cystourethrogram <VCUG>
Indication
1-all children with recurrent UTI
2-Abnormality detected on abd US
3-suspect obstruction
Role:
Diagnosis of vesicoureteric reflux ,posterior urethral valve
40. 6-renal scanning
Idea
DMSA, or dimercaptosuccinic acid, is a radioactive substance
(called a tracer) that is injected into a vein and enters the
kidneys. It is detected by special cameras and enables a scan to
be taken of the inside of the kidneys. :
Aim;
1-evaluate the functioning tissue of kidneys
2-measure the relative function of each kidney
3-diagnosis of pyelonephritis <parenchymal filling defect>
4-diagnosis of renal scar <most sesitive study to detect scar>
43. PREVENTION
1-if recurrence are frequent ,identify the predisposing
factor
2-circumcision in male to decrease recurrence
3-Adequate fluid intake ,frequent voiding
4-urine culture should be obtained 1week after
termination of ttt of UTI to asure that urine is sterile
44. 5-antibiotic prophylaxis:
indicated:
1-recurrent febrile UTI even normal urinary tract
2-Persistent vesicoureteric reflux or any structural
abnormality
3-UTI in child<1y waiting imaging
Duration:6mon or more
Antibiotic prophylaxis not advised in:
1-obstruction,stones
2-neurogenic bladder
45. Drugs for prophylaxis
remarksDose mg/kg/ddrug
Avoid in infants <3 mo, glucose-6-
phosphate dehydrogenase deficiency
1-2Cotrimoxazol
May cause vomiting and nausea;
avoid in infants <3 mo, G6PD
deficiency, renal insufficiency
1-2
Nitrofurantoin1
Drug of choice in first 3-6 mo of life10Cephalexin
An alternative agent in early infancy5Cefadroxil
46. Treatment
Indication of hospitalization:
1-only functioning kidney
2-immunosupresed:DM
3-persistent vomiting
4-Failure to respond to treatment
5-age :<3 mon
6-lack of adequate outpatient follow up
7-potential sepsis
8-urinary tract obstruction or underlying disease
47. 1- acute cystitis
Treatment can be delayed till results of culture are
known or initiated before results if severe by using :
orA-amoxicillin <50mg/kg /d>
B-co trimexazole:<20mg/kg/d>for sulfamethoxazole
or<4mg/kg/d>for trimethoprim
C-nitrofurantoin :5-7mg/kg/d
Duration:7-10d
48. 2-acute pyelonephritis
Inpatient
1-parentral antibiotics
A-gm +ve,-ve ;ceftriaxone 50-75mg/kg/d ,max 2gm or
Cefotaxime 100mg/kg/d
Or
B-gm+ve;ampicillin 100mg/kg/d and gm-ve :
aminoglycoside as gentamicin 3-5mg/kg/d
Daily monitor of RFT, gentamicin level to avoid
nephrotoxicity
49. Duration:parentral till 48 hrs after fever subside then
oral 3rd cephalosporins till end of 14 d
2-IV FLUIDS especially if vomiting,hypotension
3-symptomatic antipyretic ,antiemetic
Outpatient management
Oral 3rd cephalosporins for 14 d
50. complications
1-renal abscess
2-renal scarring
3-impaired renal function
4-ACUTE LOBAR NEPHRONIA
Local renal bacterial infection involve >1 lobe
5-perinephric abscess
6-urethral stricture
7-later on infertility as obstruction of ejaculatory ducts
8-epididymo orchitis< DD :acute scrotum>
9-pyonephrosis
51. Renal abscess
CP:1-mostly patient with acute pyelonephritis without
improvement after 3 d of medical ttt
2-chills fever local renal pain
INV;
1-ABD US 2-CT SCAN
MANAGEMENT
1-HOSPITALIZE ;parentral AB ,antipyretic,analgesic
2-follow up :clinically,radiologically
3-drainage if
A-fail medical ttt
B-large abscess
52.
53.
54. Perinephric abscess
Def:suppurative collection between renal capsule ,perirenal
fascia
Cause;mostly rupture of renal abscess
symptoms;fever,chills,unilateral flank pain
Signs; scoliosis,bulge of renal angle with overlying skin
erythema ,tendrenes
INV;
1-abd US 2- CT SCAN
TTT;
1-Parentral antibiotic
2-drainage
55.
56. TB of urinary tract
Pathology;
1-renal<most common site>
A-acute miliary
Usually bilateral ,fatal,no caseation
B-chronic
2-caseocavernous1-pyelonephritis
4-autonephrectomy3-pyonephrosis -
6-calcifications5-fibrosis
2-ureteric
Most common site is pelviureteric junction
Ureter is dilated ,tortous ,indurated <pipe stem>
3-bladder
Most common ureteric orifice
58. Management
Standard treatment of TB is rifampin, INH,
pyrazinamide, and ethambutol for 2 months, then
rifampin and INH for 4 more months
59.
60. 1-Age below which UTI is admitted and treated by parentral Ab
<3m/5m /1y/6m>
2-drug of choice for UTI prophylaxis in 2mon child is
<nitrofurantoin/cotrimexazole/cephalexin>
3-child 3y presented with dysuria,fever
inv. Show pyuria,urine culture 10,000 colony of Ecoli is
A-consider UTI
B-Insignificant results
C-repeat urine culture
4-which of following regardind UTI prophylaxis is false
A-recommended for child with urinary tract obstruction
B-recurrent febrile UTI even no urinary tract abnormality
C-infant awaiting urinary tract imaging
