Taralan Tambunan

Department of Child Health Faculty of Medicine

University of Indonesia
Jakarta
 URINARY TRACT INFECTION (UTI)

Definition
 Infection within the urinary tract
 Renal parenchymal infection
 Infection or the urinary bladder

UTI in Children
 A common health problem
 Cumulative incidence: 2%-8% by 10 years of age
 Unexplained fever in neonates
 TERMINOLOGY
SIGNIFICANT BACTERIURIA
The presence of > 100.000 CFU/ml fresh voided clean catch or
catheterized urine specimen

SYMPTOMATIC UTI
Clinical symptoms: dysuria, frequency, urgency
with or without fever and flank pain
1. Acute cystitis (lower UTI)
2. Acute pyelonephritis

ASYMPTOMATIC BACTERIURIA (ABU)RECURRENT UTI

- Repeated symptomatic episode of UTI with symptom-free intervals
- Caused by reinfection

RELAPSE UTI:
persistence of the same bacterial species
Practice Parameter
- To minimize the risk of chronic renal damage
- Within reasonable economic constraint

Steps:
1. Identifying UTI
2. Short term treatment
3. Evaluation of urinary tract abnormality
RECOGNISING THE CHILD AT RISK FOR UTI

 Over diagnosis
 Unnecessary treatment
 Unnecessary imaging evaluation

 Under diagnosis
 Missing the opportunity to treat the acute
infection & possible the underlying
abnormality

IMPORTANT: Accurate diagnosis

 CLINICAL PRESENTATION
Classical Acute PN
 High fever (39 – 410C)
 Other systemic symptoms
 Back or flank pain
 Renal tenderness

Neonate
 Fever
 Vomiting
 Jaundice
 Tearful, restlessness
 Failure to thrive
Infant / Toddler
 Fever of unknown origin (FUO)
 Diarrhea
 Restlessness
 Diaper rash
 Failure to thrive

School Age Periods

Local symptomas / signs
 Dysuria, polakisuria, urgency
 Loin pain, enuresis
 Clinical signs and symptoms of UTI
Newborns Infants and Preschoolers School Age Children
Jaundice
Sepsis Diarrhea
Failure to thrive Failure to thrive
Vomiting Vomiting Vomiting
Fever Fever Fever
Strong-smelling urine Strong-smelling urine
Abdominal or flank pain Abdominal of flank pain
New onset urinary New onset urinary
incontinence incontinence
Dysuria (preschoolers) Dysuria
Urgency (preschoolers) Urgency
Frequency

Adapted from Todd, 1995 (S)

THE CLINICAL DECISION RULE TO IDENTIFY
THE RISK FOR UTI FOR GIRLS
≤ 2 YEARS OF AGE

1. Temperature of 39º C or more

2. Fever for 2 days or more
3. White race
4. Age less than one year
5. Absence of another potential source of fever

≥ 2 variables  Predicted UTI:

- Sensitivity: 0.95 (95% CI: 0.85; 0.99)
- Specificity: 0.31 (95% CI: 0.28; 0.34)

 Gorelic and Shaw, 2000

 Jaundice: Early diagnostic sign
of UTI in infancy

 Maybe the first sign of a UTI

 7,5% of asymptomatic jaundice infant < 8 weeks old

 RSCM: 24 out of 38 jaundice infant

 Garcia FJ, Pediatrics, 2002.

 Oswari et al, Sari Pediatr, 2005
 Diagnostic approach
History & standard check list
1. Voiding pattern
- onset, frequency, urgency
- hold the urine
2. Wetting
- nighttime, daytime, or combination
- night wetting/week
- wake with wetting
- deep sleeper?
- family history
3. UTI
- dysuria, bad odour, cloudy colour
4. Stream abnormality
- push or wait to initiate voiding
- strong or weak stream?
- start and stop?
- stream straight?
5. Bowel function
- frequency, hard or soft stool
- fecal soiling
Physical examination
 Full exam is essential!

growth
vital sign
G-1 tract
urogenital
neurologic
Skin over the spine: hair tuft, dimple
GIRLS: Synechia vulvae

BOYS: - Phimosis

- Postitis / Balano-postitis
METHODS OF URINE COLLECTION
 Mid-Stream specimen
 Bag sample: high false –  rate
 Suprapubic puncture: gold STD
 Catheterization: Sensitivity: 95%
Specificity: 99%
Sensitivity and Specificity or Components of the urinalysis
alone and combination
Test Sensitivity % Specificity %
(Range) (Range)
Leukocyte esterase 83 (67-94) 78 (64-92)
Nitrite 53 (15-82) 98 (90-100)
Leukocyte esterase or 93 (90-100) 72 (58-91)
nitrite positive
Microscopy: WBCs 73 (32-100) 81 (45-98)
Microscopy: bacteria 81 (16-99) 83 (11-100)
Leukocyte esterase or 99.8 (99-100) 70 (60-92)
nitrite or microscopy
positive
AAP, 1999
 Meta analysis of urine screening test (48 articles)

Microscopy: WBCs and bacteria 

(≥ 10 HPF, P10) (any B)

Bivariate
Multivariate P10 and B: the best combination

 HUICOL et al: Pediatr Infect Dis J, 2002

 Table 2. Criteria for the diagnosis of urinary tract infection*
Method of collection Colony count Probability of infection
(pure culture)
Suprapubic aspiration Gram-negative bacilli: > 99%
any number
Gram-positive cocci:
> a few thousand
Transurethral 95%
catheterization >105 Infection likely
104 to 105 Suspicious; repeat
103 to 104 Infection unlikely
< 103
Clean void Infection likely
Boy: > 104 95%
Girl: 3 specimens ≥ 105 90%
2 specimens ≥ 105 80%
1 specimens ≥ 105 Suspicious; repeat
5 x 104 to 105 Asymptomatic: infection
10 to4 5 x 104 unlikely

< 104 Infection unlikely

Ref. Hellerstein, 1982
 Radiologic Evaluation
The AIMS
1. To uncover any underlying
urologic abnormality (VUR,
duplicated collecting system,
obstruction)
2. To identify patients with chronic
renal damage/ scarring from
previously UTI
3. To assist the diagnosis of acute
PN

Indication / Guidelines for Selection

1. All neonates with first UTI
2. All males with first UTI at any age
3. All patients with recurrent UTI
4. All patients with PN
RADIOLOGIC EVALUATION

• Previous recommendation:
• UTI  early investigation:
USG, VCUG, DMSA scan

Based on the basic presumption:

1. Significant number of girls with first
UTI ESRD or hypertension

2. Early diagnosis of VUR or scars

prevent such progression
Table 3. Approximate current cost (in US$)*

Imaging USA Switzerland Britain Israel

investigation
USG 320 80 70 100
VCUG 260 370 135 90
IVP 240 290 135 110
DMSA renal 510 150 290

* ref. Stark (1997)

COST-BENEFIT RATIO
 Economic
 Unnecessary radiation
 Psychological stress to children
 Stress, inconvenience, time loss to parents
Investigation

UTI Prevent ESRD

Treatment

* ref. Stark (1997)

 A Suggested alternative approach
1.  Children: febrile UTI (acute PN?) VCUG &
 Infants with any UTI USG

2. GIRLS:
 2nd or 3nd UTI: Lower UTI
 Family hist of VUR

3. GIRLS: 1St UTI/Lower UTI

 Follow Up: 6-12 mo
Fever (+)  Urine culture

Ref. Stark, 1997

 UTI

US. / VCUG

US-normal US-renal parenchymal

damage and / or
VCUG-VUR grade 0-2 VCUG-VUR grade 3 & above

No renal scan indicated Renal scan

DIAGNOSTIC APPROACH (MALE NEONATE)

Ref. Goldman et al, 2000

Department of Child Health Faculty of Medicine Univ. of Indonesia
recommendation
UTI

< 2 yrs 2 – 5 yrs > 5 yrs

  
USG USG USG
MCU
normal abnormal normal abnormal
normal abnormal    
  observe MCU observe IVP/DMSA
observe IVP/DMSA

normal abnormal normal abnormal

   
observe IVP/DMSA observe MCU

Algorithm for imaging after urinary tract infection in children

Table 4. The sensitivity of clinical findings in the diagnosis
of upper UTI according to DMSA scan

Investigation Sensitivity (%)

1. Clinical findings 53.84

2. WBC count ≥ 15.000/mm3 25.92
3. ESR ≥ 25 mm/h 29.62
4. CRP ≥20 mg/L 14.81
5. Antibody Coated Bacteria 62.96
(ACB) 
6. US parenchymal involv. 25.00
7. IVP parenchymal involv. 9.09

* ref. Bircan et al. 1993

 Clinical and laboratory data

DMSA positive DMSA negative P value

Age (months) 8.9 ± 5.8 7.0 ± 5.9 0.019
Fever 39.6 ± 0.7 39.2 ± 1.2 0.114
GI symptoms
Diarrhea 10 (11%) 21 (22%) 0.038
Vomiting 32 (35%) 31 (33%) 0.753
Irritability 12 (13%) 7 (7%) 0.198
Seizures 4 (4%) 7 (7%) 0.380
URI symptoms 10 (11%) 16 (17%) 0.237
ESR 87 ± 33 52 ± 30 0.0001
WBC 23,880 ± 9,857 19,990 ± 8,454 0.009
CRP 18.3 ± 9.7 9.7 ± 14.0 0.00001
Pyuria 51/62 (82%) 53/75 (71%) 0.114
Nitrite test 34/66 (47%) 27/74 (41%) 0.073
DMSA dimercaptosuccinic acid renal scan, GI gastrointestinal, URI upper respiratory
infection, ESR erythrocyte sedimentation rate, WBC white blood cell count,
CRP C-reactive protein
DIAGNOSIS of UTI
Lower parts:
- Cystitis
- Meatitis / postitis
- Urethritis
- Balanitis
- (phimosis)

Upper parts:
- Pyelonephritis
- Pyelitis (?)

Uncertain: UTI