Pediatric

Urinary Tract Infection

Aprianda Saputra/ANS
 INTRODUCTION
Urinary tract infection is an infection in any parts in urinary tract system

Sood A, Penna FJ, Eleswarapu S, et al. Incidence, admission rates, and economic burden of pediatric emergency department visits for urinary tract
infection: Data from the nationwide emergency department sample, 2006 to 2011. J Pediatr Urol 2015;11:246.e1-8.
 Classification according to site

Lower urinary
Upper urinary tract
tract
• Bladder
• Kidney
• Urethra
• Ureter

EAU Pediatric Urology Guideline (2020)

 Classification according to episode
First UTI
First episode of UTI without any history UTI before
Maybe sign of anatomical anomalies that predispose to complications of UTI and potential
renal damage

Recurrent infection
• unresolved infection
initial therapy is inadequate for elimination of bacterial growth in the urinary
tract
• persistent infection
infection bacteria from a site within the urinary tract that cannot be eradicated

Re-infection
each episode can be caused by a variety of new infecting organisms

EAU Pediatric Urology Guideline (2020)

 Classification according to Severity

Simple
mild pyrexia; are able to take fluids and oral medication

Severe
fever of > 39°C, the feeling of being ill, persistent vomiting

EAU Pediatric Urology Guideline (2020)

 Classification according to Symptom

Asymptomatic
leucocyturia but no other symptoms.

Symptomatic
Irritative voiding symptoms, suprapubic pain (cystitis),
costovertebrae pain/tenderness, fever, and malaise

EAU Pediatric Urology Guideline (2020)

 Classification according to Complicating Factors
• Uncomplicated UTI
occurs in a patient with a morphologically and functionally normal upper
and lower urinary tract, normal renal function and competent immune system.

• Complicated UTI
Occurs in patient with mechanical or functional obstructions of the urinary
tract,

EAU Pediatric Urology Guideline (2020)

Patient approach
Patient approach
Urinalysis
Method Findings

Suprapubic aspiration If a UTI is present, bacteria are likely to be proliferating in bladder urine with
growth of any organism

Catheterization Febrile infants and children with UTI usually have >50,000 CFU/mL of a single
urinary pathogen; however, UTI may be present with 10,000-50,000 CFU/mL
of a single organism.

Midstream UTI is indicated when >100,000 CFU/mL of a single urinary pathogen is

present in a symptomatic patient. Pyuria usually present. A UTI may be present
with 10,000-50,000 CFU/mL of a single bacterium.

Any method in a girl or If the patient is asymptomatic, bacterial growth is usually >100,000 CFU/mL of
boy the same organism on different days. If pyuria is absent, this result probably
indicates colonization rather than infection.

© NICE 2017. Urinary tract infection in under 16s: diagnosis and management. Available from: www.nice.org.uk/guidance/CG54.
EAU Pediatric Urology Guideline (2020)
PYELONEPHRITIS
 Definition : Infection in single or both kidney

Escherichia coli - This is by far the most common

organism, causing more than 90% of all cases of acute
pyelonephritis

William V. Raszka and Omar Khan

Pediatrics in Review October 2005, 26 (10) 364-370; DOI: https://doi.org/10.1542/pir.26-10-364
 Pathogenesis

https://calgaryguide.ucalgary.ca/upper-urinary-tract-infection-uuti-pathogenesis-and-clinical-findings/
 Clinical Findings:

Infants and young children aged 2 months to 2 years often present with
nonspecific symptoms

Preschoolers and school-age children MOSTLY complain of abdominal pain or

flank pain. Their urine is typically malodorous, and hematuria

Adolescents are most likely to present with the classic adult symptoms of fever,
often with chills, rigors, and flank pain.

William V. Raszka and Omar Khan

Pediatrics in Review October 2005, 26 (10) 364-370; DOI: https://doi.org/10.1542/pir.26-10-364
 Treatment

NICE National Institute for Health and Care Excellence 2018

 URETERITIS

Gabriella Azzarone, Sheila Liewehr and Katherine O'Connor

Pediatrics in Review December 2007, 28 (12) 474-476; DOI:
https://doi.org/10.1542/pir.28-12-474
 Definition : Infection of the ureter

Present with symptoms of cystitis or pyelonephritis

with suprapubic/flank pain, dysuria, haematuria and/or
fever. White cell count may also be elevated

 Wasnik AP, Elsayes KM, Kaza RK et-al. Multimodality imaging in ureteric and periureteric pathologic abnormalities. AJR Am J
Roentgenol. 2011;197 (6): W1083-92. doi:10.2214/AJR.11.6623
 Pathogenesis
most commonly infectious from
associated cystitis but there are many
causes

ascending urinary Escherichia coli

tract infection Aerobacter aerogenes

chronic
inflammation direct spread from haematogenous
secondary to adjacent organs spread
ureteric stents

 Wasnik AP, Elsayes KM, Kaza RK et-al. Multimodality imaging in ureteric and periureteric pathologic abnormalities. AJR Am J Roentgenol.
2011;197 (6): W1083-92. doi:10.2214/AJR.11.6623
 RADIOGRAPHIC FEATURES
CT urography. Lippincott Williams & Wilkins. ISBN:0781787548.

CT-SCAN
diffuse, circumferential urothelial wall thickening and
contrast-enhancement
periureteric or perinephric fat stranding
 Treatment

(i) follow up should be carried out, expecting that hydronephrosis will improve
(ii) if there is no improvement, a ureteral stent should be placed in the diseased ureter
(iii) if there is no improvement after removal of the ureteral stent, steroid therapy should
be initiated
(iv) if there is no response to steroid therapy, surgery such as a substitute ureter should be
considered.
 Cystitis

Gabriella Azzarone, Sheila Liewehr and Katherine O'Connor

Pediatrics in Review December 2007, 28 (12) 474-476; DOI: https://doi.org/10.1542/pir.28-12-
 Definition : Infection within the bladder

It count as lower tract UTI. In all age groups, the

most common pathogen causing cystitis
is Escherichia coli (95%)

The characteristic in cystitis  localized symptoms

 lower abdominal/suprapubic pain, dysuria,
urinary frequency and urgency

Gabriella Azzarone, Sheila Liewehr and Katherine O'Connor

Pediatrics in Review December 2007, 28 (12) 474-476; DOI: https://doi.org/10.1542/pir.28-12-474
 Pathogenesis

https://calgaryguide.ucalgary.ca/lower-urinary-tract-infection-pathogenesis-and-clinical-findings/
 Clinical Findings
Infant Younger < 5 y.o > 5 y.o

Fever with non-specific

fever and gastrointestinal classic lower urinary tract
symptoms (failure to thrive,
symptoms are most common. symptoms
diarrhea, etc)

Physical examintation findings

Palpable bladder Suprapubic tenderness to
Dribbling, poor stream, or palpation
straining to void

Gabriella Azzarone, Sheila Liewehr and Katherine O'Connor

Pediatrics in Review December 2007, 28 (12) 474-476; DOI: https://doi.org/10.1542/pir.28-12-474
 Treatment

NICE National Institute for Health and Care Excellence 2018

 Urethritis

Farhat, W., & McLorie, G. (2001). Urethral Syndromes in Children. Pediatrics in Review, 22(1), 17–21. doi:10.1542/pir.22-1-17 
 Classification
Bulbar
Non - Infectious
urethritis

Urethritis
Gonococcal Urethritis (GU)

Infectious

Non-Gonococcal Urethritis
(NGU)

Farhat, W., & McLorie, G. (2001). Urethral Syndromes in Children. Pediatrics in Review, 22(1), 17–21. doi:10.1542/pir.22-1-17 
 Pathogenesis GU
Bacterial components (pili and other Bacterial porins and
Attachment to the
proteins) allow adherence to host proteins form pores in
mucosoal cell surface
mucosalcells host cell membrane

bacterial invade and

Bacterial phagocytosis Survival and replication
replicate within columnar
by circulating monocytes
epithelial cells

Dissemination of Sign and symptoms of gonorrhea

pathogen infection

https://calgaryguide.ucalgary.ca/gonorrhea-pathogenesis/
 Pathogenesis NGU

C. trachomatis infects columnar epithelial

cells at mucosal sites

replicates in host cells Cell Death

https://calgaryguide.ucalgary.ca/gonorrhea-pathogenesis/
 Urethritis
Case Cause Symptoms Therapy

Non-Infectious Bulbar Urethritis Scar Low Flowrate Conservative

Infectious Gonoccocal Urethritis Neisseria Pain Antibiotics

Gonorrhoeae
Non-Gonoccocal Chlamydia Pain Antibiotics
Urethritis thracomatis
Treatment
Gonococcal Urethritis Infants and Children Who Weigh ≤45 kg and Who Have Uncomplicated Gonococcal sign
www.cdc.gov Ceftriaxone 25–50 mg/kg IV or IM in a single dose, not to exceed 125 mg IM

Children Who Weigh ≤45 kg and Who Have Bacteremia or Arthritis

Ceftriaxone 50 mg/kg (maximum dose: 1 g) IM or IV in a single dose daily for 7 days

Children Who Weigh >45 kg and Who Have Bacteremia or Arthritis

Ceftriaxone 1 g IM or IV in a single dose daily every 24 hours for 7 days

Non-Gonococcal Infants & Children BW <45Kg

Urethritis Erythromycin base or ethylsuccinate 50 mg/kg/day orally divided into 4 doses daily for 14 days

Children BW ≥45 Kg, <8 y.o

Azithromycin 1 g orally in a single dose

Children ≥8 y.o
Azithromycin 1 g orally in a single dose OR
Doxycycline 100 mg orally twice a day for 7 days
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