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Incidence of pediatric urinary tract infection by age group and gender Age (y) Female (%) Male (%) <1 0.7 2.7 1 5 0.9 1.4 0.1 0.2 6 16 0.7 2.3 0.04 0.2 18 24 10.8 0.83 Pediatric Clinics of North America, Pediatric UTI s June, 2006 $  UTI:PathogenesisAnatomy of girls promotes UTI-moist periurethral and vaginal areas promote growth of uropathogens, shorter urethral length increases chance for ascending infection into urinary tract May be caused by any pathogen Most common enteric pathogens #1:Ecoli GBS in neonates <ZZZ UTI:Pathogenesis Gram-negative rods E coli Pseudomonas aeruginosa Klebsiella spp Citrobacter spp Enterobacter cloacae Morganella morganii Proteus mirabilis Providencia stuartii Serratia spp Gram-negative cocci Neisseria gonorrhea *ZZ pGram-positive cocci Enterococcus spp Streptococcus group B Staphylococcus aureus Staphylococcus epidermidis Staphylococcus saprophyticus Streptococcus group D Streptococcus faecalis Other pathogens Candida spp Chlamydia trachomatis Adenovirus Data from Chon C, Lai F, Shortliffe LM. Pediatric urinary tract infections. Pediatr Clin N Am 2001;48(6):1443. (qZp UTI:Risk FactorsNeonates/infants-higher risk b/c of incompletely developed immune system, breast feeding has been shown to protect against UTI for the first 7 months of life Uncircumcised infant boys-since 1980 s studies have shown increased frequency of UTI in uncircumcised boys during first year of life, bacteruria 10-12X more common in first 6 months of life\\UTI:Risk FactorsAnatomic abnormalities-usually seen in children <5yo, posterior urethral valves, vesicoureteral reflux Functional abnormalities-neurogenic bladder Sexual activity-increases risk of UTI in young womenUTI:PresentationNonspecific Infants <3mo:FTT, diarrhea, irritability, lethargy, fever, malodorous urine, jaundice, oliguria, polyuria Children <2yo:fever, v, anorexia FTT Children 2-5yo:abd pain and fever After 5yo:classic signs-dysuria, frequency, urgencyZ UTI:diagnosisVUrine Cx is needed for diagnosis Bagged sample is fine for ruling OUT UTI, but cathed UA or SPA needed to rule IN UTI. Clean catch UA is fine for older children and young adults. UTI is established when UA via cath or SPA has 105cfu/ml of a single uropathogen. If UA is equivocal, check CBC, CRP, ESR to help determine if treatment is needed.WZWUTI:Imaging StudiesU/S, VCUG-what to do? Current Recs are to image: Children <5yo with febrile UTI Girls <3yo with first UTI Boys any age with first UTI Children with recurrent UTI Children who don t respond promptly to abx This is NOT evidence based*11 UTI:ImagingRHoberman et al from NEJM 2003 demonstrated that renal u/s within 72hours of febrile UTI in children is of limited value b/c& . Renal anomaly in children in USA diagnosed on prenatal U/S U/S does not change management-tx is based on clinical signs and sx s U/S not reliable in dx of scarring or VUR** UTI:ImagingmVCUG-good test for establishing presence and degree of VUR. Ok to do once UA is negative, at about day 3-4 of illness once increased bladder contractility has resolved Like renal u/s, use is not evidence based but continues to be standard of care Not evidence based b/c no good studies yet proving prophylactic abx reduce rates of reinfection and renal scarring. nZnUTI:ManagementEmpiric treatment starts before causative agent is identified Base empiric tx on clinical status of child, predominant uropathogens for pt s age group and community sensitivities, pt compliance, ability of f/u Remember to consider if the infection is a first infection or a recurrent, and if recurrent if the infection is unresolved, persistant, or new $bZZcM  UTI:ManagementUncomplicated UTI-nontoxic, taking fluids, reliable caretakers, daily follow up Ok for outpt treatment, oral abx Amox, Bactrim, nitrofurantoin, cephalosporins For children >2yo, 3-5d is adequate&PsPsUTI:ManagementAcutely ill, immunocompromised, infant <2mo is considered to have complicated UTI- Treat Inpatient, IV abx Sepsis evaluation with SPA and bld cultures Amp or cephalosporin plus aminoglycoside 3rd(ceftriax, ceftaz) or 4th(cefipime) gen cephalosporin alone*SZZS %UTI:management of acutely ill patientTreat with IV abx till afebrile and clinically better, about 48-72hrs, then change to PO based on cx and sens. Treat pts 2mo-2yrs for 7-14days total Treat older pts for same length of time, though less data to support extended course!UTI:Prophylactic abx therapyrProphylactic abx goal is to decrease chance for renal damage and scarring which only occur in presence of infection RX for pt s with h/o VUR, immunosupressed pt, pt with obstruction Continue till resolution of underlying cause of predisposition to UTI s Also for pts with recurrent UTI s=2 UTI/6mo or 3UTI/12 mo. :Z:"UTI:Prophylactic abx tx5Nitrofurantoin, Cephalexin, Bactrim, fluoroquinolones# UTI:Summary:Important to recognize and treat UTI s in children to prevent renal scarring and subsequent HTN and CRI in adulthood Important to identify if the infection is a first infection or a recurrence for proper treatment Children often present atypically so high index of suspicion is needed $ UTI:SummaryOk to d/c IV abx after 2-3 days tx and complete the course PO if pt is doing well While use of U/S and VCUG are not evidence based, continue to be recommended and are standard of care. 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