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Urinary Tract Infections in Children

In the neonatal age, the males have a much higher predominance of UTI’s than females. That’s an important feature that then changes when they get older, to much much higher predominance in girls urinary tract infections in children, bladder infection. But in the neonatal age, more boys than girls have UTI’s. For instance, the most common cause - no matter what age - is by far E. coli. So there is no hesitation about the answer to what’s the most common etiology. It doesn’t matter the age or the gender. Then, if there is anything that goes beyond that, remember that gram negatives as the next ones, way lower than E. coli.

In terms of pathogenesis, the main thing is that in the neonatal period, the spread is hematogenous whereas anywhere after that in age, it is ascending through contamination. Ascending through the urethra. So that’s an important feature that neonates usually have urosepsis.

Next is in clinical presentation. The important thing is the presentation by age groups. In the neonate, UTI presents as any other sepsis. So it has to be thought of as a possible cause and urine has to be checked. As a general sepsis workup is done, urine culture is part of that workup and it mustn’t be forgotten, because that’s a very very important cause of sepsis. The findings, the clinical presentation is not necessarily any different than any other sepsis. They don’t complain of flank pain or abdominal pain. So that’s important to remember. In older infants, also, looks like any sepsis. It will be more associated with not wanting to eat so well. Starting to be FTT if it goes on for awhile. They might start crying on urination if there is a very perceptive parent.

Other things on physical exam is palpating kidneys. Kidneys with hydronephrosis can be palpated. They can be felt as a mass and that’s just hydronephrosis causing it. Blood pressure obviously is important, and spinal exam. Anything in the back that indicates either overt or an occult meningomyelocele or spina bifida can already raise the suspicion of neurogenic bladder, etc. Spinal exam and reflexes and sensation. We a lot of times don’t do this exam properly and that’s an important finding.

In terms of diagnosis, the important things to remember are that in an SPA, a suprapubic aspiration, - which is the gold standard for obtaining a urine culture - any bacterial growth is significant. The bladder has to be sterile. In mid-stream, clean catch, if there have been three specimens that have greater than 100,000 colonies, then statistically there is a 95% likelihood of infection.

Risk factors for scarring of the kidneys, which is the final sequela that we want to prevent, are obstruction, reflux, young age, delay in treatment, number of infections and bacteria of low virulence which causes delay in diagnosis and treatment. So what we don’t want to find is an infection with … or we do want to find, if there is an infection, an anatomical abnormality that caused the high incidence of infection, and treat it properly. The treatments range between IV or PO.

Then there are these other tests for finding out whether or not there is a scar, which is called a DMSA scan. It shows scarring. There is now a CT-urogram showing scarring and function together, so there are further studies you could do.

The management of reflux is prevention of further infections with antibiotic prophylaxis, but also treatment of risk factors such as a not-completely empty bladder, double voiding and regular emptying, treatment of constipation, and prevention of bubble baths, wiping properly - front to back - etc. And we repeat the VCUG’s in about a year or 18-months to see how the grade is going; from 3 to 2, to 1. Sometimes from 3 it disappears completely with the VCUG. I tend now to go 18 -months.

Hemolytic uremic syndrome. Hemolytic uremic syndrome will present with the typical case of a two-year-old girl or boy. There is no specific increased incidence in girls or boys. Five day history of diarrhea. The PMD examines on day number three and finds signs of mild dehydration. Recommends Pedialyte. The baby is having diarrhea, is getting dehydrated. If they can drink and replenish some of the electrolytes it will be okay. But two days later the parents notice the child is pale and listless, looks puffy now. And they do not know when she last voided because of the diarrhea.