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Other measures:
•Cranberry juice has been shown to be as effective as antibiotic prophylaxis in children with vesico-ureteric reflux, though large studies are lacking.13
•Probiotics may have a role in prophylaxis of UTIs in children, but robust evidence is lacking.
References
1.Singh-Grewal D, Macdessi J, Craig J. Circumcision for the prevention of urinary tract infection in boys: A systematic review of clinical trials and observation studies. Arch Dis Child. 2005;90:853-858.
2.Mukherjee S, Joshi A, Carroll D, Chandran H, Parashar K, McCarthy L. What is the effect of circumcision on risk of urinary tract infection in boys with posterior urethral valves? J Pediatr Surg. 2009;44:417-421.
3.National Institute for Health and Clinical Excellence. Urinary tract infection in children: diagnosis, treatment and long-term management. Royal College of Obstetricians and Gynaecologists; National Collaborating Centre for Women’s and Children’s Health. 2007.
4.Coulthard MG, Lambert HJ, Keir MJ. Do systemic symptoms predict the risk of kidney scarring after urinary tract infection? Arch Dis Child. 2009;94:278-281.
5.Jones PF. Active observation in management of acute abdominal pain in childhood. BMJ. 1976;2:551-553.
6.Neilson A, Newland A. Prevalence of abnormalities on dipstick urinalysis in children with appendicitis and the adverse effects of misdiagnosis as urinary tract infection. Presentation, BAPS & EUPSA combined congress, Graz. 2009.
7.England RJ, Crabbe DC. Delayed diagnosis of appendicitis in children treated with antibiotics. Pediatr Surg Int. 2006;22:541-545.
8.National Institute for Health and Clinical Excellence. Feverish illness in children: Assessment and initial management in children younger than 5 years. National Collaborating Centre for Women’s and Children’s Health. 2007.
9.Long E,Vince J. Evidence behind the WHO guidelines: hospital care for children: what are appropriate methods of urine collection in UTI? J Trop Pediatr. 2007;53:221-224.
10.Montini G, Zucchetta P, Tomasi L, et al. Value of imaging studies after a first febrile urinary tract infection in young children: data from Italian renal infection study. Pediatrics. 2009;123:e239-e246.
20A. Neilson and S. O’Toole
11.Christian MT, McColl JH, MacKenzie JR, Beattie TJ. Risk assessment of renal cortical scarring with urinary tract infection by clinical features and ultrasonography. Arch Dis Child. 2000;82:376-380.
12.Mattoo TK. Are prophylactic antibiotics indicated after a urinary tract infection? Curr Opin Pediatr. 2009;21:203-206.
13.Nishizaki N, Someya T, Hirano D, et al. Can cranberry juice be a substitute for cefaclor prophylaxis in children with vesicoureteral reflux? Pediatr Int. 2009;51:433-434.
Chapter 3
Urinary Tract Infection:
Europe
Özgü Aydogdu and Christian Radmayr
Key Points
››Urinary tract infection (UTI) is one of the most common bacterial infections seen in children.
››Urine culture should be obtained for diagnosis, if there is clinical suspicion or positive urinalysis.
››After a maximum of two UTI episodes in a girl and one episode in a boy, investigations should be undertaken.
››Dimercapto-succinic acid (DMSA) scan is the gold standard in the prediction of renal scarring.
››Main goal of the treatment should be the elimination of symptoms in the acute episode and prevention of renal deterioration in the long term.
››Oral treatment with fluids and oral antibiotics should be preferred in case of uncomplicated UTI.
››Prophylactic antibiotics may be used to reduce the risk of recurrent UTI.
››Prevention of potential UTI is the most critical step in the management of UTI in a child.
P.P. Godbole et al. (eds.), Guide to Pediatric Urology and |
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Surgery in Clinical Practice, DOI: 10.1007/978-1-84996-366-4_3,
© Springer-Verlag London Limited 2011
22 Ö. Aydogdu and C. Radmayr
3.1 Introduction
Urinary tract infections (UTIs) remain a significant cause of serious bacterial infections in children. It represents the most common bacterial infection in children less than 2 years of age. The incidence of UTIs varies depending on age and sex. In the first year of life, mostly the first 3 months, UTIs are more common in boys (3.7%) than in girls (2%). Later the incidence changes and approximately 3% of prepubertal girls and 1% of prepubertal boys are diagnosed with UTIs.1-3
Especially younger than 2 years, UTIs have been associated with significant morbidity and long term medical problems, such as hypertension, impaired renal function and chronic kidney disease.Thus, prompt diagnosis and treatment are critical in preventing the possible pathologic sequelae of UTIs. Pediatric UTIs should be considered as complicated until proved otherwise. Potential genitourinary abnormalities should also be considered subsequent to a diagnosis of UTI, and early diagnosis and accurate management can provide patients with an improved long-term prognosis.3
3.2 Aetiology
1.The common pathogenic sources are gram-negative, mainly enteric, organisms. Escherichia coli is responsible for more than 80% of episodes of UTIs.2, 4, 5
2.Klebsiella and Proteus with Enterococcus and Staphylococcus represent 5–7% of cases.2, 4, 5
3.Groups A and B streptococci are relatively common in the newborn.2, 4, 5
3.3 Pathogenesis and Risk Factors
1.Normally the urinary tract is a sterile space and retrograde ascent is the most common mechanism of infection particularly after the third or later months of life.4, 5
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2.Nosocomial infection and involvement as a part of a systemic infection are less common.4, 5
3.Evidence on risk factors for UTI in children is limited. The most common risk factors for UTI in infants and children are age, sex, periurethral or colonization factors, genitourinary abnormalities and native immunity.5-13
•In girls, bacteria can gain access to the urinary tract more easily than in boys because of the perineal location of the urethral orifice and the shorter urethra.
•Vaginal voiding can lead to increased moisture in the perineum allowing for bacterial overgrowth.
•Phimosis predisposes to UTI. In boys, the prepuce can serve as a reservoir for potentially uropathogenic bacteria. E. coli expressing P fimbriae which adhere to the inner layer of the preputial skin and to uroepithelial cells colonize the preputial sac.
•Obstruction is one of the most common causes of UTI. A wide variety of congenital urinary tract abnormalities (posterior urethral valves, ureteropelvic junction obstruction, and ureterovesical junction obstruction) can cause UTIs through obstruction.
•Non-obstructive urinary stasis (e.g., vesico-ureteral reflux (VUR), prune belly syndrome) is another potential cause of UTIs.
•Dysfunctional voiding may result in infrequent bladder emptying and residual urine in the bladder, providing the bacteria a suitable place for multiplying enough to cause infection.
•Neurogenic bladder caused by spina bifida, spinal lesions or injury, may lead to post void residual urine and therefore is a potential risk factor for UTI.
•Children who have been catheterized and patients on clean intermittent catheterization are potential candidates of UTIs.
•Some children may have a susceptible urothelium that allows an increase in bacterial colonization.These patients may possibly have a decrease in cellular immunity.
•Other significant causes of UTIs are chronic constipation/encopresis and labial adhesion.