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DEFINITIONS

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URINARY TRACT INFECTION (UTI)

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  • An infection of the kidney, ureter, bladder, or urethra.

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PYELONEPHRITIS

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  • Inflammatory process of the kidney or upper urinary tract = UTI + systemic symptoms

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UROSEPSIS

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  • UTI/pyelonephritis + systemic inflammatory response syndrome (SIRS) criteria

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ETIOLOGY

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COMMON ORGANISMS

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  • Ascending genitourinary (GU) infections: E. coli, gram-negative bacteria (Klebsiella, Proteus, Enterobacter, Pseudomonas), gram-positive bacteria (enterococci, staphylococci, group B Streptococcus)

  • Catheter-associated UTI (CAUTI): fungi

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PREDISPOSING RISK FACTORS

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  • Congenital anomalies: hydronephrosis, posterior urethral valves, vesicoureteral reflux

  • Neurologic abnormalities: neurogenic bladder, quadriplegia

  • Dysfunctional elimination: constipation, voiding dysfunction

  • Indwelling catheters

  • Sexual activity

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CLINICAL MANIFESTATIONS

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NEONATES/INFANTS

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  • Fever of unknown origin

  • Jaundice

  • Irritability

  • Poor feeding or failure to thrive (FTT)

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OLDER CHILDREN

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  • Fever

  • UTI symptoms: urinary frequency, urgency, dysuria, enuresis

  • Pain: flank, back, abdominal, costovertebral angle (CVA), suprapubic

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SYSTEMIC SYMPTOMS IN ANY AGE

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  • Fever, chills, rigors

  • Nausea/vomiting, diarrhea

  • Shock

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DIAGNOSIS

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LABORATORY EVALUATION

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  • Urinalysis (UA): pyuria + bacteriuria +/− hematuria

    • Routine “test of cure” not necessary

    • Repeat within 48 to 72 hours if clinical response is poor

  • Positive urine Gram stain and culture

    • Any bacteria from suprapubic tap

    • >50k CFU/mL from catheterization specimen

    • >100k CFU/mL from “clean catch” (exclude polymicrobial growth)

  • Blood culture: to identify concomitant bacteremia

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IMAGING

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  • Recommended for the following patients:

    • Children <5 years with febrile UTI

    • Females <3 years with first UTI

    • Males of any age with first UTI

    • Children with recurrent UTI

    • Children who do not respond promptly to antimicrobial therapy

  • Renal-bladder ultrasound:

    • Identifies gross anatomy abnormalities

    • Obtain in patients with poor clinical response within 48 hours of antimicrobial therapy

  • Voiding cystourethrogram (VCUG):

    • Identifies vesicourethral reflux (VUR)

    • Perform immediately after therapy

  • Technetium 99m-dimercaptosuccinic acid (99mTc-DMSA) scan:

    • Identifies acute pyelonephritis (of limited value) and renal scars (if performed >5 months after infection)

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TREATMENT

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See Surviving Sepsis Guidelines to reverse shock

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ANTIMICROBIAL THERAPY

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  • Empiric IV antibiotics:

    • Second- (cefuroxime) or third-generation (cefotaxime, ceftriaxone) cephalosporin

    • Ampicillin-sulbactam

    • Gentamicin

  • Switch to enteral antimicrobial: afebrile and able to tolerate enteral medications

  • Narrow antimicrobial therapy: based on culture results

  • Duration: 10 to 14 days

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COMPLICATIONS

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RENAL OR PERINEPHRIC ABSCESS

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  • Suspect when fever is persistent despite appropriate antimicrobial therapy

  • Treatments: drainage + antimicrobial therapy

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SUGGESTED READINGS

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Kalra OP, Raizada A. Approach to a patient with urosepsis. J Glob Infect Dis. 2009;1:57–63.  [PubMed: 20300389]
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Roberts KB. Urinary tract infection treatment and evaluation update. Pediatr Infect Dis J. 2004;23:1163–1164.  [PubMed: ...

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