Urinary tract infections (UTI) are characterized by a content of 5 x 104 colonies / ml defined in a catheter urine or in older children in the repeated random urine of ?105 colonies / ml. In infants, UTIs are often associated with anatomical malformations. UTI can cause sepsis fever, failure to thrive, flank pain and signs, especially in young children. Treatment is with antibiotics. To follow-up imaging studies of the urinary tract are performed.

UTI can the involvement of the kidneys, bladder, or have both a consequence. Sexually transmitted infections of the urethra (z. B. gonococcal or chlamydial urethritis) are not usually referred to as UTI, although the urinary tract are affected.

Urinary tract infections (UTI) are characterized by a content of 5 x 104 colonies / ml defined in a catheter urine or in older children in the repeated random urine of ?105 colonies / ml. In infants, UTIs are often associated with anatomical malformations. UTI can cause sepsis fever, failure to thrive, flank pain and signs, especially in young children. Treatment is with antibiotics. To follow-up imaging studies of the urinary tract are performed. UTI can the involvement of the kidneys, bladder, or have both a consequence. Sexually transmitted infections of the urethra (z. B. gonococcal or chlamydial urethritis) are not usually referred to as UTI, although the urinary tract are affected. Among the mechanisms that keep the urinary tract sterile, include the acidity of urine and the free flow of urine with normal emptying ways normal ureterovesical and urethral sphincters, a healthy immunological status and an unchanged mucosa. Anomalies in one of these protective mechanisms predispose to a UTI. Etiology At the age of 6 years have undergone 3-7% of girls and 1-2% of boys a urinary tract infection. The age of the sizes incidence of UTI is bimodal, with a peak in infancy and another peak between the ages of 2 to 4 years (the time of dry down for many children). The ratio of female: male is 1: 1 to 1: 4 in the first 2 months of life. (Estimates vary probably because of the different proportions of uncircumcised men in the study groups and because of the exclusion of children with urological abnormalities that are now recognized more frequently even in utero by prenatal ultrasound diagnostics). The ratio of female to male increases with age and is constantly at the age of 2 months to 1 year at 2: 1, during the second year at 4: 1 and after 4 years at> 5: 1. For girls, the infection is ascending, and not likely to cause bacteremia. The significant prevalence of UTI in girls after infancy is due both to the shorter female urethra and on male circumcision. Predisposing factors in younger children have deformities and disabilities of the urinary tract premature birth Permanent urinary catheter In boys, lack of circumcision Other predisposing factors in younger children include constipation and Hirschsprung’s disease. Predisposing factors in older children may be diabetes Trauma In women, sexual intercourse urinary tract abnormalities in children urinary tract infections in children are a possible indication of a malformation of the urinary tract (eg. As obstruction, neurogenic bladder, doubling the urethra). These malformations often have a recurring infection result, especially when vesicoureteral reflux is present (VUR). About 20-30% of infants and children aged from 12 to 36 months with a UTI have VUR. The younger the child at the first HWI is, the higher the probability of VUR. The VUR is divided according to the above table in different degrees of severity (see Table: severity of vesicoureteral reflux). Recurrent UTI is clearly associated with VUR, especially VUR of higher classes. This connection is probably due to two factors – VUR predisposes to infection and recurrent infections can worsen VUR. The relative contribution of each factor in children with recurrent UTI is unclear. Children with serious reflux may have a higher risk of hypertension and renal failure (caused by constant infections and chronic pyelonephritis) to develop. However, the evidence for this is not definitive (urinary tract infections (UTI) in children: Vesicoureteral reflux (VUR)). Grades of vesicoureteral reflux grade properties I Only the ureters are involved, but not the renal pelvis. II Reflux reaches the renal pelvis, but the cups are not expanded. III The ureter and renal pelvis are dilated, with minimal or no flattening of Cups. IV The dilation is increased, and the acute angle of the collecting system fornices are no longer recognizable. V The ureters, the pelvis and chalices are grossly enlarged. Papillary impressions are often missing. * As defined by the International Reflux Study Committee. Many pathogens pathogens can cause urinary tract infections in an anatomically malformed urinary tract. At relatively normal urinary tract are the most common pathogens responsible strains of Escherichia coli with specific attachment factors for transitional epithelium of the bladder and ureters E. coli for> 80 to 90% of UTIs in all pediatric age groups. The remaining causes are other gram-negative enterobacteria, especially Klebsiella, Proteus mirabilis, and Pseudomonas aeruginosa. Enterococci (Group D streptococci) and coagulase-negative staphylococci (eg., Staphylococcus saprophyticus) are the most common gram-positive organisms in the urinary tract. Hardly ever are fungi and mycobacteria that cause, and occur in immunocompromised patients. Adenoviruses rarely cause UTIs, and if so, the disease is usually a hemorrhagic cystitis, also prädominat among immunocompromised hosts. Symptoms and signs In newborns, the symptoms of a urinary tract infection nonspecific and include poor feeding, diarrhea, failure to thrive, vomiting, mild jaundice (which is usually a direct bilirubin increase is), lethargy, fever or hypothermia. A neonatal sepsis can develop. In infants and young children <2 years, the symptoms are also to locate bad (about fever, gastrointestinal symptoms such as vomiting, diarrhea, abdominal pain, or foul-smelling urine). About 4 to 10% of febrile children without localized signs have UTI. It was only in children> 2 years, the classic image of cystitis or pyelonephritis shows. Symptoms of cystitis include dysuria, urinary frequency, hematuria, urinary retention, suprapubic pain, urinary urgency, pruritus, incontinence, foul smelling urine and enuresis. Symptoms of pyelonephritis can be high fever, chills and kostovertebrale pain and sensitivity. Physical findings, let the abnormalities of the urinary tract suspect are abdominal tumors, enlarged kidneys, missing endings of the urethral meatus and malformation of the lower spine. A reduced pressure of the urine stream may be the only indication of an obstruction or a neurogenic bladder. Diagnostic analysis and culture of urine Usually imaging techniques to show the urinary tract Urinalysis A reliable diagnosis of urinary tract infection requires the presence of pyuria in the urinalysis and positive bacterial culture in properly collected urine before an antimicrobial drug is given. The diagnosis of probable UTI can be performed on urine analysis by the presence of pyuria, while the culture results are pending. Most doctors get the urine in infants and young children by transurethral catheterization. Suprapubic puncture is boys with moderate to severe phimosis reserved. For both techniques is required clinical experience. Compared with the suprapubic aspiration catheterization is less invasive, safer and something has a sensitivity of 95% and a specificity of 99%. Samples from urine bags are not reliable and should not be used for diagnosis. Results of urine culture be interpreted basieredn on colony numbers. When urine is taken by catheterization or by suprapubic aspiration, is ? 5 x 104 colonies / ml typical of a HWI. In clean recovered midstream urine bacteriuria is regarded as significant if a single pathogenic germ (not the total number of mixed flora) occurs with ?105 colonies / ml. However occasionally symptomatic UTIs children may have, despite low bacterial counts in urine culture. The urine should be examined with a urinalysis and culture be created as soon as possible or it should be stored at 4 ° C when the investigation for more than 10 minutes delayed. Sometimes a UTI may be, even though the number of bacteria is less than in the above guidelines. Reasons for this may be an antibiotic treatment, a dilute urine (spec. Density <1003) or an obstruction. Sterile cultures include a UTI from in general, except the child receives antibiotics or the urine was contaminated with a skin disinfectant. Microscopic examination of the urine is very helpful, but not mandatory. The sensitivity of pyuria (> 3 leukocytes / field in a centrifuged urine) is approximately 96% for a UTI and 91% specific. The increase in the threshold of pyuria to> 10 leukocytes / high-power field in swirled urine sediment reduces the sensitivity to 81%, but is specific (97%). A white blood cell count> 10 / ul in a non-centrifuged urine has a higher sensitivity of 90%. This investigation is not conducted in many laboratories. The presence of bacteria in urinalysis of woven or non spunbonded fresh urine is about 80 to 90% sensitive, but only 66% specific; Gram coloration of the urine to detect the presence of bacteria is approximately 80% sensitive and 80% specific. As catheterized the urethra of a male baby or small child © Elsevier Inc. All rights reserved. This video is personal information. The users to copy, reproduce, license, subscribe, sell, rent or distribution is prohibited by this video. var model = {videoId: ‘4573317169001’, playerId ‘H1xmEWTatg_default’, imageUrl ‘http://f1.media.brightcove.com/8/3850378299001/3850378299001_4573318863001_vs-56292fbae4b00ce9d4097026-672293877001.jpg?pubId=3850378299001&videoId=4573317169001’ title: All rights reserved © Elsevier Inc. ‘As the urethra of a male baby or small child is catheterized’ description: ” credits’. This video is personal information. The users to copy, reproduce, license, subscribe, sell, rent or distribution is prohibited by this video ‘, hideCredits: true hideTitle: false, hideDescription: true loadImageUrlWithAjax: true};. var panel = $ (MManual.utils.getCurrentScript ()) Closest ( ‘video element panel..’); ko.applyBindings (model, panel.get (0)); Normally, urine test strips are used (Urinstix) for the detection of gram-negative bacteria (nitrite test) or leukocytes (leukocyte esterase test). Are both positive, this corresponds to a sensitivity of 93 to 97% of UTI, and of the accuracy is at 72 to 93%. The sensitivity is lower for each individual test, especially for the nitrite test (50% sensitivity), as it may take several hours to produce the bacterial metabolism nitrites, and frequent urination in children may preclude nitrite detection. The specificity of nitrate test is very high (approximately 98%), and it can be concluded with a positive result in a freshly collected sample to a HWI. Sensitivity of the Leukozytenesterasetests is 83 up to 96% and the specificity is 78 to 90%. The distinction between lower and upper urinary tract infections can be difficult. High fever, pain in the costovertebral transition and a marked pyuria with cylinders may be an indication of a pyelonephritis. An elevated C-reactive protein levels also tends to be associated with pyelonephritis. However, many children develop upper UTI without these symptoms and findings. Studies on the distinction between an infection of the lower and upper urinary tract infection are unnecessary, since the treatment therefore not ändert.Blutuntersuchung blood count and inflammatory parameters (z. B. ESR, CRP) can help to diagnose an infection with equivocal urine findings. Some experts determine the urea and creatinine at the first HWI. Blood cultures are in infants with UTI and in children> 1-2 years that appear septic angemessen.Bildgebende process for the preparation of the urinary tract Many relevant renal or urological abnormalities are discovered today in utero by prenatal routine ultrasound, but a normal result excludes the possibility an anatomical anomaly is not enough. Thus, typically a renal and bladder ultrasound in children takes place <3 years after their first febrile urinary tract infection. Some doctors perform imaging in children up to 7 years of age or older. exclude ultrasound of the kidneys and bladder Helps in children with febrile UTIs obstruction and hydronephrosis and is carried out usually within a week after the diagnosis of UTI in infants. An ultrasound is done within 48 hours when children do not respond quickly to antimicrobial agents, or when their disease is unusually heavy. Beyond childhood sonography can be done in the few weeks after UTI diagnosis. Voiding cystourethrography (VCUG) and radionuclide cystography (RNC) are better than ultrasound for detecting VUR and anatomical anomalies and previously recommended for most children after a first urinary tract infection. However VCUG and RNC both include the use of radiation and are more uncomfortable than sonography. Also learn the role that VUR plays in the development of chronic kidney disease, a re-evaluation, so that the immediate diagnosis of VUR is less urgent. So VCUG is no longer routinely recommended after the first UTI in children, especially if the ultrasound is normal and when children respond quickly to antibiotic therapy. A MZU is reserved exclusively for children with: Sonographic abnormalities (. Eg scars, significant hydronephrosis, evidence of obstructive uropathy or suspected VUR) Complex UTI (ie sustained high fever, body other than E. coli) Recurrent febrile UTI If a MZU must be carried out, it does so at the earliest possible time after a clinical improvement, best carried out at the end of therapy when the bladder has contracted again and the urine is sterile. Can not be created until the end of the therapy these recordings, children should so long given prophylaxis until VUR was excluded. Radionuclide scan is now used to detect especially evidence of scarring of the kidneys. It is by means of technetium-99m Dimercaptosuccinat- (DMSA-) Radionuklidscanning diagnosed., Which is the renal parenchyma. The DMSA scan is not a routine test, but it can be durchgefführt when children have risk factors such as abnormal ultrasound results, high fever and other organisms as E. coli. Only prognosis rare in properly treated children renal insufficiency develops, unless their urinary tract have uncorrectable anatomical malformations. Frequent infections, however, can cause the presence of VUR scars on the kidneys, which then lead to renal hypertension and renal failure. For children with severe reflux (VUR), a permanent scarring occur 4-6 times more common than in children with weaker reflux and 8-10 times more often than in children without reflux. Treatment Antibiotics In severe VUR is sometimes antibiotic prophylaxis and surgical intervention used. The treatment of urinary tract infection is to eliminate the goal of the acute infection, to prevent Urosepsis and get the parenchymal renal function. Antibiotic therapy is started at all toxic-looking or even with non-toxic looking children with dwahrscheinlicher UTI (positive leukocyte esterase test or nitrite test or microscopic secured pyuria). In others, the results of the urine culture can be awaited, which are important to confirm both the diagnosis of UTI and to render antimicrobial susceptibility results. In children between 2 months and 2 years with sepsis, dehydration or inability to retain oral fluids, use parenteral antibiotics, typically the 3rd generation cephalosporins (eg. As ceftriaxone 75 mg / kg IV / IM every 24 hours or cefotaxime 50 mg / kg iv every 6 or 8 hours). A cephalosporin of the first generation (z. B. cefazolin) may be used when the local excitation is known to be sensitive. Aminoglycosides (eg. As gentamicin), although potentially nephrotoxic, can be helpful in complex HWI (e. B. abnormalities of the urinary tract, the presence of indwelling catheters, recurrent urinary tract infection) to potentially treatable resistant Gram-negative bacteria such as Pseudomonas. In case of negative blood cultures and good clinical response, a suitable oral antibiotic can be selected and about 7 or 14 days are treated consistently on the basis of an antibiogram. The selection is based on the sensitivity antimkrobieller: z. B. cefixime, cephalexin, trimethoprim-sulfamethoxazole (TMP-SMX) or amoxicillin / clavulanic acid or - alternatively - fluoroquinolone in children who z. As an age of> 1 year, with a complex UTI that multidrug-resistant pathogens such as E. coli, P. aeruginosa or other gram-negative bacteria has been triggered. Insufficient clinical response suggests a resistant pathogen or an obstruction and it demands an urgent examination with ultrasound and repeated urine cultures. For non-septic, nichtdehydrierten infants and young children who are still able to take oral fluids, oral antibiotics can be given initially. The drug of choice is 1. TMP / SMX 5-6 mg / kg (the TMP component) 2 times daily. Alternatively, a cephalosporin such as cefdinir can 7 mg / kg 2 times a day, cefprozil 15 mg / kg 2 times a day, cefixime 8 mg / kg 1 time daily and Cephalexin 25 mg / kg 4 times daily or amoxicillin / Clavulanic- acid 15 mg / kg / dose be used 2 times per day. The therapy is adapted to the culture results and the corresponding antibiogram. The treatment usually takes 14 to 21 days. A urine culture is repeated 2-3 days after initiation of therapy, only if a clinical efficacy is not obvious. Vesicoureteral reflux (VUR) It has long been believed that by antibiotic prophylaxis reduced the recurrence of urinary tract infections and kidney damage is prevented, and that it should be started after the first or second HWI febrile children with VUR. However, this conclusion was not based on long-term, placebo-controlled trials (important because it was observed that VUR often subsides with time, when the children are older). A recent large, controlled study “the Randomized Intervention for Children with vesicoureteral reflux (RIVUR) (1) showed that antibiotic prophylaxis with TMP / SMX HWI relapses compared to placebo by 50% (from about 25% to 13 %), but showed no difference regarding. the rate of renal scarring after 2 years (8% in each group). the children in the study, UTI developed while taking prophylactic antibiotics three times more likely to have infected with resistant pathogens to be. However, since the 2-year follow-up period is probably too short to draw any firm conclusions regarding the prevention of scarring of the kidneys, an additional study may show that antibiotic prophylaxis offers some protection to the kidneys, but with the risk of more antibiotic-resistant infections. Therefore, the optimal strategy is still somewhat uncertain. Nevertheless, it is for the child he who VUR grade of IV or V, recommended an open repair or endoscopic injection of polymeric fillers generally, is often completed in conjunction with an antibiotic prophylaxis until healing. For children with lower levels of VUR further research is required. Since kidney complications after only one or two urinary tract infections are probably unlikely for further research an acceptable strategy may be to monitor children closely for UTIs to treat them once they occur, and then to reconsider antimicrobial prophylaxis in these children with recurrent infections. Among the drugs which in general are used for the prophylaxis (if prophylaxis is desired) include nitrofurantoin 2 mg / kg p.o. 1 times a day or TMP / MX 3 mg / kg p.o. be (TMP component) 1 times a day usually at bedtime verabreicht.Behandlungshinweise 1. The RIVUR Trial Investigators: Antimicrobial prophylaxis for children with VUR. NEJM 370: 2367 to 2376, 2014. Key points UTIs in children are often associated with Harnwegsanomalien as obstruction, neurogenic bladder and kidney double. The age with the greatest incidence of UTI is bimodal, a highlight in infancy and the other peak usually aged dry down in many children. E. coli causes most UTIs in all pediatric age groups; the remaining causes are generally Gram-negative enterobacteria (e.g., Klebsiella, P mirabilis, P aeruginosa…); often involved gram-positive organisms are group D streptococci and coagulase-negative staphylococci (eg., S. saprophyticus). Newborns and children <2 years with nonspecific symptoms and complaints (. Eg poor nutrition, diarrhea, failure to thrive, vomiting) may have a urinary tract infection; Children> 2 years usually show symptoms and discomfort of cystitis or pyelonephritis. Antibiotic therapy is started at all toxic-looking or even with non-toxic looking children with a positive leukocyte esterase test or nitrite test or microscopic secured pyuria). For children with severe vesicoureteral reflux (VUR) is administered to a surgical correction is performed antibiotic prophylaxis; at lower degrees of VUR the benefits of prophylactic antibiotics is unclear and close monitoring for recurrent UTI may be an acceptable treatment strategy for individual children.

Health Life Media Team

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