Upper Urinary Tract Infections

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PYELONEPHRITIS 

CLINICAL DESCRIPTION

Acute pyelonephritis is a bacterial infection causing inflammation of the kidneys and is one of the most common diseases of the kidney. Pyelonephritis occurs as a complication of an ascending urinary tract infection (UTI) which spreads from the bladder to the kidneys and their collecting systems

CLINICAL FEATURES 

SIGNS AND SYMPTOMS

  • Fevers, costovertebral angle pain, nausea, vomiting

INVESTIGATIONS

  • Full blood count
  • Urine dipstick, microscopy, culture and sensitivity
  • Urea, electrolytes and creatinine
  • KUB Ultrasound

TREATMENT

PHARMACOLOGICAL

  • Give Ciprofloxacin 500mg orally 12 hourly for 10-14 days or
  • Give Co-amoxiclav 375 mg 8 hourly for 10-14 days
  • IV fluids if clinically indicated

Complications and referral criteria: Ongoing pain and fevers despite antibiotic use. Worsening of kidney function.

Alternatively

  • Give Gentamycin 240mg IM or IV STAT
  • Followed by any of the above oral antibiotics for 10-14 days
  • Refer patients with recurrent UTI for further investigations

URINARY TRACT INFECTIONS (UTIs) IN CHILDREN 

CLINICAL FEATURES

SIGNS AND SYMPTOMS

In young children

  • non-specific e.g. vomiting, fever, irritability, or failure to thrive

Older children: 

  • fever
  • abdominal pain
  • dysuria
  • increased frequency of passing urine

INVESTIGATIONS

  • Urine dipstick
  • Urine microscopy and culture
    • clean catch sample of urine
    • In sick infants, suprapubic aspiration of urine may be required
    • consider UTI if more than 5 white cells per high power field
    • Blood culture
  • LP if systemically unwell
  • Indications for abdominal ultrasound scan in children with UTI:
    • In all male infants with UTI
    • Recurrent UTIs
    • Abdominal mass or abnormal voiding
    • Not responding to treatment

TREATMENT

Age/Presentation

Treatment

 

<3 months

Admit the child and treat with: Gentamicin.

Preterm 3mg/kg

Term neonate 5mg/kg

>2 weeks :7.5mg/kg IV daily and Benzylpenicillin 50,000 IU/kg 12 hourly in first week of life then 6 hourly thereafter.

 

Consider Blood Culture and Lumbar Puncture Adjust antibiotics as guided by culture results.

 

Second line:

Ceftriaxone 50mg/kg IV 24 hourly  

3 months or older child with signs of systemic illness (T>38C, and rigors, renal angle tenderness)

Admit and treat with Gentamicin 7.5mg/kg IV and Benzylpenicillin 50,000 IU/kg IV ^ hourly or Ceftriaxone 50mg/kg IV 24 hourly.

 

Change to oral antibiotic when fever settled and improving to complete 10 days treatment.

>3 months or older child with no signs of systemic illness

Treat with oral antibiotics: Cotrimoxazole 10mg/kg every 12hrs for 3 days or Ciprofloxacin 10mg/kg 12 hourly for 5 days or Nitrofurantoin 1.5mg/kg 6 hourly for 5 days

Complications

  • Renal scarring
  • Chronic kidney disease

REFERRAL CRITERIA

  • Atypical UTI:
    • Seriously ill
    • Poor urine flow
    • Abdominal or bladder mass
    • Raised creatinine if measured
    • Septicemia
    • Failure to respond to treatment with suitable antibiotics within 48 hours
  • Recurrent UTIs:
    • 2 or more episodes of UTI with acute pyelonephritis/upper urinary tract infection
    • One episode of UTI with acute pyelonephritis/upper urinary tract infection plus one more episode of UTI with cystitis/lower urinary tract infection
    • Three or more episodes of UTI with cystitis/lower urinary tract infections