Chapter 82 Urinary Tract Infections
PATHOPHYSIOLOGY
Urinary tract infection (UTI) is the colonization of bacteria anywhere along the urinary tract. Infections can be of the lower urinary tract (urethra or bladder, also known as cystitis) or the upper urinary tract (ureters or the kidney, also known as pyelonephritis). The infectious agent is generally enteric in nature, most commonly Escherichia coli, followed by Klebsiella, Proteus, Enterococcus and coagulase-negative staphylococci. The presence of urine and stool around the urinary meatus allows the bacteria to proliferate and ascend upward to the urethra. Voiding is the first line of defense in preventing the causative agent from invading the urethra and bladder walls. Females have a shorter urethra, and bacteria enter at the end of micturition; males have a longer urethra and antibacterial properties that help to contribute to lower incidence of infection. UTI is second in frequency of occurrence of infections to upper respiratory tract infections.
There is an increased incidence in infants and young children learning to toilet-train. Children at risk are those with disorders that do not allow for full bladder emptying such as underlying defects of the urinary system, chronic disease, and neurologic disorders. Immunocompromised children are also at risk.
INCIDENCE
1. Neonatal-infancy period—boys increased incidence over girls
2. Beyond 1 year of life—girls have an increased incidence over boys (10:1)
3. Peak incidence not caused by structural abnormalities is 2 to 6 years
4. E. coli causes 80% of infections.
5. Most recurrence occurs after 3 to 6 months, with 60% to 80% of girls having a recurrence within 18 months.
6. Incidence of symptomatic UTI is lower than that of asymptomatic UTI.
7. UTI rarely leads to permanent damage, end-stage renal disease, or chronic pyelonephritis.
8. Uncircumcised boys typically experience two or three UTIs in childhood.
CLINICAL MANIFESTATIONS
LABORATORY AND DIAGNOSTIC TESTS
1. Urine culture (definitive diagnosis)—to determine presence and amount of microorganisms (obtain sample from midstream urine or urethral catheterization)
2. Suprapubic aspiration—to obtain sterile urine
3. Intravenous pyelogram—to visualize kidney and bladder
4. Voiding cystourethrogram—to establish presence of vesicoureteral reflux and abnormalities
5. Cystoscopy—to visualize interior of bladder and urethra (not routinely performed)
6. Retrograde pyelography—to visualize contour and size of ureters and kidneys
7. Cystometry—to assess filling capacity of bladder and effectiveness of detrusor reflux
MEDICAL MANAGEMENT
Before treatment is initiated, a diagnosis must be made based on the child’s symptoms and results of the culture and sensitivity testing identifying the organism. Most of the commonly acquired UTIs can be effectively treated with 7 to 14 days of antibiotic therapy. The most commonly used antibiotics are trimethoprim-sulfamethoxazole, nitrofurantoin, amoxicillin, sulfisoxazole, ceftriaxone, ampicillin, and gentamicin. Preferred treatment is the oral route; however, infants younger than 3 months of age or children with suspected pyelonephritis may require intravenous (IV) antibiotic therapy.
NURSING INTERVENTIONS
1. Monitor child’s therapeutic response to and untoward effects of medication.
2. Encourage intake of fluids according to normal guidelines.
3. Administer antibiotics as ordered.
4. Monitor patient’s clinical status (if patient is admitted to hospital).
Discharge Planning and Home Care
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Hockenberry MJ, et al. Wong’s nursing care of infants and children, ed 7. St. Louis: Mosby, 2004.
Ma JF, Shortliffe LM. Urinary tract infection in children: Etiology and epidemiology. Urol Clin North Am. 2004;31(3):517.
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