Overview

How does the urinary tract normally function?

The kidneys filter and remove waste and water from the blood to produce urine. They get rid of about 1-1/2 to 2 quarts of urine per day in an adult and less in a child, depending on the child's age. The urine travels from the kidneys down two narrow tubes called the ureters. The urine is then stored in a balloon-like organ called the bladder (see figure 1). In a child, the bladder can hold about 1 to 1-1/2 ounces of urine for each year of the child's age. So, the bladder of a 4-year-old child may hold about 4 to 6 ounces (less than 1 cup); an 8-year-old can hold 8 to 12 ounces. When the bladder empties, a muscle called the sphincter relaxes and urine flows out of the body through the urethra, a tube at the bottom of the bladder. The opening of the urethra is at the end of the penis in boys (see figure 2) and in front of the vagina in girls (see figure 3).

A urinary tract infection (UTI) is a bacterial infection that affects any part of the urinary tract. The main etiologic agent is Escherichia coli. Although urinecontains a variety of fluids, salts, and waste products, it does not usually have bacteria in it.[1] When bacteria get into the bladder or kidney and multiply in the urine, they may cause a UTI. The most common type of UTI is acute cystitis often referred to as a bladder infection. An infection of the upper urinary tract or kidney is known aspyelonephritis, and is potentially more serious. Although they cause discomfort, urinary tract infections can usually be easily treated with a short course of antibiotics.[2] Symptoms include frequent feeling and/or need to urinate, pain during urination, and cloudy [3] urine.

Normal urine contains no bacteria (germs). Bacteria may, at times, get into the urinary tract and the urine from the skin around the rectum and genitals by traveling up the urethra into the bladder. When this happens, the bacteria can infect and inflame the bladder and cause swelling and pain in the lower abdomen and side. This bladder infection is called cystitis.

If the bacteria travel up through the ureters to the kidneys, a kidney infection can develop. The infection is usually accompanied by pain and fever. Kidney infections are much more serious than bladder infections.

What are the signs of urinary tract infection?

A urinary tract infection causes irritation of the lining of the bladder, urethra, ureters, and kidneys, just like the inside of the nose or the throat becomes irritated with a cold. If your child is an infant or only a few years old, the signs of a urinary tract infection may not be clear, since children that young cannot tell you exactly how they feel. Your child may have a high fever, be irritable, or not eat. On the other hand, sometimes a child may have only a low-grade fever, experience nausea and vomiting, or just not seem healthy. The diaper urine may have an unusual smell. If your child has a high temperature and appears sick for more than a day without signs of a runny nose or other obvious cause for discomfort, he or she may need to be checked for a bladder infection.
Children aged 2-6 years y Children in this age group with febrile urinary tract infection (pyelonephritis) usually have systemic symptoms with loss of appetite; irritability; and abdominal, flank, or back pain. Voiding symptoms may be present or absent. Children with acute cystitis have voiding symptoms with little or no temperature elevation. Voiding dysfunction may include urgency, frequency, hesitancy, dysuria, or urinary incontinence. Suprapubic or abdominal pain may be present, and the urine sometimes has a strong or foul odor.
When bacteria enter the ureters and spread to the kidneys, symptoms such as back pain, chills, fever, nausea, and vomiting may occur, as well as the previous symptoms of lower urinary tract infection.

y y

y y y y y y y y y y y y

Burning or pain when urinating Frequent urination with only small amounts of urine Fever Diarrhea Vomiting Irritability or fussiness Less active Stomach pain Back pain Wets his or her clothes even though he or she is potty trained Urine that smells bad Bloody urine

Causes

The most common cause of UTIs are bacteria from the bowel that live on the skin near the rectum or in the vagina, which can spread and enter the urinary tract through the urethra. Once these bacteria enter the urethra, they travel upward, causing infection in the bladder and sometimes other parts of the urinary tract. E coli usually causes a child's first infection, but other

gram-negative bacilli and enterococci may also cause infection. Staphylococcal infections, especially those due toStaphylococcus saprophyticus, are common causes of urinary tract infection among female adolescents.
Sexual intercourse is a common cause of urinary tract infections because the female anatomy can make women more prone to urinary tract infections. During sexual activity, bacteria in the vaginal area are sometimes massaged into the urethra. Another cause of bladder infections or UTI is waiting too long to urinate. The bladder is a muscle that stretches to hold urine and contracts when the urine is released. Waiting too long past the time you first feel the need to urinate can cause the bladder to stretch beyond its capacity. Over time, this can weaken the bladder muscle. When the bladder is weakened, it may not empty completely and some urine is left in the bladder. This may increase the risk of urinary tract infections or bladder infections.

Children who frequently delay a trip to the bathroom are more likely to develop UTIs. Regular urination helps keep the urinary tract sterile by flushing away bacteria. Holding in urine allows bacteria to grow. Keeping the sphincter muscle tight for a long time also makes it more difficult to relax that muscle when it is time to urinate. As a result, the childs bladder may not empty completely. This dysfunctional voiding can set the stage for a urinary infection.
Other factors that also may increase a woman's risk of developing UTI include pregnancy, having urinary tract infections or bladder infections as a child, menopause, or diabetes.

What are the causes of UTI?

Normally, urine is sterile. It is usually free of bacteria, viruses, and fungi but does contain fluids, salts, and waste products. An infection occurs when tiny organisms, usually bacteria from the digestive tract, cling to the opening of the urethra and begin to multiply. The urethra is the tube that carries urine from the bladder to outside the body. Most infections arise from one type of bacteria, Escherichia coli (E. coli), which normally lives in the colon. In many cases, bacteria first travel to the urethra. When bacteria multiply, an infection can occur. An infection limited to the urethra is called urethritis. If bacteria move to the bladder and multiply, a bladder infection, called cystitis, results. If the infection is not treated promptly, bacteria may then travel further up the ureters to multiply and infect the kidneys. A kidney infection is called pyelonephritis. Microorganisms called Chlamydia and Mycoplasma may also cause UTIs in both men and women, but these infections tend to remain limited to the urethra and reproductive system. Unlike E. coli, Chlamydia and Mycoplasma may be sexually transmitted, and infections require treatment of both partners. The urinary system is structured in a way that helps ward off infection. The ureters and bladder normally prevent urine from backing up toward the kidneys, and the flow of urine from the bladder helps wash bacteria out of the body. In men, the prostate gland

produces secretions that slow bacterial growth. In both sexes, immune defenses also prevent infection. But despite these safeguards, infections still occur.

Risk factors
[edit]Sexual

activity

In young sexually active women, sex is the cause of some bladder infections, with the risk of infection related to the frequency of sex.[4] The term "honeymoon cystitis" has been applied to this phenomenon of frequent UTIs during early marriage. In post menopausal women sexual activity does not affect the risk of developing a UTI.[4] Spermicide use independent of sexual frequency increase the risk of UTIs.[4] [edit]Gender Women are more prone to UTIs than men because in females, the urethra is much closer to the anus than in males and they lack the bacteriostatic properties of prostatic secretions. UTI's more commonly progress to bladder infections in females due to the much shorter length of the female urethra.[9] Among the elderly, UTI frequency is roughly equal proportions in women and men. This is due, in part, to an enlarged prostate in older men. As the gland grows, it obstructs the urethra, leading to increased difficulty in micturition. Because there is less urine flushing the urethra, there is a higher incidence of colonization. [edit]Urinary

catheters

Urinary catheters are a risk factor for urinary tract infections. The risk of an associated infection can be decreased by only catheterizing when necessary, using aseptic technique for insertion, and maintaining unobstructed closed drainage of the catheter.[10][11][12] [edit]Genetics A predisposition for bladder infections may run in families.[4] [edit]Others Other risk factors include diabetics[4] sickle-cell disease or anatomical malformations of the urinary tract such as prostate enlargement. While ascending infections are generally the rule for lower urinary tract infections and cystitis, the same is not necessarily true for upper urinary tract infections like pyelonephritis which may originate from a blood born infection. Risk factors for urinary tract infection include the following: y Children who receive broad-spectrum antibiotics (eg, amoxicillin, cephalexin) that are likely to alter GI and periurethral flora are at increased risk for urinary tract infection because these drugs disturb the natural defense against colonization by pathogenic bacteria.

Prolonged incubation of bacteria in bladder urine due to incomplete bladder emptying or infrequent voiding compromises an important bladder defense against infection. Symptoms of voiding dysfunction, such as urgency, frequency, hesitancy, dribbling, or incontinence may occur in the absence of infection or local irritation because of uninhibited detrusor contractions. When the child attempts to prevent incontinence during a detrusor contraction by posturing (eg, obstructing the urethra), bacteria-laden urine in the distal urethra may be milked back into the urinary bladder (urethrovesical reflux). This mode of bacterial access is a common risk factor for urinary tract infection among pediatric patients who use posturing or pelvic withholding procedures to prevent incontinence. Voiding dysfunction is not usually encountered in a child without neurogenic or anatomic abnormality of the bladder until the child is in the process of achieving daytime urinary control. Children with voiding dysfunction may attempt to prevent incontinence during an uninhibited detrusor contraction by voluntarily increasing outlet resistance. This may be achieved by using various posturing maneuvers, such as tightening of the pelvic-floor muscles, applying direct pressure to the urethra with the hands, or performing the Vincent curtsy, which consists squatting on the floor and pressing the heel of one foot against the urethra. Constipation, with the rectum chronically dilated by feces, is an important cause of voiding dysfunction. Neurogenic or anatomic abnormalities of the urinary bladder may also cause voiding dysfunction. Neonatal circumcision decreases the risk of urinary tract infection by about 90% in male infants during the first year of life. The risk of urinary tract infection in a circumcised infant is about 1 in 1000 during the first year, whereas an uncircumcised male infant has a 1 in 100 risk of developing a urinary tract infection. Given this risk, 111 healthy male infants must be circumcised to prevent 1 urinary tract infection. The risk and long-term effect of scarring due to 1 preventable urinary tract infection in a male infant are not known.

Laboratory Studies
The diagnosis of urinary tract infection (UTI) is based on quantitative cultures of a properly collected urine specimen (see the tables below). A midstream, clean-catch specimen may be obtained from children who have urinary control. In the infant or child unable to void on request, the specimen for culture should be obtained by means of suprapubic aspiration or urethral catheterization. Suprapubic aspiration is the method of choice for obtaining urine from the uncircumcised boy with a redundant or tight foreskin and from children of either sex with clinically significant periurethral irritation.

Diagnosis

Multiple bacilli (rod-shaped bacteria, here shown as black and bean-shaped) shown between white cells at urinary microscopy. This is called bacteriuria and pyuria, respectively. These changes are indicative of a urinary tract infection.

In straight forward cases a diagnosis may be made and treatment given based on symptoms alone
[4] without further laboratory confirmation. In complicated or questionable cases confirmation

via urinalysis looking for the presence of nitrites, leukocytes or leukocyte esterase or via urine microscopy looking for the presence of red blood cells, white blood cells, and bacteria maybe useful.[4] Urine culture showing a quantitative count of greater than or equal to 10 colony forming units (CFU) per mL of a typical urinary tract organism along with antibiotic sensitives is useful to guide antibiotic choice.
[4]

However women with negative cultures may still improve with antibiotic treatment.[4]

Most cases of lower urinary tract infections in females are benign and do not need exhaustive laboratory work-ups. However, UTI in young infants may receive some imaging study, typically a retrograde urethrogram, to ascertain the presence/absence of congenital urinary tract anomalies. All males with a confirmed UTI should be investigated further. Specific methods of investigation include x-ray, nuclear medicine, MRI and CAT scans.

Urinalysis for Presumptive Diagnosis of Urinary Tract Infection Method Bright-field or phase-contrast microscopy of centrifuged urinary sediment Gram stain of uncentrifuged or centrifuged urinary sediment Nitrite and leukocyte esterase test Bacteria Findings

Bacteria Positive = Urinary tract infection likely

Nitrite test

Positive = Urinary tract infection probable Positive = Nonspecific

Leukocyte esterase test

Quantitative Urine Culture for the Diagnosis of Urinary Tract Infection Method Suprapubic aspiration Finding If a urinary tract infection is present, bacteria are likely to be proliferating in bladder urine with growth of any organism except 2000-3000 CFU/mL coagulase-negative staphylococci. Febrile infants and children with urinary tract infection usually have >50,000 CFU/mL of a single urinary pathogen; however, urinary tract infection may be present with 10,000-50,000 CFU/mL of a single organism.* Urinary tract infection is indicated when >100,000 CFU/mL of a single urinary pathogen is present in a symptomatic patient. Pyuria usually present. A urinary tract infection may be present with 10,000-50,000 CFU/mL of a single bacterium.* If the patient is asymptomatic, bacterial growth is usually >100,000 CFU/mL of the same organism on different days. If pyuria is absent, this result probably indicates colonization rather than infection.

Catheterization in a girl or midstream clean-void collection in a circumcised boy

Midstream clean-void collection in a girl or uncircumcised boy

Any method in a girl or boy

Diagnosis
Children with urinary tract infections do not always present with symptoms such as frequency, dysuria or flank pain. Infants may present with fever and irritability or other subtle symptoms, such as lethargy. Older children may also have nonspecific symptoms, such as abdominal pain or unexplained fever. A urinalysis should be obtained in a child with unexplained fever or symptoms that suggest a urinary tract infection. In young children with urinary tract infections, urinalysis may be negative in 20 percent of cases. Barnaff and colleagues recommend a urine culture for all male patients under six months of age and all female patients under two years of age who have a temperature of 39C (102.2F) or higher. Because a documented infection may warrant a thorough radiographic evaluation, empiric treatment on the basis of symptoms or urinalysis alone should be avoided.
3

The rightsholder did not grant rights to reproduce this item in electronic media. For the missing item, see the original print version of this publication.

While the most reliable method of obtaining urine for a culture is suprapubic aspiration, this procedure often causes FIGURE 1. (A) Acute pyelonephritis demonstrated in a technetium-99m anxiety in the child, the parent and the physician. Urine dimercaptosuccinic acid (DMSA) renal scan. Note the photopenic area with preservation of specimens may therefore be obtained by placing a plastic bag over the perineum of infants, and by obtaining a voided renal contour (arrow). (B)Follow-up scan demonstrating cortical defect consistent with specimen in older children. Because "bagged" and voided subsequent renal scar formation (arrow). specimens may be contaminated, results must be interpreted in conjunction with the urinalysis and the clinical setting. Pyuria and/or classic symptoms support the diagnosis of a urinary tract infection, whereas a positive culture in a child with a normal urinalysis and/or atypical symptoms may represent contamination. In patients whose diagnosis is complicated, and when the uncertainty of contamination must be avoided, a catheterized or suprapubic specimen can be obtained. Because catheterization may introduce bacteria into the bladder, a single dose of oral antibiotic should be given to prevent iatrogenic infection. While the presence or absence of a true urinary tract infection is occasionally difficult to determine, the distinction between cystitis and pyelonephritis is even more problematic. No clinical findings (such as fever or flank pain) and no laboratory studies (such as erythrocyte sedimentation rate or white blood cell count) are accurate in distinguishing pyelonephritis from cystitis. Fortunately, this distinction is rarely crucial. The management of the child is dictated by the clinical severity of the illness, rather than by the specific site of infection in the urinary tract. Furthermore, since the risk of reflux is similar in all patients with a urinary tract infection, the distinction between cystitis and pyelonephritis is not important in guiding the need for radiographic evaluation.
4

In rare circumstances, when distinguishing the diagnosis of pyelonephritis from some other infection is important, a technetium-99m dimercaptosuccinic acid (DMSA) renal flow scan is the best study to obtain. Patients with a normal scan during an acute infection do not have pyelonephritis and will not develop scarring. However, an area of photopenia on a DMSA scan identifies a region of pyelonephritis that is at risk for eventual scar formation(Figure 1). Because this test is invasive, expensive, exposes the child to radiation and is unlikely to alter the management of the infection, it is not used in the routine evaluation of children with urinary tract infections.
5

Imaging Studies
Ultrasonography: Sonography of the urinary tract.Urinary sonography is a safe, noninvasive study that is easy to perform. It is useful in excluding obstructive urography and in identifying children with a solitary or ectopic kidney and some patients with moderate renal damage caused by pyelonephritis.

Voiding cystourethrography or nuclear cystography y Traditionally VCUG has been recommended for infants and children after a first febrile urinary tract infection. This is based on the assumptions that most upper UTIs occur because of urinary bladder infection and that vesicoureteral reflux (VUR) transfers bacteria in the bladder to the

kidney. However, using cortical imaging, current data show that upper tract infection occurs equally in children with and without VUR.

Medication
Antibiotics are used to treat urinary tract infection (UTI) and to prevent recurrences. Avoid nephrotoxic drugs whenever possible. On occasion, analgesic therapy may be used to provide relief because of voiding symptoms.

Antibiotic agents
These are used for bacterial infections of the urinary tract. Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.

Ceftriaxone (Rocephin)

Initial parenteral therapy for complicated pyelonephritis in pediatric patients beyond neonatal period. y y y y
Dosing Interactions Contraindications Precautions

Adult

1-2 g IV/IM q12-24h

Pediatric

Infants and children: 50-75 mg/kg/d IV/IM divided q12-24h

Cefotaxime (Claforan)

Used as initial parenteral therapy for pediatric patients with acute complicated pyelonephritis. May be used for neonates or jaundiced patients. In infants, 2- to 8-wk regimen also includes ampicillin. Requires dosing q6-8h. y y y y
Dosing Interactions Contraindications Precautions

Adult

1-2 g IV/IM q6-8h

Pediatric

0-4 weeks and <1200 g: 100 mg/kg/d IV/IM divided q12h >7 days and 1200-2000 g: 150 mg/kg/d IV/IM divided q8h >7 days and >2000 g: 150 mg/kg/d IV/IM divided q6-8h

Ampicillin (Marcillin, Omnipen, Polycillin)

Parenteral therapy for initial treatment of patients with acute pyelonephritis, with gram-positive cocci in urinary sediment, or when no organisms observed. y y y y
Dosing Interactions Contraindications Precautions

Adult

500 mg IV/IM q4-6h

Pediatric

100-200 mg/kg/d IV/IM divided q4-6h

Amoxicillin and clavulanate (Augmentin)

PO therapy for completion of initial treatment of infection with susceptible organism. Amoxicillin inhibits bacterial cell-wall synthesis by binding to penicillin-binding proteins. Addition of clavulanate inhibits betalactamase producing bacteria. Good alternative antibiotic for patients allergic or intolerant to macrolide class. Usually well tolerated and provides good coverage to most infectious agents. Not effective against Mycoplasma or and Legionella species. Half-life of PO dosage form 1-1.3 h. Has good tissue penetration but does not enter CSF. For patients >3 mo, base dosing protocol on amoxicillin content. Because of different amoxicillin clavulanic acid ratios in 250-mg tab (250-125) vs 250 mg chewable-tab (250-62.5), do not use 250-mg tab until child weighs >40 kg. y y y y
Dosing Interactions Contraindications Precautions

Adult

500-875 mg q12h PO or 250-500 mg PO q8h for 7-10 d

Pediatric

<3 months: 125 mg/5 mL PO susp; 30 mg/kg/d (based on amoxicillin component) divided bid for 7-10 d >3 months: if 200 mg/5 mL or 400 mg/5 mL susp used, 45 mg/kg/d PO divided q12h; 125 mg/5 mL or 250 mg/5 mL susp used, 40 mg/kg/d PO divided bid for 7-10 d >40 kg: Administer as in adults

Gentamicin (Garamycin)

Initial parenteral therapy for patients with bacterial pyelonephritis who are allergic to cephalosporins. For complicated UTI, sometimes used in combination with a cephalosporin. y y y y
Dosing Interactions Contraindications Precautions

Adult

3-6 mg/kg/d IV/IM divided q8h

Pediatric

Premature neonate and <1000 g: 3.5 mg/kg/dose IV/IM q48h Term neonate and <7 days: 3.5-5 mg/kg/dose IV q24h Infants and children <5 years: 2.5 mg/kg/dose IV q8h Children >5 years: 2-2.5 mg/kg/dose IV q8h

Sulfisoxazole (Gantrisin)

PO treatment for bacterial UTI. Sulfonamide derivative that exerts bacteriostatic action by antagonizing para-aminobenzoic acid (PABA), an essential component in folic acid synthesis. y y y y
Dosing Interactions Contraindications Precautions

Adult

2-4 g PO initially, then 4-8 g/d PO divided q4-6h

Pediatric

<2 months: Contraindicated >2 months: 75 mg/kg PO loading dose, then 120-150 mg/kg/d PO divided q4-6h; not to exceed 6 g/d

Sulfamethoxazole and trimethoprim (Bactrim, Cotrim, Septra)

PO treatment for bacterial UTI and for prevention of reinfection. y y y y

Dosing Interactions Contraindications Precautions

Adult

UTI: TMP 160 mgSMZ 800 mg (ie, 1 double-strength tab) PO q12h for 10-14 d

Pediatric

<2 months: Contraindicated >2 months: UTI: 6-12 mg/kg/d (based on trimethoprim component) PO divided q12h Reinfection prophylaxis: 1-2 mg/kg/d (based on trimethoprim component) PO qd

Cephalexin (Biocef, Cefanex, Keflex)

PO treatment for bacterial UTI and for prevention of infection in infants <6-8 wk. y y y y
Dosing Interactions Contraindications Precautions

Adult

250-500 mg PO q6h
Pediatric

<6-8 weeks: 20-50 mg/kg/d PO divided q6h Prophylaxis: 10 mg/kg/d PO qd

Cefixime (Suprax)

PO treatment for acute bacterial UTI. By binding to 1 or more penicillin-binding proteins, arrests bacterial cell-wall synthesis and inhibits bacterial growth. y y y y
Dosing Interactions Contraindications Precautions

Adult

400 mg/d PO divided q12-24h

Pediatric

8 mg/kg/d PO q12-24h; not to exceed 400 mg/d

Cefpodoxime (Vantin)

PO treatment for acute bacterial UTI. Indicated to manage infections caused by susceptible mixed aerobic-anaerobic microorganisms. y y
Dosing Interactions

y y

Contraindications Precautions

Adult

100-400 mg/dose PO q12h

Pediatric

>6 months to 12 years: 10 mg/kg/d PO divided q12h >12 years: Administer as in adults

Nitrofurantoin (Furadantin, Macrobid, Macrodantin)

PO treatment of bacterial lower UTI (cystitis) and for prevention of reinfection. Synthetic nitrofuran; interferes with bacterial carbohydrate metabolism by inhibiting acetylcoenzyme A. Bacteriostatic at low concentrations (5-10 mcg/mL) and bactericidal at higher concentrations. y y y y
Dosing Interactions Contraindications Precautions

Adult

Acute UTI: 50-100 mg PO q6h Prevention of reinfection: 50-100 mg PO qhs

Pediatric

Lower UTI: 5-7 mg/kg/d PO divided q6h Prevention of reinfection: 1-2 mg/kg/d PO divided q12-24h

Trimethoprim (Proloprim, Trimpex)

PO antibiotic to prevent UTI. Dihydrofolate reductase inhibitor that prevents production of tetrahydrofolic acid in bacteria. Active in vitro against broad range of gram-positive and gram-negative bacteria, including uropathogens, eg, Enterobacteriaceae and Staphylococcus saprophyticus. Resistance usually mediated by decreased cell permeability or alterations amount or structure of dihydrofolate reductase. Demonstrates synergy with sulfonamides, potentiating inhibition of bacterial tetrahydrofolate production. y y y y
Dosing Interactions Contraindications Precautions

Adult

Prophylaxis: 100 mg PO qd
Pediatric

Prophylaxis: 1-2 mg/kg PO qd

Systemic analgesics
These agents are used to provide relief from voiding symptoms due to urinary tract infection.

Acetaminophen (Tylenol, Panadol, Tempra)

Nonopioid systemic analgesic used for moderate voiding discomfort caused by UTI. y y y y
Dosing Interactions Contraindications Precautions

Adult

325-650 mg PO q4-6h
Pediatric

Neonates: 10-15 mg/kg PO q6-8h Infants and children: 10-15 mg/kg PO q4-6h

Urinary bladder analgesics

These agents are used to relieve burning, spasticity, and pain during voiding due to urinary tract infection.

Phenazopyridine (Azo-Standard, Pyridium, Urodine)

Exerts local topical anesthetic or analgesic action on urinary mucosa. Used for symptomatic relief of pain, burning, urgency, frequency, and other discomforts arising from irritation of lower urinary tract mucosa caused by infection, trauma, surgery, endoscopic procedures, passage of sound, or catheters. Analgesic action may reduce or eliminate need for systemic analgesics. y y y y
Dosing Interactions Contraindications Precautions

Adult

100-200 mg PO q4-6h for 2 d

Pediatric

12 mg/kg/d PO divided q8h for 2 d

The way the antibiotic is given and the number of days that it must be taken depend in part on the type of infection and how severe it is. When a child is sick or not able to drink fluids, the antibiotic may need to be put directly into the bloodstream through a vein in the arm or hand. Otherwise, the medicine (liquid or pills) may be given by mouth or by shots. The medicine is given for at least 3 to 5 days and possibly for as long as several weeks. The daily treatment schedule recommended depends on the specific drug prescribed: The schedule may call for a

single dose each day or up to four doses each day. In some cases, your child will need to take the medicine until further tests are finished.
An additional urine test may be ordered about a week after completing treatment to be sure the infection is cured.

Antibiotic Regimen. Oral antibiotic treatment cures 94% of uncomplicated urinary tract infections, although the rate of recurrence remains high. The following are antibiotics used for uncomplicated UTIs.

Specific Antibiotics Used for Most UTIs Beta-Lactams The beta-lactam antibiotics share common chemical features and include penicillins, cephalosporins, and some newer similar agents. Their primary actions to interfere with bacterial cell walls. Many have been important in the treatment of urinary tract infections. Penicillins (Amoxicillin). Until recent years, the standard treatment for a UTI was 10 days of amoxicillin, a penicillin antibiotic, but it is now ineffective against E. coli bacteria in up to 25% of cases. A combination of amoxicillin-clavulanate (Augmentin) is now sometimes given for drug-resistant infections. Amoxicillin or Augmentin may be useful for UTIs caused by gram-positive organisms, including Enterococcusspecies and S. saprophyticus. Cephalosporins. Antibiotics known as cephalosporins are also alternatives for infections that do not respond to standard treatments or for special populations. They are often classed in the following: First generation includes cephalexin (Keflex), cefadroxil (Duricef, Ultracef), and cephradine (Velosef). Second generation include cefaclor (Ceclor), cefuroxime (Ceftin), cefprozil (Cefzil), and loracarbef (Lorabid). Third generation include cefpodoxime (Vantin), cefdinir (Omnicef) cefditoren (Sprectracef), cefixime (Suprax), and ceftibuten (Cedex). Ceftriaxone (Rocephin) is an injected cephalosporin. These are effective against a wide range of gramnegative bacteria.

y y y

Other Beta-Lactam Agents. Other beta-lactam antibiotics have been developed. For example, pivmecillinam (a form of mecillinam), is commonly used in Europe for UTIs. It appears to be safe during pregnancy. Trimethoprim-Sulfamethoxazole (TMP-SMX) The current typical treatment is a three-day course of the combination drug trimethoprim-sulfamethoxazole, commonly called TMP-SMX (Bactrim, Cotrim, Septra). A one-day course is somewhat less effective but poses a lower risk for side effects. Longer courses (7 to 10 days) are no more effective than the three-day course

and have a higher rate of side effects. It should not be used in patients whose infections occurred after dental work or in patients allergic to sulfa drugs. Allergic reactions can be very serious. Trimethoprim (Proloprim, Trimpex) is sometimes used alone in those allergic to sulfa drugs. It should be noted that TMP-SMX interferes with the effectiveness of oral contraceptives. High rates of bacterial resistance to TMP-SMX are being observed in parts of the US, such as the Southeast, Southwest, and southern California. Still, even regional rates approach 30%, cure rates with TMP-SMX reach 80% to 85%. Fluoroquinolones (Quinolones) Fluoroquinolones (also simply called quinolones) interfere with the bacteria's genetic material so they cannot reproduce. They are the standard alternatives to TMP-SMX. Examples of quinolones include ofloxacin (Floxacin), ciprofloxacin (Cipro), norfloxacin (Noroxin), levofloxacin (Levaquin), gatifloxacin (Tequin), and sparfloxacin (Zagam). These antibiotics are effective against a wide range of organisms but are expensive and, in general, used in the following circumstances: In patients with complicated or catheter-induced UTIs. In patients who do not respond or who are allergic to TMP-SMX. In communities where there are high rates of bacteria resistant to TMP-SMX. In elderly patients. A 2001 study of older women with UTIs (mean age 80), about half of whom were living in nursing homes, found that 96% responded to ciprofloxacin, compared with 87% to TMP-SMX.

y y y y

Pregnant women should not take fluoroquinolone antibiotics. They also have more adverse effects in children than other antibiotics and should not be the first-line option in most situations. Antibiotics Used Specifically for UTIs Nitrofurantoin. Nitrofurantoin (Furadantin, Macrodantin) is a relatively inexpensive antibiotic that is used specifically for urinary tract infections. It is an effective alternative to TMP-SMX or a quinolone. Unlike many of the other drugs, however, it must be given seven to 10 days, even in cases of simple cystitis. (Shorter course treatments are being investigated.) It is not useful for treating kidney infections. Nitrofurantoin frequently causes stomach upset and interacts with many drugs. Other chronic or serious medical conditions may also affect its use. It should not be used in pregnant women within a week or two of delivery, in nursing mothers, or in those with kidney disease. Fosfomycin. The antibiotic fosfomycin (Monurol), which comes in an orangeflavored, soluble powder, is proving to be another good alternative. It can be an effective one-dose treatment for many women, including those who are pregnant. To date, bacterial resistance rates to this antibiotic are very low. Tetracyclines Tetracyclines inhibit bacterial growth. They include doxycycline, tetracycline, and minocycline. Long-term treatment with tetracycline or doxycycline may be used for infections that are caused by Mycoplasma or Chlamydia. Tetracyclines have unique side effects among antibiotics, including skin reactions to sunlight, possible burning in

the throat, and tooth discoloration. Aminoglycosides Aminoglycosides (gentamicin, kanamycin, tobramycin, amikacin) are given by injection for very serious bacterial infections. They can be given only in combination with other antibiotics. Gentamicin is the most commonly used aminoglycoside for serious UTIs. They can have very serious side effects, including damage to hearing, sense of balance, and kidneys.

Tips for Preventing Urinary Tract Infections The most important tip to prevent urinary tract infections, bladder infections, and kidney infections is to practice good personal hygiene. Always wipe from front to back after a bowel movement or urination, and wash the skin around and between the rectum and vagina daily. Washing before and after sexual intercourse also may decrease a woman's risk of UTI. Drinking plenty of fluids (water) each day will help flush bacterium out of the urinary system. Emptying the bladder as soon as the urge to urinate occurs also may help decrease the risk of bladder infection or UTI. Urinating before and after sex can flush out any bacteria that may enter the urethra during sexual intercourse. Vitamin C makes the urine acidic and helps to reduce the number of potentially harmful bacteria in the urinary tract system. Wear only panties with a cotton crotch, which allows moisture to escape. Other materials can trap moisture and create a potential breeding ground for bacteria. Avoid thongs. Cranberry juice is often said to reduce frequency of bladder infections, though it should not be considered an actual treatment. Cranberry supplements are available over-the-counter and many women find they work when an UTI has occurred; however, a physician's diagnosis is still necessary even if cranberry juice or related herbals reduce pain or symptoms. If you experience frequent urinary tract infections changing sexual positions that cause less friction on the urethra may help. Some physicians prescribe an antibiotic to be taken immediately following sex for women who tend to have frequent UTIs. In infants and toddlers, frequent diaper changes can help prevent the spread of bacteria that cause UTIs. When kids begin to self-care, it's important to teach them good hygiene. After every bowel movement, girls should remember to wipe from front to rear not rear to front to prevent germs from spreading from the rectum to the urethra. Kids should also be taught not to "hold it in" when they have to go because urine that remains in the bladder gives bacteria a good place to grow.

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School-age girls should avoid bubble baths and strong soaps that might cause irritation, and they should also wear cotton underwear instead of nylon because it's less likely to encourage bacterial growth. Other ways to decrease the risk of UTIs include drinking enough fluids and avoiding caffeine, which can irritate the bladder.

Although urinary tract infections are common and distinctly painful, they usually are easy to treat once properly diagnosed and only last a few days. When treated promptly and properly, UTIs are rarely serious.

Pathophysiology
Almost all urinary tract infections are ascending in origin. Disturbance of the normal periurethral flora, which is part of the host defense against colonization by pathogenic bacteria, predisposes a person to a urinary tract infection. Bacteria of the periurethral flora also inhabit the distal urethra. Urine in the proximal urethra, urinary bladder, and other proximal sites in the urinary tract is normally sterile. Uropathogens must gain access to the urinary bladder and proliferate for infection to occur. Uropathogens in the distal urethra may gain access to the bladder because of turbulent urine flow during normal voiding or because of dysfunctional voiding. Successful urinary bladder colonization is unlikely unless bladder defense mechanisms are impaired because normal voiding usually results in an essentially complete washout of contaminating bacteria.1 After birth, the periurethral area, including the distal urethra, becomes colonized with aerobic and anaerobic microorganisms that appear to function as a defense barrier against colonization by uropathogens. In early childhood, enterobacteria and enterococci are part of the normal periurethral flora. Escherichia coli is the dominant gram-negative species in young girls, whereas E coli and Proteus species predominate in boys. Children as old as about 5 years are predisposed to have urinary tract infections, partly because of periurethral colonization by E coli,enterococci, and Proteus species. These potential uropathogens usually diminish in the first year of life and are rarely found in children older than 5 years. Studies of girls and women prone to urinary tract infection showed that periurethral colonization occurs with the specific bacterium that causes the next infection. Deregulation of candidate genes in humans may predispose patients to recurrent urinary tract infections. The identification of a genetic component may allow the identification of at-risk individuals to predict genetic recurrences in their offspring.2 Thus far, 6 of 14 genes investigated in humans may be associated with susceptibility to recurrent urinary tract infections; the genes possible responsible include HSPA1B, CXCR1, CXCR2, TLR2, TLR4, and TGF 1.