Transcript Externconference24-05

Extern conference
24 May 2007
History
• A 3-month-old boy
• 1 day PTA he had low graded fever .His
mother noticed that he had frequently voided
and occurred red colored urine once. He was
crying during maturation.
• No history of straining, dripping or
constipation.
• No previous history of urinary tract infection.
History
• He had no cough, running nose, vomiting or
diarrhea. He was still active and able to take
breast feeding as usual.
• No previous hospitalization and surgery.
• No underlying disease.
History
• Past history: Uncomplicated pregnancy, no
history of oligohydramnios, full term, normal
labor, no anomaly was detected, BW 2,910
gm, APGAR score 4,9 at 1 and 5 minutes
respectively, no respiratory tract
complications.
History
• Developmental history : holds head up, reaches
objects, smiles socially, coos
• Immunization : up-to-date.
• Family history : He is the third child. His parents
and two brothers are all healthy. No history of
urinary tract infection.
• No history of drug allergy.
• Feeding : Exclusive breast feeding8 feeds/day
Physical examination
• V/S : T 38.5ºc, RR 40/min, PR 140/min, BP
87/40 mmHg
• BW 4.8 kg (P10),length 62 cm (P75),
HC 40 cm, AF 2x2 cm, PF closed
• GA : active, looked well, no abnormal
features, not pale, no jaundice, no dyspnea,
no bulging of fontanelles, good skin turgor, no
sunken eyeball, no dry lips
Physical examination
• Skin: no skin lesions
• HEENT : pharynx and tonsils not injected
• RS : normal breath sounds, no adventitious
sounds
• CVS : normal S1&S2 , no murmur
• Abdomen : soft, no distension, active bowel
sound, no mass, liver& spleen not palpable,
bimanual palpation negative, no bladder
distension
Physical examination
• Perineum : phimosis, descended both testes
• NS : equal movement of extremities,
DTR 2+ all, stiff neck and Brudzinski’s sign
are negative
Problem list
1.
2.
3.
4.
Acute febrile illness for 1 day
History of frequent voiding for 1 day
History of red colored urine for 1 day
Phimosis
Investigations
Investigation
• CBC : Hb 9.8 g/dL, Hct 30.7%,MCV 82.1 fL
WBC 20,890 /mm3, N 48%, L41%, Mo 9%,
Platelet 413,000/mm3
• BUN : 8 mg/dL
• Cr : 0.3 mg/dL
• Electrolyte : was not performed
Investigation
• UA :
pH 5, Sp.gr. 1.020, glucose & ketone –,
protein 3+, blood 2+, leukocyte & nitrite +,
WBC 50-100/HPF, RBC 2-3/HPF,bacteria 2+,
no cast
• Urine culture (Catheterization): pending
• Hemoculture : pending
Urinary tract infection
Urinary tract infection
• Incidence of symptomatic UTI in children
• boys
• girls
1%
with peak during neonatal period
3-5%
with peak during toilet training
Jack S. elder. Urinary tract infection in Richard E. Behrman, Richard E.(eds):
Nelson textbook of pediatrics, 2003, PP 1785-1789
Bacteriology
• Gram negative bacilli:
– E.coli esp p .frimbriae most common (80% of UTI)
– Klebsiella
– Proteus
• Gram positive:
– Staphylococcus saprophyticus
– Enterococcus sp.
• Rare anaerobic bacteria
Pathophysiology
•
•
•
Ascending infection
Urinary stasis or
Urinary tract
abnormalities
Reflux
Infrequent or
incomplete voiding
Hematogenous spread
• Neonates
• Nonspecific symptoms
Risk factor
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Female
Uncircumcised male
VUR
Toilet training
Voiding dysfunction
Obstructive uropathy
Urethral instrumentation
Wiping from back to front
Bubble bath
Tight clothing
11. Pin worm
12. Constipation
13. P. fimbriae bacteria
14. Anatomic abnormality
15. Neuropathic bladder
16. Sexual activity
17. pregnancy
Jack S. elder. Urinary tract infection in Richard E. Behrman, Richard E.(eds):
Nelson textbook of pediatrics, 2003, PP 1785-1789
Risk factor
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Female
Uncircumcised male
VUR
Toilet training
Voiding dysfunction
Obstructive uropathy
Urethral instrumentation
Wiping from back to front
Bubble bath
Tight clothing
11. Pin worm
12. Constipation
13. P. fimbriae bacteria
14. Anatomic abnormality
15. Neuropathic bladder
16. Sexual activity
17. pregnancy
Jack S. elder. Urinary tract infection in Richard E. Behrman, Richard E.(eds):
Nelson textbook of pediatrics, 2003, PP 1785-1789
Urinary tract infection
• Classifications
1. Pyelonephritis
2. Cystitis
3. Asymptomatic bacteriuria
Jack S. elder. Urinary tract infection in Richard E. Behrman, Richard E.(eds):
Nelson textbook of pediatrics, 2003, PP 1785-1789
Clinical manifestation
• Lower urinary tract
– Dysuria
– Frequency
– Enuresis
– Suprapubic pain
– Low grade fever
• Upper urinary tract
– High fever
– Nausea, vomiting
– Flank pain
– Lethargy
– Toxic appearance
Clinical manifestation
• Lower urinary tract
– Dysuria
– Frequency
– Enuresis
– Suprapubic pain
– Low grade fever
• Upper urinary tract
– High fever (38.5)
– Nausea, vomiting
– Flank pain
– Lethargy
– Toxic appearance
Physical examination
•
•
•
•
•
•
Hypertension (hydronephrosis or renal parenchyma disease)
Abdominal tenderness or mass
Palpable bladder, tenderness
CVA tenderness
Drippling, poor stream, or straining to void
External genitalia
Initial investigations
• BUN, Cr, serum electrolytes
• CBC
• Urinalysis
– Leukocyte esterase, Nitrite
– WBC
– Bacteria
• Urine culture
•  Hemoculture
Initial investigations
• BUN, Cr, serum electrolytes
• CBC
CBC : Hb 9.8 g/dL, Hct 30.7%, MCV 82.1 fL
• Urinalysis
WBC 20,890 /mm3, N 48%,
L41%, Mo 9%,Platelet 413,000/mm3
– Leukocyte esterase, Nitrite
BUN : 8 mg/dL Cr : 0.3 mg/dL
– WBC
– Bacteria
• Urine culture
• Hemoculture
Diagnostic evaluation
• Gold standard: urine culture
• Urinalysis
• Dipstick :
Leukocyte esterase +
Nitrite +
• Microscopic : WBC > 5-10 cell/HPF
Bacteria any/HPF
Diagnostic evaluation
• Gold standard: urine culture
• Urinalysis
• Dipstick :
Leukocyte esterase +
Nitrite +
• Microscopic : WBC > 5-10 cell/HPF
Bacteria any/HPF
UA : pH 5, Sp.gr. 1.020, glucose & ketone –,
protein 3+, blood 2+, leukocyte & nitrite +,
WBC 50-100/HPF, RBC 2-3/HPF,bacteria 2+,no cast
Urine culture (Catheterization): pending
Diagnostic evaluation
method
Number (CFU/ml)
Suprapubic aspiration
Any number
Transurethral
catheterization
≥ 103
Midstream urine
≥ 104 with symptoms
≥ 105
แนวทางการรักษาผู้ป่วยที่มีการติดเชือ
้ ในทางเดินปัสสาวะ, ในประสิทธิ์ ฟูตระกูลและคณะ:
ราชวิทยาลัยกุมารแพทย์แห่งประเทศไทย
Treatment
Neonate
• Ampicillin 50-100 mg/kg/day IV and
Gentamicin 3-5 mg/kg/day IV or IM or
• Third generation Cephalosporins
• Hospitalization is suggested for symptomatic
young infants (less than three months of age)
Treatment
Children with acute severe pyelonephritis
• aminoglycosides eg. Gentamicin 5 mg/kg/day
(Be careful in renal impairment patient) or
• Third generation Cephalosporins eg.
Cefotaxime 100 -200 mg/kg/day, Ceftriaxone
50-100 mg/kg/day
• Hospitalization is suggested
Treatment
Children with a less toxic appearance and
uncomplicated UTI
• Cotrimoxazole 6-12 mg of trimethoprim/kg/day PO or
• Amoxycillin-clavulanic acid 30 mg/kg/day of
amoxycillin PO or
• Cephalosporins
• OPD case
• No information of using Quinolones in children
Treatment
•
•
Supportive treatment
Duration:
–
–
Acute pyelonephritis 10-14 days
Lower tract infection 7-10 days
In this patient
Supportive treatment
• Correct dehydration : Intravenous fluid
• Paracetamol prn for fever
• F/U : signs and symptoms, BP,U/A, urine
culture (catheterization)
In this patient
Specific treatment
• ATB:
– Ceftriaxone 75 mg/kg/day
• Phimosis:
– Prednisolone cream apply to the prepuce bid
– Daily gentle retraction
Urine culture (cath)
E. coli , ESBL-negative > 105
CFU/ml
Sensitive to ceftriaxone
Hemoculture : no growth
Complications
• Acute
–
–
–
–
Dehydration
Pyelonephritis
Sepsis
Renal abscess
• Long term
– Hypertension
– Impaired kidney
function
– Renal scarring
– Renal failure
– Pregnancy
complications
Investigations
- Urinalysis: should return to normal in 2-3 days
- Urine culture: 1 week after completed course
of ATB
Progression
- Urinalysis: should return to normal in 2-3 days
- Urine culture: 1 week after completed course
of ATB
Urinalysis: 72 hours later :pH 6,
Sp.gr.1.015, leukocyte& nitriteneg, WBC 0-1/HPF, RBC-neg,
bacteria-neg
urine culture (cath) : no growth
Indication for further investigation
1.
2.
3.
4.
5.
Age < 5 years
Febrile UTI
School age girl with UTI ≥ 2 times
Male with UTI
Suspect anatomical abnormality in KUB
system
จักรชัย จึงธีรพานิช, urinary tract infection.ประไพพิมพ์ ธีระคุปต์และคณะ:
ปัญหาสารน้้าอิเลกโทรไลต์และโรคไตในเด็ก, 2004, หน้า 323-337
Imaging studies
1.
2.
3.
4.
Ultrasonography (U/S)
Voiding cystourethrography (VCUG)
Indirect radionuclide cystography (IRC)
DMSA scan
Imaging studies
U/S+VCUG
Hydronephrosis
Hydroureter no
VUR
IRC
VUR
DMSA
scan
Prophylaxis
Specialist
consultation
No detectable
abnormality
Prophylaxis
Educations
Follow up
Educations & Follow up
•
Educations
–
–
–
–
•
Hygiene
Constipations
Treat phimosis
sign and symptoms of infections
Follow up for 1 year
–
–
–
Recurrence UTI
Urinalysis
Urine culture
In this patient
• Ultrasonography KUB :
– No detectable abnormality
• VCUG :
– No detectable abnormality
KUB ultrasonography: normal
VCUG: normal
VCUG: VUR
Posterior urethral valves
Prophylaxis
Indication
1. VUR until resolves or surgical corrected
2. Neonates and infants with febrile UTI and abnormal
renal scan
3. Recurrence > 3 times/year esp.with bladder instability
4. Neurogenic bladder
5. Obstructive uropathy
Jack S. elder. Urinary tract infection in Richard E. Behrman, Richard E.(eds):
Nelson textbook of pediatrics, 2003, PP 1785-1789
Prophylaxis
TMP-SMX
1-2
Nitrofurantoin
1-2
At least 6-12 months
In children< 6 weeks
Cephalexin
10
Amoxycillin
10
mg TMP/kg/day or
mg/kg/day
mg/kg/day
mg/kg/day
(American Academy of Pediatrics)
Progression
• Switch to oral ATB: Ceftributen 9 mg/kg/day
• Prophylaxis : Cotrimoxazole 2 mg/kg/day
Continue antibiotic prophylaxis 6 months
Take home message
• Febrile infant without any localizing sign
should take urinalysis.
• UTI in children associated with GU anomaly
– Obstructive anomaly 0-4%
– VUR 8-40%
Further investigations and follow up should be
concerned
• Recurrent UTI should always look for risk
factor
Special thanks
ผศ.นพ. อนิรุธ ภัทรากาญจน์
อ.พญ. วิภาเพ็ญ เนียมสมบุญ
Thank you