Transcript Logic antibiotic use in children with urinary tract infection

3/12/1392
1
Logic antibiotic use in children
with urinary tract infection
Dr mostafavi N
Pediatric infectious disease departement
Isfahan university of medical sciences
3/12/1392
2
Presenting symptoms in UTI
Age group
Most common
common
Least common
< 3 mo
3mo- 2 yr
> 2 yr
3/12/1392
3
Presenting symptoms in UTI
Age group
Most common
common
Least common
< 3 mo
Fever only
Vomiting
Irritability
Poor feeding
Failure to thrive
Jaundice
Hematuria
Offensive urine
3mo- 2 yr
Fever only
Poor feeding
Vomiting
Irritability
Failure to thrive
Hematuria
Offensive urine
> 2 yr
Frequency
Dysuria
Abdominal pain
Loin tenderness
Change to
continence
Fever only
Hematuria
Offensive urine
Cloudy urine
3/12/1392
4
Case 1

Ali is an 8 month old infant presented
with fever. What is the risk of UTI? Is he
need urinalysis and urine culture?
3/12/1392
5
Case 1

Ali is an 8 month old infant presented
with fever. What is the risk of UTI if the
child
◦
◦
◦
◦
◦
Not circumcised
Fever> 39°С
Fever without source
Fever > 24 hours
Combination of them
3/12/1392
6
Risk of UTI in boys
Numb Condition
er
1
Uncircumsised
Risk of UTI
2
Nonblack race
1%
3
T> 39 °C
1%
4
Fever > 24 h
1% each day
5
Absence of another
source of infection
1%
2%
3/12/1392
7
Risk of UTI in case 1

Ali is an 8 month old infant presented
with fever. What is the risk of UTI if the
child
◦
◦
◦
◦
◦
◦
Not circumcised 2%
Fever> 39°С : 1%
Fever without source: 1%
Fever > 24 hours: 1% each day
Nonblack race: 1%
Combination of them
3/12/1392
8
Case 2

Zahra is an 8 month old infant presented
with fever. What is the risk of UTI? Is she
need urinalysis and urine culture?
3/12/1392
9
Case 2
Zahra is an 8 month old infant presented
with fever. What is the risk of UTI if the
child
 Fever> 39°С
 Fever without source
 Fever > 2 days
 Combination of them

3/12/1392
10
Risk of UTI in girls
Number
Condition
Risk of UTI
1
Age < 12 mo
1%
2
White race
1%
3
T> 39 °C
1%
4
Fever > 2 d
1% each day
5
Absence of
1%
another source
of infection
3/12/1392
11
Risk of UTI in case 2
Zahra is an 8 month old infant presented
with fever. What is the risk of UTI if the
child
 Fever> 39°С: 1%
 Fever without source: 1%
 Fever > 2 days: 1% each day
 Age< 12 mo: 1%
 White race: 1%
 Combination of them

3/12/1392
12
Case 3

Ali is an 8 month old uncircumcised infant
presented with high grade fever( 39.5°C)
for 4 days with no other source of
infection. Which test you request for
diagnosis of UTI?
3/12/1392
13
Case 3
If the child is ill: U/A and U/C through
midstream, catheter or suprapubic and
start IV antibiotic
 If the child is well:
 Option 1: U/A and U/C through
midstream, catheter or suprapubic
 Option 2: U/A through bag and if
suggestive then U/A and U/C through
midstream, catheter or suprapubic

3/12/1392
14
The results of U/A of case 3
Case Urinalysis result
Your decision
3-1
WBC= 3-4/hpf , Nitrite= neg,
RBC= 0-1/hpf, bacteria= many
3-2
WBC= 3-4/hpf , Nitrite= neg,
RBC= many /hpf, bacteria= many
3-3
WBC= 6-8/hpf , Nitrite= neg,
RBC= 0-1/hpf, bacteria= few
3-4
WBC= 3-4/hpf , Nitrite= Pos,
RBC= 0-1/hpf, bacteria= neg
3-5
WBC= 15-20/hpf , Nitrite= neg,
RBC= 0-1/hpf, bacteria= neg
3/12/1392
15
Diagnosis of UTI

Both:
◦ Urinalysis suggestive for urinary infection as
pyuria and/or bacteriuria in gram stain of
fresh urin
◦ Presence of atleast 5 Χ 105 CFU/ml of a
uropathogen through catetherization or SPA
3/12/1392
16
The results of U/A of case 3
Case
Urinalysis result
Your decision
3-1
WBC= 3-4/hpf , Nitrite= neg, RBC= 01/hpf, bacteria= many
No UTI, decision based
on U/C
3-2
WBC= 3-4/hpf , Nitrite= neg, RBC=
many /hpf, bacteria= many
No UTI, decision based
on U/C
3-3
WBC= 6-8/hpf , Nitrite= neg, RBC= 01/hpf, bacteria= few
Suspected UTI, repeat
U/A
3-4
WBC= 3-4/hpf , Nitrite= Pos, RBC= 01/hpf, bacteria= neg
Suspected UTI if exam
on fresh urine, repeat
U/A
3-5
WBC= 15-20/hpf , Nitrite= neg, RBC=
0-1/hpf, bacteria= neg
Suspected UTI, start
antibiotic and final
decision based on U/C
3/12/1392
17
The results of U/A and U/C of case 3
Case
Urinalysis result
U/C result
Your decision
3-1
WBC= 3-4/hpf , Nitrite= neg,
RBC= 0-1/hpf, bacteria= many
> 105 Ecoli
No UTI, contamination in
bag sample, asymptomatic
bacteriuria
3-2
WBC= 3-4/hpf , Nitrite= neg,
RBC= 1-2 /hpf, bacteria= many
> 105 s. epiderm No UTI, Contamination
3-3
WBC= 6-8/hpf , Nitrite= neg,
RBC= 0-1/hpf, bacteria= few
Negative
No UTI
3-4
WBC= 3-4/hpf , Nitrite= Pos,
RBC= 0-1/hpf, bacteria= neg
> 105 Ecoli
suspected UTI,
contamination in bag
sample, asymptomatic
bacteriuria
3-5
WBC= 15-20/hpf , Nitrite= neg,
RBC= 0-1/hpf, bacteria= neg
> 105 Ecoli
UTI, treat based on
sensitivity
3-6
WBC= 15-20/hpf , Nitrite= neg,
RBC= 0-1/hpf, bacteria= neg
103 Ecoli
Suspected UTI, repeat
U/A, U/C
3/12/1392
18
Pyuria + negative UC






Fever
Exercise
Streptococcal
infections
Urethritis
Kawasaki
Interstitial nephritis(
eos.)






3/12/1392
Partially treated UTI
Viral infections
Renal TB
Renal abscess
UTI + obstruction
Inflammation near
UT system(
appendicitis, crohn, ..)
19
Positive UC+ No pyuria
Early phase of infection
 Very frequent voiding( low count)
 Asymptomatic bacteriuria
 Contamination ( bag sample)
 Neutropenia

3/12/1392
20
Etiology of UTIs

Enteric G-:
◦
◦
◦
◦
◦

E.coli 80%
Klebsiella
Proteus
Enterobacter
Citrobacter
G+:
◦ Enterococcus: suspected in urinary catheter,
abnormality, or instrumentation
◦ S.saprophyticus
3/12/1392
21
Contamination in U/C
Lactobacillus spp
 Coagulase –negative staphylococci
 Corynebacterium spp

3/12/1392
22
Case 4

Ali is an 8 month old uncircumcised infant
presented with high grade fever( 39.5°C)
for 4 days with no other source of
infection. U/A shows many WBCs. When
you decide to admit the child in the
hospital?
3/12/1392
23
Admission of UTI patients in hospital
Indications
No indication
Vomiting or inability to
tolerate PO medications
Very high fever
Age< 2 mo
Fatigue
Clinical urosepsis( Abnormal
vital signs, ↑ CRT)
Loss of appetite
Immunocompromised Pts
Rigor
Lack of outpatient follow up
Loin pain
Failure to respond to
outpatients therapy
Abdominal pain
3/12/1392
24
Case 5

Ali is an 8 month old uncircumcised infant
presented with high grade fever( 39.5°C)
for 4 days with no other source of
infection. U/A shows many WBCs.You
decide to admit the child in the hospital
due to severe vomiting and inability to
tolerate PO medications. Which antibiotic
is appropriate for the child?
3/12/1392
25
Case 6

Ali is an 8 month old uncircumcised infant
presented with high grade fever( 39.5°C)
for 4 days with no other source of
infection. U/A shows many WBCs.You
decide to treat the child with PO
medications. Which antibiotic is
appropriate for the child?
3/12/1392
26
Empiric antibiotic therapy in UTI

Admitted: ( untile afebrile and able to tolerate PO)
◦ ceftriaxone( 50-75) , cefotaxime( 100 ), cefepime(100),
Gentamicine ( 3-5)
◦ +ampicillin( 100) if enterococci suspected( urinary
catether, instrumentation, anomaly)

Out patient:
◦ Cefixime( 16 1st day then 8-10 in1-2 dose), ciprofloxacine
if psudomonas or resistant g- ( 20-30) after 17 yr
◦ Nalidixic acid(55), nitrofurantoin( 5-7) alternative for
afebriles and older children

Duration: 3-5 d for afebrile, 7-14 d for febrile
3/12/1392
27
Case 7

Ali is an 8 month old uncircumcised infant
presented with high grade fever( 39.5°C)
for 4 days with no other source of
infection. U/A shows many WBCs.You
decide to treat the child with cefixime
syrup. When you repeat U/A and U/C for
confirmation of cure?
3/12/1392
28
Case 7

There is no need to confirmation by U/A
and U/C. Improve in fever and symptoms
during 24-48 hours confirms complete
cure of the child.
3/12/1392
29
Case 8

Ali is an 8 month old uncircumcised infant
presented with high grade fever( 39.5°C)
for 4 days with no other source of
infection. U/A shows many WBCs.You
decide to treat the child with cefixime
syrup. When you send renal and bladder
ultrasonography, voiding cysto uretero
graphy, and Dimercapto methyl succinic
acid assay?
3/12/1392
30
Renal sonography

All febrile UTI after acute phase
• In patients who not respond to AB after 48 hr
during acute phase
• No need in afebrile UTIs
3/12/1392
31
Indications of Voiding CystoUretheroGraphy
• > 1 febrile UTI
 1ST febrile UTI+ abnormal renal
sonography( hydronephrosis, scarring, …)
 1ST febrile UTI+ poor growth/
hypertension/ non Ecoli growth
3/12/1392
32
DiMercaptoSuccinic Acid renal
scintigraphy
No indication after febrile UTIs
 Currently for investigational purpuses
 Careful F/U of all children obviate need to
DMSA

3/12/1392
33
Case 9

Ali is an 8 month old uncircumcised infant
presented with high grade fever( 39.5°C)
for 4 days with no other source of
infection. U/A shows many WBCs.You
decide to treat the child with cefixime
syrup. After 2 days the results of U/C
shows growth of more than 105 Ecoli
sensitive to meropneme and resistant to
all PO antibiotics. The child became
afebrile and well. What's your decision?
3/12/1392
34
50-90 rule
If the organism of the infection was
resistant to an antibiotic, the chance for
response is 50%
 If the organism of the infection was
sensitive to an antibiotic, the chance for
response is 90%
 Repeat U/C for confirmation of cure, and
continue cefixime

3/12/1392
35
Case 10

Ali is an 8 month old uncircumcised infant
presented with high grade fever( 39.5°C)
for 4 days with no other source of
infection. U/A shows many WBCs.You
decide to treat the child with cefixime
syrup. After 2 days the results of U/C
shows growth of more than 105 Ecoli
sensitive to cefixime. The child became
afebrile and well. What's your follow up
for the child?
3/12/1392
36
Follow up of UTI
Treat predisposing conditions of UTI
 UA and UC in all febrile illness to detect
and treat UTI immediately
 Regular monitoring of weight, height, and
blood pressure
 Prophylactic antibiotic for grade 3-5 VUR

 Corte, nitrofurantoin, cephalexin,
amoxicillin
 Once daily
 1/4 -1/3 usual dose
3/12/1392
37
Predisposing factors of UTI
1.
↑Perineal colonization
1. Uncircumcised
male
2. Wiping from
back to front in
girls
3. Tight clothing(
underwear)
4. Labial adhesion

↑Ascending to kidney and
renal tubules
1. Vesico ureteral reflux
2. Voiding dysfunction
1.
2.
3.
4.
5.
Onset of toilet training
Infrequent voiding
School aged children
Constipation
Neuropathic bladder
3. Obstructive uropathy (
stasis)
1.
2.
3.
3/12/1392
Hydronephrosis
Renal stone
Anatomical defects
38
Case 11

Ali is an 8 month old uncircumcised infant
presented with high grade fever( 39.5°C)
for 4 days with no other source of
infection. U/A shows many WBCs.You
decide to treat the child with cefixime
syrup. After 2 days the results of U/C
shows growth of more than 105 Ecoli
sensitive to cefixime. The child became
afebrile and well. When you refer the
child to pediatric nephrologist?
3/12/1392
39
Referral to pediatric nephrologist
Grade 3-5 VUR
 Obstractive uropathy
 Impaired kidney function
 Elevated blood pressure
 Proteinuria
 Refractory bladder and bowel dysfunction

3/12/1392
40
3/12/1392
41