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6 September 20076 September 2007

History6 year-old girl with fever for 3 days4 days PTA, she had watery stool for 6-7

times a day, without blood or mucous. She had no rhinorhea or cough.

3 days PTA, she had high-graded fever. Her mother told that she was inactive and slept most of the time. She got over-the-counter drugs, paracetamol and ORS. Her diarrhea was improved but the other symptoms still persist.

History6 year-old girl with fever for 3

days2 days PTA, she had difficulty in

voiding, increased in frequency, red-colored urine but no history of passing stone. She developed flank pain and still had high fever so her mother brought her to Siriraj hospital.

History6 year-old girl with fever for 3 dayShe has no underlying disease and also

no family history of renal disease, stones or urinary tract problems.

No history of drug allergy

Physical ExaminationV/S T 38.6oC, P 120/min, RR 22/min,

BP 104/60mmHg,Wt. 20 kg(P50), Ht. 122cm(P50-75)

GA an alert Thai girl, good consciousness,looked weak, not pale, no jaundice,no edema

HEENT dry lips, no sunken eyeballs, good skin turgor, pharynx & tonsils not injected,TM normal, no cervical lymphadenopathy

RS normal breath sounds, no adventitious sound

Physical ExaminationCVS normal S1,S2, no murmur, all

peripheral pulses 2+Abdomen soft, not tender, no

guarding/rigidity, rebound tenderness -ve, liver & spleen not palpable

Back no scoliosis, bilateral CVA tenderness

NS E4V5M6, otherwise within normal limits

GU no labial adhesion

Problem List

Could you help usfind out the problem

in this patient??

Problem ListHigh-graded fever 3 daysUrinary symptoms 2 days

•Dysuria•Urinary frequency•Red-colored urine•Bilateral CVA tenderness

Mild dehydration

Investigation

Now it’s time for Extern,

Please!!Please!!

InvestigationCBC : Hb 12.3 g/dl, Hct 36.8%, WBC

16170(PMN 67.1%, L 26.3%), Platelet 259000

InvestigationBl.Chemistry : BUN 11, Cr 0.5,

Na 137, K 3.8, Cl 103, HCO3 18

InvestigationU/A : pH 8.0, Sp.Gr.1.015, protein 4+,

sugar -ve, leukocyte +ve, nitrite +veRBC 20-30, WBC >200/HPFbacteria 2+, sq.epithelial cell 0-1

InvestigationGram stain : numerous PMNs,

with small gram -ve rods (10-20/OF)

InvestigationH/C, MUC : pending

InvestigationUrinalysis

Urine Gram stainUrine CultureComplete blood countHemoculture BUN, Cr, electrolytes

InvestigationCBC : Hb 12.3 g/dl, Hct 36.8%, WBC 16170WBC 16170

(PMN 67.1%, L 26.3%), Platelet 259000Bl.Chemistry : BUN 11, Cr 0.5,

Na 137, K 3.8, Cl 103, HCOHCO33 18 18U/A : pH 8.0, Sp.Gr.1.015, protein 4+protein 4+,

ketone 2+ketone 2+, sugar -ve, leukocyte +veleukocyte +ve,nitrite +venitrite +ve, RBC 20-30RBC 20-30, WBC WBC >200/HPF>200/HPFbacteria 2+bacteria 2+, sq.epithelial cell 0-1

Gram stain : numerous PMNs,numerous PMNs,with small gram -ve rodswith small gram -ve rods (10-20/OF)

H/C, MUC : pending

leukocytosis

leukocytosis

Metabolic

acidosis

Metabolic

acidosis

What does it mean??

What does it mean??

Provisional Diagnosis

Acute pyelonephritiswith mild dehydration

UTI Urinary

Tract InfectionExtern ConferenceExtern ConferenceSeptember 2007September 2007

Background

Urinary tract is relatively common site of infection in infants and young children

Prevalence of UTI Girls Boys age <6yr 6.6% 1.8% school age 0.7-2.3%0.04-0.2%

Background

UTIs are important because the cause acute morbidity and may result in long-term medical problems

Clinical presentation tends to be nonspecific and valid urine specimen can’t be obtained without invasive methods

Background UTIs associate with renal scarring

which may lead to HT and renal failure

Probably the most common preventable cause of end-stage renal diseases

Relationship between renal scarring

and number of UTIs

Pathophysiology Ascending infection

• Most common• Urinary stasis• Urinary tract abnormalities/Reflux• Infrequent/incomplete voiding

Hematogenous spreading• Non-specific symptoms• Common in neonates

Lymphatic spreading Direct extension

Key aspect to the management of UTI

4 phases :

Recognizing the child at risk for Recognizing the child at risk for UTIUTI

Making the correct diagnosisShort-term treatment of UTIEvaluation of the child with UTI for

possible urinary tract abnormality

Risk factors1.Genetics

•Female•Congenital anomalies

2.Behavioral•Constipation•Toilet training•Wiping from back to front•Tight clothing•Sexual activity

Risk factors3.Biologic

•Genitourinary abnormality• vesico-ureteral reflux• obstructive uropathy• neuropathic bladder• uncircumcised boy• labial adhesion

•Voiding dysfunction•DM•Pregnancy•Immunocompromised host

Clinical Presentation In younger children, UTI is difficult to

make diagnosis and requires a high index of suspicion. Symptoms include vomiting, smelly urine, poor feeding, poor weight gain, altered temperature, abdominal distention, failure to thrive

For older children, more specific symptoms are usually elicited

Clinical PresentationUpper tract

symptoms High-graded fever Flank pain Nausea/vomitting Severe malaise Polyuria

Lower tract symptoms

Low-graded fever Dysuria Frequency Incontinence Nocturnal enuresis

Key aspect to the management of UTI

4 phases :

Recognizing the child at risk for UTI

Making the correct diagnosisMaking the correct diagnosisShort-term treatment of UTIEvaluation of the child with UTI for

possible urinary tract abnormality

Diagnosis of UTI Requires urine culture and should be

obtained by urethral catheterization or suprapubic aspiration (SPA)

In older children, midstream clean-voided urine can be obtained for culture

Specimen should be process promptly, unless refrigerated to prevent bacterial overgrowth

The diagnosis cannot be established by a culture of urine collected in a bag

Diagnosis of UTI

Based on the number of colony-forming units

SPA : any number Urethral catheterization : >104 CFU/ml Midstream clean-voided :

• Boys >104 CFU/ml• Girls >105 CFU/ml

Urinalysis & UTI

2 most useful tests in urinalysis for possible

UTI

Leucocyte esterase: good sensitivity

Nitrite: good specificity

Leucocyte esterase: good sensitivity

Nitrite: good specificity

Diagnosis of UTI

Urinalysis cannot substitutea urine culture to document

the presence of UTI,

But valuable in selecting patients for prompt initiation of treatment while waiting for

the results of urine culture

In this patientU/A : pH 8.0, Sp.Gr.1.015,

protein 4+, sugar -ve, leukocyte +ve,nitrite +veRBC 20-30,WBC >200/HPFbacteria 2+, sq.epithelial cell 0-1

Key aspect to the management of UTI

4 phases :

Recognizing the child at risk for UTI

Making the correct diagnosisShort-term treatment of UTIShort-term treatment of UTIEvaluation of the child with UTI for

possible urinary tract abnormality

Treatment If the child is seriously ill at

presentation, the first steps in treatment are fluid resuscitation

Otherwise, the main aim is to initiate appropriate antibiotic therapy promptly

Which antibiotic?Oral or intravenous?How long to treat?

Treatment The majority of organisms causing

UTI originate from the GI tract, most common being Escherichia coli

If the patient is assessed as toxic, dehydrated or unable to retain oral intake, initial ATB therapy should be administered parenterally and hospitalization should be considered

Otherwise, ATB should be initiated parenterally or orally

TreatmentATB for parenteral treatment of UTI

In this case, we prescribedCeftriaxone 75 mg/kg/day,

divided into 2 doses

Progress 15-17 Aug, 07

Progress Note 15/8/07

Specific treatment Ceftriaxone 75mg/kg/day IV ODSymptomatic treatment Correct dehydration with IV fluid Paracetamol 10-15mg/kg/dose prn

for fever

• Observe clinical signs & symptoms

TreatmentATB for oral treatment of UTI

Treatment If the patient have not had expected

clinical response within 2 days, should be reevaluated and another urine specimen should be obtained

Routine reculturing after 2 days of ATB is not necessary if the clinical improves and the pathogen determined to be sensitive

Traditional length of treatment is 7- to 10-day ATB course, but prefer 14 days for ill-appearing children with clinical evidence of pyelonephritis

Key aspect to the management of UTI

4 phases :

Recognizing the child at risk for UTI

Making the correct diagnosisShort-term treatment of UTIEvaluation of the child with UTI for Evaluation of the child with UTI for

possible urinary tract abnormalitypossible urinary tract abnormality

Further Management After 7-14day course of ATB, children

with UTI in the “high-risk group” should receive ATB in prophylactic dosage until the imaging studies are completed

Recurrent febrile UTIand renal scarring followsan exponential curve

Risk of recurrence is highest during the first months after UTI

Further ManagementHigh risk patient : Age <5years Pyelonephritis or septicemia Recurrent UTIs Voiding disorders/Incontinence History, physical signs or family history of

urinary tract anomalies, including VURAll should have a KUB ultrasound and VCUG

ATB prophylaxisNight-time dose of ATB to prevent further infection• Age <2mth : Amoxycillin 10mg/kg PO hs• Age >2mth : TMP/SMX 2mg of TMP/kg PO hs

Some ATB for prophylaxis of UTI

Further Investigation

VCUGVCUG

U/SU/S

normalnormal

Diuretic Renogram

(UPJ obstruction)

Diuretic Renogram

(UPJ obstruction)

hydronephrhydronephrosisosis

DMSAor IVP

DMSAor IVP

No VURNo VURVURVUR No VURNo VURVURVUR

VCUGVCUG

ATB prophylaxis

ATB prophylaxis Hygiene Education

Stop Prophylaxis

Hygiene EducationStop Prophylaxis

VUR vesicoureteric reflux

Grades of severity are categorized ; I to V based on the extent of the reflux and associated dilatation of ureter and pelvis

VUR vesicoureteric reflux

VUR is a self-limited disease, but the duration of the disease depends on severity

VUR gr.I, II : give ATB prophylaxis90% resolves in 5yr

VUR gr.III, IV (bilateral) age >6yr, gr.V (bilateral) age >1yrconsult urologist for reimplant surgery

Progress Note 16/8/07

The patient becomes active, good appetite. She had no signs of dehydration, and her urinary symptoms was gone

V/S : T 36.5oC, P 100/min, RR 20/min, BP 100/60mmHg

U/A : pH 7, Sp.Gr.1.015, protein –ve, sugar –ve, leukocyte –ve, nitrite –ve, WBC 2-3/HPF, RBC 0-1/HPF, bacteria few, no epithelial cell

Progress Note 17/8/07

MUC : E.coli (ESBL -ve) >105CFU/mlsensitive to 3rd generation cephalosporin

H/C : pending After she was afebrile for 48hrs, the ATB

was switched to oral form. We chose Ceftibuten (9mg/kg/day) PO once a day for complete 14day-course therapy

U/S KUB appointment on 9 September 07

Discharge and follow-up 2wks later and plan for ATB prophylaxis

Remember! TakeHome MSGs

Conclusion

Key aspectKey aspect to management of UTI

Recognizing the child at risk for UTI Making the correct diagnosis Short-term treatment of UTI Evaluation of the child with UTI for

possible urinary tract abnormality

Special thanks : . Assistant Professor Suroj

Supavekin&

Dr.Jariya Tarugsa

Thank You . for your attention