extern conference 24 may 2007. history a 3-month-old boy 1 day pta he had low graded fever.his...

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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. Acute febrile illness for 1 day2. History of frequent voiding for 1 day3. History of red colored urine for 1 day4. 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 infectionUrinary tract infectionUrinary tract infectionUrinary tract infection

Urinary tract infection

• Incidence of symptomatic UTI in children• boys 1%

with peak during neonatal period• girls 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 infectionAscending infection• Urinary stasis or

Urinary tract abnormalities

• Reflux• Infrequent or

incomplete voiding

Hematogenous spreadHematogenous spread• Neonates • Nonspecific

symptoms

Risk factor

1. Female2. Uncircumcised male3. VUR4. Toilet training5. Voiding dysfunction6. Obstructive uropathy7. Urethral instrumentation8. Wiping from back to

front9. Bubble bath10. Tight clothing

11. Pin worm12.Constipation13.P. fimbriae bacteria14.Anatomic abnormality15.Neuropathic bladder16.Sexual activity17.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. Female2. Uncircumcised male3. VUR4. Toilet training5. Voiding dysfunction6. Obstructive uropathy7. Urethral instrumentation8. Wiping from back to

front9. Bubble bath10. Tight clothing

11. Pin worm12. Constipation13. P. fimbriae bacteria14. Anatomic abnormality15. Neuropathic bladder16. Sexual activity17. 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

• Classifications1 . Pyelonephritis2 . Cystitis3 . 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• Dripp ling, poor stream, or straining to voi

d• 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• Urinalysis

– Leukocyte esterase, Nitrite– WBC– Bacteria

• Urine culture Hemoculture

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

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/HPFUA : 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 castUrine culture (Catheterization): pending

Diagnostic evaluation

method Number (CFU/ml)

Suprapubic aspiration Any number

Transurethral catheterization

≥ 103

Midstream urine ≥ 104 with symptoms≥ 105

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Treatment

Neonate• Ampicillin 50-100 mg/kg/day IV and G

entamicin 3-5 mg/kg/day IV or IM or • Third generation Cephalosporins• Hospitalization is suggested for symptom

atic young infants (less than three month s 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, Ceftria

xone 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:

– A cute 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/mlSensitive to ceftriaxone

Hemoculture : no growth

Complications

• Acute – Dehydration– P yelonephritis– S epsis– Renal abscess

• Long term – Hypertension– Impaired kidney

function– R enal scarring– R enal 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 ATBUrinalysis: 72 hours

later :pH 6, Sp.gr.1.015, leukocyte& nitrite-neg, WBC 0-1/HPF, RBC-neg, bacteria-negurine culture (cath) : no growth

Indication for further investigation

1. Age < 5 years2. Febrile UTI3. School age girl with UTI ≥ 2 times4. Male with UTI5. Suspect anatomical abnormality in KUB

system

จักรชื้ย จั/งธิ์�รพาน�ชื้, urinary tract infection.ป่ระไพพ�มีพ) ธิ์�ระค'ป่ติ)และคณะ:ป่�ญห่าสารน1�าอ�เลกโทรไลติ)และโรคไติในเด3ก, 2004, ห่น�า -323337

Imaging studies

1. Ultrasonography (U/S)2. Voiding cystourethrography (VCUG)3. Indirect radionuclide cystography (IRC)4. DMSA scan

U/S+VCUG

HydronephrosiHydronephrosis s

Hydroureter Hydroureter no VURno VUR

Prophylaxis Specialist

consultation

VURVUR No detectable No detectable abnormalityabnormality

Prophylaxis EducationsFollow up

Imaging studies

DMSA DMSA scanscan

IRCIRC

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

Indication1. VUR until resolves or surgical corrected2. Neonates and infants with febrile UTI and

abnormal renal scan3. Recurrence > 3 times/year esp.with bladder

instability4. 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 mg TMP/kg/day or

Nitrofurantoin 1-2 mg/kg/dayAt least 6-12 months

In children< 6 weeks Cephalexin 10 mg/kg/dayAmoxycillin 10 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

ผู้ศ.นพ . อน�ร'ธิ์ ภัทรากาญจัน)อ.พญ . ว�ภัาเพ3ญ เน�ยมีสมีบุ'ญ

Thank you