rollo clifford. diagnosis treatment assessment: history examination referral

DCH GUIDELINES FOR CHILDHOOD UTI(Informed by NICE)

ROLLO CLIFFORD

DiagnosisTreatmentAssessment:HistoryExamination

Referral

UTI in 30mins

DIAGNOSIS

Reduced feeding or Vomits more than usual. Fever with no other obvious explanation. Sleepy and lethargic Stops gaining weight or unexpected loss. Has jaundice which gets worse when more than

a week old. (Unusual smell to urine) (Seems to be in pain at times and when urine is

passed)

Suspecting UTI in Infants

Urine sample essential – if do not, Murphy’s law tends to apply!

MSU, CCU, OK – Bag not. Stick test – if positive to nitrites or

leucocytes, lab sample + consider Rx. Lab sample as urgent if:

◦ Known urinary tract anomaly◦ Symptoms suggestive of pyelonephritis◦ Under 3 years with suggestive symptoms

White cap bottle if small sample but to labe quickly.

Urine Collection ProtocolMessages for Primary Care

TREATMENT

Treat rapidly if upper tract features Infants nearly always in this category Amoxycillin excellent – if sensitive – toss a

coin? Trimethoprim/Augmentin/Cephalexin Follow up and check sensitivities

Key Messages

ASSESSMENT

Initial symptomatologyFeverVomitingSite of any pain/discomfort

Diagnostic accuracy – method of urine collection

Presentation

Previous infections / undiagnosed fevers Recurrent loin pain Possible neurological symptoms Family history – renal anomalies, renal

failure, hypertension

PMH / FH

Dysfunctional Elimination Syndrome Urge syndrome Staccato voiding Fractional and incomplete voiding Voiding postponement

Constipation / Stool retention / Enuresis Soiling

Vaginal reflux

Poos and Wees

Fluid intake – too few drinks or, in some cases, interfering with appetite.

Hygiene – bubble baths, washing hair in bath, frequency, wiping, odour.

Symptoms suggestive of thread worm infection. School toilets and access

Other Issues and Risks

Plotted height and weight with comparison with previous centiles

Blood pressure measurement Abdominal examination Genital examination in pre-pubertal children

(unless recorded normal elsewhere) Urinalysis

Examination

For all under 4 or in referral categories Renal size Dilation of collecting system and ureter Bladder emptying Congenital abnormality Large calculi No – ionising radiation Atraumatic Costs about 1/10 of an isotope scan

Investigation - ultrasound

Exclude scarring Exclude reflux – which may predispose to

future scarring.

Ultrasound can not:

TO REFER OR NOT TO REFER

Symptoms of cystitis only – i.e. No upper tract symptoms

Age >12 months Clear diagnosis Normal ultrasound Single infection Associated factors e.g. Constipation/soiling,

manageable in primary care Time to make above assessment with

confidence.

Who does not need referral?

Recogntion of infection (infants especially) Prevention of future infection

◦ Bladder habit◦ Hygiene issues◦ Diet (incl. fluids) and Constipation

Provide leaflet

Advice and prevention

Severe systemic upset

Inadequate fluid intake/vomiting

Infants

Acute Referral

Any upper tract symptoms – fever >38, loin pain, vomiting, obvious systemic upset.

Two or more infectionsAny abnormality on ultrasound.Diagnostic doubtAssociated risk factors which prove difficult to

manage – e.g. constipation/soiling.GP preference

OP Referral

Symptoms or ultrasound findings suggest severe obstruction (e.g. Possible urethral valves / gross renal or ureteric dilation on ultrasound – particularly if during infancy and if bilateral)

Urgent discussion - telephone