rollo clifford. diagnosis treatment assessment: history examination referral
TRANSCRIPT
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