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Extern conference 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. 2. 3. 4. Acute febrile illness for 1 day History of frequent voiding for 1 day History of red colored urine for 1 day 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 infection Urinary tract infection • Incidence of symptomatic UTI in children • boys • girls 1% with peak during neonatal period 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 infection Urinary stasis or Urinary tract abnormalities Reflux Infrequent or incomplete voiding Hematogenous spread • Neonates • Nonspecific symptoms Risk factor 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Female Uncircumcised male VUR Toilet training Voiding dysfunction Obstructive uropathy Urethral instrumentation Wiping from back to front Bubble bath Tight clothing 11. Pin worm 12. Constipation 13. P. fimbriae bacteria 14. Anatomic abnormality 15. Neuropathic bladder 16. Sexual activity 17. 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. 2. 3. 4. 5. 6. 7. 8. 9. 10. Female Uncircumcised male VUR Toilet training Voiding dysfunction Obstructive uropathy Urethral instrumentation Wiping from back to front Bubble bath Tight clothing 11. Pin worm 12. Constipation 13. P. fimbriae bacteria 14. Anatomic abnormality 15. Neuropathic bladder 16. Sexual activity 17. 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 • Classifications 1. Pyelonephritis 2. Cystitis 3. 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 Drippling, poor stream, or straining to void 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 CBC : Hb 9.8 g/dL, Hct 30.7%, MCV 82.1 fL • Urinalysis WBC 20,890 /mm3, N 48%, L41%, Mo 9%,Platelet 413,000/mm3 – Leukocyte esterase, Nitrite BUN : 8 mg/dL Cr : 0.3 mg/dL – WBC – Bacteria • Urine culture • Hemoculture 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/HPF 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 Diagnostic evaluation method Number (CFU/ml) Suprapubic aspiration Any number Transurethral catheterization ≥ 103 Midstream urine ≥ 104 with symptoms ≥ 105 แนวทางการรักษาผู้ป่วยที่มีการติดเชือ ้ ในทางเดินปัสสาวะ, ในประสิทธิ์ ฟูตระกูลและคณะ: ราชวิทยาลัยกุมารแพทย์แห่งประเทศไทย Treatment Neonate • Ampicillin 50-100 mg/kg/day IV and Gentamicin 3-5 mg/kg/day IV or IM or • Third generation Cephalosporins • Hospitalization is suggested for symptomatic young infants (less than three months 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, Ceftriaxone 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: – – Acute 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/ml Sensitive to ceftriaxone Hemoculture : no growth Complications • Acute – – – – Dehydration Pyelonephritis Sepsis Renal abscess • Long term – Hypertension – Impaired kidney function – Renal scarring – Renal 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 ATB Urinalysis: 72 hours later :pH 6, Sp.gr.1.015, leukocyte& nitriteneg, WBC 0-1/HPF, RBC-neg, bacteria-neg urine culture (cath) : no growth Indication for further investigation 1. 2. 3. 4. 5. Age < 5 years Febrile UTI School age girl with UTI ≥ 2 times Male with UTI Suspect anatomical abnormality in KUB system จักรชัย จึงธีรพานิช, urinary tract infection.ประไพพิมพ์ ธีระคุปต์และคณะ: ปัญหาสารน้้าอิเลกโทรไลต์และโรคไตในเด็ก, 2004, หน้า 323-337 Imaging studies 1. 2. 3. 4. Ultrasonography (U/S) Voiding cystourethrography (VCUG) Indirect radionuclide cystography (IRC) DMSA scan Imaging studies U/S+VCUG Hydronephrosis Hydroureter no VUR IRC VUR DMSA scan Prophylaxis Specialist consultation No detectable abnormality Prophylaxis Educations Follow up 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 Indication 1. VUR until resolves or surgical corrected 2. Neonates and infants with febrile UTI and abnormal renal scan 3. Recurrence > 3 times/year esp.with bladder instability 4. 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 Nitrofurantoin 1-2 At least 6-12 months In children< 6 weeks Cephalexin 10 Amoxycillin 10 mg TMP/kg/day or mg/kg/day mg/kg/day 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 ผศ.นพ. อนิรุธ ภัทรากาญจน์ อ.พญ. วิภาเพ็ญ เนียมสมบุญ Thank you