Transcript the

the
Extern
Conference
6 September 2007
History
6 year-old girl with fever for 3 days
4 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.
History
6 year-old girl with fever for 3 days
2 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.
History
6 year-old girl with fever for 3 day
She has no underlying disease and also no
family history of renal disease, stones or
urinary tract problems.
No history of drug allergy
Physical Examination
V/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 Examination
CVS
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 us
find out the problem
in this patient??
Problem List
High-graded fever
3 days
Urinary symptoms
2 days
• Dysuria
• Urinary frequency
• Red-colored urine
• Bilateral CVA tenderness
Mild dehydration
Investigation
Now it’s time for Extern,
Please!!
Investigation
CBC : Hb 12.3 g/dl, Hct 36.8%, WBC 16170
(PMN 67.1%, L 26.3%), Platelet 259000
Investigation
Bl.Chemistry : BUN 11, Cr 0.5,
Na 137, K 3.8, Cl 103, HCO3 18
Investigation
U/A : pH 8.0, Sp.Gr.1.015, protein 4+,
sugar -ve, leukocyte +ve, nitrite +ve
RBC 20-30, WBC >200/HPF
bacteria 2+, sq.epithelial cell 0-1
Investigation
Gram stain : numerous PMNs,
with small gram -ve rods (10-20/OF)
Investigation
H/C, MUC : pending
Investigation
Urinalysis
Urine Gram stain
Urine Culture
Complete blood count
Hemoculture
BUN, Cr, electrolytes
Investigation
leukocytosis
CBC : Hb 12.3 g/dl, Hct 36.8%, WBC 16170
(PMN 67.1%, L 26.3%), Platelet 259000
Bl.Chemistry : BUN 11, Cr 0.5,
Metabolic
Na 137, K 3.8, Cl 103, HCO3 18
acidosis
U/A : pH 8.0, Sp.Gr.1.015, protein 4+,
ketone 2+, sugar -ve, leukocyte +ve,
nitrite +ve, RBC 20-30, WBC >200/HPF
bacteria 2+, sq.epithelial cell 0-1
Gram stain : numerous PMNs,
What does
with small gram -ve rods (10-20/OF) it mean??
H/C, MUC : pending
Provisional Diagnosis
Acute pyelonephritis
with mild dehydration
UTI
Urinary
Tract Infection
Extern Conference
September 2007
Background
 Urinary tract is relatively common site of
infection in infants and young children
 Prevalence of UTI
age <6yr
school age
Girls
Boys
6.6%
1.8%
0.7-2.3% 0.04-0.2%
Background
 UTIs are important because the cause
acute morbidity and may result in longterm 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 UTI
 Making the correct diagnosis
 Short-term treatment of UTI
 Evaluation of the child with UTI for
possible urinary tract abnormality
Risk factors
1. Genetics
• Female
• Congenital anomalies
2. Behavioral
• Constipation
• Toilet training
• Wiping from back to front
• Tight clothing
• Sexual activity
Risk factors
3. 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 Presentation
Upper tract symptoms
 High-graded fever
 Flank pain
 Nausea/vomitting Lower tract symptoms
 Low-graded fever
 Severe malaise
 Dysuria
 Polyuria
 Frequency
 Incontinence
 Nocturnal enuresis
Key aspect
to the management of UTI
4 phases :
 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
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
Leucocyte esterase
2 most useful tests in
: good sensitivity
urinalysis for possible UTI Nitrite
: good specificity
Diagnosis of UTI
Urinalysis cannot substitute
a 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 patient
U/A : pH 8.0, Sp.Gr.1.015,
protein 4+, sugar -ve,
leukocyte +ve,
nitrite +ve
RBC 20-30,
WBC >200/HPF
bacteria 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 diagnosis
 Short-term treatment of UTI
 Evaluation 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
Treatment
ATB for parenteral treatment of UTI
In this case, we prescribed
Ceftriaxone 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 OD
Symptomatic treatment
 Correct dehydration with IV fluid
 Paracetamol 10-15mg/kg/dose prn for fever
• Observe clinical signs & symptoms
Treatment
ATB 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 10day ATB course, but prefer 14 days for illappearing 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 diagnosis
 Short-term treatment of UTI
 Evaluation of the child with UTI for
possible 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 UTI
and renal scarring follows
an exponential curve
 Risk of recurrence is
highest during the first
months after UTI
Further Management
High risk patient :
 Age <5years
 Pyelonephritis or septicemia
 Recurrent UTIs
 Voiding disorders/Incontinence
 History, physical signs or family history of
urinary tract anomalies, including VUR
All should have a KUB ultrasound and VCUG
ATB prophylaxis
Night-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
U/S
hydronephrosis
normal
VCUG
VUR
DMSA
or IVP
No VUR
Diuretic
Renogram
(UPJ obstruction)
VCUG
VUR
ATB
prophylaxis
No VUR
Hygiene Education
Stop 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 prophylaxis
90% resolves in 5yr
 VUR gr.III, IV (bilateral) age >6yr,
gr.V (bilateral)
age >1yr
consult 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/ml
sensitive 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 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 :
.
Suroj Supavekin
&
Dr.Jariya Tarugsa
Assistant Professor
Thank You
for your attention
.