Joanne and Arvin

Plans for Diagnosis and Management

1. Immediate stabilization • Day 1 (01-26-10)• Patient was hydrated and

placed under diet– 1800 kcal/day, 270g CHO, 15g

CHON, 25g fats divided into 3 meals and 2 snacks.

Course in the Ward


2. Complete History and Physical Exam

3 of the following 5 criteria (Acute Pyelonephritis):

1) clinical symptoms of APN (chilling, nausea, vomiting, flank pain)

2) CVA tenderness3) leukocytosis (higher than

10,000/µL)4) fever (higher than 38.5 )℃5) WBC count ≥5 cells/hpf on

centrifuged urine sediment

Course in the Ward

Reference: The Philippine Clinical Practice Guideline on the Diagnosis and Management of Urinary Tract Infections: A Quick Reference Guide for Clinicians* Report of the Task Force on Urinary Tract Infections 1998


3. Patients presenting with signs and symptoms of pyelonephritis should have a urine culture and blood culture.– The results of the urine

culture may not be available for 48 hours therefore a urinalysis and CBC can be used to support presumptive diagnosis of pyelonephritis.

• CBC with platelet count:– WBC of 35.5 predominantly

neutrophils. • Urinalysis

– Yellow, slightly turbid, pH 6.5 sp gr 1.005, albumin (-), sugar (-), RBC 0-2/hpf, pus cell 8-12/hpf and bacteria +++.

• Urine GS/CS and Blood C/S were not done prior to antibiotic therapy.

Course in the Ward



4. Broad spectrum IV antibiotics should be started until the results of the urine culture are available and a more selective antibiotic can be identified.

5. Paracetamol 500mg/tab, 1 tab q4h prn for fever

• Ceftriaxone (2g/IV OD) and Paracetamol (500mg/tab, 1 tab q4h prn) were both started

Course in the Ward

Empiric Therapy



• Empiric Therapy– Sepsis secondary to acute pyelonephritis

• Parenteral regimen: ceftriaxone 1-2 g once a day; ciprofloxacin 200-400 mg every 12 hours; ofloxacin 200-400 mg every 12 hours; gentamicin 3-5 mg/kg once a day or 1 mg/kg every 8 hours.



6. Request for chest x-ray and sputum examination for acid-fast bacilli.

• Chest X-Ray was requested• Negative AFB smear on day 1, 2

and 3 of hospital stay

Course in the Ward


• A. PULMONARY TB DSSM Result:– Smear (+)

• A patient with at least 2 sputum specimens positive for AFB, with or without radiographic abnormalities consistent with active TB.

• A patient with 1 sputum specimen positive for AFB and with radiographic abnormalities consistent with active pulmonary TB as determined by a physician

• A patient with 1 sputum specimen positive for AFB and sputum culture positive for M. tuberculosis


• DSSM Result: – Smear (-)

• A patient with at least 3 sputum specimens negative for AFB with radiographic abnormalities consistent with active TB, and there had been no response to a course of antibiotics and/or TBDC to treat the patient with a full course of anti-TB chemotherapy


• Types:A. New – A patient who has never had treatment for

TB or who has taken anti-TB drugs for less than one month.

B. Relapse – A patient previously treated for TB who has been declared cured or treatment completed, and is diagnosed with bacteriologically positive (smear or culture) TB.

C. Failure – A patient who, while on treatment, is sputum smear positive at five months or later during the course of treatment.


D. Return after default (RAD) – A patient who returns to treatment with positive bacteriology (smear or culture), following interruption of treatment for 2 months or more.

E. Transfer-in – A patient who has been transferred from another facility with proper referral slip to continue treatment.


F. Others – All cases that do not fit into any of the above definitions. This group includes: • a patient who is starting treatment again after

interrupting treatment for more than 2 months and has remained or became smear-negative

• a sputum smear negative patient initially before starting treatment and became sputum smear-positive during the Rx.


• Category I (2 HRZE/ 4HR)– New pulmonary smear (+) cases– New seriously ill pulmonary smear (-) cases with extensive lung lesions on

CXR as assessed by TB Diagnostic Committee– New extra-pulmonary TB– Concomitant HIX infxn– Intensive phase – HRZE for 2 months– Maintenance phase – HR for 4 months

• Category II (2 HRZES/ 1HRZE/ 5HRE)– failure cases– relapse cases– return after default RAD (smear +)– other ( smear+ or -)– Intensive phase – HRZES for 2 months then HRZE for 1 month– Maintenance phase – HRE for 5 months


• Category III ( 2 HRZ(E) / 4HR) – new smear (-) but with minimal PTB on CXR as

assessed by TB diagnostic committee– ethambutol may be omitted for non-cavitary, smear

(-), fully susceptible cases • Category IV

– chronic ( still smear (+) after supervised re-treatment)

– refer to specialized facility or DOTS plus/ PMTM Center


• Treatment regimen for category II:– 2HRZES/HRZE/4HRE– 30-37kg

• Intensive phase – first 2 mon.• 2 HRZE, 0.75g streptomycin• 3rd mon. 2 HRZE.• Continuation phase – 2 HR, 1 E 400 mg

– 38-54 kg• Intensive phase – first 2 mon.• 3 HRZE, 0.75g streptomycin• 3rd mon. 3 HRZE• Continuation phase – 3 HR, 2 E 400 mg


• Treatment regimen for category II: – 55-70kg

» Intensive phase – first 2 mon.» 4 HRZE, 0.75g streptomycin» 3rd mon. 4 HRZE» Continuation phase – 4 HR, 3 E 400 mg

– >70kg» Intensive phase – first 2 mon.» 5 HRZE, 0.75g streptomycin» 3rd mon. 5 HRZE» Continuation phase – 5HR, 3 E 400 mg

• Follow-up: Category II - end of 3rd month and 5th month, start of 8th month

Insert CHEST X-RAY FINDINGS and picture

Plans for Dx and Mx of Pneumonia• Usual Dx and Mx plans for

pneumonia were complicated by the CC. of Pyelonephritis.

• Pneumonia Dx based on clinical presentation and confirmed by chest x-ray.

• Hydrate the patient• CBC• Gram stain and culture of the

sputum• Sputum AFB smear to rule out

active TB

Course in the Ward• Patient was hydrated and

placed under diet• CBC • Urinalysis • Chest X-Ray was requested• Negative AFB smear on day

1, 2 and 3 of hospital stay

CAP

Any of the ff:RR ≥30/min

PR ≥125/minTemp ≥40 or ≤35°C

Suspected aspirationExtrapulmonary evidence of

sepsisUnstable comorbid conditions

CXR: multilobar, pleural effusion, abscess, progression of lesion to 75% in 24 hours

Low risk CAP

Out-patient

NO

YES

Any of the ff:1.Shock or signs of

hypoperfusion, hypotension, altered mental state, urine

output <30ml/hr2.PaO2 < 60mmHg or acute hypercapnea

(PaCO2 > 50mmHg) at room air

YES

NO

Moderate risk CAP

In-patient

High risk CAP

ICU

Philippine Community-Acquired Pneumonia (CAP) Guidelines 2004

Plans for Dx and Mx• The course in the ward for

treating Pyelonephritis and Pneumonia are similar.

• Empirical regimen is administered:– Azithromycin 500 mg IV q 24

h plus β-lactam IV (cefotaxime 1 to 2 g q 8 to 12 h; ceftriaxone 1 g q 24 h)

– Macrolides

Course in the ward.• Ceftriaxone (2g/IV OD) and

Paracetamol (500mg/tab, 1 tab q4h prn) were both started

• (In treating the pyelonephritis, the pneumonia also could have been treated)


• Routine urologic evaluation (ultrasound or CT scan of the kidney) and routine use of imaging procedures are not recommended.

• Radiologic evaluation should be considered if the patient remains febrile within 72 hours of treatment to rule out the presence of nephrolithiasis, renal or perirenal abscesses, or other complications of pyelonephritis.

Course in the Ward



• Day 2 (01-27-10)• Spot sputum AFB stain still

showed no acid fast bacilli. • Urine and blood specimen were

collected for urine GS and CS, and blood culture

• There were still episodes of fever and cough, with no dysuria

• Crackles were heard bilaterally on both lung fields

• Ceftriaxone was continued and Erdosteine (300mg/cap, 1 cap BID) was started.

Course in the Ward

Day 2 (01-27-10)

• Serum sodium and potassium levels were requested – Hyponatremia and hypokalemia

• Kalium durule, 2 durules TID x 6 doses was given and hydration with PNSS was continued.

• A repeat CBC showed WBC of 11.80. (35.5 in Day 1)

• FBS was also requested showing normal value.

Day 3 (01-28-10)

• Spot sputum AFB stain still showed no acid fast bacilli. • Patient was referred to DOTS for further evaluation

and management. • Patient was afebrile, with stable vital signs, no dysuria

but still has cough and (+) bilateral crackles• Ceftriaxone was shifted to Cefixime 200mg/cap, 1 cap

BID for 5 days (until Feb 1, 2010)• Patient had stable vital signs. The rest of the hospital

stay was unremarkable. Patient was then discharged improved and stable.

• Discharge Medications: – Cefixime 200mg/cap, 1 cap BID for 5 days (until

Feb 1, 2010)• Special Instructions

– Refer back to DOTS with X-ray and sputum AFB results as outpatient, increase oral fluid intake

• Follow-up or Transfer Instruction– To come back at Med OPD on Feb 11, 2010 (Thurs,

8am) with DOTS referral.

LABORATORY RESULTS

CBCDate Jan 26 2010 Jan 28 2010Hgb (NV: 120-170 g/dl) 127 113RBC (NV: 3.8-5.5x106/µL ) 4.41 3.98Hct (NV: 0.37-0.54) 0.37 0.33MCV (NV: 78-101 fL) 84.3 83.7MCH (NV: 27-31 pg) 28.9 28.3MCHC (NV: 32-36 g/dl) 34.3 33.8RDW (NV: 11.6-14.6) 12.6 12.9MPV (NV: 7.4-10.4 fL) 5.5 5.3Plt (NV: 150-450x109/L 320 298WBC (NV: 4.5-10x109/L 35.5 11.8Neutro (NV: 0.5-0.9) 0.92 0.63Bands (NV: 0-0.05) 0.09 -Segmenters (NV: 0.5-0.7) 0.83 0.63Lym (NV: 0.20-0.40) 0.08 0.34Mono (NV: 0-0.07) - 0.02Eos (NV: 0-0.01) - 0.01Baso (NV: 0-0.01) - -

Abnormal Findings

Jan 26 2010

Jan 28 2010

Hgb (NV: 120-170 g/dl)

127 113

Hct (NV: 0.37-0.54) 0.37 0.33WBC (NV: 4.5-10x109/L)

35.5 11.8

Neutro (NV: 0.5-0.9) 0.92 0.63Segmenters (NV: 0.5-0.7)

0.83 0.63

Blood ChemistryDate Jan 27, 2010

(Day 2)

Sodium (NV: 137-147 mmol/L) 133

Potassium (NV: 3.8-5 mmol/L) 3.3

FBS (NV: <100mg/dl) 87

UrinalysisDate Jan 26 2010Color YellowTransparency TurbidpH 6.5Specific Gravity 1.005Albumin NegativeSugar NegativeHyaline casts 0-2/coverslipRBC 0-2/hpfPus cell 8-12/hpfSquamous cell ++Bacteria +++

Urine GS/CS

• Urine culture showed no growth after 2 days of incubation

• Urine gram stain showed no findings on centrifuged and on uncentrifuged urine.

Blood Culture

• Blood culture showed no growth after 5 days of incubation.

Joanne and Arvin

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