The Extern Conference 6 September 2007. History 6 year-old girl with fever for 3 days 4 days PTA,...
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Transcript of The Extern Conference 6 September 2007. History 6 year-old girl with fever for 3 days 4 days PTA,...
History6 year-old girl with fever for 3 days4 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.
History6 year-old girl with fever for 3
days2 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.
History6 year-old girl with fever for 3 dayShe has no underlying disease and also
no family history of renal disease, stones or urinary tract problems.
No history of drug allergy
Physical ExaminationV/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 ExaminationCVS 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 ListHigh-graded fever 3 daysUrinary symptoms 2 days
•Dysuria•Urinary frequency•Red-colored urine•Bilateral CVA tenderness
Mild dehydration
InvestigationU/A : pH 8.0, Sp.Gr.1.015, protein 4+,
sugar -ve, leukocyte +ve, nitrite +veRBC 20-30, WBC >200/HPFbacteria 2+, sq.epithelial cell 0-1
InvestigationUrinalysis
Urine Gram stainUrine CultureComplete blood countHemoculture BUN, Cr, electrolytes
InvestigationCBC : Hb 12.3 g/dl, Hct 36.8%, WBC 16170WBC 16170
(PMN 67.1%, L 26.3%), Platelet 259000Bl.Chemistry : BUN 11, Cr 0.5,
Na 137, K 3.8, Cl 103, HCOHCO33 18 18U/A : pH 8.0, Sp.Gr.1.015, protein 4+protein 4+,
ketone 2+ketone 2+, sugar -ve, leukocyte +veleukocyte +ve,nitrite +venitrite +ve, RBC 20-30RBC 20-30, WBC WBC >200/HPF>200/HPFbacteria 2+bacteria 2+, sq.epithelial cell 0-1
Gram stain : numerous PMNs,numerous PMNs,with small gram -ve rodswith small gram -ve rods (10-20/OF)
H/C, MUC : pending
leukocytosis
leukocytosis
Metabolic
acidosis
Metabolic
acidosis
What does it mean??
What does it mean??
Background
Urinary tract is relatively common site of infection in infants and young children
Prevalence of UTI Girls Boys age <6yr 6.6% 1.8% school age 0.7-2.3%0.04-0.2%
Background
UTIs are important because the cause acute morbidity and may result in long-term 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 Recognizing the child at risk for UTIUTI
Making the correct diagnosisShort-term treatment of UTIEvaluation of the child with UTI for
possible urinary tract abnormality
Risk factors1.Genetics
•Female•Congenital anomalies
2.Behavioral•Constipation•Toilet training•Wiping from back to front•Tight clothing•Sexual activity
Risk factors3.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 PresentationUpper tract
symptoms High-graded fever Flank pain Nausea/vomitting Severe malaise Polyuria
Lower tract symptoms
Low-graded fever Dysuria Frequency Incontinence Nocturnal enuresis
Key aspect to the management of UTI
4 phases :
Recognizing the child at risk for UTI
Making the correct diagnosisMaking the correct diagnosisShort-term treatment of UTIEvaluation 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
2 most useful tests in urinalysis for possible
UTI
Leucocyte esterase: good sensitivity
Nitrite: good specificity
Leucocyte esterase: good sensitivity
Nitrite: good specificity
Diagnosis of UTI
Urinalysis cannot substitutea 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 patientU/A : pH 8.0, Sp.Gr.1.015,
protein 4+, sugar -ve, leukocyte +ve,nitrite +veRBC 20-30,WBC >200/HPFbacteria 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 diagnosisShort-term treatment of UTIShort-term treatment of UTIEvaluation 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
TreatmentATB for parenteral treatment of UTI
In this case, we prescribedCeftriaxone 75 mg/kg/day,
divided into 2 doses
Progress Note 15/8/07
Specific treatment Ceftriaxone 75mg/kg/day IV ODSymptomatic treatment Correct dehydration with IV fluid Paracetamol 10-15mg/kg/dose prn
for fever
• Observe clinical signs & symptoms
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 10-day ATB course, but prefer 14 days for ill-appearing 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 diagnosisShort-term treatment of UTIEvaluation of the child with UTI for Evaluation of the child with UTI for
possible urinary tract abnormalitypossible 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 UTIand renal scarring followsan exponential curve
Risk of recurrence is highest during the first months after UTI
Further ManagementHigh risk patient : Age <5years Pyelonephritis or septicemia Recurrent UTIs Voiding disorders/Incontinence History, physical signs or family history of
urinary tract anomalies, including VURAll should have a KUB ultrasound and VCUG
ATB prophylaxisNight-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
VCUGVCUG
U/SU/S
normalnormal
Diuretic Renogram
(UPJ obstruction)
Diuretic Renogram
(UPJ obstruction)
hydronephrhydronephrosisosis
DMSAor IVP
DMSAor IVP
No VURNo VURVURVUR No VURNo VURVURVUR
VCUGVCUG
ATB prophylaxis
ATB prophylaxis Hygiene Education
Stop Prophylaxis
Hygiene EducationStop 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 prophylaxis90% resolves in 5yr
VUR gr.III, IV (bilateral) age >6yr, gr.V (bilateral) age >1yrconsult 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/mlsensitive 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
Conclusion
Key aspectKey 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