Morning ReportJuly 12, 2012
Problem Characteristics
Ill-appearing/Toxic
Well-appearing/Non-toxic
Localized problem
Systemic problem
Acquired Congenital
New problemRecurrence of old problem
Symptoms
Acute /subacute Chronic
Localized Diffuse
Single Multiple
Static Progressive
Constant Intermittent
Single Episode Recurrent
Abrupt Gradual
Severe Mild
Painful Nonpainful
Bilious Nonbilious
Sharp/Stabbing Dull/Vague
Predisposing Conditions Age, gender, preceding
events (trauma, viral illness, etc), medication use, past medical history (diagnoses, surgeries, etc)
Pathophysiological Insult What is physically
happening in the body, organisms involved, etc.
Clinical Manifestations Signs and symptoms Labs and imaging
Female (8%) > Male (1%)*** Uncircumcised = 5+ fold increased risk Obstruction
Anatomic abnormality Posterior urethral valves UPJ obstruction Ureterocele
Nephrolithiasis Renal tumor Indwelling catheter
Constipation***
Ascension of bowel flora Organisms***
E. coli = most common…up to 70% Other GNR (especially in neonates) Klebsiella Pseudomonas aeruginosa Staph saprophyticus (sexually active girls) Enterococcus
Nephritogenic bacterial strains of E. coli possess fimbriae that bind to uro-epithelial cells as well as other virulence factors.
Babies and young children Fever Feeding problems +/- FTT Jaundice Malodorous urine Decreased activity or irritability Vomiting, diarrhea, abdominal pain
>2yo = more classic symptoms Urgency, frequency, hesitancy Dysuria Back or abdominal pain
Urinalysis*** +nitrite (more specific) +leukocyte esterase (more sensitive) Pyuria…presence of at least 5 WBC per hpf Bacteriuria
Urine culture*** Gold standard Must have > 50,000cfu on an adequate
specimen Catheterization Supra-pubic aspiration Bag urine culture is NOT appropriate!!
Infection of the urinary tract anywhere from the urethra to the renal parenchyma.
Infants have risk of concurrent bacteremia.***
Epidemiology*** 7-9% of infants (<3mo) with a fever and no
identifiable source are diagnosed with UTI.*** Most common cause of serious bacterial
infections (SBI) in babies < 3mo. Is seen in conjunction with viral illnesses (i.e.
RSV) in neonates.
Oral vs. Intravenous Once the identification and sensitivity are
known, antibiotics should be tailored appropriately***
Treatment duration = 7-14 days***
First time UTI*** (CHANGED in 2011) Renal and bladder ultrasound
Timing is dependant upon clinical picture… VCUG only if US reveals
Hydronephrosis Renal scarring Other findings that would suggest high-grade VUR
or obstructive uropathy
Recurrence of febrile UTI*** VCUG
Prior to 2011 Guidelines Antibiotic prophylaxis in children until VCUG
performed and if ANY grade of reflux (VUR)
Not shown to make statistically significant difference in Grades I – IV Reflux in terms of prevention of UTI recurrence.
High grade reflux should be referred to urology
Renal damage caused by a combination of VUR and urinary tract infections (often recurrent) that occur in childhood.
Asymptomatic in early stages***
Can cause long term complications HTN*** Proteinuria Progressive renal failure Increased risk of pregnancy-related
complications
Noon conference = Intern clinical reasoning with Dr. English
INTERNS ONLY!