extern conference 24 may 2007. history a 3-month-old boy 1 day pta he had low graded fever.his...
TRANSCRIPT
Extern conferenceExtern 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. Acute febrile illness for 1 day2. History of frequent voiding for 1 day3. History of red colored urine for 1 day4. 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 infectionUrinary tract infectionUrinary tract infectionUrinary tract infection
Urinary tract infection
• Incidence of symptomatic UTI in children• boys 1%
with peak during neonatal period• girls 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 infectionAscending infection• Urinary stasis or
Urinary tract abnormalities
• Reflux• Infrequent or
incomplete voiding
Hematogenous spreadHematogenous spread• Neonates • Nonspecific
symptoms
Risk factor
1. Female2. Uncircumcised male3. VUR4. Toilet training5. Voiding dysfunction6. Obstructive uropathy7. Urethral instrumentation8. Wiping from back to
front9. Bubble bath10. Tight clothing
11. Pin worm12.Constipation13.P. fimbriae bacteria14.Anatomic abnormality15.Neuropathic bladder16.Sexual activity17.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. Female2. Uncircumcised male3. VUR4. Toilet training5. Voiding dysfunction6. Obstructive uropathy7. Urethral instrumentation8. Wiping from back to
front9. Bubble bath10. Tight clothing
11. Pin worm12. Constipation13. P. fimbriae bacteria14. Anatomic abnormality15. Neuropathic bladder16. Sexual activity17. 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
• Classifications1 . Pyelonephritis2 . Cystitis3 . 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• Dripp ling, poor stream, or straining to voi
d• 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• Urinalysis
– Leukocyte esterase, Nitrite– WBC– Bacteria
• Urine culture Hemoculture
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
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/HPFUA : 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 castUrine culture (Catheterization): pending
Diagnostic evaluation
method Number (CFU/ml)
Suprapubic aspiration Any number
Transurethral catheterization
≥ 103
Midstream urine ≥ 104 with symptoms≥ 105
แนวทางการรกษาผู้ �ป่�วยท��มี�การติ�ดเชื้��อในทางเด�นป่�สสาวะ , ในป่ระส�ทธิ์�" ฟู ติระก ลและคณะ:ราชื้ว�ทยาลยก'มีารแพทย)แห่+งป่ระเทศไทย
Treatment
Neonate• Ampicillin 50-100 mg/kg/day IV and G
entamicin 3-5 mg/kg/day IV or IM or • Third generation Cephalosporins• Hospitalization is suggested for symptom
atic young infants (less than three month s 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, Ceftria
xone 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:
– A cute 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/mlSensitive to ceftriaxone
Hemoculture : no growth
Complications
• Acute – Dehydration– P yelonephritis– S epsis– Renal abscess
• Long term – Hypertension– Impaired kidney
function– R enal scarring– R enal 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 ATBUrinalysis: 72 hours
later :pH 6, Sp.gr.1.015, leukocyte& nitrite-neg, WBC 0-1/HPF, RBC-neg, bacteria-negurine culture (cath) : no growth
Indication for further investigation
1. Age < 5 years2. Febrile UTI3. School age girl with UTI ≥ 2 times4. Male with UTI5. Suspect anatomical abnormality in KUB
system
จักรชื้ย จั/งธิ์�รพาน�ชื้, urinary tract infection.ป่ระไพพ�มีพ) ธิ์�ระค'ป่ติ)และคณะ:ป่�ญห่าสารน1�าอ�เลกโทรไลติ)และโรคไติในเด3ก, 2004, ห่น�า -323337
Imaging studies
1. Ultrasonography (U/S)2. Voiding cystourethrography (VCUG)3. Indirect radionuclide cystography (IRC)4. DMSA scan
U/S+VCUG
HydronephrosiHydronephrosis s
Hydroureter Hydroureter no VURno VUR
Prophylaxis Specialist
consultation
VURVUR No detectable No detectable abnormalityabnormality
Prophylaxis EducationsFollow up
Imaging studies
DMSA DMSA scanscan
IRCIRC
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
Indication1. VUR until resolves or surgical corrected2. Neonates and infants with febrile UTI and
abnormal renal scan3. Recurrence > 3 times/year esp.with bladder
instability4. 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 mg TMP/kg/day or
Nitrofurantoin 1-2 mg/kg/dayAt least 6-12 months
In children< 6 weeks Cephalexin 10 mg/kg/dayAmoxycillin 10 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
ผู้ศ.นพ . อน�ร'ธิ์ ภัทรากาญจัน)อ.พญ . ว�ภัาเพ3ญ เน�ยมีสมีบุ'ญ
Thank you