Extern 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 38.5 º c, RR 40/min, PR 140/min, BP 87/40 mmHg BW 4.8 kg (P 10 ),length 62 cm (P 75 ), 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 S 1 &S 2, 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 day 2.History of frequent voiding for 1 day 3.History of red colored urine for 1 day 4.Phimosis

Investigations

Investigation CBC : Hb 9.8 g/dL, Hct 30.7%,MCV 82.1 fL WBC 20,890 /mm 3, N 48%, L41%, Mo 9%, Platelet 413,000/mm 3 BUN : 8 mg/dL Cr : 0.3 mg/dL Electrolyte : was not performed

Investigation UA : pH 5, Sp.gr , glucose & ketone –, protein 3+, blood 2+, leukocyte & nitrite +, WBC /HPF, RBC 2-3/HPF,bacteria 2+, no cast Urine culture (Catheterization): pending Hemoculture : pending

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

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 infection Urinary stasis or Urinary tract abnormalities Reflux Infrequent or incomplete voiding Hematogenous spread Neonates Nonspecific symptoms

Risk factor 1.Female 2.Uncircumcised male 3.VUR 4.Toilet training 5.Voiding dysfunction 6.Obstructive uropathy 7.Urethral instrumentation 8.Wiping from back to front 9.Bubble bath 10.Tight clothing 11. Pin worm 12.Constipation 13.P. fimbriae bacteria 14.Anatomic abnormality 15.Neuropathic bladder 16.Sexual activity 17.pregnancy Jack S. elder. Urinary tract infection in Richard E. Behrman, Richard E.(eds): Nelson textbook of pediatrics, 2003, PP

Risk factor 1.Female 2.Uncircumcised male 3.VUR 4.Toilet training 5.Voiding dysfunction 6.Obstructive uropathy 7.Urethral instrumentation 8.Wiping from back to front 9.Bubble bath 10.Tight clothing 11. Pin worm 12.Constipation 13.P. fimbriae bacteria 14.Anatomic abnormality 15.Neuropathic bladder 16.Sexual activity 17.pregnancy Jack S. elder. Urinary tract infection in Richard E. Behrman, Richard E.(eds): Nelson textbook of pediatrics, 2003, PP

Urinary tract infection Classifications 1. Pyelonephritis 2. Cystitis 3. Asymptomatic bacteriuria Jack S. elder. Urinary tract infection in Richard E. Behrman, Richard E.(eds): Nelson textbook of pediatrics, 2003, PP

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 Drippling, poor stream, or straining to void 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/HPF UA : pH 5, Sp.gr , glucose & ketone –, protein 3+, blood 2+, leukocyte & nitrite +, WBC /HPF, RBC 2-3/HPF,bacteria 2+,no cast Urine culture (Catheterization): pending

Diagnostic evaluation methodNumber (CFU/ml) Suprapubic aspirationAny number Transurethral catheterization ≥ 10 3 Midstream urine≥ 10 4 with symptoms ≥ 10 5 แนวทางการรักษาผู้ป่วยที่มีการติดเชื้อในทางเดินปัสสาวะ, ในประสิทธิ์ ฟูตระกูลและคณะ: ราชวิทยาลัยกุมารแพทย์แห่งประเทศไทย

Treatment Neonate Ampicillin mg/kg/day IV and Gentamicin 3-5 mg/kg/day IV or IM or Third generation Cephalosporins Hospitalization is suggested for symptomatic young infants (less than three months 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 mg/kg/day, Ceftriaxone 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: –Acute pyelonephritis 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/ml Sensitive to ceftriaxone Hemoculture : no growth

Complications Acute –Dehydration –Pyelonephritis –Sepsis –Renal abscess Long term –Hypertension –Impaired kidney function –Renal scarring –Renal 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 ATB Urinalysis: 72 hours later :pH 6, Sp.gr.1.015, leukocyte& nitrite- neg, WBC 0-1/HPF, RBC-neg, bacteria-neg urine culture (cath) : no growth

Indication for further investigation 1.Age < 5 years 2.Febrile UTI 3.School age girl with UTI ≥ 2 times 4.Male with UTI 5.Suspect anatomical abnormality in KUB system จักรชัย จึงธีรพานิช, urinary tract infection.ประไพพิมพ์ ธีระคุปต์และคณะ: ปัญหาสารน้ำอิเลกโทรไลต์และโรคไตในเด็ก, 2004, หน้า

Imaging studies 1.Ultrasonography (U/S) 2.Voiding cystourethrography (VCUG) 3.Indirect radionuclide cystography (IRC) 4.DMSA scan

U/S+VCUG Hydronephrosis Hydroureter no VUR Prophylaxis Specialist consultationVUR No detectable abnormality Prophylaxis Educations Follow up Imaging studies DMSA scan IRC

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 Indication 1.VUR until resolves or surgical corrected 2.Neonates and infants with febrile UTI and abnormal renal scan 3.Recurrence > 3 times/year esp.with bladder instability 4.Neurogenic bladder 5.Obstructive uropathy Jack S. elder. Urinary tract infection in Richard E. Behrman, Richard E.(eds): Nelson textbook of pediatrics, 2003, PP

Prophylaxis TMP-SMX 1-2 mg TMP/kg/day or Nitrofurantoin 1-2 mg/kg/day At least 6-12 months In children< 6 weeks Cephalexin 10 mg/kg/day Amoxycillin10 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 ผศ.นพ. อนิรุธ ภัทรากาญจน์ อ.พญ. วิภาเพ็ญ เนียมสมบุญ

Thank you