Morning Report July 12, 2012

Problem Characteristics Ill-appearing/ Toxic Well-appearing/ Non-toxic Localized problem Systemic problem AcquiredCongenital New problem Recurrence of old problem Symptoms Acute /subacuteChronic LocalizedDiffuse SingleMultiple StaticProgressive ConstantIntermittent Single EpisodeRecurrent AbruptGradual SevereMild PainfulNonpainful BiliousNonbilious Sharp/StabbingDull/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!