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Happy Monday!

Happy Monday!. Morning Report July 8th, 201 3. Semantic Qualifiers. Illness Script. Predisposing Conditions Age, gender, preceding events (trauma, viral illness, etc), medication use, past medical history (diagnoses, surgeries, etc) Pathophysiological Insult

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Happy Monday!

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  1. Happy Monday! Morning Report July 8th, 2013

  2. Semantic Qualifiers

  3. Illness Script • 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

  4. FYI: Fever in a Neonate

  5. Predisposing Conditions • Incidence: Female (8%) > Male (1%)*** • Uncircumcised = 5+ fold increased risk • Obstruction • Anatomic abnormality • Posterior urethral valves • UPJ obstruction • Ureterocele • Nephrolithiasis • Renal tumor • Indwelling catheter • Constipation***

  6. Pathophysiology • Ascension of bowel flora • Organisms*** • E. coli = most common…up to 70% • Other GNR and GBS (especially in neonates) • Klebsiella • Pseudomonas aeruginosa • Staph saprophyticus (sexually active girls) • Enterococcus • Staphylococcus (renal abscess, pyelonephritis) • Nephritogenic bacterial strains of E. coli (fimbriae bind to uro-epithelial cells)

  7. Clinical Manifestations • Babies and young children • Fever (or hypothermia) • 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

  8. Clinical Manifestations • 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!!

  9. Diagnosis of UTI • UA suggesting infection • Pyuria and/or bacteriuria • Urine Culture • At least 50,000 cfu/ml from sample obtained via catheterization/SPA

  10. UTI • 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.

  11. Definitions

  12. Lower vs. Upper UTI Lower Tract UTI Upper Tract UTI • Dysuria • Frequency • Urgency • Suprapubic pain • Discharge • Dribbling/incontinence • Hematuria • Cloudy hurine • Pelvic/perineal pain • Constitutional symptoms • Lower UTI symptoms + • Fever • Chills • Costovertebral/Flank pain • Nausea • Vomiting

  13. Admission • If < 3 months • Ill or toxic appearing • Dehydration • Inability to take PO • Failed outpatient treatment • Chronic disease ( SCD, DM, CF, immunocompromise)

  14. Treatment*** • Oral vs. Intravenous • Once the identification and sensitivity are known, antibiotics should be tailored appropriately*** • Treatment duration = 7-14 days*** Augmentin Bactrim Suprax Vantin Cefzil Ceftin Keflex

  15. Further Evaluation • 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

  16. VCUG

  17. Prophylaxis??*** • 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

  18. Reflux Nephropathy • 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

  19. Anticipatory Guidance*** • For Clinicians – recurrent UTIs should lead clinician to research previous bacterial isolates/sensitivities • Instruct parents to seek medical evaluation for future febrile illness • Ensure that recurrent infection can be detected and dx and treatment is not delayed

  20. Noon conference June Compliance is due today 

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