Extern conference

1. Extern conference 24 May 2007

2. 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. • Noprevious history of urinary tract infection.

3. 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.

4. 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.

5. 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

6. 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

7. 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

8. Physical examination • Perineum : phimosis, descended both testes • NS : equal movement of extremities, DTR 2+ all, stiff neck and Brudzinski’s sign are negative

9. Problem list • Acute febrile illness for 1 day • History of frequent voiding for 1 day • History of red colored urine for 1 day • Phimosis

10. Investigations

11. 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

12. 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

13. Urinary tract infection Urinary tract infection

14. 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

15. Bacteriology • Gram negative bacilli: • E.coli esp p .frimbriaemost common (80% of UTI) • Klebsiella • Proteus • Gram positive: • Staphylococcus saprophyticus • Enterococcus sp. • Rare anaerobic bacteria

16. Ascending infection Urinary stasis or Urinary tract abnormalities Reflux Infrequent or incomplete voiding Hematogenous spread Neonates Nonspecific symptoms Pathophysiology

17. Female Uncircumcised male VUR Toilet training Voiding dysfunction Obstructive uropathy Urethral instrumentation Wiping from back to front Bubble bath Tight clothing 11.Pin worm Constipation P. fimbriae bacteria Anatomic abnormality Neuropathic bladder Sexual activity pregnancy Risk factor Jack S. elder. Urinary tract infection in Richard E. Behrman, Richard E.(eds): Nelson textbook of pediatrics, 2003, PP 1785-1789

18. Female Uncircumcised male VUR Toilet training Voiding dysfunction Obstructive uropathy Urethral instrumentation Wiping from back to front Bubble bath Tight clothing 11. Pin worm Constipation P. fimbriae bacteria Anatomic abnormality Neuropathic bladder Sexual activity pregnancy Risk factor Jack S. elder. Urinary tract infection in Richard E. Behrman, Richard E.(eds): Nelson textbook of pediatrics, 2003, PP 1785-1789

19. 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 1785-1789

20. 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

21. 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 Clinical manifestation

22. 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

23. Initial investigations • BUN, Cr, serum electrolytes • CBC • Urinalysis • Leukocyte esterase, Nitrite • WBC • Bacteria • Urine culture •  Hemoculture

24. 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

25. Diagnostic evaluation • Gold standard: urine culture • Urinalysis • Dipstick : Leukocyte esterase + Nitrite + • Microscopic : WBC > 5-10 cell/HPF Bacteria any/HPF

26. 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. 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

27. Diagnostic evaluation แนวทางการรักษาผู้ป่วยที่มีการติดเชื้อในทางเดินปัสสาวะ, ในประสิทธิ์ ฟูตระกูลและคณะ: ราชวิทยาลัยกุมารแพทย์แห่งประเทศไทย

28. Treatment Neonate • Ampicillin 50-100 mg/kg/day IV andGentamicin3-5 mg/kg/day IV or IM or • Third generation Cephalosporins • Hospitalization is suggested for symptomatic young infants (less than three months of age)

29. Treatment Children with acute severe pyelonephritis • aminoglycosides eg. Gentamicin 5 mg/kg/day (Be careful in renal impairment patient) or • Third generation Cephalosporinseg. Cefotaxime 100 -200 mg/kg/day, Ceftriaxone 50-100 mg/kg/day • Hospitalization is suggested

30. Treatment Children with a less toxic appearance and uncomplicated UTI • Cotrimoxazole6-12 mg of trimethoprim/kg/day PO or • Amoxycillin-clavulanic acid30 mg/kg/dayof amoxycillin PO or • Cephalosporins • OPD case • No information of using Quinolonesin children

31. Treatment • Supportive treatment • Duration: • Acute pyelonephritis 10-14 days • Lower tract infection 7-10 days

32. In this patient Supportive treatment • Correct dehydration : Intravenous fluid • Paracetamol prn for fever • F/U : signs and symptoms, BP,U/A, urine culture (catheterization)

33. In this patient Specific treatment • ATB: • Ceftriaxone 75 mg/kg/day • Phimosis: • Prednisolone cream apply to the prepuce bid • Daily gentle retraction

35. Urine culture (cath) • E. coli , ESBL-negative > 105 CFU/ml • Sensitive to ceftriaxone • Hemoculture : no growth

36. Acute Dehydration Pyelonephritis Sepsis Renal abscess Long term Hypertension Impaired kidney function Renal scarring Renal failure Pregnancy complications Complications

37. Investigations • Urinalysis: should return to normal in 2-3 days - Urine culture: 1 week after completed course of ATB

38. 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

39. Indication for further investigation • Age < 5 years • Febrile UTI • School age girl with UTI ≥ 2 times • Male with UTI • Suspect anatomical abnormality in KUB system จักรชัย จึงธีรพานิช, urinary tract infection.ประไพพิมพ์ ธีระคุปต์และคณะ: ปัญหาสารน้ำอิเลกโทรไลต์และโรคไตในเด็ก, 2004, หน้า 323-337

40. Imaging studies • Ultrasonography (U/S) • Voiding cystourethrography (VCUG) • Indirect radionuclide cystography (IRC) • DMSA scan

41. Imaging studies Hydronephrosis Hydroureter no VUR No detectable abnormality VUR DMSA scan IRC Prophylaxis Educations Follow up

42. Educations Hygiene Constipations Treat phimosis sign and symptoms of infections Follow up for 1 year Recurrence UTI Urinalysis Urine culture Educations & Follow up

43. In this patient • Ultrasonography KUB : • No detectable abnormality • VCUG : • No detectable abnormality

44. KUB ultrasonography: normal

45. VCUG: normal

46. VCUG: VUR

47. Posterior urethral valves

48. Indication VUR until resolves or surgical corrected Neonates and infants with febrile UTI and abnormal renal scan Recurrence > 3 times/year esp.with bladder instability Neurogenic bladder Obstructive uropathy Prophylaxis Jack S. elder. Urinary tract infection in Richard E. Behrman, Richard E.(eds): Nelson textbook of pediatrics, 2003, PP 1785-1789

49. 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 Amoxycillin 10 mg/kg/day Prophylaxis (American Academy of Pediatrics)

50. Progression • Switch to oral ATB: Ceftributen 9 mg/kg/day • Prophylaxis : Cotrimoxazole 2 mg/kg/day Continue antibiotic prophylaxis 6 months