Urinary Tract Infection September 2014 - PowerPoint Presentation

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Urinary Tract InfectionSeptember 2014

Pediatric Continuity Clinic CurriculumCreated by: Michelle Y. Spencer, MD

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Objectives

Describe the association of urinary tract infections (UTIs) and unexplained fever in infantsDiscuss the management of suspected UTIReview the use of radiologic studies to diagnose vesicoureteral reflux (VUR)

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Case #1

A 3 m.o. male presents to acute clinic with 2 day history of tactile fever, frequent emesis and poor feeding. On exam, baby is fussy with temperature 38.4, HR 115 and BP 94/59 and no other significant abnormalities.Discussion Questions:What is the next step in evaluating this patient with fever?What are the indications for hospitalization?

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What is the next step in evaluating this patient with fever?

Obtain urinalysisThe prevalence of UTI in febrile infants who have no obvious source is about 7-9% in those < 3 m.o. regardless of sexIt decreases to 2% for males > 3 m.o. and females > 12 m.o.The

“gold standard” for diagnosing UTI is the urine culture

obtained by suprapubic aspiration, urethral catheterization, a ‘clean catch’ midstream specimen and bag collection (least preferable).

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Interpreting the urine dipstick

Nitrite test: presence of gram-negative bacteria in urine that reduce dietary nitrate to nitrite37% sensitive and 100% specific. Positive predictive value 90% and negative predictive value 100%Leukocyte esterase test: presence of leukocytes (best performed on a fresh specimen)73% sensitive and specific. Positive predictive value 34% and negative predictive value 95%

Presence may be related to vaginal secretions, dehydration, interstitial nephritis, etc.

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General Criteria to Diagnose UTISuprapubic

AspirationAny growth of gram negative bacilli or > 1,000 units/ml of gram positive cocciUrethral CatheterizationGreater than 50,000 colony forming units/ml for circumcised/uncircumcised males and all femalesMidstream Clean CatchGreater than 100,000 colony forming units/ml. These values pertain to pure, one pathogen colony growth

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What are the indications for hospitalization?

Infants < 3 months old should be hospitalized to receive IV fluids and antibiotics. NOTE: Each hospital might have different protocolIndications for hospitalization for older infants through adolescents: DehydrationInability to take oral fluids

Ill appearing infant or childPatients who have chronic diseases: sickle cell, diabetes, cystic fibrosis or urinary tract abnormalitiesPresence of perinephric abscess

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Flow Chart for Evaluation & Management of UTI in Older Children and Adolescents

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Case #2

A 5 y.o. female presents with 3 day history of fever and dysuria. Clean catch urine dipstick reveals spec grav 1.015, pH 6.0, positive nitrites, bacteria and leukocyte esterase.Discussion Questions:What is the most likely organism causing this patient’s symptoms?

What is the most appropriate next step in management?

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What is the most likely organism causing this patient’s symptoms?Escherichia coli (E. coli)

accounts for up to 70% of urinary tract infectionsOther bacterial pathogens:Pseudomonas aeruginosa (nonenteric gram negative)Enterococcus

faecalisKlebsiella pneumoniae

Group B strep (predominately in neonates)Proteus mirabilis (boys > 1 y.o

. and associated with renal calculi)

Coag

negative Staphylococcus

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Other pathogens causing UTIFungal UTI caused by Candida

albicans Associated with instrumentation or the urinary tractViral UTI caused by Adenovirus and BK virus (hemorrhagic cystitis)

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What is the most appropriate next step in management?

Send urine cultureStart antibiotic therapyTimely appropriate treatment is helpful in preventing renal injury that may lead to scarringCystitisMost cases 3-7 day course of antibiotics

PyelonephritisStart 10 day course of appropriate oral or IV antibiotic for initial treatmentIn cases of prolonged fever or renal abscess consider 14 days

3. Obtain radiologic imaging

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Appropriate Antibiotic Therapy

Uncomplicated Cystitis: Choice of agents -Cefixime(Suprax) -Cefdinir

(Omnicef) -Ceftibuten

(Cedax)Ciprofloxacin

Nitrofuratoin

There is increasing resistance to

A

moxicillin, Ampicillin, Trimethoprim-

sulfamethoxazole

(> 2 months of age), Amoxicillin-

clavulanate

, Cephalexin

Uncomplicated Acute Pyelonephritis

Similar to cystitis Ciprofloxacin 500 mg BID or extended release 1000 mg once daily

Adjust antibiotic as indicated after bacterial sensitivity available.

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Radiologic ImagingFluoroscopic VCUG is the gold standard for diagnosing VUR

VCUG should be done after infected urine becomes sterile or after completion of full course of antibiotics, though studies have shown that it could be done after 48-72 hours after initiation of antibioticsRenal ultrasound is safe and fast way of detecting congenital renal urinary tract anomalies that may be associated with UTI and VURCan be obtained within 2-4 weeks of initial UTI

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Indications for Ultrasonography Patients <

2 years of age with a first febrile UTI Patients of any age with recurrent febrile UTIs Patients of any age with a UTI who have a family history of renal or urologic disease, poor growth,or hypertension Patients who do not respond as expected to appropriate antimicrobial therapy

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Indications for Voiding Cystourethrogram

Patients of any age with two or more febrile UTIs.Patients of any age with a first febrile UTI who have any anomalies on renal ultrasound or a family history of renal or urologic disease; and children with poor growth or hypertension

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The content on the next slide has small font, but is packed with important information for review at your leisure

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Case #3

A 2 y.o. boy presents to clinic for follow up after completing 14 day course of antibiotics for pyelonephritis. You ordered a VCUG and the results reveal bilateral vesicoureteral reflux (grade III on the right and grade IV of the left).Discussion Questions:What is the most appropriate next step in management?

Which condition has strong association with UTI ?

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What is the most appropriate next step in management?Start prophylactic antibiotic therapy

Prophylactic dose if ¼ to ½ of the therapeutic doseSuggested Dosing

TMP-SMZ 2 mg/kg daily or 5 mg/kg twice weekly

Nitrofurantoin 1-2 mg/kg daily

Cephalexin

10 mg/kg daily

Ampicillin

20

mg/kg daily

Amoxicillin 10 mg/kg daily

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Vesicoureteral reflux (VUR)

Occurs when urine within the bladder flows back up into the ureter and often back into the kidney.Primary concern is exposing the kidneys to infected urine → acute pyelonephritis and renal scarringAll grades of VUR have potential for spontaneous resolution over a period of time. Percent resolution at 5 year follow up

Grade I 82% Grade II 80%Grade III 46%Grades V 30%Grade V 13%

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Which condition has strong association with UTI ?CONSTIPATION

The association is believed to result from compression of the bladder and bladder neckAlso distended colon or fecal soiling provides an abundant reservoir of pathogensConstipation in children increases the likelihood of urinary incontinence bladder overactivity, dysfunctional voiding, recurrent UTIs and persistence or progression of VUR

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Other host risk factors predisposing to Urinary Tract Infection

Lack of circumcision of male infants (<1 year of age)Male gender in first 6 to 8 postnatal monthsLack of breastfeeding in first 6 postnatal monthsConstipationDysfunctional voiding pattern

Recent history of antibiotic use for any purposeUrinary tract infection in the past 6 monthsIndwelling catheters or intermittent catheterizationFamily history of recurrent urinary tract infection

Recent sexual intercourseUse of a diaphragm for birth control or spermicidal agents

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Management of VURMedical management is appropriate for all stages of VUR particularly in younger children

Prophylactic antibiotics, treatment of constipation and voiding dysfunction if presentSurgical management is reserved for patients who fail medical management or Grade IV/VBreakthrough UTIs or persistent VUR with evidence of renal injuryClose monitoring with periodic VCUG examination (yearly – to every 2 years)

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PREP QUESTIONS

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A 4-year-old girl presents to your office for evaluation 1 month after an episode of pyelonephritis, after which she was diagnosed with grade III vesicoureteral reflux. The patient is healthy with normal growth parameters and development. She has no significant past medical history or past surgical history. According to her parents, she has been toilet trained since 18 months of age. Findings on physical examination are unremarkable; vital signs are normal. Her urine analysis in the office shows specific gravity of 1.010, pH of 6.0, and no protein, blood, leukocyte esterase, or nitrites. There is no history of urinary tract infections in the parents or the 2-year-old sister.

PREP 2014 #214

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Of the following, the MOST appropriate next step in the management of this patient is to

evaluate the patient for voiding dysfunction order urine culture for evaluating resolution of the urinary tract infection order serum electrolytes and serum creatinine for evaluating renal function refer the patient for surgical correction of her reflux screen the 2-year-old sibling with voiding

cystourethrographyPREP 2014 #214

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A 3-month-old female infant presents to your office for follow-up of pyelonephritis diagnosed 2 months ago. After treatment of her urinary tract infection, she had a contrast voiding

cystourethrogram (VCUG) that showed narrowing of the distal urethra and a normal urinary stream upon voiding (Item Q36). Her physical examination is unremarkable. She is currently on oral amoxicillin for urinary tract infection prophylaxis. Of the following, the MOST appropriate next step in the management of this patient isintravenous pyelography

referral to urology for surgical correction repeat urine culture

repeat VCUG in 1 year stop prophylactic antibiotics

PREP 2014 #36

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Narrow urethra on VCUG

(

also termed

spinning top urethral

deformity

)

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ReferencesPediatrics in Review Article: “Urinary tract infections and Vesicoureteral Reflux in Infants and Children” (2010)

AAP Clinical Guideline or Practice ParameterNelson’s referenceHarriet LaneUptodate

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BONUS PREP QUESTIONS

If time permits 

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A 17-year-old, sexually active boy has complaints of intermittent burning with urination for the last 2 weeks. He says he sometimes sees some staining on his underwear but has not noticed any penile discharge or genital lesions. He reports that he has never had a sexually-transmitted infection and that he always uses condoms. He is otherwise healthy and has no systemic complaints, hematuria, or urgency.

On physical examination, he is at sexual maturity rating 5 for pubertal development. Other than some moistness at the urethral meatus, his genital examination findings are normal. PREP 2014 #20

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Of the following, the organism MOST likely responsible for this boy’s symptoms isChlamydia

trachomatisEscherichia coli Mycoplasma genitalium Neisseria

gonorrhoeae Ureaplasma urealyticum

PREP 2014 #20

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A 1-year-old with genitourinary malformations recently underwent corrective urological surgery and was discharged home in stable condition with an indwelling urinary catheter. The patient presents 10 days after discharge with fever and vomiting. Physical examination is significant only for a febrile infant (40.1°C) with mild dehydration. The urine is cloudy, and a spot urine test strip analysis shows a pH of 6.0, specific gravity of 1.040, 4+ leukocyte esterase, and no nitrites, blood, or protein. The patient is admitted to the hospital

parenteral antibiotics are started.PREP 2014 #72

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Of the following, the MOST appropriate empiric antibiotic choice for this patient is intravenousampicillin

ampicillin and ceftriaxone ceftriaxone cefuroxime and gentamicin

gentamicin

PREP 2014 #72

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THANK YOU!