Pediatric Continuity Clinic Curriculum Created by Michelle Y Spencer MD Objectives Describe the association of urinary tract infections UTIs and unexplained fever in infants Discuss the management of suspected UTI ID: 930053
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Urinary Tract InfectionSeptember 2014
Pediatric Continuity Clinic CurriculumCreated by: Michelle Y. Spencer, MD
Slide2Objectives
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)
Slide3Case #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?
Slide4What 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).
Slide5Interpreting 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.
Slide6General 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
Slide7What 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
Slide8Flow Chart for Evaluation & Management of UTI in Older Children and Adolescents
Slide9Case #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?
Slide10What 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
Slide11Other pathogens causing UTIFungal UTI caused by Candida
albicans Associated with instrumentation or the urinary tractViral UTI caused by Adenovirus and BK virus (hemorrhagic cystitis)
Slide12What 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
Slide13Appropriate 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.
Slide14Radiologic 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
Slide15Indications 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
Slide16Indications 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
Slide17The content on the next slide has small font, but is packed with important information for review at your leisure
Slide18Slide19Case #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 ?
Slide20What 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
Slide21Vesicoureteral 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%
Slide22Which 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
Slide23Other 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
Slide24Management 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)
Slide25PREP QUESTIONS
Slide26A 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
Slide27Of 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
Slide28A 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
Slide29Narrow urethra on VCUG
(
also termed
spinning top urethral
deformity
)
Slide30ReferencesPediatrics in Review Article: “Urinary tract infections and Vesicoureteral Reflux in Infants and Children” (2010)
AAP Clinical Guideline or Practice ParameterNelson’s referenceHarriet LaneUptodate
Slide31BONUS PREP QUESTIONS
If time permits
Slide32A 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
Slide33Of the following, the organism MOST likely responsible for this boy’s symptoms isChlamydia
trachomatisEscherichia coli Mycoplasma genitalium Neisseria
gonorrhoeae Ureaplasma urealyticum
PREP 2014 #20
Slide34A 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
Slide35Of the following, the MOST appropriate empiric antibiotic choice for this patient is intravenousampicillin
ampicillin and ceftriaxone ceftriaxone cefuroxime and gentamicin
gentamicin
PREP 2014 #72
Slide36THANK YOU!