2Case 1: 7 months old girl 3 days fever General condition worsening last 2 daysSleepy, but gives good contact when awakeEats less than usual, but drinks OK and has wet dipersNo rhinorrhea, coughing, vomiting or diarrheaPreviously healthy
3Examination Sleeps initially, but wakes up and gives contact No smile, uncomfortable, but the mother is able to calm herSkin color and turgor normal. Mucus membranes wetTonus OKCapillary refill time 2 secRR 45, HF 160, T 39,5, SaO2 95%Auscultation: normal heart and lung sounds
4LabCRP 235Urine bag sample: leukocytes +++, blood +, protein +, nitritis –Catheter sample confirms the results, with positive microscopi
5ManagementDiagnosis?Admit to hospital?Other solutions?Follow up?
7History General condition Fever Focal infectious symptoms? Vomiting FeedingConsciousnessHydration (diuresis)FeverFocal infectious symptoms?VomitingPrevious history: ultrasound during pregnancy
8Clinical examination Typically no focal signs of infection General appearance – septic?Respiratory frequenceHeart RateCapillary refill timeSkin colourConsciousnessActivity
9Laboratory investigations Urine sampleLeukocytes sensitive, nitritis specificCollection bag sample can only be used to exclude UTI!Midflow sample, catheter or bladder punctureMicroscopyUrine cultureBlood sampleCRP, WBC, kreatinin, Na, K, Hb, urea, blood gasesBlood culture
10Imaging Chest x-ray? Ultrasound Voiding cystourethrogram DMSA ScintigraphyAcute diagnostic of pyelonephritis and chronic renal scarring
11TreatmentOralMecillinam, Trimetoprim-sulpha, (3rd gen cefalosphorin), (Amoxicillin-clavulanate)i.vampicillin-gentacimin, mecillinam, cefotaxim
12Risk factors <6months Septic No effect of treatment within 48 hours Pathologic prenatal ultrasoundResidiving pyelonephritisNon E.coliUnusual presentation (older boys)Heredity for vesikuloureteral refluxHigh kreatinin or BP
13Case 2: 2 months old boy High fever 1,5 day No vomiting or diarrhea Eats ok, diuresis normalGeneral condition slightly reduced, more sleepy
14Examination No smile, but excellent contact. Good activity No focal signsAuscultation: normal
15Lab:CRP 131Urine sample (mid flow): Leukocytes 3+, blood 2x, protein 2+, nitritis +Admit to hospital?