1. the Extern Conference 6 September 2007

2. History 6 year-old girl with fever for 3 days 4 days PTA, she had watery stool for 6-7 times a day, without blood or mucous. She had no rhinorhea or cough. 3 days PTA, she had high-graded fever. Her mother told that she was inactive and slept most of the time. She got over-the-counter drugs, paracetamol and ORS. Her diarrhea was improved but the other symptoms still persist.

3. History 6 year-old girl with fever for 3 days 2 days PTA, she had difficulty in voiding, increased in frequency, red-colored urine but no history of passing stone. She developed flank pain and still had high fever so her mother brought her to Siriraj hospital.

4. History 6 year-old girl with fever for 3 day She has no underlying disease and also no family history of renal disease, stones or urinary tract problems. No history of drug allergy

5. Physical Examination V/ST 38.6 o C, P 120/min, RR 22/min, BP 104/60mmHg, Wt. 20 kg(P 50 ), Ht. 122cm(P 50-75 ) GAan alert Thai girl, good consciousness, looked weak, not pale, no jaundice, no edema HEENTdry lips, no sunken eyeballs, good skin turgor, pharynx & tonsils not injected, TM normal, no cervical lymphadenopathy RSnormal breath sounds, no adventitious sound

6. Physical Examination CVSnormal S 1,S 2, no murmur, all peripheral pulses 2+ Abdomen soft, not tender, no guarding/rigidity, rebound tenderness -ve, liver & spleen not palpable Backno scoliosis, bilateral CVA tenderness NSE4V5M6, otherwise within normal limits GUno labial adhesion

7. Problem List Could you help us find out the problem in this patient??

8. Problem List  High-graded fever 3 days  Urinary symptoms2 days Dysuria Urinary frequency Red-colored urine Bilateral CVA tenderness  Mild dehydration

9. Investigation Now it’s time for Extern,Please!!

10. Investigation CBC : Hb 12.3 g/dl, Hct 36.8%, WBC 16170 (PMN 67.1%, L 26.3%), Platelet 259000

11. Investigation Bl.Chemistry : BUN 11, Cr 0.5, Na 137, K 3.8, Cl 103, HCO 3 18

12. Investigation U/A : pH 8.0, Sp.Gr.1.015, protein 4+, sugar -ve, leukocyte +ve, nitrite +ve RBC 20-30, WBC >200/HPF bacteria 2+, sq.epithelial cell 0-1

13. Investigation Gram stain : numerous PMNs, with small gram -ve rods (10-20/OF)

14. Investigation H/C, MUC : pending

15. Investigation  Urinalysis Urine Gram stain  Urine Culture  Complete blood count  Hemoculture  BUN, Cr, electrolytes

16. Investigation WBC 16170 CBC : Hb 12.3 g/dl, Hct 36.8%, WBC 16170 (PMN 67.1%, L 26.3%), Platelet 259000 HCO 3 18 Bl.Chemistry : BUN 11, Cr 0.5, Na 137, K 3.8, Cl 103, HCO 3 18 protein 4+ ketone 2+leukocyte +ve nitrite +veRBC 20-30WBC >200/HPF bacteria 2+ U/A : pH 8.0, Sp.Gr.1.015, protein 4+, ketone 2+, sugar -ve, leukocyte +ve, nitrite +ve, RBC 20-30, WBC >200/HPF bacteria 2+, sq.epithelial cell 0-1 numerous PMNs, with small gram -ve rods Gram stain : numerous PMNs, with small gram -ve rods (10-20/OF) H/C, MUC : pending leukocytosis Metabolic acidosis What does it mean??

17. Provisional Diagnosis  Acute pyelonephritis with mild dehydration

18. UTI Urinary Tract Infection Extern Conference September 2007

19. Background  Urinary tract is relatively common site of infection in infants and young children  Prevalence of UTIGirlsBoys age <6yr6.6%1.8% school age0.7-2.3%0.04-0.2%

20. Background  UTIs are important because the cause acute morbidity and may result in long- term medical problems  Clinical presentation tends to be nonspecific and valid urine specimen can’t be obtained without invasive methods

21. Background  UTIs associate with renal scarring which may lead to HT and renal failure  Probably the most common preventable cause of end-stage renal diseases Relationship between renal scarring and number of UTIs

22. Pathophysiology  Ascending infection Most common Urinary stasis Urinary tract abnormalities/Reflux Infrequent/incomplete voiding  Hematogenous spreading Non-specific symptoms Common in neonates  Lymphatic spreading  Direct extension

23. Key aspect to the management of UTI 4 phases :  Recognizing the child at risk for UTI  Making the correct diagnosis  Short-term treatment of UTI  Evaluation of the child with UTI for possible urinary tract abnormality

24. Risk factors 1.Genetics Female Congenital anomalies 2.Behavioral Constipation Toilet training Wiping from back to front Tight clothing Sexual activity

25. Risk factors 3.Biologic Genitourinary abnormality vesico-ureteral reflux obstructive uropathy neuropathic bladder uncircumcised boy labial adhesion Voiding dysfunction DM Pregnancy Immunocompromised host

26. Clinical Presentation  In younger children, UTI is difficult to make diagnosis and requires a high index of suspicion. Symptoms include vomiting, smelly urine, poor feeding, poor weight gain, altered temperature, abdominal distention, failure to thrive  For older children, more specific symptoms are usually elicited

27. Clinical Presentation Upper tract symptoms  High-graded fever  Flank pain  Nausea/vomitting  Severe malaise  Polyuria Lower tract symptoms  Low-graded fever  Dysuria  Frequency  Incontinence  Nocturnal enuresis

28. Key aspect to the management of UTI 4 phases :  Recognizing the child at risk for UTI  Making the correct diagnosis  Short-term treatment of UTI  Evaluation of the child with UTI for possible urinary tract abnormality

29. Diagnosis of UTI  Requires urine culture and should be obtained by urethral catheterization or suprapubic aspiration (SPA)  In older children, midstream clean-voided urine can be obtained for culture  Specimen should be process promptly, unless refrigerated to prevent bacterial overgrowth  The diagnosis cannot be established by a culture of urine collected in a bag

30. Diagnosis of UTI Based on the number of colony-forming units  SPA : any number  Urethral catheterization : >10 4 CFU/ml  Midstream clean-voided : Boys >10 4 CFU/ml Girls >10 5 CFU/ml

31. Urinalysis & UTI 2 most useful tests in urinalysis for possible UTI Leucocyte esterase : good sensitivity Nitrite : good specificity Leucocyte esterase : good sensitivity Nitrite : good specificity

32. Diagnosis of UTI Urinalysis cannot substitute a urine culture to document the presence of UTI, But valuable in selecting patients for prompt initiation of treatment while waiting for the results of urine culture

33. In this patient U/A : pH 8.0, Sp.Gr.1.015, protein 4+, sugar -ve, leukocyte +ve, nitrite +ve RBC 20-30, WBC >200/HPF bacteria 2+, sq.epithelial cell 0-1

34. Key aspect to the management of UTI 4 phases :  Recognizing the child at risk for UTI  Making the correct diagnosis  Short-term treatment of UTI  Evaluation of the child with UTI for possible urinary tract abnormality

35. Treatment  If the child is seriously ill at presentation, the first steps in treatment are fluid resuscitation  Otherwise, the main aim is to initiate appropriate antibiotic therapy promptly Which antibiotic? Oral or intravenous? How long to treat?

36. Treatment  The majority of organisms causing UTI originate from the GI tract, most common being Escherichia coli  If the patient is assessed as toxic, dehydrated or unable to retain oral intake, initial ATB therapy should be administered parenterally and hospitalization should be considered  Otherwise, ATB should be initiated parenterally or orally

37. Treatment ATB for parenteral treatment of UTI In this case, we prescribed Ceftriaxone 75 mg/kg/day, divided into 2 doses

38. Progress 15-17 Aug, 07

39. Progress Note 15/8/07 Specific treatment  Ceftriaxone 75mg/kg/day IV OD Symptomatic treatment  Correct dehydration with IV fluid  Paracetamol 10-15mg/kg/dose prn for fever Observe clinical signs & symptoms

40. Treatment ATB for oral treatment of UTI

41. Treatment  If the patient have not had expected clinical response within 2 days, should be reevaluated and another urine specimen should be obtained  Routine reculturing after 2 days of ATB is not necessary if the clinical improves and the pathogen determined to be sensitive  Traditional length of treatment is 7- to 10- day ATB course, but prefer 14 days for ill- appearing children with clinical evidence of pyelonephritis

42. Key aspect to the management of UTI 4 phases :  Recognizing the child at risk for UTI  Making the correct diagnosis  Short-term treatment of UTI  Evaluation of the child with UTI for possible urinary tract abnormality

43. Further Management  After 7-14day course of ATB, children with UTI in the “high-risk group” should receive ATB in prophylactic dosage until the imaging studies are completed  Recurrent febrile UTI and renal scarring follows an exponential curve  Risk of recurrence is highest during the first months after UTI

44. Further Management High risk patient :  Age <5years  Pyelonephritis or septicemia  Recurrent UTIs  Voiding disorders/Incontinence  History, physical signs or family history of urinary tract anomalies, including VUR All should have a KUB ultrasound and VCUG

45. ATB prophylaxis Night-time dose of ATB to prevent further infection Age <2mth : Amoxycillin 10mg/kg PO hs Age >2mth : TMP/SMX 2mg of TMP/kg PO hs Some ATB for prophylaxis of UTI

46. Further Investigation VCUG U/S normal Diuretic Renogram (UPJ obstruction) Diuretic Renogram (UPJ obstruction) hydronephrosis DMSA or IVP No VUR VUR VUR VCUG ATB prophylaxis Hygiene Education Stop Prophylaxis

47. VUR vesicoureteric reflux Grades of severity are categorized ; I to V based on the extent of the reflux and associated dilatation of ureter and pelvis

48. VUR vesicoureteric reflux  VUR is a self-limited disease, but the duration of the disease depends on severity  VUR gr.I, II : give ATB prophylaxis 90% resolves in 5yr  VUR gr.III, IV (bilateral) age >6yr, gr.V (bilateral) age >1yr consult urologist for reimplant surgery

49. Progress Note 16/8/07  The patient becomes active, good appetite. She had no signs of dehydration, and her urinary symptoms was gone V/S : T 36.5 o C, P 100/min, RR 20/min, BP 100/60mmHg U/A : pH 7, Sp.Gr.1.015, protein –ve, sugar –ve, leukocyte –ve, nitrite –ve, WBC 2-3/HPF, RBC 0-1/HPF, bacteria few, no epithelial cell

50. Progress Note 17/8/07  MUC : E.coli (ESBL -ve) >10 5 CFU/ml sensitive to 3 rd generation cephalosporin  H/C : pending  After she was afebrile for 48hrs, the ATB was switched to oral form. We chose Ceftibuten (9mg/kg/day) PO once a day for complete 14day-course therapy  U/S KUB appointment on 9 September 07  Discharge and follow-up 2wks later and plan for ATB prophylaxis

51. Remember! TakeHome MSGs

52. Conclusion Key aspect Key aspect to management of UTI  Recognizing the child at risk for UTI  Making the correct diagnosis  Short-term treatment of UTI  Evaluation of the child with UTI for possible urinary tract abnormality

53. Special thanks :. Assistant Professor Suroj Supavekin & Dr.Jariya Tarugsa

54. Thank You. for your attention