Morning Report September 6, 2011

UTIs Lower Upper Bladder Urethra Kidneys Renal pelvis Ureters Upper is pyelonephritis

Risk Factors Age Sex Infants Teenagers First 3 postnatal months Males First 6 years Females Infants and preschool children more than school age children. Adolescents – sexually active girls and homosexual boys More common in uncircumcised

Risk Factors Previous history Sibling with UTI Catheterization Structural Abnormalities Cause complicated UTIs Most important risk factor for the development of pyelonephritis?? VUR Up to 50% may have an abnormality found at time of first UTI VUR

Common Bugs E.coli Enterobacter Proteus Klebsiella 90% Pyelonephritis 80% is E.coli – virulence factors helping with adherance

Defense Empty bladder regularly

Signs and Symptoms Younger children and infants Fever Irritability Poor feeding Lethargy Abd pain Vomiting Loose stools Pyelonephritis – highly variable/ bolded more common in pyelo but 25% may have no classic signs

Signs and Sypmtoms Older children/adolescents Cystitis: consist of dysuria, frequency, urgency, suprapubic pain, and/or hematuria Pyelonephritis: consist of the above symptoms (symptoms of cystitis may or may not be present) together with fever (>38ºC), chills, flank pain, costovertebral angle tenderness, and nausea/vomiting May mimic PID

To Bag or Not to Bag? Bag specimen Urethral catheterization Bag can only exclude if normal, although in younger kids, they may still have UTI and have normal UA Urethral catheterization Suprapubic aspiration Clean Catch Older children Consider in any child 2 months to 2 years with unexplained fever – only suprapubic aspiration or transurethral cath What can a bag do?? Bag can only exclude if normal although in younger kids, they may still have UTI and have normal UA

Results Leukocyte esterase WBCs Nitrites Bacteria Gram stain Casts are diagnostic of pyelonephritis Nitrites Bacteria Gram stain LE – enzyme in WBC – sensitive but not specific >5WBCs is pyuria – sensitive but not specific – However, WBCs casts are diagnostic of pyelonephritis Nitrites – Gram negatives reduce nitrates to nitrites in urine – insensitive but specific Bacteria in spun sample is not specific or sensitive Unspun gram stain is diagnostic

Results Pyelonephritis Elevated peripheral WBC count ESR CRP None are sensitive or specific enough to include or exclude Pyelo is mostly a clinical diagnosis based on signs and symptoms. However, these may help in some situations

Results Culture results Diagnostic confirmation Suprapubic tap Cath Any growth Cath >50,000 Midstream Catch >100,000

Imaging Not needed to confirm diagnosis of pyelo! U/S CT DMSA More sensitive DMSA Test of choice Detects renal scarring Not routinely used

Treatment Cystitis Nitrofurantoin TMP-SMX Fluoroquinolones *Avoid if suspected early pyleonephritis due to poor plasma concentration TMP-SMX Do not use if local resistance is over 10-20% Fluoroquinolones pyelonephritis

Treatment Pyleonephritis Outpatient Inpatient Mild to moderate illness Severe illness Stabilized prior to D/C High fever Pain Poor po intake Pregnancy Poor compliance More serious infection than cystitis→ efficacy of an antimicrobial agent is of greater importance When possible use Amoxil or Bactrim/ 10-14 days for uncomplicated pyelo/ NO nitrofurantoin – not significant levels in plasma so it won’t cover kidneys well

Treatment Outpatient Inpatient (IV) Ciprofloxacin (5 to 7 days) Fluoroquinolone Levofloxacin (5 to 7 days) Aminoglycosides Ceftriaxone (24 hour dose while waiting on susceptability) Cephalosprorins Bactrim (14 days) *Transition to oral abx once tolerating po

Follow up No f/u culture needed < 5 years old Antibiotics until work up complete Renal U/S VCUG Older children may warrant eval if febrile UTI or pyelonephritis occurs AAP recommendation – First Febrile UTI - U/S to look at anatomy – obstruction, major scarring, cysts or renal dysplasia VCUG will show reflux

Complications Bacteremia Obstruction Abscess Recurrence Renal Scarring HTN For pyelonephritis – Bacteremia – younger than 2 months Abscess – persistent fever or symptoms 48 to 72 hours – US or CT Early detection is very important to decrease risk of complications Long term follow up required for some

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