Morning Report July 8th, 2013

Problem Characteristics Ill-appearing/ Toxic Well-appearing/ Non-toxic Localized problemSystemic problem AcquiredCongenital New problem Recurrence of old problem Symptoms Acute /subacuteChronic LocalizedDiffuse SingleMultiple StaticProgressive ConstantIntermittent Single EpisodeRecurrent AbruptGradual SevereMild PainfulNonpainful BiliousNonbilious Sharp/StabbingDull/Vague

 Predisposing Conditions  Age, gender, preceding events (trauma, viral illness, etc), medication use, past medical history (diagnoses, surgeries, etc)  Pathophysiological Insult  What is physically happening in the body, organisms involved, etc.  Clinical Manifestations  Signs and symptoms  Labs and imaging

 Incidence: Female (8%) > Male (1%)***  Uncircumcised = 5+ fold increased risk  Obstruction  Anatomic abnormality  Posterior urethral valves  UPJ obstruction  Ureterocele  Nephrolithiasis  Renal tumor  Indwelling catheter  Constipation***

 Ascension of bowel flora  Organisms***  E. coli = most common…up to 70%  Other GNR and GBS (especially in neonates)  Klebsiella  Pseudomonas aeruginosa  Staph saprophyticus (sexually active girls)  Enterococcus  Staphylococcus (renal abscess, pyelonephritis)  Nephritogenic bacterial strains of E. coli (fimbriae bind to uro-epithelial cells)

 Babies and young children  Fever (or hypothermia)  Feeding problems +/- FTT  Jaundice  Malodorous urine  Decreased activity or irritability  Vomiting, diarrhea, abdominal pain  >2yo = more classic symptoms  Urgency, frequency, hesitancy  Dysuria  Back or abdominal pain

 Urinalysis***  +nitrite (more specific)  +leukocyte esterase (more sensitive)  Pyuria…presence of at least 5 WBC per hpf  Bacteriuria  Urine culture***  Gold standard  Must have > 50,000cfu on an adequate specimen  Catheterization  Supra-pubic aspiration  Bag urine culture is NOT appropriate!!

 UA suggesting infection  Pyuria and/or bacteriuria  Urine Culture  At least 50,000 cfu/ml from sample obtained via catheterization/SPA

 Infection of the urinary tract anywhere from the urethra to the renal parenchyma.  Infants have risk of concurrent bacteremia.***  Epidemiology***  7-9% of infants (<3mo) with a fever and no identifiable source are diagnosed with UTI.***  Most common cause of serious bacterial infections (SBI) in babies < 3mo.  Is seen in conjunction with viral illnesses (i.e. RSV) in neonates.

LOWER TRACT UTIUPPER TRACT UTI  Dysuria  Frequency  Urgency  Suprapubic pain  Discharge  Dribbling/incontinence  Hematuria  Cloudy hurine  Pelvic/perineal pain  Constitutional symptoms  Lower UTI symptoms +  Fever  Chills  Costovertebral/Flank pain  Nausea  Vomiting

 If < 3 months  Ill or toxic appearing  Dehydration  Inability to take PO  Failed outpatient treatment  Chronic disease ( SCD, DM, CF, immunocompromise)

 Oral vs. Intravenous  Once the identification and sensitivity are known, antibiotics should be tailored appropriately***  Treatment duration = 7-14 days*** Augmentin Bactrim Suprax Vantin Cefzil Ceftin Keflex

 First time UTI*** (CHANGED in 2011)  Renal and bladder ultrasound  Timing is dependant upon clinical picture…  VCUG only if US reveals  Hydronephrosis  Renal scarring  Other findings that would suggest high-grade VUR or obstructive uropathy  Recurrence of febrile UTI***  VCUG

 Prior to 2011 Guidelines  Antibiotic prophylaxis in children until VCUG performed and if ANY grade of reflux (VUR)  Not shown to make statistically significant difference in Grades I – IV Reflux in terms of prevention of UTI recurrence.  High grade reflux should be referred to urology

 Renal damage caused by a combination of VUR and urinary tract infections (often recurrent) that occur in childhood.  Asymptomatic in early stages***  Can cause long term complications  HTN***  Proteinuria  Progressive renal failure  Increased risk of pregnancy-related complications

 For Clinicians – recurrent UTIs should lead clinician to research previous bacterial isolates/sensitivities  Instruct parents to seek medical evaluation for future febrile illness  Ensure that recurrent infection can be detected and dx and treatment is not delayed

Noon conference June Compliance is due today