1. Morning Report
September 6, 2011

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

3. 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

4. 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

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

6. Defense
Empty bladder regularly

7. 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

8. 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

9. 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

10. 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

11. 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

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

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

14. 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

15. 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/ days for uncomplicated pyelo/ NO nitrofurantoin – not significant levels in plasma so it won’t cover kidneys well

16. 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

17. 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

18. 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

19. Noon Conference
Basics of Clinical Teaching, Dr. English
Students off!