Morning ReportJuly 8th, 2013

Problem Characteristics

Ill-appearing/Toxic

Well-appearing/Non-toxic

Localized problem

Systemic problem

Acquired Congenital

New problemRecurrence of old problem

Symptoms

Acute /subacute Chronic

Localized Diffuse

Single Multiple

Static Progressive

Constant Intermittent

Single Episode Recurrent

Abrupt Gradual

Severe Mild

Painful Nonpainful

Bilious Nonbilious

Sharp/Stabbing Dull/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 UTI UPPER 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***

AugmentinBactrim

SupraxVantinCefzilCeftinKeflex

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