Case conferenceUrinary tract infection

Int Patcharapon Udomluck

Identification data

• เด็�กชายไทย อาย� 13 ปี • สั�ญชาติ� ไทย ศาสันา พุ�ทธ• ภู�มิ�ลำ�าเนา หมิ�� 8 อ พุรหมิพุ�รามิ จั�งหวั�ด็ พุ�ษณุ�โลำก• ปีระวั�ติ�ได็&จัาก ผู้�&ปี(วัย• เข้&าร�บการร�กษาเมิ+,อวั�นท-, 7 พุฤษภูาคมิ 2557

Chief complaint & Present illness

• ปีวัด็เอวัด็&านข้วัา 1 วั�นก�อนมิา• 1 วั�นก�อน ปีวัด็ท&องด็&านข้วัา แลำะปีวัด็เอวั อาการ

ค�อยๆปีวัด็ ปีวัด็ลำ�กษณุะบ-บๆ ปีวัด็นานเปี2นช�,วัโมิง ร&าวัไปีหลำ�ง มิ-ไข้& มิ-ปี3สัสัาวัะแสับข้�ด็ ปี3สัสัาวัะเข้&มิข้45นสั-

แด็งคลำ�5า ปี3สัสัาวัะบ�อย ข้ย�บแลำ&วัปีวัด็มิากข้45น ทาน ยาแก&ปีวัด็ไมิ�เบา จั4งมิาโรงพุยาบาลำ

Past history & family history

• Past history– ปีฏิ�เสัธโรคปีระจั�าติ�วั, ปีฏิ�เสัธปีระวั�ติ�ผู้�าติ�ด็– เคยมิ-ปีระวั�ติ� ติ�อยมิวัย โด็นเพุ+,อนเติะท-,สั-ข้&างด็&านข้วัา เมิ+,อ 1

เด็+อนก�อน หลำ�งจัากน�5นมิ-ปีวัด็บ&าง ไมิ�ช�5า ไมิ�ได็&มิาโรงพุยาบาลำ• Personal history

– ปีฏิ�เสัธ ด็+,มิสั�รา หร+อสั�บบ�หร-,– ปีฏิ�เสัธแพุ&ยาแพุ&อาหาร

• Family history– ปีฏิ�เสัธ โรคปีระจั�าติ�วัในครอบคร�วั ปีฏิ�เสัธโรคน�,วัในครอบคร�วั

Physical examinations

• Vital signs : BT 38.2 oc RR 18 /min

PR 80 bpm full, regular BP 110/70 mmHg

• BW 45 kg / Height 160 cm

• General appearance: A Thai boy , Good consciousness, looked illed , no cyanosis, no dyspnea

• Skin: no rash, no petechiae, no ecchymosis,

Physical examinations• Head: normal shape, no evidence of

head trauma• Eyes: not pale conjunctiva, no

conjunctivitis , no icteric sclera , no sunken eyeballs, no dry lips and mucosa

• Ears: normal pinna, normal external auditory canal, no discharge

• Nose: no rhinorrhea • Throat & mouth: no oral ulcer, no

injected pharynx , no tonsil enlargement

Physical examinations• Cardiovascular: no active precordium, no peripheral

pulse deficit ,full, regular, no heave, no thrill, PMI at left 5th lCS MCL, no murmur , capillary refill < 2 sec

• Lungs: no chest wall deformity, equal chest movement, trachea in midline, no retraction, normal breath sound, no adventitious sound

• Abdomen: normal contour, no distension, active bowel sound, soft, not tender, no abnormal mass , CVA tenderness at Right

• Extremities: no edema, no deformity• Lymph nodes: can’t be palpated• Genitalia : Normal male type, no phimosis , no

discharge

Physical examinations

Neurological systems• Mental status : good

consciousness , E4V5M6• Sensory : no decrease

sensation• Motor : normal tone , motor

power gr. V all

Problem list

• Acute febrile illness with symptom of urinary tract infection– Frequently urination – Dysuria– Red color urine– Right flank pain + CVA tenderness at Right

• History of trauma

Investigation

• CBC• UA with Urine culture• Film KUB• U/S KUB

CBC

• WBC 6,340 cell/ul• Neu 54.9 %• Lymph 36 %• Mono 7.3 %• Eos 1.6 %• Baso 0.2 %• Anisocytosis few• Microcytosis few

• RBC 5,790,000 /ul• Hb 12.8 g/dL• Hct 40.1 %• MCV 69.3 fL• RDW 14.2 %• Platelet 267,000

/ul

Urine analysis

• Color Amber• Transparency Turbid1+

• Specific gravity 1.030• pH 5.5

• Protein Neg• Glucose Neg• Leukocyte• Nitrite

• Epi. Cells 1-2 cell/HPF• WBC 5-10 cell/HPF• RBC 50-100

cell/HPF • Bacteria

Film KUB

U/S KUB

• Study reveals normal shape and echogenicity of both kidneys without evidence of stone,mass or hydronephrosis

• Right kidney is measured about 9.1x4.7.3.9 cm• Left kidney is measured about 9.2x4.9x3.5 cm• Urinary bladder shows no stone or mass.• Prostate gland is unremarkable• IMP : No demonstrated urinary tract stone or

urinary tract obstruction

Treatment

• Ceftriazone 2 gm IV OD x 7 days• Paracetamol 1 tab PO prn for fever q 4-6 hr• 0.9%NaCl IV rate 80 ml/hr

Progression

U/C – no growth

Follow up U/A

• Color Yellow• Transparency Clear

• Specific gravity 1.010• pH 6.0

• Protein Neg• Glucose Neg• Leukocyte• Nitrite

• Epi. Cells 0-1 cell/HPF• WBC 3-5 cell/HPF• RBC 5-10

cell/HPF • Bacteria

Urinary tract infectionin Pediatrics

Prevalence

• During the 1st yr Male : female = 2.8-5.4:1• Beyond 1 yr Male : female = 1:10

• Girls– First UTI usually occurs by the age of 5 yr

with peaks during infancy and toilet training– After the first UTI, 60-80% of girls will develop a second

UTI develop within 18 mo.

Etiology

• Females– Escherichia coli (75-90 %) , Klebsiella and Proteus

• Males– Proteus (30 % ) risk to Triple phosphate stone

• Other pathogen– Pseudomonas – Staphylococcus saprophyticus – S. epidermidis – Coag-neg staphy

• Viral infections, particularly adenovirus, may also occur, especially as a cause of cystitis

Pathogenesis and Pathology

• Ascending infections– Arise from the fecal flora colonize the perineum urethra

enter the bladder

– Uncircumcised boys, the bacteria beneath the prepuce

– Normally the simple and compound papillae in the kidney have an antireflux mechanism BUT Some compound papillae, typically located in the upper and lower poles of the kidney, allow intrarenal reflux

– Voiding dysfunction, Infrequent Urinary stasis

• Hematogenous spread (Rare) – renal infection

Risk Factors for Urinary Tract Infection

• Female • Uncircumcised male • Vesicoureteral reflux • Toilet training • Voiding dysfunction • Obstructive uropathy • Urethral instrumentation • Wiping from back to front

• Bubble bath • Tight clothing (underwear) • Pinworm infestation • Constipation • P fimbriated bacteria • Anatomic abnormality• Neuropathic bladder • Sexual activity • Pregnancy

Classification

• Symptomatic bacteriuria– Upper UTI - Pyelonephritis– Lower UTI - Cystitis

• Asymptomatic bacteriuria

Symptomatic bacteriuriaPyelonephritis Cystitis

- Flank pain- Fever- Malaise- N/V - Occasionally diarrhea- Infants = nonspecific

symptoms such as jaundice, poor feeding, irritability, and weight loss

- Dysuria- Urgency- Frequency- Suprapubic pain- Incontinence- Malodorous urine- * No fever

Asymptomatic bacteriuria

• Positive urine culture without any manifestations of infection and occurs almost exclusively in girls

• If left untreated in Pregnant women , can result in a symptomatic UTI

Physical examination

• Hypertension (hydronephrosis or renal parenchyma disease)

• Abdominal tenderness or mass• Palpable bladder, tenderness • CVA tenderness• Drippling, poor stream, or straining to void• External genitalia

Investigation

• Urine examination – Color : Clear or cloudy, Malodor– pH : Base – Urea splitting organism (Proteus, Klebsiella)– Concentrating ability – Impair in acute pyelonephritis– Pyuria (leukocytes in the urine) > 5 cell/HPF

• * Can be present or not in urine infection

– Nitrites and leukocyte esterase - usually positive in infected urine

– Microscopic hematuria is common in acute cystitis– WBC casts - suggest renal involvement (Rarely seen)

• Urine gram (Spun urine) – Bact 10 /HPF

Diagnosis

• Urine culture (Necessary for confirmation)• Sample collection

– Bag collection– Clean voided (Midstream urine)– Suprapubic puncture– Catheterization

• Placing the sample in a refrigerator 4 c within 2 hr

Investigation

• CBC - Leukocytosis, neutrophilia• Elevated ESR and CRP are common ( nonspecific

markers of bacterial infection )• With a renal abscess, WBC > 20,000 to 25,000/mm3

• Blood cultures should be considered– Because sepsis is common in pyelonephritis

Principle of management

1. Treatment of acute infection2. Prevention of further infection3. Adequate investigation4. Arrangement of further treatment5. Follow up - Prevention of recurrence and

long-term complications

Treatment

Indication for hospitalize• Age <2 months • Sepsis or potential bacteremia • Immunocompromised patient • Vomiting or inability to tolerate oral

medication • Lack of adequate outpatient follow-up• Failure to respond to outpatient therapy

Treatment

• Mild symptom or doubtful diagnosis Oral antibiotic before the results of culture are

known (Repeat culture - if the results are uncertain)

OPD case• Severe symptom

Urine culture with treatment immediately (IV) Hospitalization

Some Antimicrobrils for Oral Treatment of UTI

Nitrofurantoin 5-7 mg/kg/day hr in 3 to 4 divided doses

Some Antimicrobrils for Parenteral Treatment of UTI

3-5 12,8 h

Treatment

• Acute pyelonephritis Hospitalization 14-day course of broad-spectrum antibiotics capable

of reaching significant tissue levels is preferable• Cystitis

7 – 10 day of antibiotic• Not recommend Short course or Single dose • The safety and efficacy of oral ciprofloxacin in

children is under study

Prophylaxis antibiotic

• Indication– Vesicoureteral reflux– Age < 2 yr with Acute pyelonephritis Prophylaxis

antibiotic 6 month– Neonates and infants with febrile UTI and abnormal renal

scan– Recurrence > 3 times/year esp.with bladder instability– Neurogenic bladder– Obstructive uropathy

Prophylaxis antibiotic

• Duration – VUR case and Case risk to Urine stasis

(Neurogenic bladder, Calculi)• Prophylaxis - Until Age 6 yr with Normal renal growth ,

no new scar and no recurrence acute pyelonephritis

– No VUR• Prophylaxis antibiotic 3 – 6 month

Some Antimicrobials for Prophylaxis of UTI

AmoxycillinCephalexin Induced bacterial resistant

Radiologic investigation

• For identify anatomic abnormalities• Indication

1. Male with UTI2. Age < 5 years3. Age ≥ 5 yrs in girl with UTI ≥ 2 times4. Febrile UTI5. Suspect anatomical abnormality in KUB system

Imaging studies

1. Ultrasonography (U/S)2. Voiding cystourethrography (VCUG)3. Intravenous pyelogram (IVP)4. DMSA (2,3 dimercaptosuccinic a) scan

Recurrent UTI, pyelonephritis , BUN Cr rising, HT

ปีกติ�

KUB ultrasonography: normal

IVP

• Nephrogram Pelvicalyceal systems Ureter Bladder

• Acute obstruct Prolong and dense nephrogram Dilatation over obstruction point Delayed excretion in Pelvicalyceal system Filling defect

IVP

Normal Pelvicalyceal system (Cup shaped)

HydronephrosisUPJ Obstruct

VCUG: normal

VCUG: VUR

Posterior urethral valves

Follow up

• Reinfection within 2 yrs - Boys 25 % ,Girls 50%• After treatment

– 48 – 72 hr ( UA should return to normal )– 7 – 10 day (Urine culture) – Every month ( 3 month )– Every 3 month ( 2 yrs ) (Urine culture)

• Education– Hygiene– Toilet training – Double voiding technique , Defecation– Phimosis in boys and Labial adhesion in girls

Complications

• Acute – Dehydration– Pyelonephritis – Sepsis – Renal abscess

• Long term – Hypertension– Impaired kidney function– Renal scarring – Renal failure– Pregnancy complications

Other type of cystitis• Acute hemorrhagic cystitis

– Caused by E. coli / attributed also to Adenovirus types 11 and 21– More frequent in males– Self-limiting, with hematuria lasting 4 days

• Eosinophilic cystitis – Exposure to an allergen– Filling defects in the bladder caused by masses that consist

histologically of inflammatory infiltrates with eosinophils– Treatment – antihistamines , NSAIDs

• Interstitial cystitis– Irritative voiding symptoms + negative U/C– Diagnosis by cystoscopic mucosal ulcers with bladder distention– Treatments included bladder hydrodistention and laser ablation of

ulcerated areas, but no treatment yields sustained relief

Obstructive uropathy

• Calyceal – Pelvis – Ureter – Bladder – Urethra• Intrinsic causes

– Vesicoureteral reflux– Congenital anomalies– Tumor (Wilm, Papilloma)– Stone– Fibrosis or stricture

• Extrinsic causes– Aberrant vessel– Tumor

Congenital anomalies of urinary system

• Kidney– Number– Size– Location (Ectopic)– Fusion (Horseshoe)

• Ureter– Duplication– UPJ obstruct– Ureterocele

• Bladder– Duplication– Diverticulum

• Urethral– Urethral vale– Duplication– Diverticulum– Epispadias– Hypospadias

Vesicoureteral reflux

• 2 type– Primary VUR - Congenital familial disorder

• Abnormalities of ureterovesical junction lateral and cephalad displacement of ureteric orifice + Short intramural ureter “ Golf hole “

Vesicoureteral reflux

– Secondary VUR - Outflow obstruction • Anatomical obstruction - posterior urethral valve • Functional obstruction - neurogenic bladder , bladder

trabeculation , diverticula

• Severe VUR Intrarenal reflux

Simple type collecting duct

obligue & slitlike opening

Compound typecollecting duct

Perpendicula &round opening

Vesicoureteral reflux

• Grading

• Intrarenal Reflux Renal Scarring Hypertension , Chronic renal failure

Treatment Recommendations for Vesicoureteral Reflux Diagnosed Following a Urinary Tract Infection

American Urological Association Pediatric Vesicoureteral Reflux Guidelines Panel Report