Acute Pyelonephritis m.arief 01-038
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Transcript of Acute Pyelonephritis m.arief 01-038
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Acute Pyelonephritis in Children
M.Arief Rachman 01-038
Consultant : dr Alfred Siahaan SpA
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BACKGROUND
Urinary tract infection (UTI) is one of the
most common bacterial infection in infants.
The most severe form of UTI is acute
pyelonephritis, which results in significant
acute morbidity and may cause permanent
renal damage.
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BACKGROUND
Published guidelines recommend
treatment of acute pyelonephritis initially
with intravenous (IV) therapy followed by
oral therapy for seven to 14 days though
there is no consensus on the duration of
either IV or oral therapy.
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DEFINITION
Urinary tract infection (UTI) is defined as
the presence of bacteria in urine along
with symptoms of infection.
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Acute pyelonephritis is a potentially
organ- and/or life-threatening infection that
characteristically causes some scarring of
the kidney with each infection and maylead to significant damage to the kidney
(any given episode), kidney failure.
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ETIOLOGY
Escherichia coliis the most common
infecting pathogen in children, accounting
for up to 80 percent of UTIs. Other
pathogens include Staphylococcus andStreptococcus species, a variety of
enterobacteria (e.g., Klebsiella, Proteus)
and, occasionally, Candida albicans.
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INTRARENAL REFLUX OF BACTERIA
IMMUNE RESPONSE COMPLEMENT ACTIVATION
BACTERIAL ENDOTOXIN
CHEMOTAXiS
BACTERIAL KILLING PHAGOCYTOSIS GRANULOCYTE AGGREGATION
SUPEROXIDE & LYSOZIME RELEASE
TUBULAR CELL DEATH
INTERSTITIAL INVASION FOCAL ISHEMIA
RENAL SCAR
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PATHOGENESIS
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DIAGNOSIS
CLINICAL PRESENTATION
URINE CULTURE / URINALYSIS
IMAGING STUDIES
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CLINICAL PRESENTATION
Fever
Flank pain
Malaise Nausea
Vomiting
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URINE CULTURESample of urine Colony specimen Infection
Supra pubic punction Any negative gram
bacterial
> 99%
Cathterized specimen >10 5
104-105
103-104
104
3x specimen>105
2x specimen>105
1x specimen >105
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URINALYSIS
Gross hematuria
significant pyuria (>20 WBCs/hpf)
The dipstick leukocyte esterase test (LET)
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HISTOLOGICAL STUDIES
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HISTOLOGICAL STUDIES
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HISTOLOGICAL STUDIES
The inflammation can destroy the tubules,forming abscesses. The presence of polysin the tubules is strong evidence of
possible bacterial infection. Polys are seenin the interstitium/interstitial capillaries aswell.
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PIV
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DMSA Renal Scan
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The SPECT technique for 99mTc-DMSA scintigraphy was used tomake it comparable to the other cross-sectional imaging techniques.The images were obtained 23 hours after an intravenous injectionof 99mTc-DMSA in a dose of approximately 3.7 MBq/kg (100Ci/kg).
The SPECT images were reconstructed in coronal, sagittal, and
transverse planes by using a Butterworth filter with a frequencycutoff of 0.4 cycles per centimeter.
The criterion for the diagnosis of acute pyelonephritis was subjectiveevidence of focal areas of decreased uptake seen with at least twoprojections. No attempt was made to quantify the severity ofdecreased uptake (Fig 1a).
http://radiology.rsnajnls.org/cgi/content/full/218/1/101http://radiology.rsnajnls.org/cgi/content/full/218/1/101 -
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USG
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Longitudinal power Doppler US image of
the left kidney demonstrates markedly
decreased blood flow (arrows) to the lower
pole
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MRI
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Coronal contrast agent-enhanced fast multiplanarinversion recovery MR image (2,000-2,500/17; inversiontime, 160 msec) of the same piglet as in a demonstratesfoci (arrows) of high signal intensity in the upper and
lower poles of the right kidney and the lower pole of theleft kidney.
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CT Scan
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CT Scan
Figure 2. Transverse spiral CT scan
obtained after intravenous administration
of contrast agent demonstrates well-
defined foci (arrows) of decreasedattenuation in the anterior cortex of the
right kidney and posterior cortex of the left
kidney.
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RISK FACTORS
Obstruction (intrinsic/extrinsic)
Urinary diversion procedures
Foreign bodies Vesicoureteral reflux
Neurogenic bladder
Treatment of acute pyelonephritis in
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Treatment of acute pyelonephritis in
children
Ceftriaxone (Rocephin
Pediatric Dose
>7 d: 25-50 mg/kg/d IV/IM; not to exceed 125
mg/dInfants and children: 50-75 mg/kg/d IV/IMdivided q12h; not to exceed 2 g/d
Third-generation cephalosporin with broad-
spectrum, gram-negative activity; lower efficacyagainst gram-positive organisms; higher efficacyagainst resistant organisms.
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Gentamicin (Garamycin)
Pediatric Dose
5 years: 1.5-2.5 mg/kg/dose IV/IM q8h or
6-7.5 mg/kg/d divided q8h; not to exceed
300 mg/d; monitor as in adults
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Ampicillin (Principen, Omnipen, Marcillin)
Pediatric Dose
50-100 mg/kg/d PO divided q4-6h; 100-400 mg/kg/d IM/IV divided q4-6h
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Amoxicillin (Amoxil, Trimox
Pediatric Dose
20-50 mg/kg/d PO divided q8h
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Cephalexin (Keflex
Pediatric Dose
25-50 mg/kg/d PO q6h; not to exceed 3g/d
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Nitrofurantoin (Macrobid, Macrodantin)
Pediatric Dose
>1 month: 5-7 mg/kg/d PO divided q6h;not to exceed 400 mg/d
Long-term therapy: 1-2 mg/kg/d PO
divided 12-24 h; not to exceed 100 mg/d
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Trimethoprim and sulfamethoxazole
(Bactrim, Bactrim DS, Septra, Septra DS)
Pediatric Dose
2 months: 15-20 mg/kg/d, based on TMP,
PO tid/qid for 14 d
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Vancomycin (Vancocin
Pediatric Dose
40 mg/kg/d IV divided tid/qid 7-10 d
Potent antibiotic directed against gram-positiveorganisms and active against Enterococcusspecies
Indicated for patients who cannot receive or did
not respond to penicillins and cephalosporins orpatients who have infections with resistantstaphylococci
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Patient Education
Good hygiene (including "front-to-back"
wiping after urination in girls)
avoidance of bubble baths, Chemical
irritants and tight clothing might be
recommended.
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Algorithm for the management of urinary tract infection in children
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EVIDENCE BASE MEDICINE
A 9 month old girl presents with high fever,
vomiting, lethargy, and bacteriologically
confirmed urinary tract infection.
The diagnosisacute pyelonephritis
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1. How should she be treated?
2. Which antibiotics should be given and by
which route?
3. For how long should antibiotics be
given?
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How should she be treated?
Infants aged 1 month or less with urinary
tract infection require intravenous
antibiotics
The choice of specific antibiotics should be
based on data about local uropathogens.
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which route?
Two trials including 306 and 387 childrencompared oral (cefixime,amoxicillin) withintravenous (ceftriaxone) treatment for
three days or defervescence followed bycefixime or amoxicillin. Total duration was10 or 14 days. No differences in the timeto defervescence, recurrence of urinary
tract infection, or frequency of renalparenchymal abnormality at 6-12 monthswere evident between the two groups
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Which antibiotic should be given?
trimethoprim alone or in combination with
sulphamethoxazole, cephalexin or
amoxicillin
If intravenous antibiotics are required,
aminoglycosides or third generation
cephalosporins
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How long should antibiotics be given for?
there is evidencethat short course
treatment (3-4 days) is as effective as
standard course (7-10 days) treatment
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conclusions
These results suggest that children with
acute pyelonephritis can be treated
effectively with oral cefixime or with short
courses (2-4 days) of IV therapy followed
by oral therapy. If IV therapy is chosen,
single daily dosing with aminoglycosides issafe and effective.
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