Uti case ped
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Transcript of Uti case ped
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