UTI in Children - PowerPoint

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UTI in Children - PowerPoint Powered By Docstoc
					Dr. Yee McArthur
          GPST2
     09/02/2011
Why ?
 Common


 Difficult to identify


 Significant complications


 Guideline for Management ( imaging, prophylaxis and
  prolonged follow up )
Definition

 Infection of kidneys, ureters, bladder and urethera


 Upper Urinary tract infection - Pyelonephritis


 Lower urinary tract infection- Cystitis, Urethritis
Which Organism?
 Most common organism is


 (a) Klebsiella

 (b) E. Coli

 (c) Pseudomonas
Terminology
(1) Atypical UTI : Seriously ill
                   Raised creatinine
                   Septicaemia
                   Failure to respond to Tx within 48 hours
                   Infection with non E.Coli organisms
(2) Recurrent UTI :Two or more episodes of UTI with
                 acute pyelonephritis/upper urinary
                 tract infection
                 Three or more episodes of UTI
                 with cystitis/lower urinary tract infection
Epidemiology
 One of the most common infections of the childhood


 Age under one M > F     why?
 Age above one   F>M

 4% of boys and 12 % of girls will have had UTI by the age of
  16 years
 Of these : 4 % will have kidneys scars
             50 % will develop hypertension
             10% of those scarred will develop renal failure
Guidelines
                              Assess Symptoms & Signs

   Assess the risk of serious illnesses in line with ‘Feverish illnesses in children’



             Collect the urine sample using a method suitable for age


              Assess symptoms and signs to identify or exclude acute
                   pyelonephritis/upper urinary tract infection
                Assess risk factors for serious underlying pathology



        Provide acute management according to age group and presence or
           absence of acute pyelonephritis/upper urinary tract infection



         Arrange imaging tests if required using age, presence of atypical
               illness and recurrence as criteria for choice of tests



        Arrange follow up for infants and children with recurrent UTI,
             risk factors, atypical illness and abnormal imaging
Risk Factors
 antenatally-diagnosed renal abnormality
 family history of vesicoureteric reflux ? (VUR) or renal disease
 history suggesting previous UTI or confirmed previous UTI
 recurrent fever of uncertain origin
 poor urine flow ( phimosis)
 dysfunctional voiding
 constipation why?
 abdominal mass, evidence of spinal lesion
 poor growth
 high blood pressure
 blood group Lewis antigen
Presentation
Age                           Symptoms & Signs
Group       Most common             →              Least common
< 3mths     Fever, Vomiting    Poor feeding              Abdominal pain
            Lethargy,          Failure to thrive         Jaundice
            Irritability                                 Haematuria
                                                         Offensive urine
>3mths      Fever              Abdominal pain,           Lethergy,
Preverbal                      Loin tenderness           Irritability
                               Vomiting                  Haematuria
                               Poor feeding              Offensive urine
                                                         Failure to thrive
>3mths      Frequency          Abdominal pain            Fever, Malaise
Verbal      Dysuria            Loin tenderness           Vomiting
                               Dysfunctional voiding     Haematuria
                               Changes to continence     Offensive/Cloudy
                                                         urine
Kidneys scarring
 Can occur


(1) within 24 hours

(2) in 72 hours

(3) in 5-7 days
When to check urine sample


 Symptoms and signs suggestive of urinary tract infection


 Unexplained fever of 38 C or higher ( a urine sample tested
  after 24 hours at the latest)

 with an alternative site of infection but who remain unwell
Collecting Urine Sample

 Clean catch urine sample is the recommended method


 Non-invasive : Urine collection pad


 Catheter sample or SPA
Preserving


 If the sample needs to be cultured but cannot be
 cultured within 4 hours of collection, either
 refrigerate it or preserve it with boric acid
 immediately
Diagnosis and Management
                     Age under 3 months

 Refer to paediatric specialist care.


 Urine sample for urgent microscopy and culture.


 Manage in line with ‘Feverish illness in children’
Age 3 months to 3 years
Traffic light system for identifying likelihood of
serious illness

              Green: low risk     Amber: Interme:          Red: High
Color         Normal              pallor                   Pale/mottled/ashen/blue
              skin/lips/tongue
Activity      Nor.respond/cry/a   Not normal respond       Unable/difficult to rouse,
              lert/smile                                   weak or high pitched cry
Respiratory                       Nasal flaring            Grunting
                                  Tachypnoea               Tachypnoea
                                  O2 sat ≤95% on air       Moderate or severe chest
                                  Crackles                 indrawing
Hydration     Normal skin/ eyes   Dry mucous mem:          Reduced skin turgor
              Moist mucous        Poor feedong in infant
              mem:                CRT≥3 sec
                                  Reduced UO
Other         None of the         Fever for ≥ 5 days       •   Age 0–3 months,T ≥ 38°C
              amber/red S/S       • Swelling of a limb     •   Age 3–6 months,T ≥ 39°C
                                  or joint                 •   Non-blanching rash
                                  • Non-weight bearing/    •   Bulging fontanelle
                                  not using an extremity   •   Neck stiffness
                                  • A new lump > 2 cm      •   Status epilepticus
                                                           •   Focal neurological signs
                                                           •   Focal seizures
                                                           •   Bile-stained vomiting
Age > 3 year
Both Leucocytes &      Start antibiotic for UTI.
Nitrite                If high or intermediate risk of serious
are positive           illness or past history of UTI, send urine
                       for culture
If Leucocytes is       Start antibiotic treatment if fresh sample
Negative and           was tested.
Nitrite is positive    Send urine sample for culture.
If Leucocyte is        Send urine sample for microscopy and
positive and Nitrite   culture.
is negative            Only start antibiotic treatment for UTI if
                       there is good clinical evidence of UTI.
                       Result may indicate infection elsewhere.
                       Treat depending on results of culture
Both Leucocyte and     Do not start treatment for UTI.
Nitrite are negative   Explore other causes of illness.
                       Do not send urine sample for culture
                       unless recommended
Indications for Culture
 diagnosis of acute pyelonephritis/upper urinary tract
    infection
    high to intermediate risk of serious illness
    under 3 years
    a single positive result for leukocyte esterase or nitrite
    recurrent UTI
    infection that does not respond to treatment within 24–48
    hours
    clinical symptoms and dipstick tests do not correlate
Microscopy Results

              Pyuria Positive          Pyuria Negative
Bacteriuria            UTI                   UTI
positive
Bacteriuria   Antibiotic should be          No UTI
negative       started if clinically
                       UTI
Localisation of UTI

Bacteriuria and fever of 38°C   Acute pyelonephritis/upper
or higher                       urinary tract infection

Bacteriuria, loin pain/         Acute pyelonephritis/upper
tenderness and fever of less    urinary tract infection
than 38°C

Bacteriuria but no systemic     Cystitis/lower urinary tract
features                        infection
            Acute Management
High risk of serious Arrange urgent referral to a paediatric specialist
illness              in line with ‘Feverish illness in children
Age < 3months         Immediately refer to a paediatric specialist.
                      Treat with parenteral antibiotics in line with
                      ‘Feverish illness in children
Age > 3months or      Consider referral to a paediatric specialist.
older with acute      Treat with oral antibiotics for 7–10 days. Use
pyelonephritis or     antibiotic with low resistance pattern.
upper UTI             If oral antibiotics cannot be used, use
                      intravenous (IV) antibiotics for 2–4 days,
                      followed by oral antibiotics for a total duration of
                      10 days.
Age > 3 months        Treat with oral antibiotics for 3 days.
with cystitis or      If the child is still unwell after 24–48 hours they
lower UTI             should be reassessed.
                      If no alternative diagnosis, send urine for
                      culture.
  Imaging Guidelines
     Test         Responds well to    Atypical UTI     Recurrent UTI
                     treatment
                  within 48 hours
     Age          <6mth 6mt    >3yr <6m 6mt      >3yr <6m 6mt      >3yr
                        h to        th  h to          th  h to
                        3yr             3yr               3yr

USG during         No    No    No    Yes   Yes   Yes   Yes   No    No
acute infection
USG within         Yes   No    No    No    No    No    No    Yes   Yes
6months
DMSA 4-6           No    No    No    Yes   Yes   No    Yes   Yes   Yes
months
following the
acute infection

MCUG               No    No    No    Yes   No    No    Yes   No    No
Referral And Assessment
 Recurrent UTI or abnormal imaging results should be
  assessed by a paediatric specialist.

 Assessment of infants and children with renal parenchymal
  defects should include height, weight,blood pressure and
  routine testing for proteinuria.

 Infants and children with a minor, unilateral renal
  parenchymal defect do not need long-term follow-up unless
  they have recurrent UTI or family history or lifestyle risk
  factors for hypertension.
Follow up
Long Term F/U

•Infants and children who have bilateral renal abnormalities,
impaired kidney function, raised blood pressure and/or
proteinuria should receive monitoring and appropriate
management by a paediatric nephrologist to slow the
progression of chronic kidney disease.

No F/U

No imaging investigtion- no f/u
Normal investigation results
Asymptomatic after an episode of UTI
Asymptomatic bacteuria
Information following UTI

 The need for treatment, the importance of completing
  treatment and advice about prevention and long-term
  management (if appropriate)
 The possibility of a UTI recurring and prevention of recurrance
 recognising symptoms quickly
 prognosis
Prognosis
 Most recover quickly and completely with antibiotic treatment.


 Recurrence of urinary tract infection is more likely in:
   Younger children i.e. aged less than 6 months
   Girls compared to boys
   Vesicoureteral reflux

 Vesicoureteric reflux (VUR) is found in about 1% of normal
  infants and normally resolves over several years.However, it is
  a risk factor for pyelonephritis, which can cause renal
  scarring, which can lead to hypertension & impaired renal
  function.
Antibiotics
  DON’T : Treat asymptomatic bacteuria
          Use antibiotic prophylaxis routinely after 1st UTI


   DO   : Use different antibiotic, not a higher dose of same
          antibiotic, for children who are already on
          prophylactic antibiotic


 A Cochrane systematic review suggests that treatment for 2-4
 days seems to be as effective as treatment for 7 - 14 days for
          eradicating lower tract UTI in children.
References
 www.patient.co.uk › PatientPlus
 www.nice.org.uk/CG54
 www.gp-training.net/protocol/paediatrics/uti_children.htm
 www.cks.nhs.uk/patient.../urinary_tract_infection_childre
  n
 clinicalevidence.bmj.com/ceweb/conditions/chd/0306/0306.js
  p
 www.gpnotebook.co.uk/simplepage.cfm?ID=1268383753
Thank You

				
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