儿科泌尿道感染（英文PPT）Pediatrics Urinary Tract Infections.ppt 58页

PediatricUrinaryTractInfectionsEddieNeedham,MD,FAAFPProgramDirectorEmoryFamilyMedicineResidencyProgram ObjectivesDefineUrinaryTractInfection(UTI)ListantibiotictreatmentoptionsforUTIListtheworkupafterafirstfebrileUTIBefamiliarwiththerationaleforusingprophylacticantibioticsafterthefirstfebrileUTI Case1Afouryearoldpreviouslyhealthygirlpresentstoclinicwithc/odysuria.Shehasnofeverandhasastablehomewithreliableparents.ImmunizationsareUTD.UAshows+Nitritesand+LEWBC–unknownbecausewedon’tcurrentlyspinourownurinesatDunwoody. Whatisyourplan?Urineculture?Antibiotics?Rocephininclinic?Oralantibiotics?Admittothehospital?Workup(We’lldefinethislater)? Case2An18montholdfemalepresentswithincreasedirritabilityx3days,subjectivefevers,anddecreasedappetite.PMHx–usualchildhoodillnesses–AOMx1,URIsx2,AGEx1.Benignrecoveries.Immunizationsareup-to-date(UTD)Goodsocialsupport Case2-ExamVitalSigns–normalforageexceptT102.5Generalappearance–fussy,easilyconsolable,nontoxicHEENT–normalwithclearpharynxandTMsAULungs-CTACV–normalAbdomen–softSkin–norash FeverwithoutaSourceGuideline ClinicManagementDrawbloodforCBCandpotentiallyabloodculture?Urineculture?Antibiotics?Rocephininclinic?Oralantibiotics?Admittothehospital?Workup(We’lldefinethislater)? ClinicworkupAreyouabletodrawblood?Canyouperformabladdercatheterization?TwoQ-tiptechniqueforlittlegirls EvaluationYourcatheterUAconfirmsthediagnosis.Yousendtheurineforculture.Whatnow?Childadmitted?Childgoeshome?Whatdoestheevidencesay? PediatricUTIsandEBMUpto7%ofgirlsand2%ofboysexperienceasymptomaticculture-provenUTIpriorto6yearsofage.Offebrileneonates,upto7%haveUTIs.(SeeFeverwithoutasourceguidelines)MostUTIsinchildrenarefromascendingbacteriaE.coli(60-80%),Proteus,Klebsiella,Enterococcus,andcoag.neg.staph. EpidemiologyTheoverallprevalenceofUTIisapproximately5percentinfebrileinfantsbutvarieswidelybyraceandsex.Caucasianchildrenhadatwo-tofourfoldhigherprevalenceofUTIascomparedtoAfrican-AmericanchildrenFemaleshaveatwo-tofourfoldhigherprevalenceofUTIthandocircumcisedmalesCaucasianfemaleswithatemperatureof39ºChaveaUTIprevalenceof16percent ApproximateprobabilityofurinarytractinfectioninfebrileinfantsandyoungchildrenbydemographicgroupDemographicgroupPrevalence(pretestprobability)OddsCircumcisedboys>1yr<1percent.01(1in100)Circumcisedboys<1yr2percent.02(1in50)Blackgirls4percent.04(1in25)Uncircumcisedboys<2yr8percent.09(1in12)Whitegirls<2yr16percent.19(1in5)Datafrom:Hoberman,A,Chao,HP,Keller,DM,etal.Prevalenceofurinarytractinfectioninfebrileinfants.JPediatr1993;123:17.Shaw,KN,Gorelick,M,McGowan,KL,etal.Prevalenceofurinarytractinfectioninfebrileyoungchildrenintheemergencydepartment.Pediatrics1998;102:e16. DefinitionofUTIoncultureMethodofurinecollectionDiagnosticthresholdClean-catchinvoidinggirls100,000CFUpermL10,000–100,000repeatcultureClean-catchinvoidingboys10,000CFUpermLCatheter10,000CFU1,000–10,000repeatcultureSuprapubicaspirationAnycoloniesofGNRsMorethanafewthousandGPCsHillersteinS.Recurrenturinarytractinfectionsinchildren.PediatrInfectDis1982;1:275. SymptomsClassicUTIsymptomsinolderchildrenDysuria,frequency,urgency,small-volumevoids,lowerabdominalpain.InfantswithUTIshavenonspecificsymptomsFever,irritability,vomiting,poorappetite Neonatalhematuria?Nope,it’suricacidcrystals EvaluationInchildrenwithahighlikelihoodofUTI,aurinecultureisrequired.Inchildrenwithalowlikelihood,anegativedipstickinaclearurinereducestheneedforculture.Ifthedipstickshows(+)LEand/or(+)Nitrites,sendaurineculture.ThedipstickisnotsufficienttodiagnoseUTI’sbecausefalsepositivescanoccur. UrinedipsticksInacohortstudywithan18%baselineprevalenceofUTI,negativeLEandnitratesondipstickhadanegativepredictivevalueof96%.NPV=Truenegative_________________Truenegative+falsenegative LeukocyteEsteraseandNitritesLEisproducedfromthebreakdownofleukocytes.NotalwaysindicativeofinfectionVaginitis/vulvitiscanleadtoinflammationwithoutinfection+LENitritesareproducedbybacteriathatmetabolizenitrates:E.coli,Klebsiella,Proteus(GNRs)MuchmorepredictiveofUTIGPCsdonotproducenitrites BloodculturesBloodculturesaregenerallyunnecessaryinmostchildrenwithUTI.TheyaremorefrequentlypositiveinchildrenyoungerthantwomonthswhoseurinegrowsGroupBstreporStaph.Aureus.Ingeneral,we’llsendfebrilechildrenlessthantwomonthsoldtotheERforemergentevaluation/labs. TreatmentofUTIsTheefficacyoforalregimensisaseffectiveasparenteralregimens-thisisgreatnewsforoutpatienttherapyIfthechildisnotrespondingtheempirictreatmentwithintwodayswhileawaitingcultureresults,repeattheurinecultureandperformarenalultrasound.HobermanA,WaldER,HickeyRW,BaskinM,CharronM,MajdM,etal.Oralversusinitialintravenoustherapyforurinarytractinfectionsinyoungfebrilechildren.Pediatrics1999;104:79-86.BakerPC,NelsonDS,SchunkJE.Theadditionofceftriaxonetooraltherapydoesnotimproveoutcomeinfebrilechildrenwithurinarytractinfections.ArchPediatrAdolescMed2001;155:135-9. AntibioticChoicesTrimethoprim-sulfamethoxizoleisagoodchoiceaftertwomonthsoflifeOtherchoices:Amoxicillin–someresistancewithE.coliCephalosporins:cefixime(Suprax),cefpodoxime(Vantin),cefprozil(Cefzil),loracarbef(Lorabid)NocephalosporinscoverenterococcusTreatfor7-14days.Onedaycoursenoteffective. Furthertesting/work-upAftertheUTIresolves,whattypeofworkupshouldensue? 1999ClinicalPracticeGuidelinesfromtheAAPRoutineimagingforchildrentwomonthstotwoyearsofageisrecommended.UltrasoundallchildrenwithfebrileUTIsConsiderVCUG/RenalscintigraphyCommitteeonQualityImprovement,SubcommitteeonUrinaryTractInfection.Practiceparameter:thediagnosis,treatment,andevaluationoftheinitialurinarytractinfectioninfebrileinfantsandyoungchildren.[publishedcorrectionsappearinPediatrics2000;105:141,1999;103:1052,and1999;104:118].Pediatrics1999;103:843-52. Newerinformation255children<5yearsoldadmittedwiththeirfirstuncomplicatedfebrileUTI(pyelo)RenalultrasounddidnotchangemanagementZamirG,SakranW,HorowitzY,KorenA,MironD.Urinarytractinfection:isthereaneedforroutinerenalultrasonography?ArchDisChild2004;89:466-8 NewerInformation150children2–10yearsoldwithfirstUTIwererandomizedtoroutineimaging(U/SandVCUG)ortoselectiveimaging(forrecurrentUTIorpersistentproblems)21%(1in5)intheselectivegrouphadimagingperformedRoutineimagingincreasedtheuseofprophylacticantibiotics(28%vs5%)NochangeinrateofrecurrentUTIs(26%vs21%)Nochangeinrateofrenalscarring(9%vs9%)DickPT.AnnualMeetingofCanadianPediatricSociety,June12-16,2002.PediatricNotes2002;26(27):105 VesicoureteralRefluxandTreatmentApproximately40%ofchildrenwithfebrileUTIshaveVUR.Approximately8%ofchildrenwithfebrileUTIsdemonstraterenalscarringwhenstudied.TreatmentrecommendationsaremadetostoptheprogressionofVURwithmedications/antibioticsand/orsurgery.Nodata/EBMdemonstratethattreatmentofVURpreventsrenalscarring,hypertensionandCKDNuutinenM,UhariM.Recurrenceandfollow-upafterurinarytractinfectionundertheageof1year.PediatrNephrol2001;16:69-72 AntibioticprophylaxisChildrenwithVURaretreatedprophylacticallywithantibioticstopreventpotentialrenalscarring.Nitrofurantoinortrimethoprim-sulfamethoxizoleHalfthestandarddoseadministeredatbedtimeFamilyphysicianswouldgenerallyhaveapediatricurologistinvolvedtoassistinmakingtreatmentdecisions. HowlongtocontinueAbx?Althoughtheevidenceisnotconclusive,itappearstheriskofscarringdiminisheswithage.Accordingly,someexpertsrecommendcessationofprophylaxisafterage5to7years,eveniflow-gradeVURpersists.Inonestudyof51low-risk(novoidingabnormalitiesorrenalscarring)olderchildren(meanage8.6years)withgradesItoIVVUR,cessationofprophylacticantibioticsresultedinnonewrenalscarringonannualDMSACooperCS,etal.Theoutcomeofstoppingprophylacticantibioticsinolderchildrenwithvesicoureteralreflux.JUrol2000Jan;163(1):269-72;discussion272-3. IndicationstoorderradiologicstudiesChildrenyoungerthan5yearsofagewithafebrileUTIGirlsyoungerthan3yearsofagewithafirstUTIMalesofanyagewithafirstUTI(PUV)ChildrenwithrecurrentUTIChildrenwithUTIwhodonotrespondpromptlytotherapyUpToDate–accessedSeptember12,2007 StudiestoconsiderRenalUltrasoundWillevaluateforperinephricabscessinpatientsnotrespondingtoantibiotics.Canevaluateforhydronephrosis/hydroureterOfnote,dilationofthekidneysandureterscaneasilybeseenonroutineanatomyscansduringpregnancy.PickingupvesicoureteralrefluxwhileasymptomaticDoesthishelporhurt?StagingofVUR,antibiotics,etc... Hydronephrosis Malewiththefindingsbelow.Cause? StudiestoconsiderVoidingcystourethrogram–twotechniquesOneinvolvesfluoroscopiccontrast–moreradiationbutbetterdelineationofanatomyforgradingVURTheotherusesaradionuclide–lessradiationandmoresensitivethancontrast NormalVCUG Vesicoureteralreflux(VUR) Megaureter StudiestoconsiderRenalscintigraphyusingdimercaptosuccinicacid(DMSA)Candetectscarringinthekidneys.Renalcellstakeupthetracer.Thosecellsdamagedbypyelonephritisorscarringdonottakeupthetracer.Managementorfollowupofpatientsdoesnotchangeinmostcases.Thus,notgenerallyusedforinitialevaluation. Scarinthesuperiorandinferiorpoleoftherightkidney MythsBathinginbubblebathscausesUTIsWipingback-to-frontcausesUTIsCranberryjuicehelpsUTIs–onlyproventobeofminimalbenefitinadultwomen.Noprovenbenefittochildren VURTreatment1997AUAguidelinesChildrenyoungerthan1yearofage,regardlessofgradeofreflux,shouldbetreatedmedically,astheyhaveahighlikelihoodofspontaneousresolution.SurgeryisareasonableoptioniftheyhavegradeVrefluxandrenalscarring.AllpatientswithgradeIorIIreflux,eitherwithunilateralorbilateraldisease,shouldbetreatedmedically,astheyhavehighlikelihoodofspontaneousresolution.Childrenbetween1and5yearsofagewithgradeIIIorIVreflux,eitherunilateralorbilateraldisease,shouldbetreatedmedically.Surgeryisareasonableoptionifthereisbilateralrefluxandrenalscarring.Childrenbetween1and5yearsofagewithgradeV,eitherunilateralorbilateraldisease,withoutrenalscarring,canbetreatedmedically.Ifthereisrenalscarring,surgeryisrecommendedforbothunilateralandbilateraldisease.ElderJS,etal.PediatricVesicoureteralRefluxGuidelinesPanelsummaryreportonthemanagementofprimaryvesicoureteralrefluxinchildren,JUrol1997May;157(5):1846-51. VURTreatmentChildren6yearsorolderwithunilateralgradeIIItoIVrefluxwithoutrenalscarringcanbetreatedmedically.Iftherefluxisbilateraland/orthereisrenalscarring,surgicaltreatmentisrecommended.Children6yearsorolderwithgradeVrefluxshouldbetreatedsurgicallywithorwithoutevidenceofrenalscarring,astheirrefluxisunlikelytoresolvespontaneously.Surgeryalsoshouldbeconsideredifmedicaltherapyfailseitherbecauseofpoorcompliance,breakthroughinfectionsonaccountofantibioticresistance,orsignificantantibioticsideeffects.Finally,considerationofpatientandparentpreferenceisimportantinthefinaldecision. So,backtoourcases… Case1Afouryearoldpreviouslyhealthygirlpresentstoclinicwithc/odysuria.Shehasnofeverandhasastablehomewithreliableparents.ImmunizationsareUTD.UAshows+Nitritesand+LEWBConUA–unknown. Whatisyourplan?Urineculture?Antibiotics?Rocephininclinic?Oralantibiotics?Admittothehospital?Workup(We’lldefinethislater)? EBManswerSheisafebrile–noneedforradiologicstudiesSendtheurineforcultureStartempiricantibioticsfor7-14days Case2An18montholdfemalepresentswithincreasedirritabilityx3days,subjectivefevers,anddecreasedappetite.PMHx–usualchildhoodillnesses–AOMx1,URIsx2,AGEx1.Benignrecoveries.Immunizationsareup-to-date(UTD)Goodsocialsupport Case2-ExamVitalSigns–normalforageexceptT102.5Generalappearance–fussy,easilyconsolable,nontoxicHEENT–normalwithclearpharynxandTMsAULungs-CTACV–normalAbdomen–softSkin–norash FeverwithoutaSourceGuideline ClinicManagementDrawbloodforCBCandpotentiallyabloodculture?Urineculture?Antibiotics?Rocephininclinic?Oralantibiotics?Admittothehospital?Workup(We’lldefinethislater)? ClinicworkupAreyouabletodrawblood?Canyouperformabladdercatheterization?TwoQ-tiptechniqueforlittlegirls EvaluationYourcatheterUAconfirmsthediagnosis.Yousendtheurineforculture.Whatnow?Childadmitted?Childgoeshome?Whatdoestheevidencesay? Case#2EBMvsrealityanswerOption#1–youngchildwithpotentialseriousbacterialillness–sendtoERforexpeditedevaluation.Option#2–notonaFridayafternoonDrawbloodforCBCandbloodcultureinclinicObtainaUAConsiderantibioticsBringthechildbackin24hoursforre-evaluationandreviewoflabs. Case#2EBManswerIftheUAshowsaUTIIfyouhaveagoodsocialsupport/parentsIfchildistoleratingoralintakeIfthechildisnontoxicYoumaystartoralantibioticswithfollowupthenextday.NotagoodsolutiononFridays–nofollow-uponSaturday. ObjectivesDefineUrinaryTractInfection(UTI)>100,000CFUincleancatchgirls>10,000CFUcleancatchguys>10,000catheterspecimenListantibiotictreatmentoptionsforUTIAmoxicillin,Bactrim,CephalosporinsListtheworkupafterafirstfebrileUTIConsiderrenalU/SandVCUGBefamiliarwiththerationaleforusingprophylacticantibioticsafterthefirstfebrileUTIPreventrenalcomplications/scarring/pyelonephritis