- 1020.00 KB
- 2022-05-26 16:47:29 发布
- 1、本文档共5页,可阅读全部内容。
- 2、本文档内容版权归属内容提供方,所产生的收益全部归内容提供方所有。如果您对本文有版权争议,可选择认领,认领后既往收益都归您。
- 3、本文档由用户上传,本站不保证质量和数量令人满意,可能有诸多瑕疵,付费之前,请仔细先通过免费阅读内容等途径辨别内容交易风险。如存在严重挂羊头卖狗肉之情形,可联系本站下载客服投诉处理。
- 文档侵权举报电话:19940600175。
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-catchinvoidinggirls100,000CFUpermL10,000–100,000repeatcultureClean-catchinvoidingboys10,000CFUpermLCatheter10,000CFU1,000–10,000repeatcultureSuprapubicaspirationAnycoloniesofGNRsMorethanafewthousandGPCsHillersteinS.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-thisisgreatnewsforoutpatienttherapyIfthechildisnotrespondingtheempirictreatmentwithintwodayswhileawaitingcultureresults,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