Paediatric UTI

Paediatrics Presentation: Urinary Tract Infections in Children : 

Paediatrics Presentation: Urinary Tract Infections in Children By Laura Surgenor

Contents: 

Contents A bit of background on the topic Case presentation An overview of the most recent NICE guidance on the topic Questions!

Why this topic?: 

Why this topic? Estimated incidence of serious infections in children aged 0–5 years in the UK; data from Hospital Episode Statistics (HES) Diagnosis group Incidence (per 100 000) Pneumonia 664 Septicaemia 388 Urinary tract infection 333 Meningitis 30.2 Septic arthritis 9.25 Osteomyelitis 6.17 Other bacterial infection 0.66 Encephalitis 3.65 Kawasaki disease 10.2

Historical perspective: 

Historical perspective The prognosis for children with UTI has much greatly improved Prior to effective treatment post mortems were found to show chronic infection and kidneys with pyelonephritic scarring. This followed a clinical course of recurrent episodes of acute pyelonephritis/upper urinary tract infection, renal failure, hypertension and proteinuria Ransley and Risdon demonstrated how the first infection could be devastating to the renal parenchyma of a mini-pig infected urine could enter the renal parenchyma in a retrograde direction via the collecting ducts causing renal scarring They then showed how early antibiotic treatment could prevent or attenuate renal scarring

PC: 7 year old girl presenting with 1 day hx of pyrexia, dysuria and left sided loin pain : 

PC: 7 year old girl presenting with 1 day hx of pyrexia, dysuria and left sided loin pain HPC: Sore peri-anal region for 1/52, tender on wiping 3/7 ago woke up at 3am feeling warm and sweaty Complained of dysuria and increased frequency No reduced urinary flow Left sided loin pain, constant dull ache that did not radiate Pain made better by lying flat and exacerbated by sitting upright Woke her mum up and had a temp of 37.5 ᵒC and rigors, tried Calpol but noticed no significant difference Eating and drinking well No vomiting No diarrhoea No rashes No photophobia No recent overseas travel No contact with similar illness in others/siblings, or infectious outbreaks

Past Medical History: 

Past Medical History Hx of recurrent UTIs: First was at age 2 with and had a febrile convulsion: admitted to ODGH Second was at age 3 with fever and night sweats: admitted to ODGH Broken wrist aged 5: un-displaced greenstick fracture of the distal right radius No surgical hx Pregnancy hx No Antenatal infections No Rhesus incompatibility or haemolytic disease No exposure to prescribed, recreational drugs or over-the-counter (OTC) medication No maternal illness or problems in pregnancy No renal abnormalities diagnosed on antenatal scans Peri-natal hx Gestation 37 weeks SROM Mode of delivery: normal vaginal delivery with ventouse Birthweight 3.2 kg No resuscitation required No Birth injuries

PowerPoint Presentation: 

Development hx Normal Parental recall of major milestones Sat up aged 8 months Crawling aged 9 months Walking aged 12 months Toilet trained aged 3.5 years Immunizations hx Up to date 2months DTaP/IPV/Hib + PCV 3 months DTaP/IPV/Hib + men C 4 months DTaP/IPV/Hib + men C + PCV 12 months Hib +men C 13 months MMR + PCV 3yrs 4m-5yrs MMR+ DTaP + IPV

Drug history: 

Drug history No known drug allergies Previous medications; prophylactic Trimethoprim: stopped 2 years ago No regular prescribed medications No OTC/ herbal medications Family history 55 7 56 Both parents are fit and well No family history of renal disease No family history of hypertension No family history of vesico-ureteric reflux (VUR) 5

Social History: 

Social History Lives at home with mother, father and 5 year old brother Hobbies; playing cello and horse riding No schooling problems: says she enjoys school and has lots of friends No pets Childcare (if parents work): grandparents Parental occupation(s): mum is a optician dad is an accountant No smoking in the home ROS Neuro: no fits, no faints, no funny turns, no headaches Respiratory: no coughs, no difficulty breathing, no wheeze Cardiovascular: no palpitations, no chest pain, no cyanosis Gastrointestinal: no diarrhoea, no constipation, no abdo pain ENT: no sore throat, no ear pain, no coryzal symptoms Skin: no rashes

O/E : 

O/E Appeared uncomfortable at rest No pallor HR 123 Temp 37.8 ᵒ C BP 87/55 RR 24 SaO2 97% in room air CRT < 2 seconds Abdomen No abdominal distension Tender in L lumbar region and renal angle No hepatomegaly No splenomegaly Kidneys both ballotable: painful on L side Bowel sounds present S1 +S2 + 0 Lungs clear ENT Nil of note

Differential Diagnosis: 

Differential Diagnosis Upper UTI/ Acute Pyelonephritis Lower UTI/Cystitis Investigations Bloods: FBC, U&E, CRP, INR Blood cultures Urine collection ; Dipstick and MC&S Scans: USS Kidneys

Results : 

Results Bloods CRP 42 ↑ (<10mg/L) Hb 13 (11.5-16g) MCV 79 (76-96 fL) WCC 23.9 ↑ (4-11) Neutrophils 22.4 (40-75%) Lymphocytes 0.6 (20-45%) INR 1.4 ↓ (2-3) Na 133 (135-145) K 3.9 (3.5-5) Ur 4.1 (2.5-6.7) Cr 53 ↓ (70-150) Urinalysis Colour yellow Glu negative Bil negative Ket + SG 1.010 BLD ++ PH 7.0 Pro negative UBG 3.2umol/L NIT + LEU ++ Urine culture showed coliforms

USS KUB: 

USS KUB Unremarkable appearance of R. kidney L. kidney appeared swollen with altered echogenicity keeping with pyelonephritis No evidence of hydronephrosis No evidence of calculus formation Ureters are not dilated Bladder is well filled with echogenic fluid in keeping with infection The bladder empties at micturition USS Kidneys R. Kidney: normal size and texture L. Kidney: reduced in size with dilation of the L. renal pelvis with scarring

So what happened to this patient..: 

So what happened to this patient.. Diagnosis: Left sided pyelonephritis with renal scarring due to recurrent upper UTIs Treatment IV cefuroxine

Defining UTI: 

Defining UTI a combination of clinical features and the presence of bacteria in the urine Acute pyelonephritis/upper urinary tract infection- Bacteriuria and pyrexia > 38ᵒC or loin pain with pyrexia <38ᵒC Cystitis/lower urinary tract infection- Bacteriuria with no systemic symptoms

How to make the diagnosis: 

How to make the diagnosis Presenting symptoms and signs in infants and children with UTI Age Group Signs and signs Most common Least common Infants younger than 3 months Fever Vomiting Lethargy Irritability Poor feeding Failure to thrive Abdominal pain Jaundice Haematuria Offensive urine Infants and children, 3 months or older Pre verbal Fever Abdominal pain Loin tenderness Vomiting Poor feeding Lethargy Irritability Haematuria Offensive urine Failure to thrive Verbal Frequency Dysuria Dysfunctional voiding Changes to continence Abdominal pain Loin tenderness Fever Malaise Vomiting Haematuria Offensive urine Cloudy urine

Urinalysis: 

Urinalysis Leukocyte positive + Nitrite positive + UTI Leukocyte positive - Nitrite positive + Suspected: treat as UTI Leukocyte positive + Nitrite positive - Suspected: await MC&S unless clinically apparent Leukocyte positive - Nitrite positive - No UTI

Lower UTI or Upper UTI?: 

Lower UTI or Upper UTI? Infants and children who have bacteriuria and fever of 38 °C or higher should be considered to have acute pyelonephritis/upper urinary tract infection. Infants and children presenting with fever lower than 38 °C with loin pain/tenderness and bacteriuria should be considered to have acute pyelonephritis/upper urinary tract infection. All other infants and children who have bacteriuria but no systemic symptoms or signs should be considered to have cystitis/lower urinary tract infection. Laboratory tests for localising UTI C-reactive protein alone should not be used Imaging tests for localising UTI not recommended power Doppler ultrasound dimercaptosuccinic acid (DMSA) scintigraphy scan

Acute Management: 

Acute Management For infants and children 3 months or older with acute pyelonephritis/upper urinary tract infection: • Treat with oral antibiotics for 7–10 days . The use of an oral antibiotic with low resistance patterns is recommended, for example, cephalosporin or co-amoxiclav. • If oral antibiotics cannot be used, treat with an IV antibiotic agent such as cefotaxime or ceftriaxone for 2–4 days followed by oral antibiotics for a total duration of 10 days.

Long-term management : 

Long-term management Prevention of recurrence Dysfunctional elimination syndromes and constipation should be addressed in infants and children who have had a UTI. Children who have had a UTI should be encouraged to drink an adequate amount. Children who have had a UTI should have ready access to clean toilets when required and should not be expected to delay voiding. Antibiotic prophylaxis Antibiotic prophylaxis should not be routinely recommended in infants and children following first-time UTI. Imaging tests Infants and children who have had a UTI should be imaged

Imaging tests : 

Imaging tests Infants and children with atypical UTI should have ultrasound of the urinary tract during the acute infection to identify structural abnormalities of the urinary tract such as obstruction. Indicated for: 1. Atypical UTI includes: • seriously ill • poor urine flow • abdominal or bladder mass • raised creatinine • septicaemia • failure to respond to treatment with suitable antibiotics 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, or • one episode of UTI with acute pyelonephritis/upper urinary tract infection plus one or more episode of UTI with cystitis/lower urinary tract infection, or three or more episodes of UTI with cystitis/lower urinary tract infection.

Imaging tests: 

Imaging tests USS: shows structural abnormalities, scars, hydronephrosis DMSA : shows inflammation of renal parenchyma MCUG : used to detect VUR MAG 3 cystogram: used to detect functional clearance,can identify stasis of urine and VUR

Prognosis and complications: 

Prognosis and complications Chronic pyelonephritis Chronic renal failure Hypertension VUR accounts for CRF in 20% of children and 5-10% of adults

The end!: 

The end!