Upload
andifandiyar
View
219
Download
0
Embed Size (px)
Citation preview
8/10/2019 Urinary Tract Disorder
1/23
Urinary Tract DisorderMANAGEMENT OF CHIDHOOD
URYNARY TRACT INFECTION
8/10/2019 Urinary Tract Disorder
2/23
A. Definition of Terms
Urinary tract infection (UTI) Presence of proliferating bacteria in theurinary tract causing tissue invasion andinflammation
Upper UTI or pylonephritis Infection involving the renalparenchymacausing systemic and local sympstoms
Lower UTI or cystitis Infection limited to the lower urinary tract(with acute volding sympstoms as the majorfeature)
Asymtomatic or covert bacteriuria Colonizationof the urinary tract by
uropatoghens without causing anysympstoms
Atypical or complicated UTI UTI associated with anatomical or functionalabnormalities of the urinary tracrt :
a) Evidence of obstructive uropathy:i. Poor urine flowii. Abdominal or bladder mass
b) Seriously ill (toxic)c) Septicemad) Raised creatiniee) Failure to respond to antibiotic treatment
within 48 hours.
Recurrent UTI a) 2 episodes of acute pyelonephritis or
b) 1 episode of acute pyelonephritis/upper UTI+ 1 episode of cytitis/lower UTI or
c 3 e isodes of c tilis/lower UTI
8/10/2019 Urinary Tract Disorder
3/23
B. Diagnosis of UTI
I. Guidelines for diagnosis:
1. All infants and children with unexplained fever 38.5
0c
2. Infants and children with alternative site of infection who
remained unwell.3. Infants and children wih signs and symtomps suggestive of UTI
8/10/2019 Urinary Tract Disorder
4/23
4
II. Signs and symptoms1. Signs and symptoms of UTI differ according to
age :
Infants present with non-specific signs and symptomsand there fore of UTI requires a HIGH INDEX of
suspicion
8/10/2019 Urinary Tract Disorder
5/23
5
Age group Signs and symptoms from most common to leastcommon
Infants
8/10/2019 Urinary Tract Disorder
6/23
6
Clinical Upper tract Lower tract
Age
8/10/2019 Urinary Tract Disorder
7/23
7
Leucocyte (+) Leucocyte (-)Nitrite (+) Send for urine
Treat as UTIStart antiiotics
Send for urine cultureStart antibiotics (iffreshly voided stamplewas obtained)
Nitrite (-) Send for microscopyand cultureStart antibiotics only ifwith goodEvidence of UTI
Not UTIExplore other causes offeverSend for microscopy ifwith known structuralabnormalities
III. Work-up1. Dipstik
*Dipstick (positive leucocyte esterase and nitrite) is useful torule in UTI in children2 years
8/10/2019 Urinary Tract Disorder
8/23
8
Method of collection Colony count/ml (pureculture)
Probability of infection(%)*
Suprapubic
Aspiration
Gram-negative bacilli : any
numberGram-positive cocci :>103
>99%
TransurethralCatheterization
>105
5 x 104
103-
8/10/2019 Urinary Tract Disorder
9/23
9
a.The following should be considered indeterminate and shoud berepeated :
i. Significant growth of 2 pathogensii. A predominant pathogen with a contaminantiii. Intermediate growth of a single pathogen.
b. Contamination rate of urine obtained by the following are :i. Bag specimen : 62,8 %ii. Catheterization : 9,1 %
c. Infants whose urine was obtained by bag versus catheter were 4to 5 times more likely to have unnecessary treatment andradilogical investigation, 12- fold more likely to have unnecessaryhospitalization, and were more likely to have delayed diagnosisand treatment.
8/10/2019 Urinary Tract Disorder
10/23
10
C. Imaging
I. Goals of imaging :
1. To identify those with underlying structural renal abnormalities, especially
obstructive uropathies requiring surgery
2. To identify those with factors predisposing them to increased risk of recurrent
UTI3. To identify those with renal parenchymal damage (primarity in those with
severe or bilateral disease), predisposing them to increased risk of:
a. Hypertension (38%)
b. Pre-eclampsia in pregnancy
The prevalence of structural abnormalities in the urinary tract in infantsand childreb with UTI ranges fro 1075 %
About 5-35% have significant obstruction requiring surgery
8/10/2019 Urinary Tract Disorder
11/23
8/10/2019 Urinary Tract Disorder
12/23
II. Renal ultrasound: Non-invasive procedure
Gives information on :a.Renal size and shapeb.Bladder size and configuration, bladder wall thicknessc.Presence or absence of pelvicalyceal and ureteral
dilatation.
Recommendation:Renal ultrasound scan should be done as initial investigation to detct
dilatation secondary to obstruction and other abnormalities in: All children with presumptive upper tract UTI
Infants age
8/10/2019 Urinary Tract Disorder
13/23
13
III Micturating cystourethrogram (MCUG): Gives information on :
a.Bladder lesionsb.Urethral lesions especially posterior urethral valves in boysc.Competence of vesicoureteric junction and the grade of
vesicoureteric reflux (VUR) if present
8/10/2019 Urinary Tract Disorder
14/23
14
IV. 99mTecnetium Dimercaptosuccinic acid (DMSA) scan Gives information on :a.Focal areas of decreased uptake indicating:i. Acute pyelonephritis in the acute stage
ii. Established scars when DMSA done 3 months laterNote: 50% of children with scarring had normal MCUGb. Differential function of the 2 kidneys
Recommendation:DMSA scan is indicated in :
All children age
8/10/2019 Urinary Tract Disorder
15/23
15
V. Diuretic renography with 99mTecnetium Mercaptoacetyltriglycine(MAG3)
If there is delayed excretion, furosemide at1 mg/kg is given afterminutes.
Gives information on:a.Renal perfusionb.Uptake, excretion and drainage of radotracerc.Differentisl function of both kidneys
Note : To distinguish between a true mechanical obstruction andnonobstructive pelvicalyceal dilatation. T >20 minutes suggest thepresence of an underlying mechanical obstruction.
Recommendaion :MAG3 renogram is indicated when :
Pelvicalyceal dilatation 1 cm on ultrasound examination Vesicoureteric stenosis is suspected in the presence of uteric
dilatation on ultrasound examination and absence ofvesicoureteric reflux on MCUG
8/10/2019 Urinary Tract Disorder
16/23
16
VI. Algorithm for investigation of UTI1. Boys
Ultrasound of urinarytract
PC dilatation
None21 cm 0,4 to
8/10/2019 Urinary Tract Disorder
17/23
8/10/2019 Urinary Tract Disorder
18/23
18
D. TreatmentI. Principles of treatment1. The drug of choice should be based on the resistance
patterns of the uropatogens in the hospital as well as ofrecent antibacterial treatment received by the patient.
2. The drug should have minimal adverse effects on themajor organ systems.
3. A high concentration of the drug should be preesnt in theurine after administration.
4. Oral antibiotics are efficacious in both lower and uppertract infections.
5. Second and third generation cephalosporins should beavoided as empiric therapy in non-atypical UTI to avoidincrease in antibiotic resistance.
6. Urinaru antiseptics such as nalidixic acid and
nitrofurantoin should not be the initial drug choice inupper tract UTI
Antibiotic Frequency Therapeutic dose Prophylactic dose
8/10/2019 Urinary Tract Disorder
19/23
19
Antibiotic Frequency Therapeutic dose(mg/kg/dose)
Prophylactic dose(mg/kg ON)
Ampicilin/sulbactam(Unasyn)
Q12H 15-25 (ampicilin)(maximum 2 g)
Amoxcilin Q8H 10-25 (maximum 1g) 10
Amoxycilin/Clauvulanic acid (Augmentin 7:1)
Q12H 10-25 (amoxcilin)(maximum 1g)
Cefaclor Q8H 10-15 (maximum500mg)
10
Cephalexin Q6H
Q12H
7.5 (maximum 250 mg)
15 (maximum 500mg)
7.5
Cefuroxime Q12-24H 10-15 (maximum 500mg)
Co-trimoxazole*Trimethoprim(TMP1 mg)Sulphamethoxazole(SMX 5 mg)OR Trimethoprim
Q12H
Q12H
3-4 (TMP)
3-4
2
2
Nalidixic acid*# Q6H 7.5-15 (maximum 100mg). Reduce to 7.5mg/kg/dose after 2weeks (maximum 50
15 Q12H
8/10/2019 Urinary Tract Disorder
20/23
II. Intranvenous antibiotics1. Intravenous antibiotics are indicated in :
a.Infants
8/10/2019 Urinary Tract Disorder
21/23
21
4. Second and third generation cephalosporins should be avoided innon-atypical UTI to avoid increase in antibiotic resistance.
5. Intravenous cefriaxone is the drug of choice in atypical or
complicated UTI. Cefriaxone should be avoided in the first 2 weeksof life as it may affect bilirubin transport in the liver.
6. In atypical or complicated UTI, if an aminoglycoside is requiredbased on antibiotic sensitivity results, amikacin is theaminoglycoside is required based on antibiotic sensitivity results,amikacin is the aminoglycoside of choice as its nephrotoxic
potential may be lower than gentamicin7. Commonly used parenteral antibiotics-intravenous (IV) and
intramuscular (IM)
8/10/2019 Urinary Tract Disorder
22/23
Antibiotic Route Frequency Dose (mg/kg
dose)
Comment
Amikacin IV,IM Single daily dose Term Neonate: 15
1 week to 10
years: 25 (D1),
then 18>10
years:20 (D1),
then 15
(maximum 1.5
g/day)
Monitor levels
Through level W2)
25 (Adult 1 g)
50 (maximum 2 g)
Gentamicin IV,IM Q8H
Q12H(W1)
Q8H (W2)
Q6H(>W2)
15-25 (Adult 0.5-
1g)
Severe : 50
(maximum 2 g)
Renal adjusment
Gentamicin IV,IM Q24H Term neonate to Monitor levels
8/10/2019 Urinary Tract Disorder
23/23