Paeds: UTI Flashcards Preview

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Flashcards in Paeds: UTI Deck (46):
1

Symptoms and Signs

Fever
Vomiting
Lethargy
Irritability

2

Symptoms and Signs

- Poor feeding
Failure to thrive

3

Symptoms and Signs

Abdominal pain
Jaundice
Haematuria
Offensive urine

4

Infants and children >3 months (preverbal)
Most common

Fever

5

Infants and children >3 months (preverbal) Less common

- Abdominal pain
- Loin tenderness
- Vomiting
Poor feeding

6

Infants and children >3 months (preverbal) Least common

- Lethargy
- Irritability
- Haematuria
- Offensive urine
Failure to thrive

7

Infant and children >3 months verbal;
Most common

Fever
Dysuria

8

Infant and children >3 months verbal;
Less common

- Dysfunctional voiding
- Changes in continence
- Abdominal pain
Loin tenderness

9

Infant and children >3 months verbal; Least common

- Fever
- Malaise
- Vomiting
- Haematuria
- Offensive urine
Cloudy urine

10

Infants symptoms of UTI

- Fever
- Vomiting
- Lethargy or irritability
- Poor feeding/failure to thrive
- Jaundice
- Septicaemia
- Offensive urine
Febrile convulsion (>6 months)

11

Children
symptoms of UTI

- Dysuria and frequency
- Abdominal pain or loin tenderness
- Fever with or without rigors (exaggerated shivering)
- Lethargy and anorexia
- Vomiting, diarrhoea
- Haematuria
- Offensive/cloudy urine
- Febrile convulsion
Recurrence of enuresis

12


Collection of samples:
Child in nappies:

1. Clean catch (recommended method)
2. An adhesive plastic bag applied to the perineum after careful washing – may be contamination from the skin
3. A urethral catheter (urgency in obtaining sample)
4. Suprapubic aspiration – in severely ill infants requiring urgent diagnosis and treatment

13

Older children:
collection of samples

Mid stream urine may be possible
Note: Cleaning of area needed as contamination high in boys due to foreskin and reflux into the vagina.

14

Leucocyte esterase and nitrite positive

Regard as UTI

15

Leucocyte esterase negative and nitrite positive

Start antibiotic treatment

16

Leucocyte esterase positive and nitrite negative

Only start antibiotic treatment if clinical evidence of UTI
Diagnosis depends on urine culture

17

Leucocyte esterase and nitrite negative

UTI unlikely. Repeat or send urine for culture if clinical hx suggests
UTI

18

Blood, protein and glucose present on stick testing

Useful in any unwell child to identify other diseases e.g. nephritis, DM but will not discriminate between children with and without UTIs

19

Bacterial and host factors that predispose to infection:
Causative organism:

- E.coli
- Klebsiella
- Proteus
- Pseudomonas
- Strep. faecalis

- Newborn: likely to be haematogenous

20

Proteus organism more common in

(more common in boys – potentially due to presence under prepuce)

21

Pseudomonas may indicate

may indicate the presence of some structural abnormality in the urinary tract affecting drainage.

22

Predisposing Factors:

1. Infecting organism
2. Antenatally diagnosed renal or urinary tract abnormality
3. Incomplete bladder emptying
4. Vesicoureteric reflex

23

Incomplete bladder emptying

- Infrequent voiding, resulting in bladder enlargement
- Vulvitis
- Incomplete micturition with residual post-micturition bladder volumes
- Obstruction by a loaded rectum from constipation
- Neuropathic bladder
Vesicoureteric reflux

24

Vesicoureteric reflux: Definition

A developmental anomaly of the vesicoureteric junctions
Displaced laterally and enter directly into the bladder

25

Vesicoureteric reflux:
Cause

Familial with a 30-50% chance of occurring in first-degree relative.
May also occur with bladder pathology e.g. neuropathic bladder or urethral obstruction or temporarily after a UTI

26

Vesicoureteric reflux:
Presentation

Mild (reflux into ureter only) to Severe (Gross dilatation o ureter, renal pelvis and calyces)

27

Vesicoureteric reflux:
Severe reflux leads to

Predisposes to intrarenal reflux and renal scarring with UTI via
Backflow of urine from the renal pelvis into the papillary collecting ducts; intrarenal reflux

28

Vesicoureteric reflux:
Reflux with associated ureteric dilatation is important, as:

- Urine returning to the bladder from the ureters after voiding results in incomplete bladder emptying, which encourages infection
- The kidneys may become infected (pyelonephritis), particularily if there is intrarenal reflux
Bladder voiding pressure is transmitted to the renal papillae; this may contribute to renal damage if voiding pressure are high

29

Vesicoureteric reflux:
Consequence

Chronic renal failure due to scarring leading to hypertension in childhood or early adult life (10%)

30

Vesicoureteric reflux:
Outcome

Mild – resolves spontaneously

31

Investigation:
NICE recommendation

NICE don’t recommend an ultrasound for first UTI if there was response to antibiotic treatment within 48h, unless

32

Paediatrician protocol

1. First proven urinary tract infection
2. Antibiotic therapy + ultrasound of kidneys and urinary tract
Ultrasound

33

After ultrasound in

MCUG and DMSA

34

After ultrasound in >1 year and

DMSA

35

Atypical UTI symtpoms

- Seriously ill or septicaemia
- Poor urine flow
- Abdominal or bladder mass
- Raise creatinine
- Failure to respond to suitable antibiotics within 48h
- Infection with non-E.coli organism

36

Ultrasound with reveal:

- Serious structural abnormalities and urinary obstruction
- Renal defects (but poor at identifying renal scars).

37

MSUG: for

micturating cystorethrogram – useful for reflux but INVASIVE

38

DMSA scan

radionuclide scan – for scarring

39

Plain abdo X-ray:

if haematuria look for stones

40

Management All infants

- Referral to hospital
IV antibiotics e.g. cefotaxime until temp reduced

41

Management Infants >3 months and children with acute pyelonephritis/upper urinary tract infection (bacteruria and fever > 38oC) or bacteruria and loin pain/tenderness even if fever is

- Oral antibiotics with low resistance patterns (e.g. co-amoxiclav for 7-10 days) or
IV antibiotics cefotaxime 2-4 days followed by oral antibiotics for 7-10 days total

42

Management Children with cystitis/lower UTI infection (dysuria but no systemic symptoms or signs)

Oral antibiotics for 3 days

43

Medical measures for the prevention of UTI:

Ensure washout of organisms that ascend into the bladder from the perineum, and to reduce the presence ofaggressive organisms in the stool, perineum and under the foreskin.

44

Prevention and advice for parents

- High fluid intake to produce a high urine output
- Regular voiding
- Ensuring complete bladder emptying by encouraging the child to try a second time to empty his bladder after a minute or two, commonly know as double micturition, this empties any urine residue or refluxed urine returing to the bladder
- Prevention or treatment of constipation
- Good perineal hygiene
- Lactobacillus acidophilus, a probiotic to encourage colonization of the gut by this organism that might potentially cause invasive disease
Antibiotic prophylaxis:

45

Antibiotics prophylaxis

- often used in the under 2 with a congenital abnormality: trimethoprim (2mg/kg at night), but nitrofurantoin or cephalexin may be given

46

Follow-up

- Urine culture in nonspecific illness
- Low-dose prophylaxis can be used
- Circumcision considered
- Anti-reflux surgery with evidence of progression
- Blood pressure checked if renal disease present
- Regular assessment of renal growth and function if bilateral defects present

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