Morning Report
July 12, 2012
Problem Characteristics
Ill-appearing/
Toxic
Well-appearing/
Non-toxic
Localizedproblem
Systemic problem
Acquired
Congenital
New problem
Recurrence of oldproblem
Symptoms
Acute /subacute
Chronic
Localized
Diffuse
Single
Multiple
Static
Progressive
Constant
Intermittent
Single Episode
Recurrent
Abrupt
Gradual
Severe
Mild
Painful
Nonpainful
Bilious
Nonbilious
Sharp/Stabbing
Dull/Vague
Predisposing Conditions
Age, gender, preceding events(trauma, viral illness, etc),medication use, past medicalhistory (diagnoses, surgeries,etc)
Pathophysiological Insult
What is physically happeningin the body, organismsinvolved, etc.
Clinical Manifestations
Signs and symptoms
Labs and imaging
Female (8%) > Male (1%)***
Uncircumcised = 5+ fold increased risk
Obstruction
Anatomic abnormality
Posterior urethral valves
UPJ obstruction
Ureterocele
Nephrolithiasis
Renal tumor
Indwelling catheter
Constipation***
Ascension of bowel flora
Organisms***
E. coli = most common…up to 70%
Other GNR (especially in neonates)
Klebsiella
Pseudomonas aeruginosa
Staph saprophyticus (sexually active girls)
Enterococcus
Nephritogenic bacterial strains of E. colipossess fimbriae that bind to uro-epithelialcells as well as other virulence factors.
Babies and young children
Fever
Feeding problems +/- FTT
Jaundice
Malodorous urine
Decreased activity or irritability
Vomiting, diarrhea, abdominal pain
>2yo = more classic symptoms
Urgency, frequency, hesitancy
Dysuria
Back or abdominal pain
Urinalysis***
+nitrite (more specific)
+leukocyte esterase (more sensitive)
Pyuria…presence of at least 5 WBC per hpf
Bacteriuria
Urine culture***
Gold standard
Must have > 50,000cfu on an adequate specimen
Catheterization
Supra-pubic aspiration
Bag urine culture is NOT appropriate!!
Infection of the urinary tract anywhere fromthe urethra to the renal parenchyma.
Infants have risk of concurrentbacteremia.***
Epidemiology***
7-9% of infants (<3mo) with a fever and noidentifiable source are diagnosed with UTI.***
Most common cause of serious bacterialinfections (SBI) in babies < 3mo.
Is seen in conjunction with viral illnesses (i.e.RSV) in neonates.
Oral vs. Intravenous
Once the identification and sensitivity areknown, antibiotics should be tailoredappropriately***
Treatment duration = 7-14 days***
First time UTI*** (CHANGED in 2011)
Renal and bladder ultrasound
Timing is dependant upon clinical picture…
VCUG only if US reveals
Hydronephrosis
Renal scarring
Other findings that would suggest high-grade VURor obstructive uropathy
Recurrence of febrile UTI***
VCUG
Prior to 2011 Guidelines
Antibiotic prophylaxis in children until VCUGperformed and if ANY grade of reflux (VUR)
Not shown to make statistically significantdifference in Grades I – IV Reflux in terms ofprevention of UTI recurrence.
High grade reflux should be referred to urology
Renal damage caused by a combination ofVUR and urinary tract infections (oftenrecurrent) that occur in childhood.
Asymptomatic in early stages***
Can cause long term complications
HTN***
Proteinuria
Progressive renal failure
Increased risk of pregnancy-relatedcomplications
Noon conference = Intern clinicalreasoning with Dr. English INTERNS ONLY!
