3121392 1 Logic antibiotic use in children with

3/12/1392 1

Logic antibiotic use in children with urinary tract infection Dr mostafavi N Pediatric infectious disease departement Isfahan university of medical sciences 3/12/1392 2

Presenting symptoms in UTI Age group Most common Least common < 3 mo 3 mo- 2 yr > 2 yr 3/12/1392 3

Presenting symptoms in UTI Age group Most common Least common < 3 mo Fever only Vomiting Irritability Poor feeding Failure to thrive Jaundice Hematuria Offensive urine 3 mo- 2 yr Fever only Poor feeding Vomiting Irritability Failure to thrive Hematuria Offensive urine > 2 yr Frequency Dysuria Abdominal pain Loin tenderness Change to continence Fever only Hematuria Offensive urine Cloudy urine 3/12/1392 4

Case 1 �Ali is an 8 month old infant presented with fever. What is the risk of UTI? Is he need urinalysis and urine culture? 3/12/1392 5

Case 1 �Ali is an 8 month old infant presented with fever. What is the risk of UTI if the child ◦ Not circumcised ◦ Fever> 39°С ◦ Fever without source ◦ Fever > 24 hours ◦ Combination of them 3/12/1392 6

Risk of UTI in boys Numb Condition er 1 Uncircumsised Risk of UTI 2 Nonblack race 1% 3 T> 39 °C 1% 4 Fever > 24 h 1% each day 5 Absence of another source of infection 1% 3/12/1392 2% 7

Risk of UTI in case 1 �Ali is an 8 month old infant presented with fever. What is the risk of UTI if the child ◦ Not circumcised 2% ◦ Fever> 39°С : 1% ◦ Fever without source: 1% ◦ Fever > 24 hours: 1% each day ◦ Nonblack race: 1% ◦ Combination of them 3/12/1392 8

Case 2 �Zahra is an 8 month old infant presented with fever. What is the risk of UTI? Is she need urinalysis and urine culture? 3/12/1392 9

Case 2 �Zahra is an 8 month old infant presented with fever. What is the risk of UTI if the child �Fever> 39°С �Fever without source �Fever > 2 days �Combination of them 3/12/1392 10

Risk of UTI in girls Number Condition Risk of UTI 1 Age < 12 mo 1% 2 White race 1% 3 T> 39 °C 1% 4 Fever > 2 d 1% each day 5 Absence of another source of infection 1% 3/12/1392 11

Risk of UTI in case 2 �Zahra is an 8 month old infant presented with fever. What is the risk of UTI if the child �Fever> 39°С: 1% �Fever without source: 1% �Fever > 2 days: 1% each day �Age< 12 mo: 1% �White race: 1% �Combination of them 3/12/1392 12

Case 3 �Ali is an 8 month old uncircumcised infant presented with high grade fever( 39. 5°C) for 4 days with no other source of infection. Which test you request for diagnosis of UTI? 3/12/1392 13

Case 3 �If the child is ill: U/A and U/C through midstream, catheter or suprapubic and start IV antibiotic �If the child is well: �Option 1: U/A and U/C through midstream, catheter or suprapubic �Option 2: U/A through bag and if suggestive then U/A and U/C through midstream, catheter or suprapubic 3/12/1392 14

The results of U/A of case 3 Case Urinalysis result Your decision 3 -1 WBC= 3 -4/hpf , Nitrite= neg, RBC= 0 -1/hpf, bacteria= many 3 -2 WBC= 3 -4/hpf , Nitrite= neg, RBC= many /hpf, bacteria= many 3 -3 WBC= 6 -8/hpf , Nitrite= neg, RBC= 0 -1/hpf, bacteria= few 3 -4 WBC= 3 -4/hpf , Nitrite= Pos, RBC= 0 -1/hpf, bacteria= neg 3 -5 WBC= 15 -20/hpf , Nitrite= neg, RBC= 0 -1/hpf, bacteria= neg 3/12/1392 15

Diagnosis of UTI �Both: ◦ Urinalysis suggestive for urinary infection as pyuria and/or bacteriuria in gram stain of fresh urin ◦ Presence of atleast 5 Χ 105 CFU/ml of a uropathogen through catetherization or SPA 3/12/1392 16

The results of U/A of case 3 Case Urinalysis result Your decision 3 -1 WBC= 3 -4/hpf , Nitrite= neg, RBC= 0 No UTI, decision -1/hpf, bacteria= many based on U/C 3 -2 WBC= 3 -4/hpf , Nitrite= neg, RBC= many /hpf, bacteria= many 3 -3 WBC= 6 -8/hpf , Nitrite= neg, RBC= 0 Suspected UTI, repeat -1/hpf, bacteria= few U/A 3 -4 WBC= 3 -4/hpf , Nitrite= Pos, RBC= 0 Suspected UTI if exam -1/hpf, bacteria= neg on fresh urine, repeat U/A 3 -5 WBC= 15 -20/hpf , Nitrite= neg, RBC= 0 -1/hpf, bacteria= neg 3/12/1392 No UTI, decision based on U/C Suspected UTI, start antibiotic and final decision based on U/C 17

The results of U/A and U/C of case 3 Case Urinalysis result U/C result Your decision 3 -1 WBC= 3 -4/hpf , Nitrite= neg, RBC= 0 -1/hpf, bacteria= many > 105 Ecoli No UTI, contamination in bag sample, asymptomatic bacteriuria 3 -2 WBC= 3 -4/hpf , Nitrite= neg, RBC= 1 -2 /hpf, bacteria= many > 105 s. epiderm No UTI, Contamination 3 -3 WBC= 6 -8/hpf , Nitrite= neg, RBC= 0 -1/hpf, bacteria= few Negative No UTI 3 -4 WBC= 3 -4/hpf , Nitrite= Pos, RBC= 0 -1/hpf, bacteria= neg > 105 Ecoli suspected UTI, contamination in bag sample, asymptomatic bacteriuria 3 -5 WBC= 15 -20/hpf , Nitrite= > 105 Ecoli neg, RBC= 0 -1/hpf, bacteria= neg 3/12/1392 UTI, treat based on sensitivity 18

Pyuria + negative UC Fever Partially Exercise UTI Viral infections Renal TB Renal abscess UTI + obstruction Inflammation near UT system( appendicitis, crohn, . . ) Streptococcal infections Urethritis Kawasaki Interstitial nephritis( eos. ) 3/12/1392 treated 19

Positive UC+ No pyuria �Early phase of infection �Very frequent voiding( low count) �Asymptomatic bacteriuria �Contamination ( bag sample) �Neutropenia 3/12/1392 20

Etiology of UTIs �Enteric ◦ ◦ ◦ G-: E. coli 80% Klebsiella Proteus Enterobacter Citrobacter �G+: ◦ Enterococcus: suspected in urinary catheter, abnormality, or instrumentation ◦ S. saprophyticus 3/12/1392 21

Contamination in U/C �Lactobacillus spp �Coagulase –negative staphylococci �Corynebacterium spp 3/12/1392 22

Case 4 �Ali is an 8 month old uncircumcised infant presented with high grade fever( 39. 5°C) for 4 days with no other source of infection. U/A shows many WBCs. When you decide to admit the child in the hospital? 3/12/1392 23

Admission of UTI patients in hospital Indications No indication Vomiting or inability to tolerate PO medications Very high fever Age< 2 mo Fatigue Clinical urosepsis( Abnormal vital signs, ↑ CRT) Loss of appetite Immunocompromised Pts Rigor Lack of outpatient follow up Loin pain Failure to respond to outpatients therapy Abdominal pain 3/12/1392 24

Case 5 �Ali is an 8 month old uncircumcised infant presented with high grade fever( 39. 5°C) for 4 days with no other source of infection. U/A shows many WBCs. You decide to admit the child in the hospital due to severe vomiting and inability to tolerate PO medications. Which antibiotic is appropriate for the child? 3/12/1392 25

Case 6 �Ali is an 8 month old uncircumcised infant presented with high grade fever( 39. 5°C) for 4 days with no other source of infection. U/A shows many WBCs. You decide to treat the child with PO medications. Which antibiotic is appropriate for the child? 3/12/1392 26

Empiric antibiotic therapy in UTI � Admitted: ( untile afebrile and able to tolerate PO) ◦ ceftriaxone( 50 -75) , cefotaxime( 100 ), cefepime(100), Gentamicine ( 3 -5) ◦ +ampicillin( 100) if enterococci suspected( urinary catether, instrumentation, anomaly) � Out patient: ◦ Cefixime( 16 1 st day then 8 -10 in 1 -2 dose), ciprofloxacine if psudomonas or resistant g- ( 20 -30) after 17 yr ◦ Nalidixic acid(55), nitrofurantoin( 5 -7) alternative for afebriles and older children � Duration: 3 -5 d for afebrile, 7 -14 d for febrile 3/12/1392 27

Case 7 �Ali is an 8 month old uncircumcised infant presented with high grade fever( 39. 5°C) for 4 days with no other source of infection. U/A shows many WBCs. You decide to treat the child with cefixime syrup. When you repeat U/A and U/C for confirmation of cure? 3/12/1392 28

Case 7 �There is no need to confirmation by U/A and U/C. Improve in fever and symptoms during 24 -48 hours confirms complete cure of the child. 3/12/1392 29

Case 8 �Ali is an 8 month old uncircumcised infant presented with high grade fever( 39. 5°C) for 4 days with no other source of infection. U/A shows many WBCs. You decide to treat the child with cefixime syrup. When you send renal and bladder ultrasonography, voiding cysto uretero graphy, and Dimercapto methyl succinic acid assay? 3/12/1392 30

Renal sonography �All febrile UTI after acute phase • In patients who not respond to AB after 48 hr during acute phase • No need in afebrile UTIs 3/12/1392 31

Indications of Voiding Cysto. Urethero. Graphy • > 1 febrile UTI � 1 ST febrile UTI+ abnormal renal sonography( hydronephrosis, scarring, …) � 1 ST febrile UTI+ poor growth/ hypertension/ non Ecoli growth 3/12/1392 32

Di. Mercapto. Succinic Acid renal scintigraphy �No indication after febrile UTIs �Currently for investigational purpuses �Careful F/U of all children obviate need to DMSA 3/12/1392 33

Case 9 �Ali is an 8 month old uncircumcised infant presented with high grade fever( 39. 5°C) for 4 days with no other source of infection. U/A shows many WBCs. You decide to treat the child with cefixime syrup. After 2 days the results of U/C shows growth of more than 105 Ecoli sensitive to meropneme and resistant to all PO antibiotics. The child became afebrile and well. What's your decision? 3/12/1392 34

50 -90 rule �If the organism of the infection was resistant to an antibiotic, the chance for response is 50% �If the organism of the infection was sensitive to an antibiotic, the chance for response is 90% �Repeat U/C for confirmation of cure, and continue cefixime 3/12/1392 35

Case 10 �Ali is an 8 month old uncircumcised infant presented with high grade fever( 39. 5°C) for 4 days with no other source of infection. U/A shows many WBCs. You decide to treat the child with cefixime syrup. After 2 days the results of U/C shows growth of more than 105 Ecoli sensitive to cefixime. The child became afebrile and well. What's your follow up for the child? 3/12/1392 36

Follow up of UTI �Treat predisposing conditions of UTI �UA and UC in all febrile illness to detect and treat UTI immediately �Regular monitoring of weight, height, and blood pressure �Prophylactic antibiotic for grade 3 -5 VUR �Corte, nitrofurantoin, cephalexin, amoxicillin �Once daily � 1/4 -1/3 usual dose 3/12/1392 37

Predisposing factors of UTI 1. ↑Perineal colonization 1. Uncircumcised male 2. Wiping from back to front in girls 3. Tight clothing( underwear) 4. Labial adhesion ↑Ascending to kidney and renal tubules 1. Vesico ureteral reflux 2. Voiding dysfunction 1. 2. 3. 4. 5. Onset of toilet training Infrequent voiding School aged children Constipation Neuropathic bladder 3. Obstructive uropathy ( stasis) 1. 2. 3. 3/12/1392 Hydronephrosis Renal stone Anatomical defects 38

Case 11 �Ali is an 8 month old uncircumcised infant presented with high grade fever( 39. 5°C) for 4 days with no other source of infection. U/A shows many WBCs. You decide to treat the child with cefixime syrup. After 2 days the results of U/C shows growth of more than 105 Ecoli sensitive to cefixime. The child became afebrile and well. When you refer the child to pediatric nephrologist? 3/12/1392 39

Referral to pediatric nephrologist �Grade 3 -5 VUR �Obstractive uropathy �Impaired kidney function �Elevated blood pressure �Proteinuria �Refractory bladder and bowel dysfunction 3/12/1392 40

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