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Logic antibiotic use in children with urinary tract infection

Logic antibiotic use in children with urinary tract infection. Dr mostafavi N Pediatric infectious disease departement Isfahan university of medical sciences. Presenting symptoms in UTI. Presenting symptoms in UTI. Case 1.

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Logic antibiotic use in children with urinary tract infection

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  1. Logic antibiotic use in children with urinary tract infection Dr mostafavi N Pediatric infectious disease departement Isfahan university of medical sciences

  2. Presenting symptoms in UTI

  3. Presenting symptoms in UTI

  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?

  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

  6. Risk of UTI in boys

  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

  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?

  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

  10. Risk of UTI in girls

  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

  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?

  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

  14. The results of U/A of case 3

  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

  16. The results of U/A of case 3

  17. The results of U/A and U/C of case 3

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

  19. Positive UC+ No pyuria • Early phase of infection • Very frequent voiding( low count) • Asymptomatic bacteriuria • Contamination ( bag sample) • Neutropenia

  20. Etiology of UTIs • Enteric G-: • E.coli 80% • Klebsiella • Proteus • Enterobacter • Citrobacter • G+: • Enterococcus: suspected in urinary catheter, abnormality, or instrumentation • S.saprophyticus

  21. Contamination in U/C • Lactobacillus spp • Coagulase –negative staphylococci • Corynebacterium spp

  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?

  23. Admission of UTI patients in hospital

  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?

  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?

  26. Empiric antibiotic therapy in UTI • Admitted: ( untileafebrile 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 1st day then 8-10 in1-2 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

  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?

  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.

  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?

  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

  31. Indications of Voiding CystoUretheroGraphy • > 1 febrile UTI • 1ST febrile UTI+ abnormal renal sonography( hydronephrosis, scarring, …) • 1ST febrile UTI+ poor growth/ hypertension/ non Ecoli growth

  32. DiMercaptoSuccinic Acid renal scintigraphy • No indication after febrile UTIs • Currently for investigational purpuses • Careful F/U of all children obviate need to DMSA

  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 105Ecoli sensitive to meropneme and resistant to all PO antibiotics. The child became afebrile and well. What's your decision?

  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

  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 105Ecoli sensitive to cefixime. The child became afebrile and well. What's your follow up for the child?

  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

  37. Predisposing factors of UTI • ↑Perineal colonization • Uncircumcised male • Wiping from back to front in girls • Tight clothing( underwear) • Labial adhesion • ↑Ascending to kidney and renal tubules • Vesicoureteralreflux • Voiding dysfunction • Onset of toilet training • Infrequent voiding • School aged children • Constipation • Neuropathic bladder • Obstructive uropathy ( stasis) • 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 105Ecoli sensitive to cefixime. The child became afebrile and well. When you refer the child to pediatric nephrologist?

  39. Referral to pediatric nephrologist • Grade 3-5 VUR • Obstractive uropathy • Impaired kidney function • Elevated blood pressure • Proteinuria • Refractory bladder and bowel dysfunction

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