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2/15/2019 0 Comments

Pediatric UTI

Why is this important:

UTI is the most frequent bacterial infection in children < 2 years
Clinical presentation is non-specific and urine sample cannot be obtained without invasive measures so dx is often delayed

Who created these guidelines:

revision of practice parameters published in 1999
committee included gen peds, epidemiology/informatics, peds ID, radiology, peds urology.
Guidelines were further reviewed by multiple subgroups within AAP and 5 external organizations in the US and Canada.

Guideline objectives:

Focuses on the dx/management of initial UTI in febrile children < 2 years
studies suggest that incidence of UTI can be as high as 5% in < 2 yr with unexplained fever
Neonates < 2 months were excluded
Children w/ obvious neuro or anatomic abnormality leading to recurrent UTI were excluded

Diagnosis:

Febrile infant w/ no other source of infection requiring abx 2/2 to toxic nature
- obtain UA/Culture before abx
Febrile infant w/ no other source of infection who are non-toxic:
- MD should assess likelihood of UTI
  - Low: clinical follow up without testing
  - High (>2%): 2 options :
    - 1. Obtain UA/culture via cath or SPA
    - 2. Obtain urine via bag, complete UA and if UA is suggestive of UTI obtain 2ndsample via cath or SPA. If negative, monitor clinically w/o abx
To establish dx of UTI, MD should require both UA suggestive of infection (pyuria and bacteriuria) and 50K CFU of uropathogen cultured from non-bagged sample

What is a (+) UA

UA: nitrates not good for children, LE has high SN, WBC threshold should be 5WBC/HPF
Bacteriuria: the presence of bacteria correlates with 10^5 CFU on cx

Who should be tested ( Low risk vs. not):

Females: age < 12 months; white race; fever > 39; duration > 2 days; no other ssx of infection
- ≤ 1% chance of UTI ≤1 risk factor
- ≤2% chance ≤ 2 risk factors
Males: nonblack race; fever > 39; duration > 24 hours; no other ssx of infection
- Uncircumcised: ≤2% chance only if they have no risk factors
- Circumcised:
  - ≤1% chance: ≤ 2 risk factors
  - ≤2% chance: ≤ 3 risk factors

How should we test them?

Catheterization or suprapubic aspiration (SPA)

Dx of UTI cannot be made through urine cx collected in bag; these have an unacceptably high false positive rate and are valid only when negative. SP is only 63%

Treatment:

Base choice of route of abx practically if toxic appearing or not tolerating PO, then tx parentally, otherwise PO
Base choice of agent on local biograms
Adjust abx as needed based on culture SN results
Tx for 7-14 days (no difference found between 7,10, or 14 days but 1-3 days was inferior)

Follow up studies:

Febrile infants with UTI should undergo RUS; if toxic recommended within first 2 days of dx, if well defer to later date.
Nuclear scans not recommended
VCUG are not recommended after first UTI unless RUS is abnormal

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7/27/2018 0 Comments

Pediatric DKA and Fluid Management

Kuppermann N et al. Clinical Trial of Fluid Infusion Rates for Pediatric Diabetic Ketoacidosis. www.nejm.org/doi/full/10.1056/NEJMoa1716816N Engl J Med. 2018 Jun 14;378(24):2275-228

Cerebral edema is an uncommon complication in DKA in pediatrics.
This study did not find any significant difference in adverse neurological outcomes when comparing slightly slower vs slightly faster infusion rates.
The infusion rates they studied were at the upper and lower boundaries of currently adopted protocols. We do not know what the results who have been if they had compared even faster infusion rates to the current protocols.
Resuscitation of the DKA patient should be based on the clinical presentation of the patient along with currently accepted protocols.

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Carolinas Medical Center
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