Pediatric Infections - UTI & Bronchiolitis Flashcards
UTI Background
Overall incidence pre-pubertal patients
◦ 3% females; 1% males
◦ 9% incidence in infants < 60 days with ___
◦ 5% incidence in pediatric patients 2-24 months
By the age of __ years:
◦ 8% of girls will have had 1 UTI
◦ 2% of boys will have had 1 UTI
Potential long term complications
- fever
- 7
Risk Factors in Febrile Infants
Girls
◦ White
◦ Age < __ months
◦ Temperature ≥ __ ºC
◦ Fever ≥ __ days
◦ Absence of another source of
infection
Boys
◦ Nonblack race
◦ Temperature ≥ __ ºC
◦ Fever ≥ __ hours
◦ ___
◦ Absence of another source of
infection
Girls
- 12
- 39
- 2
Boys
- 39
- 24
- Uncircumcised
Pathogenesis
___ ascent
___ infection
Hematogenous spread
___ formation
- retrograde
- Nosocomial
- fistula
Common Pathogens
___ ≥ 80-85%!
Klebsiella
Proteus
Enterobacter
Citrobacter
Staphylococcus saprophyticus
Enterococcus
E. coli
Signs/Symptoms/Diagnosis
- Evaluate all febrile children < ___ months
- Older children should be evaluated if clinical presentation points to ___ source
- 24
- urinary
Signs/Symptoms/Diagnosis
Signs and symptoms vary by age
Newborns
- ___
- Sepsis
- Failure to thrive
- ___
- Fever
Infects/young children
- Fever
- Strong ___ urine
- hematuria
- abdominal/ ___ pain
- New-onset urinary incontinence
School-aged Children - symptoms similar to adults including:
- ___
- frequency
- urgency
Newborns
- Jaundice, Vomiting
- smelling
Infants/young children
- smelling
- flank
School-aged children
- Dysuria
Methods of Urine Collection
Clean catch
◦ Older patient groups
Catheterization
◦ Preferred for < ___ month age group
___ - ___ ___ (SPA)
◦ Gold-standard, but invasive (usually reserved for young children who fail
catheterization)
Bag specimen not recommended
◦ Unacceptably high rates of false ___ cultures
- 24
- Supra-pubic aspiration
- positive
Urinalysis
Performed with culture
Test urinalysis on any “fresh” urine specimen
◦ < __ hour after voiding if room temp
◦ < __ hours after voiding if refrigerated
Dipstick
- Yields ___ results
- Leukocyte ___ - Suggests inflammation and presence of WBCs
- More ___ , less ___ - false positive common
- ___ of leukocyte esterase in asymptomatic bacteriuria is an advantage
- Separates asymptomatic bacteriuria from true ___
- 1, 4
- rapid
- esterase
- sensitive, specific
- absence
- UTI
Urinalysis: Urine Dipstick
Nitrite
◦ Less ___ , more ___
◦ False positive uncommon
Converted from dietary nitrates in most gram ___ enteric bacteria in urine
◦ Process takes ~ __ hours; babies empty bladders more frequently
When nitrite and leukocyte esterase are both negative → 100% predictive
When both are positive → 80-90% ___ and 60-98% ___
- sensitive, specific
- negative
- 4
- sensitive, specific
Urine Microscopy
- More expensive
- Evaluates ___ , ___ , and ___ in sample
- ___ = > 5-10 WBCs per μL
- Bacteruria = any bacterial per μL
- WBCs, RBCs, and bacteria
- Pyuria
Urine Culture
SPA: > ___ CF/mL
Catheter specimen: > ___ CFU/mL
◦ Older standard was 50,000 – may be appropriate in some situations
◦ Data suggest lower cutoff has good balance of specificity/sensitivity
Clean catch: > ___ CFU/mL
Obtain cultures and urinalysis ___ starting antibiotics whenever possible!
- 10,000
- 10,000
- 100,000
- before
Treatment
Oral and IV equally ___
Most patients can have oral therapy
Choose IV for patients who are:
◦ “Toxic”
◦ Unable to retain oral intake
Can change to oral therapy when patient has clinical ___ – usually within 24-48 hours
- efficacious
- improvement
Duration of Therapy
Controversial
◦ __ - __ days for ages 2-24 months
◦ 10-14 days for ___
◦ __ - __ days for cystitis in older female patients
◦ ___ day therapy inferior in children
Older children may be able to get by with a __ day course of therapy (girls),
though studies used a wide age range
- 7-14
- pyelonephritis
- 3-7
- single
- 3
Treatment Options
Empiric therapy determined using local resistance patterns
Obtain cultures when possible to direct treatment
___ :
◦ In a lot of areas, good E. coli susceptibility
◦ Q6H might be better, but Q8H reasonable
___ traditionally 1st line (mentioned in guidelines)
◦ E. coli resistance makes it less acceptable choice (E. coli makes beta-lactamase; ___ / ___ might be better choice; Klebsiella makes beta-lactamase as well)
◦ Higher cure rates with ___ / ___ or amox/clav
- cephalexin
- amoxicillin
- amoxicillin/clavulanate
- trimethoprim/sulfamethoxazole
Treatment Options
___ / ___
◦ Can target E. coli that make beta-lactamases
___ / ___
◦ E. coli susceptibility varies; usually can still get high concentrations in urine
◦ Available oral suspension, given Q12H
◦ Dosed based on trimethoprim
◦ ADR: hyperkalemia, crystalluria, renal damage, SJS
___ ?
◦ Must confirm ONLY ___ ; can’t achieve adequate blood concentrations to treat pyelo or urosepsis
◦ Can be hard to confirm no pyelo in infants/young children – usually avoid
- Amoxicillin/clavulanate
- SMX/TMP
- Nitrofurantoin, cystitis
Fluoroquinolones in Children
Traditionally NOT used in children; resistance = major concern
May be useful in some circumstances
◦ MDR pathogens with no safe alternative
◦ IV therapy is not feasible
◦ No other effective oral agent
AAP guidelines recommend FQ use for ___ or other MDR gram-negative bacteria
Peds pearls:
◦ Don’t give ___ suspension through a feeding tube – will clog!
◦ Quinolone liquids often require PAs – consider if you can make tablet (1/4 or ½) work
- Pseudomonas
- Ciprofloxacin
Follow-up
Considerations for renal/bladder ultrasound and voiding cystography
◦ All boys
◦ All girls < __ years of age
◦ Girls 3-7 years with fever > ___ C
◦ AAP recommends only ultrasound for __ - __ months of age
- 3
- 38.5
- 2-24
Prevention
Efficacy of prophylaxis is questionable
Some clinicians perceive benefit in children with ___ ___ (VUR)
◦ No benefit found in mild to moderate
◦ Some benefit with severe VUR
Continuous prophylaxis may not reduce risk of ___ or ___ damage
- vesicoureteral reflux
- pyelonephritis, renal
Bronchiolitis
Caused by ___ LRTI in infants and young children
Acute inflammation, edema, increased mucus
Each year, in US children under 5 ___ leads to:
◦ Approx. 2.1 million outpatient visits
◦ Approx. 58,000-80,000 admissions
◦ 100-300 deaths (compare to ~200 for influenza A in 23-24 season)
◦ Cost: $1.73 billion
- viral
- RSV
Clinical Presentation
Cold-like symptoms
◦ Fever
◦ Rhinorrhea
◦ Cough
◦ Sneezing
Increased work of ___
◦ Nasal flaring
◦ Accessory muscle breathing
◦ Can progress to respiratory failure in some cases
May take up to __ weeks to resolve; symptoms often peak around day __
- breathing
- 2, 5
What causes bronchiolitis?
Many different ___ cause similar symptoms
Most common is ___
Others include rhinovirus (2nd most common), metapneumovirus, influenza,
adeovirus, parainfluenza, coronavirus
- viruses
- RSV
RSV
One of most common diseases of childhood
___ % children infected before 24 months
◦ Up to 40% have symptomatic infection w/initial infection
Re-infection throughout life is common (no ___ immunity)
Incubation period 2-8 days
◦ Symptoms may persist for up to one month
Season generally November to April in IN (varies with location, high mask use)
- 90%
- long term
Bronchiolitis Risk Factors
- Age < __ months
- ___ birth
- Cyanotic or complicated CHD
- Chronic lung disease
- Weakened ____
- 6
- Pre-term
- immune system
Bronchiolitis Treatment
Mainstay of treatment = ____ THERAPY
◦ Oxygen
◦ Hydration
◦ Mechanical ventilation
◦ ECMO
Data suggest many other therapies don’t impact LOS or reduce hospitalization
◦ β-adrenergic agonist
◦ Corticosteroids
◦ Antibiotics – not indicated for viral illness
◦ Ribavirin NOT recommended for routine use
SUPPORTIVE
Bronchiolitis Prevention
Non-pharmacologic
◦ Hand washing
◦ Isolation
◦ “Sick pods”
Pharmacologic: Influenza vaccine
◦ Everyone 6 months and older
◦ Children 6 months to 8 years who have NOT gotten 2 doses – > 2 doses separated by at least 4 week
RSV specific
◦ ___ (Beyfortus®) - new
◦ ___ RSV vaccination while pregnant
◦ Palivizumab (Synagis®) – old/going away?
- Nirsevimab
- Maternal
RSV Protection for Infants
Two ways to protect babies from severe RSV disease
1) Vaccination of ___ mom’s
2) Monoclonal antibody for infants
◦ Palivizumab (Synagis) – approved 1998
◦ ___ (Beyfortus) – approved 2023
1) pregnant
2) Nirsevimab
Vaccination of Pregnant People
Bivalent RSVpreF vaccine (Abrysvo - Pfizer)
* Reduces baby’s risk of being hospitalized from RSV by ___ % in the first six months after birth
Who qualifies:
* Administered ___ and during start of RSV season (Sept through Jan)
* People who are ___ through ___ weeks pregnant
* Some increased risk of preterm birth in trials
Provides protection if given at least ___ days before delivery
* In most* cases, this replaces infant RSV immunization
- 57%
- before
- 32-36
- 14
Monoclonal Antibodies for Infants
___ (Beyfortus)
- Birth parent did NOT get RSV vaccination at least ___ days before delivery
- Typically for infants < __ months of age
- High risk patients may receive dose in 2nd RSV season (rare)
Weight-based dosing
* < 5 kg = 50 mg
* 5 kg or more = 100 mg
Only indicated for ___ of RSV (not active infection); has not been studied as
treatment of RSV disease
- Nirsevimab
- 14
- 8
- prevention
Second Nirsevimab Dose?
Infants and children aged __ - __ months entering ___ season with increased risk for severe disease may get 2nd dose
* Chronic ___ disease of prematurity
* Chronic ___ therapy, diuretic therapy, or supplemental oxygen within 6-month period before the start of the second RSV season
* Severely immunocompromised children
* ___ significant congenital heart disease
* Cardiopulmonary bypass = extra dose
* American Indian or Alaska Native children
* 2nd season dose = 200 mg
- 8-19 ,2nd
- lung
- corticosteroid
- Hemodynamically
