UTI

Question 1

Vaccines and fever

Answer 1

major adverse effect to vaccines is fever that occurs within 24-48 hrs on first dose of particular inoculation

Question 2

Fever without a source

Answer 2

Complete history has been obtained and detailed PE performed and no source of fever found
*most common = viral syndrome

Question 3

Possible etiologies serious bacterial illness (SBI)

Answer 3

UTI
Meningitis
Sepsis
PNA
Bacterial gastroenteritis
Osteomyelitis
Septic arthritis
Occult bacteremia

Question 4

Occult bacteremia

Answer 4

Child with bacteremia that appears well –> generally does NOT develop into SBI
Strep pneumo, Hib, neisseria, salmonella

Question 5

Meningitis in Infants

Answer 5

Kernig's or Brudzinski's signs, nuchal rigidity
Fever, hypothermia
Bulging fontanelles, lethargy
Irritability, restlessness
Paroxysmal crying, poor feeding
Vomiting, diarrhea

Question 6

WBC differential

Answer 6

Leukocytosis with a “left-shift” (immature neutrophils) indicates a bacterial infection rather than a viral infection

Question 7

Oral vs IV antibiotics

Answer 7

Oral - UTIs can mostly be managed with oral meds

IV - if patient appears “toxic” or cannot retain oral medications

Question 8

Role of prophylactic Abx in UTI kids

Answer 8

have been shown to be beneficial in reducing UTIs in kids with vesiculo-ureteral reflux

Question 9

Kernig’s sign

Answer 9

resistance with extension of knee

Question 10

Brudzinski’s sign

Answer 10

flexion of hip and knee in response to flexion of neck by examiner

Question 11

DDx of infant with fever

Answer 11

UTI
PNA
Sepsis
Bacterial/Viral meningitis
Roseola
Occult bacteremia
Herpes simplex
Otitis media
Vaccine reaction

Question 12

UTI

Answer 12

commonly presents as fever and no focus on PE, fussiness and lack of appetite
RISKS: uncircumcised male, female

Question 13

PNA

Answer 13

most children with PNA have cough, tachypnea, fever, rales, low SaO2
consider CXR

Question 14

Sepsis

Answer 14

systemic response to infectious agent - inflammation throughout body –> vasodilation and increased permeability
FEVER, looking toxic, tachycardia, poor perfusion, bacteremia

Question 15

Bacterial Meningitis

Answer 15

S. pneumo or N. meningitidis
Kernig's or Brudzinski's signs, nuchal rigidity
Fever, hypothermia
Bulging fontanelles, lethargy
Irritability, restlessness
Paroxysmal crying, poor feeding
Vomiting, diarrhea

Question 16

Viral Meningitis

Answer 16

symptoms typically less severe than bacterial

- enterovirus is most common

Question 17

Roseola

Answer 17

common viral illness in kids under 2

• HHV-6
• high fever for 5 days followed by rash

Question 18

Testing for fever without source

Answer 18

UA and urine culture - need a clean sample
CBC - left-shift = bacterial origin likely
Blood culture - if febrile and looks ill, it may be necessary
LP - unable to ID fever source, inconsolable, pale -> think about it

Question 19

UA interpretation

Answer 19

Pyuria - >5 WBCs per field
Nitrie Test - happens with gram (-) –> reduces nitrate to nitrite (E.Coli and Klebsiella), positive test has high specificity
Leukocyte esterase - product of broken-down leukocytes

Question 20

Follow-up from first pyelonephritis episode

Answer 20

US of kidneys and bladder - renal structure and dilation
Voiding Cystourethrogram - demonstrates presence of vesicoureteral reflux if present –> don’t do unless findings on US suggest it

Question 21

Managing Occult Bacteremia

Answer 21

Empiric treatment not recommended

- close follow up and document everything

Question 22

IV ABx treatment for pyelonephritis

Answer 22

1. Ampicillin/Gentamicin - resistance rising so make sure to use gentamicin to get coverage against E. Coli
2. Ceftriaxone - excellent coverage against gram (-), excellent safety for kids
3. Piperacillin/tazobactam - good coverage against gram (-) and covers pseudomonas

Question 23

Oral ABx treatment for pyelonephritis

Answer 23

1. Keflex (1st gen) - inexpensive and well tolerated
2. Sulfisoxazole - wide resistance, don’t use
3. Nutrofurantoin - good [ ] only reached in urine, not blood
4. Ciprofloxacin - expensive, possible adverse effect
5. Augmentin - effective but skin and GI side effects
6. Bactrim - effective but sulfa