Acute Pyelonephritis m.arief 01-038

7/28/2019 Acute Pyelonephritis m.arief 01-038

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Acute Pyelonephritis in Children

M.Arief Rachman 01-038

Consultant : dr Alfred Siahaan SpA


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BACKGROUND

Urinary tract infection (UTI) is one of the

most common bacterial infection in infants.

The most severe form of UTI is acute

pyelonephritis, which results in significant

acute morbidity and may cause permanent

renal damage.


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BACKGROUND

Published guidelines recommend

treatment of acute pyelonephritis initially

with intravenous (IV) therapy followed by

oral therapy for seven to 14 days though

there is no consensus on the duration of

either IV or oral therapy.


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DEFINITION

Urinary tract infection (UTI) is defined as

the presence of bacteria in urine along

with symptoms of infection.


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Acute pyelonephritis is a potentially

organ- and/or life-threatening infection that

characteristically causes some scarring of

the kidney with each infection and maylead to significant damage to the kidney

(any given episode), kidney failure.


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ETIOLOGY

Escherichia coliis the most common

infecting pathogen in children, accounting

for up to 80 percent of UTIs. Other

pathogens include Staphylococcus andStreptococcus species, a variety of

enterobacteria (e.g., Klebsiella, Proteus)

and, occasionally, Candida albicans.


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INTRARENAL REFLUX OF BACTERIA

IMMUNE RESPONSE COMPLEMENT ACTIVATION

BACTERIAL ENDOTOXIN

CHEMOTAXiS

BACTERIAL KILLING PHAGOCYTOSIS GRANULOCYTE AGGREGATION

SUPEROXIDE & LYSOZIME RELEASE

TUBULAR CELL DEATH

INTERSTITIAL INVASION FOCAL ISHEMIA

RENAL SCAR


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PATHOGENESIS


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DIAGNOSIS

CLINICAL PRESENTATION

URINE CULTURE / URINALYSIS

IMAGING STUDIES


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CLINICAL PRESENTATION

Fever

Flank pain

Malaise Nausea

Vomiting


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URINE CULTURESample of urine Colony specimen Infection

Supra pubic punction Any negative gram

bacterial

> 99%

Cathterized specimen >10 5

104-105

103-104

104

3x specimen>105

2x specimen>105

1x specimen >105


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URINALYSIS

Gross hematuria

significant pyuria (>20 WBCs/hpf)

The dipstick leukocyte esterase test (LET)


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HISTOLOGICAL STUDIES


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The inflammation can destroy the tubules,forming abscesses. The presence of polysin the tubules is strong evidence of

possible bacterial infection. Polys are seenin the interstitium/interstitial capillaries aswell.


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PIV


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DMSA Renal Scan


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The SPECT technique for 99mTc-DMSA scintigraphy was used tomake it comparable to the other cross-sectional imaging techniques.The images were obtained 23 hours after an intravenous injectionof 99mTc-DMSA in a dose of approximately 3.7 MBq/kg (100Ci/kg).

The SPECT images were reconstructed in coronal, sagittal, and

transverse planes by using a Butterworth filter with a frequencycutoff of 0.4 cycles per centimeter.

The criterion for the diagnosis of acute pyelonephritis was subjectiveevidence of focal areas of decreased uptake seen with at least twoprojections. No attempt was made to quantify the severity ofdecreased uptake (Fig 1a).
http://radiology.rsnajnls.org/cgi/content/full/218/1/101http://radiology.rsnajnls.org/cgi/content/full/218/1/101


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USG


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Longitudinal power Doppler US image of

the left kidney demonstrates markedly

decreased blood flow (arrows) to the lower

pole


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MRI


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Coronal contrast agent-enhanced fast multiplanarinversion recovery MR image (2,000-2,500/17; inversiontime, 160 msec) of the same piglet as in a demonstratesfoci (arrows) of high signal intensity in the upper and

lower poles of the right kidney and the lower pole of theleft kidney.


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CT Scan


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CT Scan

Figure 2. Transverse spiral CT scan

obtained after intravenous administration

of contrast agent demonstrates well-

defined foci (arrows) of decreasedattenuation in the anterior cortex of the

right kidney and posterior cortex of the left

kidney.


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RISK FACTORS

Obstruction (intrinsic/extrinsic)

Urinary diversion procedures

Foreign bodies Vesicoureteral reflux

Neurogenic bladder

Treatment of acute pyelonephritis in


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Treatment of acute pyelonephritis in

children

Ceftriaxone (Rocephin

Pediatric Dose

>7 d: 25-50 mg/kg/d IV/IM; not to exceed 125

mg/dInfants and children: 50-75 mg/kg/d IV/IMdivided q12h; not to exceed 2 g/d

Third-generation cephalosporin with broad-

spectrum, gram-negative activity; lower efficacyagainst gram-positive organisms; higher efficacyagainst resistant organisms.


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Gentamicin (Garamycin)

Pediatric Dose

5 years: 1.5-2.5 mg/kg/dose IV/IM q8h or

6-7.5 mg/kg/d divided q8h; not to exceed

300 mg/d; monitor as in adults


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Ampicillin (Principen, Omnipen, Marcillin)

Pediatric Dose

50-100 mg/kg/d PO divided q4-6h; 100-400 mg/kg/d IM/IV divided q4-6h


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Amoxicillin (Amoxil, Trimox

Pediatric Dose

20-50 mg/kg/d PO divided q8h


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Cephalexin (Keflex

Pediatric Dose

25-50 mg/kg/d PO q6h; not to exceed 3g/d


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Nitrofurantoin (Macrobid, Macrodantin)

Pediatric Dose

>1 month: 5-7 mg/kg/d PO divided q6h;not to exceed 400 mg/d

Long-term therapy: 1-2 mg/kg/d PO

divided 12-24 h; not to exceed 100 mg/d


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Trimethoprim and sulfamethoxazole

(Bactrim, Bactrim DS, Septra, Septra DS)

Pediatric Dose

2 months: 15-20 mg/kg/d, based on TMP,

PO tid/qid for 14 d


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Vancomycin (Vancocin

Pediatric Dose

40 mg/kg/d IV divided tid/qid 7-10 d

Potent antibiotic directed against gram-positiveorganisms and active against Enterococcusspecies

Indicated for patients who cannot receive or did

not respond to penicillins and cephalosporins orpatients who have infections with resistantstaphylococci


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Patient Education

Good hygiene (including "front-to-back"

wiping after urination in girls)

avoidance of bubble baths, Chemical

irritants and tight clothing might be

recommended.


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Algorithm for the management of urinary tract infection in children


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EVIDENCE BASE MEDICINE

A 9 month old girl presents with high fever,

vomiting, lethargy, and bacteriologically

confirmed urinary tract infection.

The diagnosisacute pyelonephritis


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1. How should she be treated?

2. Which antibiotics should be given and by

which route?

3. For how long should antibiotics be

given?


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How should she be treated?

Infants aged 1 month or less with urinary

tract infection require intravenous

antibiotics

The choice of specific antibiotics should be

based on data about local uropathogens.


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which route?

Two trials including 306 and 387 childrencompared oral (cefixime,amoxicillin) withintravenous (ceftriaxone) treatment for

three days or defervescence followed bycefixime or amoxicillin. Total duration was10 or 14 days. No differences in the timeto defervescence, recurrence of urinary

tract infection, or frequency of renalparenchymal abnormality at 6-12 monthswere evident between the two groups


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Which antibiotic should be given?

trimethoprim alone or in combination with

sulphamethoxazole, cephalexin or

amoxicillin

If intravenous antibiotics are required,

aminoglycosides or third generation

cephalosporins


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How long should antibiotics be given for?

there is evidencethat short course

treatment (3-4 days) is as effective as

standard course (7-10 days) treatment


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conclusions

These results suggest that children with

acute pyelonephritis can be treated

effectively with oral cefixime or with short

courses (2-4 days) of IV therapy followed

by oral therapy. If IV therapy is chosen,

single daily dosing with aminoglycosides issafe and effective.


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Acute Pyelonephritis m.arief 01-038