Acute Pyelonephritis in Children

M.Arief Rachman

01-038

Consultant : dr Alfred Siahaan SpA

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.

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.

DEFINITION
Urinary tract infection (UTI) is defined as the presence of bacteria in urine along with symptoms of infection.

 Acute pyelonephritis is a potentially organ- and/or life-threatening infection that characteristically causes some scarring of the kidney with each infection and may lead to significant damage to the kidney (any given episode), kidney failure.

ETIOLOGY
Escherichia coli is the most common infecting pathogen in children, accounting for up to 80 percent of UTIs. Other pathogens include Staphylococcus and Streptococcus species, a variety of enterobacteria (e.g., Klebsiella, Proteus) and, occasionally, Candida albicans.

INTRARENAL REFLUX OF BACTERIA

IMMUNE RESPONSE

COMPLEMENT ACTIVATION BACTERIAL ENDOTOXIN CHEMOTAXiS

BACTERIAL KILLING

PHAGOCYTOSIS

GRANULOCYTE AGGREGATION

SUPEROXIDE & LYSOZIME RELEASE TUBULAR CELL DEATH INTERSTITIAL INVASION RENAL SCAR
FOCAL ISHEMIA

PATHOGENESIS

DIAGNOSIS
CLINICAL PRESENTATION URINE CULTURE / URINALYSIS IMAGING STUDIES

CLINICAL PRESENTATION
Fever Flank pain Malaise Nausea Vomiting

URINE CULTURE
Sample of urine Colony specimen Infection Supra pubic punction Any negative gram bacterial >10 5 104-105 103-104 <103 > 99%

Cathterized specimen

95% Suggest UTI Doubt UTI UTI Negative

Mid stream

>104 3x specimen>105 2x specimen>105 1x specimen >105 <104

Suggest UTI 95% 90% 80% UTI Negative

URINALYSIS
Gross hematuria significant pyuria (>20 WBCs/hpf) The dipstick leukocyte esterase test (LET)

HISTOLOGICAL STUDIES

HISTOLOGICAL STUDIES

HISTOLOGICAL STUDIES
The inflammation can destroy the tubules, forming abscesses. The presence of polys in the tubules is strong evidence of possible bacterial infection. Polys are seen in the interstitium/interstitial capillaries as well.

PIV

DMSA Renal Scan

 The SPECT technique for 99mTc-DMSA scintigraphy was used to make it comparable to the other cross-sectional imaging techniques. The images were obtained 23 hours after an intravenous injection of 99mTc-DMSA in a dose of approximately 3.7 MBq/kg (100 Ci/kg). The SPECT images were reconstructed in coronal, sagittal, and transverse planes by using a Butterworth filter with a frequency cutoff of 0.4 cycles per centimeter. The criterion for the diagnosis of acute pyelonephritis was subjective evidence of focal areas of decreased uptake seen with at least two projections. No attempt was made to quantify the severity of decreased uptake (Fig 1a).

USG

 Longitudinal power Doppler US image of the left kidney demonstrates markedly decreased blood flow (arrows) to the lower pole

MRI

 Coronal contrast agent-enhanced fast multiplanar inversion recovery MR image (2,000-2,500/17; inversion time, 160 msec) of the same piglet as in a demonstrates foci (arrows) of high signal intensity in the upper and lower poles of the right kidney and the lower pole of the left kidney.

CT Scan

CT Scan
Figure 2. Transverse spiral CT scan obtained after intravenous administration of contrast agent demonstrates welldefined foci (arrows) of decreased attenuation in the anterior cortex of the right kidney and posterior cortex of the left kidney.

RISK FACTORS
Obstruction (intrinsic/extrinsic) Urinary diversion procedures Foreign bodies Vesicoureteral reflux Neurogenic bladder

Treatment of acute pyelonephritis in children

Ceftriaxone (Rocephin Pediatric Dose >7 d: 25-50 mg/kg/d IV/IM; not to exceed 125 mg/d Infants and children: 50-75 mg/kg/d IV/IM divided q12h; not to exceed 2 g/d Third-generation cephalosporin with broadspectrum, gram-negative activity; lower efficacy against gram-positive organisms; higher efficacy against resistant organisms.

 Gentamicin (Garamycin) Pediatric Dose <5 years: 2.5 mg/kg/dose IV/IM q8h >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

 Ampicillin (Principen, Omnipen, Marcillin) Pediatric Dose 50-100 mg/kg/d PO divided q4-6h; 100400 mg/kg/d IM/IV divided q4-6h

 Amoxicillin (Amoxil, Trimox Pediatric Dose 20-50 mg/kg/d PO divided q8h

 Cephalexin (Keflex Pediatric Dose 25-50 mg/kg/d PO q6h; not to exceed 3 g/d

 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

 Trimethoprim and sulfamethoxazole (Bactrim, Bactrim DS, Septra, Septra DS) Pediatric Dose <2 months: Do not administer >2 months: 15-20 mg/kg/d, based on TMP, PO tid/qid for 14 d

Vancomycin (Vancocin Pediatric Dose 40 mg/kg/d IV divided tid/qid 7-10 d Potent antibiotic directed against gram-positive organisms and active against Enterococcus species Indicated for patients who cannot receive or did not respond to penicillins and cephalosporins or patients who have infections with resistant staphylococci

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.

Algorithm for the management of urinary tract infection in children

EVIDENCE BASE MEDICINE

A 9 month old girl presents with high fever, vomiting, lethargy, and bacteriologically confirmed urinary tract infection. The diagnosisacute pyelonephritis

1. How should she be treated? 2. Which antibiotics should be given and by which route? 3. For how long should antibiotics be given?

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.

which route?
Two trials including 306 and 387 children compared oral (cefixime,amoxicillin) with intravenous (ceftriaxone) treatment for three days or defervescence followed by cefixime or amoxicillin. Total duration was 10 or 14 days. No differences in the time to defervescence, recurrence of urinary tract infection, or frequency of renal parenchymal abnormality at 6-12 months were evident between the two groups

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

How long should antibiotics be given for?

there is evidence that short course treatment (3-4 days) is as effective as standard course (7-10 days) treatment

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 is safe and effective.