Re: Follow up for UTI in 3 yo girl

[Guest guest]

You know, I've been thinking your pediatrician up there, is perhaps a jerk? Based on your observations and notes in the past. Enough about him.Now about your kid.As you know, it depends on the age of the munchkin. The same old rubric applies: A 6 minute old human is a different creature than a 6 hour old human, is different from a 6 day old infant, is different from a 6 week old, is different from a 6 month old...6 year old.... 16 year old. After that they start to level out a bit and then it's beyond my jurisdiction sometime around 21. Like, the newborns are a separate kind of being, you know? I'm old school. Nobody can fault you or me for working up a baby under two months old, who has fever of unknown source or is vomiting with or without fever or who plain just doesn't look right. Collect all fluids for exam and culture. Consider images because it could be NEC even in a full term baby, or pneumonia. CBCs, blood cultures, spinal taps, urine cultures, even images, are all cheap; lives are not cheap. And if herpes even crosses your mind fleetingly, treat immediately and continue investigations while that drip is running. There is some new evidence coming in, opinions falter and change here and there with what appears to be the new evidence based treatment. But still I follow Patton's Rule as above until the evidence strongly suggests this results in more harm than good. But I'm thinking your kid is older than two months? Toddlers and almost toddlers who can't always tell you what hurts or where what hurts, are trickier. So much depends on age, how sick the kid looks, how reliable or capable the parents are. This is where algorithms, cookbooks and minute clinics are not working well. A good looking, smiling toddler with fever can really have the meninge, go down so fast that there is nothing you can do or could have done to keep that child from trying to go to heaven. It does happen. However, what ever the toddler has, is more likely to be the current viral thing going around than meninge. On waiting for the child to pee. Sigh. I always thank a nurse for putting a bag on the child. It's always good to have some idea of the amount of urine out put. And I'm always so happy that the kid is getting some attention in the ER before I get there. Would I use it for a culture? No. That said. If the UA is leuk or nitrite negative, that actually means something to most of us, right? unless the urine is very dilute. Still not a guarantee despite the negative predictability. So what to do while waiting for the kid to produce some urine? I'm a big believer in serial observations while we hydrate the wee wee out of the kid and the wait time accumulates. ERs may not like it, but they are usually very gracious to kids. Clean up the wee wee spots, put on some topical while holding a cup in position to catch any urine that may decide to come out with the stimulation, put on a fresh bag. Hydrate, oral or IV. If the kid can't keep the oral hydration down, well that's important information. Then after a suitable time to allow the topical to work, cath the kid. Then you're good to wait. Have quality time and a cup of tea with the parents, they will appreciate it, finish those pesky discharge dictations,make phone calls. The urine will come out. I have never, ever, regretted the time spent. Supra pubic taps are the standard with proper technique, but if there is not enough fluid in the tank, you will come up dry no matter how good the technique. So cath, wait and hydrate works for me. Hamster wheels do not like this. But I like sleeping well at night. It becomes for me, a matter of what am I treating if I treat with abx even though I don't anything to impugn? Of course this too depends on age. A 6 year old is so different from a 6 month old...Golly, long post. Saturday night logorrhea. If I've left any gaps or questions, please let's talk. Please forgive. I teach medical decision making to med students. Hence verbosity and style.Time to watch Dr. Who with the family.God speed to all of you getting through this night and sweet dreams to those who get to sleep tonight. K thanks Kathleen - I am to0 lazy to look this up- If you have a sick little one how many hrs do i wait trying ot get bagged specimen- ok that is not a c lean catch-- knowing I have to have the pee before I start antibx? The situation is febrile little munckin., no obvious cause The ER nurses tell me they will just stick a bag on but the pediatricians reprimand me if I admit I did that?(I am afraid of my local pedaitricians I admit pediatrician -fear) HAD this happen recenlty I mean how long can I waitt?he was well enough to go home for montioring I did not give him an IV( more fluids--> make him pee) I t was toughAdvice?JeanOn Sat, Jun 5, 2010 at 2:08 PM, Kathleen Patton <krpattoncomcast (DOT) net> wrote: Elaine,Since she is 3 yo with first UTI, was afebrile, is now improving with treatment and without other known complications, most would not do a VCUG. About the culture: Citrobacter koseri, can be found everywhere. It's on the skin, especially in the GU-rectal area, because it's a common intestinal inhabitant. It's also in soil, can be found in water. So could be a contaminant especially if this was a bag specimen. A 3 yo girl is a good candidate for a clean catch that you can count on, with assistance.AAP recommends unless you can get a reliable clean catch, get a transurethral or suprapubic urine. Hope this helps Further Outpatient CareThe American Academy of Pediatrics recommends all infants and young children (2 months to 2 years of age) with first UTI have a urinary tract ultrasonography and voiding cysto-urography (VCUG). These tests should be acquired promptly if patients fail to show expected clinical response within 2 days of treatment.All patients should have close follow-up to evaluate response to antibiotics.Repeat urinalysis and/or urine cultures are not needed if the patient’s condition responds to therapy as expected.Hi Folks- I would love you opinion on this, as I am trying to see if this pt can avoid a VCUG.Healthy 3 yo girl first UTI, likley from wet bathing suit, just started swimming lessons. Had lower abdo pain, freq and dysuria. No back pain no fever. Urine dip , postive for leuk-75, no blood, no nitrates. Culture grew 50,000-100,000 CFU/ML OF CITROBACTER KOSERI (DIVERSUS), so not over 100 000.Child is much better. I ordered a follow up urine culture and US, results not back yet. Should I also order a VCUG? It seems invasive and has Radiation. All my references say order a VCUG for bladder infection for girls under 5 yo. But she only had less than 100 000 CFU..maybe that does nto count as full blown UTI. My peds colleague says do VCUG. My FP colleague says not for the first UTI but on the second. What woud you all do? Thx in advance for the replies. I can always count on this brilliant group.-- M.D.www.elainemd.comOffice: Go in the directions of your dreams and live the life you've imagined.This email transmission may contain protected and privileged, highly confidential medical, Personal and Health Information (PHI) and/or legal information. The information is intended only for the use of the individual or entity named above. If you are not the intended recipient of this material, you may not use, publish, discuss, disseminate or otherwise distribute it. If you are not the intended recipient, or if you have received this transmission in error, please notify the sender immediately and confidentially destroy the information that email in error. -- PATIENTS-please remember that email may not be entirely secure, and that Email is part of the medical record and is placed into your chart ( be careful what you say!)Email is best used for appointment making and brief questionsEmail replies can be expected within 24 hours-Please CALL if the matter is more urgent . MD ph fax impcenter.org

[Guest guest]

Thank you. This helps a lot!

 

Elaine, Since she is 3 yo with first UTI, was afebrile, is now improving with treatment and without other known  complications, most would not do a VCUG. 

About the culture:  Citrobacter koseri, can be found everywhere. It's  on the skin, especially in the GU-rectal area, because it's a common intestinal inhabitant.  It's also in soil, can be found in water.  So could be a contaminant  especially if this was a bag specimen.   A 3 yo girl is a good candidate for a clean catch that you can count on, with assistance.

AAP recommends unless you can get a reliable clean catch, get a transurethral or suprapubic urine.  

Hope this helps 

Further Outpatient Care

The American Academy of Pediatrics recommends all infants and young children (2 months to 2 years of age) with first UTI have a urinary tract ultrasonography and voiding cysto-urography (VCUG). These tests should be acquired promptly if patients fail to show expected clinical response within 2 days of treatment.

All patients should have close follow-up to evaluate response to antibiotics.

Repeat urinalysis and/or urine cultures are not needed if the patient’s condition responds to therapy as expected.

Hi Folks- I would love you opinion on this, as I am trying to see if this pt can avoid a VCUG.

Healthy 3 yo girl first UTI, likley from wet bathing suit, just started swimming lessons. Had lower abdo pain, freq and dysuria. No back pain no fever. Urine dip , postive for leuk-75, no blood, no nitrates. Culture grew   50,000-100,000 CFU/ML OF CITROBACTER KOSERI (DIVERSUS), so not over 100 000.

Child is much better. I ordered a follow up urine culture and US, results not back yet. Should I also order a VCUG? It seems invasive and has Radiation. All my references say order a VCUG for bladder infection for girls under 5 yo. But she only had less than 100 000 CFU..maybe that does nto count as full blown UTI. My peds colleague says do VCUG. My FP colleague says not for the first UTI but on the second. What woud you all do? Thx in advance for the replies. I can always count on this brilliant group.

--  M.D.www.elainemd.comOffice: Go in the directions of your dreams and live the life you've imagined.

This email transmission may contain protected and privileged, highly confidential medical, Personal and Health Information (PHI) and/or legal information. The information is intended only for the use of the individual or entity named above. 

If you are not the intended recipient of this material, you may not use, publish, discuss, disseminate or otherwise distribute it. If you are not the intended recipient, or if you have received this transmission in error, please notify the sender immediately and confidentially destroy the information that email in error. 

-- M.D.www.elainemd.comOffice: Go in the directions of your dreams and live the life you've imagined.

This email transmission may contain protected and privileged, highly confidential medical, Personal and Health Information (PHI) and/or legal information. The information is intended only for the use of the individual or entity named above.

If you are not the intended recipient of this material, you may not use, publish, discuss, disseminate or otherwise distribute it. If you are not the intended recipient, or if you have received this transmission in error, please notify the sender immediately and confidentially destroy the information that email in error.