Pediatric Primary Care Case Studies (108 page)

•   Prevent urinary tract infections.

•   Resolve dysfunctional elimination syndrome.

•   Monitor vesicoureteral reflux.

•   Educate the family on how to achieve the above goals.

What additional studies are necessary to confirm the diagnosis?

Urine culture and sensitivity are indicated to identify the causative organism and specific antibiotic management. Febrile infection and more than one infection in a child less than 5 years of age require evaluation by a renal and bladder ultrasound and voiding cystourethrogram (Shortliffe, 2007).

What is the first thing you need to do to manage her UTI?

Medications

Ashley should be started on antibiotics empirically. Two months ago she was seen in the ED, at which time her urine specimen grew greater than 100,000 colonies of
Klebsiella pneumoniae
. She was treated in the ED with a single dose of ceftriaxone and discharged on oral cephalexin. The culture was sensitive to the prescribed treatment and sulfamethoxazole. Today’s clinical symptoms are consistent with a lower tract bladder infection; she does not have fever, flank pain, nausea, or vomiting, which are symptoms of pyelonephritis. She is started on trimethoprim-sulfa; when she finishes the treatment dose, she will be started on prophylaxis. Trimethoprim-sulfa is a good choice; it is inexpensive, does not need to be refrigerated, has a relatively long shelf life, and is unlikely to cause gastrointestinal upset. The side effect profile overall is low.

Antibiotic prophylaxis is appropriate for a child with a history of a febrile infection, until she has been evaluated fully. She is at risk for anatomical abnormalities and should be maintained on prophylaxis until her X-ray evaluation is complete (Gaylord & Starr, 2009).

Further Diagnostic Studies

A renal and bladder ultrasound is used to rule out kidney abnormalities, and a voiding cystourethrogram is obtained to rule out vesicoureteral reflux or bladder abnormalities. In children, it is important to discover anatomical sources for bacterial persistence that may necessitate surgical intervention (Shortliffe, 2007). A renal and bladder ultrasound and voiding cystourethrogram should be obtained in any child with a febrile urinary tract infection, any male child, and any infant or child under age 5 (Shortliffe). Patients with hydronephrosis or grade IV–V VUR should be referred to a pediatric urologist.

An X-ray evaluation was obtained. An ultrasound shows normal kidneys, with a significant postvoid residual. A voiding cystourethrogram (VCUG) shows grade II vesicoureteral reflux into the right renal pelvis. She did not empty her bladder on VCUG and has a spinning-top urethra, the classic finding of detrusor sphincter dyssynergia. Detrusor sphincter dyssynergia is a lack of coordination between the bladder contraction and relaxation of the external sphincter. This discoordination leads to incomplete evacuation of the bladder. A KUB (kidneys, ureters, and bladder) X-ray typically precedes the VCUG, and in Ashley’s case reveals a moderate stool burden. Constipation may provoke detrusor-sphincter activity. The bony structure of the spine appears normal. The X-ray evaluation is consistent with dysfunctional elimination and vesicoureteral reflux.

How do you plan to manage her dysfunctional elimination syndrome?

Dysfunctional Elimination Syndrome

Dysfunctional elimination must be addressed regardless of the results of her X-ray evaluation. She needs to be placed on a timed voiding regimen during the day. She is in the habit of holding her urine to the point of having urge incontinence. Often these children have difficulty relaxing the external sphincter and do not take time to void to completion. This is complicated by constipation, which increases colonization of the intestinal flora and may create difficulty with voiding to completion.

You explain to the mother that Ashley’s dysfunctional elimination will be managed by placing her on a strict timed voiding schedule during the day, every 2 hours by the clock, whether she has the urge to urinate or not. You suggest using a simple behavioral modification chart with days of the week and times of the day for scheduled voiding, which can be created with stickers to recognize her cooperation with the plan.

During today’s visit, Ashley is trained in the proper toileting posture to facilitate relaxation of the external sphincter and voiding to completion (Yeung, Sihoe, & Bauer, 2007). She is instructed to sit on the toilet with her legs widely separated. She should be sitting comfortably on the toilet with her feet supported. In small children this requires a seat adapter.

For constipation, she will be given a cleanout regimen, a pediatric Fleet enema given once a day for 2 to 3 days. A stool softener is also started and can be tapered as the stools become normal. There are many effective bowel management programs. The family is instructed on a high-fiber diet and increasing fluids during the day.

Urinary Tract Infection and Vesicoureteral Reflux

Ashley is started on trimethoprim-sulfamethoxazole treatment dose and then will be maintained on prophylaxis. Trimethoprim-sulfamethoxazole can be used in children
older than 2 months of age. The treatment dose is based on trimethoprim 6–12 mg/kg/day given BID for 10 days. The prophylaxis dose is also based on trimethoprim, but at 1–2 mg/kg/day. Trimethorprim-sulfamethoxzzole diffuses into vaginal fluid and decreases bacterial colonization.

Macrodantin or furadantin elixir is another effective treatment and/or prophylactic agent. It does not achieve high blood levels and should not be used for systemic or febrile infections. The most common side effect is gastrointestinal upset. To help prevent this problem, the medication should be given with food. The liquid form is not tolerated well by children. The capsules can be opened and sprinkled on applesauce, yogurt, or pudding. It can be given to children older than 2 months of age, and the treatment dose is 5–7 mg/kg/day given QID. Prophylaxis is 1–2 mg/kg/day in a single dose.

Amoxicillin is also used to treat urinary tract infections and is often used for prophylaxis in children under 3 months of age. It is tolerated well and has a low side effect profile, but can cause candidiasis in high doses. The suspension has to be refilled every 14 days, which makes it less convenient for families to use. Prophylaxis is 20 mg/kg/day in a single dose. Treatment dosing of amoxicillin is variable, based on age and severity of infection. Cephalosporins can also be used for treatment and/or prophylaxis.

Antibiotic management of pediatric UTIs is always done with caution. Age-related dosing restrictions, comorbid conditions, and severity of infection must be considered before treatment is recommended. These issues also affect the decision of whether to utilize inpatient intravenous therapy versus outpatient oral management. Children who appear toxic and those under 2 months of age who have suspected pyelonephritis should receive intravenous treatment. Ampicillin and aminoglycoside (if no known drug allergy) are started until culture and sensitivity results are final (Brown, Burns, & Cummings, 2002). Fluoroquinolones have been approved by the Food and Drug Administration (FDA) for the treatment of complicated UTIs in children. In children who present with a febrile UTI but do not appear toxic, 1 to 2 days of intramuscular ceftriaxone can provide coverage until culture results are final and appropriate oral therapy is determined

The family should be educated on the signs and symptoms of a UTI at this appointment. They should be able to differentiate between a significant upper tract or kidney infection and lower tract symptoms or bladder infection. With a history of vesicoureteral reflux, at the first sign of infection the child should be evaluated. The signs and symptoms of UTI should be revisited when discussing the X-ray evaluation with the family. If a urinalysis is positive, treatment should be started before culture results have been received to prevent the development of pyelonephritis. Vesicoureteral reflux should be evaluated by ultrasound and VCUG every 12 to 18 months. As long as the child has good overall renal growth, no evidence of scarring, no infections while on prophylaxis, and no worsening reflux, the child can be managed
conservatively. If they have breakthrough infections or upper tract changes, alternate management would need to be considered. This would warrant a referral to a pediatric urologist. Other variables that might lead to surgical management are allergies to multiple antibiotics and poor compliance with medical management.

Parent Education

You provide patient education as follows:

   Explain the diagnosis, pathophysiology, and typical progression of the disorder.

   Explain that antibiotics are necessary to hopefully prevent urinary tract infection. They do not treat or resolve vesicoureteral reflux.