UMEM Educational Pearls - By Lauren Rice

--The diagnosis and treatment of pediatric urinary tract infections (UTIs) can be broken down into different age groups. The AAP has recently updated its recommendations for children age 2 - 24 months.

--In ill-appearing febrile infants age 2 – 24 months, who require early initiation of antibiotics, clinicians should obtain urinalysis and urine culture by catheterization or suprapubic aspiration prior to administration of the first dose of antibiotics.

--Key components of diagnosing a UTI include: urinalysis with the presence of pyuria (>10 WBCs per µL) and bacteriuria. The ultimate diagnosis relies on identification of >50,000 CFUs per mL of a single urinary pathogen in culture.

--Treatment of most UTIs in well appearing infants 2-24 months can be done with oral antibiotics for a course of 7-14 days. Common antibiotics used include: amoxicillin-clavulanate, trimethoprim-sulfamethoxazole, or cephalosporins (cefpodoxime, cefixime) based on local patterns of susceptibility.

--Febrile infants with UTIs should undergo renal and bladder ultrasound (RBUS) to evaluate the renal parenchyma and identify complications of UTI in children who are not responding to treatment within 48 hours.

--Voiding cystourethrography (VCUG) to diagnose vesicoureteral reflux (VUR) as a cause of UTI should not be obtained routinely, but only in children with abnormal RBUS or with recurrent febrile UTIs.

Show References

This winter season has brought a rise in influenza and RSV activity in Maryland and in many parts of the country. It is also important to remember other potentially lethal infections that are prevalent in the winter and early spring months, such as Neisseria meningitidis. In fact, a recent study2 showed a potential increase in meningococcal disease when influenza and RSV activity is high.

What:
Encapsulated, gram-negative diplococcus
Where:
Found in nasopharyngeal secretions, carrier rates 2-30% in normal populations
Who:
Age of incidence has 2 peaks: children < 2 years old, teens 15-19 years old
Young adults who live in shared housing, such as college dorms and military recruits

Clinical Presentation:
Early non-specific symptoms of URI, fever, malaise, myalgias
Meningitis: non-specific prodrome + headache, stiff neck (not found in younger children who often present atypically with irritability and/or vomiting)
Meningococcemia: above symptoms + hypotension + petechial rash (>60% of patients)

Treatment:
Early (!) antibiotics: 3rd generation cephalosporins (<3mo: cefotaxime; older infants, children, and teens: ceftriaxone); PCN G is antibiotic of choice for susceptible isolates
Early and aggressive management of shock

Prevention:
Tetravalent vaccine, MCV4 (Menactra, Menveo), available for serogroups A, C, Y and W-135 is given routinely at age 11-12 years old with an additional booster at 16-17 years old. MCV4 does not protect against serogroup B which accounts for 30% of infections.
 

Show References

Rotavirus is the leading cause of gastroenteritis worldwide and a leading cause of infant death in the developing world.

95% of U.S. children have had a rotavirus infection by the age of 5 years.

Most cases occur in late winter and early spring.

Route of transmission is mostly fecal-oral but may be airborne in cooler months.

Most common presenting signs and symptoms include fever (1/3 of cases), vomiting (in the first 1-2 days), and diarrhea (copious, watery, lasting 5-21 days).

Diagnosis is largely based on clinical manifestations, but antigen assays are available and may be useful in patients with extraintestinal complications, such as hepatitis, pneumonitis, or encephalopathy.

Treatment is largely supportive with efforts to maintain hydration.

Prevention is key to disease control and accomplished with good hand hygiene and widespread vaccination.

Newly implemented vaccine programs worldwide have proven to be effective in decreasing hospitalizations and deaths in developing countries.

Show References

If concern arises on screening assessment, keep child in hard cervical collar and image (may start with x-ray and progress to CT if still concerned and x-rays negative).

If imaging negative, but persistent suspicion based on neurological deficits consider SCIWORA (Spinal Cord Injury WithOut Radiographic Abnormality) which exists in up to 50% of children with cervical cord injury, and may require MRI to further identify injury.

Henoch-Schonlein Purpura (aka. Anaphylactoid purpura) is a small vessel vasculitis.

Background:

• most commonly diagnosed vasculitide in childhood
• age range 3-15 years, mean age 4yo, mostly <7yo (75% cases)
• more cases in Winter and Spring months
• boys more commonly than girls (2:1)
• IgA-mediated leukoclastic vasculitis

Clinical Features:

• Rash: progresses to petechiae, purpura; occurs on lower extremities and buttocks in dependent areas
• Joints: arthritis/arthralgia mainly of large joints (knees, ankles)
• GI: colicky abdominal pain, may occur with melena (33%) or less likely, hematemesis; ultrasound for intussusception (2-14%)
• Renal: microscopic hematuria with/without proteinuria; usually transient but may lead to progressive renal disease in patients with more severe, persistent symptoms
• Orchitis and/or angioedema may also occur

Etiology:

• unknown
• preceding URI (50%)
• associated with bacteria (Strep pyogenes, Legionella, Mycoplasma), viruses (EBV, CMV, parvovirus), drugs (penicillin, cephalosporins), and insect bites

Diagnosis:

• clinical features
• lab studies that are helpful but nonspecific: high WBC, high ESR, high IgA, normal platelet and coagulation studies

Treatment:

• supportive care, may last up to 4 weeks
• steroids may be helpful but evidence has not shown true benefit
• recurrence happens in 40% of cases