Pediatric Pearl: UTI (February)

FEBRUARY UTI – Hima Khamar

Pediatric Urinary Tract Infection
By: Hima Khamar, PGY3

In a previous pediatric pearl, we discussed how to treat febrile infants below 60 days. This pearl discussed management of pediatric urinary tract infection (UTI), but also discusses patients above the age of 60 days with a fever with no obvious source in whom UTI as a source.

History and Physical

History
Duration of fever
Symptoms that suggest an alternative source
Hydration status History of recurring fever without source
History of UTI
History of constipation
Dysfunctional voiding by history
FH of vesicoureteral reflux (VUR) or renal diseases

Physical
Vital signs
Suprapubic, flank tenderness
Abdominal mass, palpable bladder
Evidence of spinal lesion
Other GU abnormalities

Signs and Symptoms of UTI: Most common to least common*
Infants < 3 months Fever
Vomiting
Lethargy
Irritability
Poor feeding
Failure to thrive
Abdominal pain
Jaundice
Haematuria
Offensive urine
Infants > 3 months – preverbal Fever Abdominal pain
Loin tenderness
Vomiting
Poor feeding
Lethargy
Irritability
Haematuria
Offensive urine
Failure to thrive
Verbal – 18 years Frequency
Dysuria
Dysfunctional voiding
Changes to continence
Abdominal pain
Loin tenderness
Fever
Malaise
Vomiting
Haematuria
Offensive urine
Cloudy urine

Risk factors for UTI
Infants >56 days who are not toilet trained

Female risk factors
–       Non-black
–       T ≥ 39°C
–       Fever ≥ 2 days
–       No source
–       < 12 months
>3 risk factors consider screening>4 risk factors recommend screening
Male risk factors
–       Non-black
–       T ≥ 39°C
–       Fever ≥ 2 days
–       No source
–       < 6 monthsCircumcised:
≥ 3 consider screening
≥ 4 recommend screening
Uncircumcised:
≥ 2 consider screening
≥ 3 recommend screening
Fully toilet trained – 18 yrs
–       Symptoms referable to urinary tract
–       Prior history of UTI, fever ≥ 2 days
–       Prolonged fever (≥ 5 days)Recommend screening for any of the above factors
 

TO CATH OR NOT TO CATH?

The AAP recommends obtaining a catheterized specimen for diagnosis of UTI, but this is a level C recommendation. Upon further reading, they basically state a bagged specimen is acceptable as well. SO BASICALLY, GET THE URINE IN WHATEVER WAY YOU CAN.

UTI Definition

DEFINITE UTI
Catheterization with >50,000 cfu/ml
Clean catch with >100,000 cfu/ml
Leukocyte esterase and nitrite positive
Nitrite positive, leukocyte esterase negative
Pyuria and bacteriuria positive
Bacteriuria positive and pyuria negative
POSSIBLE UTI
Catheterization with >10,000 cfu/ml
Clean catch with >50,000 cfu/ml
Leukocyte esterase positive, nitrite negative = only treat if good evidence for UTI
Leukocyte esterase and nitrite negative = no UTI
Pyuria positive and bacteriuria negative = only treat for UTI if have good evidence
Bacteriuria and pyuria negative = no UTI

Whom to culture?

– Infants and children who are suspected to have acute pyelonephritis/upper urinary tract infection
– Infants under 3 months
– Infants and children with a positive result for leukocyte esterase or nitrite – EVERY POSITIVE URINALYSIS SHOULD BE CULTURED
– Infants and children with recurrent UTI
– Infants and children with an infection that does not respond to treatment within 24–48 hours, if no sample has already been sent

Urine Pathogens
E. coli, Proteus sp.
Enterococcus sp.
Pseudomonas sp.
Serratia sp.
Corynebacterium Urealyticum
Klebsiella sp.
Enterobacter sp.
Group B streptococci
Staphylococcus aureus

Common Contaminants
Lactobacillus sp.
Corynebacterium sp.
Coagulase-negative staphylococci
Alpha-hemolytic streptococci

ANTIBIOTICS

Oral vs. Parenteral Antibiotics
– Most patients will tolerate oral antibiotics. Patients should receive parenteral antibiotics if patient is ill appearing, not able to tolerate PO, or has any other contraindication to oral antibiotics.

-Antibiotics are recommended for 7-14 days. Shorter courses result in spread of infection and renal scarring.

PARENTERAL ANTIBIOTICS ORAL ANTIBIOTICS
Ceftriaxone 75 mg/kg Q24h

Cefotaxime 150 mg/kg divided into Q6-8h

Ceftazidime 100-150 mg/kg divided into Q8h

Gentamicin 7.5 mg/kg divided into Q8h

Tobramycin 5 mg/kg divided into Q8h

Piperacillin 300 mg/kg divided into Q6-8h

Amox-clav 20-40 mg/kg divided into Q8h

TMP 6-12 mg/kg SMX 30-60 mg/kg divided into Q12h

Cefixime 8 mg/kg Q daily

Cefpodoxime 10 mg/kg divided into Q12h

Cefuroxime 20-30 mg/kg divided into Q12h

Cephalexin 50-100 mg/kg divided into Q6h

ADMISSION CRITERIA

– Toxic appearance
– Dehydration requiring IVF
– Failed outpatient therapy
– Febrile infants < 60 days
– Non-febrile infants 31-60 days can be considered for outpatient therapy if they have good follow up within 24 hours

IMAGING

ALL patients should have a renal bladder US (RBUS) after their first febrile UTI. RBUS should be obtained after the patient has recovered from the acute infection (4-6 weeks). Studies have shown that in the acute phase can have false positives due to structural changes that are transient caused by the infection, such as hydronephrosis. (THIS IS FOR THE OUTPATIENT PHYSICIAN)
-Obtain the RBUS during acute illness if: Hospitalized; Ill, concern for sepsis; Abdominal, pelvic mass; Inadequate response to 48 hours of therapy.
-Voiding cystourethrogram (VCUG) should not be obtained routinely after first febrile UTI.
-Obtain VCUG if RBUS is abnormal.

 

REFERENCES:
1. CHOP Clinical Pathways
2. Seattle Children’s Hospital Clinical Pathways
3. AAP Guidelines on UTI
4. NICE Guidelines on UTI

 

COW

Presenting Resident: Katrina D’Amore, PGY4
Chief  Complaint: Palpitations

Brief HPI: 36 y/o F G4P2012 at 18 weeks gestation presents complaining of palpitations that began this morning. Patient reports a history of “SVT” multiple times in the past and she even underwent ablation in 2012.  Patient states that “Adenosine never ever works for me.” Patient  denies any other symptoms and was in her usual state of health until the symptoms began this morning. Patient does report she was recently
started on Synthroid by her OB for subclinical hypothyroidism.

Pertinent PE and Vitals
VS: Afebrile, HR 203 bpm, BP 125/86, 98% on RA
Patient appears uncomfortable but not in distress. PE unremarkable except for tachycardia.

Pertinent Imaging/EKG


Working Diagnosis at time of Disposition:
Wide Complex Tachycardia: Ventricular Tachycardia vs SVT with aberrant conduction

ED & Hospital Course
Patient noted to be on 240 mg PO verapamil daily at home. Decision made to give Verapamil 5 mg IVP x 1.  Patient immediately converted to Sinus rhythm at a rate of 100 bpm. Patient seen by both OB and EP at bedside. Electrolytes and troponin WNL. Normal Echo from 01/2019. Patient ultimately d/c with close f/u. Advised by EP to take extra ½ dose of Verapamil PO if palpitations recurred at home. Synthroid
discontinued.

Pearls & Takeaways
Diagnosis: Idiopathic Ventricular Tachycardia AKA Fascicular VT AKA Verapamil-sensitive VT AKA Belhassen-type VT
• Behaves like a reentrant tachycardia – usually seen in young adults (aged 15-40) w/o any  structural heart disease (thus the term idiopathic)
• Mainly affects males (60-80% of cases)
• Fascicular VT is the most common idiopathic VT arising from the LEFT ventricle (thus the term fascicular)
• Most have QRS only modestly prolonged (~120-140ms) and fast initial forces (RS interval 60-80 ms)
• QRS relatively “narrow” due to the origin of the tachycardia being very early in the His-Purkinje system.
• Classified based on the site of origin/EKG morphology
o Posterior fascicular VT (95% of cases) – RBBB + LAD
o Anterior FT (5%) – RBBB + RAD
o Upper septal FT (very rare) – narrow QRS with RBBB
• OFTEN misdiagnosed as SVT with a RBBB – presence of capture or fusion beats indicates it is a ventricular tachycardia
• Usually stable despite high ventricular rates (>200/min)
• Will not respond to vagal maneuvers, adenosine, etc
• Belhassen et al first described its sensitivity to Verapamil
• Treatment: VERAPAMIL 2.5-10mg IVP (thus the term verapamil-sensitive VT)
• If you are uncertain of the diagnosis, first line treatment is synchronized cardioversion.

Reviriego S. Idiopathic fascicular left ventricular tachycardia. European Society of Cardiology 2010; 9 (13)
Belhassen B, Rotmensch HH, Laniado S. Response of recurrent sustained ventricular tachycardia
to verapamil. Br Heart J 1981; 46: 679-82.

TRANEXAMIC ACID (TXA)

TRANEXAMIC ACID (TXA)

By: Hima Khamar M.D., PGY3

Tranexamic acid (TXA) has become a huge asset in the world of emergency medicine when it comes to controlling hemorrhage. The main use in the ED is in traumatic hemorrhage, but there are many other uses for TXA. In this article, I will discuss some of the other uses of TXA in the hopes that the next time you come across a patient whose hemorrhage you are unable to control with conventional methods, TXA maybe an addition to your toolbox.

TXA is an antifibrinolytic agent. It reversibly binds plasminogen which prevents plasmin activation. Decreased plasmin activation results in inhibition of fibrin clot degradation, thereby stabilizing the clot. This increase in clot formation and stabilization is how TXA works to control hemorrhage.

TXA comes in both oral and intravenous formulations. The oral form comes in 500mg or 650mg tablets and is cheaper. The intravenous form comes in a vial that is usually 1000mg/10ml. Both of these formulations are used in different disease processes, which will be further discussed below.

Despite the many uses of TXA, there are only two indications for which it is approved: tooth extractions for hemophiliac patients (to be given prior to the procedure) and control of heavy menstrual bleeding (this is given orally on an outpatient basis). All the other uses are off label, despite many of them having great evidence.

USES OF TXA

  1. Traumatic hemorrhage

1g IV bolus over 10 minutes loading dose, followed by 1g IV infusion over 8 hours – MUST BE GIVEN WITHIN THE FIRST 3 HOURS.

Evidence for this came out of the CRASH 2 trial in 2010. The study concluded that TXA reduced all-cause mortality and reduced risk of death due to bleeding when compared to the placebo group. Also, the subgroup analysis showed only effective when given within 3 hours.

  1. Epistaxis

Topical. Soak cotton pledget or any other epistaxis control device, such as RhinoRocket in TXA prior to placing in the nostril.

Evidence for this came out of an RCT by Zahed et al. in 2017. The study showed topical TXA resulted in quicker resolution of epistaxis, decreased ED length of stay, decreased re-bleeding rate, and increased patient satisfaction when compared to placebo.

  1. Dental bleeding in relation to dental procedures (FDA use approved only for hemophilia patients)

Mouthwash. Create by either using 5mg of intravenous solution (1000mg/10ml) in 5ml to make 5% solution OR 650mg tablet crushed and placed in 20ml. A paste can also be created with the tablets and saline to placed directly onto the bleeding region.

Evidence for this came from multiple studies in the dental literature starting around the mid-2000s which showed TXA reduced bleeding when used in a mouth wash formulation both during the procedure and for 2-3 days after the dental procedure when compared to placebo. This was also proven in hemophilia patients and in patients on anticoagulants, such as Warfarin.

  1. Cyclic heavy menstrual bleeding (FDA approved use)

1300 mg PO 3x daily for up to 5 days.

Evidence for this came from multiple RCTs and is also in the ACOG guidelines for management of heavy menstrual bleeding.

  1. Traumatic hyphema

25 mg/kg PO 3x daily for 5-7 days.

There is not a lot of evidence for this use, but it has been looked at in small studies and it is a use recommended by the American Academy of Ophthalmology on a case by case basis. There was a study looking at topical (via drops), but the study was very small so not generalizable.

  1. Orthopedic and cardiac surgery

This is not in our realm, but orthopedic studies are by far the most numerous looking at various doses and various formulations to decrease intra-operative bleeding.

  1. Postpartum hemorrhage

1g IV bolus over 10 mins, if continues to have bleeding after 30 mins or has another re-bleed within 24 hours then give another 1g IV bolus over 10 mins. (Dosing based on study)

Evidence for this comes from the WOMAN trial published in 2017. The study concluded that “Tranexamic acid reduces death due to bleeding in women with post-partum haemorrhage with no adverse effects. When used as a treatment for postpartum haemorrhage, tranexamic acid should be given as soon as possible after bleeding onset.”

  1. Hemoptysis

1g of TXA in 20ml of saline nebulized over 30 mins. (Dosing is controversial)

Evidence for this is based on various case reports. No large RCT exists at this time. This is very experimental, but definitely worth a try in those post-tonsillectomy patients (including pediatrics), cancer patients (oral or lung), or any other causes of hemoptysis.

These are just some of the uses documented in the literature. I think over time we will see more uses of TXA. I have personally used it in penile bleeding secondary to a false track created by a misplaced Foley catheter. I have also used it to stop bleeding topically for varicose veins. There are also current ongoing studies looking at its use in GI bleeding as well. SO, CONSIDER TXA THE NEXT TIME YOU ARE IN A BIND.

 

REFERENCES:

  1. Bryant-Smith et al. Antifibrinolytics for heavy menstrual bleeding. Cochrane Database Syst Rev. 2018 Apr 15.
  2. Carter et al. Current concepts of the management of dental extractions for patients taking warfarin. Aust Dent J. 2003 Jun;48(2):89-96.
  3. Carter et al. Tranexamic acid mouthwash: a prospective randomized study of a 2-day regimen vs 5-day regimen to prevent postoperative bleeding in anticoagulated patients requiring dental extractions. Int J Oral Maxillofac Surg. 2003 Oct;32(5):504-7.
  4. Coetzee, M J. 2007. The use of topical crushed tranexamic acid tablets to control bleeding after dental surgery and from skin ulcers in haemophilia. Haemophilia. 2007 Jul;13(4):443-4.
  5. Hankerson et al. Nebulized Tranexamic Acid as a Noninvasive Therapy for Cancer-Related Hemoptysis. Journal of Palliative Medicine. 2015. Volume 18, Number 12, 1060-62.
  6. Jahadi et al. Comparison between Topical and Oral Tranexamic Acid in Management of Traumatic Hyphema. Iran J Med Sci. 2014 Mar;39(2 Suppl):178-83.
  7. Komura et al. Hemoptysis? Tryi inhaled tranexamic acid. The Journal of Emergency Medicine. 2018. Vol. 54, No. 5, pp. e97–e99.
  8. Management of acute abnormal uterine bleeding in nonpregnant reproductive-aged women. Committee Opinion No. 557. American College of Obstetricians and Gynecologists. Obstetric Gynecology 2013;121:891–6.
  9. Nuvvula et al. Efficacy of tranexamic acid mouthwash as an alternative for factor replacement in gingival bleeding during dental scaling in cases of hemophilia: A randomized clinical trial. Contemp Clin Dent. 2014 Jan;5(1):49-53.
  10. Shakur et al. Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial. Lancet 2010; 376: 23–32.
  11. Shakur et al. Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial. Lancet 2017; 389: 2105–16.
  12. Zahed et al. Topical Tranexamic Acid Compared With Anterior Nasal Packing for Treatment of Epistaxis in Patients Taking Antiplatelet Drugs: Randomized Controlled Trial. Academic Emergency Medicine. 2018 Mar;25(3):261-266.