Update on managing pediatric UTI - International Nursing Symposium

January 29, 2018 | Author: Anonymous | Category: Science, Health Science, Urology
Share Embed Donate


Short Description

Download Update on managing pediatric UTI - International Nursing Symposium...

Description

Donald McLaren, MD Seventh International Symposium in Continuing Nursing Education/March 2014

 Discuss

latest AAP guidelines for diagnosis and treatment of UTIs in febrile infants  Discuss UTI symptoms, diagnosis and treatment in children of all ages except newborns  To discuss some causes recurrent UTI and prevention of UTI and kidney damage in children with recurrent UTI

 In

febrile infants and small children, the urinary tract is the most common site of bacterial infection – about 5% of children 224 months will get at least one UTI  Some recommend UC in all 2-24 mo girls and uncircumcised males with fever >39o with no source and < 6 moa for a circumcised male (their risk much lower) (2-4 % vs. 10-25%)

 The

AAP periodically has put out guidelines for diagnosis and management of UTI in children.  The 2011 guidelines updating the 1999 guidelines: “Urinary Tract Infection: Clinical Practice Guideline for the Diagnosis and Management of the Initial UTI in Febrile Infants and Children 2-24 months” found at: http://pediatrics.aappublications.org/conten t/early/2011/08/24/peds.2011-1330

 This

has significant recommendation changes concerning diagnosis and evaluation of febrile UTIs in this age group.  We will discuss these guidelines. While there has been some controversy, the guidelines are very useful for us on the field as we work with children with possible UTI. They will decrease the amount of travel required for work-up after the initial febrile UTI in this age group over the 1999 guidelines

I

presented this topic in 2009. At that time the recommendation was that children with a first time febrile UTI needed an evaluation including a Renal Bladder US (RBUS) and VCUG (Voiding cystourethrogram)  This was because 33% had an underlying condition or vesicoureteral reflux (VUR) to explain the UTI AND  It was felt that repeated febrile UTIs in someone with VUR would result in significant sequelae – renal scarring, HTN, and eventual RF and as evidence see the next 2 slides

 When

1999 guidelines written, belief was that renal scarring occurred with UTI ONLY if VUR allowed infected urine reflux back up to the kidneys  But some then were already questioning whether this was true? Was this aggressive approach really indicated? I ended with this:  

 

Medicine is fun, exhilarating, maddening, frustrating, challenging, ever changing We in the profession must keep up as best we can to offer our patients the best care. What is dogma now may become wrong tomorrow We often don’t know what we don’t know.

 So,

as I present the 2011 guidelines, realize there is some controversy – some still think a first time UTI in a febrile child needs to be evaluated with a RUS and VCUG  But these new guidelines give us some much needed guidance for patients living overseas in deciding who needs to travel for further evaluation. They providing excellent guidance for diagnosis, treatment and workup of UTI in this group of children.

 “This

clinical practice guideline is not intended to be the sole source of guidance for the treatment of febrile infants with UTIs. Rather, it is intended to assist clinicians in decision making. It is not intended to replace clinical judgment or to establish an exclusive protocol for the care of all children with this condition.”

 Action

Statement 1: If a clinician decides that a febrile infant with no apparent source for the fever requires antimicrobial therapy because of ill appearance or another pressing reason, the clinician should ensure that a urine specimen is obtained for UA AND UC by catheterization or SPA (suprapubic urine) before antimicrobials given.

Pediatric EM Morsels © 2010-2014 http://pedemmorsels.com/hyperpyrexia-2/hyperpyrexia-2/

 To

tx first would obscure diagnosis of UTI  SPA gold standard but many consider it invasive and is more painful. May be only option in some (phimosis, labial adhesions)  Catheterization urine culture 95% sensitive, 99% specific compared to SPA  A bagged urine specimen not adequate in this age - has very high false positive rate (88% false + rate) and is only useful if negative

 If

a clinician assesses a febrile infant with no apparent source for fever as not being so ill as to require immediate antimicrobial therapy, then the clinician should assess the likelihood of UTI  2a If clinician determines the febrile infant to have a low likelihood of UTI, then clinical follow-up monitoring without testing is sufficient

 2b

If clinician determines that the febrile infant not in a low-risk group then either:  

Option 1 is to obtain a urine specimen through cath or SPA for UA and UC. OR Option 2: Obtain urine specimen by most convenient means and perform UA. If the UA results suggest UTI (+ leukocyte esterase or nitrite test; + microscopic analysis for leukocytes or bacteria), obtain the urine by cath or SPA for UA and UC (fresh < 1 hour old specimen or if refrigerated < 4 hours old)

 UTI

prevalence among febrile girls > 2X that of infant boys.  Rate for uncircumcised boys 4-20X that of circumcised boys who only have 0.2-0.4% risk  Presence of another source (i.e. OM) lowers risk by half.  New guidelines has a system based on studies to determine if risk is < 1% or at least 2%  Risk grid not absolute – if patient unlikely to keep F/U or lives in a remote location it is wise to check for UTI even if risk very low

Individual Factors • • • • •

Race: White Age: 24 hours Absence of another source of infection

Probability of UTI

# of Factors Present Circumcised No Yes

≤1%

*

No more than 2

≤2%

None

No more than 3

*Probability of UTI exceeds 1% even with no risk factors other than being uncircumcised.

 To

establish the diagnosis of UTI, clinicians should require both UA results suggesting infection (pyuria and/or bacteriuria) and the presence of at least 50 000 colonyforming units (CFUs) per mL of a uropathogen cultured from a urine specimen obtained through catheterization or SPA

+

UA AND UC now considered essential to diagnosis – UA essential, not sufficient alone  If only a + UC with - UA, considered to be either asymptomatic bacteriuria or contamination as inflammation should lead to an abnormal UA also  Asymptomatic bacteriuria known to occur in older children. 0.7% of afebrile girls had 3 cultures with a single uropathogen  Lack of pyuria distinguishes true UTI from asymptomatic bacteriuria

 Dipstick 

Positive leukocyte esterase is a marker for pyuria   



Sensitivity 94% in context of clinically suspected UTI Reported as 83% in other studies Specificity much less – 64-92% - false positives

Positive Nitrite (converted from dietary nitrates in presence of most gram negative bacteria but requires 4 hours in bladder) 

Not sensitive but very few false positives (specific) so if positive almost certainly have bacteria in the urine

>

5 WBC / hpf (25 WBC / microliter)  > 10 WBC/microliter in counting chamber  Unspun gram stained urine – 1 gm – bacteria / 10 hpf = 105 bacteria  UC of fresh or refrigerated specimen 

 

Significant > 50,000 CFUs/ml of a single urinary pathogen Lower number for SPA (> 1000 CFU/ml) Always do sensitivity if grows urinary pathogen

http://www.impactednurse.com/?p=2144

http://library.aua.edu.ag/webpath/webpath/tutorial/urine/urine.htm

 Action

Statement 4a When initiating treatment, the clinician should base the choice of route of administration on practical considerations. Oral and parenteral are equally efficacious. The choice of agent should be based on local antimicrobial sensitivity patterns (if available) and should adjust the choice according to sensitivity testing of the uropathogen

 4b

One can choose 7 to 14 days as the duration of antimicrobial therapy

 Goals   

of treatment

Eliminate infection and relieve symptoms Prevent complications Reduce likelihood of renal damage 

“Most experimental and clinical data support the concept that delays in the institution of appropriate treatment of pyelonephritis increase the risk of renal damage.”

 Most   

can be treated orally

Treat parenterally if toxic appearing Or if cannot hold down meds due to N/V Possibly if not responding or cannot get F/U

 Duration  

of treatment 7-14 days

Data comparing 7,10,14 days not available Evidence 1-3 days of treatment inferior

 Based

on local resistance patterns if possible  Must cover E. coli (80% of UTIs in this age) and other gram negative organisms  Significant degree of resistance in many places to TMP-SMP and Cephalexin  Those with multiple previous episodes of UTI often seem to be resistant to more drugs

© 2013 Answers in Genesis www.AnswersInGenesis.org.

 Amoxicillin/clavulanate

20-40 mg/kg/day

q8hr  Sulfisoxazole or TMP-SMX: 6-12 mg/kg TMP and 30-60 mg/kg SMX daily in 2 doses  Cephalosporins  

  

Cefixime – 8 mg/kg/ day in 1 dose Cefpodoxime – 10 mg/kg/day in 2 doses Cefprozil – 30 mg/kg/day in 2 doses Cefuroxime axetil – 20-30 mg/kg/day in 2 doses Cephalexin – 50-100 mg/kg/day in 4 doses

 Ceftriaxone

75 mg/kg every 24 hours  Cefotaxime 150 mg/kg/day divided q 6-8 hr  Ceftazidime 100-150 mg/kg/day divided q 8 hr  Gentamycin 7.5 mg/kg/day divided q 8 hours  Tobramycin 5 mg/kg/day divided q 8 hours  Pipercillin 300 mg/kg/day, divided q 6-8 hours

 Febrile

infants with UTIs should undergo renal and bladder ultrasonography (RBUS)

 While

not super useful, helpful in some cases  Non-invasive and no radiation  To detect anatomic abnormalities that require further evaluation and abscesses  Evaluate renal parenchyma  Assess renal size as baseline so as to monitor  Less useful now as many already had RBUS as prenatal screening (but often uncertain timing and quality of US during pregnancy)

 Timing

of RBUS within 2 days if severe or not improving  Otherwise, later better as 2 days into a UTI would not be a true baseline as E-coli endotoxin can cause edema  DMSA scan shows if patient has pyelonephritis much better but rarely changes initial treatment. Not recommended at early stage

© 2014 RemakeHealth Inc.™ All Rights Reserved. http://www.remakehealth.com

© 1994-2014 by WEBMD LLC. http://www.emedicine.medscape.com

 Action

Statement 6a: VCUG should not be performed routinely after the first febrile UTI; VCUG is indicated if there is hydronephrosis, scarring or other findings that would suggest high grade VUR or obstructive uropathy on RBUS as well as in other atypical or complex clinical circumstances  Action Statement 6b: Further evaluation should be conducted if there is a recurrence of febrile UTI (evidence quality: X; recommendation).

 Strategy 

  

for 40 years

Prevent further damage after initial UTI by determining which had treatable GU abnormalities which would increase risk of renal damage with recurrent UTI Antimicrobial prophylaxis with Bactrim or Nitrofurantoin to prevent further UTI if VUR Or if high grade VUR or failed trial of prophylactic antibiotics, VUR surgery However several studies have shown that one can get renal scarring/damage without VUR

Some studies indicate that antibiotic prophylaxis is not effective except in grade V reflux  If prophylaxis is not usually helpful AND one can get pyelonephritis, renal damage without VUR, then rationale for VCUG is questionable for VUR grades I-IV.  Grade V is not common among those with UTI (1/100) so by waiting reduce need for invasive VCUG testing after first febrile by UTI 90%  Study now underway to determine effects of prophylaxis in children 2 months – 6 years “The Randomized Intervention for Children with VUR study” (TMP-SMX in 607 children with grade I-V VUR following UTI) 

100% 80% Prophylaxis 60%

No Prophylaxis

NS

40% 20%

NS

NS

NS

NS

0% None

Grade I

Grade II

Grade III

Grade IV

N=373

N=100

N=257

N=285

N=104

Pediatric Care OnlineTM ©American Academy of Pediatrics

250

Prophylaxis No Prophylaxis

200 150 100 50 0 None

Grade I

Grade II

Grade III

Grade IV

Pediatric Care OnlineTM ©American Academy of Pediatrics

After First UTI (N=100)

After Recurrence (N=10)

No VUR

65 (65%)

2.6 (26%)

Grade I–III VUR

29 (29%)

5.6 (56%)

Grade IV VUR

5 (5%)

1.2 (12%)

Grade V VUR

1 (1%)

0.6 (6%)

Pediatric Care OnlineTM ©American Academy of Pediatrics

Impact of a More Restrictive Approach to Urinary Tract Imaging After Febrile Urinary Tract Infection  

N=103 “By restricting urinary tract imaging after an initial febrile UTI [based on NICE guidelines, 2007], rates of voiding cystourethrography and prophylactic antibiotic use decreased substantially without increasing the risk of UTI recurrence within 6 months and without an apparent decrease in detection of high-grade VUR.”

Schroeder AR, Abidari JM, Kirpekar R, et al. Impact of a more restrictive approach to urinary tract imaging after febrile urinary tract infection. Arch Pediatr Adolesc Med. 2011;165(11):1027–1032

 Action

statement 7: After confirmation of first UTI, parents should be instructed to seek prompt (ideally within 48 hours) for future febrile illnesses to ensure that recurrent infections are detected and treated promptly. 

Why? (Early treatment limits renal damage better than late treatment and risk of renal scarring increases with number of recurrences)

1. 2. 3. 4. 5. 6. 7. 8.

Relationship between UTIs and reduced renal function / hypertension Alternatives to invasive collection of urine and culture Role of VUR (and, thus, VCUG) Role of prophylaxis (RIVUR study) Genetics Hispanics Further treatment: What and for whom? Duration of treatment

TM

AAP Guideline for the Diagnosis and Management of UTIs in Febrile Infants Unanswered Questions and Unquestioned Answers Kenneth B. Roberts, MD, FAAP Professor of Pediatrics (Emeritus) University of North Carolina Roberts KB. “AAP Guideline for the Diagnosis and Management of UTIs in Febrile infants.” Pediatric Care Online Accessed 1/17/2014 at www2.aap.org/pcorss/webinars/pco/AAP%20Webinar_UTI-Roberts-Final.ppt

 80%

E. coli but also Klebsiella, Proteus, Enterobacter, Citrobacter, etc. Gram + rare.  Non-E.coli more common with anomalies of UT, younger age, previous tx with antibiotic  Few bacteremic except newborns.  Beyond newborn period due to bacteria ascending up urethra to bladder  Newborn hematogenous or ascending  Most UTIs due to UPEC (uropathogenic E. Coli); most E. Coli pyelo have P. pili fimbriae.

 Younger

age, Being female, white race  Lack of circumcision  Genetic factors  Urinary tract obstruction or VUR  Bowel/bladder dysfunction  Sexual activity  Bladder catheterization  Risk of renal scarring: recurrent UTI, delay in treatment of acute UTI, bladder/bowel dysfunction, obstruction, VUR, ? young age

 Very

non-specific in younger children  First 2 months high fever, jaundice, apnea, many more – often with sepsis  After 1-2 months: fever (especially > 39o and if >48 hours) and suprapubic tenderness  Some irritability or fussiness and other nonspecific signs: poor feeding, FTT  Foul smelling urine and GI symptoms not found to be helpful in diagnosis

 Classic

sx: fever and urinary symptoms (frequency, dysuria, urgency, incontinence, hematuria, abd. pain)  For pyelonephritis in older children fever, chills, flank pain and abdominal pain  Not all with sx have UTI: ddx of urethritis include vulvovaginitis, irritant or chemical, urethritis, urinary calculi, STD, vaginal FB  In past it was said and I always presume if UTI + fever = pyelonephritis. Not always true but cannot do a DMSA scan in all of them

http://nutravize.com

 History

-Determine if chronic symptoms, constipation, previous UTIs or undiagnosed febrile illnesses, VUR, FH, antenatally diagnosed renal abnormality, high Bp, poor growth, sexual activity and spermicides  Physical: Bp, Temp, growth parameters, tenderness of abdomen, external genitalia, low back exam, other sources of fever

 Lab

– Need + UA AND UC to confirm UTI  Usually no need for BC after 2 months  No need for creatinine unless recurrent  If potty trained can do CCUA specimen   

> 100,000 CFU/ml for CCUA > 1000 CFU/ml for SP >50,000 CFU/ml for cath culture  

If 10-50,000 repeat If same result of same and only one uropathogen treat

 50%

E. Coli resistant to Amoxicillin, Amp; increasing resistance to TMP-SMX,cephalexin, Amoxacillin-clavulanate, Amp-sulbactam  If suspect enterococcus don’t use monotherapy – add Ampicillin (urinary catheter, anatomical abnormality)  3rd gen. cephalosporins best starting drug.  Oral as good as IV for time to symptom resolution, sterilization of urine, reinfection rate, renal scarring at 6 months

 FLQs

effective but increasing resistance. ? safety in children - limit to Pseudomonas and multidrug resistant gram negative organisms  Should improve within 24-48 hours.  No need to reculture unless not improving 24 hr  Studies conflict on whether prophylaxis useful for recurrent UTI – some say only if grade V reflux – others if III-V reflux  Would try after 2nd UTI + VUR as trial  Study ongoing to see if steroids prevent renal damage with UTI

 RBUS:

Children < 2 with 1st UTI, any age with recurrent febrile UTIs, children with FH of kidney issues, HTN, poor antibiotic response.  VCUG if < 2 yo with 2 or more febrile UTIs, FH of renal/urological disease, poor growth or HTN, perhaps those with organism other than E.Coli and prophylaxis if grade > III VUR  DMSA not routine – shows pyelonephritis, most VUR III or higher, as well as scarring.  F/u with growth, weight and Bp – not UA, UC

 Refer

if dilating VUR (III-V) or obstructive uropathy, renal abnormalities, impaired kidney function, elevated Bp, bowel or bladder dysfunction that is refractory to primary care measures

 Most

have no long term sequelae  < 19 with first UTI – 25% had VUR, 2.5% had grade IV or V reflux.  VUR increases risk of acute pyelonephritis and renal scarring and 15% showed evidence of renal scarring at F/U  8% had at least one recurrence

 8-30%

have > one symptomatic reinfections.  Evaluate for, tx bowel/bladder dysfunction  No need for F/U cultures  Inform parents after febrile UTI they need to seek care soon if symptoms or fever develop  Consider prophylaxis for those without VUR if 3 febrile UTIs in 6 months or 4 in year.  With VUR grade 3-5 after second febrile UTI.  

TMP-SMX 2 mg TMP/kg or Nitrofurantoin 1-2 mg/kg 6 months and if no UTIs can stop and resume if another recurrence

90% E. coli (then other gm - organisms)  >100,000 CFU/ml uropathogen  Ddx- bladder dysfunction, vaginal FB, drug, chemical, nonspecific vulvovaginitis, cervicitis, urethritis, prostatitis, epididymo-orchitis, nephrolithiasis, urethral stricture, interstitial (autoimmune), neoplasm  Treat empirically  If > 13, uncomplicated include coverage for staph saprophyticus – TMP-SMX or cephalosporin  In older children if not complicated treat 5-7 days. If younger or complicated 7-14 days 

© 2005-2014 All Rights Reserved http://www.childrenshospital.org

 Retrograde

passage of urine into upper urinary tract from the bladder  1% newborns; 30-45% young children with UTI  Most common urological finding in children  Can be primary or secondary due to abnormally high pressures in bladder  More common in whites, girls, younger.  Strong genetic component  Diagnose by VCUG or radionuclide cystogram (RNC)

 30-60%

of those with IV or V reflux have primary renal scarring – may be developmental issue  ? if scarring result of developmental issue or due to infections ascending up to kidney due to VUR; many continue to believe latter  > ½ resolve on their own – more likely with milder degrees (I-II 80% resolve in 5 years)  High grade rarely resolve on own  Evaluate all with VUR and F/U for renal status, growth parameters, Bp, creatinine (initially) and UA for pyuria and proteinuria

 Unknown

benefits of treatment. UpToDate management based on available data, prevention of pyelonephritis, likelihood of renal scarring and of spontaneous resolution of VUR, and patient/family preference    

Screen for voiding dysfunction III-V either treat (prophylaxis) or surveillance and prompt treatment if UTI I,II observation vs. antibiotic prophylaxis with family input Trials so far display no difference in outcome between antibiotic prophylaxis, surgical VUR repair - get family input









Surgery recommended if unlikely to resolve (family input); Grade V reflux + scarring, Grade V > 6 YOA, III-V with failed medical tx Dx and tx promptly if symptoms or febrile illness. Yearly RBUS. DMSA if RBUS suggests renal scarring, poor renal growth, those with recurrent UTI and with Grade III-V VUR F/u yearly growth, Bp and UA

 Essential

to determine in children with UTI or VUR if have bladder dysfunction - problems with bladder filling or emptying which can predispose to repeated infections.  Can be from neurogenic, anatomic (ectopic ureter, obstruction) or functional causes

 Hx,  

 

Px, UA, UC – Suspect if:

Daytime urinary incontinence in school age or previously toilet trained children Urinary sx: urgency, dribbling, dysuria, daytime frequency, nocturia, hesitancy, holding maneuvers to avoid voiding, abnormal or intermittent flow or stream, incontinence, abdominal straining, holding maneuvers, post void residual, if VUR or recurrent infections Dysfunctional Voiding Symptoms Survey questionnaire or voiding diary very helpful R/O neurological or anatomical causes

http://fmymind.com/urine-trouble/

 Many

types beyond scope of talk. Will discuss only daytime wetting due to dysfunctional voiding - occurs in 20% of 4-6 years old- causes  





Overactive bladder (urgency) Voiding postponement and underactive bladder (Valsalva to urinate large volume post void residual) Dysfunctional voiding (Inability to relax urethral sphincter and/or pelvic floor musculature during voiding. Detrusor contractions during voiding against a closed external urinary sphincter. Get interrupted staccato flow pattern, prolonged voiding time) Other

http://www.vcu.edu/urology/patients/conditions/peds_urology/dys_voiding.html

 Can

reduce symptoms in as many as 40-70%  Take care of constipation  Explain to parents, patient if appropriate  Voiding behavior modification if age appropriate 

   

Educate family including how child’s voiding patterns deviate from normal Timed voiding schedule and 72 hr voiding diary Frequent voiding q 2-3 hours all day Try to empty bladder fully and use double voids Reward for following program, not for staying dry

 If

not working refer to urologist MD for testing and treatment which might include      

RBUS, VCUG, MRI, urinary flow measurement, urodynamic testing Medication Pelvic floor relaxation techniques Biofeedback Electrical stimulation therapy, botox injection, surgery,, intermittent clean catheterization If not treated risk high pressures, complications thereof – some feel all need urologist





Subcommittee on Urinary Tract Infection and Steering Committee on Quality Improvement and Management. “Urinary Tract Infection: Clinical Practice Guideline for the Diagnosis and Management of the Initial UTI in Febrile Infants and Children 2 to 24 months.” Pediatrics accessed 1/20/2014 at http://pediatrics.aappublications.org/content/early/ 2011/08/24/peds.2011-1330 Allen HA. “Fever without a source in children 3 to 36 months of age.” UpToDate accessed 1/17/2014 http://www.uptodate.com/contents/fever-withouta-source-in-children-3-to-36-months-ofage?source=search_result&search=fever+without+a+s ource&selectedTitle=1%7E15







McLorie G, Herrin JT. “Management of vesicoureteral reflux. UpToDate accessed 1/16/2014 at http://www.uptodate.com/contents/management-ofvesicoureteralreflux?source=search_result&search=Management+of+vesicou reteral&selectedTitle=1%7E68 McLorie G, Herrin JT. “Presentation, diagnosis and clinical course of vesicoureteral reflux.” UpToDate accessed 1/16/2014 at http://www.uptodate.com/contents/presentation-diagnosisand-clinical-course-of-vesicoureteralreflux?source=search_result&search=presentation%2C+diagno sis+adn+clinical+course+of+vesicoureteral+reflux&selectedTit le=1%7E150 Nepple KG, Cooper CS. “Etiology and clinical features of bladder dysfunction in children.” UpToDate accessed 1/16/2014 at http://www.uptodate.com/contents/etiologyand-clinical-features-of-bladder-dysfunction-inchildren?source=search_result&search=bladder+dysfunction&s electedTitle=3%7E150

Nepple KG, Cooper CS. “Evaluation and diagnosis of bladder dysfunction in children.” UpToDate accessed 1/16/2014 at http://www.uptodate.com/contents/evaluation-anddiagnosis-of-bladder-dysfunction-inchildren?source=search_result&search=bladder+dysfunct ion&selectedTitle=4%7E150  Nepple KG, Cooper CS. “Management of bladder dysfunction in children.” Uptodate accessed 1/16/2014 at http://www.uptodate.com/contents/managementof-bladder-dysfunction-inchildren?source=search_result&search=bladder+dysfunct ion&selectedTitle=6%7E150  O’Donovan DJ. “Urinary tract infections in newborns.” Uptodate accessed 1/20/2014 at http://www.uptodate.com/contents/urinary-tractinfections-innewborns?source=search_result&search=urinary+tract+i nfection+in+newborns&selectedTitle=1%7E150 









Palazzi DL and Campbell JR. “Acute cystitis in children older than two years and adolescents.” UpToDate accessed 1/20/2014 at http://www.uptodate.com/contents/acute-cystitis-in-children-older-than-twoyears-andadolescents?source=search_result&search=acute+cystitis&selectedTitle=2%7E74 Roberts KB. “AAP Guideline for the Diagnosis and Management of UTIs in Febrile infants.” Pediatric Care Online Accessed 1/17/2014 at www2.aap.org/pcorss/webinars/pco/AAP%20Webinar_UTI-Roberts-Final.ppt Shaikh N, Hoberman A. “Urinary tract infections in Infants and children older than one month: acute management, imaging, and prognosis.” UpToDate accessed 1/20/2014 at http://www.uptodate.com/contents/urinary-tract-infections-ininfants-and-children-older-than-one-month-acute-management-imaging-andprognosis?source=search_result&search=uti+in+children&selectedTitle=1%7E150 Shaikh N, Hoberman A. “Long-term management and prevention of urinary tract infections in children. UpToDate accessed 1/20/2014 at http://www.uptodate.com/contents/long-term-management-and-prevention-ofurinary-tract-infections-inchildren?source=search_result&search=uti+in+children&selectedTitle=5%7E150

Shaikh N, Hoberman A. “Urinary tract infections in infants and children older than one month: clinical features and diagnosis.” UpToDate Accessed 1/20/2014 at http://www.uptodate.com/contents/urinary-tractinfections-in-infants-and-children-older-than-onemonth-clinical-features-anddiagnosis?source=search_result&search=uti+in+children &selectedTitle=2%7E150  Shaikh N, Hoberman A. “Urinary tract infections in children: epidemiology and risk factors.” UpToDate accessed 1/20/2014 at http://www.uptodate.com/contents/urinary-tractinfections-in-children-epidemiology-and-riskfactors?source=search_result&search=uti+in+children&s electedTitle=3%7E150 

 Narrowest

coverage possible

View more...

Comments

Copyright � 2017 NANOPDF Inc.
SUPPORT NANOPDF