Six month old Traci is brought to the office because of a fever. Her mom said that she checked all of her baby books and since Traci had absolutely no symptoms (cough, runny nose, vomiting or diarrhea), she thought she would give it at least 24 hours before coming to the office. Since the fever was as high as 102 degrees, she thought it was time to have it checked out.
In fact, her mom almost apologized for making the appointment. "You’re going to think that I am a paranoid mom," she sheepishly said, "but the books DID say to have your child checked if the fever lasted more than 24 hours."
Traci seemed to be active and in good spirits. Despite her temperature of 101.8 degrees, I could get her to laugh and interact. Her exam was completely normal and there was no evidence of infection. Mom shrugged her shoulders and said, "See, I told you...I just over-reacted!" I then told mom that I needed to check one more thing, a urine, to make sure that Traci did not have a urinary tract infection. I went on to explain that the one organ system that you cannot asses very accurately by just a physical exam is the urinary system. Sure enough, her urinalysis was abnormal and suggestive of an infection. There were red blood cells, white blood cells and bacteria present. When I showed the results to mom, she stated, "Oh, you mean that she has a bladder infection, I get them all the time." Her mood became serious when I said, "No, this is not just a bladder infection. It is much more serious."
Urinary tract infections can be divided into two major categories depending on which portion of the renal system is involved--the lower tract and the upper tract. Lower tract infections refer to an infection of the bladder (cystitis). This is very common, especially in women, and does not usually cause fever. Because the bladder is inflamed, the symptoms include "frequency" (the feeling that one has to urinate often), "urgency" (the feeling that when you have to urinate, you have to urinate NOW), and "dysuria" (or pain upon urinating). Cystitis responds quite nicely to antibiotics and is not much of a concern.
An infection of the upper renal tracts, the kidneys and the ureters (the tubes that connect the kidneys with the bladder), is called pyelonephritis. This is a much more serious infection. Pyelonephritis causes fever, chills, back pain, and in children may cause vomiting and malaise. A person with pyelonephritis is acutely ill. A person who has a suspected urinary tract infection and has a fever should be considered to have pyelonephritis unless otherwise proved. Such was the case with Traci.
First of all, I sent a sterile urine to the lab for a culture and sensitivity. The lab will grow the urine on a culture medium to see what bacteria is present. This takes 48-72 hours. If a bacteria is present, they then do sensitivity testing on the bacteria to see which antibiotics it will respond to. This is very important because it will not only confirm that there is an infection, but it serves as a guide in the antibiotic choice. In the past decade bacteria have become more and more resistant to many of the standard antibiotics.
Next, I had to make a determination as to whether Traci needed to be hospitalized for intravenous antibiotics or not. She certainly was not "toxic" appearing. She was happy and playful, and had not been vomiting. There was no question that she would be able to tolerate oral antibiotics. If there were even a question about this, she would have been admitted to the hospital. I gave her first dose of antibiotics in the office and watched her for a while. She continued to do well, so I elected to treat her at home with oral antibiotics under her mom’s close observation. Mom was quite comfortable with this decision, but this was only with the understanding that she was to call me at 6 PM with an update, and she was to bring Traci back to the office to see me the next morning. She agreed.
As promised, she called me at exactly 6 PM to state that Traci was doing about the same, and had kept down the samples of the antibiotics that I had given to her. The next morning Traci looked equally good. Her fever had broken during the night and in the office her temperature was 98.2 degrees. Her exam was completely normal and she was her smiling self. I then gave mom antibiotic samples to last another two days after which I wanted to re-check Traci again in the office.
When she came back to the office I had the results of the culture and sensitivity from the urine sample. The bacteria was E. coli, which is the most common urinary tract bacteria, and it was sensitive to the antibiotic that she was taking. I then wrote mom a prescription for the same antibiotic to complete a ten day course, and did a repeat urine culture. This was to show that the bacteria had been completely eradicated. Having documented that Traci had a urinary tract infection, I sent her for an ultrasound of the kidneys. This was to evaluate the size and shape of the kidneys and to be sure that there was no anatomical variant that would predispose her to getting infections. Her ultrasound was completely normal.
Traci’s repeat urine culture was sterile (free of bacteria) and I then ordered a voiding cysto-urethrogram (VCUG). This is a special x-ray that is done by inserting a catheter into the bladder, injecting a dye to fill the bladder, and under flouroscopy filming the bladder as the patient voids. This test will not only evaluate the anatomy of the bladder, but will also tell if the patient has reflux. Reflux is the back flow of urine from the bladder towards the kidneys. Normally, when a person voids, the urine stays in the bladder. Reflux is not normal and can be a cause of infections as well as chronic scarring of the kidneys. If one is found to have reflux, they should be placed on long term antibiotics and followed very closely until the reflux resolves. If the reflux is severe, surgical correction may be necessary.
Any infant who is found to have a urinary tract infection should have an ultrasound of the kidneys as well as a VCUG for the above reasons. This is the accepted standard of care in this country.
Fortunately, Traci’s VCUG was normal. She completed her antibiotics and never really appeared sick with the exception of the fever. When everything was complete, her mom said to me, "Two urine cultures, an ultrasound of the kidneys, and a VCUG...to think that I almost didn’t bring her in. Better yet, to think that I was just being an over-reactive and paranoid mom..."