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Infectious Disease

  • Urinary Tract Infection in Children

Penile Disorders

Testicular Disorders

Urinary Incontinence

Urine Abnormalities

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Urinary Tract Infection in ChildrenAka: Pediatric UTI, UTI in children

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  1. See Also
    1. Urinary Tract Infection
  2. Epidemiology
    1. UTI Incidence
      1. Newborns: 0.14%
        1. Febrile newborns: 7%
      2. Symptomatic UTI under age 6 years
        1. Girls: 7%
        2. Boys: 2%
      3. School aged children: 1-2%
      4. Ages 7 to 11 year old females: 2.5%
    2. Renal abnormality (Vesicoureteral Reflux) Incidence
      1. School aged children with UTI: 25-40%
      2. Preschool sibling of child with VUR: 25-33%
      3. Child of parent with VUR: 65%
  3. Causes (single organism in most cases)
    1. Bacteria
      1. Escherichia coli (60-80%)
      2. Klebsiella
      3. Proteus (boys and associated with Nephrolithiasis)
      4. Enterococcus
      5. Pseudomonas
      6. Staphylococcus aureus
      7. Coagulase negative Staphylococcus
    2. Viral
      1. Adenovirus (hemorrhagic cystitis)
    3. Atypical causes
      1. Fungal
      2. Mycobacterium
      3. Schistosomiasis
  4. Indications to evaluate for UTI
    1. Infants
      1. Younger age (<3 months)
      2. Ill appearance
      3. Fever Without Focus
      4. Girls or uncircumcised boys
      5. Persistant fever
      6. Newman (2002) Arch Pediatr Adolesc Med 156:44
    2. Children over age 2 years
      1. Constipation
      2. Encopresis
      3. Bladder instability
      4. Infrequent voiding
      5. Koff (1998) J Urol 160:1019
  5. Signs and symptoms
    1. Infant
      1. Failure to Thrive
      2. Fever
      3. Weight Loss
      4. Nausea or Vomiting
      5. Irritability
      6. Jaundice
    2. Child
      1. Same as for adult Urinary Tract Infection
      2. Dysuria
      3. Urinary frequency or urgency
      4. Urine hesitancy
      5. Lower Abdominal Pain
      6. Urine Odor does not predict Urinary Tract Infection
  6. Diagnosis
    1. General
      1. Urinalysis dipstick can be used to rule-out UTI
        1. High Negative Predictive Value if normal
        2. Exception: Not sensitive in dilute urine (SG<1.005)
        3. Shaw (1998) Pediatrics 101:E1
      2. Urine Culture is required for UTI diagnosis
        1. Urinalysis dipstick testing is not diagnostic
    2. Urine Sample Techniques
      1. Clean catch Urine (especially first morning void)
        1. Possible in infants, but requires patience
      2. Urine catheter specimen
        1. Recommended if child under age 2 years
      3. Suprapubic Aspirate
        1. Consider for child under age 6 months old
      4. Urine Bag Collection (Not recommended)
        1. High Incidence of contamination
    3. Urinalysis (Sensitivity, Specificity)
      1. Urine Leukocyte Esterase (small or greater)
        1. Sensitivity: 83%
        2. Specificity: 95%
      2. Urine Nitrite
        1. Sensitivity: 27%
        2. Specificity: 98%
      3. Urine White Blood Cells (5 or greater) on microscopy
        1. Sensitivity: 86%
        2. Specificity: 79%
      4. Urine bacteria present on microscopy
        1. Sensitivity: 93%
        2. Specificity: 40%
    4. Urine Culture
      1. See Urine Culture for diagnostic criteria
  7. Labs
    1. Standard
      1. Urinalysis
      2. Urine Culture
    2. Suspected Pyelonephritis
      1. Complete Blood Count (CBC)
      2. Blood Culture
        1. Indicated for febrile hospitalized child
        2. UTI with bacteremia requires earlier imaging
      3. Inflammation Markers (70-80 sensitive, not specific)
        1. Erythrocyte Sedimentation Rate
        2. C-Reactive Protein
      4. Renal Function tests)
        1. Blood Urea Nitrogen
        2. Creatinine
  8. Radiology
    1. General
      1. First UTI in age <5 may no longer require imaging
      2. Does not appear to change management or outcome
      3. Zamir (2004) Arch Dis Child 89:466
    2. Available studies for anomalies in acute UTI
      1. Renal and Bladder Ultrasound
      2. DMSA Renal Cortical Scan
      3. Avoid VCUG during acute infection
  9. Management: Prevent renal scars in high risk children
    1. Children under age 2 years
    2. Recurrent Pyelonephritis
    3. Pyelonephritis with urinary anatomic abnormality
    4. Pyelonephritis untreated for more than 3 days
  10. Management: Inpatient criteria
    1. Ill appearing or toxic children
    2. Children unable to maintain oral hydration
    3. Risk of renal scar
    4. Febrile children under age 6 months to 1 year old
  11. Management: Antibiotics
    1. Oral antibiotics for 10 to 14 days
      1. Amoxicillin 20-40 mg/kg/day divided tid
        1. First choice antibiotic in age <2 months
      2. Amoxicillin-clavulonate (Augmentin)
      3. Trimethoprim Sulfamethoxazole (Septra, Bactrim)
        1. Dosing: 6-12 mg/kg TMP,30-60 mg/kg SMZ divided bid
        2. Avoid under age 2 months
        3. Poor renal penetration
      4. Second generation or Third Generation Cephalosporins
        1. Cefixime (Suprax) 8 mg/kg divided bid
        2. Cefpodoxime (Vantin) 10 mg/kg divided bid
        3. Cefprozil (Cefzil) 30 mg/kg divided bid
        4. Cephalexin (Keflex) 50-100 mg/kg divided qid
        5. Loracarbef (Lorabid) 15-30 mg/kg divided bid
    2. Intravenous antibiotics for hospitalized children
      1. Gentamicin
      2. Cefotaxime
      3. Cefuroxime
      4. Cefixime
      5. Ceftriaxone (Rocephin)
      6. Ampicillin-Sulbactam (Unasyn)
  12. Management: UTI Prophylaxis
    1. Indications
      1. Risk of vesicoureteral reflux (until evaluation)
    2. Medications (at bedtime if toilet trained)
      1. Trimethoprim Sulfamethoxazole (Septra, Bactrim)
        1. Avoid under 2 months
        2. Dosing
          1. Nightly: 2 mg TMP/10 mg SMZ per kg at bedtime
          2. Bi-weekly: 5 mg TMP/25 mg SMZ per kg twice weekly
      2. Nitrofurantoin (Furadantin, Macrodantin, Macrobid)
        1. Dosing: 1-2 mg/kg once daily
      3. Nalidixic Acid (NegGram)
        1. Dosing: 30 mg/kg/day divided bid
      4. Methenamine mandelate 75 mg/kg/day divided bid
      5. Sulfisoxazole (Gantrisin) 10-20 mg/kg/day divided bid
    3. Other prevention
      1. Circumcision in uncircumsized boys
  13. Management: Evaluation for secondary urologic anomaly
    1. Indications (recommendations are currently in flux)
      1. Single Urinary Tract Infection under age 2 years
      2. More than one Urinary Tract Infection under age 10
      3. Preschool siblings of child with urologic anomaly
      4. Preschool child of parent with vesicoureteral reflux
    2. Protocol
      1. Renal and bladder Ultrasound
      2. Voiding Cystourethrogram (VCUG)
        1. Indicated for children under age 5 years
        2. Obtain 3-6 weeks after UTI
      3. DMSA Renal Cortical Scan
        1. Indicated for girls (spares ovarian radiation)
        2. Indicated for assessment of renal scarring
  14. Prognosis: Vesicoureteral Reflux
    1. Risk End-stage renal disease if renal scarring occurs
      1. Responsible for 20% of end-stage renal disease
    2. Spontaneous Resolution Rates for Ureteral Reflux
      1. Grade I: 70-80%
      2. Grade II: 70-80%
      3. Grade III: 50%
      4. Grade IV: 15%
      5. Grade V: <15%
  15. References
    1. Alper (2005) Am Fam Physician 72:2483
    2. Bulloch (2000) Pediatrics 106:e60
    3. Fisher (1999) Pediatrics 104:109
    4. Hoberman (1999) Pediatr Infect Dis J 18:1020
    5. Hoberman (1999) Pediatrics 104:79
    6. Honkinen (2000) Pediatr Infect Dis 19:630
    7. Roberts (2000) Am Fam Physician 62(8):1815
    8. Ross (1999) Am Fam Physician 59(6):1472

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