II. Epidemiology

  1. UTI Incidence
    1. Newborns
      1. Overall: 0.14%
      2. 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%

III. Causes (single organism in most cases)

  1. Bacteria
    1. Escherichia coli (up to 85% of UTIs in children)
    2. Klebsiella
    3. Proteus (boys and associated with Nephrolithiasis)
    4. Enterococcus
    5. Pseudomonas
    6. Staphylococcus saprophyticus
    7. Coagulase negative Staphylococcus
  2. Viral
    1. Adenovirus (hemorrhagic cystitis)
  3. Atypical causes
    1. Fungal
    2. Mycobacterium
    3. Schistosomiasis

IV. Indications: Decision to evaluate for UTI

  1. Infants under age 2 months
    1. Age under 2 months is excluded from this guideline
    2. See Neonatal Sepsis guidelines
  2. Infants and children age 2 to 24 months (with fever >38 C)
    1. Risk factors for girls (<2 is reassuring and indicates a risk <1%)
      1. White race
      2. Age under 12 months
      3. Fever 39 C or higher
      4. Fever lasting more than 48 hours
      5. Absence of other source of infection
    2. Risk Factors for circumcised boys (<3 is reassuring and indicates a risk <1%)
      1. Non-black race
      2. Age under 6 months
      3. Fever 39 C or higher
      4. Fever lasting more than 24 hours
      5. Absence of other source of infection
    3. Risk Factor for uncircumcised boys
      1. Uncircumcised boys have a risk >1% even in absence of other risk factors
    4. References
      1. Newman (2002) Arch Pediatr Adolesc Med 156:44-54 [PubMed]
      2. Gorelick (2000) Arch Pediatr Adolesc Med 154(4): 386-90 [PubMed]
      3. Shaikh (2007) JAMA 298(24): 2895-2904 [PubMed]
  3. Children over age 2 years
    1. Typical Urinary Tract Infection symptoms
    2. Constipation
    3. Encopresis
    4. Bladder instability
    5. Infrequent voiding
    6. Koff (1998) J Urol 160:1019-22 [PubMed]

V. Signs and symptoms

  1. Newborn
    1. Jaundice
    2. Sepsis
    3. Failure to Thrive
    4. Vomiting
    5. Fever
  2. Infant or toddler
    1. Failure to Thrive
    2. Fever
    3. Weight Loss
    4. Nausea or Vomiting
    5. Irritability
    6. Jaundice
    7. Strong smelling urine
    8. Hematuria
    9. Abdominal Pain or flank pain
  3. Child
    1. Same as for adult Urinary Tract Infection
    2. Dysuria
    3. Urinary frequency or urgency
    4. Urine hesitancy
    5. Lower Abdominal Pain
    6. New onset Urinary Incontinence
    7. Urine Odor does not predict Urinary Tract Infection

VI. Diagnosis

  1. General
    1. Urinalysis dipstick can be used to rule-out UTI
      1. High Negative Predictive Value if normal
        1. Exception: Not sensitive in dilute urine (SG<1.005)
        2. Shaw (1998) Pediatrics 101:E1 [PubMed]
      2. Initial criteria for empirically starting UTI treatment
        1. A catheterized specimen positive for Leukocyte esterase, nitrite or microscopy with urine WBCs or Bacteria
    2. Urine Culture is required for UTI diagnosis
      1. Urinalysis dipstick testing is not diagnostic (use only for empiric initial therapy)
      2. Urine Culture is mandatory when a Urinary Tract Infection is suspected
        1. Urine sample for culture must be via catheter or SPA in children under 24 months
        2. Diagnosis requires pyuria and a catheterized specimen with >50,000 colonies of a single organism
  2. Urine Sample Techniques
    1. Urine catheter specimen
      1. Recommended if child under age 2 years
    2. Suprapubic Aspirate (SPA)
      1. Consider for child under age 6 months old
    3. Clean catch Urine (especially first morning void)
      1. Possible in young children, but requires patience
    4. Urine Bag Collection (Not recommended)
      1. High Incidence of contamination
      2. May only be used to rule out UTI when risk of UTI is low (<1%, see above)
      3. If abnormal, catheterized sample or suprapubic aspirate is required
  3. Urinalysis (Sensitivity, Specificity)
    1. Urine Leukocyte Esterase (small or greater)
      1. Test Sensitivity: 83%
      2. Test Specificity: 78%
      3. Probability of UTI: 30%
    2. Urine Nitrite
      1. Test Sensitivity: 53%
      2. Test Specificity: 98%
      3. Probability of UTI: 75%
    3. Urine White Blood Cells (10 or greater) on microscopy
      1. Test Sensitivity: 73%
      2. Test Specificity: 81%
      3. Probability of UTI: 30%
    4. Urine Bacteria present on microscopy
      1. Test Sensitivity: 81%
      2. Test Specificity: 83%
      3. Probability of UTI: 35%
    5. Urine Red Blood Cells on microscopy
      1. Test Sensitivity: 47%
      2. Test Specificity: 78%
      3. Probability of UTI: 19%
  4. Urine Culture
    1. See Urine Culture for diagnostic criteria
    2. Culture sample within 4 hours or refrigerate

VII. 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 may necesitate 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

VIII. Imaging

  1. General
    1. First UTI in age <5 years old no longer requires imaging (unless indicated as below)
    2. Does not appear to change management or outcome (significant VUR Incidence is low)
    3. Zamir (2004) Arch Dis Child 89:466-8 [PubMed]
  2. Imaging indications
    1. Renal and Bladder Ultrasound
      1. Indicated for first UTI with fever at least 101.3 F (38.5 C) age under 2 years
      2. Timing: Within 48 hours for severe infection or prolonged course (otherwise wait until acute infection resolves)
    2. VCUG
      1. Do not routinely obtain for first febrile UTI
      2. Do not obtain until infection has resolved (wait at least 3-6 weeks after infection)
      3. Indicated for abnormal Ultrasound showing renal scar, Hydronephrosis or other signs of high grade VUR
      4. Also indicated for second febrile Urinary Tract Infection
    3. DMSA Renal Cortical Scan
      1. Less commonly used now (defer to local pediatric urology consultants)
      2. May be preferred in girls as spares some ovarian radiation seen in VCUG

IX. Prevention: 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

X. Management: Overall protocol for a febrile child between ages 2 and 24 months

  1. Step 1: Child requires immediate empiric antimicrobial therapy
    1. Go to Step 4
  2. Step 2: Likelihood of Urinary Tract Infection is <1% (see Decision to evaluate for UTI as above)
    1. No urine testing required
    2. Complete additional evaluation of a febrile child
    3. Follow-up in 1-2 days for re-evaluation
  3. Step 3: Negative Urinalysis (LE, Nitrite, micro) by any method
    1. No further urine testing required
    2. Complete additional evaluation of a febrile child
    3. Follow-up in 1-2 days for re-evaluation
  4. Step 4: Urine Culture by catheter or suprapubic aspirate only
    1. Determine disposition based on inpatient criteria below
    2. Start antibiotics as described below
  5. Step 5: Negative Urine Culture
    1. Stop antibiotics
    2. Complete additional evaluation of a febrile child
    3. Follow-up for Recurrent Fever
  6. Step 6: Positive Urine Culture
    1. Treat for 7-14 days adjusted for Urine Culture sensitivities
  7. Step 7: Renal and Bladder Ultrasound
    1. Obtain at any time after Urinary Tract Infection is confirmed
    2. Positive Ultrasound for anatomic abnormalities (e.g. Hydronephrosis)
      1. Obtain VCUG to evaluate for Grade IV to IV vesicoureteral reflux
  8. References
    1. Roberts (2011) Pediatrics 128(3): 595-610 [PubMed]

XI. 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

XII. Management: Antibiotics

  1. Oral antibiotics for 7 to 14 days (10 days or more if fever present)
    1. Amoxicillin-clavulonate (Augmentin) 45 mg/kg/day divided twice daily
      1. E coli resistance to Amoxicillin is increasing (>50% in some regions as of 2016)
    2. Trimethoprim Sulfamethoxazole (Septra, Bactrim)
      1. Dosing: 6-12 mg/kg/day TMP,30-60 mg/kg/day SMZ divided bid
      2. Avoid under age 2 months
      3. Poor renal penetration
      4. E coli resistance to TMP-SMZ is also increasing (25% in some regions as of 2016)
    3. Second generation or Third Generation Cephalosporins
      1. Cefixime (Suprax)
        1. Expensive
        2. Day one: 16 mg/kg for the first day
        3. Next: 8 mg/kg/day in single dose or divided bid
      2. Cefpodoxime (Vantin) 10 mg/kg/day divided bid
      3. Cefprozil (Cefzil) 30 mg/kg/day divided bid
      4. Cephalexin (Keflex) 50-100 mg/kg/day divided qid
  2. Intravenous antibiotics for hospitalized children
    1. Gentamicin 7.5 mg/kg/day divided every 8 hours
    2. Cefotaxime 150 mg/kg/day divided every 6-8 hours
    3. Ceftriaxone (Rocephin) 75 mg/kg every 24 hours
    4. Ceftazidime 100-150 mg/kg/day divided every 8 hours
    5. Tobramycin 5 mg/kg/day divided every 8 hours
    6. Piperacillin 300 mg/kg/day divided every 6-8 hours

XIII. Management: UTI Prophylaxis

  1. Indications
    1. Prophylaxis is no longer routinely recommended prior to completion of evaluation
    2. Discuss with local pediatric urology consultants
  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

XIV. Management: Evaluation for secondary urologic anomaly

  1. Indications
    1. See Imaging above
    2. Family History may dictate screening despite no prior personal UTI history
      1. Preschool siblings of child with urologic anomaly
      2. Preschool child of parent with vesicoureteral reflux
  2. Protocol
    1. See Imaging above

XV. 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%

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