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 |
Common Contaminants
|
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
The retinal photograph depicts bullous retinal detachment in the Left eye of a 1-year-old child with Coat’s disease simulating retinoblastoma. The magnetic resonance images confirm the diagnosis of retinal detachment and exclude retinoblastoma because of the absence of intraocular mass.
Chorioretinitis characteristic of toxoplasmosis. A pigmented scar is seen with an adjacent area of active chorioretinitis. The diagnosis of toxoplasmosis is based primarily on the appearance of the chorioretinal lesion rather than serologic studies. Courtesy of James T Rosenbaum, MD.
