Pediatric Pearl: UTI (February)

FEBRUARY UTI – Hima Khamar

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
E. coli, Proteus sp.
Enterococcus sp.
Pseudomonas sp.
Serratia sp.
Corynebacterium Urealyticum
Klebsiella sp.
Enterobacter sp.
Group B streptococci
Staphylococcus aureus

Common Contaminants
Lactobacillus sp.
Corynebacterium sp.
Coagulase-negative staphylococci
Alpha-hemolytic streptococci

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

 

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