Drugs & Diseases > Pediatrics: General Medicine

Pediatric Urinary Tract Infection

Updated: Nov 03, 2017

 Author: Donna J Fisher, MD; Chief Editor: Russell W Steele, MD more...

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Practice Essentials
Urinary tract infection (UTI) is one of the most common pediatric infections. It
distresses the child, concerns the parents, and may cause permanent kidney
damage. Occurrences of a first-time symptomatic UTI are highest in boys and
girls during the first year of life and markedly decrease after that.
Febrile infants younger than 2 months constitute an important subset of
children who may present with fever without a localizing source. The workup
of fever in these infants should always include evaluation for UTI. The chart
below details a treatment approach for febrile infants younger than 3 months
who have a temperature higher than 38°C.

Application of low-risk criteria

for and approach to the febrile infant: A reasonable approach for treating
febrile infants younger than 2 months who have a temperature of greater than
38°C.

Signs and symptoms

The history and clinical course of a UTI vary with the patient's age and the
specific diagnosis. No one specific sign or symptom can be used to identify
UTI in infants and children.
Children aged 0-2 months
Neonates and infants up to age 2 months who have pyelonephritis usually do
not have symptoms localized to the urinary tract. UTI is discovered as part of
an evaluation for neonatal sepsis. Neonates with UTI may display the
following symptoms:
 Jaundice
 Fever
 Failure to thrive
 Poor feeding
 Vomiting
 Irritability
Infants and children aged 2 months to 2 years
Infants with UTI may display the following symptoms:
 Poor feeding
 Fever
 Vomiting
  Strong-smelling urine
 Abdominal pain
 Irritability
Children aged 2-6 years
Preschoolers with UTI can display the following symptoms:
 Vomiting
 Abdominal pain
 Fever
 Strong-smelling urine
 Enuresis
 Urinary symptoms (dysuria, urgency, frequency)
Children older than 6 years and adolescents
School-aged children with UTI can display the following symptoms:
 Fever
 Vomiting, abdominal pain
 Flank/back pain
 Strong-smelling urine
 Urinary symptoms (dysuria, urgency, frequency)
 Enuresis
 Incontinence
Physical examination findings in pediatric patients with UTI can be
summarized as follows:
 Costovertebral angle tenderness
 Abdominal tenderness to palpation
 Suprapubic tenderness to palpation
 Palpable bladder
 Dribbling, poor stream, or straining to void
See Clinical Presentation for more detail.

Diagnosis

The American Academy of Pediatrics (AAP) criteria for the diagnosis of UTI in
children 2-24 months are the presence of pyuria and/or bacteriuria on
urinalysis and of at least 50,000 colony-forming units (CFU) per mL of a
uropathogen from the quantitative culture of a properly collected urine
specimen. [1]
Urinalysis alone is not sufficient for diagnosing UTI. However, urinalysis can
help in identifying febrile children who should receive antibacterial treatment
while culture results from a properly collected urine specimen are pending. [2]
Urine specimen collection
 A midstream, clean-catch specimen may be obtained from children who
have urinary control
 Suprapubic aspiration or urethral catheterization should be used in the
infant or child unable to void on request
Suprapubic aspiration is the method of choice for obtaining urine from the
following patients:
 Uncircumcised boys with a redundant or tight foreskin
 Girls with tight labial adhesions,
 Children of either sex with clinically significant periurethral irritation
Culture of a urine specimen from a sterile bag attached to the perineal area
has a false-positive rate too high to be suitable for diagnosing UTI; however, a
negative culture is strong evidence that UTI is absent. [1]
Laboratory studies
 Complete blood count (CBC) and basic metabolic panel (for children
with a presumptive diagnosis of pyelonephritis)
 Blood cultures (in patients with suspected bacteremia or urosepsis)
 Renal function studies (ie, serum creatinine and blood urea nitrogen
[BUN] levels)
 Electrolyte levels
Imaging studies
Imaging studies are not indicated for infants and children with a first episode
of cystitis or for those with a first febrile UTI who meet the following criteria:
 Assured follow-up
 Prompt response to treatment (afebrile within 72 h)
 A normal voiding pattern (no dribbling)
 No abdominal mass
If imaging studies of the urinary tract are warranted, they should not be
obtained until the diagnosis of UTI is confirmed. Indications for renal and
bladder ultrasonography are as follows:
 Febrile UTI in infants aged 2-24 months [1]
 Delayed or unsatisfactory response to treatment of a first febrile UTI
 An abdominal mass or abnormal voiding (dribbling of urine)
 Recurrence of febrile UTI after a satisfactory response to treatment
Voiding cystourethrography (VCUG) may be indicated after a first febrile UTI if
renal and bladder ultrasonography reveal hydronephrosis, scarring,
obstructive uropathy, or masses or if complex medical conditions are
associated with the UTI. VCUG is recommended after a second episode of
febrile UTI. [1]
See Workup for more detail.

Management
Patients with a nontoxic appearance may be treated with oral fluids and
antibiotics. Outpatient care is reasonable if the following criteria are met:
 A caregiver with appropriate observational and coping skills
 Telephone and automobile at home
 The ability to return to the hospital within 24 hours
 The patient has no need for oxygen therapy, intravenous fluids, or other
inpatient measures
Hospitalization is necessary for the following patients with UTI:
 Patients who are toxemic or septic
 Patients with signs of urinary obstruction or significant underlying
disease
 Patients who are unable to tolerate adequate oral fluids or medications
 Infants younger than 2 months with febrile UTI (presumed
pyelonephritis)
 All infants younger than 1 month with suspected UTI, even if not febrile
Treat febrile UTI as pyelonephritis, and consider parenteral antibiotics and
hospital admission for these patients.
Antibiotics for parenteral treatment are as follows:
 Ceftriaxone
 Cefotaxime
 Ampicillin
 Gentamicin
Patients aged 2 months to 2 years with a first febrile UTI
If clinical findings indicate that immediate antibiotic therapy is indicated, a
urine specimen for urinalysis and culture should be obtained before treatment
is started. Common choices for empiric oral treatment are as follows:
 A second- or third-generation cephalosporin
 Amoxicillin/clavulanate, or sulfamethoxazole-trimethoprim (SMZ-TMP)
Children with cystitis
 Antibiotic therapy is started on the basis of clinical history and urinalysis
results before the diagnosis is documented
 A 4-day course of an oral antibiotic agent is recommended for the
treatment of cystitis
 Nitrofurantoin can be given for 7 days or for 3 days after obtaining
sterile urine
 If the clinical response is not satisfactory after 2-3 days, alter therapy on
the basis of antibiotic susceptibility
 Symptomatic relief for dysuria consists of increasing fluid intake (to
enhance urine dilution and output), acetaminophen, and nonsteroidal
anti-inflammatory drugs (NSAIDs)
  If
voiding symptoms are severe and persistent, add phenazopyridine
hydrochloride (Pyridium) for a maximum of 48 hours
See Treatment and Medication for more detail.
Background
Urinary tract infection (UTI) is one of the most common pediatric infections. It
distresses the child, concerns the parents, and may cause permanent kidney
damage. Prompt diagnosis and effective treatment of a febrile UTI may
prevent acute discomfort and, in patients with recurrent infections, kidney
damage. (See Presentation, DDx, Treatment, and Medication.)
The 2 broad clinical categories of UTI are pyelonephritis (upper UTI) and
cystitis (lower UTI). The most common causative organisms are bowel flora,
typically gram-negative rods. Escherichia coli is the organism that is most
commonly isolated from pediatric patients with UTIs. However, other
organisms that gain access to the urinary tract may cause infection, including
fungi (Candida species) and viruses. (See Pathophysiology and Etiology.)
The febrile infant or child who has no other site of infection to explain the
fever, even in the absence of systemic symptoms, should be assessed for the
likelihood of pyelonephritis (upper UTI). Most episodes of UTI during the first
year of life are pyelonephritis. (See DDx.)
Febrile infants younger than 2 months constitute an important subset of
children who may present with fever without a localizing source. The workup
of fever in these infants should always include evaluation for UTI. The chart
below details a treatment approach for febrile infants younger than 3 months
who have a temperature higher than 38°C. (See Presentation and DDx.)

Application of low-risk criteria

for and approach to the febrile infant: A reasonable approach for treating
febrile infants younger than 2 months who have a temperature of greater than
38°C.
Children with UTIs who have voiding symptoms or dysuria, little or no fever,
and no systemic symptoms, likely have cystitis. After age 2 years, UTI in the
form of cystitis is common among girls.
In rare instances, UTI results in recognition of an important underlying
structural or neurogenic abnormality of the urinary tract. [2] Some clinically
significant urinary tract abnormalities may be identified using intrauterine
ultrasonography. After birth, children with such abnormalities may incur
additional kidney damage as a result of postnatal infection, but UTI is not the
major cause of the kidney impairment.
Go to Urinary Tract Infection in Males and Cystitis in Females for complete
information on these topics. For patient education information, see Urinary
Tract Infections (UTIs) and Bladder Control Problems.
Pathophysiology
Typically, UTIs develop when uropathogens that have colonized the
periurethral area ascend to the bladder via the urethra. From the bladder,
pathogens can spread up the urinary tract to the kidneys (pyelonephritis) and
possibly to the bloodstream (bacteremia). Poor containment of infection,
including bacteremia, is more often seen in infants younger than 2 months.
Urine in the proximal urethra and urinary bladder is normally sterile. Entry of
bacteria into the urinary bladder can result from turbulent flow during normal
voiding, voiding dysfunction, or catheterization. In addition, sexual intercourse
or genital manipulation may foster the entry of bacteria into the urinary
bladder. More rarely, the urinary tract may be colonized during systemic
bacteremia (sepsis); this usually happens in infancy. Pathogens can also
infect the urinary tract through direct spread via the fecal-perineal-urethral
route.
Etiology
Bacterial infections are the most common cause of UTI, with E coli being the
most frequent pathogen, causing 75-90% of UTIs. Other bacterial sources of
UTI include the following:
 Klebsiella species
 Proteus species
 Enterococcus species
 Staphylococcus saprophyticus, especially among female adolescents
and sexually active females
 Streptococcus group B, especially among neonates
 Pseudomonas aeruginosa
Fungi (Candida species) may also cause UTIs, especially after
instrumentation of the urinary tract. Adenovirus is a rare cause of UTI and
may cause hemorrhagic cystitis.

Genetic factors

Deregulation of candidate genes may predispose patients to recurrent UTIs.

The identification of a genetic component may allow the identification of at-risk
individuals and, therefore, prediction of the risk of recurrent UTI in their
offspring.[3] Genes that are possibly responsible for susceptibility to recurrent
UTIs include HSPA1B, CXCR1, CXCR2, TLR2, TLR4,and TGFβ1. [3]

Risk factors

Susceptibility to UTI may be increased by any of the following factors:

 Alteration of the periurethral flora by antibiotic therapy
 Anatomic anomaly
 Bowel and bladder dysfunction
 Constipation
Children who receive antibiotics (eg, amoxicillin, cephalexin) for other
infections are at increased risk for UTI. These agents may alter
gastrointestinal (GI) and periurethral flora, disturbing the urinary tract's natural
defense against colonization by pathogenic bacteria.
Prolonged retention of urine may permit incubation of bacteria in the bladder.
Voiding dysfunction is not usually encountered in a child without neurogenic or
anatomic abnormality of the bladder until the child is in the process of
achieving daytime urinary control.
A child with uninhibited detrusor contractions may attempt to prevent
incontinence during a detrusor contraction by increasing outlet resistance.
This may be achieved by using various posturing maneuvers, such as
tightening of the pelvic-floor muscles, applying direct pressure to the urethra
with the hands, or performing the Vincent curtsy, which consists squatting on
the floor and pressing the heel of one foot against the urethra. As a result,
bacteria-laden urine in the distal urethra may be milked back into the urinary
bladder (urethrovesical reflux).
Constipation, with the rectum chronically dilated by feces, is an important
cause of voiding dysfunction. Neurogenic or anatomic abnormalities of the
urinary bladder may also cause voiding dysfunction.
Voiding dysfunction should be evaluated and managed appropriately. Surgical
correction of underlying anatomic disorders may be indicated in select cases.
For more information, see Pediatric Vesicoureteral Reflux.
Circumcision and UTI

For male infants, neonatal circumcision substantially decreases the risk of

UTI. Schoen et al found that during the first year of life, the rate of UTI was
2.15% in uncircumcised boys, versus 0.22% in circumcised boys. [4] Risk is
particularly high during the first 3 months of life; Schaikh et al reported that in
febrile boys younger than 3 months, UTI was present in 2.4% of circumcised
boys and in 20.1% of uncircumcised boys. [5]
Epidemiology
The incidence of UTIs varies based on age, sex, and gender. Overall, UTIs
are estimated to affect 2.4-2.8% of children in the United States annually.
Occurrences of first-time, symptomatic UTIs are highest in boys and girls
during the first year of life and markedly decrease after that. Shaikh et al
found that the overall prevalence of UTI in infants presenting with fever was
7.0%. [4]By age, the rates in girls were as follows:
 0-3 months - 7.5%
 3-6 months - 5.7%
 6-12 months - 8.3%
 >12 months - 2.1%
In febrile boys less than 3 months of age, 2.4% of circumcised boys and
20.1% of uncircumcised boys had a UTI. [4]

Sex- and race-related demographics

During the first few months of life, the incidence of UTI in boys exceeds that in
girls. By the end of the first year and thereafter, first-time and recurrent UTIs
are most common in girls. The incidence of UTI in children aged 1-2 years is
8.1% in girls and 1.9% in boys.
Studies from Sweden have indicated that at least 3% of girls and 1% of boys
have a symptomatic UTI by age 11 years. Other data, however, have
suggested that 8% of girls have a symptomatic UTI during childhood and that
the incidence of a first-time UTI in boys older than 2 years is probably less
than 0.5%. In sexually active teenage girls, the incidence of UTIs approaches
10%.
In studies by Hoberman et al, the prevalence of febrile UTIs in white infants
exceeded that in black infants. [6] These investigators found that among white
female infants younger than 1 year who had a temperature of 39°C or more
and were seen in an emergency department, 17% had UTI.
Prognosis
Mortality related to UTI is exceedingly rare in otherwise healthy children in
developed countries.
Cystitis may cause voiding symptoms and require antibiotics, but it is not
associated with long-term, deleterious kidney damage. The voiding symptoms
are usually transient, clearing within 24-48 hours of effective treatment.
Morbidity associated with pyelonephritis is characterized by systemic
symptoms, such as fever, abdominal pain, vomiting, and dehydration.
Bacteremia and clinical sepsis may occur. [7]
Children with pyelonephritis may develop focal inflammation of the kidney
(focal pyelonephritis) or renal abscess. Any inflammation of the renal
parenchyma may lead to scar formation. Approximately 10-30% of children
with UTI develop some renal scarring; however, the degree of scarring
required for the development of long-term sequelae is unknown.
Long-term complications of pyelonephritis are hypertension, impaired renal
function, and end-stage renal disease.
Dehydration is the most common acute complication of UTI in the pediatric
population. Intravenous fluid replacement is necessary in more severe cases.
In developed countries, kidney damage with long-term complications as a
consequence of UTI has become less common than it was in the early 20th
century, when pyelonephritis was a frequent cause of hypertension and end-
stage renal disease in young women. This change is probably a result of
improved overall healthcare and close follow-up of children after an episode of
pyelonephritis. Currently, these complications are most commonly
encountered in infants with congenital renal damage. [8, 9]

https://emedicine.medscape.com/article/969643-overview#showa
jurnal 6 pake

Seringkali, ISK berkembang saat uropatogen naik dari kolonasi periurethral ke kandung kemih (sistitis).
Dari kandung kemih, uropatogen dapat naik saluran kemih (pielonefritis) atau menyerang aliran darah
(urosepsis). ISK akibat invasi hematogen dan langsung jarang terjadi. Urine steril, tapi uropatogen bisa
masuk saat kateterisasi, pola voiding turbulen, hubungan seksual atau manipulasi genital. Kerentanan
ISK ditentukan oleh virulensi bakteri, varian anatomi (jenis kelamin, refluks vesikoureteral [VUR],
disunat), disfungsi usus atau kandung kemih sehingga terjadi stasis urin (konstipasi dan kantung kemih
neurogenik), dan pertahanan host (genetika dan flora pada saluran periuretra dan saluran cerna) . Pada
tahun pertama kehidupan, ISK lebih banyak terjadi pada anak laki-laki daripada anak perempuan dan 10
kali lebih tinggi pada anak laki-laki yang tidak disunat, dibandingkan dengan anak laki-laki yang disunat.3
Kejadian ISK di bawah 1% pada anak laki-laki usia sekolah dan meningkat menjadi 1-3% di sekolah-
wanita usia lanjut.4 Aktivitas seksual meningkatkan risiko ISK pada gadis remaja.5 Anak-anak yang
memiliki ISK memiliki 13,19% peningkatan risiko kekambuhan dan 17% akan mengembangkan jaringan
parut ginjal.6 Namun, sedikit anak-anak (<4%) akan mengembangkan gagal ginjal stadium akhir dari ISK;
Hal ini sering merupakan hasil dari ISK berulang atau VUR.7
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