Pediatric Urinary Tract

Infections
Joshua A. Hodge, Maj, USAF, MC
Staff Family Physician
Andrews AFB, MD
 Overview
• Background
• Diagnosis
• Treatment
• Follow up
• Prevention
• Imaging
• Vesiculoureteral reflux (VUR)
• Summary
 Background
• Most common serious bacterial infection in
young children
– 5% of febrile infants
• Prevalence
– By age 7: 8% girls, 2% boys
– Highest rate in first year of life
– Higher in Caucasians
– Higher in uncircumcised boys
• Most common organism: E. coli- 80%
 Background
• Symptoms systemic in early childhood
– Fever*
– Irritability
– Lethargy
– Anorexia
– Emesis
• Potential sequelae
– Renal scarring
– Chronic renal failure
– HTN
 Background
• Anatomic risk factors
– Vesiculoureteral reflux (VUR)
• More common in girls
– Obstruction
– Posterior urethral valves
• Boys
– Voiding dysfunction
– Bladder diverticulum
 Background
• Associated risk factors
– Constipation
– Encoporesis
– Bladder instability
– Infrequent voiding
• Unsubstantiated risks
– Bathing
– Back-to-front wiping
 Diagnosis
• Single organism identified on culture
– Suprapubic aspirate > 1,000 cfu/mL
– Catheter specimen > 10,000 cfu/mL
– Clean catch specimen > 100,000 cfu/mL
– Urine bags not recommended
 Diagnosis
• Urinalysis
– Not helpful if clinical suspicion high
• i.e. older children with classic symptoms
– Useful if low likelihood of UTI
• Non-dilute urine (sg > 1.005)
• Neg nitrate and leuk esterase
• Negative predictive value > 95%
• Blood cultures not useful
 Treatment
• Initiate immediately after culture drawn
– Reduces severity of renal scarring
• Oral route preferred
• 7-14 day course is standard
– 2-4 days appears to be as effective
• Not yet recommended
 Treatment
Antibiotic Daily Dosage
Amoxicillin* 20-40mg/kg in 3 doses
Cefixime (Suprax) 8mg/kg in 2 doses
Cefpodoxime (Vantin) 10mg/kg in 2 doses
Cefprozil (Cefzil) 30mg/kg in 2 doses
Cephalexin (Keflex) 50-100mg/kg in 4 doses
Loracarbef (Lorabid) 15-30mg/kg in 2 doses
Sulfisoxazole (Gantrisin) 120-150mg/kg in 4 doses
Trimethoprim/ 6-12mg/kg & 30-60mg/kg
Sulfamethoxazole (Bactrim) In 2 doses
 Follow Up
• AAP Recommendation: 48 hours
– If not improving repeat culture &
immediate renal ultrasound
– No evidence to support repeat
culture/test of cure

Committee on Quality Improvement, Subcommittee on Urinary Tract Infection.

Practice parameter: the diagnosis, treatment, and evaluation of the initial urinary
tract infection in febrile infants and young children. Pediatrics 1999;103:843-52.
 Prevention
• Rates of recurrence
– 12% of children < 5 years old
– 18% of infants < 6 months
• Prophylactic antibiotics
– Recommended by AAP while waiting for
imaging
– Efficacy questioned
 Prevention
Antibiotic Daily Dosage
Methenamine mandelate 75mg/kg in 2 doses
(Mandelamine)
Nalidixic acid (NegGram) 30mg/kg in 2 doses

Nitrofurantoin (Macrobid) 1-2mg/kg once per day

Sulfisoxazole (Gantrisin) 10-20mg/kg in 2 doses

Trimethoprim/ 2mg/kg & 10mg/kg nightly or

sulfamethoxazole (Bactrim) 5mg/kg & 25mg/kg 2x/week
 Prevention
• Circumcision
– Lowers UTI rate in boys
• NNT = 111 to prevent one UTI
– Surgical complication rate = 1%
– Benefit does not outweigh risk and not
recommended
 Imaging
• Who to image?
– AAP
• All children 2 months to 2 years of age with
first UTI
• Renal ultrasound
• Cystogram
– Voiding cystourethrogram (VCUG)
– Radionuclide cystogram (RNC)
 Imaging
• Who to image?
– Cincinnati Children’s Hospital
• All boys
• Girls < 36 months
• Girls 3-7 with fever > 38.5º C (101.3º F)
• Same modalities recommended as AAP

Evidence based clinical practice guideline for medical management of first time
acute urinary tract infection in children 12 years of age or less. Cincinnati, Ohio:
Cincinnati Children’s Hospital Medical Center, 2005.
 Imaging
• Renal ultrasound
– GU tract anatomy
– Evaluate renal scarring

• DMSA (renal cortical scan)

– Differentiates pyelonephritis from cystitis
– Assesses renal scarring
 Imaging
• Cystogram- identify and grade vesicoureteral
reflux (VUR)
– Voiding cystourethrogram (VCUG)
• OK for girls and boys
• Demonstrates GU anatomy plus VUR
– Radionuclide cystogram (RNC)
• Low amount of radiation
• Girls only
– Little anatomic detail
 Vesicoureteral Reflux (VUR)
• Concern for pyelonephritis & renal scarring
• Prevalence in females < 18 yo
– Grade I- 7%
– Grade II- 22%
– Grade III- 6%
– Grade IV- 1%
– Grade V- <1%
 Vesicoureteral Reflux
• Standard treatment options
– Antibiotics
• Studies of prophylactic antibiotics have not
included children with VUR
– Surgery
– Antibiotics + surgery
 Vesicoureteral Reflux
• Unclear if clinical benefits to treating VUR
– Only severe VUR (Grades IV & V) associated
with recurrent UTI and pyelonephritis
• < 2% of all cases of VUR
• No causal relationship with scarring
– Risk of UTI = between surgical & medical groups
– Abx + surgery reduced # of UTIs and pyelo but
no renal damage noted in either group at 5 years

Wheeler DM, et al. Interventions for primary VUR. Cochrane Database Syst Rev.
2004(3):CD001532
 Summary
• Urine culture necessary for diagnosis
• Short courses of antibiotics may be as
effective as longer courses
• Prophylactic antibiotics are an option but
may not provide much clinical benefit
• Routine imaging does not appear to affect
outcomes
• Diagnosing VUR does not appear to affect
outcomes
 References
• Alper BS, Curry SH. Urinary tract infection in children. Am Fam
Physician 2005;72:2483-8.
• Committee on Quality Improvement, Subcommittee on Urinary Tract
Infection. Practice parameter: the diagnosis, treatment, and
evaluation of the initial urinary tract infection in febrile infants and
young children. Pediatrics 1999;103:843-52.
• Currie ML, et al. Follow-up urine cultures and fever in children with
urinary tract infection. Arch Pediatr Adolesc Med 2003;157:1237-
40.
• Evidence based clinical practice guideline for medical management
of first time acute urinary tract infection in children 12 years of age
or less. Cincinnati, Ohio: Cincinnati Children’s Hospital Medical
Center, 2005.
• Michael M, et al. Short versus standard duration oral antibiotic
therapy for acute urinary tract infection in children. Cochrane
Database Syst Rev 2004;(4):CD003966
 References
• Roberts KB. The AAP practice parameter on urinary tract infections
in febrile infants and young children. Am Fam Physician
2000;62:1815-22.
• Le Saux N, Pham B, Mohoer D. Evaluating the benefits of
antimicrobial prophylaxis to prevent urinary tract infections in
children: a systematic review. CMAJ 2000; 163:523-9.
• Michael M, et al. Short compared with standard duration of
antibiotics treatment for urinary tract infection: a systematic review
of randomised controlled trials. Arch Dis Child 2002;87:118-23.
• Singh-Grewal D, Macdessi J, Craig J. Circumcision for the
prevention of urinary tract infection in boys: a systematic review of
randomized trials and observational studies. Arch Dis Child
2005;90:853-58.
• Williams GJ, Lee A, Craig JC. Long-term antibiotics for preventing
recurrent urinary tract infection in children. Cochrane Database
Syst Rev 2004;(4):CD001534.
• Wheeler DM, et al. Interventions for primary vesicoureteric reflux.
Cochrane Database Syst Rev 2004;(3):CD001532.