AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Urinary tract infection (UTI) is one of the most common infections of childhood. It distresses the child, concerns the parents, and may cause permanent kidney damage.

In some instances, UTI results in recognition of an important underlying structural or neurogenic abnormality of the urinary tract. The febrile child with clinically significant bacteriuria and no other site of infection to explain the fever, even in the absence of systemic symptoms, has pyelonephritis (ie, upper UTI). Children with a UTI and voiding symptoms, little or no fever, and no systemic symptoms have lower UTI (cystitis).

The site of infection is often unclear when a child with pyuria and clinically significant bacteriuria has another potential source of fever (eg, otitis media, pharyngitis). When UTI is diagnosed in a child, an attempt should be made to identify any risk factors for the UTI (eg, anatomic anomaly, voiding dysfunction, constipation).

Pathophysiology

Almost all UTIs are ascending in origin. Disturbance of the normal periurethral flora, which is part of the host defense against colonization by pathogenic bacteria, predisposes a person to a UTI. Bacteria of the periurethral flora also inhabit the distal urethra. Urine in the proximal urethra, urinary bladder, and other proximal sites in the urinary tract is normally sterile. Uropathogens must gain access to the urinary bladder and proliferate for infection to occur. Uropathogens in the distal urethra may gain access to the bladder because of turbulent urine flow during normal voiding or because of dysfunctional voiding. Successful urinary bladder colonization is unlikely unless bladder defense mechanisms are impaired because normal voiding usually results in an essentially complete washout of contaminating bacteria.

After birth, the periurethral area, including the distal urethra, becomes colonized with aerobic and anaerobic microorganisms that appear to function as a defense barrier against colonization by uropathogens. In early childhood, enterobacteria and enterococci are part of the normal periurethral flora. Escherichia coli is the dominant gram-negative species in young girls, whereas E coli and Proteus species predominate in boys. Children as old as about 5 years are predisposed to have UTIs, partly because of periurethral colonization by E coli, enterococci, and Proteus species. These potential uropathogens usually diminish in the first year of life and are rarely found in children older than 5 years. Studies of girls and women prone to UTI showed that periurethral colonization occurs with the specific bacterium that causes the next infection.

Frequency

International

Studies from Sweden have indicated that at least 3% of girls and 1% of boys have a symptomatic UTI by the age of 11 years. However, data from recent epidemiologic surveys suggest incidences higher than these. Occurrences of a first-time symptomatic UTI are highest for both boys and girls during the first year of life and markedly decrease after that. The minimum cumulative incidence in both boys and girls aged 2 years is slightly over 2%. Most episodes of UTI during the first year of life are pyelonephritis. After 2 years of age first-time UTI manifesting as cystitis is common among girls. Recent data suggest that 8% of girls have a symptomatic UTI during childhood. The incidence of a first UTI in boys older than 2 years is exceedingly low, probably less than 0.5%.

Mortality/Morbidity

• Mortality related to UTI is exceedingly rare for otherwise healthy children in developed countries.
• Morbidity associated with pyelonephritis is characterized by systemic symptoms, such as fever, abdominal pain, vomiting, and dehydration. Bacteremia and clinical sepsis may occur. Children with pyelonephritis also may have cystitis. Long-term complications of pyelonephritis are hypertension, impaired kidney function, end-stage renal disease (ESRD), and complications of pregnancy (eg, UTI, pregnancy-related hypertension, low-birth-weight neonates).
• The voiding symptoms of cystitis are usually transient, clearing within 24-48 hours of effective treatment. Long-term complications of UTI are caused by renal damage secondary to pyelonephritis. Cystitis may cause voiding symptoms and require antibiotics, but it is not associated with long-term deleterious kidney damage.

Race

Data are scant. However, in studies by Hoberman et al, the prevalence of a febrile UTI in Caucasian infants exceeded that of African-American infants. These investigators found that 17% of white female infants younger than 1 year with a temperature of 39°C or more seen in an emergency department had UTIs.

Sex

• 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, both first-time and recurrent UTIs are most common in girls. The prevalence of UTI in girls between 1 and 2 years of age is 8.1%, in boys it is 1.9%. The rate in circumcised boys is low, 0.2% to 0.4%. The rate in uncircumcised boys is 5 to 20 times higher than in circumcised boys.
• In a systematic review, investigators calculated crude estimates of UTI during the first 24 months of life. Rates were 3% in boys younger than 1 year, 2% in boys older than 1 year, 7% in girls younger than 1 year, and 8% in girls aged 1-2 years (Downs, 1999).

Age

First-time UTI is most common in the first 2 years of life.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

The 2 broad clinical categories of urinary tract infection (UTI) are pyelonephritis, or upper UTI, and cystitis, or lower UTI. The history and clinical course varies with the patient's age and the specific diagnosis.

• Children aged 0-2 months: Neonates and infants in this age range who have pyelonephritis usually do not have symptoms localized to the urinary tract. UTI is discovered as part of an evaluation for neonatal sepsis.
• Infants and children aged 2 months to 2 years
• • Infants and young children in this age range with pyelonephritis may have a history of unexplained fever (eg, rectal or tympanic membrane–derived temperature of >38°C).
  • These patients are at higher risk for renal injury than are older children, possibly because the lack of localizing signs of infection delays the start of antibiotic therapy. This situation had led to a 3-day rule: An infant or child with unexplained fever should not be observed for more than 3 days without a urine specimen being obtained.
  • Some infants with pyelonephritis in this age range have fever and few other symptoms, whereas others are acutely ill and have a history of irritability, decreased oral intake, abdominal pain, vomiting, and loose bowel movements.
  • Children aged 1-2 years may present with voiding symptoms suggestive of cystitis, with crying on urination or only a foul odor to the urine in the absence of clinically significant fever (temperature <38°C).
• Children aged 2-6 years
• • Children in this age group with febrile UTI (pyelonephritis) usually have systemic symptoms with loss of appetite; irritability; and abdominal, flank, or back pain. Voiding symptoms may be present or absent.
  • Children with acute cystitis have voiding symptoms with little or no temperature elevation. Voiding dysfunction may include urgency, frequency, hesitancy, dysuria, or urinary incontinence.
  • Suprapubic or abdominal pain may be present, and the urine sometimes has a strong or foul odor.
• Children older than 6 years and adolescents
• • UTI among children in this age range usually affects the lower tract, but pyelonephritis also occurs. Symptoms are similar to those in children aged 2-6 years.
  • Girls who have pyelonephritis in infancy or early childhood, including those with persistence of vesicoureteric reflux (VUR), usually have cystitis with UTI when they are older. They are also prone to have a recurrence during pregnancy.

Physical

• Findings on physical examination, such as tenderness in the costovertebral angle or flank, may help localize the site of infection to the kidney. Suprapubic tenderness may be present.
• Infants and younger children with pyelonephritis usually have no localizing findings, but they are febrile and irritable.
• The older children with pyelonephritis often have tenderness of the flank or costovertebral angle, and those with cystitis may have suprapubic tenderness.

Causes

Proliferation of bacteria in the urinary tract is the cause of UTI.

• Infections are almost always ascending in origin and caused by bacteria in the periurethral flora and the distal urethra. These bacteria inhabit the distal GI tract and colonize the perineal area. E coli usually causes a child's first infection, but other gram-negative bacilli and enterococci may also cause infection.
• Staphylococcal infections, especially those due to Staphylococcus saprophyticus, are common causes of UTI among female adolescents.
• Entry of bacteria into the urinary bladder may be the result of 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.
• Risk factors for UTI have been described.
• • Children who receive broad-spectrum antibiotics (eg, amoxicillin, cephalexin) that are likely to alter GI and periurethral flora are at increased risk for UTI because these drugs disturb the natural defense against colonization by pathogenic bacteria.
  • Prolonged incubation of bacteria in bladder urine due to incomplete bladder emptying or infrequent voiding compromises an important bladder defense against infection. Symptoms of voiding dysfunction, such as urgency, frequency, hesitancy, dribbling, or incontinence may occur in the absence of infection or local irritation because of uninhibited detrusor contractions. When the child attempts to prevent incontinence during a detrusor contraction by posturing (eg, obstructing the urethra), bacteria-laden urine in the distal urethra may be milked back into the urinary bladder (urethrovesical reflux). This mode of bacterial access is a common risk factor for UTI among pediatric patients who use posturing or pelvic withholding procedures to prevent incontinence.
  • Voiding dysfunction is not usually encountered until a child is in the process of achieving daytime urinary control. Children with voiding dysfunction may attempt to prevent incontinence during an uninhibited detrusor contraction by voluntarily 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.
  • 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.
  • Neonatal circumcision decreases the risk of UTI by about 90% in male infants during the first year of life. The risk of UTI in a circumcised infant is about 1 in 1000 during the first year, whereas an uncircumcised male infant has a 1 in 100 risk of developing a UTI. Given this risk, 111 healthy male infants must be circumcised to prevent 1 UTI. The risk and long-term effect of scarring due to 1 preventable UTI in a male infant are not known.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Cystitis
Epididymitis
Orchitis
Prostatitis
Urethritis

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• The diagnosis is based on quantitative cultures of a properly collected urine specimen (see Table 1 and Table 2).
• • A midstream, clean-catch specimen may be obtained from children who have urinary control. In the infant or child unable to void on request, the specimen for culture should be obtained by means of suprapubic aspiration or urethral catheterization. Suprapubic aspiration is the method of choice for obtaining urine from the uncircumcised boy with a redundant or tight foreskin and from children of either sex with clinically significant periurethral irritation.
  • A culture of a urinary specimen from a sterile bag attached to the perineal area that shows no or scant growth (<10,000 colony-forming units [CFUs]/mL) is strong evidence of absent urinary tract infection (UTI). However, the false-positive rate is so high that this method of urine collection is not suitable for diagnosing a UTI.
  • Urinalysis does not substitute for urine culture to document the presence of a UTI. However, it can help in identifying febrile children who should receive antibacterial treatment while culture results from a properly collected urine specimen are pending.
• Methods of urine collection, examination, and salient findings are shown in Tables 1 and 2. 
• • Table 1. Urinalysis for Presumptive Diagnosis of UTI*

    Method	Findings
    Bright-field or phase-contrast microscopy of centrifuged urinary sediment	Bacteria
    Gram staining of uncentrifuged urinary sediment	Bacteria
    Nitrite and leukocyte esterase test	Positive = UTI likely
    Nitrite test	Positive = UTI probable
    Leukocyte esterase test	Positive = Nonspecific

    *Negative microscopic findings for bacteria do not rule out a UTI, nor do negative results of dipstick testing for nitrite and leukocyte esterase. 
  • Table 2. Quantitative Urine Culture for the Diagnosis of UTI*

    Method	Finding
    Suprapubic aspiration	If a UTI is present, bacteria are likely to be proliferating in bladder urine with growth of any organism except 2000-3000 CFU/mL coagulase-negative staphylococci.
    Catheterization in a girl or midstream clean-void collection in a circumcised boy	Febrile infants and children with UTI usually have >50,000 CFU/mL of a single urinary pathogen; however, UTI may be present with 10,000-50,000 CFU/mL of a single organism.*
    Midstream clean-void collection in a girl or uncircumcised boy	UTI is indicated when >100,000 CFU/mL of a single urinary pathogen is present in a symptomatic patient. Pyuria usually present. A UTI may be present with 10,000-50,000 CFU/mL of a single bacterium.*
    Any method in a girl or boy	If the patient is asymptomatic, bacterial growth is usually >100,000 CFU/mL of the same organism on different days. If pyuria is absent, this result probably indicates colonization rather than infection.

    *Patients with urinary frequency (ie, decreased bladder incubation time) are those most likely to have bacteria proliferating in the urinary bladder in the presence of low colony counts.
• Obtain a CBC count and basic metabolic panel for children with a presumptive diagnosis of pyelonephritis.
• Perform blood cultures in febrile infants and older patients who are clinically ill, toxic, or severely febrile.

Imaging Studies

• General considerations
• • History of imaging: In the past, the recommendation was that an infant or a child with a first febrile UTI should undergo imaging of the urinary tract. In the early years, intravenous pyelography (IVP) and voiding cystourethrography (VCUG) were performed, IVP immediately and VCUG 4-6 weeks later.
  • Ultrasonography: Sonography of the urinary tract subsequently replaced IVP. However, recent studies show that sonograms of the urinary tract obtained after a first febrile UTI seldom provide information that change management. A current recommendation is that urinary sonography should be omitted after a first febrile UTI in infants and children if they respond to treatment (afebrile within 72 h), good follow-up is assured, and no voiding abnormality (no dribbling of urine) or abdominal mass is present. The clinician's judgment should guide the decision regarding imaging studies, as opposed to a rigid rule. Urinary sonography is a safe, noninvasive study that is easy to perform. It is useful in excluding obstructive urography and in identifying children with a solitary or ectopic kidney and some patients with moderate renal damage caused by pyelonephritis.
  • VCUG or nuclear cystography
    • Traditionally VCUG has been recommended for infants and children after a first febrile UTI. This is based on the assumptions that most upper UTIs occur because of urinary bladder infection and that VUR transfers bacteria in the bladder to the kidney. However, using cortical imaging, current data show that upper tract infection occurs equally in children with and without VUR. The assumption that antibacterial prophylaxis prevents a recurrence of UTI seems reasonable, although this has not been proven. A lack of sufficient randomized control studies comparing antibacterial prophylaxis with placebo prohibits an evidence-based recommendation to prevent recurrent UTIs. Long-term, prospective randomized studies are needed.
    • Of note, a first febrile UTI is as frequent in infants with VUR as in those without radiographically demonstrated reflux. The recommendation for VCUG after a first febrile UTI is based on expert opinion and judgment, not on evidence-based guidelines.
    • Some experts suggest that cystography that requires catheterization of the urinary bladder be avoided. Their recommendation, which is not evidence based, is that renal cortical scanning (renal scintigraphy) should be performed. This study helps in identifying kidney injury and/or pyelonephritis. If the scan findings are normal, cystography is not needed. However, if the results are abnormal, VCUG should be obtained.
    • If a VCUG is to be obtained, it should obtained after the voiding pattern returns to its pre-UTI state. If the organism that caused the UTI was susceptible to the antibacterial used to treat the febrile UTI and if the response to therapy was satisfactory, follow-up urinalysis or cultures are not needed. The child should receive antibacterial therapy at least until the cystogram is obtained.
    • Some clinicians recommend waiting 4-6 weeks after febrile UTI is treated to perform VCUG. If the child is given suppressive antibacterial treatment during this period, this recommendation is acceptable. However, recent studies showed that the VCUG may be obtained within the first few days of treating febrile UTI, if the voiding pattern has returned to its pre-UTI state.
  • General recommendation: If imaging studies of the urinary tract are warranted, they should not be obtained until the diagnosis is confirmed with a quantitative urinary culture.
• Summary of imaging recommendations
• • Which children should undergo ultrasonography of the urinary tract after a first febrile UTI?
    • Patients who have a delayed or unsatisfactory response to treatment of the first febrile UTI
    • Children with an abdominal mass or abnormal voiding (dribbling of urine)
    • Any child with a first febrile UTI in whom good follow-up cannot be ensured (Good clinical and experimental data support the opinion that the best way to prevent kidney damage due to a UTI is by prompt diagnosis and effective treatment of a febrile UTI.)
    • Children with a first febrile UTI caused by an organism other than E coli
    • Children with recurrence of a febrile UTI after they have a satisfactory response to treatment of the initial febrile UTI
  • Which children should undergo VCUG after a first febrile UTI?
    • Those in whom treatment fails after 48-72 hours
    • Patients with an abnormal voiding pattern (dribbling of urine)
    • Infants and children in whom good follow-up is not assured
    • Those with an abdominal mass
    • Infants and children with recurrence of a febrile UTI
  • Which pediatric patients do not need imaging studies after a first UTI?
    • Infants and children with a first febrile UTI who are assured follow-up, who respond promptly to treatment (afebrile within 72 h), and who have a normal voiding pattern (no dribbling) and no abdominal mass
    • Infants and children with cystitis: Those with an abnormal voiding pattern after receiving effective treatment of the UTI may need to undergo an evaluation for voiding dysfunction; this may include standard VCUG.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical Care

• Infants younger than 8 weeks with a febrile urinary tract infection (UTI)
• • The diagnosis is usually based on fever and positive results form a urine specimen obtained by catheterization. Infants with such findings are usually hospitalized and receive parenteral antibiotic therapy (see Table 3 below). However, clinical judgment may indicate that home treatment is appropriate. Parenteral antibiotics may be used with daily follow-up until the patient is afebrile for 24 hours. Complete 10-14 days of therapy with an oral antibiotic active against the infecting bacteria. 
  • Table 3. Antibiotic Agents for Parenteral Treatment of a UTI

    Drug	Dosage and Route	Comment
    Ceftriaxone	50-75 mg/kg/d IV/IM as a single dose or divided q12h	Do not use in infants <6 wk of age; parenteral antibiotic with long half-life; may displace bilirubin from albumin
    Cefotaxime	150 mg/kg/d IV/IM divided q6-8h	Safe to use in infants <6 wk of age; used with ampicillin in infants aged 2-8 wk
    Ampicillin	100 mg/kg/d IV/IM divided q8h	Used with gentamicin in neonates <2 wk of age; for enterococci and patients allergic to cephalosporins
    Gentamicin	Term neonates <7 d: 3.5-5 mg/kg/dose IV q24h Infants and children <5 y: 2.5 mg/kg/dose IV q8h or single daily dosing with normal renal function of 5-7.5 mg/kg/dose IV q24h Children >5 y: 2-2.5 mg/kg/dose IV q8h or single daily dosing with normal renal function of 5-7.5 mg/kg/dose IV q24h	Monitor blood levels and kidney function if therapy extends >48 h

    Note.—IM = intramuscular; IV = intravenous; q = every.
• Infants and children 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 by means of suprapubic aspiration or catheterization before treatment is started.
  • Recent evidence suggests no significant differences in efficacy between IV antibiotic therapy given for 3 days followed by oral therapy for another 11 days and 14 days of oral therapy. These data are based on a randomized control trial of 306 children aged 1-24 months to compare oral cefixime for 14 days with IV cefotaxime for 3 days followed by oral cefixime for 11 days. No notable differences were observed in short- or long-term outcomes (eg, clinical response, reinfection, renal scars at 6 mo). These data led to the recommendation that children with a febrile UTI should receive oral treatment with a second- or third-generation cephalosporin, amoxicillin clavulanate, or sulfamethoxazole-trimethoprim (SMZ-TMP) (see Table 4). 
  • Table 4. Antibiotic Agents for the Oral Treatment of UTI

    Antibacterial Agent	Daily Dosage
    Sulfisoxazole	120-150 mg/kg divided q4-6h
    Sulfamethoxazole and trimethoprim	6-12 mg/kg TMP, 30-60 mg/kg SMZ divided q12h
    Amoxicillin and clavulanic acid	20-40 mg/kg divided q8h
    Cephalexin	20-50 mg/kg divided q6h
    Cefixime	8 mg/kg divided q12-24h
    Cefpodoxime	10 mg/kg divided q12h
    Loracarbef	15-30 mg/kg divided q12h
    Nitrofurantoin*	5-7 mg/kg divided q6h

    *Nitrofurantoin may be used to treat lower UTIs. However, because of its limited tissue penetration, nitrofurantoin is not suitable for the treatment of kidney infection.
  • A child treated with oral antibiotics should not be acutely ill or toxic, and he or she should not have persistent vomiting or moderate-to-severe dehydration.
• Daily follow-up and good compliance is essential with this management.
• Inpatient treatment of children with complicated pyelonephritis
• • Provide appropriate parenteral fluids, usually at 1-1.5 times the usual maintenance rate.
  • Parenteral treatment with a third-generation cephalosporin, such as ceftriaxone or cefotaxime (Table 3). Add ampicillin if gram-positive cocci are present in the urinary sediment or if no organisms are observed. Gentamicin is an alternative for term infants older than 7 days, for older children, and for adolescents who are allergic to cephalosporins. Monitor renal function and blood aminoglycoside levels if this medication is required for more than 48 hours.
  • Results of urine culture and sensitivity studies are usually available within 48 hours. If the pathogen is sensitive to the antibiotic used and if the child is improving, continue treatment with the parenteral route until the child is afebrile for 24-36 hours. An oral antibiotic that is effective against the infecting organism may then be substituted for parenteral therapy (see Table 4).
  • The hospitalized patient is usually ready to go home after 48-72 hours. Continue therapeutic doses of antibiotics for a total of 10-14 days of antibiotic therapy. Antibacterial therapy should be given to prevent reinfection (see Table 5 below) and continue at least until a VCUG is obtained (if one is to be obtained). 
  • Table 5. Antibiotic Agents to Prevent Reinfection

    Agent	Single Daily Dose
    Nitrofurantoin*	1-2 mg/kg PO
    Sulfamethoxazole and trimethoprim*	1-2 mg/kg TMP, 5-10 mg/kg SMZ PO
    Trimethoprim	1-2 mg/kg PO

    *Do not use nitrofurantoin or sulfa drugs in infants younger than 6 weeks. Reduced doses of an oral first-generation cephalosporin, such as cephalexin at 10 mg/kg, may be used until the child reaches the age of 6 weeks. Ampicillin or amoxicillin are not recommended because of the high incidence of resistant E coli.
• Children with cystitis
• • Children with cystitis usually do not require special medical care other than appropriate antibiotic therapy and symptomatic therapy if the voiding symptoms are marked. Antibiotic therapy is started on the basis of the practitioner's appraisal of the patient's clinical history and urinalysis results before the diagnosis is documented. Systematic reviews of treatments for cystitis in children showed no difference in the efficacy with 7-14 days of therapy compared with 2-4 days. Single-dose or single-day therapy is not recommended in children with cystitis.
  • Symptomatic relief for dysuria consists of increasing fluid intake to enhance urine dilution and output, acetaminophen, and nonsteroidal anti-inflammatory drugs. If voiding symptoms are severe and persistent, add phenazopyridine hydrochloride (Pyridium). Do not administer phenazopyridine hydrochloride for longer than 48 hours because of the risk of methemoglobinemia, hemolytic anemia, and other adverse reactions.
  • Sitting in a tub of warm water for 20-30 minutes 3-4 times a day often affords symptomatic relief. Patients with severe voiding discomfort may obtain relief by using an appropriately sized rectal suppository of belladonna and opium. Inform the patient to use these suppositories no more than 4 times a day and for no longer than 2 days.
  • A 4-day course of an oral antibiotic agent is recommended for the treatment of cystitis (see Table 4). If the clinical response is not satisfactory after 2-3 days, alter therapy on the basis of antibiotic susceptibility.

MEDICATION

Section 7 of 10  

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• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Antibiotics are used to treat urinary tract infection (UTI) and to prevent recurrences. Avoid nephrotoxic drugs whenever possible. On occasion, analgesic therapy may be used to provide relief because of voiding symptoms.

Drug Category: Antibiotic agents

These are used for bacterial infections of the urinary tract. Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.

Drug Category: Systemic analgesics

These agents are used to provide relief from voiding symptoms due to UTI.

Drug Category: Urinary bladder analgesics

These agents are used to relieve burning, spasticity, and pain during voiding due to UTI.

FOLLOW-UP

Section 8 of 10  

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• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Inpatient Care

• For patients with pyelonephritis, give a suppressive dose of antibiotics to prevent reinfection at least until the VCUG is obtained (if one is to be obtained) (see Table 5).
• In patients with pyelonephritis, some clinicians discontinue antibacterial therapy 1-2 days after VCUG, if no VUR is present.
• • However, in studies of cortical scanning, roughly one half of the children with an initial episode of pyelonephritis have VUR, and one half have no radiographically identifiable reflux. Reinfection is common in both groups, with a high incidence in the first 6 months after the initial infection.
  • Until evidence-based guidelines about the use of suppressive antibacterial therapy after an initial febrile urinary tract infection (UTI) are available, recommending 6-12 months of suppressive treatment seems reasonable. Patients with VUR of grade III should receive a prolonged course of suppressive therapy. Patients VUR of grade IV or worse should be referred to a pediatric nephrologist or urologist.

Further Outpatient Care

• For children with uncomplicated acute pyelonephritis
• • Although children with a febrile UTI may qualify for outpatient care, they still are at risk for kidney damage. Initial use of a parenteral antibiotic may increase the likelihood of promptly ceasing the bacterial proliferation in the renal tissue. However, Hoberman et al (1999) indicated that oral therapy with a third-generation cephalosporin was as effective as traditional inpatient treatment with parenteral antibacterial therapy.
  • If the patient is not allergic to a cephalosporin, initial treatment may consist of a single dose of ceftriaxone 75 mg/kg IV/IM q12-24h.
  • If the patient is allergic to cephalosporin, initial treatment may be gentamicin 2.5 mg/kg IV/IM as a single dose.
  • Start treatment with an oral antibacterial agent at therapeutic doses within the next 12-18 hours if the patient's response is satisfactory.
  • Arrange for follow-up, usually telephone follow-up, at 24 hours to monitor the response to treatment and at 48 hours to modify treatment the results of antibacterial sensitivity studies indicate a need to change.
  • Arrange for a follow-up visit after 7-10 days to check the patient's clinical course.

Deterrence/Prevention

• Avoid unnecessary use of antibiotics for upper respiratory infections and otitis media. Antibiotics can alter GI and periurethral flora and compromise natural defenses against colonization by pathogenic agents.
• Treat voiding dysfunction, especially when it is associated with posturing, which can lead to urethrovesical reflux and recurrence of UTIs.
• Consider circumcision of male neonates.

Complications

• An allergic reaction to antibiotic therapy is a risk.
• Children with pyelonephritis may develop lobar inflammation of the kidney (lobar or focal nephronia) or renal abscess.
• Any inflammation of the renal parenchyma may lead to scar formation.
• Long-term complications of pyelonephritis are hypertension, impaired renal function, ESRD, and complications of pregnancy (eg, UTI, pregnancy-related hypertension, low-birth weight neonates).

Prognosis

• In industrialized countries, kidney damage with long-term complications as a consequence of UTI per se is currently less common than it was early in the 20th century, when pyelonephritis was a frequent cause of hypertension and ESRD in young women.
• • This change is probably a result of improved overall healthcare and close follow-up of children after an episode of pyelonephritis.
  • In countries with high-quality healthcare, hypertension, impaired renal function, and ESRD are now most commonly encountered in infants with intrauterine renal damage.
• Clinically significant urinary tract abnormalities are frequently identified using intrauterine ultrasonography. After birth, these children may incur additional kidney damage as a result of postnatal infection, but UTI is not the major cause of the kidney impairment.

Patient Education

• For excellent patient education resources, visit eMedicine's Kidneys and Urinary System Center. Also, see eMedicine's patient education articles Urinary Tract Infections and Bladder Control Problems.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Medical legal confrontations related to the management of children with urinary tract infection (UTI) appear to be uncommon, but they definitely occur.
• Administration of an antibiotic to a child known to be allergic to that medication can result in a severe reaction and is a potential cause of medical legal action.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

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Article Last Updated: Jan 16, 2007