Urinary tract infection resident survival guide (pediatrics)

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Rana aljebzi, M.D.[2]

Synonyms and Keywords: Urinary tract infection in kids, UTI in kids, UTI in pediatrics, pedicatrics urinary tract infection

Urinary tract infection resident survival guide (pediatrics) Microchapters
Overview
Causes
FIRE
Diagnosis
Treatment
Do's
Don'ts

Overview

Urinary tract infections (UTIs) are common in kids. it occurs when bacteria (germs) get into the bladder(lower tract infection) or kidneys(upper tract).abdominal pain and loin tenderness, with systemic features fever, anorexia, vomiting, lethargy and malaise is the signs of upper tract infection while lower abdominal or suprapubic pain, dysuria, urinary frequency and urgency is lower tract infections signs.in younger children the typical signs are not clear and it is difficult to differentiation between upper and lower tract infection, Up to 8% of girls and 2% of boys will get a UTI by age 5 Prompt diagnosis and appropriate treatment are very important to reduce the morbidity associated with this condition,usually With the right treatment, your child should start to feel better in just a few days.

Causes

Life Threatening Causes

Urinary tract infections has two basic types,bladder infection and kidney infection. if the infection is in the bladder it is called cystitis and it causes pain and swelling in bladder, while if the infection traveled up to the kidneys in this condition ,it is called pyelonephritis and it is serious and it might harm the kidneys.

Common Causes

infection

Mechanical

FIRE: Focused Initial Rapid Evaluation

UTI should be considered in any infant or child presenting with fever without an identifiable source of infection.because it can be associated with acute mortality (i.e. urosepsis) and/or chronic medical problems like renal scarring[2], hypertension, and chronic renal insufficiency,that is why urinalysis and urine culture should be done.The AAP (American Academy of pediatrics) recommendations for imaging after an initial febrile UTI were extensive and included renal and bladder ultrasound, voiding cystourethrography (VCUG) or radionuclide cystography in all children younger than two years of age [3]

Complete Diagnostic Approach

Shown below is an algorithm summarizing the diagnosis of UTI in children according to the AAP [American Academy of Pediatrics] guidelines.

 
 
 
 
 
 
 
 
 
 
 
 
 
Child with fever and symptoms of UTI
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Unstable/Septic
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Stable
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Admit
+
IV antibiotics
+
Consider specialist consult
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Urine culture and urianalysis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
First UTI
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Recurrent UTI
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
<2years old
 
 
 
 
 
 
 
 
 
>2years old
 
 
 
 
 
 
 
 
 
 
 
 
 
Ultrasound
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Ultrasound
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Normal
 
 
 
 
 
 
 
 
 
Abnormal
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Normal
 
 
 
 
 
Abnormal
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
DMSA scan if appropriate
 
 
 
 
 
 
 
 
 
Further management
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Antibiotic for 7-14 days according to sensitivity
 
 
 
 
 
Further management according to findings
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
• MAG3 renography
• MR urography
• Delayed DMSA scan
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Obstruction
 
 
 
 
 
Vesicoureteral reflux
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
MAC3 renography
 
 
 
 
 
MCV
 

Treatment

Shown below is an algorithm summarizing the treatment of UTI in children according to the AAP [American Academy of pediatrics] guidelines.

 
 
 
 
 
 
 
 
 
 
 
 
 
Treatment of febrile children with UTI
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Stable
 
 
 
 
 
Toxic
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Oral antibiotic 7-14 days
 
 
 
 
 
Parenteral antibiotic, once improved shift to oral antibiotic
 
  • The goals of treatment are:
    • Elimination of the acute infection.
    • Prevent the complication.
    • Reduce the renal damage.

Table1

Some Empiric Antimicrobial Agents for Oral Treatment of UTI.[3]

Antimicrobial Agent Dosage
Amoxicillin-clavulanate 20–40 mg/kg per d in 3 doses
Sulfonamide
Trimethoprim-sulfamethoxazole 6–12 mg/kg trimethoprim and 30-60 mg/kg sulfamethoxazole per d in 2 doses
Sulfisoxazole 120–150 mg/kg per d in 4 doses
Cephalosporin
Cefixime 8 mg/kg per d in 1 dose
Cefpodoxime 10 mg/kg per d in 2 doses
Cefprozil 30 mg/kg per d in 2 doses
Cefuroxime axetil 20–30 mg/kg per d in 2 doses
Cephalexin 50–100 mg/kg per d in 4 doses

Table2

Some Empiric Antimicrobial Agents for Parenteral Treatment of UTI [3]

Antimicrobial Agent Dosage
Ceftriaxone 75 mg/kg, every 24 h
Cefotaxime 150 mg/kg per d, divided every 6–8 h
Ceftazidime 100–150 mg/kg per d, divided every 8 h
Gentamicin 7.5 mg/kg per d, divided every 8 h
Tobramycin 5 mg/kg per d, divided every 8 h
Piperacillin 300 mg/kg per d, divided every 6–8 h


Do's

  • Immediate empirical antimirobial.[4]
  • Diagnostic ultrasonography for kidney and bladder to detect anatomical abnormalities.
  • Voiding cystourethrogram VCUG ,indicated if US(ultrasonography) shows Hydronephrosis ,scarring,high grade Vesicoureteral Reflux.

Don'ts

  • Delay treatment while waiting results of microscopy or culture,that would be harmful.[4]
  • Routine diagnostic imaging in all children with first infection.
  • Giving prophylaxis antimicrobial to prevent febrile recurrent UTI.
  • Surgical correction of minor functional abnormalities, moderate VUR.

References

  1. Spahiu L, Hasbahta V (2010). "Most frequent causes of urinary tract infections in children". Med Arh. 64 (2): 88–90. PMID 20514772.
  2. Becknell B, Schober M, Korbel L, Spencer JD (2015). "The diagnosis, evaluation and treatment of acute and recurrent pediatric urinary tract infections". Expert Rev Anti Infect Ther. 13 (1): 81–90. doi:10.1586/14787210.2015.986097. PMC 4652790. PMID 25421102.
  3. 3.0 3.1 3.2 Subcommittee on Urinary Tract Infection, Steering Committee on Quality Improvement and Management. Roberts KB (2011). "Urinary tract infection: clinical practice guideline for the diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months". Pediatrics. 128 (3): 595–610. doi:10.1542/peds.2011-1330. PMID 21873693.
  4. 4.0 4.1 Larcombe J (1999). "Urinary tract infection in children". BMJ. 319 (7218): 1173–5. doi:10.1136/bmj.319.7218.1173. PMC 1116958. PMID 10541510.