Difference between revisions of "Urinary tract infection (peds)"

(Evaluation)
(Background)
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''This page is for pediatric patients; see [[Acute cystitis]] for adult patients.''
 
''This page is for pediatric patients; see [[Acute cystitis]] for adult patients.''
 
==Background==
 
==Background==
 +
*Most common SBI, accounts for 5-8% of children presenting for fever w/o clear source
 +
*Leukesterase has sensitivity of up to 85%; nitrates have specificity of 95-99%
 +
*UTI + fever = pyelo
 +
*Associated with bacteremia in up to 30% of infants between 4-8wk of age
 
*E. coli is responsible for ~80% of UTIs
 
*E. coli is responsible for ~80% of UTIs
 +
*Do not use nitrofurantoin in children (need bloodstream penetration)
 
*After 1yr of age, occult UTI with normal UA extremely rare  
 
*After 1yr of age, occult UTI with normal UA extremely rare  
 
*After 2yr of age, UTI remains common in girls (but associated with symptoms)  
 
*After 2yr of age, UTI remains common in girls (but associated with symptoms)  
*Associated with bacteremia in up to 30% of infants between 4-8wk of age
 
*Do not use nitrofurantoin in children (need bloodstream penetration)
 
 
*UTI in adolescent girl is suggestive of intercourse
 
*UTI in adolescent girl is suggestive of intercourse
 
*Prevalence of UTI in [[bronchiolitis]] is only 0.8% based on 2019 meta-analysis, which is far lower than in previous studies, suggesting less need for automatic testing for UTI in bronchiolitis<ref>McDaniel CE et al. Association of Diagnostic Criteria With Urinary Tract Infection Prevalence in Bronchiolitis: A Systematic Review and Meta-analysis. JAMA Pediatr. 2019;173(3):269-277. doi:10.1001/jamapediatrics.2018.5091.</ref>
 
*Prevalence of UTI in [[bronchiolitis]] is only 0.8% based on 2019 meta-analysis, which is far lower than in previous studies, suggesting less need for automatic testing for UTI in bronchiolitis<ref>McDaniel CE et al. Association of Diagnostic Criteria With Urinary Tract Infection Prevalence in Bronchiolitis: A Systematic Review and Meta-analysis. JAMA Pediatr. 2019;173(3):269-277. doi:10.1001/jamapediatrics.2018.5091.</ref>

Revision as of 16:49, 20 June 2019

This page is for pediatric patients; see Acute cystitis for adult patients.

Background

  • Most common SBI, accounts for 5-8% of children presenting for fever w/o clear source
  • Leukesterase has sensitivity of up to 85%; nitrates have specificity of 95-99%
  • UTI + fever = pyelo
  • Associated with bacteremia in up to 30% of infants between 4-8wk of age
  • E. coli is responsible for ~80% of UTIs
  • Do not use nitrofurantoin in children (need bloodstream penetration)
  • After 1yr of age, occult UTI with normal UA extremely rare
  • After 2yr of age, UTI remains common in girls (but associated with symptoms)
  • UTI in adolescent girl is suggestive of intercourse
  • Prevalence of UTI in bronchiolitis is only 0.8% based on 2019 meta-analysis, which is far lower than in previous studies, suggesting less need for automatic testing for UTI in bronchiolitis[1]

Clinical Features

  • Infants/young children: Fever without other source
  • Older children: Urinary complaints, abd/back pain

Differential Diagnosis

Pediatric Abdominal Pain

0–3 Months Old

3 mo–3 y old

3 y old–adolescence

Pediatric fever

Evaluation

Labs

  • Urinalysis
    • Obtain clean catch specimen OR cath UA
      • Neg UA = neg LE, nit, GS & <5 WBC
    • Bag urine results in 83% false positive; only useful if negative
      • UTI diagnosis cannot be established reliably through bag urine culture (Evidence A; strong recommendation; AAP 2011)
  • Urine culture
    • Send on all patients except for:
      • 1. Low-risk patients with normal UA and another explanation for symptoms
      • 2. Older adolescent females with very high post-test probability without severe illness
    • 20% of +Urine culture will have negative UA
    • Do not send urine bag specimen for culture when UA is negative and clinical suspicion is relatively low[2]
      • False positives are high due to bag contamination
      • Causes unnecessary interventions

Test Characteristic Ranges Post-test Probability (%) of UTI in Different Patients
Test Sensitivity (%) Specificity (%) Test Result LR Patient A Patient B Patient C Patient D Patient E
Leukocyte esterase 67–85 81–92 + 3.5–10.6 21–45 2–5 23–49 20–43 26–52
0.16–0.41 1–3 <1 1–3 1–3 2–4
Nitrite* 21–69 95–99 + 4.2–69 24–84 2–26 26–86 22–83 29–87
0.31–0.83 2–6 <1 3–7 2–5 3–8
Leukocytes on microscopy 51–91 45–91 + 0.90–10.1 6–43 0–5 7–47 6–41 8–50
0.10–1.09 1–8 0–1 1–9 1–7 1–10
Bacteria on microscopy 46–96 11–96 + 0.5–24.0 4–64 0–11 4–68 3–63 5–70
0.04–4.91 <1–27 <1–2 <1–30 <1–25 <1–33
Bacteria on Gram stain 80–97 87–99 + 6.2–97 32–88 3–33 35–89 30–87 38–91
0.03–0.23 <1–2 <1 <1–2 <1–2 <1–2
Combined tests                  
Any positive test on dipstick 99–100 63–70 + 2.7–3.3 13–20 1–2 19–22 16–19 21–25
0.00–0.02 <1 <1 <1 <1 <1


Patient A: Female patient in ED, <1 year old, fever with no definitive source on examination, pretest probability of UTI is 7%.

Patient B: Male patient in ED, <1 year old, circumcised, fever with no definitive source on examination, pretest probability of UTI is 0.5%.

Patient C: Male patient in ED, <1 year old, uncircumcised, fever with no definitive source on examination, pretest probability of UTI is 8%.

Patient D: Female patient in ED, 2–6 years old, no fever but GU symptoms, pretest probability of UTI is 6.5%.

Patient E: Female patient in ED, adolescent age range, no fever but urinary symptoms, pretest probability of UTI is 9%


Management

  • Know your local resistance patterns and make sure to send a urine culture

<1mo

1mo - 2yo

  • Ceftriaxone
    • 3rd gen cephalosporin
    • 50mg/kg in ED
  • Cephalexin
    • 2nd gen cephalosporin
    • 50-100mg/kg/d in 4 divided doses x14d
    • Maximum dose (all ages) 4g/24hr

>2yo

  • Amoxicillin
    • Mild to moderate infections (>40kg): 500mg PO BID for x10-14d
  • Cephalexin
    • 2nd gen cephalosporin
    • 50-100mg/kg/d in 4 divided doses x7d
  • Cefaclor
    • 2nd gen cephalosporin
    • 50-100 mg/kg/Day divided in 3 doses x5d
  • Cefixime
    • 3rd gen cephalosporin
    • 8 mg/kg once a day x 5d

>13yr adolescent

  • Consider 3 day course of treatment

Disposition

Admit

  • <1 month old
  • Toxic
  • Inability to tolerate POs

Discharge

  • 1mo - 2yr, who are well-appearing and not vomiting
    • 24-hour follow up
  • >2 years old
    • 48-hour follow up

See Also

References

  1. McDaniel CE et al. Association of Diagnostic Criteria With Urinary Tract Infection Prevalence in Bronchiolitis: A Systematic Review and Meta-analysis. JAMA Pediatr. 2019;173(3):269-277. doi:10.1001/jamapediatrics.2018.5091.
  2. Kim GA and Koo JW. Validity of bag urine culture for predicting urinary tract infections in febrile infants: a paired comparison of urine collection methods. Korean J Pediatr. 2015 May; 58(5): 183–189.