Urinary tract infection (peds): Difference between revisions
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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 without clear source | |||
*Associated with bacteremia in up to 30% of infants between 4-8wk of age | |||
*UTI + fever = pyelo | |||
*[[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) | ||
*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> | |||
==Clinical Features== | ==Clinical Features== | ||
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==Evaluation== | ==Evaluation== | ||
*[https://uticalc.pitt.edu/ University of Pittsburgh UTI Calc] | |||
*[https://www.chop.edu/clinical-pathway/urinary-tract-infection-uti-febrile-clinical-pathway Children's Hospital of Philadelphia UTI pathway] | |||
===Labs=== | ===Labs=== | ||
*[[Urinalysis]] | *[[Urinalysis]] | ||
**Obtain clean catch specimen OR cath UA | **Obtain clean catch specimen '''OR''' cath UA | ||
***Neg UA = neg LE, nit, GS & <5 WBC | ***Neg UA = neg LE, nit, GS & <5 WBC | ||
**Bag urine results in 83% false | **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) | ***UTI diagnosis cannot be established reliably through bag urine culture (Evidence A; strong recommendation; AAP 2011) | ||
*Urine culture | *Urine culture | ||
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***2. Older adolescent females with very high post-test probability without severe illness | ***2. Older adolescent females with very high post-test probability without severe illness | ||
**20% of +Urine culture will have negative UA | **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<ref>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.</ref> | |||
***False positives are high due to bag contamination | |||
***Causes unnecessary interventions | |||
<div><br></div><div> | <div><br></div><div> | ||
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| valign="top" bgcolor="#ffffff" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" rowspan="2" class="font12" | Bacteria on Gram stain | | valign="top" bgcolor="#ffffff" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" rowspan="2" class="font12" | Bacteria on Gram stain | ||
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| valign="top" bgcolor="#ffffff" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | Combined tests | | valign="top" bgcolor="#ffffff" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | Combined tests | ||
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<br> <span style="color: rgb(51, 51, 51);" class="Apple-style-span"><font style="font-size: 11px; line-height: 16px; margin: 0px 0px 9px;" class="font11">Patient A: Female patient in ED, | <br> <span style="color: rgb(51, 51, 51);" class="Apple-style-span"><font style="font-size: 11px; line-height: 16px; margin: 0px 0px 9px;" class="font11">Patient A: Female patient in ED, <1 year old, fever with no definitive source on examination, pretest probability of UTI is 7%.</font></span> | ||
<span style="color: rgb(51, 51, 51); font-family: Verdana,Arial,Helvetica,sans-serif;" class="Apple-style-span"><font style="font-size: 11px; line-height: 16px; margin: 0px 0px 9px;" class="font11">Patient B: Male patient in ED, | <span style="color: rgb(51, 51, 51); font-family: Verdana,Arial,Helvetica,sans-serif;" class="Apple-style-span"><font style="font-size: 11px; line-height: 16px; margin: 0px 0px 9px;" class="font11">Patient B: Male patient in ED, <1 year old, circumcised, fever with no definitive source on examination, pretest probability of UTI is 0.5%.</font></span> | ||
<span style="color: rgb(51, 51, 51); font-family: Verdana,Arial,Helvetica,sans-serif;" class="Apple-style-span"><font style="font-size: 11px; line-height: 16px; margin: 0px 0px 9px;" class="font11">Patient C: Male patient in ED, | <span style="color: rgb(51, 51, 51); font-family: Verdana,Arial,Helvetica,sans-serif;" class="Apple-style-span"><font style="font-size: 11px; line-height: 16px; margin: 0px 0px 9px;" class="font11">Patient C: Male patient in ED, <1 year old, uncircumcised, fever with no definitive source on examination, pretest probability of UTI is 8%.</font></span> | ||
<span style="color: rgb(51, 51, 51); font-family: Verdana,Arial,Helvetica,sans-serif;" class="Apple-style-span"><font style="font-size: 11px; line-height: 16px; margin: 0px 0px 9px;" class="font11">Patient D: Female patient in ED, 2–6 years old, no fever but GU symptoms, pretest probability of UTI is 6.5%.</font></span> | <span style="color: rgb(51, 51, 51); font-family: Verdana,Arial,Helvetica,sans-serif;" class="Apple-style-span"><font style="font-size: 11px; line-height: 16px; margin: 0px 0px 9px;" class="font11">Patient D: Female patient in ED, 2–6 years old, no fever but GU symptoms, pretest probability of UTI is 6.5%.</font></span> | ||
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==Management== | ==Management== | ||
*<1mo | *Know your local resistance patterns and make sure to send a urine culture | ||
===<1mo=== | |||
*Admit for IV [[antibiotics]] | |||
**[[Ceftazidime]] 150mg/kg/d divided every 6 h | |||
===1mo - 2yo=== | |||
*[[Ceftriaxone]] | |||
* | **3rd gen cephalosporin | ||
**[[Cephalexin]] 50-100mg/kg/d in 4 divided doses x7d | **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== | ==Disposition== |
Revision as of 20:30, 18 July 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 without clear source
- Associated with bacteremia in up to 30% of infants between 4-8wk of age
- UTI + fever = pyelo
- 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
- Emergent
- Nonemergent
3 mo–3 y old
- Emergent
- Nonemergent
3 y old–adolescence
- Emergent
- Nonemergent
Pediatric fever
- Upper respiratory infection (URI)
- UTI
- Sepsis
- Meningitis
- Febrile seizure
- Pneumonia
- Acute otitis media
- Whooping cough
- Unclear source
- Kawasaki disease
- Neonatal HSV
- Specific virus
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)
- Obtain clean catch specimen OR cath UA
- 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
- Send on all patients except for:
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
- Admit for IV antibiotics
- Ceftazidime 150mg/kg/d divided every 6 h
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
- ↑ 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.
- ↑ 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.