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

m (Rossdonaldson1 moved page UTI (Peds) to UTI (peds))
(Background)
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== Background ==
+
''This page is for pediatric patients; see [[Acute cystitis]] for adult patients.''
 
+
==Background==
*After 1yr of age occult UTI w/ nl UA extremely rare
+
*Most common SBI, accounts for 5-8% of children presenting for fever without clear source
*After 2yr of age UTI remains common in girls (but a/w symptoms)
+
*Associated with bacteremia in up to 30% of infants between 4-8wk of age
*Associated w/ 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)  
 
*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
 
*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>
  
== Diagnosis  ==
+
==Clinical Features==
 
 
=== Clinical Presentation  ===
 
 
 
 
*Infants/young children: Fever without other source  
 
*Infants/young children: Fever without other source  
 
*Older children: Urinary complaints, abd/back pain
 
*Older children: Urinary complaints, abd/back pain
  
=== Labs  ===
+
==Differential Diagnosis==
 +
{{Pediatric abdominal pain DDX}}
  
*UA
+
{{Pediatric fever DDX}}
**Obtain clean catch specimen OR cath UA  
+
 
***Neg UA = neg LE, nit, GS &amp; &lt;5 WBC  
+
==Evaluation==
**Bag urine results in 83% false pos; only useful if negative  
+
*[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===
 +
*[[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)
 
***UTI diagnosis cannot be established reliably through bag urine culture (Evidence A; strong recommendation; AAP 2011)
*UCx
+
*Urine culture 
**Send on all pts except for:  
+
**Send on all patients except for:  
***1. Low-risk pts w/ normal UA and another explanation for sx
+
***1. Low-risk patients with normal UA and another explanation for symptoms
***2. Older adolescent females w/ very high post-test probability w/o severe illness  
+
***2. Older adolescent females with very high post-test probability without severe illness  
**20% of +Ucx 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>
 
{| cellspacing="1" cellpadding="3" border="0" bgcolor="#666666" style="color: rgb(51, 51, 51); font-family: Verdana,Arial,Helvetica,sans-serif; width: 718px; height: 427px;"
 
{| cellspacing="1" cellpadding="3" border="0" bgcolor="#666666" style="color: rgb(51, 51, 51); font-family: Verdana,Arial,Helvetica,sans-serif; width: 718px; height: 427px;"
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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" | 0.16–0.41  
 
| valign="top" bgcolor="#ffffff" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | 1–3  
 
| valign="top" bgcolor="#ffffff" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | 1–3  
| valign="top" bgcolor="#ffffff" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | &lt;1  
+
| valign="top" bgcolor="#ffffff" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | <1  
 
| valign="top" bgcolor="#ffffff" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | 1–3  
 
| valign="top" bgcolor="#ffffff" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | 1–3  
 
| valign="top" bgcolor="#ffffff" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | 1–3  
 
| valign="top" bgcolor="#ffffff" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | 1–3  
 
| valign="top" bgcolor="#ffffff" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | 2–4
 
| valign="top" bgcolor="#ffffff" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | 2–4
 
|- style="font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12"
 
|- style="font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12"
| 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" | Nitrite*  
+
| 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" | Nitrite*
 
| 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" | 21–69  
 
| 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" | 21–69  
 
| 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" | 95–99  
 
| 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" | 95–99  
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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" | 0.31–0.83  
 
| valign="top" bgcolor="#ffffff" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | 0.31–0.83  
 
| valign="top" bgcolor="#ffffff" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | 2–6  
 
| valign="top" bgcolor="#ffffff" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | 2–6  
| valign="top" bgcolor="#ffffff" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | &lt;1  
+
| valign="top" bgcolor="#ffffff" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | <1  
 
| valign="top" bgcolor="#ffffff" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | 3–7  
 
| valign="top" bgcolor="#ffffff" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | 3–7  
 
| valign="top" bgcolor="#ffffff" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | 2–5  
 
| valign="top" bgcolor="#ffffff" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | 2–5  
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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" | –  
 
| valign="top" bgcolor="#ffffff" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | –  
 
| valign="top" bgcolor="#ffffff" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | 0.04–4.91  
 
| valign="top" bgcolor="#ffffff" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | 0.04–4.91  
| valign="top" bgcolor="#ffffff" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | &lt;1–27  
+
| valign="top" bgcolor="#ffffff" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | <1–27  
| valign="top" bgcolor="#ffffff" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | &lt;1–2  
+
| valign="top" bgcolor="#ffffff" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | <1–2  
| valign="top" bgcolor="#ffffff" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | &lt;1–30  
+
| valign="top" bgcolor="#ffffff" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | <1–30  
| valign="top" bgcolor="#ffffff" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | &lt;1–25  
+
| valign="top" bgcolor="#ffffff" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | <1–25  
| valign="top" bgcolor="#ffffff" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | &lt;1–33
+
| valign="top" bgcolor="#ffffff" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | <1–33
 
|- style="font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12"
 
|- style="font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12"
 
| 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" | –  
 
| valign="top" bgcolor="#ffffff" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | –  
 
| valign="top" bgcolor="#ffffff" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | 0.03–0.23  
 
| valign="top" bgcolor="#ffffff" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | 0.03–0.23  
| valign="top" bgcolor="#ffffff" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | &lt;1–2  
+
| valign="top" bgcolor="#ffffff" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | <1–2  
| valign="top" bgcolor="#ffffff" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | &lt;1  
+
| valign="top" bgcolor="#ffffff" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | <1  
| valign="top" bgcolor="#ffffff" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | &lt;1–2  
+
| valign="top" bgcolor="#ffffff" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | <1–2  
| valign="top" bgcolor="#ffffff" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | &lt;1–2  
+
| valign="top" bgcolor="#ffffff" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | <1–2  
| valign="top" bgcolor="#ffffff" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | &lt;1–2
+
| valign="top" bgcolor="#ffffff" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | <1–2
 
|- style="font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12"
 
|- style="font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12"
 
| 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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| valign="top" bgcolor="#ffffff" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | –  
 
| valign="top" bgcolor="#ffffff" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | –  
 
| valign="top" bgcolor="#ffffff" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | 0.00–0.02  
 
| valign="top" bgcolor="#ffffff" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | 0.00–0.02  
| valign="top" bgcolor="#ffffff" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | &lt;1  
+
| valign="top" bgcolor="#ffffff" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | <1  
| valign="top" bgcolor="#ffffff" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | &lt;1  
+
| valign="top" bgcolor="#ffffff" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | <1  
| valign="top" bgcolor="#ffffff" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | &lt;1  
+
| valign="top" bgcolor="#ffffff" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | <1  
| valign="top" bgcolor="#ffffff" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | &lt;1  
+
| valign="top" bgcolor="#ffffff" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | <1  
| valign="top" bgcolor="#ffffff" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | &lt;1
+
| valign="top" bgcolor="#ffffff" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | <1
 
|}
 
|}
 
</div>  
 
</div>  
<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, &lt;1 year old, fever with no definitive source on examination, pretest probability of UTI is 7%.</font></span>  
+
<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, &lt;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 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, &lt;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 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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<br>
 
<br>
  
== Treatment  ==
+
==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
  
*&lt;1mo
+
==Disposition==
**Admit for IV abx
+
===Admit===
***Ceftazidime 150mg/kg/d divided every 6 h
+
*<1 month old
*1mo - 2yo
+
*Toxic
**[[Ceftriaxone]] 50mg/kg in ED
+
*Inability to tolerate POs
**[[Cephalexin]] 50-100mg/kg/d in 4 divided doses x14d
 
*&gt;2yo
 
**Treat for 7d
 
*&gt;13yr adolescent
 
**Consider 3 day course of tx
 
  
== Disposition  ==
+
===Discharge===
 +
*1mo - 2yr, who are well-appearing and not vomiting
 +
**24-hour follow up
 +
*>2 years old
 +
**48-hour follow up
  
*Admit:
+
==See Also==
**&lt;1mo
+
*[[Urinary tract infections]]
**Toxic
 
**Inability to tolerate PO
 
*Consider d/c with 24hr f/u for:
 
**1mo - 2yr who are not vomiting / well-appearing
 
*Consider d/c with 48hr f/u for:
 
**&gt;2yr
 
  
== Source  ==
+
==References==
 +
<references/>
  
Tintinalli
 
  
[[Category:Peds]]
+
[[Category:Pediatrics]]

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

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.