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

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== Background ==
+
''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 4-8wk of age
 +
*[[E. coli]] is responsible for ~80% of UTIs
 +
*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<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==
 +
*Infants/young children: [[fever (Peds)|fever]] without other source
 +
*Older children:
 +
**[[Dysuria]], frequency, or other urinary complaints
 +
**+/- [[abdominal pain (peds)|abdominal]]/[[back pain]]
 +
*UTI + [[fever (Peds)|fever]] = [[pyelonephritis]]
 +
 
 +
==Differential Diagnosis==
 +
{{Pediatric abdominal pain DDX}}
  
*After 1yr of age occult UTI w/ nl UA extremely rare
+
{{Pediatric fever DDX}}
*After 2yr of age UTI remains common in girls (but a/w symptoms)
+
 
*Associated w/ bacteremia in up to 30% of infants between 4-8wk of age
+
==Evaluation==
*Do not use nitrofurantoin in children (need bloodstream penetration)
+
===Workup===
*UTI in adolescent girl is suggestive of intercourse
+
*[[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<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
  
== Diagnosis ==
+
===Diagnosis===
 +
<div><br></div><div>
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{| 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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|- style="font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12"
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! valign="top" bgcolor="#ffffff" align="left" rowspan="1" colspan="4" | Test Characteristic Ranges
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! valign="top" bgcolor="#ffffff" align="left" rowspan="1" colspan="5" | Post-test Probability (%) of UTI in Different Patients
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|- style="font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12"
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! valign="top" bgcolor="#ffffff" align="left" rowspan="1" | Test
 +
! valign="top" bgcolor="#ffffff" align="left" rowspan="1" | Sensitivity (%)
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! valign="top" bgcolor="#ffffff" align="left" rowspan="1" | Specificity (%)
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! valign="top" bgcolor="#ffffff" align="left" rowspan="1" | Test Result
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! valign="top" bgcolor="#ffffff" align="left" rowspan="1" | LR
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! valign="top" bgcolor="#ffffff" align="left" rowspan="1" | Patient A
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! valign="top" bgcolor="#ffffff" align="left" rowspan="1" | Patient B
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! valign="top" bgcolor="#ffffff" align="left" rowspan="1" | Patient C
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! valign="top" bgcolor="#ffffff" align="left" rowspan="1" | Patient D
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! valign="top" bgcolor="#ffffff" align="left" rowspan="1" | Patient E
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|- style="font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12"
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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" | Leukocyte esterase
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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" | 67–85
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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" | 81–92
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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" | 3.5–10.6
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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" | 21–45
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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" | 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" | 23–49
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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" | 20–43
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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" | 26–52
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|- 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" | –
 +
| 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
 +
| 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
 +
|- 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*
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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" | 21–69
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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" | 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" | +
 +
| valign="top" bgcolor="#ffffff" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | 4.2–69
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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" | 24–84
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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" | 2–26
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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" | 26–86
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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" | 22–83
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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" | 29–87
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|- 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" | –
 +
| 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" | <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
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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" | 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" | 3–8
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|- style="font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12"
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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" | Leukocytes on microscopy
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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" | 51–91
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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" | 45–91
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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" | +
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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" | 0.90–10.1
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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" | 6–43
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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" | 0–5
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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" | 7–47
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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" | 6–41
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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" | 8–50
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|- style="font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12"
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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" | –
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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" | 0.10–1.09
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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" | 1–8
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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" | 0–1
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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" | 1–9
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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" | 1–7
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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" | 1–10
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|- 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 microscopy
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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" | 46–96
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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" | 11–96
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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" | 0.5–24.0
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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" | 4–64
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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" | 0–11
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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" | 4–68
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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" | 3–63
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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" | 5–70
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|- style="font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12"
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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" | –
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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" | 0.04–4.91
 +
| valign="top" bgcolor="#ffffff" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | <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" | <1–2
 +
| valign="top" bgcolor="#ffffff" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | <1–30
 +
| valign="top" bgcolor="#ffffff" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | <1–25
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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" | <1–33
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|- style="font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12"
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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
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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" | 80–97
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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" | 87–99
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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" | +
 +
| valign="top" bgcolor="#ffffff" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | 6.2–97
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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" | 32–88
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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" | 3–33
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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" | 35–89
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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" | 30–87
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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" | 38–91
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|- style="font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12"
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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" | 0.03–0.23
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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" | <1–2
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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" | <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" | <1–2
 +
| 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
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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" | <1–2
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|- 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
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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" | &nbsp;
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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" | &nbsp;
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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" | &nbsp;
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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" | &nbsp;
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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" | &nbsp;
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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" | &nbsp;
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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" | &nbsp;
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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" | &nbsp;
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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" | &nbsp;
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|- style="font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12"
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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" | Any positive test on dipstick
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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" | 99–100
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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" | 63–70
 +
| 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" | 2.7–3.3
 +
| valign="top" bgcolor="#ffffff" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | 13–20
 +
| 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" | 19–22
 +
| valign="top" bgcolor="#ffffff" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | 16–19
 +
| valign="top" bgcolor="#ffffff" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12" | 21–25
 +
|- 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" | –
 +
| 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" | <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
 +
| 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
 +
|}
 +
</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, <1 year old, fever with no definitive source on examination, pretest probability of UTI is 7%.</font></span>
  
=== Clinical Presentation ===
+
<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>
  
*Infants/young children: Fever without other source
+
<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>
*Older children: Urinary complaints, abd/back pain
 
  
=== Labs ===
+
<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>
  
*UA
+
<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 E: Female patient in ED, adolescent age range, no fever but urinary symptoms, pretest probability of UTI is 9%</font></span>
**Obtain clean catch specimen OR cath UA
 
**Neg UA = neg LE, nit, GS & <5 WBC
 
**Bag urine results in 83% false pos; only useful if negative
 
*UCx
 
**Send on all pts except for:
 
***1. Low-risk pts w/ normal UA and another explanation for sx
 
***2. Older adolescent females w/ very high post-test probability w/o severe illness
 
**20% of +Ucx will have negative UA
 
  
<div><br/></div><div>
+
<br>
{| cellspacing="1" cellpadding="3" border="0" bgcolor="#666666" width="100%" style="color: rgb(51, 51, 51); font-family: Verdana, Arial, Helvetica, sans-serif; "
 
|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; "
 
! valign="top" bgcolor="#ffffff" colspan="4" align="left" rowspan="0" | Test Characteristic Ranges
 
! valign="top" bgcolor="#ffffff" colspan="5" align="left" rowspan="0" | Post-test Probability (%) of UTI in Different Patients
 
|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; "
 
! valign="top" bgcolor="#ffffff" align="left" rowspan="0" | Test
 
! valign="top" bgcolor="#ffffff" align="left" rowspan="0" | Sensitivity (%)
 
! valign="top" bgcolor="#ffffff" align="left" rowspan="0" | Specificity (%)
 
! valign="top" bgcolor="#ffffff" align="left" rowspan="0" | Test Result
 
! valign="top" bgcolor="#ffffff" align="left" rowspan="0" | LR
 
! valign="top" bgcolor="#ffffff" align="left" rowspan="0" | Patient A
 
! valign="top" bgcolor="#ffffff" align="left" rowspan="0" | Patient B
 
! valign="top" bgcolor="#ffffff" align="left" rowspan="0" | Patient C
 
! valign="top" bgcolor="#ffffff" align="left" rowspan="0" | Patient D
 
! valign="top" bgcolor="#ffffff" align="left" rowspan="0" | Patient E
 
|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; "
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" rowspan="2" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | Leukocyte esterase
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" rowspan="2" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | 67–85
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" rowspan="2" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | 81–92
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | +
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | 3.5–10.6
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | 21–45
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | 2–5
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | 23–49
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | 20–43
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | 26–52
 
|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; "
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | –
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | 0.16–0.41
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | 1–3
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | <1
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | 1–3
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | 1–3
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | 2–4
 
|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; "
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" rowspan="2" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | Nitrite*
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" rowspan="2" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | 21–69
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" rowspan="2" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | 95–99
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | +
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | 4.2–69
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | 24–84
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | 2–26
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | 26–86
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | 22–83
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | 29–87
 
|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; "
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | –
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | 0.31–0.83
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | 2–6
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | <1
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | 3–7
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | 2–5
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | 3–8
 
|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; "
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" rowspan="2" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | Leukocytes on microscopy
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" rowspan="2" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | 51–91
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" rowspan="2" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | 45–91
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | +
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | 0.90–10.1
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | 6–43
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | 0–5
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | 7–47
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | 6–41
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | 8–50
 
|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; "
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | –
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | 0.10–1.09
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | 1–8
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | 0–1
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | 1–9
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | 1–7
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | 1–10
 
|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; "
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" rowspan="2" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | Bacteria on microscopy
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" rowspan="2" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | 46–96
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" rowspan="2" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | 11–96
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | +
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | 0.5–24.0
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | 4–64
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | 0–11
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | 4–68
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | 3–63
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | 5–70
 
|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; "
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | –
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | 0.04–4.91
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | <1–27
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | <1–2
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | <1–30
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | <1–25
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | <1–33
 
|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; "
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" rowspan="2" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | Bacteria on Gram stain
 
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|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; "
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | –
 
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|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; "
 
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|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; "
 
| valign="top" bgcolor="#ffffff" class="font12" align="left" rowspan="2" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; " | Any positive test on dipstick
 
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|- class="font12" style="font-size: 12px; line-height: 17px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; "
 
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|}
 
</div>
 
  
 +
==Management==
 +
*Know your local resistance patterns and make sure to send a urine culture
 +
*Do not use [[nitrofurantoin]] in children (need bloodstream penetration)
  
<span class="Apple-style-span" style="color: rgb(51, 51, 51); "><font class="font11" style="font-size: 11px; line-height: 16px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; ">Patient A: Female patient in ED, <1 year old, fever with no definitive source on examination, pretest probability of UTI is 7%.</font></span>
+
===<1mo===  
 +
*Admit for IV [[antibiotics]]
 +
**[[Ceftazidime]] 150mg/kg/d divided every 6 h
  
<span class="Apple-style-span" style="color: rgb(51, 51, 51); font-family: Verdana, Arial, Helvetica, sans-serif; "><font class="font11" style="font-size: 11px; line-height: 16px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; ">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>
+
===1mo - 2yo===
 +
*[[Ceftriaxone]] 50mg/kg in ED  
 +
*[[Cephalexin]] 50-100mg/kg/d in 4 divided doses x14d
 +
**Maximum dose (all ages) 4g/24hr
  
<span class="Apple-style-span" style="color: rgb(51, 51, 51); font-family: Verdana, Arial, Helvetica, sans-serif; "><font class="font11" style="font-size: 11px; line-height: 16px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; ">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>
+
===>2yo===
 +
*[[Amoxicillin]]
 +
**Mild to moderate infections (>40kg): 500mg PO BID for x10-14d
 +
*[[Cephalexin]] 50-100mg/kg/d in 4 divided doses x7d
 +
*[[Cefaclor]] 50-100 mg/kg/d divided in 3 doses x5d
 +
*[[Cefixime]] 8 mg/kg daily x 5d
  
<span class="Apple-style-span" style="color: rgb(51, 51, 51); font-family: Verdana, Arial, Helvetica, sans-serif; "><font class="font11" style="font-size: 11px; line-height: 16px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; ">Patient D: Female patient in ED, 2–6 years old, no fever but GU symptoms, pretest probability of UTI is 6.5%.</font></span>
+
===>13yr adolescent===
 +
*Consider 3 day course of treatment
  
<span class="Apple-style-span" style="color: rgb(51, 51, 51); font-family: Verdana, Arial, Helvetica, sans-serif; "><font class="font11" style="font-size: 11px; line-height: 16px; margin-top: 0px; margin-bottom: 9px; margin-left: 0px; margin-right: 0px; ">Patient E: Female patient in ED, adolescent age range, no fever but urinary symptoms, pretest probability of UTI is 9%</font></span>
+
==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==
 +
*[[Urinary tract infections]]
  
 +
==External Links==
 +
*[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]
  
== Treatment ==
+
==References==
*<1mo
+
<references/>
**Admit for IV abx
 
*1mo - 2yo
 
**CTX 50mg/kg in ED; oral abx for 14d
 
***Cephalexin 50-100mg/kg/d in 4 divided doses
 
*>2yo
 
**Treat for 7d
 
*>13yr adolescent
 
**Consider 3 day course of tx
 
  
== Disposition ==
 
*Admit:
 
**<1mo
 
**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:
 
***>2yr
 
  
[[Category:Peds]]
+
[[Category:Pediatrics]]
 +
[[Category:ID]]
 +
[[Category:Urology]]

Latest revision as of 19:26, 4 June 2020

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 4-8wk of age
  • E. coli is responsible for ~80% of UTIs
  • 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

Differential Diagnosis

Pediatric Abdominal Pain

0–3 Months Old

3 mo–3 y old

3 y old–adolescence

Pediatric fever

Evaluation

Workup

  • 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

Diagnosis


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
  • Do not use nitrofurantoin in children (need bloodstream penetration)

<1mo

1mo - 2yo

  • Ceftriaxone 50mg/kg in ED
  • Cephalexin 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 50-100mg/kg/d in 4 divided doses x7d
  • Cefaclor 50-100 mg/kg/d divided in 3 doses x5d
  • Cefixime 8 mg/kg daily 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

External Links

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.