Urinary tract infection (peds)
Revision as of 23:07, 26 May 2015 by Rossdonaldson1 (talk | contribs)
Background
- After 1yr of age occult UTI w/ nl UA extremely rare
- 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
- Do not use nitrofurantoin in children (need bloodstream penetration)
- UTI in adolescent girl is suggestive of intercourse
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
Diagnosis
Labs
- UA
- 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
- UTI diagnosis cannot be established reliably through bag urine culture (Evidence A; strong recommendation; AAP 2011)
- Obtain clean catch specimen OR cath UA
- 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
- Send on all pts 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%
Treatment
- <1mo
- Admit for IV antibiotics
- Ceftazidime 150mg/kg/d divided every 6 h
- Admit for IV antibiotics
- 1mo - 2yo
- Ceftriaxone 50mg/kg in ED
- Cephalexin 50-100mg/kg/d in 4 divided doses x14d
- >2yo
- Treat for 7d
- >13yr adolescent
- Consider 3 day course of tx
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