Professional Documents
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TABLE OF CONTENTS
Table of content.......................................................................................................................1
Chapter I..................................................................................................................................3
Prelude.........................................................................................................................3
Chapter II.................................................................................................................................5
children........................................................................................................................5
Chapter III..............................................................................................................................16
Conclusion...................................................................................................................16
Reference.................................................................................................................................17
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Diagnosis and Treatment of UTI in children Novina Firlia 0961050083
LIST OF TABLES
LIST OF FIGURES
Figure 1. Algorithm for urine testing in children with suspected urinary tract infection (UTI).........11
Figure 2. Algorithm for imaging decisions in children with urinary tract infection...........................13
Chapter I
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Diagnosis and Treatment of UTI in children Novina Firlia 0961050083
Prelude
Urinary tract infections (UTIs) are common in kids. By the time they're 5 years old,
about 8% of girls and about 1-2% of boys have had at least one. In older kids, UTIs may
cause obvious symptoms such as burning or pain with urination (peeing). In infants and
young children, UTIs may be harder to detect because symptoms are less specific. In fact,
fever is sometimes the only sign.1
Evaluation of older children may depend on the clinical presentation and symptoms
that point toward a urinary source (e.g., leukocyte esterase or nitrite present on dipstick
testing; pyuria of at least 10 white blood cells per high-power field and bacteriuria on
microscopy). Increased rates of E. coli resistance have made amoxicillin a less acceptable
choice for treatment, and studies have found higher cure rates with
trimethoprim/sulfamethoxazole. Other treatment options include amoxicillin/clavulanate and
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Diagnosis and Treatment of UTI in children Novina Firlia 0961050083
cephalosporins. Prophylactic antibiotics do not reduce the risk of subsequent urinary tract
infections, even in children with mild to moderate vesicoureteral reflux. Constipation should
be avoided to help prevent urinary tract infections. Ultrasonography, cystography, and a renal
cortical scan should be considered in children with urinary tract infections.2
Chapter II
UTIs are typically divided into lower tract disease, where infection is localized to the bladder
and urethra (cystitis and urethritis), and upper tract disease, where it extends to the ureter and
kidney (pyelonephritis). Although both upper and lower tract disease may result in significant
morbidity, pyelonephritis in particular is associated with renal scarring and subsequent
hypertension, chronic renal disease, and preeclampsia.3
UTIs are the most common serious bacterial infections affecting infants and young
children. In recent decades, UTI has been increasingly recognized as an important occult
cause of fever in young children. Rates of UTI vary widely with respect to age, gender, race,
and other factors. Screening studies performed in emergency departments suggest an overall
prevalence of UTI of up to 5% in febrile children younger than 2 years. Peak incidence of
UTI occurs in the first year of life for all children, with a second peak occurring among
female adolescents. After infancy, females are far more likely than males to have a UTI.1,3
The normal urinary tract is sterile. Contamination by bowel flora may result in urinary
infection if a virulent organism is involved or if the child is immunosuppressed. In neonates,
infection may originate from other sources. Escherichia coli accounts for about 75 percent of
all pathogens. Proteus is more common in boys (one study found that proteus caused 33
percent of UTI infections in boys one to 16 years of age, compared with 0 percent of UTI
infections in girls of the same age). Obstructive anomalies are found in up to 4 percent and
vesicoureteric reflux in 8 to 40 percent of children being evaluated for their first UTI.
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Diagnosis and Treatment of UTI in children Novina Firlia 0961050083
Although vesicoureteric reflux is a major risk factor for adverse outcome, other factors, some
of which have not yet been identified, are also important.4
Almost all clinically significant urinary infections are monomicrobial rather than
polymicrobial. Most uncomplicated UTIs are caused by the gram-negative
Enterobacteriaceae family. causes the vast majority of acute infections. Organisms such as
Proteus, Enterobacter, Citrobacter, and Klebsiella spp. are more commonly encountered in
cases of recurrent UTI, particularly in cases of urinary anomalies.
Pseudomonas sp., while not usually a cause of UTI in healthy children, is a significant
pathogen for hospitalized children, immunocompromised children, and children with
indwelling catheters or frequent bladder instrumentation.Gram-positive organisms account
for a minority of uncomplicated UTIs (approximately 5–10%); those most commonly
encountered include Enterococcus sp., Staphylococcus saprophyticus, and group B
streptococci. S. saprophyticus tends to infect sexually active adolescent females. Candidal
UTIs typically occur in children with indwelling catheters who are receiving broad-spectrum
antibiotics or in children in the neonatal intensive care unit.3,4
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Diagnosis and Treatment of UTI in children Novina Firlia 0961050083
Risk factors — Some children have a higher chance of developing a UTI. The
following are some risk factors for UTI5 :
Young age; boys younger than one year old, and girls younger than four years of age
are at highest risk.
Being uncircumcised; there is a four to 10 times higher risk of UTIs in uncircumcised
boys. Still, most uncircumcised boys do NOT develop UTIs. (See "Patient
information: Circumcision in baby boys (Beyond the Basics)".)
Having parts of the urinary tract that did not form correctly before birth.
Having one UTI slightly increases the chance of getting another UTI.
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Diagnosis and Treatment of UTI in children Novina Firlia 0961050083
On the other hand, children may have only a low-grade fever; experience nausea,
vomiting, and diarrhea; or just not seem healthy. Children who have a high fever and appear
sick for more than a day without signs of a runny nose or other obvious cause for discomfort
should be checked for a UTI.
Older children with UTIs may complain of pain in the middle and lower abdomen.
They may urinate often. Crying or complaining that it hurts to urinate and producing only a
few drops of urine at a time are other signs of a UTI. Children may leak urine into clothing or
bedsheets. The urine may look cloudy or bloody. If a kidney is infected, children may
complain of pain in the back or side below the ribs.6,7
The physical examination of a child with suspected urinary tract infection should start
with the vital signs (temperature, pulse, breathing rate, and blood pressure, which is often
measured with the vital signs). The presence of fever (especially over 102.2 F or 39 C) is
highly correlated with the presence of a UTI. 10 All febrile children between two and 24
months of age with no obvious cause of infection should be evaluated for UTI, with the
exception of circumcised boys older than 12 months. Older children should be evaluated if
the clinical presentation points toward a urinary source.9
Blood pressure and assessment of height and weight provide helpful reassurance if
normal or stable long-term renal function. Visual examination of the abdomen for
enlargement related to potentially oversized kidney(s) or bladder is important. Tenderness
during palpation of the abdomen (especially the suprapubic region containing the bladder) or
the flank area (where the kidneys are situated) is very helpful in establishing the diagnosis.
UTI when compared to a population of similar infant boys who have been circumcised.
Lastly, consideration of other conditions that might be responsible for fever and abdominal
pain is important.10
The National Institute for Health and Clinical Excellence in the United Kingdom
endorses incorporating specific strategies for urine testing based on the child's age. In this
model, microscopy and urine culture should be performed in children younger than three
years instead of dipstick testing.1 The presence of pyuria of at least 10 white blood cells per
high-power field and bacteriuria are recommended as the criteria for diagnosing UTI with
microscopy. In young children, urine samples collected with a bag are unreliable compared
with samples collected with a catheter. Therefore, in a child who is unable to provide a clean-
catch specimen, catheterization should be considered.1,7
Urine culture is the gold standard for diagnosis of UTI, but results are unavailable for
24–48 hours. As such, several rapid diagnostic tests are available for faster UTI detection.
These include: Urine dipstick testing for leukocyte esterase (LE) and nitrites; traditional
urinalysis, which is typically done by microscopy on a centrifuged specimen; and enhanced
urinalysis, using a hemocytometer cell count and Gram stain of unspun urine.
Urine Culture -- Although growth of pathogenic bacteria from the normally sterile
urine is the gold standard for diagnosis of UTI, what constitutes a significant colony count
varies by collection method. Children who are toilet trained can use the clean-catch method,
which is susceptible to urethral contamination. Using this modality, UTI is often defined as
>105 colony-forming units (CFU) of a single pathogen.
Diagnostic Test -- Dipstick tests for UTI include leukocyte esterase, nitrite, blood, and
protein. Leukocyte esterase is the most sensitive single test in children with a suspected UTI.
The test for nitrite is more specific but less sensitive. A negative leukocyte esterase result
greatly reduces the likelihood of UTI, whereas a positive nitrite result makes it much more
likely; the converse is not true, however. Dipstick tests for blood and protein have poor
sensitivity and specificity in the detection of UTI and may be misleading. Accuracy of
positive findings is as follows (assumes a 10 percent pretest probability):
Figure 1. Algorithm for urine testing in children with suspected urinary tract infection (UTI). 1
white blood cell count, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP)
cannot reliably distinguish pyelonephritis and cystitis.While CRP is the best among these and
has a sensitivity of greater than 92% for pyelonephritis, it has a low specificity, which limits
its applicability. Although not as widely available (although a rapid test exists in some
centers), multiple studies35–38 have found that an elevated serum procalcitonin level appears
to be more highly correlated with renal involvement than an elevated CRP. If made more
available, this test could potentially alter the management and disposition of febrile patients
with UTI. 3,11
A blood culture should be performed in young infants with UTI since they are at
higher risk of bacteremia. Febrile infants older than 2 months with UTI do not routinely
require lumbar puncture. Concomitant invasive meningitis appears to be rare; an association
of UTI with aseptic meningitis has been reported but is controversial and may represent
coincidental CSF infection and bacteruria.3
Imaging procedures with the highest ratings from the American College of Radiology
Appropriateness Criteria for further evaluation of select children with UTIs are renal and
bladder ultrasonography, radionuclide cystography or voiding cystourethrography, and renal
cortical scan.12 Renal and bladder ultrasonography is effective for evaluating anatomy, but is
unreliable for detecting vesicoureteral reflux. Radionuclide cystography or voiding
cystourethrography is effective for screening and grading vesicoureteral reflux, but involves
radiation exposure and catheterization. Although voiding cystourethrography is suggested for
either girls or boys, radionuclide cystography is suggested only for girls because voiding
cystourethrography is needed for adequate anatomic imaging of the urethra and bladder in
boys. A renal cortical scan (also called scintigraphy or DMSA scan) uses technetium and is
effective for assessing renal scarring, but requires intravenous injection of radioisotope.1
Long-term outcome studies have not been performed to determine the best initial
imaging study in children diagnosed with UTI. Guidelines based on observational studies and
expert opinion recommend that all boys, girls younger than three years, and girls three to
seven years of age with a temperature of 101.3°F (38.5°C) or greater receive cystography and
ultrasonography with a first-time UTI.1,13 An optional imaging strategy for febrile children
with UTI, especially those older than three years, is to first perform ultrasonography and a
renal cortical scan. This strategy avoids bladder catheterization with cystography and
minimizes radiation exposure if the results of the scan are normal. However, if pyelonephritis
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Diagnosis and Treatment of UTI in children Novina Firlia 0961050083
or cortical scarring is found on the renal cortical scan, cystography is indicated. Observation
without imaging should be considered in girls three years or older with a temperature less
than 101.3° F and in all girls older than seven years.13
Figure 2. Algorithm for imaging decisions in children with urinary tract infection .1
Although amoxicillin has traditionally been a first-line antibiotic for UTI, increased
rates of E. coliresistance have made it a less acceptable choice, and studies have found higher
cure rates with trimethoprim/sulfamethoxazole (Bactrim, Septra). Other choices include
amoxicillin/clavulanate (Augmentin) or cephalosporins, such as cefixime (Suprax),
cefpodoxime, cefprozil (Cefzil), or cephalexin (Keflex). There was no significant difference
between short- and standard-duration therapies in the development of resistant organisms at
the end of treatment.1 Thus, a two- to four-day course of oral antibiotics appears to be as
effective as a seven- to 14-day course in children with lower UTIs. A single-dose or single-
day course may be less effective than longer courses of oral antibiotics and is not
recommended.1,2
When the presenting symptoms are nonspecific for a UTI or the urine dipstick test is
nondiagnostic, there may be a delay in treatment while culture results are pending. Parents
can be reassured that antibiotics initiated 24 hours after the onset of fever are not associated
with a higher risk of parenchymal defects than immediate antibiotics in children younger than
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two years.5 However, delaying antibiotics by four days or more may increase the risk of renal
scarring.1
COMMON ADVERSE
ANTIBIOTIC DOSING EFFECTS
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expected clinical improvement does not occur, consider further evaluation (e.g., laboratory
studies, imaging, consultation with subspecialists). Referral to a subspecialist is indicated if
vesicoureteral reflux, renal scarring, anatomic abnormalities, or renal calculi are discovered,
or if invasive imaging procedures are considered.1
Chapter III
Conclusion
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Diagnosis and Treatment of UTI in children Novina Firlia 0961050083
In conclusion, increased vigilance on the part of practitioners and screening for UTI in
febrile young children has dramatically reduced the morbidity associated with this diagnosis.
Although there are several areas that remain ripe for further study, there is good evidence
about the epidemiology, diagnosis, and treatment of UTI in children. Key principles of
improving outcomes for pediatric UTI include maintaining a high index of suspicion,
particularly in young children with fever; understanding the strengths and limitations of
screening tests for UTI; and using evidence-based guidelines to approach further anatomic
work-up of UTI, while recognizing the limitations of current knowledge in this area.
REFERENCES
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Diagnosis and Treatment of UTI in children Novina Firlia 0961050083
2. Giovanni Montini, M.D., Kjell Tullus, M.D., Ph.D., and Ian Hewitt, M.B.,
B.S.N Engl J Med 2011; 365:239-250July 21, 2011DOI: 10.1056/NEJMra1007755
7. Freedman, AL. Urinary tract infections in children. In: Litwin MS, Saigal CS,
eds. Urologic Diseases in America. U.S. Department of Health and Human Services,
Public Health Service, National Institutes of Health, National Institute of Diabetes and
Digestive and Kidney Diseases. Washington, D.C.: U.S. Government Printing Office;
2009. NIH publication 07–5512:439–458.
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