Pediatric Urinary
Tract Infection
Introduction
By the age of 11, approximately 3 percent of girls and 1 percent of boys will have
developed at least 1 bacterial urinary tract infection (UTI). As these infections
frequently occur in children too young for relating symptoms effectively, these estimates
are likely low. Fortunately, lower UTIs may resolve in up to 40 percent of cases without
treatment and upper tract "febrile" infections are adequately treated by the
antibiotic therapies prescribed for otitis media and other common bacterial infections.
Effective intervention in children with bacterial urinary tract infection includes three
elements; diagnosis, treatment, and prevention.
Diagnosis
There are two types of bacterial UTI; febrile and afebrile. Beyond early
infancy, it is reasonable to use the terms upper and lower tract urinary infection,
respectively. Lower tract symptoms include abdominal and back pain, dysuria, urgency,
frequency, incontinence, and nocturnal enuresis. All of these symptoms can occur in upper
tract infections, but the febrile child has an upper tract infection, pyelonephritis,
unless proven otherwise. In addition, vaginitis, urethritis, viral cystitis, proctitis,
and meatitis can mimic lower UTI symptoms.
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Bacterial UTI is ultimately diagnosed by culture. Spontaneous voiding is an acceptable
method for obtaining a urine sample in children who can void on command. A mid-stream
sample should be obtained after gentle cleansing with soap and water and drying. Bladder
catheterization and suprapubic aspiration (rarely necessary) are the methods of choice in
the incontinent patient. Urine collected by attaching a bag to the perineum is frequently
contaminated in spite of adequate cleansing and may be used to demonstrate a normal
urinalysis and thereby rule out a urinary tract infection in 95 percent of children. Any
bacterial growth on culture medium obtained from sterile catheterization or suprapubic
aspiration is considered significant. Most children with a UTI will have colony counts of
greater than 105/ml but lesser counts in a child with fever or evidence of a
WBC response within the urinary tract should be treated as an infection. The likelihood of
contamination is low in voided specimens by males, and as a result, all positive cultures
must be addressed.
Treatment
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In children without complicating disorders, 80-90 percent of UTIs are caused by E. coli.
Other organisms include Klebsiella-Enterobacter sp., Proteus sp., Streptococcus faecalis,
Staphylococcus saprophyticus, and Pseudomonas aeruginosa. Antimicrobials that have
established efficacy in the treatment of acute, uncomplicated UTIs in children include amoxicillin, trimethoprim-sulfamethoxazole, and cephalexin. Doses are noted in the
Pediatric Formulary section. Nitrofurantoin is an effective antibiotic, but its use is
limited to lower tract UTI as its tissue penetration is negligible.
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In recurrent infections, antimicrobial choices are similar. However, in such cases
bacterial resistance may be a problem, especially if the patient recently has received an
antimicrobial, and culture results must be monitored in order to change therapy at the
first documentation of a resistant organism. Patients who are toxic, are unable to
tolerate P.O. medicine, or have abnormal structure or function of the urinary tract,
should initially be managed as inpatients. In such cases, initial broad spectrum therapy
intravenous therapy is indicated.
-
Post-treatment urine cultures are of questionable benefit in children with symptomatic
lower UTIs, as they rarely provide information that would alter therapy. In children with
repeated infections, cultures will differentiate bacterial persistence from reinfections.
The complexities of these clinical entities warrant referral to a urologist.
Prevention
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Lower urinary tract infection is not caused by inadequate hydration, improper perineal
hygiene, and tight-fitting or irritating undergarments. History in these children should
focus on voiding habits, difficulties with constipation or encopresis, and continence.
Dysfunctional elimination of urine and stool is causative in lower UTIs. Any UTIs that
occur in proximity to sexual activity should be well controlled by post-coital voiding or
peri-activity pulse-antibiotic therapy.
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Children with febrile UTIs, or children with lower UTIs and repeated diagnosis of otitis
media or URIs, should undergo imaging of the urinary tract that includes a structural
study (ultrasound, or intravenous pyelography) and a voiding cystourethrogram. These tests
will assess for elements of obstruction, anomalies, or vesicoureteral reflux, all of which
require involvement of a specialist, if present.
-
Finally, episodes of child abuse have manifested only by frequent UTIs or voiding
complaints. This diagnostic consideration must be entertained when clinical evidence
dictates.
Reviewed by CDR Wendy Bailey, MC, USN, Pediatric Specialty Leader, Naval Medical
Center San Diego, San Diego, CA (1999).
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Preface
· Administrative Section
· Clinical Section
The
General Medical Officer Manual , NAVMEDPUB 5134, January 1, 2000
Bureau
of Medicine and Surgery, Department of the Navy, 2300 E Street NW, Washington, D.C.,
20372-5300
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