eMedicine Specialties > Emergency Medicine > Pediatric

Pediatrics, Urinary Tract Infections and Pyelonephritis: Follow-up

Author: Stephen L Thornton, MD, Attending Physician, Department of Emergency Medicine, St John's Hospital
Contributor Information and Disclosures

Updated: Dec 17, 2008

Follow-up

Further Inpatient Care

  • Hospitalization is necessary for the following individuals with urinary tract infection (UTI):
    • Patients who are toxemic or septic
    • Patients with signs of urinary obstruction or significant underlying disease
    • Patients unable to tolerate adequate oral fluids or medications
    • Infants younger than 3 months with febrile UTI (presumed pyelonephritis)
    • All infants younger than 1 month with suspected UTI even if not febrile

Further Outpatient Care

  • The American Academy of Pediatrics recommends all infants and young children (2 months to 2 years of age) with first UTI have a urinary tract ultrasonography and VCUG. These tests should be acquired promptly if patients fail to show expected clinical response within 2 days of treatment.
  • All patients should have close follow-up to evaluate response to antibiotics.
  • Repeat urinalysis and/or urine cultures are not needed if the patient’s condition responds to therapy as expected.

Inpatient & Outpatient Medications

  • Most non-toxic-appearing patients with uncomplicated cystitis will do well on oral antibiotics.
  • Any patient with suspected pyelonephritis should be started on parenteral antibiotics and then transitioned to oral antibiotics once afebrile for more than 24 hours.
  • Neonates should be kept on parenteral antibiotics for 3-4 days before being transitioned to oral antibiotics.

Deterrence/Prevention

  • Prevention of UTI is focused on the identification and correction of structural abnormalities.
  • Prophylactic antibiotics is controversial though widely practiced for patients with VUR and recurrent infections. Prophylactic antibiotics are associated with increased risk of resistant infection.

Complications

  • Dehydration is the most common complication of UTI in the pediatric population. Intravenous fluid replacement is necessary in more severe cases. Treat febrile UTI as pyelonephritis, and consider parenteral antibiotics and admission for these patients.
  • Untreated UTI may progress to renal involvement with systemic infection (eg, urosepsis).
  • Long-term complications include renal parenchyma scarring, hypertension, decreased renal function, and, in severe cases, renal failure.

Prognosis

  • Most cases of uncomplicated UTI respond readily to outpatient antibiotic treatments without further sequelae.
  • Appropriate treatment, imaging, and follow-up prevent long-term sequelae in patients with more severe cases or chronic infections.
  • Low-grade VUR usually resolves without permanent damage.
  • High-grade VUR may require surgical correction.

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • Failure to have a high index of suspicion for UTIs, especially in neonates and febrile infants
  • Failure to diagnosis and aggressively treat pyelonephritis to avoid acute and chronic complications
  • Failure to insist on proper collection of urine sample (ie, avoid bagged specimens)
  • Failure to initiate proper antibiotic treatment in a timely fashion
  • Failure to emphasize/arrange for appropriate follow-up and imaging

Special Concerns

  • Pregnancy must be considered in adolescent girls who present with symptoms of UTI and/or vaginitis and who are sexually active.
  • Antibiotic resistance among uropathogens is increasing dramatically.
 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors, Terrance K Egland, MD, and Ann G Egland, MD, to the development and writing of this article.



More on Pediatrics, Urinary Tract Infections and Pyelonephritis

Overview: Pediatrics, Urinary Tract Infections and Pyelonephritis
Differential Diagnoses & Workup: Pediatrics, Urinary Tract Infections and Pyelonephritis
Treatment & Medication: Pediatrics, Urinary Tract Infections and Pyelonephritis
Follow-up: Pediatrics, Urinary Tract Infections and Pyelonephritis
References
[ CLOSE WINDOW ]

References

  1. Lin DS, Huang FY, Chiu NC, et al. Comparison of hemocytometer leukocyte counts and standard urinalyses for predicting urinary tract infections in febrile infants. Pediatr Infect Dis J. Mar 2000;19(3):223-7. [Medline].

  2. Lin DS, Huang SH, Lin CC, et al. Urinary tract infection in febrile infants younger than eight weeks of Age. Pediatrics. Feb 2000;105(2):E20. [Medline]. [Full Text].

  3. American Academy of Pediatrics Committee on Infectious Diseases. The use of systemic fluoroquinolones. Pediatrics. Sep 2006;118(3):1287-92. [Medline]. [Full Text].

  4. Batisky D. Pediatric urinary tract infections. Pediatr Ann. May 1996;25(5):266, 269-76. [Medline].

  5. Bauer R, Kogan BA. New developments in the diagnosis and management of pediatric UTIs. Urol Clin North Am. Feb 2008;35(1):47-58; vi. [Medline].

  6. Belman AB. A perspective on vesicoureteral reflux. Urol Clin North Am. Feb 1995;22(1):139-50. [Medline].

  7. Biassoni L, Cippington S. Imaging in urinary tract infections: current strategies and new trends. Semin Nucl Med. 2007;38:56-66.

  8. Byington CL, Rittichier KK, Bassett KE, et al. Serious bacterial infections in febrile infants younger than 90 days of age: the importance of ampicillin-resistant pathogens. Pediatrics. May 2003;111(5 Pt 1):964-8. [Medline].

  9. Chang SL, Shortliffe LD. Pediatric urinary tract infections. Pediatr Clin North Am. Jun 2006;53(3):379-400, vi. [Medline].

  10. Conway PH, Cnaan A, Zaoutis T, et al. Recurrent urinary tract infections in children: risk factors and association with prophylactic antimicrobials. JAMA. Jul 11 2007;298(2):179-86. [Medline].

  11. Hellerstein S. Antibiotic treatment for urinary tract infections in pediatric patients. Minerva Pediatr. Oct 2003;55(5):395-406. [Medline].

  12. Jakobsson B, Soderlundh S, Berg U. Diagnostic significance of 99mTc-dimercaptosuccinic acid (DMSA) scintigraphy in urinary tract infection. Arch Dis Child. Nov 1992;67(11):1338-42. [Medline].

  13. Marcus N, Ashkenazi S, Yaari A, et al. Non-Escherichia coli versus Escherichia coli community-acquired urinary tract infections in children hospitalized in a tertiary center: relative frequency, risk factors, antimicrobial resistance and outcome. Pediatr Infect Dis J. Jul 2005;24(7):581-5. [Medline].

  14. Merrick MV, Notghi A, Chalmers N, et al. Long-term follow up to determine the prognostic value of imaging after urinary tract infections. Part 1: Reflux. Arch Dis Child. May 1995;72(5):388-92. [Medline].

  15. Merrick MV, Notghi A, Chalmers N, et al. Long-term follow up to determine the prognostic value of imaging after urinary tract infections. Part 2: Scarring. Arch Dis Child. May 1995;72(5):393-6. [Medline].

  16. Mucci B, Maguire B. Does routine ultrasound have a role in the investigation of children with urinary tract infection?. Clin Radiol. May 1994;49(5):324-5. [Medline].

  17. Neeb A, Bissada NK. Evolving management of pediatric urinary tract infection. J Ark Med Soc. Sep 2005;102(3):73-5. [Medline].

  18. Nelson JD. 1996-1997 Pocket Book of Pediatric Antimicrobial Therapy. 12th ed. Williams and Wilkins: 1996.

  19. Nicolleta J, Lande M. Medical evaluation and treatment of urolithiasis. Pediatr Clin N Am. 2004;53:479-491.

  20. Panaretto K, Craig J, Knight J, et al. Risk factors for recurrent urinary tract infection in preschool children. J Paediatr Child Health. Oct 1999;35(5):454-9. [Medline].

  21. Rosenfeld DL, Fleischer M, Yudd A, et al. Current recommendations for children with urinary tract infections. Clin Pediatr (Phila). May 1995;34(5):261-4. [Medline].

  22. Rushton HG. Urinary tract infections in children. Epidemiology, evaluation, and management. Pediatr Clin North Am. Oct 1997;44(5):1133-69. [Medline].

  23. Schlager TA. Urinary tract infections in children younger than 5 years of age: epidemiology, diagnosis, treatment, outcomes and prevention. Paediatr Drugs. 2001;3(3):219-27. [Medline].

  24. Shaikh N, Morone NE, Bost JE, et al. Prevalence of urinary tract infection in childhood: a meta-analysis. Pediatr Infect Dis J. Apr 2008;27(4):302-8. [Medline].

  25. [Best Evidence] Shaikh N, Morone NE, Lopez J, et al. Does this child have a urinary tract infection?. JAMA. Dec 26 2007;298(24):2895-904. [Medline].

  26. Stephens MB, Wilder L, Hsu JT. Clinical inquiries. Is screening urinalysis in children worthwhile?. J Fam Pract. Nov 2003;52(11):894-5. [Medline].

  27. Todd JK. Management of urinary tract infections: children are different. Pediatr Rev. May 1995;16(5):190-6. [Medline].

  28. Williams G, Lee A, Craig J. Antibiotics for the prevention of urinary tract infection in children: A systematic review of randomized controlled trials. J Pediatr. Jun 2001;138(6):868-74. [Medline].

  29. Williams GJ, Wei L, Lee A, et al. Long-term antibiotics for preventing recurrent urinary tract infection in children. Cochrane Database Syst Rev. Jul 19 2006;3:CD001534. [Medline].

  30. Yuksel S, Ozturk B, Kavaz A, et al. Antibiotic resistance of urinary tract pathogens and evaluation of empirical treatment in Turkish children with urinary tract infections. Int J Antimicrob Agents. Nov 2006;28(5):413-6. [Medline].

  31. Zelikovic I, Adelman RD, Nancarrow PA. Urinary tract infections in children. An update. West J Med. Nov 1992;157(5):554-61. [Medline].

  32. Zorc JJ, Kiddoo DA, Shaw KN. Diagnosis and management of pediatric urinary tract infections. Clin Microbiol Rev. Apr 2005;18(2):417-22. [Medline].

  33. Zorc JJ, Levine DA, Platt SL, et al. Clinical and demographic factors associated with urinary tract infection in young febrile infants. Pediatrics. Sep 2005;116(3):644-8. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

UTI, urinary tract infection in kids, urinary tract infection in infants, UTI in children, cystitis, UTI in infants, urosepsis, pyelonephritis, cystitis, vaginitis, bacterial infection

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Stephen L Thornton, MD, Attending Physician, Department of Emergency Medicine, St John's Hospital
Stephen L Thornton, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

David S Howes, MD, Residency Program Director, Professor of Medicine, Section of Emergency Medicine, University of Chicago/Pritzker School of Medicine
David S Howes, MD is a member of the following medical societies: American College of Emergency Physicians, American College of Physicians-American Society of Internal Medicine, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Grace M Young, MD, Associate Professor, Department of Pediatrics, University of Maryland Medical Center
Grace M Young, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Emergency Physicians
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Richard G Bachur, MD, Associate Professor of Pediatrics, Harvard Medical School; Associate Chief and Fellowship Director, Attending Physician, Division of Emergency Medicine, Children's Hospital of Boston
Richard G Bachur, MD is a member of the following medical societies: American Academy of Pediatrics, Society for Academic Emergency Medicine, and Society for Pediatric Research
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.