eMedicine Specialties > Emergency Medicine > Pediatric

Pediatrics, Urinary Tract Infections and Pyelonephritis

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

Updated: Dec 17, 2008

Introduction

Background

In the pediatric patient, urinary tract infections (UTIs) are among the most common serious bacterial infections (SBI) encountered. They are a frequent cause of fever and can cause significant morbidity if not properly identified and treated.
 
Presentation varies based on the age of the patient. Neonates and infants often present with vague, nonspecific symptoms, necessitating a high index of suspicion for UTIs in this age group. Older pediatric patients are more likely to present with more typical and localized complaints.
 
Treatment should be tailored to treat the most commonly encountered causative organisms, keeping in mind increasing antibiotic resistance among urinary pathogens. If not properly identified or treated, UTIs can progress to pyelonephritis or urosepsis. Long-term complications from UTIs may include renal scarring, hypertension, and even renal failure.

Pathophysiology

The urinary tract is normally a sterile environment and has several mechanisms that work to maintain urine sterility (urethral sphincter, length of urethra, constant anterograde flow). In most cases, failure of one of these mechanisms leads to or exacerbates infection.

The most common causative organisms are bowel flora, typically gram-negative rods. Escherichia coli is the most commonly isolated organism from pediatric patients with UTIs. However, any organism that gains access to the urinary tract system may cause infection, including fungi (Candida species) and viruses.

Pathogens can infect the urinary tract through direct spread via the fecal-perineal-urethral route or from hematogenous seeding. Hematogenous spread is much more likely in neonates than in older children. Most infections begin in the bladder, and, from there, pathogens can spread up the urinary tract to the kidneys (pyelonephritis) and possibly the bloodstream (bacteremia). Pyelonephritis may lead to renal scarring and long-term complications such as hypertension and chronic renal failure. 

Frequency

United States

  • Prevalence and incidence of UTIs varies based on age, sex, and gender.
  • Overall, UTIs are estimated to affect 2.4-2.8% of all children every year.
  • It is estimated that up to 5% of all children younger than 2 years who present to the emergency department with fever have a UTI.

International

International prevalence and incidence is difficult to accurately assess, especially in developing countries, but is assumed to be similar to that in the United States. 

Mortality/Morbidity

  • Bacteremia or urosepsis may develop from UTI. This risk is highest in neonates and very young infants.
  • Simple cystitis may progress to pyelonephritis. It is difficult to predict which patients will get pyelonephritis, though there is evidence that genetics may play a role. 
  • Approximately 10-30% of children with UTIs will develop renal scarring. 
  • Severe and/or recurrent cases of pyelonephritis may lead to kidney damage. This may cause hypertension, renal insufficiency, or renal failure.

Race

  • Studies indicate that nonblacks have a higher incidence of UTI than blacks.

Sex

  • Uncircumcised males have a significantly higher incidence of UTIs than circumcised males.
  • Uncircumcised male infants have a higher incidence of UTI than female infants during the first year of life.
  • After the first year of life, females have a much higher incidence of UTIs than males.
  • Incidence is highest in sexually active adolescent females.

Age

  • Prevalence of UTIs in the first 3 months of life is estimated to be as high as 7.5%.
  • During the first year of life, males have an incidence of UTIs of 2.7% compared with 0.7% for girls.
  • For children older than 1 year, females have a 1-2% incidence of UTIs and males have a 0.1-0.2% incidence of UTIs.
  • In sexually active teenaged females, the incidence of UTIs approaches 10%.

Clinical

History

History varies with the age of the patient and often is nonspecific for younger children. 

  • Neonates
    • Jaundice
    • Fever
    • Failure to thrive
    • Poor feeding
    • Vomiting
    • Irritability
  • Infants
    • Poor feeding
    • Fever
    • Vomiting
    • Strong-smelling urine
    • Abdominal pain
    • Irritability
  • Preschoolers
    • Vomiting
    • Abdominal pain
    • Fever
    • Strong-smelling urine
    • Enuresis
    • Urinary symptoms (dysuria, urgency, frequency)
  • School-aged children
    • Fever
    • Vomiting, abdominal pain
    • Flank/back pain
    • Strong-smelling urine
    • Urinary symptoms (dysuria, urgency, frequency)
    • Enuresis
    • Incontinence
  • Adolescents are more likely to present with typical urinary symptoms.
    • Adolescent girls are more likely to have vaginitis (35%) than UTI (17%). Those diagnosed with cystitis frequently have a concurrent vaginitis.

Physical

  • Hypertension should raise suspicion of hydronephrosis or renal parenchyma disease.
  • Costovertebral angle (CVA) tenderness
  • Abdominal tenderness to palpation
  • Suprapubic tenderness to palpation
  • Palpable bladder
  • Dribbling, poor stream, or straining to void
  • Examine external genitalia for signs of irritation, pinworms, vaginitis, trauma, or sexual abuse.

Causes

  • Bacterial infections are the most common cause of UTIs.
    • E coli is the most frequent pathogen, causing 75-90% of UTIs.
    • Klebsiella species
    • Proteus species
    • Enterococcus species
    • Staphylococcus saprophyticus, especially among sexually active females
    • Streptococcus group B, especially among neonates
    • Pseudomonas aeruginosa
  • Fungi (Candida species), especially after instrumentation of the urinary tract
  • Adenovirus (rare)

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
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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].

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Further Reading

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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

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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.

 
 
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