eMedicine Specialties > Pediatrics: General Medicine > Infectious Disease

Urinary Tract Infection: Follow-up

Author: Stanley Hellerstein, MD, Pediatric Nephrologist, Children's Mercy Hospital of Kansas City; Ernest L Glasscock, MD Chair in Pediatric Research, Professor of Pediatrics, University of Missouri School of Medicine at Kansas City
Contributor Information and Disclosures

Updated: Nov 23, 2009

Follow-up

Further Inpatient Care

  • For patients with pyelonephritis, give a suppressive dose of antibiotics to prevent reinfection at least until the voiding cystourethrography (VCUG) is obtained (if one is to be obtained).
  • In patients with pyelonephritis, some clinicians discontinue antibacterial therapy 1-2 days after VCUG, if no vesicoureteral reflux (VUR) is present.
    • However, in studies of cortical scanning, roughly one half of the children with an initial episode of pyelonephritis have VUR, and one half have no radiographically identifiable reflux. Reinfection is common in both groups, with a high incidence in the first 6 months after the initial infection.
    • Until evidence-based guidelines about the use of suppressive antibacterial therapy after an initial febrile urinary tract infection (UTI) are available, recommending 6-12 months of suppressive treatment seems reasonable. Patients with VUR of grade III should receive a prolonged course of suppressive therapy. Patients VUR of grade IV or worse should be referred to a pediatric nephrologist or urologist.

Further Outpatient Care

  • For children with uncomplicated acute pyelonephritis
    • Although children with a febrile urinary tract infection may qualify for outpatient care, they still are at risk for kidney damage. Initial use of a parenteral antibiotic may increase the likelihood of promptly ceasing the bacterial proliferation in the renal tissue. However, Hoberman et al indicated that oral therapy with a third-generation cephalosporin was as effective as traditional inpatient treatment with parenteral antibacterial therapy.10
    • If the patient is not allergic to a cephalosporin, initial treatment may consist of a single dose of ceftriaxone (75 mg/kg IV/IM q12-24h).
    • If the patient is allergic to cephalosporin, initial treatment may be gentamicin (2.5 mg/kg IV/IM as a single dose).
    • Start treatment with an oral antibacterial agent at therapeutic doses within the next 12-18 hours if the patient's response is satisfactory.
    • Arrange for follow-up, usually telephone follow-up, at 24 hours to monitor the response to treatment and at 48 hours to modify treatment the results of antibacterial sensitivity studies indicate a need to change.
    • Arrange for a follow-up visit after 7-10 days to check the patient's clinical course.

Deterrence/Prevention

  • Avoid unnecessary use of antibiotics for upper respiratory infections and otitis media. Antibiotics can alter GI and periurethral flora and compromise natural defenses against colonization by pathogenic agents.
  • Treat voiding dysfunction, especially when it is associated with posturing, which can lead to urethrovesical reflux and recurrence of urinary tract infections.
  • Consider circumcision of male neonates.
  • A recent study investigated the effect of daily cranberry juice in female children with recurrent urinary tract infections and concluded that daily consumption of concentrated cranberry juice can significantly prevent the recurrence of symptomatic urinary tract infections.11

Complications

  • An allergic reaction to antibiotic therapy is a risk.
  • Children with pyelonephritis may develop lobar inflammation of the kidney (lobar or focal nephronia) or renal abscess.
  • Any inflammation of the renal parenchyma may lead to scar formation.
  • Long-term complications of pyelonephritis are hypertension, impaired renal function, end-stage renal disease (ESRD), and complications of pregnancy (eg, urinary tract infection, pregnancy-related hypertension, low-birth weight neonates).

Prognosis

  • In industrialized countries, kidney damage with long-term complications as a consequence of urinary tract infection per se is currently less common than in the early 20th century, when pyelonephritis was a frequent cause of hypertension and ESRD in young women.
    • This change is probably a result of improved overall healthcare and close follow-up of children after an episode of pyelonephritis.
    • In countries with high-quality healthcare, hypertension, impaired renal function, and ESRD are now most commonly encountered in infants with intrauterine renal damage.
  • Clinically significant urinary tract abnormalities are frequently identified using intrauterine ultrasonography. After birth, these children may incur additional kidney damage as a result of postnatal infection, but urinary tract infection is not the major cause of the kidney impairment. The major causes of impaired kidney function are developmental abnormalities.

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • Medical legal confrontations related to the management of children with urinary tract infection (UTI) appear to be uncommon, but they definitely occur.
  • Administration of an antibiotic to a child known to be allergic to that medication can result in a severe reaction and is a potential cause of medical legal action.
 


More on Urinary Tract Infection

Overview: Urinary Tract Infection
Differential Diagnoses & Workup: Urinary Tract Infection
Treatment & Medication: Urinary Tract Infection
Follow-up: Urinary Tract Infection
Multimedia: Urinary Tract Infection
References
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References

  1. Hoberman A, Chao HP, Keller DM, et al. Prevalence of urinary tract infection in febrile infants. J Pediatr. Jul 1993;123(1):17-23. [Medline].

  2. Downs SM. Technical report: urinary tract infections in febrile infants and young children. The Urinary Tract Subcommittee of the American Academy of Pediatrics Committee on Quality Improvement. Pediatrics. Apr 1999;103(4):e54. [Medline]. [Full Text].

  3. Girardet P, Frutiger P, Lang R. Urinary tract infections in pediatric practice. A comparative study of three diagnostic tools: dip-slides, bacterioscopy and leucocyturia. Paediatrician. 1980;9(5-6):322-37. [Medline].

  4. Goldsmith BM, Campos JM. Comparison of urine dipstick, microscopy, and culture for the detection of bacteriuria in children. Clin Pediatr (Phila). Apr 1990;29(4):214-8. [Medline].

  5. Anderson JD, Chambers GK, Johnson HW. Application of a leukocyte and nitrite urine test strip to the management of children with neurogenic bladder. Diagn Microbiol Infect Dis. Jul 1993;17(1):29-33. [Medline].

  6. Craver RD, Abermanis JG. Dipstick only urinalysis screen for the pediatric emergency room. Pediatr Nephrol. Jun 1997;11(3):331-3. [Medline].

  7. Shaw KN, McGowan KL, Gorelick MH, Schwartz JS. Screening for urinary tract infection in infants in the emergency department: which test is best?. Pediatrics. Jun 1998;101(6):E1. [Medline].

  8. Anad FY. A simple method for selecting urine samples that need culturing. Ann Saudi Med. Jan-Mar 2001;21(1-2):104-5. [Medline].

  9. Bachur R, Harper MB. Reliability of the urinalysis for predicting urinary tract infections in young febrile children. Arch Pediatr Adolesc Med. Jan 2001;155(1):60-5. [Medline].

  10. Hoberman A, Wald ER, Hickey RW, et al. Oral versus initial intravenous therapy for urinary tract infections in young febrile children. Pediatrics. Jul 1999;104(1 Pt 1):79-86. [Medline].

  11. Ferrara P, Romaniello L, Vitelli O, Gatto A, Serva M, Cataldi L. Cranberry juice for the prevention of recurrent urinary tract infections: A randomized controlled trial in children. Scand J Urol Nephrol. 2009;43(5):369-372. [Medline].

  12. AAP Subcommittee on Urinary Tract Infection. Practice parameter: the diagnosis, treatment, and evaluation of the initial UTI in febrile infants and young children. AAP. Committee on Quality Improvement. Subcommittee on Urinary Tract Infection. Pediatrics. Apr 1999;103(4 Pt 1):843-52. [Medline].

  13. Alon US. Optimal timing of follow-up voiding cystourethrogram in children with vesicoureteral reflux. Am J Urol Rev. 2005;3:472-8.

  14. Alon US, Ganapathy S. Should renal ultrasonography be done routinely in children with first urinary tract infection?. Clin Pediatr (Phila). Jan 1999;38(1):21-5. [Medline].

  15. Ataei N, Madani A, Habibi R, Khorasani M. Evaluation of acute pyelonephritis with DMSA scans in children presenting after the age of 5 years. Pediatr Nephrol. 2005;20:1439-44. [Medline].

  16. Bergstrom T, Lincoln K, Redin B, Winberg J. Studies of urinary tract infections in infancy and childhood. X. Short or long-term treatment in girls with first or second-time urinary tract infections uncomplicated by obstructive urological abnormalities. Acta Paediatr Scand. May 1968;57(3):186-94. [Medline].

  17. Bloomfield P, Hodson EM, Craig JC. Antibiotics for acute pyelonephritis in children. Cochrane Database Syst Rev. Jan 25 2005;(1):CD003772. [Medline].

  18. Chandra M. Voiding and its disorders in children. In: Monographs in Clinical Pediatrics. Vol 10. Amsterdam, the Netherlands: Harwood Academic; 1998:217-29.

  19. [Guideline] Cohen AL, Rivara FP, Davis R, Christakis DA. Compliance with guidelines for the medical care of first urinary tract infectionsin infants: a population-based study. Pediatrics. Jun 2005;115(6):1474-8. [Medline].

  20. Craig JC, Knight JF, Sureshkumar P, et al. Effect of circumcision on incidence of urinary tract infection in preschool boys. J Pediatr. Jan 1996;128(1):23-7. [Medline].

  21. Dick PT, Feldman W. Routine diagnostic imaging for childhood urinary tract infections: a systematic overview. DIALYSIS. Jan 1996;128(1):15-22. [Medline].

  22. Giorgi LJ, Bratslavsky G, Kogan BA. Febrile urinary tract infections in infants: renal ultrasound remains necessary. J Urol. Feb 2005;173(2):568-70. [Medline].

  23. Hansson S, Dhamey M, Sigstrom O, et al. Dimercapto-succinic acid scintigraphy instead of voiding cystourethrography for infants with urinary tract infection. J Urol. 2004;172:1071-4.

  24. Hellerstein S. Urinary tract infections in children with specific consideration of voiding dysfunction. In: Monographs in Clinical Pediatrics. Vol 10. Amsterdam, the Netherlands: Harwood Academic; 1998:183-97.

  25. Hellerstein S. Diagnosis of infections of the urinary tract. In: Urinary Tract Infections in Children. Chicago, IL: Year Book Medical; 1982:1-14.

  26. Hellerstein S. Urinary tract infections. Old and new concepts. Pediatr Clin North Am. Dec 1995;42(6):1433-57. [Medline].

  27. Hellerstein S. Why do children have UTIs and what can we do about them?. Dialog Pediatr Urol. 1998;21:1-8.

  28. Hoberman A, Charron M, Hickey RW, et al. Imaging studies after a first febrile urinary tract infection in young children. N Engl J Med. 2003;348:195-202. [Medline].

  29. Hoberman A, Wald ER. Urinary tract infections in young febrile children. Pediatr Infect Dis J. Jan 1997;16(1):11-7. [Medline].

  30. Jahnukainen T, Chen M, Celsi G. Mechanisms of renal damage owing to infection. Pediatr Nephrol. 2005;20:1043-53. [Medline].

  31. Jakobsson B, Esbjorner E, Hansson S. Minimum incidence and diagnostic rate of first urinary tract infection. Pediatrics. Aug 1999;104(2 Pt 1):222-6. [Medline].

  32. Loening-Baucke V. Urinary incontinence and urinary tract infection and their resolution with treatment of chronic constipation of childhood. Pediatrics. Aug 1997;100(2 Pt 1):228-32. [Medline].

  33. Lu KC, Chen PY, Huang FL, et al. Is combination antimicrobial therapy required for urinary tract infection in children?. J Microbiol Immunol Infect. Mar 2003;36(1):56-60. [Medline].

  34. Malone PS. Circumcision for preventing urinary tract infection in boys: European view. Arch Dis Child. 2005;90:773-4. [Medline].

  35. Marild S, Jodal U. Incidence rate of first-time symptomatic urinary tract infection in children under 6 years of age. Acta Paediatr. May 1998;87(5):549-52. [Medline].

  36. Michael M, Hodson EM, Craig JC, et al. Short versus standard duration oral antibiotic therapy for acute urinary tract infection in children. Cochrane Database Syst Rev. 2003;(1):CD003966. [Medline].

  37. Moorthy I, Easty M, McHugh K, et al. The presence of vesicoureteric reflux does not identify a population at risk for renal scarring following a first urinary tract infection. Arch Dis Child. 2005;90:733-6. [Medline].

  38. Moorthy I, Wheat D, Gordon I. Ultrasonography in the evaluation of renal scarring using DMSA scan as the gold standard. Pediatr Nephrol. 2004;19:153-6. [Medline].

  39. Rushton HG. Commentary on clinical relevance of 99mTc-DMSA scintigraphy. J Urol. 1994;152:1068-9.

  40. Schoen EJ. Circumcision for preventing urinary tract infections in boys: North American view. Arch Dis Child. 2005;90:772-3. [Medline].

  41. Schoen EJ. The foreskin and urinary tract infections. J Pediatr. Oct 1989;115(4):663-4. [Medline].

  42. Shaw KN, Gorelick M, McGowan KL, et al. Prevalence of urinary tract infection in febrile young children in the emergency department. Pediatrics. Aug 1998;102(2):e16. [Medline].

  43. Singh-Grewal D, Macdessi J, Craig J. Circumcision for the prevention of urinary tract infection in boys:a systematic review of randomised trials and observational studies. Arch Dis Child. 2005;90:853-8. [Medline].

  44. Sreenarasimhaiah S, Hellerstein S. Urinary tract infections per se do not cause end-stage kidney disease. Pediatr Nephrol. Apr 1998;12(3):210-3. [Medline].

  45. Stark H. Urinary tract infections in girls: the cost-effectiveness of currently recommended investigative routines. Pediatr Nephrol. Apr 1997;11(2):174-7; discussion 180-1. [Medline].

  46. Taketomo CK, Hodding JH, Kraus DM. Pediatric Dosage Handbook. 9th ed. Cleveland, OH: Lexi-Comp Inc.; 2002-2003.

  47. Wiswell TE, Roscelli JD. Corroborative evidence for the decreased incidence of urinary tract infections in circumcised male infants. Pediatrics. Jul 1986;78(1):96-9. [Medline].

  48. Zamir G, Sakran W, Horowitz Y, et al. Urinary tract infection: is there a need for routine renal ultrasonography?. Arch Dis Child. 2004;89:466-8. [Medline].

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Further Reading

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Keywords

urinary tract infection, UTI, cystitis, pyelonephritis, urethritis, urinary tract abnormality, bacteriuria, upper urinary tract infection, lower tract urinary infection, pyuria, uropathogens, periurethral colonization, treatment, diagnosis

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Contributor Information and Disclosures

Author

Stanley Hellerstein, MD, Pediatric Nephrologist, Children's Mercy Hospital of Kansas City; Ernest L Glasscock, MD Chair in Pediatric Research, Professor of Pediatrics, University of Missouri School of Medicine at Kansas City
Stanley Hellerstein, MD is a member of the following medical societies: American Academy of Pediatrics, American Pediatric Society, and American Society of Pediatric Nephrology
Disclosure: Nothing to disclose.

Medical Editor

Robert W Tolan Jr, MD, Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine
Robert W Tolan Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa, and Physicians for Social Responsibility
Disclosure: GlaxoSmithKline Honoraria Speaking and teaching; MedImmune Honoraria Speaking and teaching; Merck Honoraria Speaking and teaching; sanofi pasteur Honoraria Speaking and teaching; Baxter Healthcare Honoraria Speaking and teaching

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

Leslie L Barton, MD, Professor, Program Director, Department of Pediatrics, University of Arizona School of Medicine
Leslie L Barton, MD is a member of the following medical societies: American Academy of Pediatrics, Association of Pediatric Program Directors, Infectious Diseases Society of America, and Pediatric Infectious Diseases Society
Disclosure: Nothing to disclose.

CME Editor

Daniel Rauch, MD, FAAP, Director, Pediatric Hospitalist Program, Associate Professor, Department of Pediatrics, New York University School of Medicine
Daniel Rauch, MD, FAAP is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, and Society of Hospital Medicine
Disclosure: Baxter Honoraria Consulting

Chief Editor

Russell W Steele, MD, Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine
Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, and Southern Medical Association
Disclosure: None None None

 
 
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