History
The history and clinical course of a urinary tract infection (UTI) vary with the patient's age and the specific diagnosis. No one specific sign or symptom can be used to identify UTI in infants and children.
Combinations of findings, including a prior history of UTI, circumcision in boys, and, in older children, typical symptoms such as frequency, abdominal or suprapubic discomfort, and dysuria, should be taken into account when making a decision to evaluate for UTI. [10, 11] Guidelines from the American Academy of Pediatrics recommend considering the diagnosis of UTI in patients aged 2 months to 2 years with unexplained fever. [12]
When UTI is diagnosed in a child, an attempt should be made to identify any risk factors for the UTI. These include recent broad-spectrum antibiotic therapy, an anatomic anomaly, voiding dysfunction, and constipation.
Children aged 0-2 months
Neonates and infants up to age 2 months who have pyelonephritis usually do not have symptoms localized to the urinary tract. UTI is discovered as part of an evaluation for neonatal sepsis.
Neonates with UTI may display the following symptoms:
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Jaundice
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Fever
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Poor feeding
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Vomiting
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Irritability
Infants and children aged 2 months to 2 years
Infants with UTI may display the following symptoms:
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Poor feeding
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Fever
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Vomiting
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Strong-smelling urine
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Abdominal pain
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Irritability
As with young infants, the majority of infants and young children in this age range who have pyelonephritis also lack symptoms localized to the urinary tract. However, some children aged 1-2 years may present with voiding symptoms suggestive of cystitis, with crying on urination or only a foul odor to the urine in the absence of clinically significant fever (temperature < 38°C).
Infants and young children of this age may also have only a history of unexplained fever (ie, rectal or tympanic membrane temperature of >38°C). Some infants with pyelonephritis in this age range have fever and few other symptoms, whereas others are acutely ill and have a history of irritability, decreased oral intake, abdominal pain, vomiting, and loose bowel movements. Patients in this age group are at higher risk for renal injury than are older children, possibly because the lack of localizing signs of infection delays the start of antibiotic therapy.
Children aged 2-6 years
Preschoolers with UTI can display the following symptoms:
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Vomiting
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Abdominal pain
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Fever
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Strong-smelling urine
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Enuresis
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Urinary symptoms (dysuria, urgency, frequency)
Children in this age group with febrile UTI (pyelonephritis) usually have systemic symptoms with loss of appetite, irritability, and abdominal, flank, or back pain. Voiding symptoms may be present or absent.
Children with acute cystitis have voiding symptoms with little or no temperature elevation. Voiding dysfunction may include urgency, frequency, hesitancy, dysuria, or urinary incontinence. Suprapubic or abdominal pain may be present, and the urine sometimes has a strong or foul odor.
Children older than 6 years and adolescents
School-aged children with UTI can display the following symptoms:
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Fever
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Vomiting, abdominal pain
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Flank/back pain
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Strong-smelling urine
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Urinary symptoms (dysuria, urgency, frequency)
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Enuresis
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Incontinence
Adolescents are more likely to present with typical urinary symptoms (eg, dysuria, urgency, frequency). Adolescent girls with vaginitis or a sexually transmitted infection (STI) may present with similar symptoms. In addition, adolescent girls who are diagnosed with cystitis may have a concurrent vaginitis or STI. [13]
UTI among children in this age range usually affects the lower tract, but pyelonephritis also occurs. Symptoms are similar to those in children aged 2-6 years.
Girls who have pyelonephritis in infancy or early childhood, including those with persistence of vesicoureteral reflux (VUR), usually have cystitis with UTI when they are older. They are also prone to have a recurrence during pregnancy.
Physical Examination
Infants and younger children with pyelonephritis usually have no localizing findings, but they are febrile and often irritable. Older children with pyelonephritis often have tenderness of the flank or costovertebral angle, and those with cystitis may have suprapubic tenderness. Hypertension should raise suspicion of hydronephrosis or renal parenchyma disease.
Physical examination findings in pediatric patients with UTI can be summarized as follows:
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Costovertebral angle tenderness
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Abdominal tenderness to palpation
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Suprapubic tenderness to palpation
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Palpable bladder
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Dribbling, poor stream, or straining to void
Examine the external genitalia for signs of irritation, pinworms, vaginitis, trauma, or sexual abuse.
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Application of low-risk criteria for and approach to the febrile infant: A reasonable approach for treating febrile infants younger than 2 months who have a temperature of greater than 38°C.
Tables
- Table 1. Urinalysis for Presumptive Diagnosis of Urinary Tract Infection*
- Table 2. Quantitative Urine Culture for the Diagnosis of Urinary Tract Infection*
- Table 3. Antibiotic Agents for Parenteral Treatment of a Urinary Tract Infection
- Table 4. Antibiotic Agents for the Oral Treatment of Urinary Tract Infection
- Table 5. Antibiotic Agents to Prevent Reinfection
Method |
Findings |
Bright-field or phase-contrast microscopy of centrifuged urinary sediment |
Bacteria |
Gram stain of uncentrifuged or centrifuged urinary sediment |
Bacteria |
Nitrite and leukocyte esterase test |
Positive = UTI likely |
Nitrite test |
Positive = UTI probable |
Leukocyte esterase test |
Positive = UTI probable |
*Negative microscopic findings for bacteria do not rule out a UTI, nor do negative results of dipstick testing for nitrite and leukocyte esterase. False-negative nitrite readings are especially common in children. |
|
Method |
Finding |
Suprapubic aspiration |
If a UTI is present, bacteria are likely to be proliferating in bladder urine with growth of any organism except 2000-3000 CFU/mL coagulase-negative staphylococci. |
Catheterization in a girl or midstream, clean-void collection in a circumcised boy |
Febrile infants and children with UTI usually have >50,000 CFU/mL of a single urinary pathogen; however, UTI may be present with 10,000-50,000 CFU/mL of a single organism.* |
Midstream, clean-void collection in a girl or uncircumcised boy |
UTI is indicated when >100,000 CFU/mL of a single urinary pathogen is present in a symptomatic patient. Pyuria usually present. A UTI may be present with 10,000-50,000 CFU/mL of a single bacterium.* |
Any method in a girl or boy |
If the patient is asymptomatic, bacterial growth is usually >100,000 CFU/mL of the same organism on different days. If pyuria is absent, this result probably indicates colonization rather than infection. |
*Patients with urinary frequency (ie, decreased bladder incubation time) are those most likely to have bacteria proliferating in the urinary bladder in the presence of low colony counts. |
|
Drug |
Dosage and Route |
Comment |
Ceftriaxone |
50-75 mg/kg/day IV/IM as a single dose or divided q12h |
Do not use in infants < 6 wk of age; parenteral antibiotic with long half-life; may displace bilirubin from albumin |
Cefotaxime |
150 mg/kg/day IV/IM divided q6-8h |
Safe to use in infants < 6 wk of age; used with ampicillin in infants aged 2-8 wk |
| Ceftolozane/tazobactam | 30 mg/kg IV q8h x7-14 days | Indicated for complicated UTIs approved in children from birth and older; CrCl must be above 50 mL/min/1.73 m2 |
Ampicillin |
100 mg/kg/day IV/IM divided q8h |
Used with gentamicin in neonates < 2 wk of age; for enterococci and patients allergic to cephalosporins |
Gentamicin |
Term neonates < 7 days: 3.5-5 mg/kg/dose IV q24h Infants and children < 5 years: 2.5 mg/kg/dose IV q8h or single daily dosing with normal renal function of 5-7.5 mg/kg/dose IV q24h Children ≥5 y: 2-2.5 mg/kg/dose IV q8h or single daily dosing with normal renal function of 5-7.5 mg/kg/dose IV q24h |
Monitor blood levels and kidney function if therapy extends >48 h |
Note: CrCl = creatinine clearance; IM = intramuscular; IV = intravenous; q = every; UTI = urinary tract infection. |
||
Protocol |
Daily Dosage |
Sulfamethoxazole and trimethoprim (SMZ-TMP) |
30-60 mg/kg SMZ, 6-12 mg/kg TMP divided q12h |
Amoxicillin and clavulanic acid |
20-40 mg/kg divided q8h |
Cephalexin |
50-100 mg/kg divided q6h |
Cefixime |
8 mg/kg q24h |
Cefpodoxime |
10 mg/kg divided q12h |
Nitrofurantoin* |
5-7 mg/kg divided q6h |
*Nitrofurantoin may be used to treat cystitis. It is not suitable for the treatment of pyelonephritis, because of its limited tissue penetration. |
|
Agent |
Single Daily Dose |
Nitrofurantoin * |
1-2 mg/kg PO |
Sulfamethoxazole and trimethoprim (SMZ-TMP) * |
5-10 mg/kg SMZ, 1-2 mg/kg TMP PO |
Trimethoprim |
1-2 mg/kg PO |
*Do not use nitrofurantoin or sulfa drugs in infants younger than 6 weeks. Reduced doses of an oral first-generation cephalosporin, such as cephalexin at 10 mg/kg, may be used until the child reaches age 6 weeks. Ampicillin or amoxicillin are not recommended because of the high incidence of resistant E coli. |
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