Pediatric Urinary Tract Infection Treatment & Management

Prehospital care is rarely a concern in patients with urinary tract infection (UTI). However, patients who are uroseptic and in shock may present via emergency medical services (EMS), in which case, standard supportive measures for septic patients should be followed.

Patients with a nontoxic appearance may be treated with oral fluids and antibiotics. Toxic-appearing patients must be aggressively treated with intravenous (IV) fluids and parenteral antibiotics.

Most cases of uncomplicated UTI respond readily to outpatient antibiotic treatments without further sequelae. Antibiotic resistance among uropathogens is increasing dramatically, however. Previous antibiotic exposure (ie, for otitis media) has been found to be associated with drug-resistant UTIs and should be kept in mind when choosing empiric therapy. ^[44]

The choice of outpatient versus inpatient care can often be guided by practical considerations. Outpatient care is reasonable if the following criteria are met:

• A caregiver with appropriate observational and coping skills

• Telephone and automobile at home

• The ability to return within 24 hours

• The patient has no need for oxygen therapy, IV fluids, or other inpatient measures

A Cochrane review concluded that children with acute pyelonephritis can be treated effectively with either oral antibiotics or with 2-4 days of IV therapy followed by oral therapy. ^[45] Similarly, a study by Hoberman et al indicated that oral therapy with a third-generation cephalosporin was as effective as traditional inpatient parenteral treatment. ^[46]

For parenteral therapy in a patient who is not allergic to cephalosporins, initial treatment may consist of a single dose of ceftriaxone (75 mg/kg IV/IM q12-24h). If the patient has cephalosporin allergy, initial treatment may be with gentamicin (2.5 mg/kg IV/IM as a single dose). Patients who demonstrate a satisfactory response can be switched to an oral antibacterial agent at therapeutic doses within the next 12-18 hours.

Arrange for a follow-up (which is usually performed by telephone) at 24 hours to monitor the patient's response to treatment and at 48 hours to modify treatment if 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.

Appropriate treatment, imaging to identify correctable anatomic abnormalities, and follow-up can help prevent long-term sequelae in patients with more severe cases or chronic, recurrent infections. ^[1] 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.

The American Academy of Pediatrics (AAP) recommends that all infants and young children (aged 2 mo to 2 y) with a first UTI undergo urinary tract ultrasonography; depending on the result, this may be followed by voiding cystourethrography (VCUG). ^[1] These studies should be performed promptly if patients fail to show expected clinical response within 2 days of treatment.

VCUG may detect vesicoureteric reflux (VUR). Low-grade VUR (grade 1-2) usually resolves without permanent damage, but high-grade (grade 4-5) VUR may require surgical correction.

Go to the following Medscape Reference articles for further information on these topics:

• Urinary Tract Infection in Males

• Cystitis in Females

• Pediatric Urinary Tract Infection Empiric Therapy

• Pediatric Urinary Tract Infection Organism-Specific Therapy

Hospitalization is necessary for the following patients with 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 2 months with febrile UTI (presumed pyelonephritis)

• All infants younger than 1 month with suspected UTI, even if not febrile

Treat febrile UTI as pyelonephritis, and consider parenteral antibiotics and hospital admission for these patients.

The diagnosis in infants younger than age 8 weeks with a febrile UTI is usually based on fever and on positive results from a urine specimen obtained by catheterization. In this age 10,000 colonies/mm3 defines bacteriuria. Infants with such findings are usually hospitalized and receive parenteral antibiotic therapy (see Table 3, below). However, clinical judgment may indicate that home treatment is appropriate. Parenteral antibiotics may be used with daily follow-up until the patient is afebrile for 24 hours. Complete 10-14 days of therapy with an oral antibiotic that is active against the infecting bacteria.

Table 3. Antibiotic Agents for Parenteral Treatment of a Urinary Tract Infection (Open Table in a new window)

A retrospective review of more than 1500 babies aged 29-60 days with fever and culture-proven UTIs found that infants without a high-risk medical history who were not clinically ill on presentation to an emergency department (ED) and had low-risk laboratory values were at low risk overall for bacteremia and serious adverse events, such as meningitis or the need for intensive care unit (ICU) support. ^[47] Infants in this age group who meet this criteria can be considered for briefer hospitalization and close outpatient management. If the medical history raises concern, however, these infants should be treated as younger infants are (ie, those aged 0-28 days). ^[47]

If clinical findings indicate that immediate antibiotic therapy is indicated, a urine specimen for urinalysis and culture should be obtained before treatment is started. Specimens may be collected by means of suprapubic aspiration or catheterization.

A study by Shaikh et al analyzed data for 482 children (age, 2 - 72 months) with a first or second UTI to determine whether delay in the initiation of antimicrobial therapy for febrile UTIs is associated with the occurrence and severity of renal scarring. The study found that a total of 35 children (7.2%) developed new renal scarring and that this renal scarring was significantly associated with a delay in the initiation of antimicrobial therapy. ^{[48, 49]}

According to AAP guidelines for the treatment of initial UTIs in febrile infants and children aged 2-24 months old, antibiotics can be given orally or parenterally, with the choice of route based on practical considerations. ^[1] Oral antibiotics should not be used in a child who is acutely ill or toxic, has persistent vomiting, or has moderate to severe dehydration. Daily follow-up and good compliance are essential with this approach.

The AAP recommends basing the choice of antibiotic on local sensitivity patterns, if known. The choice can be adjusted, if necessary, when results of sensitivity testing become available. Antibiotics can be given for 7 or 14 days. ^[1]

Common choices for empiric oral treatment are a second- or third-generation cephalosporin, amoxicillin/clavulanate, or sulfamethoxazole-trimethoprim (SMZ-TMP). (See Table 4, below). A Canadian retrospective chart review of 173 pediatric patients diagnosed with a clinical UTI found that if the urinalysis is positive for nitrites, 1.4% of pathogens were resistant to third-generation cephalosporin, and 8.4% were resistant to first-generation cephalosporins. ^[50]

Table 4. Antibiotic Agents for the Oral Treatment of Urinary Tract Infection (Open Table in a new window)

The AAP guidelines for the followup of these patients can be summarized as follows ^[1] :

• After 7 days of antimicrobial therapy, close clinical follow-up monitoring is required to help ensure that recurrent infections can be promptly diagnosed and treated

• Ultrasonograms of the kidneys and bladder should be obtained in order to detect anatomic abnormalities

• The routine use of VCUG after the first UTI is not recommended, since data do not support the use of antimicrobial prophylaxis to prevent recurrent febrile UTI in infants unless they have VUR above grade 4,

• VCUG is indicated if ultrasonograms of the kidney and bladder reveal hydronephrosis, scarring, or other signs that high-grade VUR or obstructive uropathy may be present

• VCUG should be performed if febrile UTI recurs, even if previous ultrasonographic findings were unremarkable

Pyelonephritis is considered complicated when it occurs in a neonate or an infant, in a patient with an anatomic abnormality of the urinary tract or abnormal renal function, or in a patient who is immunocompromised.

Provide appropriate IV fluids, usually at 1-1.5 times the usual maintenance rate. Parenteral treatment with a third-generation cephalosporin (eg, ceftriaxone, cefotaxime) is appropriate initial empiric coverage for a complicated UTI and pyelonephritis to cover for ampicillin-resistant, gram-negative pathogens (see Table 3). Add ampicillin if gram-positive cocci are present in the urinary sediment or if no organisms are observed.

Gentamicin is an alternative empiric choice and may be considered in patients with cephalosporin allergy. Monitor renal function and blood aminoglycoside levels if this medication is required for more than 48 hours.

Results of urine culture and sensitivity studies are usually available within 48 hours. If the pathogen is sensitive to the antibiotic used and the child is improving, continue treatment via the parenteral route until the child has been afebrile for 24-36 hours, has improved clinically, and is able to retain oral medications. An oral antibiotic that is effective against the infecting organism may then be substituted for parenteral therapy (see Table 4).

The hospitalized patient is usually ready to go home after 48-72 hours. Continue therapeutic doses of antibiotics for a total of 10-14 days of antibiotic therapy. Antibiotic prophylaxis can be considered (see Table 5); if chosen, it should continue until a VCUG is obtained, if one is to be performed.

Children with cystitis usually do not require special medical care other than appropriate antibiotic therapy and symptomatic treatment if voiding symptoms are marked. Antibiotic therapy is started on the basis of the practitioner's appraisal of the patient's clinical history and urinalysis results before the diagnosis is documented.

A 4-day course of an oral antibiotic agent is recommended for the treatment of cystitis (see Table 4). A systematic review of treatments for cystitis in children showed no difference in efficacy with 7-14 days of therapy compared with 2-4 days. ^[24] Single-dose or single-day therapy is not recommended in children with cystitis. If the clinical response is not satisfactory after 2-3 days, alter therapy on the basis of antibiotic susceptibility.

Symptomatic relief for dysuria is accomplished by increasing fluid intake to enhance urine dilution and output and with the use of acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs). If voiding symptoms are severe and persistent, add phenazopyridine hydrochloride (Pyridium). Do not administer phenazopyridine for longer than 48 hours, because of the risk of methemoglobinemia, hemolytic anemia, and other adverse reactions. Sitting in a tub of warm water for 20-30 minutes 3-4 times daily also often affords symptomatic relief.

Antibiotic prophylaxis

Many studies have failed to show reductions in the incidence of recurrent UTIs with the use of antibiotic prophylaxis. Several of those studies, however, did not have sufficient statistical power to detect differences or did not have stringent definitions of UTI and inclusion criteria. ^{[51, 52, 53, 54, 55]}

A study that evaluated 12 months of prophylaxis with sulfamethoxazole-trimethoprim (SMZ-TMP) compared with placebo to prevent UTI showed a small, but statistically significant, reduction in incidence but did not show any difference in renal scarring. In addition, a significant increase in UTI with SMZ-TMP ̶ resistant organisms occurred in the treatment group. ^[56]  A meta-analysis that reviewed seven randomized controlled trials that included 1427 febrile UTI patients also found no effect of antibiotic prophylaxis in preventing renal scarring. ^[57]

A meta-analysis of a selected subset of high-quality, randomized, controlled trials concluded that long-term antibiotics reduce the risk of more symptomatic infections. The benefit is small, however, and must be weighed against the likelihood that future infections may be with bacteria that are resistant to the antibiotic administered. ^[58]

A study by Selekman et al reported that patients with a history of vesicoureteral reflux being treated with continuous antibiotic prophylaxis were more likely to have a multidrug-resistant urinary tract infection (33% in the antibiotic prophylaxis group vs 6% in the placebo or no treatment group). ^[59]

Until evidence-based guidelines about the use of suppressive antibacterial therapy after an initial febrile UTI are available, use of antibiotic prophylaxis is based on expert opinion. Antibiotic prophylaxis is more often recommended for children with high-grade reflux (grade 3-5). The current AAP guidelines do not recommend prophylactic antibiotics to prevent UTI recurrences (see table 5, below). ^[1]

Table 5. Antibiotic Agents to Prevent Reinfection (Open Table in a new window)

Parents of children with a history of UTI should also be advised to 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.

Circumcision

Consider circumcision of male neonates. The AAP policy statement on circumcision is that “the health benefits of newborn male circumcision outweigh the risks and that the procedure's benefits justify access to this procedure for families who choose it.” ^[60] The AAP notes that the benefits of the procedure include prevention of UTIs. ^[60]

Cranberry products

A study by Ferrara et al investigating the effect of daily cranberry juice (50 mL) in girls aged 3-14 years with recurrent UTIs found that consumption of concentrated cranberry juice on a daily basis appeared to prevent symptomatic UTI recurrence in children. ^[61] In this study, the use of a drink containing Lactobacillus strain GG did not prevent UTI.

A systematic review of studies of cranberry products used for the prevention of UTIs showed a small, possible benefit for women with recurrent UTI, but the evidence was not statistically significant. Also, in contrast to the Ferrara study, the review did not find that cranberry products significantly reduced UTI recurrence in children. ^[62]

Consultation with a urologist is not typically required at presentation in pediatric patients with an initial febrile UTI, unless obstruction of the urinary tract is evident. However, patients with VUR of grade 4 or worse should be referred to a pediatric nephrologist or urologist. Consultation with an infectious disease specialist may be useful if there is reason to suspect infection with an unusual organism or one that is antibiotic resistant.