Clinical Overview

Urinary Tract Infection in Children

Elsevier Point of Care (

)Actualizado November 22, 2022. Copyright Elsevier BV. All rights reserved.

Synopsis
Urgent Action

 Urinary tract infection in infants and children must be identified and treated
promptly to minimize risk of renal abscess, sepsis, and renal parenchymal
damage
 Febrile children aged 72 hours to 60 days of life require evaluation for urinary
tract infection, even if another fever source is apparent upon examination (eg,
respiratory syncytial virus–positive bronchiolitis) (Related: Sepsis in Neonates)

In children who appear very ill and require immediate antibiotics, obtain urine specimen
before starting antibiotics (for culture and studies) when possible

Key Points

 Urinary tract infection in younger children may present with fever alone;
however, it may present with nonspecific signs including poor feeding,
vomiting, and/or fussiness in the absence of fever
 Older children present with symptoms including urinary frequency, dysuria, and
abdominal pain
 Fever with infection in a child of any age prompts suspicion for pyelonephritis
 Children at highest risk are young females and uncircumcised males
 Risk factors include fever (higher than 39 °C and without another source on
physical examination), White race, constipation, earlier history of infection,
history of vesicoureteral reflux, or anatomical abnormality of urinary tract or
neurogenic bladder
 Adolescents who are sexually active or have sexually transmitted diseases have
higher associations with urinary tract infection
 Suprapubic tenderness is consistent with cystitis; fever, flank pain, and
costovertebral angle tenderness are consistent with pyelonephritis
 Obtain urine specimen for culture only by catheterization or suprapubic
aspiration in non–toilet-trained children (usually aged 24 months or younger);
clean-catch urine is acceptable for toilet-trained children
 Third-generation cephalosporin is a good choice for empiric antibiotic, when
indicated, depending on patient-specific factors and local
sensitivities. Escherichia coli is the most frequent pathogen
 To establish definitive diagnosis in symptomatic young children, urine needs to
show evidence suggesting infection (ie, pyuria and/or bacteriuria) and positive
urine culture result
  Commonly reported urine culture results diagnostic in children are as follows:
growth of single organism to more than 100,000 CFU/mL on clean-catch
specimen, to more than 50,000 CFU/mL on catheter specimen, and any growth
on suprapubic specimen

Oral antibiotics are as effective as parenteral antibiotics for treatment of cystitis or

pyelonephritis in children; parenteral antibiotics are indicated for very ill children,
patients younger than 2 to 3 months, and patients unable to tolerate oral intake

 Children with initial diagnosis of uncomplicated infection should clinically

respond to antibiotics within 24 to 48 hours with improved symptoms and
defervescence
o Failure to respond within 48 hours indicates a complicated course (ie,
presence of renal abscess, obstructive uropathy, vesicoureteral reflux,
alternate diagnosis) or pathogen not covered by empiric antibiotic
o Further work-up, ultrasonography, and broadening of antibiotic coverage
are indicated
 Guidelines differ regarding optimal follow-up study to evaluate for signs of
vesicoureteral reflux or any other abnormalities that place the child at increased
risk for future infection
o American Academy Pediatrics recommends renal and bladder
ultrasonography as initial study of choice in children younger than 2
years after first febrile infection and in all children with recurrent
infection
 Most children have no long-term sequelae; chronic renal insufficiency requiring
transplant is extremely rare

Pitfalls

 Urinary tract infection frequently presents with fever and no other symptoms;
obtain urine studies in any febrile child at high risk for infection
 Presence of alternate source of fever on examination does not exclude possibility
of infection; urinary tract infection is a lower risk but can occur concurrently

 Many guidelines exist to aid in diagnosis, treatment, and follow-up diagnostic

studies; however, not all aspects addressed in guidelines are in complete agreement

 Common areas of controversy and divergent recommendations include duration

of treatment and preferred follow-up diagnostic evaluation following first febrile
urinary tract infection

 Bag urine specimens should only be used for screening urinalysis to help classify
children at lower risk for urinary tract infection when results are negative

 Negative urinalysis on bag specimen does not completely exclude possibility of

infection
 Bag urine specimens should not be used for culture owing to unacceptably high
false-positive rates
 Do not treat child with empiric antibiotics for a urinary tract infection without a
urine culture
 Most guidelines stress importance of obtaining accurate result to ensure adequate
antibiotic therapy based on culture susceptibility results

  Will help avoid unnecessary referrals, radiographic evaluation, and prolonged

antibiotic use

 Reporting of urine microscopy can be confusing; 2 standard methods of analysis are

commonly used:

 Standard microscopy: spun (centrifuged) urine sample is examined for WBC

and bacteria. Pyuria is defined as 5 or more WBC/high power field, and
bacteriuria is defined as any bacteria/high power field
 Enhanced microscopy: unspun (noncentrifuged) urine sample is run through
hemocytometer and Gram stain process. Pyuria is defined as 10 or more
WBC/mm³, and bacteriuria is defined as any bacteria/10 oil immersion fields

 Reduce risk of contamination of specimen by distal urethral bacterial flora with

meticulous technique during transurethral catheterization

 Discard first few milliliters of urine obtained by catheter

 Use a new sterile catheter with each subsequent attempt after unsuccessful
attempts (leave initial catheter in place to mark incorrect placement path)

 Definitive diagnosis in a child younger than 24 months requires both a positive

culture result on an appropriately collected specimen and a positive urinalysis result
(pyuria and/or bacteriuria) in a symptomatic patient


o Positive urine culture in a patient with negative urinalysis and absence of
symptoms is highly suggestive of asymptomatic bacteriuria, a condition
that does not require treatment (except during pregnancy)
 Maintain awareness that bowel (eg, constipation) and bladder dysfunction are
significant contributors to development of urinary tract infection in children
o Evaluate all toilet-trained children with history and physical examination
for possibility of bowel and bladder dysfunction; address bowel
dysfunction, bladder dysfunction, or both when identified

Terminology
Clinical Clarification

 Urinary tract infection in children is symptomatic, uropathogen-caused

inflammation of the lower urinary tract (cystitis) or upper urinary tract
(pyelonephritis)
Diagnosis of bacterial urinary tract infection in young children requires both urinalysis
results that suggest infection (pyuria, bacteriuria, or both) and growth of a uropathogen
on an appropriately collected urine specimen
 Asymptomatic bacteriuria is colonization of bacteria without evidence of
inflammation (no pyuria) and is not considered a urinary tract infection
 Sterile pyuria (pyuria without bacteriuria) is nonspecific and may occur with
numerous other conditions (eg, Kawasaki, chemical urethritis) in absence of infection of
the urinary tract; therefore, pyuria alone is insufficient to establish diagnosis of urinary
tract infection

Classification

 Urinary tract infections are classified according to location, severity, episode,

symptoms, and complicating factors

Location
 Lower urinary tract infection, also known as bladder infection or cystitis

 Infection limited to the bladder

Usually presents with urinary symptoms (eg, frequency, dysuria, urgency, suprapubic
discomfort) and absence of fever Upper urinary tract infection, also known as kidney
infection or pyelonephritis

 Typically begins as a lower urinary tract infection, then ascends to the kidney
 Infection involving the renal parenchyma is characterized by systemic symptoms
(eg, fever, malaise, vomiting), abdominal pain and/or flank pain, costovertebral
angle tenderness

 
o Associated with higher risk for short-term complications (eg, renal
abscess) and long-term complications (eg, renal parenchymal scarring,
hypertension)

 Severity

  Mild when children are experiencing

o Mild symptoms and able to tolerate fluids and oral medication
o Often due to a lower urinary tract infection
 Severe
o Associated with symptoms such as persistent vomiting, dehydration, or
fever (higher than 39 °C)

 Episode

  First urinary tract infection

o May be a sign of anatomical abnormalities, therefore anatomical
evaluation is recommended
 Recurrent urinary tract infection
 o Can be subdivided into unresolved infection, persistent infection and
reinfection
o Unresolved infection: the initial therapy is inadequate for elimination of
bacterial growth in the urinary tract
o Persistent infection: reemergence of bacteria that has not been eradicated
from a site within the urinary tract; same pathogen is identified
o Reinfection: episode may be caused by a new organism in contrast to
persistent urinary tract infection
o Breakthrough urinary tract infection: an infection occurring in patients
receiving antimicrobial prophylaxis

 Symptoms

  Asymptomatic bacteriuria
o Represents colonization of the bladder by nonvirulent bacteria that do
not activate a symptomatic response, or attenuation of uropathogenic
bacteria by the host
 Symptomatic urinary tract infection
o Associated with irritative voiding symptoms, suprapubic pain, fever, and
malaise

 Complicating factors

 Uncomplicated

  Infection in a patient with normal upper and lower urinary tract, renal
function within reference range, and competent immune system
 Usually associated with a narrow spectrum of infecting pathogens that are easily
eradicated by outpatient course of antibiotics

 Complicated


o
 Infections associated with known mechanical or functional
pathology of the urinary tract
 Common causes of mechanical obstruction include
posterior urethral valves, strictures, and stones
 Common causes of functional obstruction include lower
urinary tract dysfunction of either neurogenic or non-
neurogenic origin and dilating vesicoureteral reflux
 Infections often require hospitalization for parenteral antibiotic
administration

Diagnosis
Clinical Presentation

History
  Symptoms in non–toilet-trained children (generally younger than 2 years)

 Usually present with fever and/or nonspecific symptoms

 Fever

 May not be present early in course of disease

 Fever (38 °C or higher) lasting longer than 2 days without a known source for
fever on physical examination increases likelihood of urinary tract infection

 Prevalence of disease in infants with a suspected cause of fever (38.3 °C or higher)

on examination is about 3% Prevalence of disease in infants without a suspected cause
of fever is about 6% to 8% Fever (39 °C or higher) of any duration increases likelihood
of urinary tract infection
 Nonspecific symptoms

 Poor feeding
 Decreased urine output
 Increased sleep/lethargy
 Fussiness
 Vomiting, diarrhea, and abdominal pain

 Possible urinary symptoms

 Hematuria
 Malodorous urine Symptoms in older, verbal children
 Urinary symptoms (typically present)

 
o Dysuria
o Frequency
o Urgency
o New-onset incontinence (often nocturnal)
o Nocturia
o Hematuria
 Abdominal pain (sometimes present)
o Suprapubic abdominal pain or flank/back pain
 Fever (sometimes present)
 Adolescents may have vaginal discharge if urinary tract infection is associated
with unrecognized sexually transmitted disease

 Fever (higher than 39.5 °C) in any age group is the best clinical predictor of renal
parenchymal involvement
 In general, older children with cystitis present with suprapubic pain, voiding
discomfort, and absence of fever Fever (especially if high or associated with flank pain
and/or vomiting) suggests pyelonephritis Other

 Child may have previous history of urinary tract infection

 Symptoms of bowel dysfunction may be associated, including:

  Constipation
 Encopresis
  Withholding behaviors

 Symptoms of bladder dysfunction may be associated, including:


o
 Incontinence, particularly daytime wetting
 Ineffective emptying of the bladder, which can cause urinary
frequency, urgency, and dribbling
 Prolonged voiding intervals
 Perineal or penile pain
 Voiding difficulties
o Sexual activity is a risk factor for adolescents
o Recent antibiotic use raises suspicion for possible associated resistant
bacterial pathogen
o Patients with spinal cord anomaly, diabetes, or immunosuppression are at
increased risk

Physical examination

 Vital signs
o Fever
 May or may not be present early in course of disease
 Should raise concern for pyelonephritis
 Inflammation or infection of the kidneys is present in
approximately 60% of children with febrile urinary tract
infection

  Blood pressure
o Elevated blood pressure relative to age raises concern for chronic renal
disease or renal parenchymal scarring
 Growth parameters
o Signs of failure to thrive in infants or younger children are concerning
for chronic or recurrent urinary tract infections

 Abdomen

 Suprapubic tenderness
 Costovertebral angle tenderness
 Suprapubic mass (distended bladder)
 Mobile hard abdominal mass (palpable hard stool)

 Genitalia

 Uncircumcised males younger than 1 year (especially younger than 3 months)

are at higher risk than those who are circumcised

  Vaginal discharge associated with a sexually transmitted disease will increase

likelihood of urinary tract infection in females
 Neonates may present with jaundice (unconjugated/indirect or conjugated/direct
hyperbilirubinemia)
 Direct hyperbilirubinemia is more likely if onset of jaundice occurs in association
with urinary tract infection presenting after 8 days of life 7.5% of neonates with
jaundice who are otherwise asymptomatic have a urinary tract infection Presence of
alternative source of fever upon examination suggests that urinary tract infection is less
likely, but it does not completely exclude the possibility of urinary tract infection; such
alternative sources can include:


o Gastroenteritis
o Bronchiolitis
o Upper respiratory tract infection
o Croup
o Viral stomatitis
o Otitis media
o Meningitis

Causes and Risk Factors

Causes

 Bacteria

 Escherichia coli is most common uropathogen

 Responsible for about 50% to 80% of pediatric cases

Non–Escherichia coli uropathogens

 Common gram-negative organisms include:

  Proteus species
 Klebsiella species
 Pseudomonas species
 Enterobacter species
 Citrobacter species

 Common gram-positive organisms include:

 Group B streptococcus (in neonates)

 Enterococcus species
 Staphylococcus saprophyticus
o Most common gram-positive pathogen in an adolescent female
 Staphylococcus aureus (less frequent)

 Non–Escherichia coli pathogens are notable for causing

  Less vigorous inflammatory response (less severe pyuria) than Escherichia

coli
  More likely to result in renal scarring than Escherichia coli
 Lower colony count than standard defined thresholds may represent infection
caused by non–Escherichia coli species

 Infants with vesicoureteral reflux are more likely to present with urinary tract
infection from non–Escherichia coli pathogens Common bacterial contaminants of
urine specimen (ie, skin flora organisms not considered pathogens) in otherwise healthy
children

  Lactobacillus species
 Corynebacterium species
 Coagulase-negative staphylococci
 α-Hemolytic streptococci
 Micrococcus species

 Fungi

 In general, fungi are uncommon causes of treatable infection. They are present
as potential pathogens in children with significant comorbid medical problems,
including:

 
oPrematurity
oDiabetes
oImmunocompromised state
oBladder catheters
oLong-term antibiotic use
 Many types of fungi asymptomatically colonize and do not create infection (eg,
Candida species)

 Viruses

 Uncommonly cause cystitis in children and include:


o
 Adenovirus
 Coxsackievirus
 Echovirus
 Enterovirus

Risk factors and/or associations

Highest-risk populations

 In general include the following:

  Neonates
 Young infants
 Female toddlers
  Uncircumcised males younger than 1 year
 Children with structural and functional urinary tract abnormalities

 Uncircumcised males aged from birth to 3 months with fever (higher than 38 °C)
have a reported rate of urinary tract infection of approximately 21% White females
younger than 2 years with fever (39 °C or higher) without another source of infection
have a reported urinary tract infection rate of up to 16%

Age

 Overall, 75% of urinary tract infections occur in first 2 years of life

 Peak incidence is in first year of life and between second and fourth years
 Infrequent occurrence after age 6 years unless associated with dysfunctional
elimination
 Up to 3% of males and 10% of females will have at least 1 urinary tract infection
before age 16 years Higher prevalence in the following populations:

 Females younger than 4 years

Male infants (aged 1 year or younger)

 Uncircumcised males have a much greater risk of urinary tract infection compared
with circumcised males (increase has been reported as 4-fold to 20-fold) Sexually active
adolescent females

Sex

 Females older than 3 months have 2- to 4-fold higher prevalence than males

Neonatal males have higher prevalence than neonatal females

Genetics

 Family history may be positive for pyelonephritis

No increased risk of cystitis noted with positive family history

Ethnicity/race

 In the United States

o White children are most commonly affected, followed by Hispanic
children; Black children are the least affected

Prevalence of urinary tract infections is 2 to 4 times higher in White and Hispanic

children than in Black children

Other risk factors/associations

 Vesicoureteral reflux

 Prevalence in neonates and infants younger than 4 months with urinary tract
infection is estimated at up to 43% Uncircumcised penis
  Increases risk (increase has been reported as 4-fold to 20-fold)

Prematurity

 Up to 20% prevalence in febrile infants with low birth weight and in premature
neonates

Maternal urinary tract infection during pregnancy

 Associated with 5 to 6 times higher risk of infection in neonates Obstructive
uropathies (abnormalities that result in obstruction of urine flow and urinary stasis):
 Anatomical

 Posterior urethral valves

 Ureteropelvic junction obstruction
 Urethral stricture
 Neonates with infection have the highest prevalence of renal structural
abnormalities

  Neurogenic
o Congenital and acquired abnormalities of spinal cord
 Neurogenic bladder
 Myelomeningocele
 Functional
o Bowel or bladder dysfunction (eg, constipation)

 Acquired risk factors

 Earlier history of urinary tract infection

o Younger age at first infection is associated with increased risk of
recurrence
 Risk of recurrence is highest in the first 6 months of life

 Nephrolithiasis
 Sexually transmitted disease
 Sexual activity in adolescents or childhood sexual abuse Spermicide use in sexually
active females
 Indwelling urinary catheters or intermittent bladder catheterization
 Immunosuppression
 Diabetes
 Invasive devices (eg, IVs, drains, catheters), previous broad-spectrum antibiotic
exposure, and systemic immunosuppression are associated with fungal urinary tract
infections
 Overweight or obesity Poor fluid intake Lower risk of urinary tract infection


o Circumcision
o Breastfeeding

Diagnostic Procedures
  History and physical examination in most cases suggest diagnosis

 Maintain a high index of suspicion for infection; delay in testing and subsequent
treatment in young children is associated with increased risk of complications
 Fever may be the only presenting symptom in young children, but it also may be
absent
 Algorithms outlining American Academy of Pediatrics approach to diagnosis and
management for febrile infants and young children is available Indications to test in
children are based on clinical judgment and assessment of individual risk factors

 American Academy of Pediatrics guidelines assist with decision making for

younger age groups

 Most infants younger than 60 days who have fever (higher than 38°C) require full
septic work-up including all of the following:

  Blood work
 Spinal fluid analysis
 Catheterized or suprapubic urine specimen for urinalysis, microscopic analysis,
and urine culture

 Children aged 2 to 24 months

 Risk factor assessment is required to determine likelihood of infection (ie, pretest
probability); if there is no apparent source of fever and child is not at low risk, obtain a
urine specimen for urinalysis, microscopic analysis, and culture

 Clinicians use judgment to set threshold for low risk; some use threshold of 1%
or less and others use 2% or less to determine which children require further
testing

Baseline risk is approximately 5% in a child with no apparent source of fever

discovered through history or physical examination
 Presence of known source of fever diminishes the risk by one-half Febrile females
have 2 times higher risk than males; uncircumcised males have much higher risk than
circumcised males Factors associated with increased risk are additive: each individual
risk factor further increases the probability of urinary tract infection and decreases test
threshold
 Females

  White race
 Younger than 12 months
 Fever (39 °C or higher)
 Fever lasting at least 2 days
 No other cause of infection identified

 Males

 
o Race other than Black
o Uncircumcised
 o Fever (39 °C or higher) lasting longer than 24 hours
o No other cause of infection identified

 UTICalc is a tool to help determine probability of urinary tract infection based on

clinical characteristics; it helps determine need for urine testing in children aged 2 to 23
months with fever
  Probability of urinary tract infection among febrile female infants.
Probability of urinary tract infection Number of risk factors present
1% or less No more than 1
2% or less No more than 2
Greater than 2% 3 or more

Título: Risk factors include White race, younger than 12 months, temperature 39 °C or
higher, fever lasting 2 days or more, and absence of another apparent source of
infection. Although some practitioners consider risk threshold of greater than 1%
sufficient to warrant testing for urinary tract infection in febrile infants, most consider
threshold of 2% or more sufficient risk to screen for urinary tract infection.

Citación: Data from American Academy of Pediatrics Subcommittee on Urinary Tract

Infection et al: Urinary tract infection: clinical practice guideline for the diagnosis and
management of the initial UTI in febrile infants and children 2 to 24 months. Pediatrics.
138(6):e20163026, 2016; and Millner R et al: Urinary tract infections. Pediatr Clin
North Am. 66(1):1-13, 2019.

  
o
 Probability of urinary tract infection among febrile male infants.

Probability of Number of risk factors Number of risk

urinary tract present: uncircumcised factors present:
infection male circumcised male
Probability exceeds 1%
even with no risk factors
1% or less No more than 2
other than being
uncircumcised
2% or less n/a No more than 3
Probability exceeds 2% in
uncircumcised male infants
Greater than 2% 4 or more
with fever of 39 °C or
higher

 Título: Risk factors include race other than Black, temperature 39

°C or higher, fever lasting longer than 24 hours, and absence of
another apparent source of infection. Although some practitioners
consider risk threshold of greater than 1% sufficient to warrant
testing for urinary tract infection in febrile infants, most consider
threshold of 2% or more sufficient risk to screen for urinary tract
infection.
  Citación: Data from American Academy of Pediatrics
Subcommittee on Urinary Tract Infection et al: Urinary tract
infection: clinical practice guideline for the diagnosis and
management of the initial UTI in febrile infants and children 2 to
24 months. Pediatrics. Pediatrics. 138(6):e20163026, 20161; and
Millner R et al: Urinary tract infections. Pediatr Clin North Am.
66(1):1-13, 2019.

 Screen for urinary tract infection in verbal children presenting with concerning
manifestations (eg, urinary symptoms, abdominal and flank pain with or without fever)
Screen for urinary tract infection in any child presenting with fever without a source and
with known urinary tract abnormality (eg, hydronephrosis, vesicoureteral reflux,
dysplastic kidney, neurogenic bladder, voiding dysfunction) or cognitive disability
Screen for urinary tract infection in any child ill enough to require immediate treatment
with empiric antibiotics Presumptive diagnosis is individualized and based on
probability of urinary tract infection determined by suggestive symptoms, suggestive
findings on urinalysis, and demographic factors
 Screening urinalysis (urine dipstick and microscopy) helps identify children who
require empiric treatment pending result of urine culture

 Infection is unlikely in patients with urinalysis results completely within

reference range

Culture-proven urinary tract infection is noted in about 4% to 8% of children presenting

with abdominal pain or urinary symptoms with both negative nitrite and leukocyte
esterase Culture-proven infection is noted in about 90% of children presenting with
abdominal pain or urinary symptoms with both positive nitrite and leukocyte esterase
Evidence of bacteriuria (ie, nitrite-positive dipstick or significant bacteria on
microscopy) on an appropriately collected specimen is highly suggestive of infection
Evidence of pyuria (ie, positive leukocyte esterase or significant number of WBC on
microscopy)
 is suggestive of inflammation and possible urinary tract infection
 Urinary tract infection is unlikely if urine dipstick is negative for both leukocyte
esterase and nitrite
 Maintain low threshold for presumptive diagnosis in children at high risk for
complications such as renal scarring (eg, fever higher than 39 °C or fever lasting more
than 48 hours, presentation suggestive of pyelonephritis, ill appearance,
immunodeficiency, urologic abnormality)
 UTICalc is a tool that aids in estimating probability of urinary tract infection based
on clinical and laboratory characteristics Urine culture is the gold standard to confirm
diagnosis with appropriate supporting criteria
 Results are typically available 24 to 48 hours after initial evaluation Definitive
diagnosis is based on the following:

 In young children (non–toilet trained)

o Both urinalysis results suggestive of infection (pyuria and/or bacteriuria)
and presence of at least 50,000 CFU/mL of uropathogen cultured from a
specimen obtained through transurethral catheterization or any growth on
suprapubic aspiration
In older children (toilet trained)

 Symptoms of urinary tract infection and quantitative culture positive for a

uropathogen; urinalysis findings usually are consistent with inflammation (eg,
positive leukocyte esterase on urine dipstick, significant WBC on urine
microscopy)

Early ultrasonographic imaging

 Imaging is usually not necessary to diagnose a urinary tract infection in the acute
setting if there are no concerns for renal abscess or other complications

Early (within 24 hours) renal and bladder ultrasound is recommended for infants with
febrile urinary tract infection to exclude obstruction of the upper and lower urinary tract
and assess for complications; also indicated in children with atypical illness, including:
 Serious illness or septicemia Concern for urinary retention (eg, poor urine output,
abdominal mass) Raised creatinine level or significant electrolyte derangement
 Significant pain or hematuria
 No appropriate response to antibiotics within 48 hours or with growth of non–
Escherichia coli uropathogen Serum laboratory tests and blood cultures do not usually
help diagnose urinary tract infection but are indicated in children younger than 3 months
and in all cases requiring hospitalization. Tests include CBC with differential and levels
of electrolytes, BUN, creatinine, C-reactive protein, and procalcitonin
 Most biomarkers of inflammation (eg, WBC count, C-reactive protein level) have
not been shown to be reliably useful in differentiating pyelonephritis from cystitis in
children

 Elevated procalcitonin level more than 0.5 to 1 nanograms/mL may be

suggestive of renal parenchymal involvement

In general, obtaining blood cultures for healthy patients older than 2 months in the
setting of febrile urinary tract infection is not clinically useful

 
o Bacteremia is cleared by antibiotics regardless of route of administration,
and organism is invariably the same as what is obtained with urine
specimens

 Special populations with urinary tract infection or possible urinary tract infection
 Sexually active adolescents with possible cervicitis, vaginitis, urethritis, or
epididymitis on examination

 Test for sexually transmitted diseases (especially when patient presents with
sterile pyuria)

 Neonates (younger than 1 month) (Related: Sepsis in Neonates)

 These patients are at high risk for bacteremia (risk approximately 6%-36%)
and meningitis (1.5%) compared with other age groups Investigations for sepsis include
blood culture and spinal fluid culture Children with spina bifida and neurogenic bladder
(Related: Catheter-Associated Urinary Tract Infection)

 Stricter requirements for diagnosis are proposed because asymptomatic

colonization occurs in up to half of children who require clean intermittent
catheterization. Diagnostic criteria are variably reported in the literature

Some experts suggest diagnosis in patients with 2 or more symptoms of urinary tract
infection, inflammation in urinalysis (eg, greater than 10 WBC/high-powered field), and
greater than 100,000 CFU/mL of a single organism on catheter specimen Follow-up
imaging after confirmed urinary tract infection is not rigorously standardized
(guidelines lack consensus)
 Rationale is to identify patients with urinary tract abnormalities that render increased
risk for repeated infections
 Potential flaws in rationale include the notions that:

 
o Long-term sequelae from recurrent urinary tract infection appear to be
relatively rare
o Preventative treatment approaches are controversial (eg, long-term low-
dose antibiotics, surgical interventions to correct vesicoureteral reflux)

 Common modalities include:

 Renal and bladder ultrasonography

o Primarily done to assess for urinary tract structural abnormalities. Obtain
as follow-up study after treatment of urinary tract infection and acute
phase of infection has resolved (eg, at least 1-2 weeks)

Obtain follow-up bladder and renal ultrasonography after a first febrile urinary tract
infection in children younger than 24 months and after any recurrent urinary tract
infection (if not already done) Renal scan with radiolabeled succimer
(dimercaptosuccinic acid)

 Best test to identify renal parenchymal abnormalities

Consider when clinical concern exists for reduced renal function Consider, in addition
to ultrasonography, in the follow-up evaluation of children with complicated or
recurrent urinary tract infection Diffusion-weighted MRI

  Alternative to a dimercaptosuccinic acid scan which avoids radiation

exposure

 Voiding cystourethrography

 Test of choice to evaluate for vesicoureteral reflux

Invasive and involves radiation exposure therefore not recommended in the absence of
identified risk factors for vesicoureteric reflux Nuclear cystography
  Alternate test of choice to evaluate for vesicoureteral reflux; preferred by some
experts to evaluate such reflux in females
 Consider in addition to ultrasonography in the follow-up evaluation of children
with complicated or recurrent urinary tract infection

Additional guideline recommendations for diagnosis and follow-up imaging of pediatric

urinary tract infection are available

 National Institute for Health and Care Excellence guidelines (2022)

European Society for Paediatric Urology and European Association of Urology joint
guidelines (updated annually) Canadian 2014 guidelines (reaffirmed in 2020) American
Academy of Pediatrics 2011 guidelines (reaffirmed in 2016) Australasian guidelines
(updated in 2014) International Children's Continence Society 2012 recommendations


o Urinary tract infection guideline comparison.
European
American National
Association of
o Academy Institute for Canadian
Urology/Euro
of Health and Paediatric Society
pean Society
Pediatrics Care 2020
for Paediatric
2016 Institute
Urology 2016
Infants and children
Infants and
older than 2 months
children 2-
with acute urinary
24 months
Patients aged tract infection Children with
Guideline with initial
3 months to without known urinary tract
population febrile
16 years underlying urinary infection
urinary
tract pathology or
tract
risk factors for
infection
neurogenic bladder
Clean catch
Transureth midstream
ral void; collect Clean catch
catheteriza using midstream
tion or transurethral Transurethral void,
Urine
suprapubic catheterizatio catheterization in transurethral
collection
aspiration; n or non–toilet-trained catheterization
in non–
bag only suprapubic children and clean , or suprapubic
toilet-
as a aspiration catch midstream aspiration for
trained
method of when not void in toilet- diagnosis; bag
children
exclusion possible to trained children only as a
for collect urine method of
screening by exclusion
urinalysis noninvasive
methods
Significant 50,000 Not 100,000 CFU/mL Growth of
bacteriuria CFU/mL specifically or more from uropathogen
by culture defined midstream urine greater than or
 European
American National
Association of
o Academy Institute for Canadian
Urology/Euro
of Health and Paediatric Society
pean Society
Pediatrics Care 2020
for Paediatric
2016 Institute
Urology 2016
equal to 10⁴
with
symptoms and
10⁵ without
specimen, 50,000 symptoms
CFU/mL or more in from
colony a transurethral midstream
count catheterization clean catch,
(positive specimen, any growth of
urine growth in 1000-50,000
culture) a suprapubic CFU/mL from
aspiration transurethral
specimen# catheterization
, any growth
from
suprapubic
aspiration
Symptomatic
child aged 3
months or
Presumptiv Clinical signs
older: if
e along with
leukocyte
diagnostic positive
Not esterase or
criteria to dipstick and/or
specificall nitrite or Not specifically
guide microscopy
y both are addressed
initiation pending
addressed positive then
of empiric confirmatory
start empiric
antibiotic urine culture
treatment
treatment results
pending
urine culture
results†
Recommen Several Cystitis: first Best first option Patients
ded suggestion choice, may be oral younger than 2
empiric s offered trimethoprim cefixime or IV months: IV
antibiotic‡ including or gentamicin, ampicillin and
oral nitrofurantoi gentamicin with or aminoglycosid
amoxicilli n; second without ampicillin. e. Other
n choice, Other choices suggestions for
clavulanat amoxicillin include IV frequently
e, or cefalexin. cefotaxime, used IV
sulfonamid Pyelonephriti ceftriaxone, and antibiotics
es, s: first tobramycin; oral include
cefixime, choice, oral options include cefotaxime,
cefprozil, cefalexin, amoxicillin ceftriaxone,
 European
American National
Association of
o Academy Institute for Canadian
Urology/Euro
of Health and Paediatric Society
pean Society
Pediatrics Care 2020
for Paediatric
2016 Institute
Urology 2016
amoxicillin,
cephalexin
clavulanic
and
acid, and
parenteral
co- aminoglycosid
ceftriaxone
amoxiclav, es. Oral
,
IV co- antibiotics
cefotaxime clavulanate, sulfona
amoxiclav, include
, mides, cefprozil,
cefuroxime, cefixime,
gentamicin and cephalexin
ceftriaxone, cefuroxime,
,
gentamicin, sulfonamides,
tobramyci
amikacin§ amoxicillin,
n, and
clavulanic
piperacilli
acid, and
n
nitrofurantoin
Oral: febrile UTI in Parenteral:
nontoxic patients infants and
Parenteral:
older than 2-3 newborns
for patients Oral: unless
months with no younger than 2
who are vomiting,
known structural months. Other
ill- unable to
urologic considerations
appearing take oral
abnormality when include
or unable antibiotics,
good compliance is clinical
Route of to tolerate or severely
anticipated. suspicion for
antibiotic oral intake unwell, then
Consider urosepsis,
administrat or for use IV or
parenteral: infants severity of
ion whom intramuscula
younger than 2-3 illness, ability
there is r dosing.
months. Parenteral: to tolerate oral
concern Parenteral
patients requiring intake,
about for all infants
hospital admission noncompliance
complianc younger than
or for whom there , and
e. Oral: all 3 months
is concern about complicated
others
compliance with (febrile)
oral regimen infection
Definitive Urinalysis Diagnose Suggestive Positive
diagnostic results acute urinalysis and culture in an
requiremen suggestive pyelonephriti positive urine appropriately
ts of s in culture of a single collected
infection bacteriuric uropathogen from specimen in
(pyuria patients with appropriately patient with
and/or fever and/or collected specimen signs of UTI
bacteriuria loin in symptomatic (clinical signs,
) along pain/tendern infant or child positive
with at ess; diagnose (implied) dipstick and/or
least cystitis in positive
 European
American National
Association of
o Academy Institute for Canadian
Urology/Euro
of Health and Paediatric Society
pean Society
Pediatrics Care 2020
for Paediatric
2016 Institute
Urology 2016
50,000
CFU/mL bacteriuric
of a patients with
uropathoge symptoms
n from consistent
transurethr with lower
microscopy)
al catheter urinary tract
(implied)
or any infection
growth without
cultured fever/systemi
from the c signs and
suprapubic symptoms
aspiration
Upper UTI:
Uncomplicated
7-10 days; Infants and children
cystitis lasting
lower UTI: 3 with febrile UTI: 7-
3-4 days in
Treatment 7-14 days days 10 days. Older
patients older
duration total (children children without
than 3 months.
aged 3 fever and presumed
Febrile UTI 7-
months and cystitis: 2-4 days
14 days
older)
Follow-up All Younger Younger than 2 RBUS in all
studies children than 6 years: RBUS for all children with
aged 24 months: with first febrile first febrile
months or RBUS; UTI, VCUG if UTI. In all
older with VCUG and ultrasonogram is patients
first febrile DMSA for abnormal or with younger than 1
UTI: atypical/recu recurrent UTI, year with
RBUS. rrent UTI.* DMSA when febrile UTI, all
VCUG is Aged 6 diagnosis of UTI is female
indicated if months to 3 in doubt children with
ultrasonog years: RBUS febrile UTI,
ram is for and male
abnormal atypical/recu children with
and in rrent UTI, recurrent
other VCUG for febrile UTI:
atypical or atypical/recu either VCUG
complex rrent UTI or DMSA in
clinical AND bottom up or
circumstan specific top down
ces such as features||, approach¶
recurrent DMSA for
febrile UTI atypical/recu
rrent UTI.
 European
American National
Association of
o Academy Institute for Canadian
Urology/Euro
of Health and Paediatric Society
pean Society
Pediatrics Care 2020
for Paediatric
2016 Institute
Urology 2016
Older than 3
years: RBUS
for
atypical/recu
rrent UTI,
DMSA for
recurrent
UTI

o Título: DMSA, dimercaptosuccinic acid scintigraphy; RBUS, renal and

bladder ultrasound; recurrent, 2 or more episodes of pyelonephritis, 1
episode of pyelonephritis with 1 or more episodes of cystitis, 3 or more
episodes of cystitis; UTI, urinary tract infection; VCUG, voiding
cystourethrography. *Atypical, seriously ill, poor urine flow, abdominal
or bladder mass, raised creatinine, septicemia, failure to respond to
antibiotics in 48 hours, infection with non–Escherichia coli pathogen.
†Caveat for children 3 years and older: if leukocyte esterase is positive
and nitrite is negative start empiric antibiotics only with good clinical
evidence for UT. ‡Always take into account local uropathogen
susceptibility patterns, previous culture susceptibility results when
available, and recent previous antibiotic use (concern for resistant
bacteria). §Second choice recommendations for pyelonephritis consult
local microbiologist. ||Specific features: dilation on ultrasonography,
poor urine flow, non–Escherichia coli infection, family history of
vesicoureteral reflux. ¶Top down start with DMSA and, if abnormal,
obtain VCUG; bottom up start with VCUG and, if abnormal, obtain
DMSA. #Note that colony count criteria are operational rather than
absolute; in rare circumstances, low colony counts can be indicative of
UTI.
o Citación: Data from American Academy of Pediatrics Subcommittee on
Urinary Tract Infection et al: Reaffirmation of AAP clinical practice
guideline: the diagnosis and management of the initial urinary tract
infection in febrile infants and young children 2-24 months of age.
Pediatrics. 138(6), 2016; Leung AKC et al: Urinary tract infection in
children. Recent Pat Inflamm Allergy Drug Discov. 13(1):2-18, 2019;
National Institute for Health and Care Excellence: Urinary Tract
Infection (Lower): Antimicrobial Prescribing. NICE Guideline [NG109].
NICE website. Published October 2018. Updated July 2019. Accessed
May 20, 2020. https://www.nice.org.uk/guidance/ng109/chapter/Update-
information; National Institute for Health and Care Excellence:
Pyelonephritis (Acute): Antimicrobial Prescribing. NICE Guideline
[NG111]. NICE website. Published October 31, 2018. Updated
September 2019. Accessed May 20, 2020.
https://www.nice.org.uk/guidance/ng111/chapter/Update-information;
 National Institute for Health and Care Excellence: Urinary Tract
Infection in Under 16s: Diagnosis and Management. Clinical Guideline
[CG54]. NICE website. Updated October 31, 2018. Accessed May 20,
2020. https://www.nice.org.uk/guidance/cg54/chapter/Update-
information; Okarska-Napierała M et al: Urinary tract infection in
children: diagnosis, treatment, imaging--comparison of current
guidelines. J Pediatr Urol. 13(6):567-573, 2017; National Institute for
Health and Care Excellence: Fever in Under 5s: Assessment and Initial
Management. NICE Guideline [NG143]. NICE website. Published
November 7, 2019. Accessed May 20, 2020.
https://www.nice.org.uk/guidance/ng143/chapter/Update-information;
Canadian Paediatric Society: Urinary Tract Infection in Infants and
Children: Diagnosis and Management [Position Statement]. Canadian
Paediatric Society website. Reaffirmed January 1, 2020. May 20,.2020.
https://www.cps.ca/en/documents/position/urinary-tract-infections-in-
children; Radmayr C et al: Paediatric Urology. Urinary Tract Infections
in Children [joint guidelines of the European Society for Paediatric
Urology and the European Association of Urology]. EAU website.
Updated 2019. Accessed May 20, 2020.
https://uroweb.org/guideline/paediatric-urology/#3_8; and Kaufman J et
al: Urinary tract infections in children: an overview of diagnosis and
management. BMJ Paediatr Open. 3(1):e000487, 2019.

 Urine specimen collection techniques

 Invasive collection techniques such as suprapubic aspiration and bladder

catheterization have the lowest contamination rates
 Transurethral bladder catheterization is a fast and safe way to obtain urine sample
with minimal contamination (can be used for urine cultures) in non–toilet-trained
children (typically, from birth to age 24 months)

  Suprapubic aspiration with ultrasonographic guidance is considered the

method of choice, although is more invasive

 Noninvasive techniques

 Clean-catch urine mid-stream void after carefully cleaning of the external

genitalia, can be an acceptable technique for obtaining urine for screening and
urine cultures in toilet-trained children

 Some advocate use of clean catch specimen in non–toilet-trained children with

various suprapubic and sacral stimulation procedures; however, high risk of culture
contamination is noted with specimens collected with this technique and many experts
caution to use specimen only for screening urinalysis similar to a bag specimen If a
clean catch urine sample is not possible, use other noninvasive methods such as urine
collection pads taking care to follow the manufacturer's instructions for collection Bag
specimens

 Plastic bag attached to genitalia has been a widely used, noninvasive technique
to collect urine
Bag specimens should not be used for culture; culture from bagged specimen cannot be
used to reliably confirm diagnosis of a urinary tract infection
 Urine collected by bag specimen has unacceptably high false-positive rates on urine
culture owing to skin flora contamination
 Dipstick test results are reliable only when they yield negative results May be used in
low-risk populations for screening urinalysis only to rule out (or significantly decrease
likelihood) of diagnosis

 Closely monitoring child without further testing is an option if all the following
are true (however, urinary tract infection is not 100% excluded by this practice):

  Child has low risk

 Child is not receiving antibiotics
 Bag specimen test results are negative

 If any screening studies are positive on bag specimen, urine must be obtained from
urethral catheterization or suprapubic aspiration for culture and repeat urinalysis before
start of empiric antimicrobial therapy Urinalysis
 Indications include symptoms of urinary tract infection and fever without a known
source in at-risk, non–toilet-trained child
 Dipstick urinalysis is the most common initial laboratory test, although urgent
microscopic urinalysis should be used to confirm findings, particularly in younger
children
 Note that non–Escherichia coli isolates are less frequently associated with pyuria
than Escherichia coli Dipstick tests
 Leukocyte esterase

 Indicates presence of lysed granulocytes and suggests inflammation in urine;

thus, an indirect marker of pyuria

Less useful in infants because they empty their bladders more frequently Sensitivity is
79% to 94%; specificity is 72% to 87%
 Results may be negative very early in infection and in patients with
immunocompromise Low specificity makes false-positive results common
 WBC in urine with negative urine culture (sterile pyuria) may occur owing to
various conditions, including:

 
o
 Gastroenteritis
 Appendicitis
 Noninfected renal stones (reactive inflammation)
 Kawasaki disease
 Streptococcal infections or perineal inflammation
 Sexually transmitted infections
 Fever
 Recent strenuous exercise

 Distinguishes asymptomatic bacteriuria from urinary tract infection

 Patients with asymptomatic bacteriuria typically have negative test results Nitrites
  Marker of by-products from some uropathogenic gram-negative bacteria (except
Pseudomonas species); indirect marker of bacteriuria

Urine must be present in bladder for about 4 hours before bacteria convert dietary
nitrates to nitrites

  Test is less useful in infants because they empty their bladders more
frequently

 Sensitivity is poor (mean is 53%, with wide range); specificity is 90% to 100% Urine
microscopy
 Pyuria (WBCs in urine) and bacteriuria (bacteria in urine) may be assessed by
several methods
 Standard microscopy: spun (centrifuged) urine assessed visually

 Pyuria defined as 5 or more WBCs per high-power field

 Sensitivity averages 73% and specificity averages 81% (however, sensitivity and
specificity range widely across reports) Bacteriuria defined as presence of any bacteria
on a gram-stained specimen per high-power field
 Sensitivity averages 81% and specificity averages 83% (however, sensitivity and
specificity range widely across reports) Enhanced microscopy (enhanced urinalysis):
automatic hemacytometer or counting chamber on nonspun (noncentrifuged) urine for
WBC counts; microscopy for estimation of bacterial count

 Sensitivity and specificity are about 10% better than with standard method
(reports vary)
 Superior in certain clinical situations (eg, evaluation of very young infants)

Pyuria defined as 10 or more WBCs/mm³ (WBCs/μL)

 Sensitivity is about 91%; specificity, about 96% (reports vary) Bacteriuria is defined
as any bacteria in 10 oil immersion fields of gram-stained smear Automated system:
microscopic particle analyzers and flow cytometry are used to assess nonspun urine
sample
 Conversion to WBC/high-powered field or WBC/mm³ is performed after
measurement
 Definitions of pyuria and bacteriuria vary depending on specific system used
 Test characteristic appears to be comparable to enhanced microscopy for detection of
pyuria but inferior (less sensitive and specific) for detection of bacteriuria Squamous
epithelial cells

 More than 5 cells per high-powered field may represent local skin contamination

Consider repeating clean catch when sample is found to contain 5 or more squamous
epithelial cells Combined test performance

 Test results positive for leukocyte esterase or nitrites have sensitivity of 93%
and specificity of about 72%
Test results positive for leukocyte esterase, nitrites, or bacteriuria have 99.8%
sensitivity and 70% specificity Urine culture

 Obtain for children who have had catheterization for febrile illness, symptoms
concerning for infection, or urinalysis positive for 1 or more of the following:
o Leukocyte esterase
o Nitrites
o Pyuria (WBC in urine)
o Bacteriuria (bacteria in urine)
 Catheter or suprapubic specimen is required to establish definitive diagnosis of
urinary tract infection in a non–toilet-trained child

Interpret culture results in context of quantitative CFU/mL, number and types of

bacterial species identified, time elapsed in processing of urine sample, and clinical
context Positive culture result depends on urine collection method; thresholds vary
between guidelines
 Cutoff definitions vary; they are operational and not absolute
 Lower colony counts in a symptomatic patient may be significant; low colony count
results may represent infection caused by non–Escherichia coli species Lower colony
counts may be significant in neonates, patients with immunodeficiency, underlying
urinary tract abnormalities, and children already taking antibiotics Low colony counts
may represent early infection, contamination, or asymptomatic bacteriuria Urine
catheterization technique
 American guidelines definition: 50,000 or more CFU/mL of a single urinary pathogen
European guidelines definition: 1000 to 50,000 CFU/mL of a single urinary pathogen
Other sources' definition: 10,000 (10⁴) or more CFU/mL with a positive urinalysis
Suprapubic aspiration

 100 (10²) or more CFU/mL of a single urinary pathogen

  Cutoff threshold also defined as any growth of a single urinary pathogen

 Clean-catch method

 Classical definition: 100,000 (10⁵) or more CFU/mL of a single urinary

pathogen

European guidelines definition: 10⁴ or more CFU/mL in symptomatic patient and 10⁵ or
more CFU/mL in asymptomatic patient Timing

 Positive culture results usually take 12 to 24 hours before bacterial growth is

detected

1 to 2 days are required to identify bacterium in positive cultures and 3 to 4 days before
susceptibilities are known Contamination

 Factors that raise suspicion of a contaminated culture specimen, particularly in

otherwise healthy patients, include the following:
o Low colony counts relative to collection method
Growth of more than a single organism Growth of a single nonuropathogenic organism,
such as:

  Lactobacillus species
 Corynebacterium species
 α-Hemolytic streptococci
 Micrococcus species
 Coagulase-negative staphylococci
 Candida species (in an otherwise healthy person)

 Any growth from a bag specimen Note that factors usually raise suspicion for
contamination in patients with normal urinary tracts and may represent true urinary tract
infection in patients with abnormal urinary tract


o Repeat urine cultures
 Few indications exist; consider for patients with resistant
pathogens and patients with failure to respond to usual therapy

 Renal and bladder ultrasonography

 Reliably identifies a renal abscess, pyonephrosis with obstructive uropathy, urinary

stone, or urinary obstruction in the acute setting
 Abnormal anatomical findings (in the acute or follow-up setting) can include:
abnormal kidney size, renal scarring, hydroureter, hydronephrosis, duplicated collecting
system, ureterocele, or bladder diverticula

 Directly identifies anatomical abnormalities and indirectly identifies functional

abnormalities that increase risk for recurrent infection and subsequent renal
scarring
 Few children with renal tract obstruction or grades 4 and 5 vesicoureteral reflux
will have routine ultrasonography

 Postvoid evaluation of bladder in toilet-trained children can be useful to assess for

functional bladder abnormalities and retention syndrome
 Limitations to renal ultrasonography

  Not accurate in identifying all renal scarring from previous urinary tract
infections and can miss some renal scarring
 Unreliably identifies acute pyelonephritis without obstruction
 Does not reliably identify signs of low-grade vesicoureteral reflux

 Follow-up imaging

 Youth of child is inversely proportional to risk of detecting an abnormality (on

follow-up ancillary study) that will predispose the child to future urinary tract
infections and potential complications

 Structural abnormalities occur in 10% to 75% (median, about 30%) of children

scanned after a first urinary tract infection Controversial in the setting of first febrile
infection; variability exists between recommendations for imaging in acute and follow-
up settings, and is largely based on individual clinical scenario and clinical judgment
 American Academy of Pediatrics recommends routine imaging after first febrile
urinary tract infection in infants and children younger than 24 months

  If screening ultrasonographic results that are within reference range, no

further studies are indicated after the first uncomplicated urinary tract infection

 American College of Radiology suggests that there is no clear benefit for imaging of
patients aged 2 months or older who respond well to treatment after first febrile urinary
tract infection; this is true because:

  Long-term complication rates after a febrile urinary tract infection are low,
and
 Benefit of treatment (ie, prophylactic antibiotics or surgery for reflux) is
uncertain in most patients older than 2 months

 Australasian guideline (2014) does not recommend routine ultrasonography after a

first infection except in the following patients:

  Patients who have not had imaging of kidney and urinary tract by second- or
third-trimester antenatal ultrasonography
 Patients with concurrent bacteremia
 Infants younger than 3 months
 Patients with urine culture finding of atypical organisms (eg, Staphylococcus
aureus, Pseudomonas species)
 Patients with lack of clinical response by sensitive organism within 48 hours
 Patients with renal impairment or significant electrolyte derangement
 Patients with abdominal mass or poor urinary stream

 National Institute for Health and Care Excellence guidelines are detailed and have
additional imaging recommendations

 
o

 Follow-up ultrasonography is recommended in the
following patients:
 All children younger than 6 months should have
ultrasonography within 6 weeks of the first urinary
tract infection (when not required during acute
phase of infection)
 All children aged 6 months and older with
recurrent infection
 Infants and children aged 6 months or
older with first-time urinary tract infection
that responds to treatment do not require
routine ultrasonography unless they have
atypical infection
 Voiding cystourethrography
 Test of choice for diagnosis of vesicoureteral reflux in any age group
 Test of choice to evaluate for vesicoureteral reflux in males because test allows clear
demonstration of urethral pathology Obtain if screening ultrasonogram shows
hydronephrosis, renal scarring, or findings suggestive of high-grade vesicoureteral
reflux or obstructive uropathy Obtain in infants after first episode of febrile UTI with a
non–Escherichia coli infection Consider after first febrile urinary tract infection in
infants younger than about 2 months or first febrile urinary tract infection in a
circumcised male Obtain in infants and children 2 to 24 months if there is recurrence of
febrile urinary tract infection Obtain in infants and children younger than 24 months
presenting with atypical or complex clinical circumstances Nuclear cystography

 Alternate test of choice to evaluate for vesicoureteral reflux

 Preferred by some experts to evaluate vesicoureteral reflux in females and for
follow-up of vesicoureteral reflux

Associated with a lower radiation exposure than voiding cystourethrography Renal

cortical scintigraphy with radiolabeled succimer (dimercaptosuccinic acid) as the
radiotracer

 Test of choice to assess for renal scarring and acute pyelonephritis

Indirectly evaluates for high-grade vesicoureteral reflux

 Children with negative scan results have less than 1% probability of having high-
grade vesicoureteral reflux Radiation dose is much higher than with voiding
cystourethrography (10-fold higher) and nuclear cystography (100-fold higher) No
longer recommended by American Academy of Pediatrics for patients aged 2 to 24
months as part of routine screening evaluation after a first febrile urinary tract infection
Diffusion-weighted MRI


o Alternative to a dimercaptosuccinic acid scan which avoids radiation
exposure
o Has been shown to accurately diagnose acute pyelonephritis and detect
late renal scars

Before starting any procedure to obtain urine from a non–toilet-trained child,

have a sterile container ready to catch midstream urine in the event the child
urinates before the procedure

Transurethral bladder catheterization

General explanation

 Yields reliable results and may be better tolerated than suprapubic aspiration

 Use sterile technique to catheterize urethra to obtain urine specimen

 Can use topical or intraurethral lidocaine to reduce discomfort Bedside
ultrasonographic estimation of bladder volume before catheterization improves
likelihood of successful catheterization Meticulous technique reduces possibility of
contamination by distal urethral bacterial flora
 
o Discard first few milliliters of urine obtained via catheter
o Use a new sterile catheter with each subsequent attempt after
unsuccessful attempts (leave initial catheter in place to mark incorrect
path of placement)
Indication

 Concern for urinary tract infection in non–toilet-trained child

Interpretation of results

 Positive urine culture result is defined by uropathogen population more than

50,000 CFU/mL

Using this collection technique (as compared with suprapubic aspiration), sensitivity is
95% and specificity is 99%

Suprapubic aspiration

General explanation

 Gold standard method of obtaining urine specimen for culture. Yields the most
reliable culture results of any collection method

Higher procedure failure rate and perception that procedure is more invasive than
transurethral catheterization has led to minimal use outside neonatal ICU Success rates
for obtaining urine vary from 23% to 90% per attempt; rates improve with
ultrasonographic guidance
 Requires technical expertise and training
 Use sterile technique

 Insert 22-gauge needle 1 to 2 cm cephalad to pubic symphysis, midline, at an

angle of 10° to 20° from vertical while aspirating until urine is retrieved from
bladder
Indication

 Inability to obtain urine by catheterization technique, such as in:

o Males with moderate to severe phimosis
o Females with tight labial adhesions

Interpretation of results

 Positive urine culture result is variably defined by any growth of uropathogen to

quantitative growth cutoff threshold of 10²

Differential Diagnosis

Most common

 Asymptomatic bacteriuria in a febrile child

 Small number of healthy, asymptomatic children have bacteriuria

 Defined as urine culture with more than 50,000 CFU of a single uropathogen
and absence of pyuria

 Often found in otherwise healthy school-aged or adolescent females; may be present

in infants
 Condition is most common in children with urinary tract abnormalities and in those
requiring intermittent catheterization There is no way to reliably differentiate between
preexisting asymptomatic bacteriuria and urinary tract infection in a febrile child with
signs of urinary tract infection based on a positive culture result in the acute setting
 Diagnosis usually requires time; asymptomatic bacteriuria persists outside febrile
illness time frame
 Differentiate by absence of pyuria (via WBC count or leukocyte esterase test) on
initial urinalysis and persistence of a positive culture result despite absence of
symptoms
 Asymptomatic bacteriuria does not appear to increase risk of developing urinary
tract infection or renal scarring; screening for condition and treatment are not typically
indicated Asymptomatic bacteriuria is not treated with antibiotics except during
pregnancy Sexually transmitted diseases

 Urethral inflammation can cause dysuria, hematuria, and urethral discharge

(Related: Gonorrhea)
 Males present with urethritis (Related: Urethritis)
 Can present concomitantly with urinary tract infection

 However, 29% of sexually active adolescent females with urinary symptoms have a
sexually transmitted disease only


o Pelvic inflammatory disease and cervicitis present with cervical motion,
abdominal tenderness, and vaginal discharge (Related: Pelvic
Inflammatory Disease)
o Differentiate based on history, physical examination, urine culture, and
specific testing for sexually transmitted diseases (eg, chlamydia,
gonorrhea, trichomoniasis)
 Hemorrhagic viral cystitis
o Symptoms include:
 Dysuria
 Urinary urgency and frequency
 Hematuria (usually at beginning of urine stream and tapering off
by end)
 Suprapubic pain and/or tenderness
o Usually associated with adenoviral or other upper respiratory infection
o Screening urinalysis finds absence of signs of bacteriuria; differentiate
based on urine culture
 Nephrolithiasis
o Presents with the following:
 Flank pain or renal colic
 Urinary symptoms
  Gross or microscopic hematuria
 Absence of fever
o Many children with urinary stones have positive family history
o Concomitant infection with urinary stone is a consideration when patient
is presenting with pain disproportionate to or uncharacteristic of
uncomplicated urinary tract infection
o Differentiate based on history and urine culture
 Vulvovaginitis (caused by chemical, irritant, bacteria, yeast)
o Usually presents with dysuria and absence of urinary frequency
o Physical examination may show vaginal discharge, inflammation around
urinary meatus, or skin breakdown in perineum
o Bacterial vaginitis in a child may be caused by a vaginal foreign body
(Related: Bacterial Vaginosis)
o May be caused by trichomoniasis in adolescents
o Differentiate based on physical examination and urine culture
 Sexual abuse or periurethral trauma
o Can present with dysuria, hematuria, or urinary retention (Related:
Bladder and Urethral Injury)
o Urinary frequency is uncommon
o Signs of perineal or perianal trauma may be present on examination
o Differentiate based on history, physical examination, information
obtained from social services consultation, and urine culture

Treatment
Goals

 Treat symptoms of fever, dysuria, and pain

 Eliminate infection and prevent severe systemic illness. Start empiric treatment
with antibiotics and modify them based on culture and sensitivity test
 Prevent or reduce possible long-term complications with adequate follow-up

Disposition

Admission criteria

Age younger than 2 to 3 months Severe illness or dehydration Inability to tolerate oral
fluids or medications High risk for nonadherent follow-up Immunocompromised status
Underlying urologic conditions or indwelling devices (eg, stents, catheters)

Renal obstruction

No response to outpatient therapy

Criteria for ICU admission

 Hypotension or septic shock

Recommendations for specialist referral

  Refer to pediatric urologist any patient with complex infection, at high risk for
recurrent infection, or with evidence of renal damage, including the following:

  Pyonephrosis, renal or perirenal abscess, and emphysematous pyelonephritis

 Imaging abnormalities (eg, hydronephrosis, obstruction, renal scarring)
 Vesicoureteral reflux
 Recurrent urinary tract infections
 High risk for serious illness

 Consider referring the following patients to pediatric urologist:

 Infants younger than 3 months

 Children with pyelonephritis or febrile urinary tract infection

 Refer patients with the following to pediatric nephrologist:

 Renal scarring
 Abnormal renal function that persists despite urinary tract infection treatment

 Consult with infectious disease specialist about any patient found to have urinary
tract infection with uncommon organism or multidrug resistant organism

Treatment Options

Most febrile but otherwise healthy infants and children can be managed as outpatients

If there is high clinical suspicion for urinary tract infection and urinalysis is suggestive
of infection on an appropriately collected urine specimen, start empiric treatment
 Positive urinary dipstick result (ie, leukocyte esterase or nitrite) and/or positive
microscopy (ie, bacteriuria or pyuria) UTICalc is a tool that aids in estimating
probability of urinary tract infection based on clinical and laboratory characteristics
National Institute for Health and Care Excellence recommends starting empiric
antibiotics if leukocyte esterase or nitrite or both are positive in children 3 months or
older
 Caveat being in children 3 years and older with positive leukocyte esterase only
(negative nitrite), empiric antibiotics are recommended only with good clinical evidence
of urinary tract infection (eg, obvious urinary symptoms) pending culture results
Algorithm outlining American Academy of Pediatrics' approach to diagnosis and
management for febrile infants and young children is available

 Consider early initiation of empiric antibiotics pending culture results in patients

at high risk for developing renal scarring (eg, prolonged fever, clinical
pyelonephritis, immunodeficiency, known urologic abnormality)

Before starting empiric antibiotics, obtain a catheter or suprapubic urine specimen for
culture in any febrile child aged 24 months or younger (for confirmatory diagnosis)

 If possible, obtain urine before emergent empiric antibiotic administration in a

febrile child to evaluate for urinary tract infection (if child is at risk)
 Never start empiric antibiotics to treat a presumptive urinary tract infection based on
bag specimen result alone; always obtain a catheter or suprapubic specimen for
urinalysis and culture before starting antimicrobial therapy if screening bag specimen
results are concerning for urinary tract infection

Route of antibiotic administration

 Oral antibiotics are as effective as parenteral antibiotics for treatment of urinary

tract infections in most otherwise healthy children

Parenteral therapy is reserved for children who appear very ill, who are unable to
tolerate oral medications, or who are younger than 3 months Consider parenteral
therapy in children with immunocompromise, indwelling devices (eg, stents, catheters),
and complicated infection in consultation with specialist (eg, urologist, nephrologist)
Continue parenteral antibiotic therapy until child is afebrile and tolerating oral intake,
then transition to oral antibiotic to finish course

Empiric antibiotic selection

 Base initial empiric antibiotic choice on local community sensitivity patterns,

then adjust antibiotic based on patient's own culture and sensitivity results

 Gram stain may help with initial choice of antibiotics. Many recommended empiric
antibiotics (eg, first- and second-generation cephalosporins) do not adequately cover
gram-positive uropathogens (eg, Enterococcus species, Staphylococcus saprophyticus)
 Consider child's previous antimicrobial exposure and alter empiric antibiotic choice
accordingly
 Consider known underlying medical problems (eg, immunodeficiency, diabetes),
vesicoureteral reflux, or anatomical abnormalities that may alter treatment approach
 Earlier history of urinary tract infection decreases threshold for treatment with
empiric antibiotics; review previous culture and susceptibility results
 Resistance of Escherichia coli to amoxicillin, amoxicillin-clavulanate,
sulfamethoxazole-trimethoprim, and first-generation cephalosporins is increasing;
several sources suggest avoiding amoxicillin as first line therapy In general, most
sources recommend a third-generation cephalosporin for children managed as
outpatients
 Some clinicians administer an initial parenteral dose of ceftriaxone to infants
younger than 6 months owing to increased risk of bacteremia and sepsis in this age
group, although this does not have proven better outcomes National Institute for Health
and Care Excellence guidelines recommend:

 For cystitis: trimethoprim (in those at low risk for resistance) or nitrofurantoin as
first line treatment in children aged 3 months or older; cephalexin or
amoxicillin is an alternative, if sensitive organism is cultured

For pyelonephritis: cephalexin or amoxicillin-clavulanate (only if culture results

available and susceptible) as first line treatment for children aged 3 months and older In
general, most sources recommend use of a third-generation cephalosporin or an
aminoglycoside for children requiring admission and parenteral antibiotics
 Treat infants younger than 2 to 3 months with combination therapy (ampicillin-
gentamicin or ampicillin-cefotaxime) National Institute for Health and Care Excellence
guidelines recommend amoxicillin-clavulanate (if pathogen is known to be susceptible),
cefuroxime, ceftriaxone, gentamicin, or amikacin for children older than 3 months
Discontinue empiric antibiotics if culture fails to yield bacterial growth by 48 hours

 Narrow spectrum or modify selection of empiric antibiotic as needed after

results of culture and sensitivity are available

Children with initial diagnosis of uncomplicated urinary tract infection should have
clinical response to antibiotics within 24 to 48 hours (ie, improved symptoms,
defervescence)

 Lack of response within 48 hours indicates a complicated course (eg, renal abscess,
obstruction presence, alternative diagnosis) or a pathogen not covered by empiric
antibiotics Consider further work-up, ultrasonography, and broadening antibiotic
coverage Duration of antibiotic therapy is not rigorously standardized (guidelines lack
consensus)
 Antibiotic therapy is typically given for at least 7 to 10 days in patients with febrile
uncomplicated urinary tract infection
 Shorter courses of antibiotics are likely as effective as longer courses for
uncomplicated cystitis Duration of therapy may be reduced to 5 days in cases of
infection limited to lower urinary tract in patients aged 3 months or older European
guidelines suggest at 4-to-7 day course of oral or parenteral therapy A longer course of
10 to 14 days is generally given to patients in the following populations:

 Children with complicated urinary tract infection

Children younger than 2 years Children with recurrent infections Children with
pyelonephritis All adolescent males

Additional guidelines for treatment of pediatric urinary tract infection are available

 National Institute for Health and Care Excellence guidelines (2022)

European Society for Paediatric Urology and European Association of Urology joint
guidelines (updated annually) Kidney Health Australia 2014 guidelines Canadian
Paediatric Society 2014 guidelines (reaffirmed in 2020) International Children's
Continence Society 2012 recommendations American Academy of Pediatrics 2011
guidelines (reaffirmed in 2016)

Drug therapy

 Antibiotics
o Cephalosporins (do not cover Enterococcus species)
 Parenteral agents
 Ceftriaxone

  Avoid in neonates with hyperbilirubinemia

  Ceftriaxone Sodium Solution for injection; Infants, Children, and Adolescents:
50 to 75 mg/kg/day divided every 12 to 24 hours (Max: 2 g/day) for 7 to 14
days.

 Cefotaxime

 
o Cefotaxime Sodium Solution for injection; Neonates younger than 32
weeks gestation and 0 to 7 days: 50 mg/kg/dose IV/IM every 12 hours.
o Cefotaxime Sodium Solution for injection; Neonates younger than 32
weeks gestation and 8 to 13 days: 50 mg/kg/dose IV/IM every 8 to 12
hours.
o Cefotaxime Sodium Solution for injection; Neonates younger than 32
weeks gestation and 14 days and older: 50 mg/kg/dose IV/IM every 8
hours.
o Cefotaxime Sodium Solution for injection; Neonates 32 weeks gestation
and older and 0 to 7 days: 50 mg/kg/dose IV/IM every 12 hours.
o Cefotaxime Sodium Solution for injection; Neonates 32 weeks gestation
and older and 8 days and older: 50 mg/kg/dose IV/IM every 8 hours.
o Cefotaxime Sodium Solution for injection; Infants, Children, and
Adolescents weighing less than 50 kg: 150 to 180 mg/kg/day IV/IM
divided every 6 to 8 hours (Max: 2 g/dose); treat for 7 to 14 days for the
treatment of initial UTI in febrile infants and young children (2 months
to 2 years).
o Cefotaxime Sodium Solution for injection; Children and Adolescents
weighing 50 kg or more: 1 g IV/IM every 12 hours for uncomplicated
infections; 1 to 2 g IV/IM every 8 hours for moderate to severe
infections, and 2 g IV every 6 to 8 hours for severe infections. Max: 12
g/day.
 Ceftazidime
o Ceftazidime Sodium Solution for injection; Neonates younger than 32
weeks gestation and 0 to 13 days: 30 to 50 mg/kg/dose IV/IM every 12
hours.
o Ceftazidime Sodium Solution for injection; Neonates younger than 32
weeks gestation and 14 days and older: 50 mg/kg/dose IV/IM every 8
hours recommended by AAP; FDA-approved labeling recommends 30
mg/kg/dose IV every 12 hours.
o Ceftazidime Sodium Solution for injection; Neonates 32 weeks gestation
and older and 0 to 7 days: 30 to 50 mg/kg/dose IV/IM every 12 hours.
o Ceftazidime Sodium Solution for injection; Neonates 32 weeks gestation
and older and 8 days and older: 50 mg/kg/dose IV/IM every 8 hours
recommended by AAP; FDA-approved labeling recommends 30
mg/kg/dose IV every 12 hours.
o Ceftazidime Sodium Solution for injection; Infants and Children: 30 to
50 mg/kg/dose IV/IM every 8 hours (Max: 2 g/dose); use higher doses
(e.g., 50 mg/kg/dose IV every 8 hours) for immunocompromised
patients; 200 to 300 mg/kg/day IV divided every 8 hours (Max: 12
g/day) is recommended by AAP for serious Pseudomonas infections;
treat for 7 to 14 days for UTI in febrile infants and young children (2
months to 2 years).
 Oral agents

 Cefixime

  Cefixime Oral suspension; Infants 2 to 5 months†: 8 mg/kg/dose PO once

daily for 7 to 14 days.
o Off-label use in this age group
 Cefixime Oral suspension; Infants and Children 6 months to 2 years: 8
mg/kg/day PO divided every 12 to 24 hours for 7 to 14 days.
 Cefixime Oral suspension; Children 3 years and older weighing 45 kg or less: 8
mg/kg/day PO divided every 12 to 24 hours.
 Cefixime Oral suspension; Children weighing more than 45 kg and Adolescents:
400 mg/day PO divided every 12 to 24 hours.

 Cefdinir

 Cefdinir Oral suspension; Infants, Children, and Adolescents: 7 mg/kg/dose PO

every 12 hours or 14 mg/kg/dose PO every 24 hours. Treat febrile infants and
young children 2 to 24 months of age for 7 to 14 days; shorter courses (2 to 4
days) may be used in older children with uncomplicated cystitis.
 Cefdinir Oral suspension; Infants, Children, and Adolescents: 7 mg/kg/dose PO
every 12 hours or 14 mg/kg/dose PO every 24 hours. Treat febrile infants and
young children 2 to 24 months of age for 7 to 14 days; shorter courses (2 to 4
days) may be used in older children with uncomplicated cystitis.
 Cefdinir Oral suspension; Infants, Children, and Adolescents: 7 mg/kg/dose PO
every 12 hours or 14 mg/kg/dose PO every 24 hours. Treat febrile infants and
young children 2 to 24 months of age for 7 to 14 days; shorter courses (2 to 4
days) may be used in older children with uncomplicated cystitis.

 Cefpodoxime

 Cefpodoxime Proxetil Oral suspension; Infants 2 months and older† and

Children younger than 12 years†: 5 mg/kg/dose PO every 12 hours for 7 to 14
days; shorter course of 2 to 4 days may be used in older children with
uncomplicated cystitis. Max adult dose: 100 mg/dose.
 Cefpodoxime Proxetil Oral tablet; Adolescents and Children 12 years and older:
100 mg PO every 12 hours for 7 days; shorter course of 2 to 4 days may be used
in older children with uncomplicated cystitis.

 Cefprozil

 Cefprozil Oral suspension; Infants and Children 2 months to 2 years: 15

mg/kg/dose PO every 12 hours for 7 to 14 days for the treatment of initial UTI
in febrile children; shorter courses of therapy (i.e., 3 to 5 days) may be adequate
for uncomplicated UTI.
 Cefprozil Oral tablet; Children and Adolescents 3 to 17 years: 15 mg/kg/dose
(Max: 500 mg/dose) PO every 12 hours for 3 to 5 days; longer course (i.e., 7 to
14 days) may be necessary.

 Cephalexin
  
o
 Cephalexin Monohydrate Oral suspension; Infants† and Children
2 months to 2 years: 50 to 100 mg/kg/day PO in 4 divided doses
for 7 to 14 days per AAP for initial UTI in febrile infants and
young children. General FDA-approved dosage in children older
than 1 year is 25 to 50 mg/kg/day PO in 2 to 4 divided doses; 50
to 100 mg/kg/day PO in 3 to 4 divided doses may be used for
severe infections. A treatment duration of 7 to 14 days is
recommended for most indications.
 Off-label use in infants
 Cephalexin Monohydrate Oral suspension; Children and
Adolescents 3 to 17 years: 25 to 50 mg/kg/day PO in 2 to 4
divided doses (Max: 2 g/day); 50 to 100 mg/kg/day PO in 3 to 4
divided doses (Max: 4 g/day) may be used for severe infections.
In general, a treatment duration of 7 to 14 days is recommended
for most indications.

 Broad-spectrum aminopenicillins (covers Enterococcus species)

 Parenteral agents
o Ampicillin

 
o Ampicillin Sodium Solution for injection; Neonates 34 weeks gestation
and younger and 0 to 7 days†: 50 mg/kg/dose IV/IM every 12 hours.
o Ampicillin Sodium Solution for injection; Neonates 34 weeks gestation
and younger and older than 7 days†: 75 mg/kg/dose IV/IM every 12
hours.
o Ampicillin Sodium Solution for injection; Neonates older than 34 weeks
gestation†: 50 mg/kg/dose IV/IM every 8 hours.
o Ampicillin Sodium Solution for injection; Infants, Children, and
Adolescents: 50 to 200 mg/kg/day IV/IM divided every 6 hours (Max: 8
g/day).

 Oral agents

 Amoxicillin-clavulanate combination

 
o
 Amoxicillin Trihydrate, Clavulanate Potassium Oral suspension;
Neonates and Infants 2 months and younger: 30 mg/kg/day
amoxicillin component PO divided every 12 hours.
 Amoxicillin Trihydrate, Clavulanate Potassium Oral suspension;
Infants, Children, and Adolescents 3 months to 17 years weighing
less than 40 kg (every 12 hour regimens): 25 mg/kg/day
amoxicillin component PO divided every 12 hours for
mild/moderate infections and 45 mg/kg/day amoxicillin
component PO divided every 12 hours for severe infections.
  Amoxicillin Trihydrate, Clavulanate Potassium Oral tablet;
Children and Adolescents weighing 40 kg or more (every 12 hour
regimens): 500 mg amoxicillin with 125 mg clavulanic acid PO
every 12 hours for mild/moderate infections and 875 mg
amoxicillin with 125 mg clavulanic acid PO every 12 hours for
severe infections.

 Aminoglycosides

 Potentially nephrotoxic; use with care in patients with impaired renal function
 Gentamicin

 
o Conventional dosing
 Gentamicin Sulfate Solution for injection; Neonates 0 to 7 days
weighing less than 1.2 kg: 2.5 mg/kg/dose IV/IM every 18 to 24
hours. FDA-approved dosage = 2.5 mg/kg/dose IV/IM every 12
hours.
 Gentamicin Sulfate Solution for injection; Neonates 0 to 7 days
weighing 1.2 to 2 kg: 2.5 mg/kg/dose IV/IM every 12 to 18
hours.
 Gentamicin Sulfate Solution for injection; Neonates 0 to 7 days
weighing more than 2 kg: 2.5 mg/kg/dose IV/IM every 12 hours;
extend interval to 18 to 24 hours for neonates on ECMO.
Individualize subsequent dosing based on serum concentrations.
Dosage adjustment needed after decannulation.
 Gentamicin Sulfate Solution for injection; Neonates 8 to 29 days
weighing less than 1.2 kg: 2.5 mg/kg/dose IV/IM every 18 to 24
hours. FDA-approved dosage = 2.5 mg/kg/dose IV/IM every 8
hours.
 Gentamicin Sulfate Solution for injection; Neonates 8 to 29 days
weighing 1.2 to 2 kg: 2.5 mg/kg/dose IV/IM every 8 to 12 hours.
 Gentamicin Sulfate Solution for injection; Neonates 8 to 29 days
weighing more than 2 kg: 2.5 mg/kg/dose IV/IM every 8 hours;
extend interval to 18 to 24 hours for neonates on ECMO.
Individualize subsequent dosing based on serum concentrations.
Dosage adjustment needed after decannulation.
 Gentamicin Sulfate Solution for injection; Infants: 2.5
mg/kg/dose IV/IM every 8 hours; treat for 7 to 14 days for initial
UTI in febrile patients 2 to 24 months of age.
 Gentamicin Sulfate Solution for injection; Children and
Adolescents: 2 to 2.5 mg/kg/dose IV/IM every 8 hours; treat for 7
to 14 days for initial UTI in febrile patients 2 to 24 months of
age.

 Nitrofurantoin
 Not indicated for febrile urinary tract infection. Does not achieve therapeutic serum
or renal concentrations to effectively treat pyelonephritis
   Nitrofurantoin Oral suspension; Infants, Children, and Adolescents weighing
less than 42 kg: 5 to 7 mg/kg/day PO in 4 divided doses. Give for 7 days or for
at least 3 days after urine is sterile.
 Nitrofurantoin Oral suspension; Children and Adolescents weighing 42 kg or
more: 50 to 100 mg PO every 6 hours. Give for 7 days or for at least 3 days after
urine is sterile.

 Sulfonamides

 Sulfamethoxazole-trimethoprim combination

 Useful for Staphylococcus saprophyticus infection

 
o Sulfamethoxazole, Trimethoprim Oral suspension; Infants and Children
2 months to 2 years: 6 to 12 mg/kg/day (trimethoprim component) PO
divided every 12 hours for 7 to 14 days.
o Sulfamethoxazole, Trimethoprim Oral suspension; Children and
Adolescents 3 to 17 years: 8 mg/kg/day (trimethoprim component) PO
every 12 hours (Max: 320 mg trimethoprim/1,600 mg
sulfamethoxazole/day) for 10 days.

 Fluoroquinolones

 Ciprofloxacin

 Approved for second line treatment of complicated or multidrug-resistant infections

 
o
 Ideally reserved for patients older than 18 years owing to
potential risk of damaging cartilage
 Ciprofloxacin Hydrochloride Oral tablet; Children and
Adolescents: 10 to 20 mg/kg/dose PO every 12 hours
(Max: 750 mg/dose) for 7 to 14 days; FDA-approved
labeling recommends a duration up to 21 days.

 Analgesics

 Phenazopyridine

 
o Avoid in patients with glucose-6-phosphate dehydrogenase deficiency or
moderate to severe renal impairment
o Appropriate for children aged 6 years or older
 Phenazopyridine Hydrochloride Oral tablet; Children 6 to 11
years†: Use not established; off-label use has been described. Use
only under the prescription of a health care professional; do not
self-treat. Dose used: 4 mg/kg/dose PO 3 times daily with or after
meals for up to 2 days.
  Off-label use in these age groups
 Phenazopyridine Hydrochloride Oral tablet; Children and
Adolescents 12 to 17 years: 190 to 200 mg PO 3 times daily with
or after meals. Non-prescription use or use with an antibacterial
agent for urinary tract infection should not exceed 2 days.

 

Select empiric antibiotics for treating urinary tract infection in infants and young
children.

Empiric antibiotic Typical dosing Maximum dosage

Oral agents
Cefixime 8 mg/kg/day in 1 dose 400 mg/day
10 mg/kg/day divided in 2
Cefpodoxime 100 mg/dose
doses
30 mg/kg/day divided in 2
Cefprozil 500 mg/day
doses
20-30 mg/kg/day divided in 2
Cefuroxime axetil 500 mg/dose
doses
50-100 mg/kg/day divided in
Cephalexin 4 g/day
4 doses
Amoxicillin- 25-45 mg/kg/day divided in 2
875 mg/dose
clavulanate doses
6-12 mg/kg/day
Trimethoprim-
(trimethoprim component) 160 mg/dose
sulfamethoxazole
divided in 2 doses
5-7 mg/kg/day divided in 4
Nitrofurantoin 100 mg/dose
doses
Parenteral agents
Ceftriaxone 50-75 mg/kg every 24 hours 2 g/dose
150 mg/kg/day divided every
Cefotaxime 2 g/dose
6 to 8 hours
150 mg/kg/day divided every 2 g/dose (FDA-approved
Ceftazidime
8 hours maximum)
7.5 mg/kg/day divided every 7.5 mg/kg/day (FDA-
Gentamicin
8 hours approved maximum)
50-200 mg/kg/day divided
Ampicillin 2 g/dose
every 6 hours
5 mg/kg/day divided every 8 10 mg/kg/day (FDA-
Tobramycin
hours approved maximum)

Título: American Academy of Pediatrics recommends total course of therapy of

7 to 14 days for infants and young children with culture proven urinary tract
infection. Oral dosing is as effective as parenteral dosing; reserve parenteral
dosing for very ill-appearing patients, patients unable to tolerate oral intake, and
when compliance is in question. Transition to oral antibiotics when clinical
improvement is established and patient is tolerating oral intake (typically within
 24-48 hours). Note local susceptibility patterns to coliforms and uropathogens to
antimicrobial agents before selecting most appropriate empiric agent. Resistance
to cephalexin and trimethoprim-sulfisoxazole are increasing in certain
geographic regions.

Citación: Data from American Academy of Pediatrics Subcommittee on Urinary

Tract Infection et al: Urinary tract infection: clinical practice guideline for the
diagnosis and management of the initial UTI in febrile infants and children 2 to
24 months. Pediatrics. Pediatrics. 138(6):e20163026, 2016; and Millner R et al:
Urinary tract infections. Pediatr Clin North Am. 66(1):1-13, 2019.

Nondrug and supportive care

Fever and pain

 Ibuprofen
 Acetaminophen

Urinary analgesics

 Pyridium may be used for severe dysuria in older children and adolescents

Hydration

 Encourage oral fluid intake

 Provide IV hydration to any child with clinical signs of dehydration or poor
urine output

Evaluate all toilet-trained children for possibility of bowel and bladder dysfunction
using history and physical examination

 Address bladder and bowel dysfunction if present

 Urologic anticipatory guidance mantra is that "a happy bladder is an empty bladder;
an even happier bladder is an empty rectum" Bladder training
 Timed voiding (every 2-3 hours) to avoid bladder distention and stasis
 Double voiding: attempt to urinate immediately after initial void
 Avoidance of caffeine, carbonated beverages, citrus, chocolate, and food colorants
 Biofeedback for pelvic floor muscle relaxation
 Anticholinergic medications α-Blockers Training for constipation
 Daily sit-downs: 10 minutes sitting on toilet after breakfast and dinner; follow
behavior with positive reinforcement (eg, reward with star on a chart) Encourage
adequate dietary fiber (dietary fiber supplementation is not routinely recommended)
Laxatives (polyethylene glycol is first line maintenance pharmacologic treatment)

Anticipatory guidance

 Parents should seek medical attention within 48 hours in case of future febrile
illness or urinary symptoms to ensure that recurrent infections are detected and
treated promptly (especially in children younger than 2 years)
Comorbidities

 Children with indwelling catheter (Related: Catheter-Associated Urinary Tract

Infection)
o Catheter removal may help eradicate infection

Monitoring

 Patients receiving gentamicin

o Monitor serum gentamicin levels and consider monitoring serum
creatinine in patients treated with gentamicin for more than 48 hours

Monitoring after diagnosis

 Monitor for clinical improvement

o Expect normalization of temperature within 24 to 48 hours with
successful treatment

Expect sterile urine within 24 hours and disappearance of leukocyturia by day 3 or 4

with successful treatment Consider possible presence of antibiotic-resistant
uropathogen, congenital uropathy, or acute urinary obstruction if condition does not
respond to standard care


o Test urine sensitivity and modify treatment accordingly
o Ensure appropriate outpatient imaging is scheduled

Complications and Prognosis

Complications

 Short-term complications

 Sepsis

 6% to 36% of neonatal infections are complicated by sepsis (reports vary)

(Related: Sepsis in Neonates)

  Renal abscess or perinephric abscess

 Pyonephrosis with obstructive uropathy
 Advent of chronic pyelonephritis
o Emphysematous pyelonephritis is rare in children

 Recurrent infections

 Up to 30% of infants and children experience recurrent infections

Most recurrent infections occur within 3 to 6 months after the first episode Assess for
bowel and bladder dysfunction through history and physical examination
 Untreated dysfunction may contribute to recurrent infections and lead to renal
complications
 Children with recurrent infection are at risk for renal scarring
 Risk factors for recurrent infection in young children include:

 White race

Age 3 to 5 years Vesicoureteral reflux

 Higher grades of vesicoureteral reflux (ie, grades 4-5) may be associated with further
increased risk Presence of baseline bowel and bladder dysfunction Presence of renal
scarring at baseline Antimicrobial prophylaxis is controversial and not standardized
 Long-term antibiotic use may reduce risk of recurrent urinary tract infection in
children who have had at least 1 previous infection, but the benefit appears to be small
Use of long-term antibiotic prophylaxis is associated with increased risk of
antimicrobial resistance among children with recurrent infections Insufficient and
conflicting evidence along with inconsistent guideline recommendations confound the
decision
 Individual factors (eg, age, sex, circumcision status, presence and severity of
vesicoureteral reflux) must be weighed against potential harms associated with daily
antibiotic use and possibility of antimicrobial resistance
 Risk factors for recurrence in infants with vesicoureteral reflux include:

 
o Earlier occurrence of first infection
o Higher grades of reflux
o Bilateral reflux
o First infection caused by an organism that is not Escherichia coli

 Overall decision is individualized based on urologist recommendations; prophylactic

antibiotics may be recommended for infants and children at highest risk for recurrence
 Evidence exists for use to prevent renal scarring in infant females with dilating
reflux grade 3 and 4 Other experts support antibiotic prophylaxis in all children with
vesicoureteral reflux regardless of reflux grade Some guidelines suggest consideration
for antimicrobial prophylaxis for recurrent infections regardless of presence of reflux
Trimethoprim-sulfamethoxazole is first line antibiotic of choice in most infants and
children requiring prophylaxis; trimethoprim, nitrofurantoin, cephalexin, or amoxicillin
is recommended by the National Institute of Health and Care Excellence
 Optimum duration of therapy is not available; most children receive at least 6
months to 2 years of prophylaxis Probiotics may have a role in reducing risk of
recurrent urinary tract infection in children with a normal urinary tract; however, results
have been conflicting and insufficient evidence exists to recommend for or against use
Data to support other treatment for children with recurrent infection and vesicoureteral
reflux are not convincing

 
o
 Invasive procedures aimed at diminishing backflow of urine from
bladder toward kidneys are reserved for patients with recurring
symptomatic infections unimproved by other less invasive
preventive measures and include:
  Surgery to reimplant the ureter
 Injection of agents to increase stiffness of the ureter

 Long-term view

 Complications after uncomplicated cystitis are rare

Complications after pyelonephritis

 Overall, very few children (less than 5%) will develop hypertension; end stage
renal failure is exceedingly rare

Renal parenchymal scarring occurs in about 15% of children overall after the first
episode of infection
 Future hypertension occurs in 10% to 30% of children (possibly more) with renal
parenchymal scarring Other long-term consequences of renal scarring are not well
described Risk of renal scarring in children younger than 1 year is up to 43% after first
infection
 Future development of renal scarring is predicted by any 1 of the following:

 
o
 Initial fever (higher than 39 °C)
 Causative organism other than Escherichia coli
 Abnormal ultrasonographic finding
 Polymorphonuclear cell count of 60% or higher
 C-reactive protein level of 40 mg/L or higher
 Vesicoureteral reflux (grade 3 or higher)

 Impaired renal function

 Proteinuria
 Chronic renal insufficiency requiring transplant is extremely rare

 Child with normal kidneys is not at risk for developing end-stage renal disease

End-stage renal disease caused by recurrent childhood urinary tract infections occurs in
0.3% of patients


o
 Chronic pyelonephritis

Prognosis

 Most children have no long-term sequelae

Screening and Prevention

Screening
At-risk populations

 Patients scheduled for invasive urologic procedures must undergo urinalysis to

exclude urinary tract infection

Screening tests

 Urinalysis (dipstick or microscopic)

Prevention

 American Academy of Pediatrics notes the health benefits of circumcision but

recognizes that ultimately, the decision remains with the parents

Encourage breastfeeding, which is preventive Avoid and treat voiding dysfunction

  Encourage healthy bladder habits including fully emptying bladder and not
withholding urine
 Encourage regular bowel movements and treat constipation

 Apply topical corticosteroid to prepuce in males with physiologic phimosis Avoid

unnecessary antibiotic use

  Disturbances in normal periurethral flora fosters potential uropathogen

colonization

 Adolescents

 Encourage condom use if sexually active; discuss risk of sexually transmitted

disease due to unprotected intercourse

Other harmless, yet unproven, recommended preventive measures that may decrease
risk include:

 Drinking enough fluid

Avoiding bubble baths Improving cleaning methods after bowel movements and proper
perineal hygiene
 Frequently changing diapers to avoid prolonged perineal exposure to urine and feces
 Consuming cranberry juice