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Urinary Tract Infections In Children
Introduction
Urinary tract infection (UTI) is one of the most common bacterial infections in children. UTI is typically caused when bacteria ascend from the urethra into the urinary tract. Infection may occur anywhere from the urethra to the renal parenchyma. Upper tract UTI is a UTI involving the kidneys and ureters, whereas lower tract UTI is a UTI involving the bladder and urethra. Commonly used terms for UTI based on the location of infection are urethritis (infection limited to the urethral mucosa), cystitis (infection limited to the bladder), and pyelonephritis (infection further ascending to the kidneys).
Bacteria may be present in the urinary tract without causing inflammation and symptoms. This condition is called asymptomatic bacteriuria. Sterile pyuria is increased white blood cells in urine with no bacterial growth on urine culture.
Complicated UTIs are UTIs in newborns, urosepsis, a bladder and/or an abdominal mass, congenital anomalies of kidneys and the urinary tract (CAKUT), organisms other than Escherichia coli, atypical clinical course, renal abscess and absence of clinical response to an antibiotic within 72 hours.
Etiology
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Etiology
Colonic bacteria are typically responsible for UTIs. Escherichia coli is the most common organism, accounting for up to 85% to 90% of UTIs. Klebsiella, Proteus, Enterococcus, and Enterobacter species are other common causative organisms.[1][2]
Proteus spp is associated with renal stone formation, and organisms such as Pseudomonas spp, Staphylococcus aureus, and group B Streptococcus are usually associated with CAKUT, genitourinary surgery, catheterization, or recent antibiotic use. Enterococci are a common cause of catheter-associated UTIs.
Hematogenous spread to the urinary system can occur in newborns and children with immunodeficiency. Group B Streptococcus, Candida spp, Staphylococcus aureus, and salmonellae can spread through the hematogenous route and cause pyelonephritis.[3]
Epidemiology
Prevalence rates of UTI vary by gender, age, race, and circumcision status. UTIs affect 8.4% of girls and 1.7% of boys before 7 years of age. The incidence of UTI peaks during infancy for females and males, around the time of toilet training, and at the beginning of sexual activity in girls. The significant risk factors of UTI in children are female sex, younger age, white race, uncircumcised infant boy, duration of fever, high-grade vesicoureteral reflux (VUR), previous history of UTIs, CAKUT, bowel and bladder dysfunction (BBD), spinal dysraphism and indwelling bladder catheterization. Additional risk factors in older children and adolescents are sexual activity, pregnancy, the presence of kidney stones, immune deficiency, and diabetes. The use of prior antibiotics, particularly with penicillin or ampicillin, also increases the risk of UTI.[4]
Approximately 7% of infants with a fever may have an underlying UTI as the cause.[5] Females younger than 1 year of age and uncircumcised male infants younger than 3 months of age have the highest prevalence of UTI.[5] The prevalence of UTI in male infants is markedly affected by circumcision status. Uncircumcised febrile male infants younger than 3 months of age have a 20% risk of UTI, compared to a 2.4% risk of circumcised male infants.
The University of Pittsburgh recently developed a UTI calculator to help physicians estimate the probability of UTI in febrile young children (2 to 23 months of age). It is based on risk factors: age younger than 12 months, female sex or uncircumcised male, absence of another source for fever, duration of fever longer than 48 hours, history of UTI, and maximum temperature >39 °C. This calculator decreased unnecessary testing, missed diagnoses, and treatment delays. It helped in tailoring treatment and improved outcomes.[6]
The 2 risk factors shown to have the highest 2-year recurrence rate are VUR and BBD, with the combination of both leading to an even higher risk.[7]
There is little evidence that showed any difference in the child's wiping technique from front to back vs back to front. Encopresis without constipation and bubble baths have not been established to cause UTI.
Pathophysiology
Frequent flushing of the urinary tract is the primary defense mechanism against UTI. Uropathogenic E. coli (UPEC) strains possess extraintestinal virulence attributed to distinct antigens and genes that increase their virulence. Key virulence factors for UPEC include P-fimbriae, toxins, protectins, and siderophores. UPEC's ability to adhere to the uroepithelium is due to fimbriae on the cell surface, which adhere to the host epithelium in a lock-and-key pattern. This adhesion disrupts the regular flushing action of urine flow and emptying.[8]
Constipation is believed to cause bladder and bladder neck compression, leading to increased bladder storage pressure and postvoid residual urine volume. Additionally, a distended colon or fecal soiling creates a substantial reservoir of pathogens in the colon.
Sexual intercourse, pregnancy, infrequent voiding patterns, history of cystitis, VUR, anatomic abnormalities, urolithiasis, and the presence of a foreign body can increase the risk of cystitis in adolescents.
History and Physical
Presentation symptoms vary with age and site of infection in the urinary tract. Infants, during the first 3 months of life, exhibit symptoms that include fever, vomiting, hypothermia, jaundice, difficulty feeding, failure to thrive, and/or irritability. In young children under 2 years of age, symptoms are nonspecific and generally present late due to the inability to express symptoms or localize pain. Fever with no apparent source is the most common presentation of UTI during the first 2 years of life. Older children are more able to localize and report specific symptoms associated with UTIs.[3]
A focused history and physical examination with positive urinary findings are essential for a definitive diagnosis of UTI. The history of symptoms is based on the location of inflammation within the urinary tract.
Urethritis presents with dysuria, pruritus, or urethral discharge.
Acute cystitis presents with symptoms of dysuria, hematuria, urgency or frequency, cloudy or malodorous urine, and suprapubic pain.
Acute pyelonephritis presents with symptoms of fever, flank pain, abdominal pain, vomiting, or other systemic findings.
Other pertinent history items include a history of constipation, symptoms of voiding dysfunction, a previous history of UTI, and recent antibiotic treatment.
Relevant signs on examination include abdominal distention, a distended bladder, a flank mass consistent with hydronephrosis, palpable stool, costovertebral angle tenderness, and/or suprapubic tenderness.
Evaluation
Nonspecific symptoms make diagnosis of UTI challenging in younger children, and a definite diagnosis requires an uncontaminated urine sample. Common methods for urine sampling in non-toilet-trained children include bagged specimens, midstream clean catch, catheterization, and suprapubic needle aspiration.
The "Quick-Wee" method has been reported, in which cold (2.8°C), saline-soaked gauze is rubbed onto the suprapubic area of non-toilet-trained children to stimulate urination and obtain a noncontaminated urine specimen.[9][10]
Urine test strip or dipstick analysis is only validated for ruling in or out infection provided nitrite (a marker of some gram-negative bacteria) and leucocyte esterase (LE), a marker of WBCs, are used in combination.[11] The presence of blood and/or protein on a urine dipstick test is not a reliable indicator of UTI.
Urine Collection: Urine sampling with a bag should only be analyzed for urinalysis (UA) and not culture, as the bacteria growing on the skin in the genital area but not in the urinary tract could potentially contaminate the bagged specimen. When evaluating UTIs in younger children, the physician can review the pros and cons of urine collection through bag vs catheterization. Urine obtained using a bag can be painless but may take time for the infant to void and, if abnormal, can proceed to catheterization to confirm. Urine obtained using a catheterization can be painful, but it is quick, has less risk of contamination, and can be sent for culture.
The diagnosis of a UTI is not reliably achieved through a urine culture collected using a bagged specimen.[12] Cultures of urine samples obtained via perineal bag application demonstrate unacceptably high false-positive results and are considered valid only when they yield negative outcomes. The urine specimen should be obtained for both UA and culture before administering the antibiotic.
In older, toilet-trained children, midstream urine specimens can be obtained in a sterile cup after cleaning the skin around the genital area. Gentle retraction of the prepuce (if possible) is important to obtain an uncontaminated specimen in uncircumcised boys.
Suprapubic needle aspiration of urine from the bladder is less commonly used because it is painful, and the success rate is low. The UA should be performed within 1 hour at room temperature or 4 hours of refrigerated sample.
Interpretation of UA
Leucocyte esterase: LE is an enzyme produced by leucocytes or white blood cells (WBC) and can be found in the urine if leucocytes are active (pyuria). The results are typically reported semiquantitatively (negative, trace, 1+, 2+, and 3+). The LE result can be a false negative in neutropenic patients and in younger children who frequently void.
Various organisms have been linked to varying levels of pyuria; specifically, Enterococcus species, Klebsiella species, and Pseudomonas species appear to cause infection even in the absence of significant pyuria.[13] Many children with a fever and an infection outside of the urinary tract may also have pyuria; thus, the test's sensitivity and specificity are low (see Table 1. The Sensitivity and Specificity of Findings on UA).
Nitrites: Nitrites are generated in the bladder through the metabolic action of gram-negative bacteria on dietary nitrate. The effectiveness of nitrite testing can also be influenced by age, as younger children tend to void more frequently, which reduces the time available for nitrite accumulation before urine sampling. Initial research studies indicate that a bladder dwell time of 4 hours is required to convert dietary nitrates into nitrites.[14] Furthermore, it is worth noting that certain bacteria, such as Pseudomonas species and gram-positive organisms like Enterococcus, do not participate in the conversion of urine nitrates to nitrites. Thus, when compared to LE, nitrites have lower sensitivity but higher specificity in diagnosing UTI.[15]
Microscopy: In most laboratories, detecting nitrites or LE will automatically initiate a microscopic examination for the presence of bacteria, WBCs, and red blood cells (RBCs). Uninfected urine should not show visible bacteria on microscopy. Therefore, the presence of bacteria observed under high-field microscopy strongly correlates with bacteriuria and UTIs. Additionally, a urine sample with more than 5 WBCs per high-power field (hpf) or 25 WBCs per microliter (µL) is considered abnormal and highly indicative of a UTI in symptomatic patients. The presence of pyuria helps in distinguishing a true UTI from asymptomatic bacteriuria.
Sterile pyuria: This condition consists of white cells in urine in the absence of bacteria on the urine culture. It can be caused by dehydration, vigorous exercise, a partially treated UTI, viral, fungal, or parasitic infections, streptococcal infections, sexually transmitted infections, pelvic inflammatory disease, tuberculosis, and appendicitis (when an inflamed appendix is too close to the bladder). It can also occur with immunologic conditions, such as Kawasaki disease, acute glomerulonephritis, systemic lupus erythematosus, or with kidney stones, foreign body, analgesic nephropathy, interstitial nephritis, and papillary necrosis.[16]
Table 1. The Sensitivity and Specificity of Findings on UA, Alone and in Combination- Adapted from the AAP Urinary Tract Infection Guidelines [15]
| Urinalysis Findings | Sensitivity | Specificity |
| Leukocyte esterase test | 83 (67–94) | 78 (64–92) |
| Nitrite test | 53 (15–82) | 98 (90–100) |
| Leukocyte esterase or nitrite test, positive findings | 93 (90–100) | 72 (58–91) |
| Microscopy, white blood cells | 73 (32–100) | 81 (45–98) |
| Microscopy, bacteria | 81 (16–99) | 83 (11–100) |
| Leukocyte esterase test, nitrite test, or microscopy, positive findings | 99.8 (99–100) | 70 (60–92) |
Urine Culture: The AAP defines the diagnosis of a UTI to include clinical symptoms, UA with evidence of inflammation (at least 5 WBC per hpf or LE), and urine culture results with at least 50,000 CFU/mL of a uropathogenic organism.[15] The diagnostic bacterial account for UTI depends on the urine sample collection method, requiring >100,000 colony forming units (CFU)/mL for mid-stream urine specimens, >50,000 CFU/mL for catheterization, and only >1000 CFU/mL for suprapubic aspiration.[17]
Asymptomatic bacteriuria is the presence of significant growth of a single uropathogen in an appropriately collected urine specimen without inflammation or pyuria and symptoms of UTI.[18][19] Children with neurogenic bladder dysfunction (eg, spina bifida and spinal cord injury), indwelling urinary catheters, and those using clean intermittent catheterization have high rates of pyuria and asymptomatic bacteriuria. The presence of bacteriuria only in these patient cohorts is not diagnostic of a UTI.[19]
As per the AAP guidelines, if the UA results indicate the possibility of a UTI, which includes positive findings of LE or nitrite tests or microscopic analysis revealing leukocytes or bacteria, it is advisable to obtain a urine specimen through catheterization or suprapubic aspiration for culture. However, in cases where the UA of freshly collected urine (within 1 hour since void) shows negative results for LE and nitrite tests, it may be reasonable to monitor the patient's clinical condition without initiating antimicrobial therapy. It is important to acknowledge that negative UA results do not entirely rule out the presence of a UTI. The incidence of coexisting bacterial meningitis is infrequent in neonates with UTIs. Neonates with UTI who appear well, along with a procalcitonin value <0.35 ng/mL, are at a low risk for bacterial meningitis. In such cases, avoiding routine lumbar punctures in these neonates may be worth considering.[20]
Blood tests are not routinely ordered in patients with UTI. Patients with acute pyelonephritis may have an elevated WBC count and other nonspecific markers of inflammation, such as erythrocyte sedimentation rate, C-reactive protein, and procalcitonin. These markers can help differentiate pyelonephritis from cystitis; however, these markers are neither sensitive nor specific to confirm or rule out the diagnosis of pyelonephritis. Compared to C-reactive protein and leucocytosis, procalcitonin is more predictive of acute pyelonephritis during the early phase of infection and late renal scarring identified by DMSA scans.[21]
Renal Ultrasound: A renal ultrasound examination is advised in all young children with a first febrile UTI and in older children with recurrent UTI. Ultrasonography of the kidneys and bladder should be performed to detect anatomic or structural abnormalities.[15] The timing of the ultrasonographic examination depends on the clinical situation. Children who are very ill or who do not improve as expected (generally within 12 to 36 hours) should undergo ultrasonography within the first few days to assess them for an obstructive anatomic abnormality or renal abscess. Children with less severe infections can undergo ultrasonography after the acute phase of the infection has passed to reduce false positive findings from renal inflammation, which can persist for 1 to 2 weeks.
Voiding Cystourethrography: A voiding cystourethrogram (VCUG) is the preferred diagnostic test to confirm the presence of vesicoureteral reflux (VUR) and to assess its severity. However, routine VCUG is NOT recommended after the first UTI.[15] It should ONLY be considered when renal and bladder ultrasonography identifies hydroureter, hydronephrosis, scarring, or other suggestive findings or in case of a recurrent febrile UTI.
It may be considered after the first UTI, especially in atypical pathogen or complex clinical scenarios.[17] In neonates with a history of antenatal hydronephrosis, a VCUG is indicated if there is moderate to severe hydronephrosis, ureteral dilation is observed on postnatal ultrasonography, or in the presence of bladder abnormalities suggestive of bladder outlet obstruction. Routine VCUG after a first febrile UTI may not be justified due to its invasive nature, cost, discomfort, potential UTI risk, and radiation risks. This test should be considered in cases of recurrent UTI and upper tract abnormalities on ultrasound to identify patients with VUR.
VUR is graded as low-grade (I-III) and high-grade (IV-V). The International Reflux study group classifies VUR into 5 grades as follows: [22]
- Grade I: Reflux into the middle of the ureter without dilation
- Grade II: Reflux into the ureter and collecting system without dilation
- Grade III: Reflux into the ureter and collecting system with mild dilation and mild blunting of calyces
- Grade IV: Reflux into the ureter and collecting system with gross dilation and severe blunting of calyces
- Grade V: Massive reflux with gross dilation of ureter and collecting system, blunting of all calyces, and tortuosity of the entire collecting system
Contrast-Enhanced Voiding Urosonogram: To limit radiation exposure in children needing VCUG, a contrast-enhanced voiding urosonogram (ceVUS) has been offered as an alternative. This test requires bladder catheterization, which is an unpleasant experience for young patients. Contrast material must be instilled, and the patient will be asked to void on command while scanned with ultrasound. False-negative results are reported in 3% of patients. The lack of availability in all centers should not deter physicians from considering ceVUS in situations where VUR and obstructive uropathies can be diagnosed in real-time with no radiation.[23][24]
Dimercaptosuccinic Acid Scan: A renal scan using 99m technetium-dimercaptosuccinic acid (DMSA) may be considered in children with renal parenchymal abnormalities on ultrasound or recurrent febrile UTIs. A DMSA scan is the gold standard for diagnosing acute pyelonephritis and renal scarring; however, it is not advised for routine care of acute pyelonephritis. This test should be performed 6 months after acute infection to diagnose renal scarring (reflux nephropathy) following acute pyelonephritis.[15][25]
Treatment / Management
Urine culture results usually take 12 to 24 hours before bacterial growth results, another 1 day before the specific bacteria is identified, and 2 to 3 days before the final susceptibilities of bacteria are available. Antibiotics should be empirically initiated in patients with suspected UTIs after UA and before culture results to resolve the infection promptly. The choice of oral antibiotic should be tailored based on bacterial susceptibility results.
At present, the preferred treatment options for acute uncomplicated UTIs consist of second or third-generation cephalosporins or amoxicillin-clavulanate. The American Academy of Pediatrics (AAP) provides guidelines regarding suggested empirical antibiotic agents for the treatment of UTIs.
When it comes to management, parenteral antibiotic therapy is recommended for infants aged 2 months or younger and for any child who exhibits a toxic appearance, bacteremia and/or sepsis, hemodynamic instability, immunocompromised status, an inability to tolerate oral medications or a lack of response to oral medication (see Table 2. Empirical Antibiotic Agents for Parenteral Treatment of UTI).
For UTIs, including acute pyelonephritis, oral antibiotics alone demonstrate equivalent efficacy to intravenous (IV) antibiotics if the patient is nontoxic. If IV antibiotics are deemed necessary, transitioning the patient to oral antibiotics is recommended as soon they improve clinically and tolerate oral medications (see Table 3. Empirical Antibiotic Agents for Oral Treatment).
Table 2. Empirical Antibiotic Agents for Parenteral Treatment of UTI - adapted from AAP Urinary Tract Infection Guidelines [15](A1)
| Antibiotic medication | Suggested dosage and frequency of administration |
| Ceftriaxone | 75 mg/kg, every 24 h |
| Cefotaxime | 150 mg/kg per day, divided every 6–8 h |
| Ceftazidime | 100–150 mg/kg per day, divided every 8 h |
| Gentamicin | 7.5 mg/kg per day, divided every 8 h |
| Tobramycin | 5 mg/kg per day, divided every 8 h |
| Piperacillin | 300 mg/kg per day, divided every 6–8 h |
Table 3. Empirical Antibiotic Agents for Oral Treatment of UTI - adapted from AAP Urinary Tract Infection Guidelines [15](A1)
| Antibiotic medication | Suggested dosage and frequency of administration |
| Amoxicillin clavulanate | 20–40 mg/kg per day in 3 doses |
| Sulfonamides | |
| Trimethoprim-sulfamethoxazole (TMP-SMX, should not be used in infants less than 2 mo of age) | 6–12 mg/kg trimethoprim and 30–60 mg/kg sulfamethoxazole per day in 2 doses |
| Sulfisoxazole | 120–150 mg/kg per day in 4 doses |
| Cephalosporins | |
| Cefixime | 8 mg/kg per day in 1 dose |
| Cefpodoxime | 10 mg/kg per day in 2 doses |
| Cefprozil | 30 mg/kg per day in 2 doses |
| Cefuroxime axetil | 20–30 mg/kg per day in 2 doses |
| Cephalexin | 50–100 mg/kg per day in 4 doses |
First-generation cephalosporins, such as cephalexin, typically offer effective coverage against uropathogens and are well-tolerated, readily available, and cost-effective. However, they require administration at least 3 times a day. Trimethoprim-sulfamethoxazole (TMP- SMX) is another well-tolerated and inexpensive option, with a dosing regimen of twice daily.
Nitrofurantoin is effective against uropathogens but is not suitable for treating pyelonephritis, particularly in younger children, as it does not penetrate renal parenchyma or the bloodstream effectively. It's important to note that in certain areas, there has been an increase in resistance to this antibiotic in recent years.
Length of Antibiotic Treatment
The length of antibiotic treatment should be based on the child's age and the severity of the presentation, including whether it affects the lower or upper urinary tract.
For infants, toddlers younger than 24 months, and older children with pyelonephritis, antibiotics are recommended for 7 to 14 days.
For older children with cystitis, a 3 to 7-day antibiotic course may be sufficient. A 2 to 4-day course of oral antibiotics works just as effectively as a 7 to 14-day course for children with cystitis.
Children with acute pyelonephritis can be treated with oral antibiotics for 10 to 14 days or with IV antibiotics for 2 to 4 days, followed by oral therapy.[12] (A1)
Asymptomatic bacteriuria should not be generally treated except during pregnancy, as they may develop acute infection leading to pyelonephritis. Pregnant women with asymptomatic bacteriuria need treatment with antibiotics for 3 to 7 days, and appropriate treatment decreases the risk of premature birth and low birth weight.
Management of Recurrent UTI
The management of recurrent UTIs involves the identification and management of risk factors, including CAKUT and BBD. Patients with recurrent UTIs should be evaluated by renal ultrasound to check for any signs of obstructive uropathy. A VCUG is used to diagnose and grade VUR.
Preventing UTI by screening and treating BBD is underappreciated, safe, and effective. Inquiring about constipation symptoms, daytime wetting, and withholding behaviors will help identify children with bowel or bladder dysfunction.[26] It is important to optimize bowel and bladder function and personal hygiene by behavioral interventions. This includes maintaining adequate hydration to enhance bladder cycling, adhering to timed voiding schedules every 3 to 4 hours, and engaging in pelvic floor muscle training with/without biofeedback therapy. The initial approach to treat constipation in children involves increasing fiber intake, ensuring proper hydration, and using stool softeners.[27] Polyethylene glycol is the most common stool softener prescribed in children. Additionally, children are encouraged to sit on the toilet for 10 minutes following meals to take benefit of the gastrocolic reflex. If these measures do not effectively address constipation, further interventions such as retrograde enemas, anterograde continence enemas, and disimpaction procedures may be considered. There is a lack of substantial evidence to support the recommendation of cranberry juice in preventing UTIs.[28](A1)
Recurrent UTI is defined as 2 or more UTIs in 6 months or 3 within 1 year. More than 30% of children who experience UTI will have recurrent UTI. Antibiotic prophylaxis decreases the risk of recurrent UTIs in children with VUR but not of renal scarring.[29] It is important for the healthcare professional to advise parents to promptly seek medical evaluation in the event of any future febrile illnesses in a child with recurrent UTIs to ensure early detection and timely treatment (within 48 hours) to limit renal damage.(A1)
Antibiotic prophylaxis is indicated in children with grade III or higher VUR, VUR with recurrent UTI, VUR in patients with BBD, and non-toilet-trained children with any grade of VUR.[30]
TMP-SMX is bactericidal and preferred for prophylaxis in children with VUR.
Nitrofurantoin is bacteriostatic and is indicated for children with sulfa allergy and those having breakthrough infections with TMP-SMX prophylaxis.
Amoxicillin prophylaxis is recommended for infants younger than 2 months because both TMP/SMX and nitrofurantoin interfere with hepatic conjugation and increase the risk of hyperbilirubinemia.
Prophylaxis with TMP-SMX can reduce the likelihood of UTI recurrence by 50%.
Antibiotic resistance is a major risk of long-term prophylaxis; hence, it should be used carefully.[31]
The prophylactic dose of antibiotics is generally one-quarter to one-half of the therapeutic dose for acute infection (see Table 4. Suggested Dosages of Antibiotics Commonly Used for Prophylaxis).[32]
Table 4. Suggested Dosages of Antibiotics Commonly Used for Prophylaxis
| Antibiotic agent | Suggested prophylactic dosage |
| TMP-SMX | TMP 2 mg/kg as a single daily dose or 5 mg/kg of TMP twice a week |
| Nitrofurantoin | 1 to 2 mg/kg as a single daily dose |
| Cephalexin | 10 mg/kg as a single daily dose |
| Ampicillin | 20 mg/kg as a single daily dose |
| Amoxicillin | 10 mg/kg as a single daily dose |
Surgical intervention is typically considered for children with persistent VUR when they continue to experience breakthrough infections with a risk of renal scarring despite receiving antibiotic prophylaxis. Surgical correction of VUR aims to prevent the backward flow of urine from the bladder into the ureters and kidneys, reducing the risk of UTIs and renal damage.
Two notable surgical approaches are commonly employed to address VUR. The first approach is an endoscopic injection for VUR (ambulatory cystoscopic injection of a bulking agent, typically dextranomer and hyaluronic acid [Deflux ®]), which is a less invasive option and is suitable for lower-grade VUR. The second approach is ureteric reimplantation (open, laparoscopic, or robotic-assisted), which involves surgically enhancing the antireflux mechanism and is a more invasive surgical option but with a higher success rate, suitable for persistent high-grade VUR.[17]
Circumcision has been observed to lower the occurrence of UTIs in boys with a history of antenatal hydronephrosis during the first year of life.[33] (A1)
Differential Diagnosis
Based on the location of inflammation in the urinary tract, clinical presentation varies in urethritis, cystitis, and acute pyelonephritis (see Table 5. Differentiating Acute Pyelonephritis from Cystitis).
Table 5. Differentiating Acute Pyelonephritis from Cystitis [26]
|
Age distribution |
Acute Pyelonephritis more common in younger children |
Cystitis more common in children older than 2 years |
| Fever | >38°C | Afebrile or low-grade fever ≤38°C |
| Recent viral illness | N/A | Viral cystitis |
| Systemic symptoms (fever, vomiting) | Common | Uncommon |
| Local symptoms | Flank pain or flank tenderness | Dysuria, frequency, urgency, suprapubic pain, urinary incontinence, and/or hematuria |
| Causative agent | Bacterial (E. coli is the most common) | Bacterial (E. coli - most common), viral, chemical, and fungal |
| Urinary Findings | ||
| Gross hematuria | Uncommon | May have blood/clots |
| Urine culture for bacteria | Positive | Positive in bacterial cystitis, Negative results in viral, chemical, and fungal cystitis |
| Renal ultrasound | Normal or may reveal hyperemia or edema of the kidney | Normal/thickened urinary bladder wall, with/without debris |
| Renal complication | Renal scarring | None |
Other differential diagnoses include viral infection, renal stones, orchitis, epididymitis, sexually transmitted infections, appendicitis, and pelvic infection.
Prognosis
The majority of children who experience UTI have a good outcome and usually do not suffer long-term damage to their urinary tract as a result of the infection. Routine follow-up UA and urine culture after the resolution of UTI symptoms is not necessary unless clinically required.[34]
When bacteria from the urinary tract enter the bloodstream, it can lead to urosepsis and meningitis. Neonates and immunocompromised children are particularly vulnerable to systemic infections.
Complications
Acute complications from UTI are similar to those of any febrile illness, such as dehydration and electrolyte abnormalities.
The long-term complications of acute pyelonephritis and persistent VUR are renal scarring and reflux nephropathy. The prevalence of renal scarring after febrile UTI is approximately 15%.[35] Children with reflux nephropathy are at risk of developing microalbuminuria, proteinuria, hypertension, or chronic kidney disease later in their lives. Bilateral reflux nephropathy can progress to chronic kidney disease, ultimately leading to end-stage renal disease necessitating dialysis and renal transplantation.
Consultations
Consultations for UTIs in children may include the following:
- General pediatrics
- Pediatric hospital medicine
- Pediatric nephrology
- Pediatric urology
- Pediatric infectious diseases
- Pediatric radiology
- Epidemiology
Deterrence and Patient Education
Parents of children born with antenatal hydronephrosis should be educated about the increased risk of UTI, symptoms suggestive of UTI, and the need to seek medical advice and test urine if the child exhibits any of these symptoms.
Parents of newborn males who are diagnosed with antenatal hydronephrosis should be educated on the benefits of circumcision in reducing UTIs.
In boys with phimosis, circumcision may be necessary to prevent recurrence of UTI. In boys who are not circumcised, gentle retraction and cleaning should be performed daily.
Children and their caregivers should be informed of the importance of maintaining adequate hydration, continuing timed voiding schedules, and increasing fiber intake in case of BBD. Clinicians should actively screen for and manage BBD in older children. This proactive approach to handling these dysfunctions significantly reduces the risk of UTIs. BBD is a common yet often underappreciated contributor to recurrent UTIs.
Patients with UTIs should be informed about taking their antibiotics as prescribed and not stopping halfway, even if they feel better.
Parents of children with recurrent UTIs should be advised to promptly seek medical evaluation in the event of any future febrile illnesses to ensure early detection and timely treatment (within 48 hours) to limit renal damage.
Children with recurrent UTIs and high-grade VUR should be advised to take prophylactic antibiotics as prescribed by their physician.
Sexually active female adolescents should be advised to void right after sexual intercourse as it helps flush the bacteria out of the bladder.
Enhancing Healthcare Team Outcomes
Caring for children with UTIs necessitates a collaborative approach among healthcare professionals to ensure appropriate patient care and improve overall outcomes. Emergency medicine physicians, critical care physicians, pediatric advanced care practitioners, nurses, pharmacists, and other health professionals involved in the care of these patients should possess the essential clinical knowledge and skills to diagnose and manage UTIs accurately. This includes expertise in recognizing the varied clinical presentations and understanding how to interpret UA and urine culture results. The team approach, coupled with appropriate clinical knowledge, has improved early detection and management of pediatric UTIs.
Patient and caregiver education about prophylactic antibiotic compliance is essential to prevent morbidity from recurrence. The key to preventing recurrences is patient education. Once a UTI has been diagnosed, the patient should be encouraged to drink more fluids and should be on an optimal bowel regimen in cases of constipation. Primary care pediatricians should refer children with recurrent UTIs to the nephrologist and urologist to rule out reflux and other anatomical defects and to further manage the patient.
Efficient interprofessional communication holds a central role, facilitating seamless information exchange and collaborative decision-making among team members. Care coordination is pivotal in ensuring that the patient's journey, from diagnosis to treatment and follow-up, is well-managed, thus reducing errors and enhancing overall patient safety. By embracing these core principles of expertise, strategy, responsibility, interprofessional communication, and care coordination, healthcare professionals can deliver patient-centered care. This approach ultimately leads to improved patient outcomes and enhances team performance in the management of UTIs in children.
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