Urinary Tract Infection
in the pediatric patient
Meaghan Eddy, RN, BSN
FNP student
Definition
• Includes bacterial infection of any
structure within the urinary tract
• A majority of UTI’s are located in the
bladder or urethra
• The higher up the Urinary tract, the
more serious
Severe and recurrent infections may lead to:
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Renal scarring
Hypertension
End-Stage Renal Dysfunction in adulthood
May be life threatening
in the neonate/infant
Common Pathogens
• E. Coli- the most common cause of
uncomplicated UTI. Estimates range from 7595% on infections
• Staphylococcus saprophyticus- generally
more aggressive, more likely to evolve to a
pyelonephritis or result in recurrent UTIs.
• Entereobacteriaceae such as proteus and
klebsiella less common
• Group B strep- more in neonates
History/ROS
• Previous UTI’s?
• Hygiene habits?
• Voiding/Bowel habits? (frequency, dribbling, weak urinary stream, daytime enuresis)
• Sexual activity, sexual abuse
• Family history of VUR, recurrent UTI, kidney problems?
• Presence of diaper rash, pinworms?
Physiologic predisposition
Uti should be a top differential in children with known:
• Known vesicoureteral reflux
• Congenital malformations of urinary tract structures
• Disturbances in neurologic function such as a myelomeningeoceal, hydrocephalus,
cerebral palsy
Risk Factors in General Population
• Caucasians (2-4x higher than AA)
• Females (2-4x higher than circumcised males)
• Preterm and Low Birth-weight infants
• Uncircumcised males during first year of life
• Bottle-fed infants (lack of IgA provided in breastfeeding to fight mucosal
invasion by bacteria)
Risk Factors Cont’d
• Familial Predisposition
• Sexual Activity, specifically use of spermicidal condoms/foams
• Dysfunctional Voiding
cause in 40% of toilet trained children with first UTI, 80% in those with recurrent UTI
Clinical Findings
(by age group)
Neonates
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Jaundice
Hypothermia
FTT
Sepsis
Vomiting/Diarrhea
Cyanosis
Abdominal Distension
Lethargy
Infants
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Malaise
Irritability
Difficulty Feeding
FTT
Fever (esp. in pyelonephritis)
Vomiting/Diarrhea
Malodorous Urine
Abdominal Pain/colic
Toddlers/Preschoolers
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Changes to voiding pattern
Malodorous urine
Abdominal/Flank pain (esp. in pyelonephritis)
Enuresis
Vomiting/diarrhea (esp. in pyelonephritis)
Fever
Diaper rash if not potty trained
School-Age to Adolescence
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Frequency, Urgency, Discomfort
Malodorous Urine
Abdominal/Flank Pain (esp in pyelonephritis)
Suprapubic tenderness
Fever/Chills (esp. in pyelonephritis)
Malaise
Vomiting/diarrhea (esp. in pyelonephritis)
Other physical exam findings
• Females may have vaginal erythema,
edema, irritation, or discharge; presence
of labial adhesions
• Parents may report a weak, dribbling
stream with urination
• Presence of sacral dimpling, decrease in
perineal sensation, decrease in lower
extremity reflexes
Diagnostic studies
Urine Specimen
not all collection methods are created equal!
Suprapubic bladder aspiration
-99% accurate
-should consider in very ill children
Clean catch
-catch midstream void
-first morning’s urine
-refrigerate until culture
-have female sit backward on
toilet to separate labia and
decrease contamination
Bag collection
-high degree of contaminants
-only useful to rule out UTI
Straight cath
-95% sensitivity
-should be used in very ill
children and infants
Pertinent findings on UA
**UA is not diagnostic**
• Cloudiness suspicious
• Leukocyte esterase: detects pyuria
• Nitrites- will only be present in urine sitting in
bladder >4 hours, with gram-negative bacteria
• presence of more than five white blood cells
• bacteria viewed per high-powered microscope
field of the spun urinary sediment
?? Differential Diagnosis ??
• Infants: bacteremia, meningitis
• Children: Vulvovaginitis, STI, Vaginal foreign body, Sexual
Abuse, Abdominal Disease, Renal Calculi, dysfunctional voiding,
dysuria-pyuria syndrome, appendicitis, pelvic abscess, pelvic
inflammatory disease
Urine Culture/Sensitivity
*Diagnostic of UTI*
Always order in presence of suspicious symptoms, even if UA is normal
Positive organism ID and sensitivity
Culture results of more than 100,000
cfu/ml, 50,000 in children 2-24mo per
AAP guidelines
Repeat culture if growth is around 10,000 cfu/ml unless
collected by aspiration/catheterization- then diagnostic
Additional Labs to think about:
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CBC
ESR
C-reactive Protein
BUN/Cr
Blood Cultures
If the child appears ill, is less than 12 months, or pyelonephritis is
suspected
Recommendations for anti-microbial therapy
Inpatient treatment Intravenous options:
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Ceftriaxone 75 mg/kg every 24 h
Cefotaxime 150 mg/kg/d divided every 6 h
Ceftazidime 150 mg/kg/d divided every 6 h
Cefazolin 50 mg/kg/d divided every 8 h
Gentamicin 7.5 mg/kg/d divided every 8 h
Tobramycin 5 mg/kg/d divided every 8 h
Ticarcillin 300 mg/kg/d divided every 6 h
Ampicillin 100 mg/kg/d divided every 6 h
Oral Antibiotic options
• Amoxicillin 20–40 mg/kg/d in 3 doses
• Sulfonamides:
-TMP in combination with SMX (6–12 mg TMP, 30–60 mg
SMX per kg per d in 2 doses)
-Sulfisoxazole 120–150 mg/kg/d in 4 doses
• Cephalosporins:
-Cefixime 8 mg/kg/d in 2 doses
-Cefpodixime 10 mg/kg/d in 2 doses
-Cefprozil 30 mg/kg/d in 2 doses
-Cephalexin 50–100 mg/kg/d in 4 doses
-Loracarbef 15–30 mg/kg/d in 2 doses
10-14 day
Courses with
Best cure rates
per AAP
Patient/Parent Education
(for the uncomplicated patient)
• Avoid bubble baths
• Avoid Tight fitting clothing (girls)
• Wipe “back to front”
• Don’t hold urine for long periods of
time
So, a UTI is diagnosed, antibiotics are started…. but
When is further testing needed?
• New AAP guidelines released August 2011
• Children ages 2-24 months included in the new guidelines
Options for further testing include:
Renal/bladder ultrasound
Voiding cystourethrography (VCUG)
Intravenous pyelogram (IVP)
DSMA scan
Children 2-24 months
• Ultrasound should be performed of kidneys/bladder for detection of anatomic
abnormalities in all pts.
• Perform U/S promptly if no improvement of symptoms after 48 hours of antibiotics
• VCUG no longer recommended after febrile UTI unless ultrasound is abnormal or this
is a recurrent problem
• No recommendations for prophylactic antibiotics in children with no VUR, or VUR
grades I-IV.
Children older than 24 months
• Recommendations vary greatly
• Most recommend ultrasound at minimum for any child with
pyelonephritis, suspicious factors such as HTN, weak urine stream, family
history of UTI, known abnormal voiding patterns
• VCUG recommended in children less than 5, with abnormal ultrasound,
presence of abnormal voiding before uti
• Consider VCUG in a febrile or highly complicated UTI
**VCUG should be done 4-6 weeks after infection is cleared**
Degrees of Vesicoureteral reflux
What Next?
• Consider DMSA scan to determine renal scarring in the presence of VUR
• Grades i-iv may spontaneously resolve, less likely in older children
• prophylactic antibiotics are recommended by Dept of Ped. Urology at
Johns Hopkins, not recommended by AAP for 2-24mo children.
recommendation is Bactrim/Septra
• Consider referral to Pediatric Urology
Prophylaxis options
TMP in combination with SMX
2 mg of TMP, 10 mg of SMX per kg as single bedtime dose
or 5 mg of TMP, 25 mg of SMX per kg twice per week
Nitrofurantoin 1–2 mg/kg as single daily dose
Sulfisoxazole 10–20 mg/kg divided every 12 h
Nalidixic acid 30 mg/kg divided every 12 h
Methenamine mandelate 75 mg/kg divided every 12
h
References
American Academy of Pediatrics. (2011). Practice
Parameter: The Diagnosis, Treatment, and Evaluation of
the Initial Urinary Tract Infection in Febrile Infants and
Young Children. Pediatrics, 103(4), 843-852.
Burns, C.E., Dunn, A.M., Brady, M.A., Starr, N.B., &
Blosser, C.G. (2009). Pediatric Primary Care (4th ed.). St.
Louis, MO: Saunders Elsevier
Johns Hopkins Medicine. (2012). Vesicoureteral Reflux.
Retrieved from
http://urology.jhu.edu/pediatric/diseases/reflux.php .