- 351 -
20.
URINARY TRACT INFECTIONS
Mark Schuster, M.D., Ph.D.
This review is based on textbooks of pediatrics (Roth and Gonzales
in Oski et al., 1994), pediatric primary care (Woodhead in Dershewitz,
1993), and pediatric infectious disease (Marks and Arrieta in Feigin and
Cherry, 1992).
Several articles were also identified from the textbook
bibliographies and from a MEDLINE search of English-language review
articles on urinary tract infections (UTIs) and pyelonephritis in
pediatric age groups published between January 1990 and March 1995.
IMPORTANCE
The urinary tract ranks second only to the upper respiratory tract
as a source of morbidity from bacterial infection in children (Roth and
Gonzales in Oski et al., 1994).
About one percent of boys and three
percent of girls will have had a symptomatic UTI by their eleventh
birthday (Stull and LiPuma, 1991).
Most UTIs are successfully treated without significant sequelae
(Zelikovic et al., 1992).
However, vesicoureteral reflux (VUR) of
infected urine into the renal parenchyma (also known as reflux
nephropathy) can cause renal scarring.
Reflux-associated scarring is
the most common single cause of renal hypertension and chronic renal
failure in children (White, 1990); it can also cause growth failure.
Once renal scarring has occurred, no remedial or preventive measures can
be taken (Treves, 1994).
Up to 50 percent of children younger than five years old who have
UTI and fever (which is common with UTI) also have VUR, and over 80
percent of children younger than five years old who have recurrent UTI
and persistent VUR develop renal scarring (Woodhead in Dershewitz,
1993).
Most renal scars seem to appear before five years old, though
new scar formation and progression of scarring have been shown in older
children (Andrich and Majd, 1992).
Timely identification of acute
infection, appropriate treatment, detection of patients at risk for
renal scarring, and prevention of recurrent infection can greatly reduce
- 352 -
the risk of an adverse outcome (Woodhead in Dershewitz, 1993).
management thus has two primary aims:
UTI
the relief of symptoms and the
prevention of renal damage (White, 1990).
EFFICACY AND/OR EFFECTIVENESS OF INTERVENTIONS
Screening
There is no consensus on whether asymptomatic children should be
screened routinely for bacteriuria (bacteria in the urine).
Kemper and
Avner (1992) make the case that because of high costs and false positive
rates, routine screening of asymptomatic preschool children with
urinalysis (UA) should not be done.
Diagnosis
Infants with a UTI may have nonspecific symptoms such as fever,
irritability, and other signs of systemic illness, including failure to
thrive, vomiting, and diarrhea.
Signs of bladder obstruction such as
abdominal distention, weak or threadlike urinary stream, infrequent
voiding, and discolored or malodorous urine may be present (Woodhead in
Dershewitz, 1993).
Decreased feeding, lethargy, jaundice, hepatomegaly,
and splenomegaly may also be present.
A child with UTI may also be
asymptomatic (Lebel in Oski et al., 1994).
Febrile infants without an
apparent source of fever should be evaluated for UTI (Stull and LiPuma,
1991).
UTIs are diagnosed in 7.5 percent of infants less than two
months who have fever (Lebel in Oski et al., 1994).
Infants with UTI
should be evaluated for other potential sources of infection with
examination of blood and cerebrospinal fluid (Sherbotie and Cornfeld,
1991; Lebel in Oski et al., 1994).
Preschool children may complain of voiding discomfort, or they may
develop recurrent (secondary) enuresis, in addition to fever and
abdominal or flank pain.
School-age children typically have "classic"
signs and symptoms of UTI, including dysuria, frequency, urgency,
abdominal or flank pain, and fever (Woodhead in Dershewitz, 1993).
Hematuria may occur with UTI (Marks and Arrieta in Feigin and Cherry,
1992a).
An association between sexual abuse and UTIs has been proposed
but has not been demonstrated (Stull and LiPuma, 1991).
- 353 -
Diagnosis is made by urine culture.
A midstream clean-catch urine
specimen may be used if the child is toilet-trained. If not, urine may
be obtained by percutaneous bladder tap or urethral catheterization.
In
addition, a urine bag collection is adequate if the culture is negative;
however, a positive culture could result from a contaminant from the
rectum, skin, or prepuce, so it must be confirmed by one of the other
two methods (Roth and Gonzales in Oski et al., 1994; Woodhead in
Dershewitz, 1993).
Urine cultures from bags may sometimes be so
suggestive of UTI that some physicians might believe it is unnecessary
to collect a more reliable culture, particularly since antibiotic
therapy does not present much risk.
However, the radiologic work-up
(discussed below) is quite invasive and so treatment based on bag urine
cultures should be the exception rather than the rule.
The culture must
be obtained before antibiotics are given because a single dose prior to
urine collection can lead to a false-negative result (Roth and Gonzales
in Oski et al., 1994).
Bacterial colony counts greater than 100,000 colonies/ml urine for
a single organism should be interpreted as diagnostic of a UTI.
Colony
counts of 10,000 to 100,000 colonies/ml urine associated with clinical
signs and symptoms are suggestive of a UTI, but a repeat culture should
be done (this may not always be possible if the patient has already
started antibiotics).
Colony counts less than 10,000/ml may be
considered positive if the organism is staphylococcus or a fungus or if
the patient has an indwelling catheter.
Any bacterial growth from a
suprapubic aspirate should be considered positive (Marks and Arrieta in
Feigin and Cherry, 1992a).
Though urinalysis may be used to screen for possible UTI (Woodhead
in Dershewitz, 1993), a positive urinalysis must be confirmed with a
culture in order to make the diagnosis.
UTIs can be subdivided into two categories based on anatomical
location: lower tract infection (cystitis) and upper tract infection
(pyelonephritis) (Zelikovic et al., 1992).
distinguish between the two in children.
It can be difficult to
Dysuria, frequency, urgency,
enuresis, suprapubic pain, and a low-grade fever are more common in
cystitis, whereas high fever, nausea, vomiting, flank pain, and lethargy
- 354 -
are usually associated with acute pyelonephritis.
Overlap in symptoms
occurs often (Roth and Gonzales in Oski et al., 1994) and can make
specific diagnosis difficult.
Andrich and Majd (1992) say that clinical and laboratory findings
are not adequate to diagnose pyelonephritis, and therefore argue for
performing renal cortical scintigraphy (RCS) with DMSA
(dimercaptosuccinic acid) or GHA (glucoheptonate) in all patients with a
febrile UTI, especially young children who are particularly susceptible
to scarring.
RCS is recommended during the first 2-3 days if the child
is hospitalized and within the first 2-3 weeks if the child is treated
as an outpatient.
However, this is not a typical recommendation of
pediatric textbooks, and we have found no analysis weighing the costs
and benefits of performing RCS on all children with a UTI.
Standard
clinical practice remains presumptive treatment of all young children
with a UTI for pyelonephritis.
Treatment
Infants with UTI are at risk of developing serious sequelae,
including sepsis, electrolyte abnormalities, and shock.
treated with parenteral antibiotics.
They should be
A repeat urine culture should be
obtained after 48 hours to assure that urine has been sterilized
(Sherbotie and Cornfeld, 1991; Lebel in Oski et al., 1994).
Parenteral
antibiotic therapy should be continued in infants for 5-7 days.
If the
baby has improved clinically after 3-5 afebrile days and has sterile
urine, antibiotics may be given orally to complete a 10-14 day course.
For ill-appearing patients and those with genitourinary abnormalities
and pyelonephritis, at least 7 days of parenteral antibiotics are
recommended, followed by prolonged oral antimicrobial therapy (e.g., 2-3
weeks) once clinical improvement and microbiologic cure are documented
(Sherbotie and Cornfeld, 1991).
If the child is not afebrile within 1-2
days or if the repeat urine culture is positive, the child needs an
immediate evaluation for urologic obstruction or abscess (in addition to
reconfirming bacterial antibiotic susceptibilities) (see radiologic
work-up below) (Lebel in Oski et al., 1994).
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A repeat culture should be obtained 2-3 days after the start of
standard 10-day therapy or 3-4 days after completion of short-course
therapy.
Sterile urine demonstrates antibiotic effectiveness.
If urine
is not sterile or the patient remains symptomatic, another urine
specimen should be sent for bacterial identification and susceptibility
testing and a broad-spectrum antibiotic should be prescribed.
Urine
should be recultured 3 days later to confirm effectiveness (Woodhead in
Dershewitz, 1993).
Any child with symptomatic pyelonephritis should be managed in
hospital with parenteral antibiotics (Woodhead in Dershewitz, 1993).
Other children can be treated adequately on an outpatient basis with a
7-10 day course.
A higher recurrence rate occurs with shorter courses
of antibiotics (Roth and Gonzales in Oski et al., 1994).
A broad-
spectrum antibiotic is used initially (Roth and Gonzales in Oski et al.,
1994; Woodhead in Dershewitz, 1993).
is not sensitive to it.
It must be changed if the organism
Treatment for 10 days is adequate (Woodhead in
Dershewitz, 1993).
Some clinicians believe that bacterial identification and
determination of antibiotic susceptibilities are not necessary in most
uncomplicated UTIs.
Because most UTIs are caused by E. coli (a type of
bacteria) sensitive to commonly used antibiotics, rapid clinical
response to treatment and a negative culture 2-4 days after initiation
of treatment serve the same ends as sensitivity testing.
However, the
patient with systemic toxicity at initial presentation or who fails to
respond promptly to treatment should have these done (Woodhead in
Dershewitz, 1993).
Follow-up Care
Recommendations for follow-up culture (to document eradication of
infection) are quite variable, ranging from one week after completion of
therapy (Roth and Gonzales in Oski et al., 1994) to one month afterwards
or just before radiologic evaluation (Woodhead in Dershewitz, 1993).
Woodhead (in Dershewitz, 1993) recommends further follow-up every three
months for one year and then annually for 2-3 years.
not mention such persistent follow-up.
However, others do
- 356 -
Prophylaxis
Children with at least four UTIs per year should receive daily
prophylactic low-dose antibiotics for 9-12 months (Roth and Gonzales in
Oski et al., 1994).
Woodhead (in Dershewitz, 1993) recommends
prophylaxis for 6 months.
Lebel (in Oski et al., 1994) also recommends
prophylaxis for recurrent UTIs. Because the length of prophylaxis is
open to debate, the shorter time period (6 months) will be used for an
indicator.
Any child who needs a radiologic study for VUR should receive low
dose prophylactic antibiotics until the voiding cystourethrogram (VCUG)
has been done (Woodhead in Dershewitz, 1993).
Radiologic Studies
There is consensus that some children with UTIs need to have a
radiologic work-up, but there is disagreement over the particulars of
which ages and which genders need what type of work up.
Work-up is
recommended for all boys (Roth and Gonzales in Oski et al., 1994;
Woodhead in Dershewitz, 1993; Sherbotie and Cornfeld, 1991; Gillenwater,
1991).
Andrich and Majd (1992) specify that it is necessary only for
boys less than 10 years old.
There is less consensus for girls, with
recommendations including: girls less than 3 years old or girls older
than 3 with systemic toxicity, recurrent UTIs, or failure of infection
to respond promptly to therapy (Woodhead in Dershewitz, 1993); girls
less than 5 years old, girls with evidence of genitourinary
abnormalities, and girls older than 5 with recurrent symptomatic
bacteriuria (Sherbotie and Cornfeld, 1991); girls less than 10 years
old, girls who fail to respond to antibiotic therapy, and girls with
recurrent UTIs (Andrich and Majd, 1992); all girls (Gillenwater, 1991).
Given these disagreements, our indicators for radiologic work-ups cover
all boys less than 10 years old, all girls less than 3 years old, and
any other children who require hospitalization (as a proxy for systemic
toxicity).
There are several radiographic studies that can be done to evaluate
urinary tract anatomy and function.
to use vary.
Recommendations for which studies
Roth and Gonzales (in Oski et al., 1994) recommend (1)
- 357 -
VCUG and (2) renal ultrasound (RUS), intravenous pyelogram (IVP), or
nuclear medicine renal scan, though they say the VCUG is not necessary
for the older girl with simple cystitis.
Woodhead (in Dershewitz, 1993)
recommends (1) VCUG or radionuclide cystogram and (2) IVP or RUS.
Gillenwater (1991) recommends (1) radionuclide or contrast cystograms
and (2) RUS or intravenous urograms.
Andrich and Majd (1992) recommend
(1) VCUG in boys and isotope cystogram (IC) or VCUG in girls and (2) RUS
for afebrile, nontoxic-appearing children.
If the cystogram is
positive, RCS should be done to see if there is evidence of previous
unsuspected renal parenchymal infection.
If RUS shows hydronephrosis,
diuretic renography (with DTPA or MAG3) must be done to determine if it
is obstructive or nonobstructive (Andrich and Majd, 1992).
Our indicators accept any of several options for radiologic workup:
(1) VCUG for boys and IC or VCUG in girls, and (2) RUS, IVP, or
nuclear medicine renal scan.
A key concern is the amount of radiation
exposure from these various methods.
IC may be preferred for girls
under 5 because of the lower radiation exposure as compared to VCUG and
concerns about effect on the ovaries.
Similarly, IVP has higher levels
of radiation exposure than the other tests and may not provide enough
additional information to justify the increased risk.
This review does
not address recommendations for further work-up and treatment following
these radiologic studies.
There are variable recommendations for how long after diagnosis the
VCUG (or IC) should be done, ranging from a few days or as soon as the
patient is asymptomatic (Andrich and Majd, 1992) to 4-6 weeks after the
infection has been treated (Woodhead in Dershewitz, 1993).
Our
indicator accepts any time within the first three months after
diagnosis, as long as the patient has been on prophylactic antibiotics
from completion of the treatment regimen until the time of the VCUG or
IC.
If the symptoms with each recurrence remain consistent with
cystitis, there is no need for repeated invasive evaluations.
However,
for the child with a persistent problem with UTIs, it seems prudent to
repeat a renal ultrasound every 2-3 years to document normal renal
growth (Roth and Gonzales in Oski et al., 1994).
- 358 -
Reflux and Other Abnormalities
There is consensus that children with VUR need prophylactic
antibiotics until the reflux resolves (Woodhead in Dershewitz, 1993;
Andrich and Majd; Gillenwater, 1991).
Lebel (in Oski et al., 1994)
specifies that children with Grade II or higher reflux need prophylaxis.
In addition, Andrich and Majd raise the idea that any child whose
RCS shows renal parenchymal involvement should be considered for
prophylaxis as well
(Andrich and Majd, 1992).
However, neither doing
RCS nor prophylaxing all children with a positive RCS has become a
standard of practice.
When VUR is diagnosed, it must be evaluated yearly with VCUG or
radionuclide cystogram.
There should be monitoring of renal growth with
US or IVP as long as VUR persists. Low-grade VUR resolves spontaneously
in almost 80 percent of cases and urologic evaluation is unnecessary
unless VUR is complicated by poor growth, hypertension, or reduced renal
function (Woodhead in Dershewitz, 1993).
minimize radiation exposure.
Andrich and Majd prefer IC to
Infants with reflux should have RUS and
VCUG or radionuclide scan repeated in 6-12 months (Lebel in Oski et al.,
1994).
Higher grades of reflux do not spontaneously resolve and indicate
more severe urinary tract damage.
Patients with high grade VUR should
have urologic evaluation and almost always require urethral
reimplantation (Woodhead in Dershewitz, 1993; Gillenwater, 1991),
although exact management is controversial (White, 1990; O'Donnell,
1990).
Optimal treatment for moderate degrees of reflux has not been
established (Gillenwater, 1991).
Infants with obstructive signs (e.g., midline lower abdominal
distention; flank mass; infrequent or prolonged voiding; weak,
dribbling, or threadlike urinary stream; or ballooning of the penile
urethra) must be evaluated by a pediatric urologist.
Children with any
degree of VUR with hypertension, growth retardation, reduced renal
function, anemia, or other structural renal abnormalities should also
have urologic evaluation (Woodhead in Dershewitz, 1993).
Asymptomatic siblings of children with VUR require screening
because up to 45 percent will also have VUR compared to less than one
- 359 -
percent of the general population (Andrich and Majd, 1992).
Andrich and
Majd (1992) prefer IC to limit radiation but acknowledge that some
radiologists will find the VCUG more reliable because they perform it
more often.
RECOMMENDED QUALITY INDICATORS FOR URINARY TRACT INFECTION
The following criteria apply to urinary tract infections for infants and children.
Diagnosis
Indicator
1.
2.
3.
4.
If an infant or child presents with any of the
following symptoms/signs,* either a urine
culture should be performed or a urinalysis
should be performed; if urinalysis is positive, a
urine culture should be performed:
a. malodorous urine, abnormal urinary stream,
or change in urinary stream in an infant or
child;
b. failure to thrive in an infant or child;
c. vomiting associated with fever in an infant;
d. jaundice associated with fever in a neonate;
e. pain/discomfort with urination (dysuria),
frequency, urgency, flank pain (unrelated to
trauma) in a child;
f. hematuria unrelated to trauma in infant or
child; or
g. secondary enuresis in a child.
In order to diagnose UTI, a positive culture
from one of the following methods of urine
collection is necessary:
– bladder tap, or
– catheterization, or
– clean catch.
In order to rule out UTI, a negative UA or
culture from one of the following methods of
urine collection is necessary:
– bladder tap, or
– catheterization, or
– clean catch, or
– urine bag.
If the culture shows greater than 100,000
colonies/ml urine of a single organism, then the
patient should be diagnosed and treated for
UTI.
Quality of
evidence
III
Literature
Benefits
Comments
Marks and
Arietta in
Feigin and
Cherry, 1992a;
Woodhead in
Dershewitz,
1993; Lebel in
Oski et al.,
1994
Prevent chronic renal failure.
Prevent scarring and renal
hypertension.
Without proper diagnosis, an untreated
UTI in children can cause complications,
including vesicoureteal reflux of infected
urine (which can lead to renal scarring,
which can cause renal hypertension and
chronic renal failure). Of note, the
sources used in this review sometimes
distinguish between infants and children
without specifying the age cut-off between
them. We will define infants as children
who have not reached their first birthday.
III
Roth and
Gonzales in
Oski et al.,
1994;
Woodhead in
Dershewitz,
1993
Roth and
Gonzales in
Oski et al.,
1994;
Woodhead in
Dershewitz,
1993
Marks and
Arrieta in
Feigin and
Cherry, 1992a
Prevent allergic reactions from
antibiotics. Prevent
complications of invasive
procedures.
Bag urine collection has a high false
positive rate. False positives are not
trivial, not only because of inappropriate
antibiotic usage but also because of
potential complications of radiologic
procedures discussed below.
Prevent allergic reactions from
antibiotics. Prevent
complications of invasive
procedures.
Bag urine collection has a high false
positive rate. False positives are not
trivial, not only because of inappropriate
antibiotic usage but also because of
potential complications of radiologic
procedures discussed below.
III
III
360
Prevent allergic reactions from
antibiotics. Prevent
complications of invasive
radiologic procedures. Prevent
chronic renal failure. Prevent
renal scarring and hypertension.
5.
If there is bacterial growth of a single organism
with at least 10,000 colonies/ml urine from a
catherized specimen, then UTI should be
diagnosed and treated.
III
Marks and
Arrieta in
Feigin and
Cherry, 1992a
6.
Growth of 10,000 to 100,000 colonies/ml urine
from clean catch should be followed up with a
repeat urine culture if the patient has not
already been treated.
III
Marks and
Arrieta in
Feigin and
Cherry, 1992a
7.
If there is any bacterial growth from a
specimen obtained from a bladder tap then a
UTI should be diagnosed and treated.
III
8.
Urine culture must be obtained by clean catch,
catheterization, or bladder tap before
antibiotics are given.
III
Marks and
Arrieta in
Feigin and
Cherry, 1992a
Roth and
Gonzales in
Oski et al.,
1994
361
Prevent allergic reactions from
antibiotics. Prevent
complications of invasive
radiologic procedures. Prevent
chronic renal failure. Prevent
renal scarring and hypertension.
Prevent allergic reactions from
antibiotics. Prevent
complications of invasive
radiologic procedures. Prevent
chronic renal failure. Prevent
renal scarring and hypertension.
Prevent pyelonephritis.
Specimens from clean catch and catheter
collection are less likely to have
contaminants.
Prevent allergic reactions from
antibiotics. Prevent
pyelonephritis. Prevent chronic
renal failure. Prevent renal
hypertension. Avoid invasive
radiologic work-up.
Pre-antibiotic culture allows determination
of whether the patient actually has a UTI.
It also allows determination of antibiotic
sensitivities, which enables switching to
proper treatment if necessary. There may
be extenuating circumstances where
antibiotics cannot wait for culture. For
example, a child may have strong
evidence of meningococcal sepsis but
clinicians may be unsuccessful in
obtaining a urine sample. This child will
need antibiotics immediately. However,
such situations should be uncommon and
distributed randomly among sites, so that
they will not need to be accounted for at
present.
This is a borderline result that may be due
to contamination or infection. Repeat
culture helps determine whether there is
true infection.
A bladder tap specimen is unlikely to have
a contaminant.
Treatment
Indicator
Quality of
evidence
III
Literature
Benefits
Comments
Sherbotie and
Cornfeld, 1991
Prevent sepsis. Prevent renal
scarring, renal hypertension, and
chronic renal failure.
Prevent sepsis. Prevent renal
scarring, renal hypertension, and
chronic renal failure.
IV antibiotics are more likely than oral
antibiotics to be effective in infants.
Prevent sepsis. Prevent renal
scarring, renal hypertension, and
chronic renal failure.
Prevent sepsis. Prevent renal
scarring, renal hypertension, and
chronic renal failure.
Once it is clear the infection is under
control, it is safe to switch to oral
antibiotics.
Sherbotie and Cornfeld recommend the
repeat culture after 48 hours, but do not
give a deadline for the culture. Repeat
culture assures that treatment is effective.
If a UTI is untreated, a child with
vesicoureteal reflux of infected urine can
develop renal scarring, which can cause
renal hypertension and chronic renal
failure.
IV antibiotics assure adequate treatment
so that complications (see benefits) are
less likely to occur, but oral antibiotics
allow for less invasive treatment (and
decreased hospitalization) when that is
acceptable.
If sensitivities are not available to show
that the antibiotic is appropriate, a repeat
culture will show whether the antibiotic is
working.
If the child is being treated with an
inappropriate antibiotic, one would want to
correct the treatment immediately.
9.
All infants with a diagnosis of UTI must initially
receive intravenous antibiotics.
10.
IV antibiotics may be switched to oral
antibiotics if the infant has had at least 3 days
without fever, a negative repeat urine culture,
and negative blood and CSF culture.
Infants with UTI should receive a total of at
least 10 days of antibiotics (IV and oral).
III
Sherbotie and
Cornfeld, 1991
III
Sherbotie and
Cornfeld, 1991
12.
Infants with UTI should have a repeat urine
culture between 48 hours and the end of the
fifth day of IV therapy.
III
Sherbotie and
Cornfeld, 1991
13.
Children with UTI and systemic symptoms
such as hypotension, poor perfusion, anorexia,
or emesis, should be treated initially with IV
antibiotics.
III
Woodhead in
Dershewitz,
1993
Prevent sepsis. Prevent renal
scarring, renal hypertension, and
chronic renal failure.
14.
If the child is being treated with oral antibiotics,
by the fourth day, either (1) antibiotic
sensitivities must be determined, or (2) a
repeat culture must be sent.
When antibiotic sensitivities are checked, if the
organism is not sensitive to the antibiotic, the
antibiotic should be switched to one to which
the organism is sensitive within 1 day.
All children with the diagnosis of UTI should
receive at least 7 days of antibiotics.
III
Woodhead in
Dershewitz,
1993
Prevent sepsis. Prevent renal
scarring, renal hypertension, and
chronic renal failure.
III
Prevent sepsis. Prevent renal
scarring, renal hypertension, and
chronic renal failure.
17.
All children with the diagnosis of pyelonephritis
should be treated initially with IV antibiotics.
III
18.
A child with four UTIs in a single year should
receive prophylactic antibiotics for at least six
months.
III
Inferred from
Woodhead in
Dershewitz,
1993
Roth and
Gonzales in
Oski et al.,
1994
Woodhead in
Dershewitz,
1993
Woodhead in
Dershewitz,
1993
11.
15.
16.
III
362
Once it is clear the infection is under
control, it is safe to switch to oral
antibiotics.
Prevent sepsis. Prevent renal
scarring, renal hypertension, and
chronic renal failure.
Antibiotics must be taken long enough to
ensure adequate treatment.
Prevent sepsis. Prevent renal
scarring, renal hypertension, and
chronic renal failure.
Prevent sepsis. Prevent renal
scarring, renal hypertension, and
chronic renal failure.
Oral antibiotics are not considered
adequate for pyelonephritis, which is more
serious than simple UTI.
Prophylaxis prevents future UTIs and
therefore damage to kidneys and urologic
system.
19.
Radiologic Work-up
Any boy less than 10 years old with a first UTI
or with systemic symptoms** (and/or who has
not had the following study before) should
have a VCUG and one of the following within
three months of diagnosis:
– RUS, or
– IVP, or
– nuclear medicine renal scan.
Andrich and
Majd, 1992;
Gillenwater,
1991; Roth
and Gonzalez
in Oski et al.,
1994;
Sherbotie and
Cornfeld,
1991;
Woodhead in
Dershewitz,
1993
Andrich and
Majd, 1992;
Gillenwater,
1991; Roth
and Gonzalez
in Oski et al.,
1994;
Sherbotie and
Cornfeld,
1991;
Woodhead in
Dershewitz,
1993
Lebel in Oski
et al., 1994
Prevent sepsis. Prevent renal
scarring, renal hypertension, and
chronic renal failure.
UTIs are rare in boys and are often
associated with anatomic abnormalities.
Prevent sepsis. Prevent renal
scarring, renal hypertension, and
chronic renal failure.
Uncomplicated UTIs are not uncommon in
older girls, so a radiologic work-up is not
typicallly necessary.
Prevent sepsis. Prevent renal
scarring, renal hypertension, and
chronic renal failure. Prevent
damage to the urologic system.
Even with appropriate antibiotics, a UTI
will often not resolve if there is an abscess
or obstruction.
III
Woodhead in
Dershewitz,
1993
Prevent sepsis. Prevent renal
scarring, renal hypertension, and
chronic renal failure.
Antibiotic treatment prevents reflux of
infected urine. Reflux of infected urine is
more likely to cause scarring than reflux of
uninfected urine.
III
Woodhead in
Dershewitz,
1993; Lebel in
Oski et al.,
1994;
Gillenwater,
1991; Andrich
and Majd,
1992
Prevent sepsis. Prevent renal
scarring, renal hypertension, and
chronic renal failure.
Antibiotic treatment prevents reflux of
infected urine. Reflux of infected urine is
more likely to cause scarring than reflux of
uninfected urine.
III
20.
Any girl less than 3 years old with a first UTI or
less than 10 years old with systemic
symptoms** (and/or who has not had the
following studies before) should have a VCUG
or IC and one of the following within three
months of diagnosis:
– RUS, or
– IVP, or
– nuclear medicine renal scan.
III
21.
If a child with a diagnosis of UTI remains febrile
for more than 48 hours on therapy, or if repeat
urine culture is positive despite appropriate
antibiotics, the child needs an immediate
evaluation for urologic obstruction or abscess
with renal ultrasound (RUS), intravenous
pyelogram (IVP), or nuclear medicine renal
scan.
Children who have a VCUG or IC following a
UTI should be on prophylactic or therapeutic
antibiotics continuously from the beginning of
therapy for the UTI until the time of the study.
Vesicoureteral Reflux (VUR)
Children diagnosed with Grade II or higher
VUR should be on prophylactic antibiotics until
the reflux has resolved.
III
22.
23.
363
24.
Children with VUR should have annual
monitoring with VCUG or nuclear cystogram.
III
Woodhead in
Dershewitz,
1993
Prevent allergic reaction to
antibiotics. Decrease antibiotic
resistance.
25.
Children with high grade (Grade IV or higher)
VUR or other anatomic abnormalities, such as
posterior urethral valves, abnormal urethral
implantation, or horse-shoe kidney, should be
referred to a urologist.
III
Woodhead in
Dershewitz,
1993;
Gillenwater,
1991
Prevent allergic reaction to
antibiotics. Decrease antibiotic
resistance.
26.
Children with obstructive symptoms should be
referred to a urologist.
III
27.
Children with VUR or other anatomic
abnormalities who also have hypertension,
decreased renal function, failure to thrive, or
other related signs, should be referred to a
pediatric nephrologist for treatment of renal
insufficiency and hypertension.
III
Woodhead in
Dershewitz,
1993
Prevent damage to the urologic
system.
Clinicians who do not believe in surgical
management of reflux may not consider it
necessary to refer to a urologist.
However, urologists have the best training
and experience to determine whether
surgical or medical treatment is most
appropriate.
Specialist evaluation is important to
ensure proper course of treatment.
Prevent renal failure.
Staff recommended this indicator.
*Indicators for laboratory tests in the presence of fever in children under 36 months of age can be found in Chapter 12.
Quality of Evidence Codes:
I:
II-1:
II-2:
II-3:
III:
RCT
Nonrandomized controlled trials
Cohort or case analysis
Multiple time series
Opinions or descriptive studies
364
The goal of annual monitoring is to detect
early damage to kidneys as well as
resolution of reflux. Determination of need
for continued prophylaxis can be made
based on monitoring test results.
The references do not specify which
grades count as "high grade," but
common practice would count at least
Grade III as high grade. Some clinicians
would refer for Grade II.
- 365 -
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