tq ¥a t Cas~hoo,Ml, MD
lhnse No.13•941
.I,
.
An Official Publication of the
Philip.pine Pediatric 'Society, Inc.
, ;.l ..·
") ~
Clinical Practice Guideline
In The Approach And
Treatment Of Urinary Tract
Infection In Children
In The Philippine Setting
I. UlGAll Ulli l lllES
llflst Graduate Intern
::.is (Olil'1
CtiU
""°'
Practice Guideline in the Approach and Treatment of Urinary Tract fnfection
In Children in the Philippine Setting
Work on .the Practice Guideline in the Approach and Treatment;'ofUrinary
Tract Infection in Children in the PhiJippines Setting was started in mid~l999 upon
the request of The Phil Health Insurance Corporation coursed through Dr Zenaida L
Antonio, the PPS President the". A PPS Task Force on UTI was organized in
_ cooperation with the Pediatric Nephrology Society of the Philippi.,es through the
efforts of its President Dr Myrna B Rosel. The Task Force on UTI involved
representatives from the Pediatric N~phrology Society of the Philippines ·[Dr
Beatrice B Canonigo, Dr &onia B Gonzalez, Dr Bettina C Cercenia, Dr Dolores D
Bonzon, Dr Ma Norma V Zamora]:-..-Pediatric Urologist [Dr David T Bolong) and a
representative of the Pediatric Infectious Disease Soeiety of the Philippines [Dr
Josefina C Carlos]. The drafts were passed around among committee members and
PNSP members for comments and suggestions. By JanlW'Y 2000, it was presented in
a Postgraduate Course. It was submitted to the Philippine Pediatric Society April
2001.
Urinary tract infection is on~ of the most commonly encotmtered infections
in children. Recurrence is high, acute morbidity is c..->mmon· [es:,eciaHy in the very
young] and renal scarring may be a consequence. Reduction in renal function and
hypertension can be long term results. Accurate diagnosis for ·urinary tract .infection
is a must. Undue diagnosis can cause um1ecessary worlc-up, e;q>enSe and anxiety to
the parents; undiagnosed, may result to renal damage.
The objective was to d~eJop_a_gwdeline-on- the approach on UTI on
children in the Philippines based o~ available accq,t~ evi~ence. The target
population: chil<ktm below 18 years old• It.is intended to used by J»ediatricians,
General practition~s and pediatric care givers.
tl,,
oe
Intended health outcome: [1] Recognition of the child with UTI, [2] Making the
diagnosis ofUTI, [3] Short-tern.treatment ofUTI,.[4] Evaluation of the.chif(J with
Utt [5] Prtv~io~ ofUTI and its consequen~'.
.
·
· ·
MEDLINE database was searched · using four · separate search ~ e s
corresponding with the four phases of the diagnosis an,d treatn:,ent ofU'n. The istles
and ab~s resulting from these search~ Was 4istri~ :among .CQinUiittee
metribers who identified those articles that are definjtely or potentially useful. The
arti~les were reproduced in full. However, the Committee based and modeled this
Practice Guidelin~ on the on the Technical Report .on "Urinary Tract Infections in
Febrile Infants and Young ChiJdren" of ·the American Academy of Pediatrics
[Pediatrics, Vol 103, No 4, April 1999, pp 843-852] - the most comprehensive
d~ment on UTI in Children eiistfog tQ date.
Materials/Review of articles
evaluated according to grading [ ~:
Infectious Disease Society of America Quality Standards for Infecti~ Diseases]
CATEGORY
A
B
C
D
E
GRADE ·
I
II
ill
oEFINITION
Good evidence to support a recommendation for use.
Moderate~vidence to support a recommendation for
use
Poor evidence to support a recommendation for or
against use
Moderate evidence to support a recommendation
agairu,i use
_
.
.
Good evidence to support a recommenda.tion against
use
DEFlNlTlON
Evidence from at least one properly randomized, controlled
-trial
Evidence from at least one will designed trial without
randomization;
from cohort or case controlled analytic studies:
uncontrolled experitneots
·-
Evidence froin opinion of respected authorities, based on ·
clinical experience,·
Descriptive studies, .or reports of expert committees
To-meet n~s iri the Pl)ilippine setting, modification int~ age of focus has
been adapted in our gaj~line.-~~g(~bceQtratmg on We z" JllOS to 2
age ·
group,
guideline m~y be applied: the full
of pedi~-age
Ill~
so, we .w ~ be ~le to provid~ ~ .cliµi,cjan.with a logi¢al
lJ!f in Children in our setting.
in dtis first guideline expected and work
wdl be undertaken as·deeined necessary;
·
·
·
·
to
levisions
yeao,
group:
range
is
APPROACH TO URINARY TRACT INFECTION IN A PHPtIPPINE
SETrING
REPORT BY THE PPS TASX FORCE ON l/RINARY·T.RACT INFECTION
1,
Objective:
To develop a guideline on t~ approach on Urinary tract i11fection in children i
Philippines based on avai_Jable accepted evidence.
The target population: Children below 18 years of age
Setting: Philippines
For whom intended: Pediatrician, general practitioners and pediatric care givers
Method:
1.
2.
3.
4.
Development of conceptual evidence based·model
Development of a Decision tree based on the evidence available
A conjprehensive review of available data .(local and intemaiional)
Algotitlun based on_cost-benefit
MODEL:
Suspect-Probabili_ty of UTT--~.:.Diagnosis of UTr--Treatment~Work~
-Jong-term ff-up
Materials/Review of articles shall be evaluated according to grading ·(Source
Irifecflous Disease Society of America Quality Standard~ for Infectious Diseases)
~'
C ,
/ CATEGORY
A
~erMle evidence to SQ
b
E
.
.
of each recommendatioliiot ot
DEFINfrlON ,
. ·
rt -~~ion (Qr~
M ~ .evidence.·to support
use
Good evidence to SU
·.
·nst if• use
a·reoonwi~dadon against
areconimencfafio1( ·.·nst u~·
n which recommendatio ns.are based,.__
ar
f
·d
Catesi;ories reflectiAA the au ,tv o ev1 ence o
GRAQE .
·
DEFINITION
.
Evidence from at least one properly randomized, controikd
1
.Etrial
vidence from at least one well designed in trial withom
randomization; from coh~rt or caStHX>ntroJJed analytical
studies: uncontrolled exoenments
Evidence from opinion of respected authorities, based o"n
c)inica} experience, descriptive studies, .or reports of expert
II
m
"
committees
-
·-
THE CHILD wrrHPROBABLE URINARY TRACT INFECTION
l TheSUSPECf:
J. The neo~tes presenting with the clinical signs ~d symptoms as presented
in table 1.
Febrile infants (>38 C) below 2 years of age (Table 1 Downs)
Older children manifesting symptoms referab_Je to urinary tract .(Table I)
The evidence for this recommendation A/Il. Hoberman A {6,7,8); Shaw (9),
2.
3.
Downs (5)
Table l
• In gen_eral manifestations of urinary tract _infections are non-scientific.
However, there are some signs and symptoms that are associated with UTI.
SIGNIS- -Neonates
-e1:;iNI€-AL
SYMPTOM
• -Teµiper~re inmability
f+]
(+J
•
f+J
• P09.r;feediJJg - -- _
•
•
Y§.iJ@~g . . . - - ..
:t!~fii orifiit~&i.tity
.. .
.
•"' q "·
~~\lft
P~r Wejght -.
.gail)ffa!lµre tQ th.dve _
. [+l
- [+l -_-
Adolacents
•
Abdotninal p~in
Freq1,1ency. dribbling,
urgency dysuria
Weak urinary stream
•
•
Malodorous urine
Enuresis
•
Flank pains
[+]
. £+1 . .
[+]
[+] ·
[+]
[+]
[+]
[+]
· • ota~fi~·, '. - '
•
•
School ,j\ge
[+]
• - Septic . -
•
.• . '. J~jiqi'~
Older Infan1J
[+]
[+]
[+}
[+J
[+)
[+]
[+]
[+]
t+l
[+)
[+]
[+)
IL THE FOLLOWING l.f; AN ALGORITHM ON THE DIAGNOSL.f;, WORK-UP,
TREATMENT AND FOUOW-UP OF CHILDREN WITH URINARY TRACT
INFECTION.
SUSPECTED URINARY TRACT INFECTION
Urinalyaia (....,.;,,c af'UJJ)
(+) Lc:utocytc C111cn1rc or N'ddo TOIi
Or:aHaniaocl
l')turia:! MIC¥«.Jll'nn3
Ph)'lical - - - -....
(+) Urine culri. of a propaty
&aninaliGn
coll"'cd - - ipCC81Q
FF.VF.R ~11.SC
ABSENr
PRESENr
CBC (C-fQM.'C pn,lcm, ESR)
BUN, Crcaliaim
Oplimal('-RP, E3R, BloodC..S
Onl Aabl>ioliu
Aibittollorp&lJ
KUBUfl.,JRmd
Pa-cm,-alAlllililolira(IV,D.9 __
Pre and poll w,il
-KUB UTZ, J'" and poll void
Ooodltaiic-
.~..,_12bcua
Poer~
Ak41-72boua
- Good~ .
. • • 43:;!2 boua
RalllCSI
Campld• 7-14 dayl
> • CUllal'II
Rqiat-_~
oflNalmall
u.~
1-iloa iiitial wino cas
(If .miJ#).
CCJllllllc!o 7~J~ cby, of
C l ( ~,
Nq:inogy follov,-up
Mcmii«Bloodl'rWIR
1Jrim11sis
U weeks
u,_- C'Dlmrc.
GHL(L~)
. .. Taing clcpaldl oa
ckfflioaoldal;ap:mlitl
b-"'- -i..fioa o(lll:alm:llt
• 'C1lually d,Ja,: lft'Q 1•10i: il&IGI . . . . . . _
May nit ID aal mlibiolict
C011ip1,w7-Uofa)'1
Ill DIAGNOSIS
HISTORY:
Chock list refer to table I
History of previous . proven UTI, constipation, voiding disorders such as
incontinence, previous surgeries especially pelvic surgeries, ambulatory problem etc
PHYSICAL EXAMINATION:
A thorough physical examination js a must. The examiner should look for congenital
defects that coexists. Back examination such as presence of dimples, hair tufts in the
lumbosacral area indicating probable neurogenic bladders. Lower extr,emities must
also be examined. Thorough neurologic examination must be included. Rectal
examination is part of the examination.
URINALYSIS:
The urinalysis is the foundation by which every child with suspec-.ed urinary tract
intection would either have further ~ork up or put .aside for observation; A study
~h a very high sensitivity but low specificity will put children to unnecessary
invasive work-up. A study with a low sensitivity and high specificity wiIJ miss
children at risk of long term complications of urinary tract infection.
Proper Collection of urine: Tliis is the corner stone of the algorithm. ·
Requirement :
I . For infants below one year ·of age, a suprapubic tap is recommended.
2. A catheterized urine is a good alternative to obtain urine specimen.
3. Midstream urine collection for cooperative patients-older girls,
circumcised boys and older boys whose foreskjn is easily retlacted.
Initial urinalysis:
a. Gram stain on an uncentrifuged urine specimen has the best sensitivity
(0,93)and false positive rate (0:05). Evidente i~ A/1-Il
b~ Urine dipstick tests has a sen~tivity 0.88 for the presence o{ leucocyte
esterase or nitrate. A false positive :rate of only 0.04 for the presence of
eith~ Jeucocyte esterase of nitrite: Evidente is Ail.
c. Pyuria has lower true positjv.e rate
higher false positive rate: .for
presence of >5 WBC/bpf in a centrifuged 'urine the: TPR was 0.67 and the
FP-R .21, whet~ for >IO WBC/mm3 in un<:eiltrifuged·unne. the TPR is
0.77 and FPR 0.11. Gorelick (10)1 i;>own(5 table 3c.). Evidente .is C/1.
.
of
a·
CAVEAT:
Para1lel combinations of test results maximize sensitivity. A study within one hour of
urine collection using careful on-site microscopy with .a positive ·combination for
.leukocytes and bacteria has a sensitivity of 99% or greater. When any component of
the urinalysis is positive - such as · LE; nitrite, .·blood, proteins, microscopy fur
leukocytes; microscopy of bacteria-, and the urinalysis is considered as positive. the
sensitivity is 100%1 but the spec·fi . .
.
I 1c1ty IS onl 6°'
Houston (12), Hoberman (13). Evidenc~ i, B/D Y ro-Hoberman (7), Lohr (ll),
Urine Culture:
THE GOLD STANDARD IS ANY
SUPRAPUBJC TAP. This is do~e in inf' BAbCTERIAL GROWTH J\FTER A
.
• •
bd .
ants elow one
f
,
th1s age 1s mtraa ommal. A diaper th t h b
year o age. The bladder at
a bladder containing enough urine to a:o•:S
een dry for thirty minutes will indicate
I
1
inch long gauge 25 needle puncture one art. empty tap. With a 3-cc syringe and ari
.
' shun away &
cen m1eter abov. e the symphysis
. pubis in the
nu·drme. For care givers
that
01
be the next best choice. Refer to table .2
suprapubac taps, catheterization would
Mid~:~m catch in a cooperative and · ro 1
.
. .
.
seos1tJV1ty and specificity.
p per Y prepared patient wall give a high
Table 2
°
•
Urine Culture: Interpretation ofUTI
Method of CoUection
Quantitative Culture: lITJ present
•
Suprapubic aspiration
Grqwth of urinmy pathogen in
any number (exception is up to
2-3 Jff CFU/ml of coagulasoocganvc staphylococci)
•
Cadieterization
Febrile infants or children usually
have 50,000 CFU/ml evidence of
a smgle urinary pathogen; but .
infection.may be
. ~ l with counts
from> IOOOCRJ/nil (HobennanA
(7), Down (7), +
•
Midstream clean-void
Sympto~tic patients usually
have lo' CFU/ml of a single .
u·nruuy.,..YAl'5""'·
............_
•
Midstream clean-void
.Asyniptomatic p ~ at~
r-
two~ oo difi'ctaJt
Days with 1<>5 CRU
pathogen
of the same
+ Culture of urine specimens obtained by catheteriz.atioil has a specificity of 83%. to
89% compared with cultures of urine specimens obtained by tap. If only ~ltures of
>l OOOCFU/ml are considered~ catheterized cultures have a.95% sensitivity and 99%
specificity.
•
Routine reculturing - of the urine after 2 days of antimicrobial therapy is
generally not necessary if the infant or young child has had expected
clinical response and the uropathogen is determined to be sensitive to the
antinucrobiaJ bein~ ·administered.
WARNING ON THE USE OF BAG SPECIMEN FOR CULTURE:
Culture of bag specimen is 100% s.ensitive ·but have a specificity of only 14-84%Taylor (14), Puerto M (15). With prevalence rate of only 5%, the use of culture frori1
the urine specimens from a bag to rule in UTl is likely to result in a large number of
false positive results. Sp«;ifically, with prevalence of 5%. That is, 85% of Positive
cultures of bag specimen would be false- Down(5). Evidence is D/U
W. WORK-UP
Table3
Reference
Age group
Prevalence · Detectable
of
by
abnormality ultrasound
51%
42%
~(5)
Less 3 yrs old
Down (5)
Any age group
38% .
Bu,bi~KA
(16)
Chikb-en
15%
Elzouki AY Children
(17)
~mellie JM Under 14
26%
(18)
Hobaman
-(19)
100%
79%
100-/4
(mcluding
lVP)
JOO%
29°/4
Emphasis on
VUR
All
abnormalities
-·
.'-'. Boy·s
"
Includes
100-/4
DMSA
Infa11tsand
-
Not useful
100%
37¾
Good
screemng
100%
young childrc.n
Hiraoka M Less 8 months
(20)
VCUG
100"/4
25~50%
Comment
Detectable
byutzand
;
..
~aodIVP
follow up UTJ
if normal
w:umound,
workupif
with
UTI
DMSAasa
: ,·
MucciB
;_<2i> ••
·children
.
'
:
:
·"
·' '
~trife (22) ·· !
er~~>
Rickwood
Children
(23)
14%
. ·'3.8¾
.
I
'
·-p~
994/4
. 100%
scrr.e~,
·Uses nuqear
.
.
•
' !-
•
~-. . !'
cy~
~itive,
f3,%, .
::
Honkinen
(24)
3% .
Children
specjfic
(inlkiequate
52%
as a sludv)
18%
Complete
wcxk
up:willneed
VCUG/DDClear
cystoeram
Ultrasonography alone as a work up for patients with proven urinary tract infection is
inadequate. It is sensitive(99-95% CI 96%-1000/4) but it its' specificity modest (43%32%-55%)-Rickwood (23) Evidence is A/IJ.
111e use of voiding cystourethrography (6r nuclear cystogram) evaluates the presence
or absence of vesicoureteral reflux.
·
,.
VesicoureteraJ reflux is the n1ost common abnonnality found in-patients ~th urinary
tract infection. The prevalence is 30% to 40% - Down (5-table 6 and table 7 review
ofliterature). Evidence is A/II
V. TREATMENT:
•
Some antimicrobials for onl treatment of UTI
Amoxicillin
TMP in combination with SMX
kg per day in 2 doses
6-12 mg TMP. 30-60 SMX per
Sulfisoxazole
120-150 mg/kg/day in 4 doses
Cefixime
8 mg/kg/day in 2 doses
Cephalexin
50-100 mg/kg/day in 4 doses
Cetpdoxime
10 mg/kg/day in 2 doses
Cefprozil_
Loracarbef
•
20-40 mg/kg/day in 3 doses
. 30 mg/kg/day in 2 doses
150-30 .mgllqyday in 2 doses
Some antibiotics for p;u-ental treatment of UTl
Ceftriaxone
75 mg/kg every 24 hours
Cefotaxime
hours
150 mg.lkg/day ·divided every 6
Ceftazidime
150 mg/kg/day divided every 6
hours
Cefazolin
50 mg/kg/day divided every 8
hours
Gentamicin
hours
7.5 mg/kg/day divided every 8
Tobramycin
hours
S mg/kg/day divided every 8
Ticatcillin
hours
300 mg/Jqy'day divided every 6
Ampicillin
hours.
I00 mgikg/day divided every 6
.
•
Prophylactic antibiotics - low serum levels bu_t with high ~nary level
- Has minimal effects on fecal flora
--Low cost and well tolerated
½ of the regular dose given at bedtime
•
Some antimicrobial for prohylaxis of UTI
TMP in combination with SMX
kg as single bedtime dose
SMX per kg twice per week
2 mg TMP,10 mg ofSMX per
Or 5 mg of TMP, 25 mg of
Nitrofurantoin
1-2 mg/leg as single daily dose
Sulfisoxazole
hours
10-20 mg/kg divided every 12
Nalidixic Acid
hours
· . 30 mg/kg divided every 12
Methenamine mandelate
75 mg/kg divided every 12 hours
.: BibliQgraphy;
1. Siegle SR. Sokoloff B. Asymptomatic and symptomatic urinary tract
infel.~ion in infancy.
Am J Dis Child 1973; 125:45-47
2. Mc lntyre PB, Gray SV, Vance JC. Unsuspected infections in febrile
conwlsionsMed JAust 1990; 152, 183
3. Pryl~. CV, Luders D. The bacteriology of the urine in infants and
children with gastroenteritis. Pediatrics 1961; 877-885
4. Shonlife. Ch 57 . . Urinary tract infection in infants and children.
Campbdlls 7rh edition; \Valsh, Retick. Vaughn, Wein
5. Downs SM, Technical Report Urinary Tract Infections in Febrile
Infants and Young Children; ·Pediatrics Vo] l 03 No4 April
6. H~bermanA, Wald ER,Reynolds EA,Penchansky L·Cha
M
.
cu tu.re necessary to rule out· urinar tract .
. . . rron ;Is urme
children? Ped Infect Dis J 1996 Apri ( )-J:~hon rn young febrile
5
7. HobermanA, Wald ER, Reynolds EA, p4 . h , k
i
d b · · IO
· urine specimens obtained
enc ans YL Charron- p ·
ach"·1dracter,~r'.a
cath~~ lonn' yuna
1 en WIL, leYer, J Pediatrics 1994 Apr; 12 ( ): _ • Young
4
8. Hoberman A, Chao HP. Keller OM Hickey R,4 D513· 9tnu
Prevalenc
· ·
·
·
'
aVJs
EJlis D
w
.Jul; 123(1e):o,17-23
unnary tract infection in febrile infants· l 11Ped·a1r 1993.
1
9. Shaw K, Mcgowan K, Gorelick MH Shaw!lrt-. JS · s
·
•
• £
•
•
•
....IL
, . , creenmg for
unnaryPed
tract 1D1ectton rn the Emergency Deparment· · i.: h
.
Best?
. . VoI 101 No6, June 1998
. Wmc test JS
. . 1atncs
10. Child
Gorelick MH, Shaw K, Screening for Urinary tract inflect· ·
M
·p
· . Vol 104 Nos November 1999 10nm
ren: etaana lys1s.
ed1atncs.
11. Lohr JA, Portilla MG: Ge_uder TG, Dunn !'IL• Dudley SM, Making a
presumbpt1Ye d1agoos,s of unna,y tract 1DIOC11on by using a urioa!ys;.
peri'ormed in an on-sit laboratory. J Pediatr 1994: 124:513-9
12. Houstone IB Pus cell and bacteria) C<rums in tbe diagnosi~ for urinary
tract infections in childhood. Arch Dis Chil 1963: 38 600-605
13. Hoberman A, Wald ER, Penchansky L, Reynolds EA, Young S.
Enhanced urinalysis as a screening for urinary tract infection. Pediatrics
. 1993;91:ll96-ll99
14. Taylor CM, White RH The feasibility of screening preschoorchildren
for urinary tract infection using dislides. lnt J Peditr Nephrol 1983 Jun;
(2):113-4
15. Puerto M, De Julian C, Soto M, Del Pow S, Aipador R.Perinea} bag vs
· catheterization of suprapubic aspiration _for the diagnosis of un in
infants in emergency room
_
16. Burbige KA, Retik AB, Colodny AH, Bauer 'SB, Lebowitz R Urinary
tract infection in Boys.J Urol 1984 Sep:11,_
2(3):54 l
17. Elzo~i AY, Mir NA. Jeswai OP, symptomatic uri~ry !ract infection
in pediatric patients-a developmeDtal aspect. Int J Pediatnc Nephrology
1985 Oct-Dec:6(4):267-70
.
.
. .
J8 S. 11 . JM Ridgen SP Prescod · NP. Urmary tract mfectJon. a
me ie
'of four methods
' of investigation. Arc h 01s· Ch'ld
. comparison
. I 1995
72 3 2 7 5
( ): n,
; ·W0aId ER • Urin:irv
19. Marb
Ho . ;erman
· - 1 tract Infections in •vour febrile
Children Pediatri Infec Dis J 1997 Jan: 15( 1): l l-7
.
'0 Hiraoka I-A· Hashimoto G; Hori C: Tsuchida S: Ts~kahara _H; Koms~o
' Ultrasonography tor
, t11e detec f1011 o1 uretenc
. - · Y· S do M
. .reflux. lJl
infan~s Wi;h urinary tract infection. Acta Paedtr Jpn Ju•:
.
. . M uirre B. Does routme ultrasoun~ ha\ie_a ro
. .
21. investigation
Muce1 'B, aq
.
.
tract infection?
Chn Radml 1994
of children
wit. I1 urmary
.
l8(3)i24t5:h,
May; 49(5)?24-5 . .
. Schlueter FJ. Gelfand MJ: Babcock
22. Strife JL; Bisset GS~ Kirks DR~ ()raphy and renal ul.trawnography·
KKDS, Han Bk Nuclear cys oo