UPDATING THE CLINICAL PRACTICE GUIDELINES: “UTI CPG”
Dolores D. Bonzon, MD
Urinary tract infection (UTI) is a common bacterial infection causing illness in infants and children.
It may be difficult to recognize UTI in children because the presenting signs and symptoms are nonspecific, particularly in infants and children younger than 3 years. Collecting urine and interpreting
results are also not easy in this age group, so it may not always be possible to unequivocally confirm
the diagnosis.
In the past 30–50 years, the natural history of UTI in children has changed as a result of the
introduction of antibiotics and improvements in healthcare. This change has contributed to
uncertainty about the most appropriate and effective way to manage UTI in children, and whether or
not investigations and follow-up are justified.
Current UTI management, which includes imaging, prophylaxis and prolonged follow-up, has placed
a heavy burden on and can be traumatic for both patients and their families. It is costly, based on
limited evidence and is unpleasant for children and distressing for their parents or carers.
In 1991, UK guidelines on acute urinary tract infections in childhood were prompted by the great
variation in the management of this condition. They emphasized that urinary tract infections and
vesicoureteric reflux can cause scarred kidneys (reflux nephropathy), leading to hypertension and
chronic renal failure. US guidelines also emphasized the need to diagnose, treat promptly, and
investigate children with a confirmed urinary tract infection, especially those under two years of
age who are at greatest risk of renal damage.
Enthusiasm for extensively investigating children with UTI for vesicoureteric reflux has lessened
with the finding of globally “scarred” kidneys due to dysplasia in infants born with antenatally
detected urinary tract abnormalities, gross vesicoureteric reflux and no urinary tract infection. In
addition, the widespread use of DMSA scan has revealed parenchymal defects in many kidneys
after infection that do not develop into renal scarring. Indeed many scars are present in the
absence of demonstrable reflux. Evidence is also accumulating that prophylactic antibiotics do
not significantly decrease the risk of recurrent urinary tract infections and may increase the risk
of resistant organisms.
Clearly, there is a need to provide pediatricians and other clinicians with consistent clinically and
cost effective practice for the diagnosis, treatment and further management of urinary tract
infection in childhood. The parents and carers need to be informed of the management issues
and be involved in making a correct diagnosis of UTI especially in obtaining properly collected
urine specimens and in making clinical decisions as to further diagnostic investigations.
This session will look at recent guidelines and clinical trials on the management of urinary tract
infection in children specifically pertaining to imaging investigations and antibiotic treatment
both therapeutic and prophylactic.
References:
1. Imaging Studies after a First Febrile Urinary Tract Infection in Young Children.
Alejandro Hoberman, M.D., et al. N Engl J Med 2003; 348:195-202.
2. Antibiotic treatment for pyelonephritis in children: multicentre randomised controlled
non-inferiority trial. Giovanni Montini et al. , British Medical Journal 2007;335:386-392
3. Antibiotic Prophylaxis and Recurrent Urinary Tract Infection in Children. Jonathan C.
Craig, M.B., Ch.B., Ph.D., et al. N Engl J Med 2009; 361:1748-59.
4. Diagnosis and Management of Urinary Tract Infection in Children: summary of NICE
guidance. Rintaro Mori et al. British Medical Journal 2007; 143-145.
5. AAP Practice Parameter: The Diagnosis, Treatment, and Evaluation of the
Initial Urinary Tract Infection in Febrile Infants and Young Children. Pediatrics Vol. 103
No. 4 April 1999 843- 852
6. Vesicoureteral Reflux: The Role of Antibiotic Prophylaxis. Ellen R. Wald. Pediatrics
2006; 117:919-922
7. Imaging in childhood urinary tract infections: time to reduce investigations. Stephen D.
Marks, et al. Pediatr Nephrol (2008) 23:9–17