View source for Urinary tract infection (peds)

''This page is for pediatric patients; see [[Acute cystitis]] for adult patients.''
==Background==
*Most common SBI, accounts for 5-8% of children presenting for fever without clear source
*Associated with bacteremia in up to 30% of infants 4-8wk of age
*[[E. coli]] is responsible for ~80% of UTIs
*After 1yr of age, occult UTI with normal UA extremely rare 
*After 2yr of age, UTI remains common in girls (but associated with symptoms) 
*UTI in adolescent girl is suggestive of intercourse
*Prevalence of UTI in [[bronchiolitis]] is only 0.8% based on 2019 meta-analysis, which is far lower than in previous studies, suggesting less need for automatic testing for UTI in bronchiolitis<ref>McDaniel CE et al. Association of Diagnostic Criteria With Urinary Tract Infection Prevalence in Bronchiolitis: A Systematic Review and Meta-analysis. JAMA Pediatr. 2019;173(3):269-277. doi:10.1001/jamapediatrics.2018.5091.</ref>

==Clinical Features==
*Infants/young children: [[fever (Peds)|fever]] without other source 
*Older children: 
**[[Dysuria]], frequency, or other urinary complaints
**+/- [[abdominal pain (peds)|abdominal]]/[[back pain]]
*UTI + [[fever (Peds)|fever]] = [[pyelonephritis]]

==Differential Diagnosis==
{{Pediatric abdominal pain DDX}}

{{Pediatric fever DDX}}

==Evaluation==
===Workup===
*[[Urinalysis]] 
**Obtain clean catch specimen '''OR''' cath UA 
***Neg UA = neg LE, nit, GS & <5 WBC 
**Bag urine results in 83% false positive; only useful if negative 
***UTI diagnosis cannot be established reliably through bag urine culture (Evidence A; strong recommendation; AAP 2011)
*Urine culture  
**Send on all patients except for: 
***1. Low-risk patients with normal UA and another explanation for symptoms 
***2. Older adolescent females with very high post-test probability without severe illness 
**20% of +Urine culture will have negative UA
**Do not send urine bag specimen for culture when UA is negative and clinical suspicion is relatively low<ref>Kim GA and Koo JW. Validity of bag urine culture for predicting urinary tract infections in febrile infants: a paired comparison of urine collection methods. Korean J Pediatr. 2015 May; 58(5): 183–189.</ref>
***False positives are high due to bag contamination

===Diagnosis===
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|- style="font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12"
! valign="top" bgcolor="#ffffff" align="left" rowspan="1" colspan="4" | Test Characteristic Ranges 
! valign="top" bgcolor="#ffffff" align="left" rowspan="1" colspan="5" | Post-test Probability (%) of UTI in Different Patients
|- style="font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12"
! valign="top" bgcolor="#ffffff" align="left" rowspan="1" | Test 
! valign="top" bgcolor="#ffffff" align="left" rowspan="1" | Sensitivity (%) 
! valign="top" bgcolor="#ffffff" align="left" rowspan="1" | Specificity (%) 
! valign="top" bgcolor="#ffffff" align="left" rowspan="1" | Test Result 
! valign="top" bgcolor="#ffffff" align="left" rowspan="1" | LR 
! valign="top" bgcolor="#ffffff" align="left" rowspan="1" | Patient A 
! valign="top" bgcolor="#ffffff" align="left" rowspan="1" | Patient B 
! valign="top" bgcolor="#ffffff" align="left" rowspan="1" | Patient C 
! valign="top" bgcolor="#ffffff" align="left" rowspan="1" | Patient D 
! valign="top" bgcolor="#ffffff" align="left" rowspan="1" | Patient E
|- style="font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" class="font12"
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| valign="top" bgcolor="#ffffff" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" rowspan="2" class="font12" | 67–85 
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| valign="top" bgcolor="#ffffff" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" rowspan="2" class="font12" | Nitrite*
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| valign="top" bgcolor="#ffffff" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" rowspan="2" class="font12" | Bacteria on Gram stain 
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| valign="top" bgcolor="#ffffff" align="left" style="color: rgb(51, 51, 51); font-size: 12px; line-height: 17px; margin: 0px 0px 9px;" rowspan="2" class="font12" | Any positive test on dipstick 
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<br> <span style="color: rgb(51, 51, 51);" class="Apple-style-span"><font style="font-size: 11px; line-height: 16px; margin: 0px 0px 9px;" class="font11">Patient A: Female patient in ED, <1 year old, fever with no definitive source on examination, pretest probability of UTI is 7%.</font></span> 

<span style="color: rgb(51, 51, 51); font-family: Verdana,Arial,Helvetica,sans-serif;" class="Apple-style-span"><font style="font-size: 11px; line-height: 16px; margin: 0px 0px 9px;" class="font11">Patient B: Male patient in ED, <1 year old, circumcised, fever with no definitive source on examination, pretest probability of UTI is 0.5%.</font></span> 

<span style="color: rgb(51, 51, 51); font-family: Verdana,Arial,Helvetica,sans-serif;" class="Apple-style-span"><font style="font-size: 11px; line-height: 16px; margin: 0px 0px 9px;" class="font11">Patient C: Male patient in ED, <1 year old, uncircumcised, fever with no definitive source on examination, pretest probability of UTI is 8%.</font></span> 

<span style="color: rgb(51, 51, 51); font-family: Verdana,Arial,Helvetica,sans-serif;" class="Apple-style-span"><font style="font-size: 11px; line-height: 16px; margin: 0px 0px 9px;" class="font11">Patient D: Female patient in ED, 2–6 years old, no fever but GU symptoms, pretest probability of UTI is 6.5%.</font></span> 

<span style="color: rgb(51, 51, 51); font-family: Verdana,Arial,Helvetica,sans-serif;" class="Apple-style-span"><font style="font-size: 11px; line-height: 16px; margin: 0px 0px 9px;" class="font11">Patient E: Female patient in ED, adolescent age range, no fever but urinary symptoms, pretest probability of UTI is 9%</font></span> 

<br>

==Management==
*Know your local resistance patterns and make sure to send a urine culture
*Do not use [[nitrofurantoin]] in children (need bloodstream penetration)

===<1mo=== 
*Admit for IV [[antibiotics]]
**[[Ceftazidime]] 150mg/kg/d divided every 6 h 

===1mo - 2yo===
*[[Ceftriaxone]] 50mg/kg in ED 
*[[Cephalexin]] 50-100mg/kg/d in 4 divided doses x14d 
**Maximum dose (all ages) 4g/24hr

===>2yo===
*[[Amoxicillin]] 
**Mild to moderate infections (>40kg): 500mg PO BID for x10-14d
*[[Cephalexin]] 50-100mg/kg/d in 4 divided doses x7d 
*[[Cefaclor]] 50-100 mg/kg/d divided in 3 doses x5d
*[[Cefixime]] 8 mg/kg daily x 5d

===>13yr adolescent===
*Consider 3 day course of treatment

==Disposition==
===Admit===
*<1 month old
*Toxic 
*Inability to tolerate POs

===Discharge===
*1mo - 2yr, who are well-appearing and not vomiting
**24-hour follow up 
*>2 years old
**48-hour follow up

==See Also==
*[[Urinary tract infections]]

==External Links==
*[https://uticalc.pitt.edu/ University of Pittsburgh UTI Calc]
*[https://www.chop.edu/clinical-pathway/urinary-tract-infection-uti-febrile-clinical-pathway Children's Hospital of Philadelphia UTI pathway]

==References==
<references/>


[[Category:Pediatrics]]
[[Category:ID]]
[[Category:Urology]]