1. Urinary Tract Infection in the pediatric patient
Meaghan Eddy, RN, BSN
FNP student

2. 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

3. Severe and recurrent infections may lead to:
Renal scarring
Hypertension
End-Stage Renal Dysfunction in adulthood
May be life threatening
in the neonate/infant

4. Common Pathogens
E. Coli- the most common cause of uncomplicated UTI. Estimates range from 75-95% 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

5. 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?

6. 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

7. 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)

8. Risk Factors Cont’d Dysfunctional Voiding 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

9. Clinical Findings (by age group)

10. Neonates Jaundice Hypothermia FTT Sepsis Vomiting/Diarrhea Cyanosis
Abdominal Distension
Lethargy

11. Infants Malaise Irritability Difficulty Feeding FTT
Fever (esp. in pyelonephritis)
Vomiting/Diarrhea
Malodorous Urine
Abdominal Pain/colic

12. Toddlers/Preschoolers
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

13. School-Age to Adolescence
Frequency, Urgency, Discomfort
Malodorous Urine
Abdominal/Flank Pain (esp in pyelonephritis)
Suprapubic tenderness
Fever/Chills (esp. in pyelonephritis)
Malaise
Vomiting/diarrhea (esp. in pyelonephritis)

14. 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

15. not all collection methods are created equal!
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

16. 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

17. ?? 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

18. 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

19. Additional Labs to think about:
CBC
ESR
C-reactive Protein
BUN/Cr
Blood Cultures
If the child appears ill, is less than 12 months, or pyelonephritis is suspected

20. Recommendations for anti-microbial therapy
Inpatient treatment Intravenous options:
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

21. 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

22. 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

23. So, a UTI is diagnosed, antibiotics are started…
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

24. 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.

25. 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**

26. Degrees of Vesicoureteral reflux

27. 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

28. 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

29. 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),
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 .