Managing urinary tract infections

Abstract

Urinary tract infections (UTI) are common in childhood. Presence of pyuria and bacteriuria in an appropriately collected urine sample are diagnostic of UTI. The risk of UTI is increased with an underlying urological abnormality such as vesicoureteral reflux, constipation, and voiding dysfunction. Patients with acute pyelonephritis are at risk of renal scarring and subsequent complications such as hypertension, proteinuria with and without FSGS, pregnancy-related complications and even end-stage renal failure. The relevance and the sequence of the renal imaging following initial UTI, and the role of antimicrobial prophylaxis and surgical intervention are currently undergoing an intense debate. Prompt treatment of UTI and appropriate follow-up of those at increased risk of recurrence and/or renal scarring are important.

This is a preview of subscription content, access via your institution.

References

  1. 1.

    Uhari M, Nuutinen M (1988) Epidemiology of symptomatic infections of the urinary tract in children. BMJ 297:450–452

    CAS  PubMed  PubMed Central  Google Scholar 

  2. 2.

    Dunand BA (2009) Urinary Tract Infections. In: Avner ED HW, Niaudet P, Yoshikawa N. (ed) Pediatric Nephrology. Springer

  3. 3.

    Bell LE, Mattoo TK (2009) Update on childhood urinary tract infection and vesicoureteral reflux. Semin Nephrol 29:349–359

    PubMed  Google Scholar 

  4. 4.

    Conway PH, Cnaan A, Zaoutis T, Henry BV, Grundmeier RW, Keren R (2007) Recurrent urinary tract infections in children: risk factors and association with prophylactic antimicrobials. JAMA 298:179–186

    CAS  PubMed  Google Scholar 

  5. 5.

    Dai B, Liu Y, Jia J, Mei C (2010) Long-term antibiotics for the prevention of recurrent urinary tract infection in children: a systematic review and meta-analysis. Arch Dis Child 95:499–508

    PubMed  Google Scholar 

  6. 6.

    Peters CA, Skoog SJ, Arant BS Jr, Copp HL, Elder JS, Hudson RG, Khoury AE, Lorenzo AJ, Pohl HG, Shapiro E, Snodgrass WT, Diaz M (2010) Summary of the AUA guideline on management of primary vesicoureteral reflux in children. J Urol 184:1134–1144

    PubMed  Google Scholar 

  7. 7.

    Shaikh N, Ewing AL, Bhatnagar S, Hoberman A (2010) Risk of renal scarring in children with a first urinary tract infection: a systematic review. Pediatrics 126:1084–1091

    PubMed  Google Scholar 

  8. 8.

    Bensman A, Dunand O, UlinskiT (2009) Urinary Tract Infections. In: Avner ED, Harmon WE, Niaudet P, Yoshikawa N (Eds) Pediatric Nephrology. Springer, Berlin, pp 1299-1309

  9. 9.

    Akram M, Shahid M, Khan AU (2007) Etiology and antibiotic resistance patterns of community-acquired urinary tract infections in J N M C Hospital Aligarh, India. Ann Clin Microbiol Antimicrob 6:4

    PubMed  PubMed Central  Google Scholar 

  10. 10.

    Chakupurakal R, Ahmed M, Sobithadevi DN, Chinnappan S, Reynolds T (2010) Urinary tract pathogens and resistance pattern. J Clin Pathol 63:652–654

    CAS  PubMed  Google Scholar 

  11. 11.

    Lutter SA, Currie ML, Mitz LB, Greenbaum LA (2005) Antibiotic resistance patterns in children hospitalized for urinary tract infections. Arch Pediatr Adolesc Med 159:924–928

    PubMed  Google Scholar 

  12. 12.

    American Academy of Pediatrics (1999) Practice parameter: the diagnosis, treatment, and evaluation of the initial urinary tract infection in febrile infants and young children. American Academy of Pediatrics. Committee on quality improvement. Subcommittee on urinary tract infection. Pediatrics 103:843-852

    Google Scholar 

  13. 13.

    Winberg J, Andersen HJ, Bergstrom T, Jacobsson B, Larson H, Lincoln K (1974) Epidemiology of symptomatic urinary tract infection in childhood. Acta Paediatr Scand Suppl:1-20

  14. 14.

    Williams GJ, Macaskill P, Chan SF, Turner RM, Hodson E, Craig JC (2010) Absolute and relative accuracy of rapid urine tests for urinary tract infection in children: a meta-analysis. Lancet Infect Dis 10:240–250

    PubMed  Google Scholar 

  15. 15.

    Keren R, Carpenter MA, Hoberman A, Shaikh N, Matoo TK, Chesney RW, Matthews R, Gerson AC, Greenfield SP, Fivush B, McLurie GA, Rushton HG, Canning D, Nelson CP, Greenbaum L, Bukowski T, Primack W, Sutherland R, Hosking J, Stewart D, Elder J, Moxey-Mims M, Nyberg L (2008) Rationale and design issues of the Randomized Intervention for Children With Vesicoureteral Reflux (RIVUR) study. Pediatrics 122(Suppl 5):S240–S250

    PubMed  PubMed Central  Google Scholar 

  16. 16.

    Hellerstein S (1982) Recurrent urinary tract infections in children. Pediatr Infect Dis 1:271–281

    CAS  PubMed  Google Scholar 

  17. 17.

    Coulthard MG, Kalra M, Lambert HJ, Nelson A, Smith T, Perry JD (2010) Redefining urinary tract infections by bacterial colony counts. Pediatrics 125:335–341

    PubMed  Google Scholar 

  18. 18.

    Linshaw M (1996) Asymptomatic bacteriuria and vesicoureteral reflux in children. Kidney Int 50:312–329

    CAS  PubMed  Google Scholar 

  19. 19.

    Ottolini MC, Shaer CM, Rushton HG, Majd M, Gonzales EC, Patel KM (1995) Relationship of asymptomatic bacteriuria and renal scarring in children with neuropathic bladders who are practicing clean intermittent catheterization. J Pediatr 127:368–372

    CAS  PubMed  Google Scholar 

  20. 20.

    Bensman A (2002) Should children with asymptomatic bacteriuria (ABU) undergo imaging studies of the urinary tract? Pediatr Nephrol 17:76–77

    CAS  PubMed  Google Scholar 

  21. 21.

    Hansson S, Martinell J, Stokland E, Jodal U (1997) The natural history of bacteriuria in childhood. Infect Dis Clin North Am 11:499–512

    CAS  PubMed  Google Scholar 

  22. 22.

    Wettergren B, Hellstrom M, Stokland E, Jodal U (1990) Six year follow up of infants with bacteriuria on screening. BMJ 301:845–848

    CAS  PubMed  PubMed Central  Google Scholar 

  23. 23.

    Lavocat MP, Granjon D, Allard D, Gay C, Freycon MT, Dubois F (1997) Imaging of pyelonephritis. Pediatr Radiol 27:159–165

    CAS  PubMed  Google Scholar 

  24. 24.

    Ahmed M, Eggleston D, Kapur G, Jain A, Valentini RP, Mattoo TK (2008) Dimercaptosuccinic acid (DMSA) renal scan in the evaluation of hypertension in children. Pediatr Nephrol 23:435–438

    PubMed  Google Scholar 

  25. 25.

    Lebowitz RL, Olbing H, Parkkulainen KV, Smellie JM, Tamminen-Mobius TE (1985) International system of radiographic grading of vesicoureteric reflux. International reflux study in children. Pediatr Radiol 15:105–109

    CAS  PubMed  Google Scholar 

  26. 26.

    Ditchfield MR, Summerville D, Grimwood K, Cook DJ, Powell HR, Sloane R, Nolan TM, de Campo JF (2002) Time course of transient cortical scintigraphic defects associated with acute pyelonephritis. Pediatr Radiol 32:849–852

    PubMed  Google Scholar 

  27. 27.

    Baumer JH, Jones RW (2007) Urinary tract infection in children, National Institute for Health and Clinical Excellence. Arch Dis Child Educ Pract Ed 92:189–192

    CAS  PubMed  Google Scholar 

  28. 28.

    Coulthard MG (2008) Is reflux nephropathy preventable, and will the NICE childhood UTI guidelines help? Arch Dis Child 93:196–199

    PubMed  Google Scholar 

  29. 29.

    Coulthard MG (2007) NICE on childhood UTI: Nasty processes produce nasty guidelines. BMJ 335:463; author reply 463-464

  30. 30.

    Tse NK, Yuen SL, Chiu MC, Lai WM, Tong PC (2009) Imaging studies for first urinary tract infection in infants less than 6 months old: can they be more selective? Pediatr Nephrol 24:1699–1703

    PubMed  Google Scholar 

  31. 31.

    Herz D, Merguerian P, McQuiston L, Danielson C, Gheen M, Brenfleck L (2010) 5-year prospective results of dimercapto-succinic acid imaging in children with febrile urinary tract infection: proof that the top-down approach works. J Urol 184:1703–1709

    PubMed  Google Scholar 

  32. 32.

    Lee MD, Lin CC, Huang FY, Tsai TC, Huang CT, Tsai JD (2009) Screening young children with a first febrile urinary tract infection for high-grade vesicoureteral reflux with renal ultrasound scanning and technetium-99 m-labeled dimercaptosuccinic acid scanning. J Pediatr 154:797–802

    PubMed  Google Scholar 

  33. 33.

    Ziessman HA, Majd M (2009) Importance of methodology on (99 m)technetium dimercapto-succinic acid scintigraphic image quality: imaging pilot study for RIVUR (Randomized Intervention for Children With Vesicoureteral Reflux) multicenter investigation. J Urol 182:272–279

    PubMed  Google Scholar 

  34. 34.

    Hiraoka M, Hashimoto G, Tsuchida S, Tsukahara H, Ohshima Y, Mayumi M (2003) Early treatment of urinary infection prevents renal damage on cortical scintigraphy. Pediatr Nephrol 18:115–118

    PubMed  Google Scholar 

  35. 35.

    Hewitt IK, Zucchetta P, Rigon L, Maschio F, Molinari PP, Tomasi L, Toffolo A, Pavanello L, Crivellaro C, Bellato S, Montini G (2008) Early treatment of acute pyelonephritis in children fails to reduce renal scarring: data from the Italian renal infection study trials. Pediatrics 122:486–490

    PubMed  Google Scholar 

  36. 36.

    Doganis D, Siafas K, Mavrikou M, Issaris G, Martirosova A, Perperidis G, Konstantopoulos A, Sinaniotis K (2007) Does early treatment of urinary tract infection prevent renal damage? Pediatrics 120:e922–e928

    PubMed  Google Scholar 

  37. 37.

    Hodson EM, Willis NS, Craig JC (2007) Antibiotics for acute pyelonephritis in children. Cochrane Database Syst Rev:CD003772

  38. 38.

    Montini G, Toffolo A, Zucchetta P, Dall'Amico R, Gobber D, Calderan A, Maschio F, Pavanello L, Molinari PP, Scorrano D, Zanchetta S, Cassar W, Brisotto P, Corsini A, Sartori S, Da Dalt L, Murer L, Zacchello G (2007) Antibiotic treatment for pyelonephritis in children: multicentre randomised controlled non-inferiority trial. BMJ 335:386

    CAS  PubMed  PubMed Central  Google Scholar 

  39. 39.

    Hoberman A, Wald ER (1997) Urinary tract infections in young febrile children. Pediatr Infect Dis J 16:11–17

    CAS  PubMed  Google Scholar 

  40. 40.

    Pantell RH, Newman TB, Bernzweig J, Bergman DA, Takayama JI, Segal M, Finch SA, Wasserman RC (2004) Management and outcomes of care of fever in early infancy. JAMA 291:1203–1212

    PubMed  Google Scholar 

  41. 41.

    Williams G, Craig, C. (2008) Diagnosis and Management of Urinary Tract Infections. In: Geary D, Schaefer F (ed) Comprehensive Pediatric Nephrology. Mosby, pp 539-548

  42. 42.

    Zhanel GG, Hisanaga TL, Laing NM, DeCorby MR, Nichol KA, Weshnoweski B, Johnson J, Noreddin A, Low DE, Karlowsky JA, Hoban DJ (2006) Antibiotic resistance in Escherichia coli outpatient urinary isolates: final results from the North American Urinary Tract Infection Collaborative Alliance (NAUTICA). Int J Antimicrob Agents 27:468–475

    CAS  PubMed  Google Scholar 

  43. 43.

    Zhanel GG, Hisanaga TL, Laing NM, DeCorby MR, Nichol KA, Palatnik LP, Johnson J, Noreddin A, Harding GK, Nicolle LE, Hoban DJ (2005) Antibiotic resistance in outpatient urinary isolates: final results from the North American Urinary Tract Infection Collaborative Alliance (NAUTICA). Int J Antimicrob Agents 26:380–388

    CAS  PubMed  Google Scholar 

  44. 44.

    Prelog M, Schiefecker D, Fille M, Wurzner R, Brunner A, Zimmerhackl LB (2008) Febrile urinary tract infection in children: ampicillin and trimethoprim insufficient as empirical mono-therapy. Pediatr Nephrol 23:597–602

    PubMed  Google Scholar 

  45. 45.

    Fabre R, Merens A, Lefebvre F, Epifanoff G, Cerutti F, Pupin H, Tardif D, Cavallo JD, Ternois I (2010) Susceptibility to antibiotics of Escherichia coli isolated from community-acquired urinary tract infections. Méd Mal Infect 40:555–559

    CAS  PubMed  Google Scholar 

  46. 46.

    Michael M, Hodson EM, Craig JC, Martin S, Moyer VA (2003) Short versus standard duration oral antibiotic therapy for acute urinary tract infection in children. Cochrane Database Syst Rev:CD003966

  47. 47.

    Oreskovic NM, Sembrano EU (2007) Repeat urine cultures in children who are admitted with urinary tract infections. Pediatrics 119:e325–e329

    PubMed  Google Scholar 

  48. 48.

    Currie ML, Mitz L, Raasch CS, Greenbaum LA (2003) Follow-up urine cultures and fever in children with urinary tract infection. Arch Pediatr Adolesc Med 157:1237–1240

    PubMed  Google Scholar 

  49. 49.

    Cheng CH, Tsai MH, Huang YC, Su LH, Tsau YK, Lin CJ, Chiu CH, Lin TY (2008) Antibiotic resistance patterns of community-acquired urinary tract infections in children with vesicoureteral reflux receiving prophylactic antibiotic therapy. Pediatrics 122:1212–1217

    PubMed  Google Scholar 

  50. 50.

    Williams GJ, Wei L, Lee A, Craig JC (2006) Long-term antibiotics for preventing recurrent urinary tract infection in children. Cochrane Database Syst Rev 3:CD001534

  51. 51.

    Garin EH, Olavarria F, Garcia Nieto V, Valenciano B, Campos A, Young L (2006) Clinical significance of primary vesicoureteral reflux and urinary antibiotic prophylaxis after acute pyelonephritis: a multicenter, randomized, controlled study. Pediatrics 117:626–632

    Google Scholar 

  52. 52.

    Roussey-Kesler G, Gadjos V, Idres N, Horen B, Ichay L, Leclair MD, Raymond F, Grellier A, Hazart I, de Parscau L, Salomon R, Champion G, Leroy V, Guigonis V, Siret D, Palcoux JB, Taque S, Lemoigne A, Nguyen JM, Guyot C (2008) Antibiotic prophylaxis for the prevention of recurrent urinary tract infection in children with low grade vesicoureteral reflux: results from a prospective randomized study. J Urol 179:674–679, discussion 679

    CAS  Google Scholar 

  53. 53.

    Pennesi M, Travan L, Peratoner L, Bordugo A, Cattaneo A, Ronfani L, Minisini S, Ventura A (2008) Is antibiotic prophylaxis in children with vesicoureteral reflux effective in preventing pyelonephritis and renal scars? A randomized, controlled trial. Pediatrics 121:e1489–e1494

    PubMed  Google Scholar 

  54. 54.

    Montini G, Rigon L, Zucchetta P, Fregonese F, Toffolo A, Gobber D, Cecchin D, Pavanello L, Molinari PP, Maschio F, Zanchetta S, Cassar W, Casadio L, Crivellaro C, Fortunati P, Corsini A, Calderan A, Comacchio S, Tommasi L, Hewitt IK, Da Dalt L, Zacchello G, Dall'Amico R (2008) Prophylaxis after first febrile urinary tract infection in children? A multicenter, randomized, controlled, noninferiority trial. Pediatrics 122:1064–1071

    PubMed  Google Scholar 

  55. 55.

    Craig JC, Simpson JM, Williams GJ, Lowe A, Reynolds GJ, McTaggart SJ, Hodson EM, Carapetis JR, Cranswick NE, Smith G, Irwig LM, Caldwell PH, Hamilton S, Roy LP (2009) Antibiotic prophylaxis and recurrent urinary tract infection in children. N Engl J Med 361:1748–1759

    CAS  PubMed  Google Scholar 

  56. 56.

    Brandstrom P, Esbjorner E, Herthelius M, Swerkersson S, Jodal U, Hansson S (2010) The Swedish reflux trial in children: III. Urinary tract infection pattern. J Urol 184:286–291

    PubMed  Google Scholar 

  57. 57.

    Brandstrom P, Neveus T, Sixt R, Stokland E, Jodal U, Hansson S (2010) The Swedish reflux trial in children: IV. Renal damage. J Urol 184:292–297

    PubMed  Google Scholar 

  58. 58.

    Holmdahl G, Brandstrom P, Lackgren G, Sillen U, Stokland E, Jodal U, Hansson S (2010) The Swedish reflux trial in children: II. Vesicoureteral reflux outcome. J Urol 184:280–285

    PubMed  Google Scholar 

Download references

Author information

Affiliations

Authors

Corresponding author

Correspondence to Tej K. Mattoo.

Additional information

Answers:

1. b. Uretheral catheterization or suprapubic aspiration should be performed in infants and newborn

2. d. LE and nitrite

3. d. Can be a normal finding in children with neurogenic bladder

4. c. DMSA renal scan

Multiple-choice questions

Multiple-choice questions

(Answers appear following the reference list)

1. Which one of the following statements regarding UTI diagnosis is true?

  1. a.

    Clean-catch urine sample can be used in all children

  1. b.

    Uretheral catheterization or suprapubic aspiration should be performed in infants and newborn

  1. c.

    Uretheral catheterization has a lower likelihood of contamination compared with suprapubic aspiration

  1. d.

    Periuretheral adhesive bag can be used in boys but not girls because of contamination risk

  1. e.

    Any bacterial growth from a catheterized urine sample is considered significant

2. Of the following, which one is the most specific test for UTI by dipstick?

  1. a.

    LE alone

  1. b.

    Nitrite alone

  1. c.

    Protein and blood

  1. d.

    LE and nitrite

  1. e.

    Protein and LE

3. Which one of the following characterizes asymptomatic bacteriuria?

  1. a.

    Pyuria is present

  1. b.

    Most commonly caused by Pseudomonas Aeruginosa

  1. c.

    Antibiotic treatment is indicated

  1. d.

    Can be a normal finding in children with neurogenic bladder

  1. e.

    Increased risk of scarring if antibiotic prophylaxis is not used

4. Which of the following tests is the current gold standard for diagnosing renal scarring?

  1. a.

    Ultrasound examination

  1. b.

    Intravenous pyelography

  1. c.

    DMSA renal scan

  1. d.

    CT scan

  1. e.

    Radionuclear cystography (RNC)

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Saadeh, S.A., Mattoo, T.K. Managing urinary tract infections. Pediatr Nephrol 26, 1967–1976 (2011). https://doi.org/10.1007/s00467-011-1801-5

Download citation

Keywords

  • Urinary tract infection
  • Vesicoureteric reflux
  • Management