Pediatric UTI
Screen UTI
Screen UTI
- <3 years old, if fever with unclear source
- >3 years old, consider testing if presence of dysuria, urinary frequency, hematuria, abdominal/back pain, daytime incontinence
- Consider low risk UTI (<1%) if female and no more than one of following
- <1 years old
- White race
- T>39° C
- Fever >2d
- Absence of source
- Consider low risk UTI (<1%) if female and no more than one of following
Symptoms
Symptoms
- Lower urinary tract (cystitis)
- Dysuria, frequency, urgency, malodorous urine, enuresis, hematuria, suprapubic pain
- Upper urinary tract (pyelonephritis)
- Fever, chills, CVA pain/tenderness
- Infants may have non-specific signs (poor appetite, failure to thrive, lethargy, irritability, vomiting, diarrhea)
Urinalysis and Urine Culture
Urinalysis and Urine Culture
- Catheterization or mid-stream if toilet trained for culture
- May consider 25 mins after feeding, holding baby upright, tap on bladder x30s then massage sacrum x30s (repeat maneuvers until micturition)
- May consider bag urine to screen by microscopy (positive if >10-20 WBC/hpf, or LE, NT positive) then catheterization needed
- Criteria for UTI
- Positive urine specimen from suprapubic bladder puncture
- >1000 cfu/mL from bladder catheterisation
- >10^4 with symptoms or >10^5 without symptoms from midstream void
- Sterile pyuria may be due to incomplete antibiotic treatment, urolithiasis, foreign body, infection by Mycobacterium tuberculosis, Chlamydia trachomatis
- Negative nitrites not reliable if infant empties bladder frequently (requires 4h to convert)
Treatment (usually 7-14d)
Treatment (usually 7-14d)
- Ampicillin 50 mg/kg/dose IV q6h + Gentamicin 7.5 mg/kg IV/IM once daily
- Cefixime 8mg/kg PO daily (max 400mg/d)
- TMP/SMX 6-12mg/kg/day divided q12h (max 320mg TMP daily), avoid in newborns
- Amox/Clav 7:1 suspension, 45mg/kg/day of Amox divided q8h (max 3g Amox daily)
- Alternatives
- Amoxicillin 50 mg/kg/day divided q8h (max 3g daily)
- Cephalexin 50 mg/kg/day divided q6h (max 500mg/dose)
Disposition
Disposition
- Admit if <2 months old or complicated
- Consider discharge if well and >2 months old with follow-up
Imaging
Imaging
- Renal-Bladder Ultrasound if child
- <2yo with first febrile UTI within 2w of acute illness
- Recurrent UTIs
- Pyelonephritis (Complicated)
- Family/personal history of urologic/renal abnormalities
- VCUG if
- Hydronephrosis on ultrasound that suggests high grade (4-5) VUR, in addition consult urology or nephrology
- <2yo with second febrile UTI
Prevention
Prevention
- Prophylaxis not routinely recommended, but may consider in Grade IV/V VUR or significant urological anomaly
References:
- CPS 2014. Diagnosis and Management. https://www.cps.ca/en/documents/position/urinary-tract-infections-in-children
- CPS 2015. Prophylaxis https://www.cps.ca/en/documents/position/prophylactic-antibiotics-recurrent-urinary-tract-infections