Pediatrics
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This past September, the American Academy of Pediatrics (AAP) published its new clinical practice guidelines for the diagnosis and management of initial Urinary Tract Infections (UTI) in febrile infants and children. The last guideline for UTIs was published in 1999. What’s in the new guidelines that Emergency Physicians should know about?      

The new guideline applies to infants and children who are 2-24 months old and have no neurological or other abnormalities known to increase risk for a UTI. The major difference between this new practice parameter and the old recommendations is the flexibility of not ordering a urine analysis (UA) in every febrile child with no source on physical exam. Instead, providers are encouraged to test only children at increased risk for UTI. The AAP is fairly conservative about risk. For the committee developing the guideline, about 10% considered a risk of 1% to be significant, and a majority a risk above 2%.  

The guideline(s) reinforces that urine should be collected by catheterization or suprapubic bladder aspiration and discourages bagged specimens. It requires that a UTI be diagnosed by both a positive UA  (pyuria and/or bacteriuria) and a positive culture, in an effort to avoid over treatment of asymptomatic bacteriuria.

The guideline discusses starting antibiotics either orally or parenterally in ED patients who are nontoxic and not vomiting. The duration of antibiotics is 7-14 days, but not shorter than that. Follow-up requires a renal ultrasound but no longer a VCUG (voiding cystourethrogram) for the first UTI. Finally, if a child comes back after an initial UTI and has another fever with no source, the guideline recommends checking another urine since recurrent UTIs can lead to scarring of the kidneys.

The Details

When should I check a UA?
Under the old guidelines, children 2-24 months with fever and no source on physical exam all had a UA ordered. The new guideline is more selective. Under the new recommendations, a clinician looks at the risk of UTI and decides whether or not urine testing is warranted.
If the child looks toxic/sick or there is another pressing reason to treat (such as an immunocompromised state) – get a UA before giving antibiotics. Waiting until after antibiotics are given may obscure the diagnosis.
If the child is well-appearing, decide if they are at high risk or low risk for having a UTI.

Risk factors for girls:

  • White race
  • Age < 12 months
  • Temp > 39 C
  • Fever > 2 days
  • Absence of another source of infection on exam


The probability of UTI is:

  • Less than 1% if one risk factor is present
  • Less than 2% if two risk factors are present.


Risk factors for boys:

  • Uncircumcised
  • Non-black race
  • Temp > 39 C
  • Fever > 2 days
  • Absence of another source of infection on exam


For boys, being uncircumcised causes the risk of UTI to be greater than 1% even with no other risk factors present. Otherwise, the probability of UTI is < 1% if two risk factors are present, < 2% if three risk factors are present.

How do I get a UA?
Catheterization or suprapubic bladder aspiration is strongly recommended.
If you get a bagged specimen, do not use it for culture, only for urinalysis. If the urinalysis suggests no infection, you can stop there, but if it suggests that a UTI is present, you should collect urine for culture through catheterization or suprapubic bladder aspiration. This can add quite a bit of time to your work-up…and will make you quite popular with the nurses.

How do I know it’s a UTI?
The patient has to have both a positive urinalysis and a positive culture.
What’s a positive urinalysis? Pyuria and/or bacteriuria. Leukocyte Esterase is a good surrogate for pyuria, nitrite for bacteriuria. A urine gram stain that is unspun and shows bacteria correlates well with a culture showing 105 colony forming units.
What is a positive culture? 50,000 colony forming units of a single organism known to cause a UTI
Because we do not have access to culture results in the ED, the diagnosis will be made on the basis of the UA.

How do I treat?
a.  The usual antibiotics, such as cephalosporins, augmentin, or bactrim should all be considered based on your local patterns of susceptibility. Nitrofurantoin is not a good choice because it collects in the bladder but does not achieve high enough concentrations in the blood stream to treat pyelonephritis.
b. IV or PO? The new guidelines say initiating therapy PO is fine as long as the patient is not vomiting and tolerates PO.
c. How long should I treat? The new guidelines say anywhere from 7-14 days.

What comes next?
If the child is not improving or is unusually sick, a renal ultrasound should be done to look for renal or perirenal abscess or pyonephrosis. Otherwise, the child’s personal physician should arrange for a renal ultrasound at a later time.
VCUG is no longer recommended after the first UTI.

Anything else?
The risk of scarring to the kidneys goes up with recurrent UTIs. Early therapy can prevent this! For this reason, children who have had a documented UTI in the past should have urine tested the next time they have a fever.

Urinary Tract Infection: Clinical Practice Guideline for the Diagnosis and Management of the Initial UTI in Febrile Infants and Children 2 to 24 Months. Pediatrics. 2011;128(3)595-609

Amy Levine, MD, is an associate professor of pediatric emergency medicine at UNC Chapel Hill.
 

 

 

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