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October 02, 2020
Latest evidence and recommendations on paediatric UTI diagnosis and management 1
Introduction
UTI is a common and potentially serious infection in children, from infancy through to older adolescence. Challenges and controversies exist in the diagnosis, investigation and management of paediatric UTI. This review paper gives an overview of these aspects with highlights from recent evidence and guideline recommendations.
Key points
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Epidemiology, aetiology and burden
- Prevalence of UTI in febrile infants, unwell children in general practice and older children with urinary symptoms is 6–8% but varies with age.
Peak prevalence occurs in young infants, toddlers and older adolescents.
- Over 30% of children with UTI experience recurrent infection – risk factors for recurrence include vesicoureteric reflux (VUR) and bladder–bowel dysfunction.
- Escherichia coli is the most common uropathogen (80% of cases); Klebsiella, Proteus, Enterobacter and Enterococcus spp. are other common causative agents.
- Short-term morbidity can arise from infection within the renal system or haematogenous spread.
- Approximately 5% of infants <12 months with UTI have bacteraemia.
- Long-term morbidity from upper tract UTI includes renal injury and scarring, although the risk of developing subsequent chronic kidney disease is minimal in the absence of structural renal anomalies or recurrent UTI.
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Diagnosis
- Clinical features may be very non-specific, especially in younger children (e.g. lethargy, irritability, poor feeding), and UTI is important to consider in infants with fever without focus; older children may report dysuria or flank pain.
- Since clinical diagnosis is unreliable, a urine sample is required for a diagnosis.
- Continent children can provide a mid-stream urine sample.
- Pre-continent children pose a challenge for sample collection and the optimal method remains controversial: the optimal non-invasive method involves waiting for spontaneous urine voiding and performing a ‘clean catch’ (contamination rate ~25%); invasive methods include urine extraction via urethral catheterisation or suprapubic needle aspiration (SPA), with contamination rates of 10% and 1%, respectively – most international guidelines recommend catheter or SPA as gold standard.
- Cleaning the perigenital skin before sample collection can minimise contamination.
- Urine dipsticks and microscopy are useful screening tools.
- The threshold for diagnosis from laboratory culture varies between guidelines, i.e. 50–100 x103 CFU/ml; recent evidence suggests a threshold of 10 x103 CFU/ml would increase sensitivity without reducing specificity
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Initial management
- Prompt treatment helps prevent short-term morbidity (e.g. urosepsis) and long-term renal scarring.
- Antibiotic resistance is an increasing challenge – initial empiric antibiotic therapy must be guided by local guidelines and once culture results are available the treatment should be reviewed for its suitability.
- Recommended duration of therapy varies across guidelines from short courses of 3 days for uncomplicated cystitis to longer courses of 7–14 days for both cystitis and pyelonephritis; Cochrane reviews suggest short (2–4 days) courses are as effective as longer courses for uncomplicated cystitis.
- Most children can be managed at home although a small proportion require admission for intravenous therapy, e.g. very young and very unwell children; children with significant renal tract abnormalities; and children not responding to oral therapy.
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Imaging
- Recommendations for imaging (to identify renal scarring and complications) vary across guidelines – targeted imaging and surveillance strategies in selected indications is appropriate.
- Ultrasound is generally recommended in febrile UTI in children, especially in children up to 2 years of age.
- Dimercaptosuccinic acid (DMSA) scan may be indicated if the UTI is atypical, recurrent, or if the initial ultrasound is significantly abnormal.
- Voiding cystourethrogram (VCUG) is the gold standard for identifying and quantifying VUR, although there is a lack of consensus on exactly who to image.
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Special cases
- Reflux
- Mild hydronephrosis and VUR are likely normal physiological states that resolve spontaneously; active management strategies for higher grade VUR should be considered.
- Anatomical abnormalities
- Anatomical abnormalities of the renal system, often detected on antenatal ultrasound screening, may predispose to UTI morbidity; significant abnormalities warrant follow-up.
- Recurrent UTI
- Antibiotic prophylaxis is of modest benefit but increases antibiotic resistance – it is not indicated after the first or second UTI in otherwise healthy children.
- Simple hygiene (e.g. wiping front to back in females) can avoid introducing bacteria into the urethral orifice.
- Active management of toilet training and constipation is important to prevent functional bladder–-bowel dysfunction.
- Antibiotic prophylaxis is of modest benefit but increases antibiotic resistance – it is not indicated after the first or second UTI in otherwise healthy children.
- Reflux
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