Urinary tract infections in children: Epidemiology and risk factors
- Nader Shaikh, MD
Nader Shaikh, MD
- Assistant Professor of Pediatrics
- University of Pittsburgh School of Medicine
- Alejandro Hoberman, MD
Alejandro Hoberman, MD
- Associate Professor of Pediatrics
- University of Pittsburgh School of Medicine
- Section Editors
- Morven S Edwards, MD
Morven S Edwards, MD
- Section Editor — Pediatric Infectious Diseases
- Professor of Pediatrics
- Baylor College of Medicine
- Tej K Mattoo, MD, DCH, FRCP
Tej K Mattoo, MD, DCH, FRCP
- Section Editor — Pediatric Nephrology
- Professor of Pediatrics
- Wayne State University School of Medicine
Urinary tract infection (UTI) is a common and important clinical problem in childhood. Upper UTIs (ie, acute pyelonephritis) may lead to renal scarring, hypertension, and end-stage renal disease. Although children with pyelonephritis tend to present with fever, it is often difficult on clinical grounds to distinguish cystitis from pyelonephritis, particularly in young children (those younger than two years) . Thus, we have defined UTI broadly here without attempting to distinguish cystitis from pyelonephritis. Acute cystitis in older children is discussed separately. (See "Acute cystitis: Clinical features and diagnosis in children older than two years and adolescents".)
The presence of risk factors for UTI and renal scarring in a child presenting with fever and/or urinary symptoms is helpful in guiding diagnostic testing and management. The epidemiology and risk factors for UTI and renal scarring in children will be reviewed here. Clinical features, diagnosis, and management of UTI, and UTI in newborns (younger than one month of age) are discussed separately. (See "Urinary tract infections in infants and children older than one month: Clinical features and diagnosis" and "Urinary tract infections in infants older than one month and young children: Acute management, imaging, and prognosis" and "Urinary tract infections in children: Long-term management and prevention" and "Urinary tract infections in neonates".)
Prevalence — Awareness of the prevalence of UTI in various subgroups of children enables the clinician to grossly estimate the probability of infection in the patient (ie, the pretest probability) (table 1). This information is important in the evaluation of a child with suspected UTI. (See "Urinary tract infections in infants and children older than one month: Clinical features and diagnosis", section on 'Laboratory evaluation'.)
In young children with fever — The prevalence of UTI in children <2 years presenting with fever has been the subject of several large prospective studies and a meta-analysis (table 1) [2-4]. Important points that emerged from these studies include:
●The overall prevalence of UTI is approximately 7 percent in febrile infants and young children but varies by age, race/ethnicity, sex, and circumcision status.
- Hoberman A, Charron M, Hickey RW, et al. Imaging studies after a first febrile urinary tract infection in young children. N Engl J Med 2003; 348:195.
- Hoberman A, Chao HP, Keller DM, et al. Prevalence of urinary tract infection in febrile infants. J Pediatr 1993; 123:17.
- Shaw KN, Gorelick M, McGowan KL, et al. Prevalence of urinary tract infection in febrile young children in the emergency department. Pediatrics 1998; 102:e16.
- Shaikh N, Morone NE, Bost JE, Farrell MH. Prevalence of urinary tract infection in childhood: a meta-analysis. Pediatr Infect Dis J 2008; 27:302.
- Edlin RS, Shapiro DJ, Hersh AL, Copp HL. Antibiotic resistance patterns of outpatient pediatric urinary tract infections. J Urol 2013; 190:222.
- Shaikh N, Craig JC, Rovers MM, et al. Identification of children and adolescents at risk for renal scarring after a first urinary tract infection: a meta-analysis with individual patient data. JAMA Pediatr 2014; 168:893.
- Sobel JD, Vazquez JA. Fungal infections of the urinary tract. World J Urol 1999; 17:410.
- Wald ER. Cystitis and pyelonephritis. In: Feigin and Cherry’s Textbook of Pediatric Infectious Diseases, 7th ed, Cherry JD, Harrison GJ, Kaplan SL, et al (Eds), Elsevier Saunders, Philadelphia 2014. p.535.
- Kauffman CA, Vazquez JA, Sobel JD, et al. Prospective multicenter surveillance study of funguria in hospitalized patients. The National Institute for Allergy and Infectious Diseases (NIAID) Mycoses Study Group. Clin Infect Dis 2000; 30:14.
- Smellie JM, Poulton A, Prescod NP. Retrospective study of children with renal scarring associated with reflux and urinary infection. BMJ 1994; 308:1193.
- Hoberman A, Wald ER, Hickey RW, et al. Oral versus initial intravenous therapy for urinary tract infections in young febrile children. Pediatrics 1999; 104:79.
- Schlager TA, Whittam TS, Hendley JO, et al. Comparison of expression of virulence factors by Escherichia coli causing cystitis and E. coli colonizing the periurethra of healthy girls. J Infect Dis 1995; 172:772.
- Godaly G, Bergsten G, Hang L, et al. Neutrophil recruitment, chemokine receptors, and resistance to mucosal infection. J Leukoc Biol 2001; 69:899.
- Svanborg C, Bergsten G, Fischer H, et al. Uropathogenic Escherichia coli as a model of host-parasite interaction. Curr Opin Microbiol 2006; 9:33.
- Svanborg C, Frendéus B, Godaly G, et al. Toll-like receptor signaling and chemokine receptor expression influence the severity of urinary tract infection. J Infect Dis 2001; 183 Suppl 1:S61.
- Mårild S, Jodal U. Incidence rate of first-time symptomatic urinary tract infection in children under 6 years of age. Acta Paediatr 1998; 87:549.
- Singh-Grewal D, Macdessi J, Craig J. Circumcision for the prevention of urinary tract infection in boys: a systematic review of randomised trials and observational studies. Arch Dis Child 2005; 90:853.
- Fussell EN, Kaack MB, Cherry R, Roberts JA. Adherence of bacteria to human foreskins. J Urol 1988; 140:997.
- Hiraoka M, Tsukahara H, Ohshima Y, Mayumi M. Meatus tightly covered by the prepuce is associated with urinary infection. Pediatr Int 2002; 44:658.
- Shim YH, Lee JW, Lee SJ. The risk factors of recurrent urinary tract infection in infants with normal urinary systems. Pediatr Nephrol 2009; 24:309.
- American Academy of Pediatrics Task Force on Circumcision. Male circumcision. Pediatrics 2012; 130:e756.
- Chessare JB. Circumcision: is the risk of urinary tract infection really the pivotal issue? Clin Pediatr (Phila) 1992; 31:100.
- Mårild S, Wettergren B, Hellström M, et al. Bacterial virulence and inflammatory response in infants with febrile urinary tract infection or screening bacteriuria. J Pediatr 1988; 112:348.
- Lundstedt AC, Leijonhufvud I, Ragnarsdottir B, et al. Inherited susceptibility to acute pyelonephritis: a family study of urinary tract infection. J Infect Dis 2007; 195:1227.
- Jantausch BA, Criss VR, O'Donnell R, et al. Association of Lewis blood group phenotypes with urinary tract infection in children. J Pediatr 1994; 124:863.
- Sheinfeld J, Schaeffer AJ, Cordon-Cardo C, et al. Association of the Lewis blood-group phenotype with recurrent urinary tract infections in women. N Engl J Med 1989; 320:773.
- Ragnarsdóttir B, Samuelsson M, Gustafsson MC, et al. Reduced toll-like receptor 4 expression in children with asymptomatic bacteriuria. J Infect Dis 2007; 196:475.
- Haraoka M, Hang L, Frendéus B, et al. Neutrophil recruitment and resistance to urinary tract infection. J Infect Dis 1999; 180:1220.
- Wan J, Kaplinsky R, Greenfield S. Toilet habits of children evaluated for urinary tract infection. J Urol 1995; 154:797.
- Nuutinen M, Uhari M. Recurrence and follow-up after urinary tract infection under the age of 1 year. Pediatr Nephrol 2001; 16:69.
- Panaretto K, Craig J, Knight J, et al. Risk factors for recurrent urinary tract infection in preschool children. J Paediatr Child Health 1999; 35:454.
- Elo J, Tallgren LG, Sarna S, et al. The role of vesicoureteral reflux in paediatric urinary-tract infection. Scand J Urol Nephrol 1981; 15:243.
- Feldman AS, Bauer SB. Diagnosis and management of dysfunctional voiding. Curr Opin Pediatr 2006; 18:139.
- Hellström A, Hanson E, Hansson S, et al. Association between urinary symptoms at 7 years old and previous urinary tract infection. Arch Dis Child 1991; 66:232.
- Shaikh N, Hoberman A, Wise B, et al. Dysfunctional elimination syndrome: is it related to urinary tract infection or vesicoureteral reflux diagnosed early in life? Pediatrics 2003; 112:1134.
- Snodgrass W. Relationship of voiding dysfunction to urinary tract infection and vesicoureteral reflux in children. Urology 1991; 38:341.
- Naseer SR, Steinhardt GF. New renal scars in children with urinary tract infections, vesicoureteral reflux and voiding dysfunction: a prospective evaluation. J Urol 1997; 158:566.
- Mazzola BL, von Vigier RO, Marchand S, et al. Behavioral and functional abnormalities linked with recurrent urinary tract infections in girls. J Nephrol 2003; 16:133.
- Bulum B, Özçakar ZB, Kavaz A, et al. Lower urinary tract dysfunction is frequently seen in urinary tract infections in children and is often associated with reduced quality of life. Acta Paediatr 2014; 103:e454.
- van Gool JD, Hjälmås K, Tamminen-Möbius T, Olbing H. Historical clues to the complex of dysfunctional voiding, urinary tract infection and vesicoureteral reflux. The International Reflux Study in Children. J Urol 1992; 148:1699.
- Koff SA, Wagner TT, Jayanthi VR. The relationship among dysfunctional elimination syndromes, primary vesicoureteral reflux and urinary tract infections in children. J Urol 1998; 160:1019.
- Seruca H. Vesicoureteral reflux and voiding dysfunction: a prospective study. J Urol 1989; 142:494.
- RIVUR Trial Investigators, Hoberman A, Greenfield SP, et al. Antimicrobial prophylaxis for children with vesicoureteral reflux. N Engl J Med 2014; 370:2367.
- Keren R, Shaikh N, Pohl H, et al. Risk Factors for Recurrent Urinary Tract Infection and Renal Scarring. Pediatrics 2015; 136:e13.
- Carpenter MA, Hoberman A, Mattoo TK, et al. The RIVUR trial: profile and baseline clinical associations of children with vesicoureteral reflux. Pediatrics 2013; 132:e34.
- Wiswell TE, Miller GM, Gelston HM Jr, et al. Effect of circumcision status on periurethral bacterial flora during the first year of life. J Pediatr 1988; 113:442.
- Hooton TM, Scholes D, Stapleton AE, et al. A prospective study of asymptomatic bacteriuria in sexually active young women. N Engl J Med 2000; 343:992.
- Winberg J, Herthelius-Elman M, Möllby R, Nord CE. Pathogenesis of urinary tract infection--experimental studies of vaginal resistance to colonization. Pediatr Nephrol 1993; 7:509.
- Shaikh N, Mattoo TK, Keren R, et al. Early Antibiotic Treatment for Pediatric Febrile Urinary Tract Infection and Renal Scarring. JAMA Pediatr 2016; 170:848.
- Gleeson FV, Gordon I. Imaging in urinary tract infection. Arch Dis Child 1991; 66:1282.
- Martinell J, Claesson I, Lidin-Janson G, Jodal U. Urinary infection, reflux and renal scarring in females continuously followed for 13-38 years. Pediatr Nephrol 1995; 9:131.
- Olbing H, Claësson I, Ebel KD, et al. Renal scars and parenchymal thinning in children with vesicoureteral reflux: a 5-year report of the International Reflux Study in Children (European branch). J Urol 1992; 148:1653.
- Ditchfield MR, Summerville D, Grimwood K, et al. Time course of transient cortical scintigraphic defects associated with acute pyelonephritis. Pediatr Radiol 2002; 32:849.
- Goldraich NP, Goldraich IH. Followup of conservatively treated children with high and low grade vesicoureteral reflux: a prospective study. J Urol 1992; 148:1688.
- Benador D, Benador N, Slosman D, et al. Are younger children at highest risk of renal sequelae after pyelonephritis? Lancet 1997; 349:17.
- Lin KY, Chiu NT, Chen MJ, et al. Acute pyelonephritis and sequelae of renal scar in pediatric first febrile urinary tract infection. Pediatr Nephrol 2003; 18:362.
- Ataei N, Madani A, Habibi R, Khorasani M. Evaluation of acute pyelonephritis with DMSA scans in children presenting after the age of 5 years. Pediatr Nephrol 2005; 20:1439.
- Pecile P, Miorin E, Romanello C, et al. Age-related renal parenchymal lesions in children with first febrile urinary tract infections. Pediatrics 2009; 124:23.
- Mattoo TK, Chesney RW, Greenfield SP, et al. Renal Scarring in the Randomized Intervention for Children with Vesicoureteral Reflux (RIVUR) Trial. Clin J Am Soc Nephrol 2016; 11:54.
- Huang YY, Chen MJ, Chiu NT, et al. Adjunctive oral methylprednisolone in pediatric acute pyelonephritis alleviates renal scarring. Pediatrics 2011; 128:e496.
- - In young children with fever
- - In older children
- HOST FACTORS
- Lack of circumcision
- Female infants
- Genetic factors
- Urinary obstruction
- Bladder and bowel dysfunction
- Vesicoureteral reflux
- Sexual activity
- Bladder catheterization
- BACTERIAL-HOST INTERACTIONS
- RISK FACTORS FOR RENAL SCARRING
- General risk factors
- Prediction of renal scarring after first UTI
- INFORMATION FOR PATIENTS