Urinary tract infections in infants and children older than one month: Acute management, imaging, and prognosis

INTRODUCTION

Urinary tract infections (UTI) are a common and important clinical problem in childhood. Upper urinary tract infections (ie, acute pyelonephritis) may lead to renal scarring, hypertension, and end-stage renal dysfunction. Although children with pyelonephritis tend to present with fever, it can be difficult on clinical grounds to distinguish cystitis from pyelonephritis, particularly in young children (those younger than two years) [1]. 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 in children older than two years and adolescents".)

The acute management and prognosis of UTI in children will be reviewed here. The epidemiology, risk factors, clinical features, diagnosis, long-term management, and prevention of UTI in children and UTI in newborns are discussed separately. (See "Urinary tract infections in children: Epidemiology and risk factors" and "Urinary tract infections in infants and children older than one month: Clinical features and diagnosis" and "Urinary tract infections in children: Long-term management and prevention" and "Urinary tract infections in newborns".)

OVERVIEW

Goals — The goals of treatment for urinary tract infections (UTI) include [2,3]:

Elimination of infection and prevention of urosepsis

Prevention of recurrence and long-term complications including hypertension, renal scarring, and impaired renal growth and function

                           

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Mar 2014. | This topic last updated: Mar 13, 2014.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2014 UpToDate, Inc.
References
Top
  1. 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.
  2. Larcombe J. Urinary tract infection in children. Clin Evid 2005; :429.
  3. Subcommittee on Urinary Tract Infection, Steering Committee on Quality Improvement and Management, Roberts KB. 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; 128:595.
  4. 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.
  5. Hodson EM, Willis NS, Craig JC. Antibiotics for acute pyelonephritis in children. Cochrane Database Syst Rev 2007; :CD003772.
  6. Chang SL, Shortliffe LD. Pediatric urinary tract infections. Pediatr Clin North Am 2006; 53:379.
  7. Zorc JJ, Kiddoo DA, Shaw KN. Diagnosis and management of pediatric urinary tract infections. Clin Microbiol Rev 2005; 18:417.
  8. Roberts JA, Kaack MB, Baskin G. Treatment of experimental pyelonephritis in the monkey. J Urol 1990; 143:150.
  9. Smellie JM, Poulton A, Prescod NP. Retrospective study of children with renal scarring associated with reflux and urinary infection. BMJ 1994; 308:1193.
  10. Smellie JM, Ransley PG, Normand IC, et al. Development of new renal scars: a collaborative study. Br Med J (Clin Res Ed) 1985; 290:1957.
  11. Hiraoka M, Hashimoto G, Tsuchida S, et al. Early treatment of urinary infection prevents renal damage on cortical scintigraphy. Pediatr Nephrol 2003; 18:115.
  12. Doganis D, Siafas K, Mavrikou M, et al. Does early treatment of urinary tract infection prevent renal damage? Pediatrics 2007; 120:e922.
  13. Fernández-Menéndez JM, Málaga S, Matesanz JL, et al. Risk factors in the development of early technetium-99m dimercaptosuccinic acid renal scintigraphy lesions during first urinary tract infection in children. Acta Paediatr 2003; 92:21.
  14. Oh MM, Kim JW, Park MG, et al. The impact of therapeutic delay time on acute scintigraphic lesion and ultimate scar formation in children with first febrile UTI. Eur J Pediatr 2012; 171:565.
  15. Coulthard MG, Lambert HJ, Vernon SJ, et al. Does prompt treatment of urinary tract infection in preschool children prevent renal scarring: mixed retrospective and prospective audits. Arch Dis Child 2014; 99:342.
  16. Shaikh N, Morone NE, Lopez J, et al. Does this child have a urinary tract infection? JAMA 2007; 298:2895.
  17. Edlin RS, Shapiro DJ, Hersh AL, Copp HL. Antibiotic resistance patterns of outpatient pediatric urinary tract infections. J Urol 2013; 190:222.
  18. Ladhani S, Gransden W. Increasing antibiotic resistance among urinary tract isolates. Arch Dis Child 2003; 88:444.
  19. Allen UD, MacDonald N, Fuite L, et al. Risk factors for resistance to "first-line" antimicrobials among urinary tract isolates of Escherichia coli in children. CMAJ 1999; 160:1436.
  20. Ismaili K, Wissing KM, Lolin K, et al. Characteristics of first urinary tract infection with fever in children: a prospective clinical and imaging study. Pediatr Infect Dis J 2011; 30:371.
  21. Goldraich NP, Manfroi A. Febrile urinary tract infection: Escherichia coli susceptibility to oral antimicrobials. Pediatr Nephrol 2002; 17:173.
  22. McLoughlin TG Jr, Joseph MM. Antibiotic resistance patterns of uropathogens in pediatric emergency department patients. Acad Emerg Med 2003; 10:347.
  23. Prais D, Straussberg R, Avitzur Y, et al. Bacterial susceptibility to oral antibiotics in community acquired urinary tract infection. Arch Dis Child 2003; 88:215.
  24. Lutter SA, Currie ML, Mitz LB, Greenbaum LA. Antibiotic resistance patterns in children hospitalized for urinary tract infections. Arch Pediatr Adolesc Med 2005; 159:924.
  25. Cheng CH, Tsai MH, Huang YC, et al. Antibiotic resistance patterns of community-acquired urinary tract infections in children with vesicoureteral reflux receiving prophylactic antibiotic therapy. Pediatrics 2008; 122:1212.
  26. Dayan N, Dabbah H, Weissman I, et al. Urinary tract infections caused by community-acquired extended-spectrum β-lactamase-producing and nonproducing bacteria: a comparative study. J Pediatr 2013; 163:1417.
  27. Hom J. Are oral antibiotics equivalent to intravenous antibiotics for the initial management of pyelonephritis in children? Paediatr Child Health 2010; 15:150.
  28. Neuhaus TJ, Berger C, Buechner K, et al. Randomised trial of oral versus sequential intravenous/oral cephalosporins in children with pyelonephritis. Eur J Pediatr 2008; 167:1037.
  29. Bonsu BK, Shuler L, Sawicki L, et al. Susceptibility of recent bacterial isolates to cefdinir and selected antibiotics among children with urinary tract infections. Acad Emerg Med 2006; 13:76.
  30. Montini G, Toffolo A, Zucchetta P, et al. Antibiotic treatment for pyelonephritis in children: multicentre randomised controlled non-inferiority trial. BMJ 2007; 335:386.
  31. Bradley JS, Jackson MA, Committee on Infectious Diseases, American Academy of Pediatrics. The use of systemic and topical fluoroquinolones. Pediatrics 2011; 128:e1034.
  32. Pickering LK. Antimicrobial resistance among enteric pathogens. Semin Pediatr Infect Dis 2004; 15:71.
  33. McNeeley DF, Eckert SJ, Noel GJ. Antimicrobial-resistant enterococcal isolates from fluoroquinolone-naive children. Pediatr Infect Dis J 2000; 19:675.
  34. Zervos MJ, Hershberger E, Nicolau DP, et al. Relationship between fluoroquinolone use and changes in susceptibility to fluoroquinolones of selected pathogens in 10 United States teaching hospitals, 1991-2000. Clin Infect Dis 2003; 37:1643.
  35. Arrieta AC, Bradley JS. Empiric use of cefepime in the treatment of serious urinary tract infections in children. Pediatr Infect Dis J 2001; 20:350.
  36. Jones ME, Karlowsky JA, Draghi DC, et al. Rates of antimicrobial resistance among common bacterial pathogens causing respiratory, blood, urine, and skin and soft tissue infections in pediatric patients. Eur J Clin Microbiol Infect Dis 2004; 23:445.
  37. Shaw KN, Gorelick MH. Urinary tract infection in the pediatric patient. Pediatr Clin North Am 1999; 46:1111.
  38. Gauthier M, Chevalier I, Sterescu A, et al. Treatment of urinary tract infections among febrile young children with daily intravenous antibiotic therapy at a day treatment center. Pediatrics 2004; 114:e469.
  39. Lieu TA, Baskin MN, Schwartz JS, Fleisher GR. Clinical and cost-effectiveness of outpatient strategies for management of febrile infants. Pediatrics 1992; 89:1135.
  40. Contopoulos-Ioannidis DG, Giotis ND, Baliatsa DV, Ioannidis JP. Extended-interval aminoglycoside administration for children: a meta-analysis. Pediatrics 2004; 114:e111.
  41. Conway PH, Cnaan A, Zaoutis T, et al. Recurrent urinary tract infections in children: risk factors and association with prophylactic antimicrobials. JAMA 2007; 298:179.
  42. Paschke AA, Zaoutis T, Conway PH, et al. Previous antimicrobial exposure is associated with drug-resistant urinary tract infections in children. Pediatrics 2010; 125:664.
  43. Michael M, Hodson EM, Craig JC, et al. Short versus standard duration oral antibiotic therapy for acute urinary tract infection in children. Cochrane Database Syst Rev 2003; :CD003966.
  44. Bachur R. Nonresponders: prolonged fever among infants with urinary tract infections. Pediatrics 2000; 105:E59.
  45. Dacher JN, Hitzel A, Avni FE, Vera P. Imaging strategies in pediatric urinary tract infection. Eur Radiol 2005; 15:1283.
  46. Cheng CH, Tsai MH, Su LH, et al. Renal abscess in children: a 10-year clinical and radiologic experience in a tertiary medical center. Pediatr Infect Dis J 2008; 27:1025.
  47. Oreskovic NM, Sembrano EU. Repeat urine cultures in children who are admitted with urinary tract infections. Pediatrics 2007; 119:e325.
  48. Currie ML, Mitz L, Raasch CS, Greenbaum LA. Follow-up urine cultures and fever in children with urinary tract infection. Arch Pediatr Adolesc Med 2003; 157:1237.
  49. National Institute for Health and Care Excellence. Urinary tract infection in children. August 2007. http://www.nice.org.uk/CG54 (Accessed on September 07, 2011).
  50. Montini G, Rigon L, Zucchetta P, et al. Prophylaxis after first febrile urinary tract infection in children? A multicenter, randomized, controlled, noninferiority trial. Pediatrics 2008; 122:1064.
  51. Craig JC, Simpson JM, Williams GJ, et al. Antibiotic prophylaxis and recurrent urinary tract infection in children. N Engl J Med 2009; 361:1748.
  52. Garin EH, Olavarria F, Garcia Nieto V, et al. Clinical significance of primary vesicoureteral reflux and urinary antibiotic prophylaxis after acute pyelonephritis: a multicenter, randomized, controlled study. Pediatrics 2006; 117:626.
  53. Pennesi M, Travan L, Peratoner L, et al. Is antibiotic prophylaxis in children with vesicoureteral reflux effective in preventing pyelonephritis and renal scars? A randomized, controlled trial. Pediatrics 2008; 121:e1489.
  54. Roussey-Kesler G, Gadjos V, Idres N, et al. 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 2008; 179:674.
  55. Brandström P, Esbjörner E, Herthelius M, et al. The Swedish reflux trial in children: III. Urinary tract infection pattern. J Urol 2010; 184:286.
  56. Hoberman A, Keren R. Antimicrobial prophylaxis for urinary tract infection in children. N Engl J Med 2009; 361:1804.
  57. Keren R, Carpenter MA, Hoberman A, et al. Rationale and design issues of the Randomized Intervention for Children With Vesicoureteral Reflux (RIVUR) study. Pediatrics 2008; 122 Suppl 5:S240.
  58. 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.
  59. Montini G, Tullus K, Hewitt I. Febrile urinary tract infections in children. N Engl J Med 2011; 365:239.
  60. Pohl HG, Rushton HG, Park JS, et al. Adjunctive oral corticosteroids reduce renal scarring: the piglet model of reflux and acute experimental pyelonephritis. J Urol 1999; 162:815.
  61. Sharifian M, Anvaripour N, Karimi A, et al. The role of dexamethasone on decreasing urinary cytokines in children with acute pyelonephritis. Pediatr Nephrol 2008; 23:1511.
  62. Huang YY, Chen MJ, Chiu NT, et al. Adjunctive oral methylprednisolone in pediatric acute pyelonephritis alleviates renal scarring. Pediatrics 2011; 128:e496.
  63. Corticosteroids for children with febrile urinary tract infections. http://clinicaltrials.gov/ct2/show/NCT01391793 (Accessed on October 13, 2011).
  64. Keren R. Imaging and treatment strategies for children after first urinary tract infection. Curr Opin Pediatr 2007; 19:705.
  65. Shaikh N, Ewing AL, Bhatnagar S, Hoberman A. Risk of renal scarring in children with a first urinary tract infection: a systematic review. Pediatrics 2010; 126:1084.
  66. Wennerström M, Hansson S, Jodal U, et al. Renal function 16 to 26 years after the first urinary tract infection in childhood. Arch Pediatr Adolesc Med 2000; 154:339.
  67. Verrier Jones K. Time to review the value of imaging after urinary tract infection in infants. Arch Dis Child 2005; 90:663.
  68. Moorthy I, Easty M, McHugh K, et al. The presence of vesicoureteric reflux does not identify a population at risk for renal scarring following a first urinary tract infection. Arch Dis Child 2005; 90:733.
  69. Westwood ME, Whiting PF, Cooper J, et al. Further investigation of confirmed urinary tract infection (UTI) in children under five years: a systematic review. BMC Pediatr 2005; 5:2.
  70. Wan J, Skoog SJ, Hulbert WC, et al. Section on Urology response to new Guidelines for the diagnosis and management of UTI. Pediatrics 2012; 129:e1051.
  71. Roberts KB, Finnell SM, Downs SM. Response to the AAP Section on Urology concerns about the AAP Urinary Tract Infection Guideline. Pediatrics 2012; 129:e1054.
  72. La Scola C, De Mutiis C, Hewitt IK, et al. Different guidelines for imaging after first UTI in febrile infants: yield, cost, and radiation. Pediatrics 2013; 131:e665.
  73. Jodal U. The natural history of bacteriuria in childhood. Infect Dis Clin North Am 1987; 1:713.
  74. Massanyi EZ, Preece J, Gupta A, et al. Utility of screening ultrasound after first febrile UTI among patients with clinically significant vesicoureteral reflux. Urology 2013; 82:905.
  75. Nelson CP, Johnson EK, Logvinenko T, Chow JS. Ultrasound as a Screening Test for Genitourinary Anomalies in Children With UTI. Pediatrics 2014; 133:e394.
  76. Friedman S, Reif S, Assia A, et al. Clinical and laboratory characteristics of non-E. coli urinary tract infections. Arch Dis Child 2006; 91:845.
  77. Alon US, Ganapathy S. Should renal ultrasonography be done routinely in children with first urinary tract infection? Clin Pediatr (Phila) 1999; 38:21.
  78. Chitty LS, Hunt GH, Moore J, Lobb MO. Effectiveness of routine ultrasonography in detecting fetal structural abnormalities in a low risk population. BMJ 1991; 303:1165.
  79. Miron D, Daas A, Sakran W, et al. Is omitting post urinary-tract-infection renal ultrasound safe after normal antenatal ultrasound? An observational study. Arch Dis Child 2007; 92:502.
  80. American College of Radiology. ACR Appropriateness Criteria. Urinary Tract Infection--Child. http://www.acr.org/SecondaryMainMenuCategories/quality_safety/app_criteria/pdf/ExpertPanelonPediatricImaging/urinarytractinfectionChildDoc10.aspx (Accessed on September 12, 2011).
  81. Honkinen O, Lehtonen OP, Ruuskanen O, et al. Cohort study of bacterial species causing urinary tract infection and urinary tract abnormalities in children. BMJ 1999; 318:770.
  82. Honkinen O, Jahnukainen T, Mertsola J, et al. Bacteremic urinary tract infection in children. Pediatr Infect Dis J 2000; 19:630.
  83. Hoberman A, Wald ER. Treatment of urinary tract infections. Pediatr Infect Dis J 1999; 18:1020.
  84. McDonald A, Scranton M, Gillespie R, et al. Voiding cystourethrograms and urinary tract infections: how long to wait? Pediatrics 2000; 105:E50.
  85. Mahant S, To T, Friedman J. Timing of voiding cystourethrogram in the investigation of urinary tract infections in children. J Pediatr 2001; 139:568.
  86. Sathapornwajana P, Dissaneewate P, McNeil E, Vachvanichsanong P. Timing of voiding cystourethrogram after urinary tract infection. Arch Dis Child 2008; 93:229.
  87. Doganis D, Mavrikou M, Delis D, et al. Timing of voiding cystourethrography in infants with first time urinary infection. Pediatr Nephrol 2009; 24:319.
  88. Craig JC, Wheeler DM, Irwig L, Howman-Giles RB. How accurate is dimercaptosuccinic acid scintigraphy for the diagnosis of acute pyelonephritis? A meta-analysis of experimental studies. J Nucl Med 2000; 41:986.
  89. Hansson S, Dhamey M, Sigström O, et al. Dimercapto-succinic acid scintigraphy instead of voiding cystourethrography for infants with urinary tract infection. J Urol 2004; 172:1071.
  90. Preda I, Jodal U, Sixt R, et al. Normal dimercaptosuccinic acid scintigraphy makes voiding cystourethrography unnecessary after urinary tract infection. J Pediatr 2007; 151:581.
  91. Tseng MH, Lin WJ, Lo WT, et al. Does a normal DMSA obviate the performance of voiding cystourethrography in evaluation of young children after their first urinary tract infection? J Pediatr 2007; 150:96.
  92. Pohl HG, Belman AB. The "top-down" approach to the evaluation of children with febrile urinary tract infection. Adv Urol 2009; :783409.
  93. Routh JC, Grant FD, Kokorowski PJ, et al. Economic and radiation costs of initial imaging approaches after a child's first febrile urinary tract infection. Clin Pediatr (Phila) 2012; 51:23.
  94. Montini G, Zucchetta P, Tomasi L, et al. Value of imaging studies after a first febrile urinary tract infection in young children: data from Italian renal infection study 1. Pediatrics 2009; 123:e239.
  95. Marks SD, Gordon I, Tullus K. Imaging in childhood urinary tract infections: time to reduce investigations. Pediatr Nephrol 2008; 23:9.
  96. Salo J, Ikäheimo R, Tapiainen T, Uhari M. Childhood urinary tract infections as a cause of chronic kidney disease. Pediatrics 2011; 128:840.
  97. Martinell J, Lidin-Janson G, Jagenburg R, et al. Girls prone to urinary infections followed into adulthood. Indices of renal disease. Pediatr Nephrol 1996; 10:139.
  98. Wennerström M, Hansson S, Hedner T, et al. Ambulatory blood pressure 16-26 years after the first urinary tract infection in childhood. J Hypertens 2000; 18:485.
  99. Smellie JM, Prescod NP, Shaw PJ, et al. Childhood reflux and urinary infection: a follow-up of 10-41 years in 226 adults. Pediatr Nephrol 1998; 12:727.