Urinary tract infections in infants and children older than one month: Clinical features and diagnosis
- 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 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 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) . As a result, 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 clinical features and diagnosis of UTI in children will be discussed here. The epidemiology, risk factors, and management of UTI in children and UTI in newborns (younger than one month of age) 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: Acute management, imaging, and prognosis" and "Urinary tract infections in children: Long-term management and prevention" and "Urinary tract infections in neonates".)
Urinary tract infections (UTI) may present with nonspecific symptoms and signs, particularly in infants and young children.
Younger children — In a meta-analysis of the diagnostic accuracy of the symptoms and signs of UTI in children younger than two years, the following findings were the most helpful in identifying children with UTI :
●History of UTI (likelihood ratio [LR] 2.3)
- 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.
- Shaikh N, Morone NE, Lopez J, et al. Does this child have a urinary tract infection? JAMA 2007; 298:2895.
- 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.
- Zorc JJ, Levine DA, Platt SL, et al. Clinical and demographic factors associated with urinary tract infection in young febrile infants. Pediatrics 2005; 116:644.
- Hoberman A, Wald ER. Urinary tract infections in young febrile children. Pediatr Infect Dis J 1997; 16:11.
- Zorc JJ, Kiddoo DA, Shaw KN. Diagnosis and management of pediatric urinary tract infections. Clin Microbiol Rev 2005; 18:417.
- Struthers S, Scanlon J, Parker K, et al. Parental reporting of smelly urine and urinary tract infection. Arch Dis Child 2003; 88:250.
- Gauthier M, Gouin S, Phan V, Gravel J. Association of malodorous urine with urinary tract infection in children aged 1 to 36 months. Pediatrics 2012; 129:885.
- Winberg J, Andersen HJ, Bergström T, et al. Epidemiology of symptomatic urinary tract infection in childhood. Acta Paediatr Scand Suppl 1974; :1.
- Majd M, Rushton HG, Jantausch B, Wiedermann BL. Relationship among vesicoureteral reflux, P-fimbriated Escherichia coli, and acute pyelonephritis in children with febrile urinary tract infection. J Pediatr 1991; 119:578.
- SMELLIE JM, HODSON CJ, EDWARDS D, NORMAND IC. CLINICAL AND RADIOLOGICAL FEATURES OF URINARY INFECTION IN CHILDHOOD. Br Med J 1964; 2:1222.
- Smellie JM, Poulton A, Prescod NP. Retrospective study of children with renal scarring associated with reflux and urinary infection. BMJ 1994; 308:1193.
- 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.
- Chang SL, Shortliffe LD. Pediatric urinary tract infections. Pediatr Clin North Am 2006; 53:379.
- 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.
- 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.
- Wald ER. To bag or not to bag. J Pediatr 2005; 147:418.
- Shaw KN, Gorelick MH. Urinary tract infection in the pediatric patient. Pediatr Clin North Am 1999; 46:1111.
- 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.
- Finnell SM, Carroll AE, Downs SM, Subcommittee on Urinary Tract Infection. Technical report—Diagnosis and management of an initial UTI in febrile infants and young children. Pediatrics 2011; 128:e749.
- Marin JR, Shaikh N, Docimo SG, et al. Videos in clinical medicine. Suprapubic bladder aspiration. N Engl J Med 2014; 371:e13.
- Al-Orifi F, McGillivray D, Tange S, Kramer MS. Urine culture from bag specimens in young children: are the risks too high? J Pediatr 2000; 137:221.
- Stein R, Dogan HS, Hoebeke P, et al. Urinary tract infections in children: EAU/ESPU guidelines. Eur Urol 2015; 67:546.
- Huicho L, Campos-Sanchez M, Alamo C. Metaanalysis of urine screening tests for determining the risk of urinary tract infection in children. Pediatr Infect Dis J 2002; 21:1.
- Gorelick MH, Shaw KN. Screening tests for urinary tract infection in children: A meta-analysis. Pediatrics 1999; 104:e54.
- Hoberman A, Wald ER, Penchansky L, et al. Enhanced urinalysis as a screening test for urinary tract infection. Pediatrics 1993; 91:1196.
- Herr SM, Wald ER, Pitetti RD, Choi SS. Enhanced urinalysis improves identification of febrile infants ages 60 days and younger at low risk for serious bacterial illness. Pediatrics 2001; 108:866.
- Shah AP, Cobb BT, Lower DR, et al. Enhanced versus automated urinalysis for screening of urinary tract infections in children in the emergency department. Pediatr Infect Dis J 2014; 33:272.
- Shaikh N, Borrell JL, Evron J, Leeflang MM. Procalcitonin, C-reactive protein, and erythrocyte sedimentation rate for the diagnosis of acute pyelonephritis in children. Cochrane Database Syst Rev 2015; 1:CD009185.
- 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.
- Bachur R, Caputo GL. Bacteremia and meningitis among infants with urinary tract infections. Pediatr Emerg Care 1995; 11:280.
- Schnadower D, Kuppermann N, Macias CG, et al. Febrile infants with urinary tract infections at very low risk for adverse events and bacteremia. Pediatrics 2010; 126:1074.
- Dayan PS, Hanson E, Bennett JE, et al. Clinical course of urinary tract infections in infants younger than 60 days of age. Pediatr Emerg Care 2004; 20:85.
- Velasco-Zúñiga R, Trujillo-Wurttele JE, Fernández-Arribas JL, et al. Predictive factors of low risk for bacteremia in infants with urinary tract infection. Pediatr Infect Dis J 2012; 31:642.
- Hernández-Bou S, Trenchs V, Alarcón M, Luaces C. Afebrile very young infants with urinary tract infection and the risk for bacteremia. Pediatr Infect Dis J 2014; 33:244.
- Honkinen O, Jahnukainen T, Mertsola J, et al. Bacteremic urinary tract infection in children. Pediatr Infect Dis J 2000; 19:630.
- KASS EH. Asymptomatic infections of the urinary tract. Trans Assoc Am Physicians 1956; 69:56.
- Hoberman A, Wald ER, Reynolds EA, et al. Pyuria and bacteriuria in urine specimens obtained by catheter from young children with fever. J Pediatr 1994; 124:513.
- Schroeder AR, Chang PW, Shen MW, et al. Diagnostic accuracy of the urinalysis for urinary tract infection in infants <3 months of age. Pediatrics 2015; 135:965.
- Hoberman A, Wald ER. Treatment of urinary tract infections. Pediatr Ann 1999; 28:688.
- Linshaw M. Asymptomatic bacteriuria and vesicoureteral reflux in children. Kidney Int 1996; 50:312.
- Wettergren B, Jodal U, Jonasson G. Epidemiology of bacteriuria during the first year of life. Acta Paediatr Scand 1985; 74:925.
- Lindberg U, Claesson I, Hanson LA, Jodal U. Asymptomatic bacteriuria in schoolgirls. VIII. Clinical course during a 3-year follow-up. J Pediatr 1978; 92:194.
- Sequelae of covert bacteriuria in schoolgirls. A four-year follow-up study. Lancet 1978; 1:889.
- Hansson S, Martinell J, Stokland E, Jodal U. The natural history of bacteriuria in childhood. Infect Dis Clin North Am 1997; 11:499.
- Fitzgerald A, Mori R, Lakhanpaul M. Interventions for covert bacteriuria in children. Cochrane Database Syst Rev 2012; 2:CD006943.
- 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.
- Hsiao AL, Chen L, Baker MD. Incidence and predictors of serious bacterial infections among 57- to 180-day-old infants. Pediatrics 2006; 117:1695.
- Stoll ML, Rubin LG. Incidence of occult bacteremia among highly febrile young children in the era of the pneumococcal conjugate vaccine: a study from a Children's Hospital Emergency Department and Urgent Care Center. Arch Pediatr Adolesc Med 2004; 158:671.
- CLINICAL PRESENTATION
- Younger children
- Older children
- CLINICAL EVALUATION
- Physical examination
- LABORATORY EVALUATION
- Urine sample
- - Decision to obtain
- - How to obtain
- Rapidly available tests
- - Dipstick analysis
- - Microscopic exam
- Urine culture
- Other laboratory tests
- DIAGNOSIS OF UTI
- Significant bacteriuria
- - False negatives
- DIFFERENTIAL DIAGNOSIS
- Asymptomatic bacteriuria
- Other considerations
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS