Urinary tract infections in children: Long-term management and prevention
- 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
- 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
- Sheldon L Kaplan, MD
Sheldon L Kaplan, MD
- Editor-in-Chief — Pediatrics
- Section Editor — Pediatric Infectious Diseases
- Professor and Vice Chairman for Clinical Affairs
- Baylor College of Medicine
Urinary tract infection (UTI) is a frequently occurring clinical problem in childhood. Upper UTIs (ie, acute pyelonephritis) may lead to renal scarring, hypertension, and end-stage renal dysfunction. 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 (aged <2 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 long-term management and prevention of UTI in children will be reviewed here. The epidemiology, risk factors, clinical features, diagnosis, acute management, and prognosis 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 infants older than one month and young children: Acute management, imaging, and prognosis" and "Urinary tract infections in neonates".)
Children without vesicoureteral reflux
Progression of renal scarring is associated with recurrent episodes of pyelonephritis [8-11]. Accordingly, prompt diagnosis and treatment of these infections is critically important in reducing renal scarring [2,12-15].
Families of young children with UTI should receive instruction about the risk of recurrent UTI and be advised to seek medical attention promptly for fever and/or urinary symptoms. The evaluation of these episodes should include urinalysis, urine culture, or both [1,16,17]; a delay in the treatment of febrile UTIs is associated with increased risk for renal scarring . (See "Urinary tract infections in infants and children older than one month: Clinical features and diagnosis", section on 'Laboratory evaluation'.)To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- 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, Wald ER, Hickey RW, et al. Oral versus initial intravenous therapy for urinary tract infections in young febrile children. Pediatrics 1999; 104:79.
- 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.
- Peters CA, Skoog SJ, Arant BS Jr, et al. Summary of the AUA Guideline on Management of Primary Vesicoureteral Reflux in Children. J Urol 2010; 184:1134.
- 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.
- Keren R, Shaikh N, Pohl H, et al. Risk Factors for Recurrent Urinary Tract Infection and Renal Scarring. Pediatrics 2015; 136:e13.
- Goldraich NP, Goldraich IH. Followup of conservatively treated children with high and low grade vesicoureteral reflux: a prospective study. J Urol 1992; 148:1688.
- 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.
- Martinell J, Hansson S, Claesson I, et al. Detection of urographic scars in girls with pyelonephritis followed for 13-38 years. Pediatr Nephrol 2000; 14:1006.
- Wennerström M, Hansson S, Jodal U, Stokland E. Primary and acquired renal scarring in boys and girls with urinary tract infection. J Pediatr 2000; 136:30.
- Merrick MV, Notghi A, Chalmers N, et al. Long-term follow up to determine the prognostic value of imaging after urinary tract infections. Part 2: Scarring. Arch Dis Child 1995; 72:393.
- Hiraoka M, Hashimoto G, Tsuchida S, et al. Early treatment of urinary infection prevents renal damage on cortical scintigraphy. Pediatr Nephrol 2003; 18:115.
- Smellie JM, Poulton A, Prescod NP. Retrospective study of children with renal scarring associated with reflux and urinary infection. BMJ 1994; 308:1193.
- 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.
- 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.
- 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.
- Reaffirmation of AAP clinical practice guideline: The diagnosis and management of the initial urinary tract infection in febrile infants and young children 2-24 months of age. Pediatrics 2016; 138:e20163026.
- 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.
- Koff SA, Lapides J, Piazza DH. Association of urinary tract infection and reflux with uninhibited bladder contractions and voluntary sphincteric obstruction. J Urol 1979; 122:373.
- Koff SA, Murtagh DS. The uninhibited bladder in children: effect of treatment on recurrence of urinary infection and on vesicoureteral reflux resolution. J Urol 1983; 130:1138.
- Seruca H. Vesicoureteral reflux and voiding dysfunction: a prospective study. J Urol 1989; 142:494.
- Feldman AS, Bauer SB. Diagnosis and management of dysfunctional voiding. Curr Opin Pediatr 2006; 18:139.
- Loening-Baucke V. Urinary incontinence and urinary tract infection and their resolution with treatment of chronic constipation of childhood. Pediatrics 1997; 100:228.
- Craig JC, Simpson JM, Williams GJ, et al. Antibiotic prophylaxis and recurrent urinary tract infection in children. N Engl J Med 2009; 361:1748.
- Williams G, Craig JC. Long-term antibiotics for preventing recurrent urinary tract infection in children. Cochrane Database Syst Rev 2011; :CD001534.
- 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.
- 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.
- Hewitt IK, Pennesi M, Morello W, et al. Antibiotic Prophylaxis for Urinary Tract Infection-Related Renal Scarring: A Systematic Review. Pediatrics 2017; 139.
- American Academy of Pediatrics. Ten things physicians and patients should question. www.choosingwisely.org/doctor-patient-lists/american-academy-of-pediatrics/ (Accessed on March 18, 2014).
- Hansson S, Jodal U, Norén L, Bjure J. Untreated bacteriuria in asymptomatic girls with renal scarring. Pediatrics 1989; 84:964.
- Jepson RG, Williams G, Craig JC. Cranberries for preventing urinary tract infections. Cochrane Database Syst Rev 2012; 10:CD001321.
- Salo J, Uhari M, Helminen M, et al. Cranberry juice for the prevention of recurrences of urinary tract infections in children: a randomized placebo-controlled trial. Clin Infect Dis 2012; 54:340.
- Ferrara P, Romaniello L, Vitelli O, et al. Cranberry juice for the prevention of recurrent urinary tract infections: a randomized controlled trial in children. Scand J Urol Nephrol 2009; 43:369.
- Schwenger EM, Tejani AM, Loewen PS. Probiotics for preventing urinary tract infections in adults and children. Cochrane Database Syst Rev 2015; :CD008772.
- LONG-TERM MANAGEMENT
- Children without vesicoureteral reflux
- - Monitor for recurrent symptoms
- - Identify and treat bowel and bladder dysfunction
- Children with vesicoureteral reflux
- PREVENTION OF RECURRENT UTI IN CHILDREN WITHOUT VESICOURETERAL REFLUX
- Antimicrobial prophylaxis
- Unproven interventions
- - Surveillance cultures
- - Cranberry juice
- - Probiotics
- SOCIETY GUIDELINE LINKS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS