Evidence Update in UTI

1. Evidence update in UTI in
children
Amira Al-Adi
R3 famco resident

2. Outline
• Diagnosis
• Management
• Imaging tests
• Surgical intervention
• Follow-up

4. Assess symptoms and signs
• Infants and children presenting with unexplained fever of
38°C or higher should have a urine sample tested after 24
hours at the latest.
• Infants and children with an alternative site of infection
should not have a urine sample tested.

5. Assess symptoms and signs

7. Urine testing
• A clean catch urine sample is the recommended
method for urine collection. If a clean catch urine
sample is unobtainable:
• When it is not possible or practical to collect urine by non-
invasive methods, catheter samples or SPA should be used.
• Before SPA is attempted, ultrasound guidance should be used
to demonstrate the presence of urine in the bladder

8. Urine testing
• If urine is to be cultured but cannot be cultured
within 4 hours of collection, the sample should be
refrigerated or preserved with boric acid
immediately.

9. Urine testing

10. Urine testing

11. Urine testing

12. Interpretation of microscopy results
Microscopy
results
Pyuria positive Pyuria negative
Bacteriuria
positive
The infant or child should
be regarded as having UTI
The infant or child should
be regarded as having UTI
Bacteriuria
negative
Antibiotic treatment
should be
started if clinically UTI
The infant or child should
be regarded
as not having UTI

13. Indications for culture
• in infants and children who have a diagnosis of acute
pyelonephritis/upper urinary tract
• infection (see determine the location of the UTI
• in infants and children with a high to intermediate risk of serious
illness
• in infants and children under 3 years
• in infants and children with a single positive result for leukocyte
esterase or nitrite
• in infants and children with recurrent UTI
• in infants and children with an infection that does not respond to
treatment within 24–48
• hours, if no sample has already been sent
• when clinical symptoms and dipstick tests do not correlate.

14. Accuracy of positive findings
• Nitrite:, 75 percent probability of UTI
• Bacteria on microscopy:, 35 percent probability
of UTI
• Leukocytes on microscopy: 30 percent probability
of UTI
• Leukocyte esterase: 30 percent probability of UTI
• Leukocyte esterase or nitrite: 27 percent
probability of UTI
• Blood:19 percent probability of UTI
• Protein: 19 percent probability of UTI

15. Determine the location of the UTI
• C-reactive protein alone should not be used to
differentiate acute pyelonephritis/upper UTI from
cystitis/lower UTI in infants and children.
• The routine use of imaging in the localisation of a UTI
is not recommended

16. Assess risk factors for serious
underlying pathology
• poor urine flow
• history suggesting previous UTI or confirmed previous UTI
• recurrent fever of uncertain origin
• antenatally-diagnosed renal abnormality
• family history of VUR or renal disease
• constipation
• dysfunctional voiding
• enlarged bladder
• abdominal mass
• evidence of spinal lesion
• poor growth
• high blood pressure.

17. Imaging schedule for infants younger
than 6 months

18. Imaging schedule for infants and children 6
months or older but younger than 3 years

19. Imaging schedule for children 3 years or
older

20. Management of UTI
• Treatment should
be with
parenteral
antibiotics
infant or child is
younger than 3
months
• treat with oral antibiotics
for 7–10 days. The use of
an oral antibiotic with low
resistancepatterns is
recommended, for
example cephalosporin or
co-amoxiclav
• if oral antibiotics cannot
be used, treat with an
intravenous (IV) antibiotic
agent such as cefotaxime
or ceftriaxone for 2–4
days followed by oral
antibiotics for a total
duration of 10 days
infant or child is 3 months
or older with acute
pyelonephritis or upper
urinary tract infection
• treat with oral
antibiotics for 3
days
• the parents or
carers should be
advised to bring
the infant or child
for reassessment
if the infant or
child is still
unwell after 24–
48 hours
infant or child is 3
months or older with
cystitis or lower urinary
tract infection

21. Prevention of UTI
• recommends that children who have had a UTI should be
encouraged to drink an adequate amount, but no
recommendations are made about specific foods or drinks for
preventing UTIs.
• antibiotic prophylaxis should not be routinely recommended
after first UTI, but may be considered for recurrent UTI.
• oral methylprednisolone in conjunction with antibiotics may
reduce renal scarring after acute pyelonephritis in
hospitalised children at high risk of renal scarring.