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Urinary tract infections in infants and children older than one

month: Clinical features and diagnosis
Authors: Nader Shaikh, MD, Alejandro Hoberman, MD
Section Editors: Morven S Edwards, MD, Tej K Mattoo, MD, DCH, FRCP
Deputy Editor: Mary M Torchia, MD

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Jul 2020. | This topic last updated: Jan 14, 2020.

INTRODUCTION

Urinary tract infections (UTI) are a common and important problem in children. Acute pyelonephritis may lead to
renal scarring, hypertension, and end-stage kidney disease.

The clinical features and diagnosis of UTI in children will be discussed here. The epidemiology, risk factors, and
management of UTI in children, acute cystitis in children older than two years, and UTI in neonates (<1 month of
age) are discussed separately:

● (See "Urinary tract infections in children: Epidemiology and risk factors".)

● (See "Urinary tract infections in infants older than one month and young children: Acute management,
imaging, and prognosis".)

● (See "Urinary tract infections in children: Long-term management and prevention".)

● (See "Acute infectious cystitis: Clinical features and diagnosis in children older than two years and
adolescents" and "Acute infectious cystitis: Management and prognosis in children older than two years and
adolescents".)

● (See "Urinary tract infections in neonates".)

TERMINOLOGY

UTI is best defined as significant bacteriuria of a clinically relevant uropathogen in a symptomatic patient. Most
patients with UTI also have pyuria, although there are exceptions. (See 'Special circumstances' below.)
In this topic, we define UTI broadly, without attempting to distinguish cystitis from pyelonephritis. Although
children with pyelonephritis tend to present with fever, it is often difficult to distinguish cystitis from pyelonephritis
clinically, particularly in children younger than two years [1].

CLINICAL PRESENTATION

Younger children

● Symptoms and signs – In infants and young children, UTI may present with nonspecific symptoms and
signs (eg, fever, irritability, poor feeding, poor weight gain) [2]. Parental report of foul-smelling urine or
gastrointestinal symptoms (eg, vomiting, diarrhea, poor feeding) is generally not helpful in diagnosing UTI
[3-5].

Fever may be the sole manifestation of UTI in infants and children <2 years of age [6-8]. In observational
studies, UTI is more common among infants and young children with maximum temperatures ≥39°C
(102.2°F) than in those with lower fevers (16 versus 7 percent for infants ≤60 days and 4 versus 2 percent
for children <2 years) [7-9]. (See "Urinary tract infections in children: Epidemiology and risk factors", section
on 'Prevalence'.)

Although fever >24 hours is associated with increased risk of UTI, evaluation for UTI should not be delayed
in children who present with possible UTI and fever for ≤24 hours' duration [10]. The risk of renal scarring
increases with increased duration of fever before initiation of antibiotics. In a retrospective cohort study of
482 children with febrile UTI, the risk of renal scarring was approximately 5 percent in children with fever
duration of one to two days, 8 percent in children with fever duration of two to three days, and 14 percent in
children with duration of fever of >3 days before initiation of antibiotics [11].

Having another source of fever identified (eg, upper respiratory tract infection [URTI], acute otitis media
[AOM], acute gastroenteritis) decreases the risk of UTI but does not eliminate it [9]. In observational studies
of young children who presented to the emergency department with fever, the prevalence of UTI ranged
from 2 to 3 percent in children with and 6 to 8 percent in those without another source of fever [7,12]. This
highlights the importance of obtaining urine cultures in febrile infants and young children without a definite
source for fever. (See 'Decision to obtain' below.)

● Predictors of culture-confirmed UTI – Clinical and demographic factors associated with increased risk of
culture-confirmed UTI were identified in a nested case-control study of febrile (>38°C [100.4°F]) children
age 2 through 23 months who were evaluated for UTI in the emergency department of a tertiary care
children's hospital [9]. They include:

• Age <12 months

• Maximum reported temperature ≥39°C (102.2°F)

• Nonblack race (as self-reported by the child's caregiver)

 • Female

• Uncircumcised male

• No other source of fever identified (eg, AOM; URTI, gastroenteritis, bronchiolitis, or other viral
syndrome; pneumonia, meningitis)

These factors have been used to develop a calculator to estimate the probability of UTI in children age 2
through 23 months (UTICalc, available from the University of Pittsburgh).

Older children — Symptoms and signs of UTI in older children include fever, urinary symptoms (dysuria,
urgency, frequency, incontinence, macroscopic hematuria), abdominal pain, suprapubic tenderness, and
costovertebral angle tenderness [13-15]. The constellation of fever, chills, and flank pain is suggestive of
pyelonephritis in older children [2].

In a meta-analysis of the diagnostic accuracy of the clinical findings of UTI in verbal children, the following
findings were the most helpful in identifying children with UTI [3]:

● Abdominal pain
● Back pain
● Dysuria, frequency, or both
● New-onset urinary incontinence

CLINICAL EVALUATION

Children with UTI symptoms should be evaluated promptly. Prompt recognition and treatment of UTI may be
important in the prevention of renal scarring. (See "Urinary tract infections in children: Epidemiology and risk
factors", section on 'Risk factors for renal scarring'.)

History — The history of the acute illness should include documentation of the height and duration of fever,
urinary symptoms (dysuria, frequency, urgency, incontinence), abdominal pain, suprapubic discomfort, back
pain, recent illnesses, antibiotics administered, and, if applicable, sexual activity.

The past medical history should include risk factors for UTI, including:

● Chronic urinary symptoms – Incontinence, lack of proper stream, frequency, urgency, withholding
maneuvers (suggestive of bladder dysfunction)

● Chronic constipation

● Previous UTI or previous undiagnosed febrile illnesses in which urine culture was not obtained

● Vesicoureteral reflux (VUR)

● Family history of frequent UTI, VUR, and other genitourinary abnormalities

 ● Antenatally diagnosed renal abnormality

● Sexually activity, particularly if barrier contraception with spermicidal agents is used (such methods
predispose to UTI by altering the normal vaginal flora [16-18])

(See "Urinary tract infections in children: Epidemiology and risk factors", section on 'Host factors'.)

Physical examination — Important aspects of the physical examination in the child with suspected UTI include
[3,19,20]:

● Documentation of blood pressure and temperature

• Temperature ≥39°C (102.2°F) is associated with acute pyelonephritis that may cause renal scarring
(odds ratio 2.3, 95% CI 1.6-3.3) [21]

• Elevated blood pressure may be an indication of renal scarring

● Growth parameters

• Poor weight gain may be an indication of chronic renal failure due to renal scarring

● Abdominal and flank examination [19]

• Suprapubic and costovertebral angle tenderness is associated with UTI

• Enlarged bladder or kidney may indicate urinary obstruction and palpable stool in the colon may
indicate constipation, both of which predispose to UTI

● Examination of the external genitalia for anatomic abnormalities (eg, phimosis, hypospadias, or labial
adhesions) and signs of vulvovaginitis, vaginal foreign body, or sexually transmitted infections, which may
predispose to UTI (see "Overview of vulvovaginal complaints in the prepubertal child")

● Evaluation of the lower back for signs of occult myelomeningocele (eg, midline pigmentation, lipoma,
vascular lesion, sinus, tuft of hair), which may be associated with a neurogenic bladder and recurrent UTI
(see "Closed spinal dysraphism: Clinical manifestations, diagnosis, and management", section on 'Clinical
manifestations')

● Evaluation for other sources of fever; another source of fever decreases the risk of UTI but does not
eliminate it altogether [7,12]

LABORATORY EVALUATION

Urine sample

Decision to obtain — The decision to obtain a urine sample for urinalysis and culture is best made on a
case-by-case basis, taking into consideration the medical history, age, sex, circumcision status, race, and the
presenting signs and symptoms (table 1 and table 2). UTICalc can be used to estimate the probability of UTI in
febrile (temperature ≥38°C [100.4° F]) children age 2 through 23 months according to clinical characteristics [9].

Other considerations include the feasibility of follow-up, parental views toward catheterization (if catheterization
is necessary), potential harm of not diagnosing an episode of UTI, harm of incorrectly diagnosing UTI, cost and
availability of testing, and benefits of early treatment. (See "Urinary tract infections in infants older than one
month and young children: Acute management, imaging, and prognosis", section on 'Overview'.)

● Children without urinary tract abnormalities – Our indications for obtaining urine samples in children
without known underlying abnormalities of the urinary tract are as follows (table 3) [9]:

• Febrile (≥38°C [100.4°F]) girls and febrile uncircumcised boys <2 years of age who are at high risk,
including:

- Infants 2 through 11 months of age, with the exception of black infants with maximum temperature
≥38°C (100.4°F) and <39°C (102.2°F) and an identified source of fever (eg, acute otitis media;
pneumonia; meningitis; upper respiratory tract infection, gastroenteritis, bronchiolitis, or other viral
syndrome)

In a nested case-control study of febrile (>38°C [100.4°F]) children who were evaluated for UTI in
the emergency department, the probability of UTI among children age 2 through 11 months ranged
from 3 to 25 percent, except for black infants with maximum temperature ≥38°C (100.4°F) and
<39°C (102.2°F) and an identified source of fever, in whom the probability of UTI was 1.3 percent
[9].

- Children between 12 and 24 months of age with maximum fever ≥39°C (102.2°F), with the
exception of black children with an identified source of fever

In the nested case-control study, the probability of UTI among children between 12 and 24 months
of age with maximum fever ≥39°C (102.2°F) ranged from 2.6 to 9.5 percent, except for black
children with an identified source of fever, in whom the probability of UTI was <1 percent [9].

- Nonblack children between 12 and 24 months of age with maximum fever ≥38°C (100.4°F) and
<39°C (102.2°F) and no other source of fever identified (probability of UTI 4.2 percent [9])

• Circumcised nonblack boys age 2 through 11 months with maximum fever ≥39°C (102.2°F) and no
other source of fever identified (probability of UTI 2.9 percent [9])

• Girls and uncircumcised boys ≥24 months of age with dysuria, frequency, new-onset incontinence,
abdominal pain, back pain, or high fever (ie, ≥39°C (102.2°F), if no other cause is apparent

• Circumcised boys ≥24 months of age with multiple symptoms (abdominal pain, back pain, dysuria,
frequency, high fever, or new-onset incontinence)
 Our indications for obtaining urine samples correspond to a pretest probability of UTI >2 percent (ie,
approximately 10 children need to be tested for every UTI detected, which are the thresholds used in
UTICalc, available from the University of Pittsburgh) [9,22-24]. Thresholds may vary depending on duration
of symptoms, feasibility of follow-up, and parental views toward catheterization.

● Children with urinary tract abnormalities – Indications to obtain urine samples in children with urinary
tract abnormalities vary with the type of abnormality and are discussed separately. For example, (see
"Myelomeningocele (spina bifida): Urinary tract complications", section on 'Urinary tract infections' and
"Management of vesicoureteral reflux", section on 'Follow-up').

How to obtain

● Children who are not toilet trained – Catheterization or suprapubic aspiration is the preferred method of
urine collection for dipstick analysis, microscopic examination, and culture of the urine in infants and young
children who are not toilet trained.

We recommend that urine obtained in a sterile collection bag not be used for culture. We also suggest that
bag urine specimens not be used for dipstick or microscopic analysis. However, others suggest that bag
urine samples can be used as a first step to determine whether a catheterized urine sample should be
obtained for culture in young children. This approach is discussed separately. (See "Urine collection
techniques in infants and children with suspected urinary tract infection", section on 'Specimen for urine
dipstick or urinalysis'.)

● Children who are toilet trained – A clean-voided specimen is the preferred method of urine collection for
dipstick analysis, microscopic examination, and culture of the urine in toilet-trained children. (See "Urine
collection techniques in infants and children with suspected urinary tract infection", section on 'Selection of
technique'.)

All urine specimens should be examined as soon as possible after collection. A delay of even a few hours at
room temperature increases both the false-positive and false-negative rates substantially [24].

Rapidly available tests

Use in determining probability of UTI — The results of urine dipstick and microscopic analysis are rapidly
available. These results can be combined with clinical features to estimate the probability of UTI in an individual
child to guide decisions about antimicrobial therapy. For children 2 through 23 months of age, UTICalc, available
through the University of Pittsburgh, can be used for this estimation. (See "Urinary tract infections in infants
older than one month and young children: Acute management, imaging, and prognosis", section on 'Empiric
therapy'.)

The sensitivity and specificity of the components of the urinalysis in predicting significant bacteriuria on culture
has been evaluated in systematic reviews and meta-analyses (table 4) [25-27].

Dipstick analysis — Dipstick tests are convenient, inexpensive, and require little training for proper usage;
they may be the only test available in some settings. They are at best 88 percent sensitive (table 4) and will
likely miss some children with UTI [26].

● Leukocyte esterase – Positive leukocyte esterase on dipstick analysis is suggestive of UTI but is
nonspecific. White blood cells (WBCs) may be present in the urine in other conditions (eg, Kawasaki
disease). (See 'Pyuria' below.)

● Nitrite – Positive nitrites on dipstick analysis indicate that UTI is likely. The nitrite test is highly specific, with
a low false-positive rate (table 4). False-negative results are common because urine must remain in the
bladder for at least four hours to accumulate a detectable amount of nitrite [28]. Thus, a negative nitrite test
does not exclude a UTI [29].

Although a dilute urine sample has been associated with decreased accuracy of dipstick nitrites,
retrospective analysis of urinalysis and urine culture results from children <24 months who underwent
bladder catheterization indicated that inclusion of urine specific gravity (SG)in the decision-making process
would not have appreciably affected the care of children with UTI [30].

Microscopic examination — Microscopic examination requires more equipment and training than dipstick
tests. If available, we prefer enhanced microscopy to standard or automated microscopy, particularly for
detection of bacteriuria.

● Standard microscopy – In standard microscopy, a centrifuged sample of unstained urine is examined for
WBCs and bacteria.

With standard microscopy, pyuria is defined as ≥5 WBC/high-power field (hpf) and bacteriuria as any
bacteria per hpf. The sensitivity, specificity, and likelihood ratios are summarized in the table (table 4).

● Enhanced microscopy – Enhanced microscopy (or enhanced urinalysis), available at some academic
centers, refers to examination of an uncentrifuged urine specimen using a hemocytometer (results reported
as WBC/mm3) and a Gram-stained smear [25,26,31].

With enhanced urinalysis, pyuria is defined as ≥10 WBC/mm3 and bacteriuria as any bacteria per 10 oil
immersion fields of a Gram-stained smear. In young children in whom the prompt diagnosis and treatment
of UTI are paramount, the enhanced urinalysis offers the best combination of sensitivity and specificity
(table 4) [25,32,33]. However, enhanced urinalysis is not available in many outpatient settings.

● Automated microscopy – Many hospital laboratories have replaced manual microscopy with automated
microscopy, which uses flow cytometry and microscopic analyzers to detect WBC and bacteria [34]. The
definitions of pyuria and bacteriuria vary with the automated microscopy system.

Although automated microscopy appears to be comparable to manual microscopy for pyuria, Gram-stained
smear of uncentrifuged urine is better for the detection of bacteriuria [33,34]. In a prospective study,
automated and enhanced manual microscopy for pyuria were similarly sensitive (80 and 84 percent,
respectively) and specific (90 and 94 percent, respectively) in predicting positive urine culture. However, for
bacteriuria, automated microscopy was less sensitive (73 versus 84 percent) and specific (85 versus 96
percent) than enhanced manual microscopy [33].
 Although SG may influence the accuracy of the WBC count with enhanced or automated microscopy
[30,35], retrospective analysis of urinalysis and urine culture results from children <24 months who
underwent bladder catheterization indicated that inclusion of urine SG in the decision-making process would
not have appreciably affected the care of children with UTI [30].

Urine culture — Quantitative urine culture is required for the diagnosis of UTI. We routinely perform urine
culture in children <2 years in whom UTI is a diagnostic consideration and in whom a sample for urinalysis or
dipstick is collected, even if the dipstick and standard and/or automated microscopic examination are negative
for WBCs and bacteria because the sensitivity of these tests is <90 percent (table 4) [36,37]. For verbal children
≥2 years of age who are toilet trained and afebrile, the results of the dipstick or microscopic analysis can be
used to decide whether to obtain a urine culture [38]. (See 'Decision to obtain' above and 'How to obtain' above
and 'Significant bacteriuria without pyuria' below and 'Society guideline links' below.)

Urine obtained for culture should be processed as soon as possible after collection. A delay of even a few hours
at room temperature increases both the false-positive and false-negative rates substantially [24].

Other laboratory tests — Other laboratory tests are not particularly helpful in the diagnosis of UTI and are not
routinely necessary in children with suspected UTI. (See "Febrile infant (younger than 90 days of age):
Outpatient evaluation" and "Fever without a source in children 3 to 36 months of age: Evaluation and
management".)

● Markers of inflammation – We do not routinely obtain markers of inflammation (eg, erythrocyte

sedimentation rate [ESR], C-reactive protein [CRP], or procalcitonin [PCT]) in the evaluation of children with
suspected UTI.

Although markers of inflammation are associated with pyelonephritis, they do not reliably differentiate
between cystitis and pyelonephritis because of their low sensitivity and/or specificity. In a meta-analysis of
studies evaluating the accuracy of PCT, CRP, and ESR in predicting dimercaptosuccinic acid-confirmed
pyelonephritis in children with culture-confirmed UTI, sensitivity ranged from 86 to 95 percent and specificity
from 38 to 71 percent [39]. Although CRP <20 mg/L (2 mg/dL) appeared to be helpful in excluding
pyelonephritis and PCT >0.5 ng/mL (0.5 mcg/L) appeared to be helpful in confirming pyelonephritis,
methodologic limitations (eg, small number of studies, unexplained heterogeneity) prevented definitive
conclusions.

Although elevated CRP has been associated with increased risk of renal scarring, it adds little to a
prediction model that includes clinical features that do not require venipuncture (eg, temperature, pathogen,
results of renal bladder ultrasonography) [21]. (See "Urinary tract infections in children: Epidemiology and
risk factors", section on 'Prediction of renal scarring after first UTI'.)

● Serum creatinine – Measurement of serum creatinine is not routinely necessary in children with suspected
UTI. However, we suggest that serum creatinine be measured in children with a history of multiple UTI and
suspected renal involvement.
 ● Blood culture – We do not routinely obtain a blood culture in children older than two months of age who
have UTI and do not require blood culture for other reasons. (See "Febrile infant (younger than 90 days of
age): Outpatient evaluation" and "Fever without a source in children 3 to 36 months of age: Evaluation and
management".)

Bacteremia occurs in 4 to 9 percent of infants with UTI [40-46]. Fever in bacteremic infants with UTI
persists, on average, one day longer than in nonbacteremic infants with UTI [47]. Nonetheless, a positive
blood culture rarely alters management because the same organism usually is isolated from the blood and
urine.

● Lumbar puncture – Given the low prevalence of bacterial meningitis in infants age 20 to 90 days with UTI
(0.25 percent, 95% CI, 0.09-0.70 percent in pooled analysis of 20 studies), lumbar puncture generally is not
warranted in infants and children >1 month of age with UTI but should be assessed on a case-by-case
basis [48,49]. (See "Bacterial meningitis in children older than one month: Clinical features and diagnosis".)

Lumbar puncture in infants younger than one month with UTI is discussed separately. (See "Urinary tract
infections in neonates".)

DIAGNOSIS OF UTI

Diagnostic criteria — UTI is best defined as significant bacteriuria of a clinically relevant uropathogen in a
symptomatic patient. Pyuria is present in most cases. However, in approximately 10 to 20 percent of children
with UTI, pyuria may be absent. (See 'Special circumstances' below.)

Significant bacteriuria

● Quantitative threshold – What constitutes significant bacteriuria depends upon the method of collection
and the identification of the isolated organism [24].

Our thresholds for significant bacteriuria according to method of collection are as follows:

• Clean-voided sample – Growth of ≥100,000 colony forming units (CFU)/mL of a single uropathogen,
or ≥100,000 CFU/mL of one uropathogen and <50,000 CFU/mL of a second uropathogen; growth of a
second uropathogen with ≥50,000 CFU/mL or growth of >2 organisms is considered contamination.

This is the same as the standard definition for significant bacteriuria on clean-catch specimens in
adults, which is based upon studies from the 1950s [50].

• Catheter sample – Growth of ≥50,000 CFU/mL of a single uropathogen, or ≥50,000 CFU/mL of one
uropathogen and <10,000 CFU/mL of a second uropathogen [24,51]; growth of a second uropathogen
with ≥10,000 CFU/mL or growth of >2 organisms is considered contamination. Although we generally
use ≥50,000 CFU/mL as the threshold for catheter samples, growth of ≥10,000 CFU/mL of a single
uropathogen may be considered sufficient to diagnose a UTI in cases where the pretest probability of
UTI is high.
 In a prospective study of febrile children <24 months of age, catheterized urine samples with 10,000 to
50,000 CFU/mL were more likely than specimens with ≥50,000 CFU/mL to yield gram-positive
organisms (excluding enterococci) or mixed organisms (65 versus 17 percent) [52].

We suggest that children who have growth of 10,000 to 50,000 CFU/mL of a single uropathogen from
an initial catheterized specimen have a repeat urine culture. We consider such children to have UTI if
the second culture grows ≥10,000 CFU/mL and pyuria is present on dipstick or microscopic urinalysis.

• Suprapubic sample – Growth of ≥1000 CFU/mL of an uropathogen.

● Clinically relevant uropathogens – Clinically relevant uropathogens in children include Escherichia coli,
Klebsiella spp, Proteus spp, Enterobacter spp, Citrobacter spp, Serratia marcescens, Staphylococcus
saprophyticus, Enterococcus spp, Streptococcus agalactiae, Pseudomonas aeruginosa, and
Staphylococcus aureus.

● Clinically irrelevant uropathogens – Lactobacillus spp, coagulase-negative staphylococci, and

Corynebacterium spp are not considered clinically relevant uropathogens [24].

Pyuria — For the diagnosis of UTI in children, pyuria is defined by one of the following (irrespective of urine
specific gravity):

● Positive leukocyte esterase (≥1+) on dipstick analysis

● ≥5 WBC/high-power field (hpf) with standardized or automated microscopy
● ≥10 WBC/mm3 on a hemocytometer with an enhanced urinalysis

The presence of WBC in the urine is not specific for UTI. Other causes of pyuria in children with symptoms that
mimic UTI include appendicitis, group A streptococcal infection, and Kawasaki disease. (See 'Differential
diagnosis' below.)

Special circumstances

Significant bacteriuria without pyuria — Pyuria is absent in approximately 10 to 20 percent of children with
UTI [20,36,53,54]. The approach to diagnosis of UTI in children with significant bacteriuria without pyuria varies
with the uropathogen that is isolated.

● Significant growth of Enterococcus spp, Klebsiella spp, or P. aeruginosa – UTI may be diagnosed in
the absence of pyuria in children with symptoms of UTI and significant growth of Enterococcus spp,
Klebsiella spp, or P. aeruginosa [36,55-57].

In a retrospective review of 1181 children (<18 years of age) with UTI who had a microscopic urinalysis for
pyuria (≥5 WBC/hpf or ≥10 WBC/mm3), 13 percent did not have pyuria [36]. UTI was defined by growth of a
single uropathogen at a concentration of ≥50,000 CFU/mL from a catheterized specimen or ≥100,000
CFU/mL from a clean-voided specimen in a child with symptoms of UTI. Only 54 percent of children with
Enterococcus UTI, 74 percent of children with Klebsiella UTI, and 62 percent of children with P. aeruginosa
UTI had pyuria, compared with 89 percent of children with E. coli UTI. However, given that E. coli was the
 most frequently isolated uropathogen (85 percent), most of the children with UTI without pyuria had an E.
coli UTI (107 of 150 children without pyuria).

● Significant growth of other uropathogens – Significant bacteriuria with an uropathogen other than
Enterococcus spp, Klebsiella spp, or P. aeruginosa without pyuria may occur [24,55]:

• Early in the course of a UTI (ie, before the local inflammatory response develops).

• If the dipstick leukocyte esterase test or microscopic analysis is falsely negative (these tests are at best
90 percent sensitive (table 4)).

• In children with colonization of the urinary tract (ie, asymptomatic bacteriuria).

Repeating the urinalysis and urine culture can help to distinguish between early infection and colonization,
particularly if the urine is obtained through catheterization or suprapubic aspiration to minimize
contamination [12].

• Pyuria and bacteriuria on the second sample is suggestive of UTI.

• The absence of pyuria and bacteriuria on the second sample is suggestive of bacterial contamination of
the initial sample.

• Bacteriuria without pyuria on the second sample may be due to true infection or asymptomatic
bacteriuria.

Clinical judgment is necessary to decide whether or not to treat with antibiotics (or continue antibiotics if
they were initiated empirically). Factors that favor antibiotic therapy or continuation of antibiotic therapy
include age <2 years, presence of fever, history of UTI or urinary tract abnormality, and clinical
worsening or lack of improvement.

Pyuria without significant bacteriuria — In children with symptoms of UTI and pyuria on dipstick or
microscopic urinalysis, the absence of significant bacteriuria does not absolutely exclude a diagnosis of UTI.
Failure to meet the threshold for significant bacteriuria (ie, false-negative urine culture) may occur under the
following circumstances [12,52]:

● A bacteriostatic antimicrobial agent is present in the urine

● Rapid rate of urine flow with reduced incubation time
● Obstruction of the ureter that interferes with the discharge of bacteria into the bladder

When false-negative urine culture is suspected, renal scintigraphy may be helpful in establishing the diagnosis
of acute pyelonephritis. (See "Urinary tract infections in infants older than one month and young children: Acute
management, imaging, and prognosis", section on 'Renal scintigraphy'.)

DIFFERENTIAL DIAGNOSIS
Other considerations in the differential diagnosis in a child with suspected UTI depend upon the presenting
symptoms and signs and results of the urinalysis. Quantitative urine culture results, results of cultures or other
microbiologic tests from other sites, and associated clinical features distinguish UTI from these conditions.

● Fever without a source – Although occult UTI is the main consideration in the differential diagnosis of
fever without a source in children age 3 to 36 months, other considerations include occult pneumonia and
occult bacteremia (rare in the conjugate vaccine era). (See "Fever without a source in children 3 to 36
months of age: Evaluation and management".)

● Fever, abdominal pain, and pyuria – Considerations include:

• Group A streptococcal infection (see "Group A streptococcal tonsillopharyngitis in children and

adolescents: Clinical features and diagnosis")

• Appendicitis (see "Acute appendicitis in children: Clinical manifestations and diagnosis")

• Kawasaki disease (see "Kawasaki disease: Clinical features and diagnosis")

● Urinary symptoms (eg, urgency, frequency, dysuria) with bacteriuria (with or without pyuria) –
Considerations include (see "Etiology and evaluation of dysuria in children and adolescents"):

• Nonspecific vulvovaginitis, irritant or chemical urethritis (eg, due to bubble bath), and vaginal foreign
body (see "Overview of vulvovaginal complaints in the prepubertal child")

• Urethritis secondary to a sexually transmitted infection, particularly chlamydia (see "Clinical

manifestations and diagnosis of Chlamydia trachomatis infections")

• Urinary calculi (see "Clinical features and diagnosis of nephrolithiasis in children")

● Urinary symptoms without bacteriuria

• Bowel and bladder dysfunction is frequently overlooked in children with urinary symptoms and a
negative urine culture, although it also contributes to the pathogenesis of UTI. (See "Urinary tract
infections in children: Epidemiology and risk factors", section on 'Bladder and bowel dysfunction'.)

● Asymptomatic bacteriuria – Asymptomatic bacteriuria in a child with nonspecific symptoms (eg, fever,
abdominal pain) caused by a condition other than UTI (eg, viral gastroenteritis) is a consideration in the
differential diagnosis of UTI in children.

Asymptomatic bacteriuria (ie, colonization of the urinary tract with bacteria in the absence of inflammation)
is rare. The prevalence of asymptomatic bacteriuria is substantially lower than the prevalence of UTI. In a
meta-analysis of 14 studies (49,806 children <19 years of age), the prevalence of asymptomatic bacteriuria
was 0.47 percent in girls and 0.37 percent in boys [58]. The bacteria tend to be of low virulence, and
spontaneous resolution is common; antibiotic treatment is not recommended [59-62]. A meta-analysis of
three randomized trials found the evidence insufficient to determine the risks and benefits but concluded
that antibiotic therapy is unlikely to benefit children in the long term [63].
SOCIETY GUIDELINE LINKS

Links to society and government-sponsored guidelines from selected countries and regions around the world are
provided separately. (See "Society guideline links: Urinary tract infections in children".)

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topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on
"patient education" and the keyword[s] of interest.)

● Basics topic (see "Patient education: Urinary tract infections in children (The Basics)")

● Beyond the Basics topic (see "Patient education: Urinary tract infections in children (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

● Urinary tract infection (UTI) is best defined as significant bacteriuria of a clinically relevant uropathogen in a
patient with pyuria. (See 'Terminology' above.)

● Fever may be the only sign of UTI in infants and young children. Older children may have urinary symptoms
(eg, abdominal pain, flank pain, dysuria, frequency, new-onset urinary incontinence). (See 'Clinical
presentation' above.)

● Important aspects of the history in a child with suspected UTI include features of the acute illness (eg, fever,
urinary symptoms) and risk factors for UTI (eg, lack of circumcision in male infants, female sex). (See
'History' above and "Urinary tract infections in children: Epidemiology and risk factors", section on 'Host
factors'.)

● The examination of the child with suspected UTI should include: measurement of temperature, blood
pressure, and growth parameters; abdominal examination for tenderness or mass; assessment of
suprapubic and costovertebral tenderness; examination of the external genitalia; evaluation of the lower
back for signs of occult myelomeningocele; and a search for other sources of fever. (See 'Physical
examination' above.)
● The laboratory evaluation for the child with suspected UTI includes urine dipstick and microscopic analysis
(table 4) and urine culture. (See 'Laboratory evaluation' above.)

● The decision to obtain a urine sample is best made on a case-by-case basis, taking into consideration the
age, sex, circumcision status, race, and the presenting signs and symptoms (table 1 and table 2). UTICalc
can be used to estimate the probability of UTI in febrile (temperature ≥38°C [100.4° F]) children age 2
through 23 months according to clinical characteristics.

We suggest that urine samples be obtained for urinalysis and culture in the following patients (table 3) [9]
(see 'Decision to obtain' above):

• Febrile (≥38°C [100.4°F]) girls and febrile uncircumcised boys younger than two years who are at high
risk, including:

- Infants 2 through 11 months of age, with the exception of black infants with maximum temperature
≥38°C (100.4°F) and <39°C (102.2°F) and an identified source of fever (eg, acute otitis media;
pneumonia; meningitis; upper respiratory tract infection, gastroenteritis, bronchiolitis, or other viral
syndrome)

- Children between 12 and 24 months of age with maximum fever ≥39°C (102.2°F), with the
exception of black children with an identified source of fever

- Nonblack children between 12 and 24 months of age with maximum fever (≥38°C [100.4°F] and
<39°C [102.2°F]) and no other source of fever identified

• Circumcised nonblack boys age 2 through 11 months with maximum fever ≥39°C (102.2°F) and no
other source of fever identified

• Girls and uncircumcised boys ≥24 months of age with dysuria, frequency, new-onset incontinence,
abdominal pain, back pain, or high fever (ie, ≥39°C [102.2°F]), if no other cause is apparent

• Circumcised boys ≥24 months of age with multiple symptoms (abdominal pain, back pain, dysuria,
frequency, high fever, or new-onset incontinence)

● Catheterization or suprapubic aspiration is the preferred method of urine collection for infants and children
who are not toilet trained. A clean-voided specimen is the preferred method for toilet-trained children. We
recommend that urine obtained in a sterile bag not be used for culture. (See 'How to obtain' above.)

● We routinely perform urine culture in children <2 years in whom UTI is a diagnostic consideration and in
whom a sample for urinalysis or dipstick test is collected, even if the dipstick and standard or automated
microscopic examination are negative for white blood cells (WBCs) and bacteriuria. For verbal children ≥2
years of age who are toilet trained and afebrile, the results of the dipstick or microscopic analysis can be
used to decide whether to obtain a urine culture. (See 'Urine culture' above.)
 ● The diagnosis of UTI requires laboratory confirmation of significant bacteriuria and pyuria. (See 'Significant
bacteriuria' above and 'Pyuria' above.)

• We define significant bacteriuria as recovery of ≥100,000 colony forming units (CFU)/mL of a single
uropathogen from a clean-catch specimen, ≥50,000 CFU/mL of a single uropathogen from a
catheterized specimen, and ≥1000 CFU/mL of uropathogenic bacteria from a suprapubic aspirate.

• Pyuria is defined by positive leukocyte esterase (≥1+) on dipstick analysis, ≥5 WBC/high-power field on
standardized microscopy, ≥10 WBC/mm3 on a hemocytometer, or pyuria according to automated
microscopy. (See 'Pyuria' above.)

• If the urine culture demonstrates significant growth of Enterococcus spp, Klebsiella spp, or
Pseudomonas aeruginosa in a child with symptoms of UTI, UTI may be diagnosed in the absence of
pyuria. (See 'Significant bacteriuria without pyuria' above.)

● Asymptomatic bacteriuria is the main consideration in the differential diagnosis of UTI in children. Other
considerations include occult bacteremia (rare), occult pneumonia, group A streptococcal infection,
appendicitis, Kawasaki disease, nonspecific vulvovaginitis, urethritis, nephrolithiasis, and bowel and bladder
dysfunction. Quantitative urine culture results, results of cultures or other microbiologic tests from other
sites, and associated clinical features distinguish UTI from these conditions. (See 'Differential diagnosis'
above.)

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50. KASS EH. Asymptomatic infections of the urinary tract. Trans Assoc Am Physicians 1956; 69:56.

51. SUBCOMMITTEE ON URINARY TRACT INFECTION. Reaffirmation of AAP Clinical Practice Guideline:
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52. Hoberman A, Wald ER, Reynolds EA, et al. Pyuria and bacteriuria in urine specimens obtained by catheter
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in infants <3 months of age. Pediatrics 2015; 135:965.

54. Williams GJ, Macaskill P, Chan SF, et al. Absolute and relative accuracy of rapid urine tests for urinary
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55. Hoberman A, Wald ER. Treatment of urinary tract infections. Pediatr Ann 1999; 28:688.

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Topic 5990 Version 50.0

GRAPHICS

Prevalence of urinary tract infection in febrile* infants and children by demographic group

Demographic group Prevalence or pretest probability (95% CI)

0 to 3 months 7.2% (5.8-8.6)

Girls 7.5% (5.1-10)

Circumcised boys 2.4% (1.4-3.5)

Uncircumcised boys 20.1% (16.8-23.4)

3 to 6 months 6.6% (1.7-11.5)

Girls 5.7% (2.3-9.4)

Boys 3.3% (1.3-5.3)

6 to 12 months 5.4% (3.4-7.4)

Girls 8.3% (3.9-12.7)

Boys 1.7% (0.5-2.9)

12 to 24 months 4.5% ¶

Girls 2.1% (1.2-3.6)

Circumcised boys >1 year <1% ¶

<19 years with urinary symptoms and/or fever Δ 7.8% (6.6-8.9)

UTI: urinary tract infection.

* Temperature ≥38°C.
¶ 95% confidence interval not available.
Δ Most of these children were older than 2 years.

Data from: 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.

Graphic 76804 Version 12.0

Pretest probability of urinary tract infection in febrile (>38°C [100.4°F]) girls and
uncircumcised boys 2 through 23 months of age with no urinary tract abnormalities

Clinical and demographic Pretest probability of UTI (percent)*

features 2 through 12 months 12 through 23 months

Maximum fever ≥39°C (102.2°F)

Other source of fever ¶

Black Δ <2 3

Nonblack 8 3

No other source of fever ¶

Black Δ 11 4

Nonblack 25 10

Maximum fever <39°C (102.2°F)

Other source of fever ¶

Black Δ <2 <2

Nonblack 3 <2

No other source of fever ¶

Black Δ 5 <2

Nonblack 12 4

This table is intended for use in conjunction with the UpToDate content on UTI in children.

UTI: urinary tract infection.

* Many clinicians would obtain urine samples for urinalysis and culture in children with a pretest probability of >2% (approximately 10% of
children need to be tested for every UTI detected).
¶ Black race denotes that the parent identifies the child as black (fully or partially).
Δ Other source of fever includes (but is not limited to) acute otitis media; pneumonia; meningitis; upper respiratory tract infection,
gastroenteritis, bronchiolitis, or other viral syndrome.

Adapted from: Shaikh N, Hoberman A, Hum SW, et al. Development and validation of a calculator for estimating the probability of urinary
tract infection in young febrile children. JAMA Pediatr 2018.

Graphic 117974 Version 2.0

Our indications for urinalysis and urine culture in febrile children age ≥2 months with
suspected urinary tract infection and no abnormalities of the urinary tract

Age and race* Indications for urine sample

Girls and uncircumcised boys

2 through 11 months, nonblack [1] Fever ≥38°C (100.4°F)

2 through 11 months, black [1] Fever ≥39°C (102.2°F)

OR
Fever ≥38°C (100.4°F) and <39°C (102.2°F) and no other source of fever identified ¶

12 to 24 months, nonblack [1] Fever ≥39°C (102.2°F)

12 to 24 months, black [1] Fever ≥39°C (102.2°F) and no other source of fever identified ¶

≥24 months One or more of the following:

Dysuria
Frequency
New-onset incontinence
Abdominal pain
Back pain
Fever ≥39°C (102.2°F) if no other cause of fever is apparent

Circumcised boys

2 through 11 months, nonblack [1] Fever ≥39°C (102.2°F) and no other source of fever identified ¶

≥24 months Two or more of the following:

Dysuria
Frequency
New-onset incontinence
Abdominal pain
Back pain
Fever ≥39°C (102.2°F) if no other cause of fever is apparent

This table is meant for use with UpToDate content on urinary tract infection in children. The indications for obtaining urine samples
correspond to a pretest probability of UTI >2% (ie, approximately 10 children need to be tested for every UTI detected, which are
the thresholds used in UTICalc, available from the University of Pittsburgh). [1] Thresholds may vary depending on duration of
symptoms, feasibility of follow-up, and parental views toward catheterization.

UA: urinalysis.
* As self-described by the child's parent or caregiver; for the purposes of this table, black includes those who are fully or partially black.
¶ Other sources of fever include: acute otitis media; pneumonia; meningitis; and upper respiratory tract infection, gastroenteritis,
bronchiolitis, and other viral syndrome, among others.

Reference:
1. Shaikh N, Hoberman A, Hum SW, et al. Development and validation of a calculator for estimating the probability of urinary tract
infection in young febrile children. JAMA Pediatr 2018; 172:550.

Graphic 126530 Version 1.0

Test characteristics of tests used to diagnose urinary tract infections in children

Positive Negative
Sensitivity Specificity
likelihood ratio* likelihood ratio ¶

Dipstick

LE 84% 78% 4 0.2

Nitrite 50% 98% 25 0.5

Nitrite or LE 88% 93% 13 0.1

Nitrite and LE 72% 96% 18 0.3

Microscopy

Uncentrifuged

Pyuria (>10/mm 3) 77% 89% 7 0.4

(all ages)

Pyuria (>10/mm 3) 90% 95% 18 0.1

(<2 years)

Bacteriuria (Gram- 93% 95% 19 0.1

stained)

Overall (P+B) = 85% 99.9% 85 0.1

enhanced

Overall (P or B) 95% 89% 9 0.1

Centrifuged

Pyuria (>5/hpf) 67% 79% 3 0.4

Bacteriuria 81% 83% 5 0.2

Overall (P+B) 66% 99% 7 0.4

LE: leukocyte esterase; P: pyuria; B: bacteriuria; hpf: high-power field.

* Positive likelihood ratio: The positive likelihood ratio is the probability that a child with a UTI will have a positive test divided by the
probability that a child without a UTI will have a positive test (eg, true positive rate/false positive rate). The higher the positive likelihood
ratio, the better the test.
¶ Negative likelihood ratio: The negative likelihood ratio is the probability that a child with a UTI will have a negative test divided by the
probability that a child without a UTI will have a negative test (eg, false negative rate/true negative rate). The lower the negative likelihood
ratio, the better the test (a perfect test has a negative likelihood ratio of zero).

References:
1. Gorelick MH, Shaw KN. Screening tests for urinary tract infection in children: A meta-analysis. Pediatrics 1999; 104:e54.
2. 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.
3. Finnell SM, Carroll AE, Downs SM, the Subcommittee on Urinary Tract Infection. Technical report--Diagnosis and management of an
initial UTI in febrile infants and young children. Pediatrics 2011; 128:e749.

Graphic 82157 Version 11.0

Contributor Disclosures
Nader Shaikh, MD Nothing to disclose Alejandro Hoberman, MD Nothing to disclose Morven S Edwards,
MD Grant/Research/Clinical Trial Support: Pfizer [Group B Streptococcus]. Tej K Mattoo, MD, DCH,
FRCP Consultant/Advisory Boards: Kite Medical Limited [Vesicoureteral reflux]. Mary M Torchia, MD Nothing to disclose

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by
vetting through a multi-level review process, and through requirements for references to be provided to support the content.
Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence.

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