An Official Publication of the

Philippine Pediatric Society, Inc.

Clinical Practice Guideline

·. ,·

,•.·

In The Approach And

Treatment Of Urinary Tract

Infection In Children

In The Philippine Setting

Categories reflectin.s_the~ality of evidence on which- ,ecommendations
~·
- - -- are based ~
GRADE
I
- - E vid;ncc- fr°Z>m at IC<t-\1 DEflNlTION
one pr~periy randomized, contrr,J!ed
trial
II Evidence from at least one well desihrned in trial without
randomization from cohort or case-controlled analytical
'
studies _uncontrolled experiments
- Evidence from opinion of respected authorities, based on
Ill
dinical experience, descriptive studies, or reports of expert
committees

THE CHILD WITH PROBABL~: URINARY TRi\CT INFECTION

I. The SUSPElT:

I. The n t presenting with the · · as presented

in table I.
2. Febnle infants (>38 C) below 2 ·cars of a (Table l Downs)
3. Older children manifesting symptoms referable to urinary tract (Table I)
The evidence for trus recomm~odation Alli. Hoberman A (6,7,8)~ Shaw (9).
Downs()}

Table I
• Jn generaJ manifestations of urinary tract infections are non-scientific.
However. there are some signs and symptoms that are associated with UTI.

CLINICAL SIGN/S Neonates Older Infant, School Ag

SYMPTOM Adokscr-nts
• Septic [+]
• Temperature instability f+J
• Poor feeding [+]
• Vomiting [f-J [·ij
[+]
• Lethargy or irritability
[+]
• Jaundice
[+] [+] [+]
• Fever
[+] f+J [+j
• Poor weight
[+ I+J
gain/failure to thrive
(+}1 [+J
• Diarrhea
[+) [+]
• Abdominal pain
f+l
• Frequency, dribbling, (+]
urgency dysuria [+ (+]
• Weak urinary stream {ii
• Malodorous urine I

• Enuresis r- (+]

• Flank_.eains I- ---
4 1-
II. THE FOLLOWING L~ AN ALGORITHM ON THE DIAGNOSL~, WORK-UP,
TREATMENT AND FOUOW-UP OF CHILDREN WITH URINARY TRACT
INFECTION.

SUSPECTED URINARY TRACT INFECTION

UJNly-.. { ~ afUTI)

(+) ~ ~ o r N " I M O'T:mll

Bae1milri,pR9Clll m..,..
Oraa•aiwt~
1')111111 ~ WBClbpC« J ~
Pll\'lli.:.u - - - - ~ • ...~r----- (+) u..e ul ;a p-,..ty
E.~ a,; caBc,c.,cdw.tpedlMD.

ABSENT

CBC ( C ~ prolcin, ESR)

BUN. Clalia.iac
Oplimal C-IU', ESll, Bblclad

AdllillO lbpil.:.
__ Psaltaal ~ (JV,l M) ___

KUB UTZ. pn: -t pool '\IOid

~~ M,y a ! tooal ~
a..,p.,. um< Culll&'\: C...-7-14~,
Ua: ~ ari,iori,:,a
hac.d on initial 'Urine cas
(lf .wailabk)
Coq,lc:te 7-14 days Ct(
O{lrQlmc:rtl

-~ Pmp,yb.-ria

··-iiw1won~-----·"i:v;;:;:
ciclili;·;;;;
;;;ic-:c:o;;;
,.,...;;;;;edi;;•US1Dii iaaiil'• ----·--·-·--------· ..
Or nudca-<.~
Wbm .-dcd: ~ l i d c rmal IUD •"WM,' >.~A)
l a i r - pyclOIJllJlby ••

..----···-·-·---··-----
Olbr.r ~ I r ; < ~ ~ .. - -·····- - - ···- - · · - - -

Urolol)' follow--wp • ,iccdcd

-----------Nephrology roDow-ap
Monilor 81ood ~
~ t;VCty u W<:Q.S
UmeCllllur'c
vflt (CIClllliniat)

5
Ill. Ill.«<,· OSIS

<. 'h·L. h. . t ref ·1 to table t

1h l\lfY nf 1 l l - -""'- '-on. unH",rna ,,.,..e.~-1 such as
'
m,·( ntincnc~. ................ , · 's cspccu1lly pelvic surseries, ambulatory problem etc

rn, SICAL 'XAMINATION:

th,lt\.\U~h ph sical enminntion i a ml»t. The examinet should look for ,__...,...,.....
th t C\x-xist, mil i n such a p f · I , r tu
l c indic.atin probable ncurogcnic Madders Lower extremities must
al he c ·nmined. Thorough ...,_...__ 10n must be included Rectal
c, · min:itton 1s part of the c.uminntion

11\t \IIUI ly is
inf tJoo would
ha

CAVEAT:

Parallel combinations of test results maximize sensitivity. A study within one hour of
uri Uecrion using careful on-site microscopy with a positive comb,nation for
leukocytes and bacteria has a sensitivity of 99% or greater. When any mponent of
uriMlyus II politi - such as LE. nitrite, blood, protans, microscopy for
leukocytes, microscopy of bacteria·, and the urinal · · considered po 'ti~. the
sensitivity is 100% but the pecificity is only 600/o-Hoberman (7), Lohr (ll),
HouSlon (I 2), Hoberman (13). Evidtnce is B/11 ;~ f'
,-r, ,.,,,r,.ie
Trine Culturt: ,..I (
·,,., .. L' e )l n tt 1 <"('ff,,. ({(A i· i-r+ 1
1~- ' 1'1 2 11,/'f

THE GOLD STANDARD rs ANY BACTERIAL GROwrH AFTER A

S~PRA~UBJC TAP. This is done in inf: w ooe year of age. The bladder at
th1 s age is intraabdominal. A diaper that has been dry for thirty minutes. will indicate
~ bladder containinp. enough urine to avoid an empty tap. With a 3-c.c ~• e and an
m~h _Ion gau e 25 needle, punctw-c one centimeter above the symphysis pubis in the
midline. For care givers that shun away from suprapubic taps. catheterization would
he the next best choice. Refer to table 2
Midstream catch in a cooperative and properly prepared patient wiJI give a high
sensitivity and specificity.
Table 2

• Urine Culture: lottrprctttion ofUTI

Method of Collection QuantitBtive Culture: lITI present

• S~bic aspiration Growth o urinary pathogen in

""'lemabd(cxcq,tioo is up to
2-3 X 10\ CRJhnl of coagu.laso-
ncgalJ\·c staphylococci)

• CadldcrizatioD Febrile infants QI' chiljhen usunlly

have 56,000 FUhnl evidence of
a single urinary pathogen, but
infeclion ma)' be present wilh counts
from >. OOOCF'Uhnl (Hobcnnan A
(7), Down (7), +

• cl~void lt-luia-.1111u·c patients at least

IYMIIIGCBtDSI on diffamt
Days with to' CRU of the same
pathogen..

+ Culture of urine specimens obtained by catheteriz.ation has a specificity of 83% to

89°/ o compared with cultures of urine ~pecimens obt~ned by !,31>· If <:'~~ cultures of
> I OOOCFU/ml are considered, catheterized cultures have a 951/o sens1t1v1ty and 99G/o
specificity.

• Routine ~ - of the urine after 2 days of antimicrobial therapy is

generally all& _ _.'tlf'/ if the infant or young child has had expected
clinical raponse and the uropathogen is determined to be sensitive tl) the
alltimicrobiaJ being_administered.
7
WARNING ON THE USE OF BAG SPECIMEN FOR CULTORE:
Culture of bag specimen is 100°/4 sensitive but have a pecificity of only 14-841/o-
Taylor (14), Puerto M (15). With prevalence rate of only 5%, the use of culture from
the urine specimens from a bag to rule in UTl is likely to r ~ h in a large number of
false positive results. Specifically, with prevalence of 5%. That is, 8So/. of positive
cultures of bag specimen would be f.alse - Dovm(5}. Evidence is Dill

W. WORK-UP

Table 3
Reference Age group Pre\'alence Detectable Detectable Comment
of by byutzand
abnormalitv ,;
ultrasowid VCUG
Do~n(5) Less 3 yrs old 51% 42% 100% Emphasis on
VUR
Down (5) Any age group 38% 100% All
abnonnalitics
Burbigc KA Children 75% 25-50% 1001/4, Boys
(16) (including
lVP)
Elzouki AY Children 26% J00°/4
(17)
,<.>meUie JM Undec 14 79% 29°/. 100°/4 Includes
(18) Dl\.-f.SA
scan and IVP
Hobcrman Infants and - Notw;cful 100%
(19) young children
Hiraoka M Less & months Jr;. Good 100-/4 Follow up UTJ
(20) screemng if normal
ultrasound,
work up if
with
UTJ
MucciB Children 14% 3% -- DMSAasa
(21) screening
.
Strife (22) Children (girls) 38% l3% 100% Uses nuclear
. . cystograrn
-
Riclwood Children 99°/4
(23) sensitive,
43%
specific
(inadequate
as a slndv)
Honkincn Children 52o/. 1&9/4 Complete
(24) wale
up will need
VCUG/noclear
·-
- ---~AUi
-

0
~ ltrasonography alone as a work up for patients with proven urinary tract infection is
madequate. lt is sensitive(99-95% Cl 96¾-100%) but it its' !>-pecificity modest (43-
0'o32%-55~1o)- Rickwood (23) Evidt!?~~ is A/IL
The use of voiding cystourclhrogr~phy (or nuclear cystogram) evaluates the presence
or absence of vesicourctcral reflu .
Vesicouretera) reflux is the most common abnonnality found in-patients with urinary
tract infection. The prevalence is 30'% to 400/4 - Down ( 5-table 6 and table 7 review
of literatw·e): Evidence is A/ll

i: TREATt,,JENT:
.
• Somt- antimicrobials for oral treatment of UTI

Amoxicillin 20-40 mg/kg/day in 3 doses

TMP in combination with SM.X 6-12 mg TMP. 30-60 SMX per

kg per day in 2 doses

Sulfisoxazole l20-l50 mg/kg/day in 4 doses

Cefixime 8 mg/kg/day in 2 doses

Cephalexin 50-100 mg/kg/day in 4 doses

Cefpdoxime 10 mg/kg/day in 2 doses

Cefprozil 30 mg/kg/day in 2 doses

Loracarbef f 50-30 mg/kg/day in 2 doses

• Some antibiotics for p reoul treatment of UTl

Ceftriaxone 75 mglkg every 24 hours

C efota."Xime 150 mg/kg/day divided every 6

hour ·

Ceftazidime 150 g/kg/day divjded every 6

hours

Cefazo1in SO m~g/day divided every 8

hou rs

Gentamicil} 7.5 mg/kg/day divjded CV~ 8

hours

9
 Tobramycin every 8
hours

Ticarcillin 100 mgl!.wday divided every 6

houB

Ampicil1in 100 mg/kg/day divided every 6

hours

• Prophylactic antibiotics - low serum levels but with high urinary ]eve)

-1--las minimal effects on fecal flora

- Low cost and well tolerated
½ of the regular dose given at bedtime

• Some antimi~robial for prohylaxis of UTI

TMP in combination with SMX 2 mg TMP~IO mg of SMX per

kg as single bedtime dose
Or 5 mg of TMP, 25 mg of
SMX per kg twice per week

:Nitrofuraotoin l-2 mg/kg as single daily dose

SuJfisoxaz.ole 10-20 mg/kg divided every 12

hours

Nalidi.'ric Acid 30 mg/kg divided every I 2

hours

Methe-namine mandelate 75 mg/kg di"ided every I 2 hour

Bibliography:
1. Siegle SR, Sokoloff B. Asymptomatic and symptomatic urinarv tract
infoction in infancy. · ·
Am J Dis Child 1973; 125:45-47
2. Mc lntyre PB, Gray SV, Vance JC. Unsuspected infections in febrile
convulsions Med J Aust 1990; 152, I 83
3. Pryles CV. luders D. The bacteriology of the urine in infants and
children with gastroenteritis. Pediatrics 1961 : 877-885
4. Shortlife. Ch 57. Urinary tract inftX--tion in infants and children.
th
Campbellls 7 edition: Walsh, Retick, Vaughn, Wein
5. Downs SM. Technical Report: Urinary Tract infections in febrile
~fants and Young Children: ·Pediatrics Vol I 03 No4 April

10