BLOG

A Clinical Practice Literature Review of Pediatric UTIs

January 21, 2021

As one of the most common bacterial infections in children, urinary tract infection (UTI) is a familiar foe for
most general pediatricians.

Catherine Spaulding, MD, Mount Sinai Urgent Care, Assistant Professor, Department of Medicine,
Department of Pediatrics, New York, NY
Content License: FreeView
Article type: Pediatrics Blog

As one of the most common bacterial infections in children,

urinary tract infection (UTI) is a familiar foe for most general
pediatricians. In a recently released article in Pediatrics, Mattoo
et al provides a state-of-the-art review of current literature
regarding UTIs 1 which compliments the AAP 2016 clinical
practice guidelines (10.1542/peds.2020-012138). Their article is
a wonderful refresher on some forgotten facts about UTIs and is
sprinkled with clinical pearls I’ve found to be very useful in
practice.

One such pearl is a calculator developed at the University of Pittsburgh that assesses the likelihood of UTI in
a febrile infant.2 Using a series of risk factors such as age, ethnicity, and temperature, the initial calculation
leads to a recommendation for or against obtaining a urine sample. If urine is obtained, the results from
urinalysis or urine dipstick are added to the calculator and the probability of a UTI is calculated. The
calculator goes one step further and suggests or rejects the need for empiric treatment based on its overall
estimate. Though I’ve only used this several times, I have found this calculator to be tremendously helpful
since it aids in the reduction of unnecessary catheterization or antibiotic use.

The calculator’s initial emphasis on risk factors and clinical symptoms rather than laboratory data alone
speaks to the limitations of the urine dipstick and culture in the diagnosis of UTI, which Mattoo et al discuss
in detail. For instance, their review reminds us that while nitrite positive urine is highly specific for UTI, its
sensitivity is rather low. Nitrites reflect the presence of gram-negative bacteria but can only be detected after
several hours of urinary stasis, which makes it a less reliable indicator of UTI in an infant or young child who
does not have voluntary bladder control.

Furthermore, while I’ve always thought the diagnosis of UTI required a colony count greater than 50,000 in
culture, this definition has been hotly debated and some studies suggest that a much lower threshold should
be used.3 It is indeed another reminder that while a urine dipstick or urine culture does have value, clinical
acumen is our greatest tool for the diagnosis of UTI.

Lastly, here are a few high-yield points to take with you to your practice:

A clean catch or catheterized urine sample should always be used for culture given a
contamination rate as high as 80% with a bagged urine sample.
A renal bladder ultrasound (RBUS) should be conducted with the first febrile UTI in children aged
2 to 24 months or after recurrent febrile UTIs in older children in order to rule out structural or
anatomic anomalies.
Voiding cystourethrogram should only be done in children with abnormalities on RBUS, prior
history of renal scarring, family history of vesicoureteral reflux, an atypical pathogen, or a very
complex clinical course.
First line outpatient antibiotic therapy includes a 7 to 10 day course of a first or second generation
cephalosporin, Bactrim or nitrofurantoin. Amoxicillin is not a good choice due to high resistance
rates.

For a more in-depth review, be sure to check out the complete article in this month’s Pediatrics.

References:

1. 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. (2016). Pediatrics, 138(6).
doi:10.1542/peds.2016-3026
2. Shaikh N, Hoberman A, Hum SW, et al. Development and Validation of a Calculator for Estimating the
Probability 71 of Urinary Tract Infection in Young Febrile Children. JAMA Pediatr 2018; 172(6): 550-6.
3. Roberts, K.B., & Wald, E. R. The Diagnosis of UTI: Colony Count Criteria Revisited. Pediatrics, 141
(2). doi: 10.1542/peds.2017-3239

Catheter-Associated Urinary Tract Infection Reduction in a Pediatric Safety Engagement Network

Annotations on Emerging Concerns About Antibiotic-Resistant Urinary Tract Infection
Urinary Tract Infection Antibiotic Trial Study Design: A Systematic Review
Facebook
Instagram

Copyright © 2021 American Academy of Pediatrics