July 14, 2010

Management of Urinary Tract Infection in Infants and Young Children

Urinary tract infections (UTI) are a common and important clinical problem in childhood. Upper urinary tract infections (ie, acute pyelonephritis) may lead to renal scarring, hypertension, and end-stage kidney disease. Although children with pyelonephritis tend to present with fever, it can be difficult on clinical grounds to distinguish cystitis from pyelonephritis, particularly in young children (those younger than two years).

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In this article:
Treatment of UTI in children
MCQ exam: clinical scenario
MCQ exam: answer
MCQ exam: explanation

Treatment of UTI in children

Since it is difficult on clinical grounds to distinguish cystitis from pyelonephritis, particularly in young children (those younger than two years), attempting to distinguish cystitis from pyelonephritis in the definition of UTI is unnecessary. The goal of treatment of urinary tract infections in infants older than one month and young children are:
  • Elimination of infection and prevention of urosepsis
  • Relief of acute symptoms (eg, fever, dysuria, frequency)
  • Prevention of recurrence and long-term complications including hypertension, renal scarring, and impaired renal growth and function
Most children older than two months with UTI can be safely managed as outpatients as long as close follow-up is possible.

Usual indications for hospitalization and/or parenteral therapy include:
  • Age <2 months
  • Clinical urosepsis (eg, toxic appearance, hypotension, poor capillary refill)
  • Immunocompromised patient
  • Vomiting or inability to tolerate oral medication
  • Lack of adequate outpatient follow-up (eg, no telephone, lives far from hospital)
  • Failure to respond to outpatient therapy
Although some studies suggest that outpatient management may be considered for select well-appearing infants 29 to 60 days of age, additional evidence is necessary.

MCQ exam: clinical scenario

A one year old boy is brought to his pediatrician by his mother who has noted colicky abdominal pain and fever. On examination his scrotal skin is erythematous and warm and he has a urethral discharge. Investigation reveals a leukocytosis and pyuria. Sedimentation of the urine revealed E. coli which is successfully treated with antibiotics by his pediatrician.

When next seen at the clinic the next week he is symptom-free.

The most appropriate next step would be:

a) complete urologic investigation
b) no further treatment or investigation is necessary
c) radionuclide scintigraphy
d) inguinal-scrotal ultrasound
e) ceftriaxone and doxycycline

MCQ questions & answers on medicalnotes.info

MCQ exam: answer

The correct answer is A.
A complete urologic investigation is the next step.

MCQ exam: explanation

Acute management of UTI in children consists of antimicrobial therapy to treat the acute infection and evaluation for possible predisposing factors (eg, urologic abnormalities). Long-term management centers on prevention of recurrence and complications.

The occurrence of epididymitis in infants suggests the presence of urinary infection and the likelihood of an associated structural genitourinary abnormality, requiring complete urologic investigation. All pediatric cases of epididymitis require immediate consultation due to the high incidence of associated genitourinary anomalies.

Reference(s)
1). UpToDate: Urinary tract infections in infants older than one month and young children: Acute management, imaging, and prognosis. Available online: https://www.uptodate.com/contents/urinary-tract-infections-in-infants-older-than-one-month-and-young-children-acute-management-imaging-and-prognosis

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