Urinary Tract Infection



Date: October 2014Guideline(s) Reviewed:Cincinnati, 2006. UTI Guideline Team, Cincinnati Children’s Hospital Medical Center: Evidence-based care guideline for medical management of first urinary tract infection in children 12 years of age or less. . Guideline 7, pages 1-23, November, 2006 NICE, 2007. National Collaborating Centre for Women’s and Children’s Health. Urinary tract infection in children: diagnosis, treatment and long-term management. 2007. Roberts, KB. Subcommittee on Urinary Tract Infection, Steering Committee on Quality Improvement and Management. Urinary Tract Infection: Clinical Practice Guideline for the Diagnosis and Management of the Initial UTI in Febrile Infants and Children 2 to 24 months. Pediatrics. 2011;128(3):595–610.Seattle Children’s Hospital Urinary Tract Infection PathwayTopic Owner: Kristi Kiyonaga, MD (kkiyonaga@)OBJECTIVESProvide criteria for accurate diagnosisProvide criteria for hospitalizationOutline appropriate, age- and development-specific therapiesReduce unnecessary laboratory testing, radiography, and hospitalizationPrevent complications of urinary tract infection (UTI)SUMMARY:DiagnosisDiagnose infants and non-toilet trained children via high quality catheter specimen (not a bag) when possible.In sexually active adolescents, test for gonorrhea (GC) and chlamydia (CT) and offer an external genitourinary (GU) exam and/or self-obtained vaginal swab.Empiric TherapyStart empiric therapy in non-toilet trained infants and children when there is clinical suspicion of UTI (presence of signs or symptoms and clinical experience), regardless or urinalysis results.Start empiric therapy in toilet trained children and adolescents when there is clinical suspicion and a positive urinalysis.Hospitalize infants 0-30 days of age with suspected UTI for empiric IV antibiotics.Empiric therapy in infants 31-60 days of age not meeting criteria for admission is ceftriaxone IM.Empiric therapy in non-toilet trained children, toilet-trained children and adolescents is cephalexin or cefuroxime.Target antibiotic therapy to sensitivities once available. Outpatient treatmentFor infants 31-60 days of age, treat for 14 days.For non-toilet trained children, treat for 7-14 days.For toilet-trained children and adolescents with cystitis, treat for 3 days. For pyelonephritis, treat for 7-14 days.Imaging and follow-upFor infants and non-toilet trained children, perform renal bladder ultrasound (RBUS) or review high quality third trimester ultrasound.For toilet-trained children and adolescents, perform RBUS on boys diagnosed with first-time UTI and girls with atypical* UTI.Do not routinely perform a VCUG. VCUG is indicated for abnormal RBUS findings or atypical* UTI.Do not routinely perform a follow-up culture for test of cure.Inclusion CriteriaBirth to 18 years of age with a corrected gestational age of at least 40 weeksSuspected or confirmed UTI (but not chronic or recurrent UTI)Exclusion CriteriaPrior history of UTIAnatomic genitourinary abnormalitiesChronic kidney disease (estimated GFR < 80 mL/min/1.73m?)Immunocompromised hostPregnancyRecent history of sexual abuseAssessment/Diagnostic Test(s)Definitions: Urinary tract infection: combination of clinical features and the presence of bacteria in the urineAcute pyelonephritis / Upper urinary tract infection: inflammation of the kidneys due to UTI that manifests with fever 38°C or higherCystitis / Lower urinary tract infection: inflammation of the bladder due to UTI that is confined to the lower urinary tract Diagnosis:Presumed UTI: Infants and non-toilet trained children: clinical features where UTI is deemed likely (Reason: Urinalysis in these age groups have been shown to be insufficient to rule in or rule out urinary tract infection.) Toilet-trained children and adolescents: combination of clinical features and a positive urinalysisDefinite UTI: combination of clinical features and a positive urinalysis and urine culturePositive urinalysis (UA): demonstrates pyuria and/or bacteriuriaLeukocyte esterase (LE) is a surrogate marker for pyuria.Nitrites are a surrogate marker for gram-negative enteric bacteriuria.≥5 WBCs per HPF on microscopy demonstrates pyuria (≥10 WBCs per μL if counting chamber is used).Presence of bacteria on microscopy demonstrates bacteriuria.Positive urine culture:Catheterized specimen: ≥ 50, 000 CFUs / ml of a single uropathogen (at SCH equivalent to ≥ 10,000 CFUs?)Clean catch specimen: ≥ 100, 000 CFUs / ml of a single uropathogenDiagnostic Testing0-60 daysTesting indicated if patient has fever, irritability, lethargy, emesis, failure to thrive, prolonged jaundice of unknown etiology.Obtain a UA and urine culture, preferably by catheterization. If catheterization is not successful or not available, obtain bag specimen only to determine if negative. DO NOT SEND BAG SPECIMEN FOR CULTURE. Consider referral to ED for definitive testing when high clinical suspicion and unable to obtain catheterized specimen. Do not use a positive UA obtained by bag or clean catch as evidence of a UTI; confirmation requires positive UA and culture of a specimen collected through catheterization.Non-toilet trained children > 60 days of ageTest febrile (>39°) girls or uncircumcised boys with ≥ 1 of the following and febrile (>39°) circumcised boys with ≥2 of the following or suprapubic tenderness alone:Ill appearingFever >39° for 48 hours without a sourceAbdominal pain / suprapubic tendernessBoys: nonblack raceGirls: white race-890905508000_____________?Note that this differs from the SCH UTI guideline because the SCH lab does not report cutoffs of 50,000 and their cutoff of 10,000 is considered fairly equivalent.00_____________?Note that this differs from the SCH UTI guideline because the SCH lab does not report cutoffs of 50,000 and their cutoff of 10,000 is considered fairly equivalent.Discuss testing options with parents and consider feasibility of catheterization. Options:I.Obtain a catheterized UA and urine culture. II.If catheterization is not successful, not available or if parents prefer noninvasive testing: obtain bag specimen only to determine if negative. If negative, no further testing required. DO NOT SEND BAG SPECIMEN FOR CULTURE. If positive, attempt to obtain urinalysis and urine culture via catheterization. * Do not use a positive UA obtained by bag urine as evidence of a UTI; confirmation requires positive UA and culture of a specimen collected through catheterization.Toilet-trained children and adolescentsTesting indicated if patient has abdominal pain, back pain, dysuria, frequency, new-onset incontinence, fever > 40° (particularly if no source).Obtain a urinalysis and urine culture from midstream clean catch. Definitive diagnosis requires that both suggest infection.Sexually active adolescents and pre-adolescents: also obtain ‘dirty’ urine for GC/CT testing and offer an external GU exam and/or a self-obtained vaginal swab.‘Dirty urine’: Do not apply alcohol wipe to external genitalia. Collect the first part 15-20 mL of the urine stream.Vaginal swab: insert swab into vagina about 2.5 inches in or as far as comfortable. Rotate for 15 to 30 seconds, then remove.DispositionOutpatient management recommended if:Tolerating poInfants 31-60 days of age who are afebrile and well-appearing Well-appearing non-toilet trained children, toilet-trained children, and adolescents Indications for hospitalization:Less than 30 days of age with presumed or definite UTI. (If febrile and age 0-60 days also refer to SCH neonatal fever pathway.)31-60 days of age if febrile with presumed or definite UTIModerately or severely ill-appearing (e.g., febrile and not tolerating po). Concerns for the family’s ability to adhere to recommended therapy, return for appropriate follow up, or seek/access emergency care (Exception: In adolescents with cystitis, adherence risk is not an admission criteria.)-19050127635*Definitive diagnosis of UTI in non-toilet trained children requires a positive urine culture obtained by catheterization. However, in situations where this is not possible and UTI treatment is started empirically, consider appropriate follow-up imaging. 020000*Definitive diagnosis of UTI in non-toilet trained children requires a positive urine culture obtained by catheterization. However, in situations where this is not possible and UTI treatment is started empirically, consider appropriate follow-up imaging. Outpatient Management31-60 days of age: IM ceftriaxone (75mg/kg/day once daily; maximum dose 2 g) until culture and sensitivities available Follow-up within 24 hoursTreatment duration is 14 days.Infants and Non-toilet trained children > 60 days of age: Start empiric therapy when there is clinical suspicion of UTI, regardless of urinalysis results.Cephalexin (50 mg/kg/day orally divided 2-4 times/day; max dose 4 g/day) or cefuroxime (10 mg/kg/dose 2 times/day).In children who are penicillin-allergic, consider TMP-SMX.May consider daily IM ceftriaxone (75mg/kg/day; maximum dose 2 g) initially.Treat with full course of antibiotics for definite UTI only (positive UA and > 50,000 CFUs / mL for cultured catheterized specimen or 100,000 CFUs / mL for cultured clean catch specimen).Treatment duration is 7-14 days.Toilet-trained children and adolescents: Start empiric therapy when there are clinical findings in addition to a positive urinalysis / microscopy.Cephalexin (50 mg/kg/day orally divided 2-4 times/day; max dose 4 g/day) or cefuroxime (10 mg/kg/dose 2 times/day).In children who are cephalosporin-allergic, consider TMP-SMX 8-10mg/kg divided 2 times/day, maximum 160mg of TMP.Treat with full course of antibiotics for definite UTI only (positive UA and > 100,000 CFUs / mL for cultured clean catch specimen).Treatment duration is 3 days in afebrile patients and 7-14 days in febrile patients (pyelonephritis).All age groups: Target antibiotic therapy to sensitivities once available.All age groups: Consider probiotics for antibiotic-associated diarrheaImaging and prophylaxisInfants 0-60 days of age and non-toilet trained children Obtain renal bladder ultrasound (RBUS) during or soon after treatment to assess renal anatomy and evaluate for hydronephrosis. Can skip if high quality (detailed anatomic survey with measurements) third trimester U/S is normal. Obtain a voiding cystourethrogram (VCUG) if:Atypical* UTIRBUS shows evidence of high-grade VUR or obstructive uropathy such as hydronephrosis, renal parenchymal loss, or kidney size discrepancy.Prophylaxis is recommended prior to VCUGInfants < 2 months: amoxicillin (20 mg/kg once daily; maximum dose 500 mg)Infants and children > 2 months: TMP-SMX (2 mg/kg of TMP once daily; maximum dose 80 mg) or nitrofurantoin (1mg/kg once daily; maximum dose 100 mg)Obtain a DMSA Scan in 12 months if:< 6 months of age with atypical* UTIRBUS shows evidence for renal parenchymal loss or kidney size discrepanciesToilet-trained children and adolescentsObtain a renal bladder ultrasound (RBUS) after treatment if:Male with first UTIFemale with atypical* UTIObtain a voiding cystourethrogram (VCUG) if:Atypical* UTIRBUS shows evidence of high-grade VUR or obstructive uropathy such as hydronephrosis, renal parenchymal loss, or kidney size discrepancy.Prophylaxis is recommended prior to VCUG: TMP-SMX (2 mg/kg of TMP once daily; maximum dose 80 mg) or nitrofurantoin (1mg/kg once daily; maximum dose 100 mg).Obtain a DMSA Scan in 12 months if RBUS shows evidence for renal parenchymal loss or kidney size discrepancies.Antibiotic ProphylaxisOngoing antibiotic prophylaxis is not recommended for patients with first febrile urinary tract infection.Antibiotic prophylaxis is not recommended for grade I-III vesicoureteral reflux.ReassessmentExpect clinical improvement within 48 hours of starting antibiotics.Expect resolution of fever within 72 hours of starting antibiotics.Reassess all infants between 31-60 days of age being treated for presumed or definite UTI as an outpatient within 24 hours.Other ConsiderationsIf a febrile infant < 60 days of age or non-toilet-trained child requires antibiotics because of ill appearance or other pressing reason, obtain urinalysis and urine culture by catheterized specimen prior to antibiotic administration.Consider asymptomatic bacteriuria in absence of pyuria, particularly in school-aged and older girls. Asymptomatic bacteriuria normally resolves spontaneously, and therefore does not require treatment with antibiotics.Address dysfunctional elimination.In adolescents with suspected UTI consider culturing visible lesions for HSV, rapid plasma reagin if GC/Chl positive, annual HIV testing, pregnancy testing-55245-1905*Atypical versus Typical UTIAn atypical UTI is defined as a UTI with one of the following properties: ? Seriously ill ? Poor urine flow ? Abdominal or bladder mass ? Elevated creatinine (eGFR < 80 ml / min / 1.73 m2) ? Septicemia ? Failure to respond to treatment with suitable antibiotics within 48 hours ? Infection caused by organism other than Escherichia coli A typical UTI is defined as a UTI without any of these conditions. 00*Atypical versus Typical UTIAn atypical UTI is defined as a UTI with one of the following properties: ? Seriously ill ? Poor urine flow ? Abdominal or bladder mass ? Elevated creatinine (eGFR < 80 ml / min / 1.73 m2) ? Septicemia ? Failure to respond to treatment with suitable antibiotics within 48 hours ? Infection caused by organism other than Escherichia coli A typical UTI is defined as a UTI without any of these conditions. ................
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