Urinary Tract Infection

Objectives:

1. Be able to identify the history and clinical findings that are concerning for a febrile urinary tract infection in children.
2. Be able to risk stratify patients as high or low risk with a febrile UTI.
3. Know the common bacteria that cause urinary tract infections in children and the appropriate antibiotic management.
4. Be able to identify when imaging or further work up is required following a febrile UTI in a child.

Articles:

• Peds in Review 2018 Urinary Tract Infections in Children
• AAP CPG: Urinary Tract Infection: Clinical Practice Guideline for the Diagnosis and Management of the Initial UTI in Febrile Infants and Children 2 to 24 Months. 2011
• Bitsori M, Galanakis E. “Treatment of Urinary Tract Infections Caused by ESBL-Producing Escheiria coli or Klebsiella pneumoniae”. The Pediatric Infectious Disease Journal. December 2019.
• Kantamlee W et al. “Outcomes of Empirical Antimicrobial Therapy for Pediatric Community-onset Febrile Urinary Tract Infection in the Era of Increasing Antimicrobial Resistance”. The Pediatric Infectious Disease Journal. February 2020.
• Foundational Paper: RIVUR trial- Randomized clinical trial that looked at children with vesicoureteral reflux and determined it beneficial for them to be on prophylactic antibiotics (TMP/SMX) to reduce febrile UTI recurrence.

Additional Resources:

• Helpful OpenPediatrics video describing diagnosis and management of UTI in children
• Another nice OpenPediatrics on how to insert a urinary catheter 
• UTI calculator: Calculates probability of child having a UTI in children 2 to 23 months old
• CHOP Clinical Pathways UTI algorithm
• Texas Children's Hospital First Febrile UTI Guideline
• Check out the PHM from Pittsburgh podcast episode about UTIs

Self-Assessment: 

1. An 18-month-old girl is brought to the emergency department because of a 2-day history of fever and vomiting. She has a fever (40.1°C) and is mildly dehydrated. Results of a spot urine test strip analysis are shown:

• Laboratory Test              Result
• pH                                  7.0
• Specific gravity               1.030
• Leukocyte esterase          3+
• Nitrites                            2+
• Blood, protein                 Negative

You suspect a urinary tract infection as the cause of the patient’s symptoms. Of the following, the MOST appropriate statement regarding the diagnosis and treatment of this patient is

1. All urinary tract infections must be treated with parenteral antibiotics
2. Bag urine specimens are not valid for the diagnosis of urinary tract infection
3. Minimum duration of treatment for urinary tract infection is 3 days
4. Positive results on either urinalysis or urine culture can establish urinary tract infection diagnosis
5. Renal ultrasonography should not be performed routinely after the first febrile urinary tract infection

2. A 15-year-old adolescent girl goes to the emergency department with her mother for evaluation of red-colored urine and a 1-day history of fever. She also reports increased frequency, pain, and a burning sensation on micturition since this morning. She has no prior history of urinary tract infections, red urine, or flank pain. She reports that she is not sexually active. Her urinalysis shows a bright red urine specimen with blood clots. She has a temperature of 38.9°C, respiratory rate of 16 breaths/min, heart rate of 90 beats/min, and blood pressure of 110/74 mm Hg. Her physical examination findings are significant only for mild suprapubic tenderness. Results of a urine test strip analysis are shown:

• Laboratory Data        Result
•  Specific gravity         1.025
•  pH                           6.0
•  Blood                       3+
•  Leukocyte esterase    3+
•  Nitrite                      Positive
•  Protein                     Negative

Of the following, the MOST likely risk factor predisposing to this adolescent’s symptoms is

1. congenital renal anomaly
2. renal stones
3. sexual activity
4. vesicoureteral reflux
5. voiding dysfunction

3. A 10-month-old female infant is seen for follow up 2 weeks after a hospital admission for a febrile Escherichia coli urinary tract infection. Ultrasonography had shown left-sided moderate hydronephrosis without ureteral dilatation and a normal right kidney. She completed a 10-day course of cefixime. A voiding cystourethrogram performed after discharge had normal findings.

Of the following, the MOST likely cause of hydronephrosis in this infant is

1. Extrarenal pelvis
2. Ureterocele
3. Uretopelvic junction obstruction
4. Uretovesical junction obstruction

4. An 18-hour-old male newborn has not voided since birth. He was delivered at 38 weeks’ gestation to a 25-year-old primigravida mother via cesarean delivery. Prenatal records indicate that she had oligohydramnios. The neonate’s vital signs are stable. He has suprapubic swelling. The remainder of the physical examination findings are unremarkable. Renal ultrasonography shows bilateral hydronephrosis with ureteronephrosis and a distended urinary bladder.

Of the following, the MOST likely diagnosis in this neonate is

1. Duplex collecting system
2. Multicystic dysplastic kidney
3. Posterior urethral valves
4. Ureteropelvic junction obstruction

Find the answers here.