Work-up of Pediatric Urinary Tract Infection

ACR Appropriateness Criteria® Urinary Tract Infection-Child: 2023 Update

Urinary tract infection (UTI) is a frequent infection in childhood. The diagnosis is usually made by history and physical examination and confirmed by urine analysis. Cystitis is infection or inflammation confined to the bladder, whereas pyelonephritis is infection or inflammation of kidneys. Pyelonephritis can cause renal scarring, which is the most severe long-term sequela of UTI and can lead to accelerated nephrosclerosis, leading to hypertension and chronic renal failure. The role of imaging is to guide treatment by identifying patients who are at high risk to develop recurrent UTIs or renal scarring. This document provides initial imaging guidelines for children presenting with first febrile UTI with appropriate response to medical management, atypical or recurrent febrile UTI, and follow-up imaging for children with established vesicoureteral reflux. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Evidence-based clinical practice guideline for management of urinary tract infection and primary vesicoureteric reflux

We present updated, evidence-based clinical practice guidelines from the Indian Society of Pediatric Nephrology (ISPN) for the management of urinary tract infection (UTI) and primary vesicoureteric reflux (VUR) in children. These guidelines conform to international standards; Institute of Medicine and AGREE checklists were used to ensure transparency, rigor, and thoroughness in the guideline development. In view of the robust methodology, these guidelines are applicable globally for the management of UTI and VUR. Seventeen recommendations and 18 clinical practice points have been formulated. Some of the key recommendations and practice points are as follows. Urine culture with > 104 colony forming units/mL is considered significant for the diagnosis of UTI in an infant if the clinical suspicion is strong. Urine leukocyte esterase and nitrite can be used as an alternative screening test to urine microscopy in a child with suspected UTI. Acute pyelonephritis can be treated with oral antibiotics in a non-toxic infant for 7-10 days. An acute-phase DMSA scan is not recommended in the evaluation of UTI. Micturating cystourethrography (MCU) is indicated in children with recurrent UTI, abnormal kidney ultrasound, and in patients below 2 years of age with non-E. coli UTI. Dimercaptosuccinic acid scan (DMSA scan) is indicated only in children with recurrent UTI and high-grade (3-5) VUR. Antibiotic prophylaxis is not indicated in children with a normal urinary tract after UTI. Prophylaxis is recommended to prevent UTI in children with bladder bowel dysfunction (BBD) and those with high-grade VUR. In children with VUR, prophylaxis should be stopped if the child is toilet trained, free of BBD, and has not had a UTI in the last 1 year. Surgical intervention in high-grade VUR can be considered for parental preference over antibiotic prophylaxis or in children developing recurrent breakthrough febrile UTIs on antibiotic prophylaxis.

Incidence of Pediatric Urinary Tract Infections Before and During the COVID-19 Pandemic

IMPORTANCE

Urinary tract infection (UTI) is common in children, but the population incidence is largely unknown. Controversy surrounds the optimal diagnostic criteria and how to balance the risks of undertreatment and overtreatment. Changes in health care use during the COVID-19 pandemic created a natural experiment to examine health care use and UTI diagnosis and outcomes.

OBJECTIVES

To examine the population incidence of UTI in children and assess the changes of the COVID-19 pandemic regarding UTI diagnoses and measures of UTI severity.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective observational cohort study used US commercial claims data from privately insured patients aged 0 to 17 years from January 1, 2016, to December 31, 2021.

EXPOSURE

Time periods included prepandemic (January 1, 2016, to February 29, 2020), early pandemic (April 1 to June 30, 2020), and midpandemic (July 1, 2020, to December 31, 2021).

MAIN OUTCOMES AND MEASURES

The primary outcome was the incidence of UTI, defined as having a UTI diagnosis code with an accompanying antibiotic prescription. Balancing measures included measures of UTI severity, including hospitalizations and intensive care unit admissions. Trends were evaluated using an interrupted time-series analysis.

RESULTS

The cohort included 13 221 117 enrollees aged 0 to 17 years, with males representing 6 744 250 (51.0%) of the population. The mean incidence of UTI diagnoses was 1.300 (95% CI, 1.296-1.304) UTIs per 100 patient-years. The UTI incidence was 0.86 per 100 patient-years at age 0 to 1 year, 1.58 per 100 patient-years at 2 to 5 years, 1.24 per 100 patient-years at 6 to 11 years, and 1.37 per 100 patient-years at 12 to 17 years, and was higher in females vs males (2.48 [95% CI, 2.46-2.50] vs 0.180 [95% CI, 0.178-0.182] per 100 patient-years). Compared with prepandemic trends, UTIs decreased in the early pandemic: -33.1% (95% CI, -39.4% to -26.1%) for all children and -52.1% (95% CI, -62.1% to -39.5%) in a subgroup of infants aged 60 days or younger. However, all measures of UTI severity decreased or were not significantly different. The UTI incidence returned to near prepandemic rates (-4.3%; 95% CI, -32.0% to 34.6% for all children) after the first 3 months of the pandemic.

CONCLUSIONS AND RELEVANCE

In this cohort study, UTI diagnosis decreased during the early pandemic period without an increase in measures of disease severity, suggesting that reduced overdiagnosis and/or reduced misdiagnosis may be an explanatory factor.

Urinary tract infection in children: A narrative review of clinical practice guidelines

Background

Urinary tract infection (UTI) has been a major burden on the community and the health-care systems all over the globe. It is the most common cause of bacterial infection in the pediatric age group, with an annual incidence of 3%. The aim of this study is to review and summarize all available guidelines on the diagnosis and management of children with UTI.

Materials and Methods

This is a narrative review of the management of children with a UTI. All biomedical databases were searched, and any guidelines published from 2000 to 2022 were retrieved, reviewed, and evaluated to be included in the summary statements. The sections of the articles were formulated according to the availability of information in the included guidelines.

Results

UTI diagnoses are based on positive urine culture from a specimen of urine obtained through catheterization or suprapubic aspiration, and diagnoses cannot be established on the bases of urine collected from a bag. The criteria for diagnosing UTI are based on the presence of at least 50,000 colony-forming units per milliliter of a uropathogen. Upon confirmation of UTI, the clinician should instruct parents to seek rapid medical assessment (ideally within 48 h) of future febrile disease to ensure that frequent infections can be detected and treated immediately. The choice of therapy depends on several factors, including the age of the child, underlying medical problems, the severity of the disease, the ability to tolerate oral medications, and most importantly local patterns of uropathogens resistance. Initial antibiotic choice of treatment should be according to the sensitivity results or known pathogens patterns with comparable efficacy of oral and parenteral route, for 7 days to 14 days duration. Renal and bladder ultrasonography is the investigation of choice for febrile UTI, and voiding cystourethrography should not be performed routinely unless indicated.

Conclusion

This review summarizes all the recommendations related to UTIs in the pediatric population. Due to the lack of appropriate data, further high-quality studies are required to improve the level and strength of recommendations in the future.

Epidemiology and Risk Factors of UTIs in Children-A Single-Center Observation

Urinary tract infections (UTIs) are one of childhood’s most common bacterial infections. The study aimed to determine the clinical symptoms, laboratory tests, risk factors, and etiology of different UTIs in children admitted to pediatric hospitals for three years. Methods: Patients with positive urine cultures diagnosed with acute pyelonephritis (APN) or cystitis (CYS) were analyzed for clinical symptoms, laboratory tests, risk factors, and etiology, depending on their age and sex. Results: We studied 948 children with UTIs (531 girls and 417 boys), with a median age of 12 (IQR 5−48 months). A total of 789 children had clinical symptoms; the main symptom was fever (63.4% of patients). Specific symptoms of UTIs were presented only in 16.3% of patients. Children with APN had shown significantly more frequent loss of appetite, vomiting, lethargy, seizures, and less frequent dysuria and haematuria than children with CYS. We found significantly higher median WBC, CRP, and leukocyturia in children with APN than with CYS. The risk factors of UTIs were presented in 46.6% of patients, of which 35.6% were children with APN and 61.7% with CYS. The main risk factor was CAKUT, more frequently diagnosed in children with CYS than APN, mainly in children <2 years. The most commonly isolated bacteria were Escherichia coli (74%). There was a higher percentage of urine samples with E. coli in girls than in boys. Other bacteria found were Klebsiella species, Pseudomonas aeruginosa, Proteus mirabilis, and Enterococcus species. Conclusions: Patients with APN were younger and had higher inflammatory markers. Often, fever is the only symptom of UTI in children, and other clinical signs are usually non-specific. The most common UTI etiology is E. coli, regardless of the clinical presentation and risk factors.

Chronic diseases and health conditions in adolescents: Sex inequalities

OBJECTIVE

To estimate the prevalence of chronic diseases and health conditions in adolescents from Campinas (São Paulo), investigating sex differences according to age group.

METHODS

This population-based study analyzed data from the ISACamp 2014/15 health survey, with a total of 1,022 adolescents interviewed. The interviewees consisted of 517 boys and 505 girls; 492 of them in the ten to 14 age group and 530 in the 15 to 19 age group. We verified the associations using the χ2 test with Rao Scott adjustment and estimated prevalence ratios (PR) with multiple Poisson regression adjusted for age. Analyses were also stratified by age group.

RESULTS

Respiratory diseases, such as rhinitis (25.3%), sinusitis (15.7%), and asthma (10.9%), were the most prevalent among adolescents. Health complaints were high, especially headaches (39.5%), emotional conditions (34.5%), allergies (27.5%), and back pain (21.3%). More than 22.0% of adolescents reported having three or more health conditions. Girls declared a higher number of health conditions (three or more) than boys (PR=2.27).

CONCLUSION

The study showed that adolescents presented a significant number of health conditions, particularly regarding complaints, indicating the need for clinical care and public policies aimed at controlling and preventing these diseases in this age group.

Chronic diseases and health conditions in adolescents: Sex inequalities

ABSTRACT Objective: To estimate the prevalence of chronic diseases and health conditions in adolescents from Campinas (São Paulo), investigating sex differences according to age group. Methods: This population-based study analyzed data from the ISACamp 2014/15 health survey, with a total of 1,022 adolescents interviewed. The interviewees consisted of 517 boys and 505 girls; 492 of them in the ten to 14 age group and 530 in the 15 to 19 age group. We verified the associations using the χ2 test with Rao Scott adjustment and estimated prevalence ratios (PR) with multiple Poisson regression adjusted for age. Analyses were also stratified by age group. Results: Respiratory diseases, such as rhinitis (25.3%), sinusitis (15.7%), and asthma (10.9%), were the most prevalent among adolescents. Health complaints were high, especially headaches (39.5%), emotional conditions (34.5%), allergies (27.5%), and back pain (21.3%). More than 22.0% of adolescents reported having three or more health conditions. Girls declared a higher number of health conditions (three or more) than boys (PR=2.27). Conclusion: The study showed that adolescents presented a significant number of health conditions, particularly regarding complaints, indicating the need for clinical care and public policies aimed at controlling and preventing these diseases in this age group.

Molecular Characterization of Extended Spectrum β-Lactamase (ESBL) and Virulence Gene-Factors in Uropathogenic Escherichia coli (UPEC) in Children in Duhok City, Kurdistan Region, Iraq

Background: The presence of extended-spectrum β-lactamase (ESBL)-producing bacteria among uropathogens is significantly increasing in children all over the world. Thus, this research was conducted to investigate the prevalence of E. coli and their antimicrobial susceptibility pattern, and both genes of ESBL-producing E. coli resistant and virulence factor in UTIs patients among children in Duhok Province, Kurdistan, Iraq. Method: a total of 67 E. coli were identified from 260 urine samples of pediatric patients diagnosed with UTIs aged (0−15 years) which were collected from Heevi Pediatric Teaching Hospital, from August 2021 to the end of February 2022. Result: a high proportion of UPEC infections at ages <5 years and the rates among girls (88%) were significantly higher than those among the boys. A wide variety of E. coli are resistant to most antibiotics, such as Amoxicillin, Ampicillin and Tetracycline, and 64% of them were positive for ESBL. Interestingly, the presence of both the ESBL marker genes (blaTEM, and blaCTX-M) as well as both virulence marker genes (pai and hly) were detected in above 90% of E. coli. Conclusion: the data illustrate an alarming increase in UPEC with ESBL production and the emergence of multidrug-resistant drugs in the early age of children. The public health sectors should further monitor the guidelines of using antibiotics in Kurdistan, Iraq.

Metabolic impact of infant formulas in young infants. An outlook from the urine metabolome

Introduction

Although breast milk is the ideal food source for newborns during the first six months of life, a high percentage of children receive infant formulas. There is evidence that specific diet habits may influence individual metabolic profile. Therefore, in newborns, such profile can be influenced by the use of infantile formulas given the composition differences that display compared to human milk. Up to now, there are no reports in the literature that address this issue.

Objectives

this work aims to compare the metabolic profile of full-term newborns that were feed with either breast milk (n = 32) or infantile formulas (n = 21). Methods: Metabolic profile was established based on urine analysis through gas chromatography-mass spectrometry (GC-MS) and nuclear magnetic resonance (H-NMR).

Results

our results evidenced a more gluconeogenic profile in breast-fed infants characterized by elevation of Kreb's cycle intermediaries like fumaric, succinic and ketoglutaric acids compared to infants receiving infant formula. In addition, infant formula fed infants presented urinary excretion of metabolites derived from specific compounds present in this type of diet that were not observed in breast-fed infants, for instance D-glucitol, and 4-deoxytetronic. Moreover, in infant formula fed infants there was excretion of basal levels of metabolites of clinical relevance like 3-hydroxy-3-methyl-glutaric, 2-methyl-3-keto-valeric and 3,4-dihydroxybutyric.

Conclusion

These results show the importance of understanding the metabolic impact of diet in newborn population in normal and pathological contexts.

Etiology and Antibiotic Susceptibility Patterns of Urinary Tract Infections in Children in a General Hospital in Kuwait: A 5-Year Retrospective Study

OBJECTIVE

The aim of this study was to determine the bacterial profile and prevalence of antibiotic resistance patterns of uropathogens, as well as to evaluate the problem with extended-spectrum β-lactamases (ESBLs)-producing isolates, causing urinary tract infections (UTIs) in children in Al-Amiri Hospital, Kuwait, over a 5-year period.

MATERIALS AND METHODS

Significant isolates from symptomatic pediatric patients with UTIs from January 2017 to December 2021 were identified by conventional methods and by the VITEK 2 identification card system. Antimicrobial susceptibility testing was performed by the disk diffusion method for Gram-positive organisms and an automated VITEK 2 system for Gram-negative organisms. ESBL-producing Enterobacterales were detected by the double-disk diffusion method and VITEK 2 system.

RESULTS

Significant bacteriuria was detected in 13.7% of the 9,742 urine samples. Escherichia coli accounted for 67.3% of these, followed by Klebsiella pneumoniae (8.9%), Proteus spp. (5.7%), and Enterococcus spp. (7.4%), respectively. High resistance rates were observed among the Enterobacterales against ampicillin, cephalothin, nitrofurantoin, amoxicillin/clavulanic acid, and trimethoprim-sulfamethoxazole. The prevalence of ESBL-producing E. coli and K. pneumoniae was 26% and 55%, respectively. The most sensitive among the antibiotics tested for Gram-negative organisms were meropenem, amikacin, gentamicin, and piperacillin/tazobactam, while the antibiotics tested for Gram-positive organisms were vancomycin, ampicillin, linezolid, and nitrofurantoin.

CONCLUSION

E. coli remains the most common uropathogen. A high percentage of uropathogens causing UTI in children were highly resistant to the first- and second-line antibiotics for the therapy of UTI. ESBL-producing bacteria were highly prevalent in children in our hospital. Local antibiograms should be used to assist with empirical UTI treatment.

Antibiotic Utilization and Efficacy Associated With Treating Pediatric Urinary Tract Infections in Texas Medicaid Patients in the First Year of Life

BACKGROUND

Historically, amoxicillin (Amoxil) has been used as a first-line agent to treat pediatric urinary tract infections (UTIs). However, emerging antibiotic resistance in urinary pathogens has led to broader treatment options, such as cefdinir (Omnicef). This shift in prescribing practices is predicted to vary among place of service and gender due to differing institutional protocols and antimicrobial stewardship practices.

OBJECTIVE

This study aimed to describe the antibiotic utilization patterns associated with treating pediatric UTIs in Texas Medicaid patients and to assess the real-world efficacy of the antibiotics that were prescribed.

METHODS

Texas Medicaid prescription and medical claims data for patients under 1 year of age were included in the analysis if they presented with a UTI to the healthcare practitioner’s office or the emergency department (ED) and were treated with an outpatient antibiotic. Treatment efficacy was assessed by whether a patient received a second (different) antibiotic within 7 days of their initial antibiotic fill.

RESULTS

A total of 12,795 visits met inclusion criteria; 12,561 visits included prescriptions for the top 4 antibiotics prescribed: cefdinir (50%), amoxicillin (25%), cephalexin (Keflex; 13%), and amoxicillin-clavulanate (Augmentin; 12%). Cefdinir utilization predominated in both places of service [office (50%) and ED (55%)], and gender [males (47%) and females (52%)]. Controlling for gender and place of service, initial treatment with amoxicillin when compared with cefdinir (OR = 2.54; 95% confidence intervals: 1.84–3.54; P < 0.001) was associated with a greater rate of treatment failure.

CONCLUSIONS

In this study of Texas Medicaid patients, the widespread utilization of cefdinir may be appropriate for the empiric treatment of uncomplicated UTIs because of its low rate of treatment failure compared to other commonly used antibiotics.

[Urinary tract infections in a pediatric setting: Bacterial ecology and antibiotic susceptibility at the Pediatric Teaching Hospital Charles-de-Gaulle in Ouagadougou (Burkina Faso)]

INTRODUCTION

Urinary tract infection is the second most common bacterial infection in children, after respiratory tract infection. The objective of this work was to study the bacterial ecology and antibiotic susceptibility of germs isolated during childhood urinary tract infections at the Paediatric University Hospital Charles-de-Gaulle in Ouagadougou.

PATIENTS AND METHOD

This was a descriptive retrospective study covering the period from July 1^st, 2010 to June 30, 2015, including 141 children from 0 to 15 years old hospitalized in the medical paediatrics department for a urinary tract infection.

RESULTS

The hospital frequency of urinary tract infection was 0.7%. The mean age of the patients was 43.1 months. Female patients accounted for 57.4%, a sex-ratio of 0.7. Gram-negative bacilli were often involved (67.4%) with Escherichia Coli and Klebsiella in 35.5% and 22% of cases respectively. The main Gram-positive bacteria were staphylococci (15.5%), enterococci (11.3%) and streptococci (5.6%). Enterobacteriaceae isolated were sensitive to netilmicin (80%), chloramphenicol (76.4%), and furan (82.6%). All strains of staphylococcus were susceptible to furan, gentamicin, chloramphenicol and cefixime. In 66.7% of cases, the isolated strains of staphylococcus were resistant to amoxicillin.

CONCLUSION

Urinary tract infection is a common problem in pediatrics. Its management must be early and adequate based on knowledge of the bacterial ecology in order to reduce the risk of long-term renal complications.

Serum Vitamin D Level and the Risk of Urinary Tract Infection in Children: A Systematic Review and Meta-Analysis

This systematic review and meta-analysis aimed to evaluate the association between serum vitamin D concentration and the risk of urinary tract infection (UTI) in children. Human studies reported the serum vitamin D level in children with UTI and healthy controls were collected from PubMed, Scopus, Embase, and Cochrane databases. The strictly standardized mean difference (SSMD) and 95% confidence interval (CI) were calculated to evaluate the relationship between serum vitamin D levels and risk of UTI. The results of analysis showed that serum vitamin D levels in children with UTI were significantly lower than healthy control children (SSMD: 0.891, 95% CI: 0.707–1.075, p < 0.000; SSMD: 0.797, 95% CI: 0.500–1.094, p < 0.000, respectively). It can be concluded that there is a significant negative relationship between serum vitamin D level and risk of UTI in children.

Predicting Urinary Tract Infections With Interval Likelihood Ratios

BACKGROUND

Protocols for diagnosing urinary tract infection (UTI) often use arbitrary cutoff values of urinalysis components to guide management. Interval likelihood ratios (ILRs) of urinalysis results may improve the test's precision in predicting UTIs. We calculated the ILR of urinalysis components to estimate the posttest probabilities of UTIs in young children.

METHODS

Review of 2144 visits to the pediatric emergency department of an urban academic hospital from December 2011 to December 2019. Inclusion criteria were age <2 years and having a urinalysis and urine culture sent. ILR boundaries for hemoglobin, protein, and leukocyte esterase were "negative," "trace," "1+," "2+" and "3+." Nitrite was positive or negative. Red blood cells and white blood cells (WBCs) were 0 to 5, 5 to 10, 10 to 20, 20 to 50, 50 to 100, and 100 to 250. Bacteria counts ranged from negative to "loaded." ILRs for each component were calculated and posttest probabilities for UTI were estimated.

RESULTS

The UTI prevalence was 9.2%, with the most common pathogen being Escherichia coli (75.2%). The ILR for leukocyte esterase ranged from 0.20 (negative) to 37.68 (3+) and WBCs ranged from 0.24 (0-5 WBCs) to 47.50 (100-250 WBCs). The ILRs for nitrites were 0.76 (negative) and 25.35 (positive). The ILR for negative bacteria on urinalysis was 0.26 and 14.04 for many bacteria.

CONCLUSIONS

The probability of UTI in young children significantly increases with 3+ leukocyte esterase, positive nitrite results, 20 to 50 or higher WBCs, and/or many or greater bacteria on urinalysis. The probability of UTI only marginally increases with trace or 1+ leukocyte esterase or 5 to 20 WBCs. Our findings can be used to more accurately predict the probability of true UTI in children.

Under-utilization of Narrow-Spectrum Antibiotics in the Ambulatory Management of Pediatric UTI: A Single-Center Experience

Objective: There are urinary tract infection (UTI) guidelines for treatment of patients <2 years old, but there is a paucity of data for other pediatric age groups including the potential role for stewardship to reduce prescription of broad-spectrum antibiotics. We assessed practice patterns for the diagnosis and empiric treatment of UTI for outpatient and school health sites affiliated with a large urban pediatric medical center. We hypothesized that outpatient providers under-utilize narrow-spectrum antibiotics, such as first-generation cephalosporins, for uncomplicated UTI. Study Design: Retrospective study from December 1st, 2015 to May 31st, 2016. Results: The study population included 903 children (70.1% female) with a median age of 11 years, evaluated in an outpatient clinic (n = 780, 86.4%) or school health site (n = 123, 13.6%). E. coli was the most common urinary pathogen (50.9%) and 92.6% of E. coli isolates were susceptible to cephalexin. However, cephalexin was prescribed empirically for only 12.8% of patients. In contrast, sulfamethoxazole-trimethoprim was commonly prescribed, but only 79% of E. coli isolates were susceptible. Antibiotics were discontinued in only three of 48 children who had negative urine cultures. Conclusions: Cephalexin may be the most appropriate first-line choice for management of outpatient UTI for our patient population. Antibiotics were rarely discontinued for those with negative urine cultures. Antibiotic stewardship in the outpatient setting could reduce unnecessary antibiotic exposure in the management of pediatric UTI.

Impact of early-life weight status on urinary tract infections in children: a nationwide population-based study in Korea

OBJECTIVES

We aimed to evaluate the association between early-life weight status and urinary tract infection (UTI) risk in children.

METHODS

A nationwide study was conducted using Korean National Health Screening (NHS) data and National Health Insurance Service data. A sample cohort was selected using data from the 2014 and 2015 NHS for infants and children (4-71 months) and followed up until the end of 2017. Participants were divided into 4 groups (underweight, normal weight, overweight, and obese) based on the weight-for-age (< 2 years) or body mass index (≥ 2 years). Hazard ratios (HRs) with 95% confidence intervals (CIs) for developing UTIs, cystitis, and acute pyelonephritis (APN) were calculated using a Cox proportional hazard model.

RESULTS

Of 1,653,106 enrolled children, 120,142 (7.3%) developed UTIs, cystitis, and APN during follow-up. The underweight, overweight, and obese groups had higher risks of UTIs than the reference group after adjusting for age, sex, birth weight, and preterm birth. Between 2 years and 6 years of age, boys with underweight had a high risk of UTI and APN, while girls with overweight and obesity revealed elevated risks of UTIs, cystitis, and APN. The HRs for APN in boys with underweight and in girls with obesity were 1.46 (95% CI, 1.03 to 2.07) and 1.41 (95% CI, 1.13 to 1.75), respectively, after adjusting for age, sex, birth weight, and preterm birth. The incidence of APN did not decrease with age in underweight and obese children aged 2-6 years.

CONCLUSIONS

Children with underweight, overweight, and obesity may be at high risk for UTIs.

Is it necessary to evaluate urinary tract infection in children with lower respiratory tract infection?

AIM

Although the incidence of urinary tract infection (UTI) in children with lower respiratory tract infection (LRTI) has been reported as 3.1-10.0%, the exact concomitant prevalence is questionable. Here, we evaluated the prevalence and related risk factors of UTI associated with LRTI in children under 36 months of age.

METHODS

We retrospectively reviewed the medical charts of 1574 patients under 36 months of age who were hospitalised with LRTI from January 2017 to December 2019 in a single centre, Seoul, South Korea. Among them, we analysed 278 patients who showed fever and performed urine evaluation. Urine was collected by catheterisation in children under 24 months of age and by voided urine between 24 and 36 months of age.

RESULTS

The prevalence of concomitant UTI and LRTI was 13.6% in children under 24 months of age. Mean age was significantly younger in the UTI versus non-UTI group (6.93 ± 7.26 months vs. 12.61 ± 11.70 months; P < 0.001). When the participants were stratified by age, the prevalence of UTI was significantly higher in children younger than 24 months of age compared to older ones (P = 0.006). UTIs were more prevalent in boys than in girls (14.6% vs. 5.8%, P = 0.018). Peak body temperature, fever duration, premature birth and detected respiratory virus type did not differ between groups.

CONCLUSIONS

It is not uncommon for children with LRTI with fever to be accompanied by UTI. When evaluating for UTI in children with febrile LRTI, age and sex must be considered.

Urinary tract infection in pediatrics: an overview

OBJECTIVE

This review aimed to provide a critical overview on the pathogenesis, clinical findings, diagnosis, imaging investigation, treatment, chemoprophylaxis, and complications of urinary tract infection in pediatric patients.

SOURCE OF DATA

Data were obtained independently by two authors, who carried out a comprehensive and non-systematic search in public databases.

SUMMARY OF FINDINGS

Urinary tract infection is the most common bacterial infection in children. Urinary tract infection in pediatric patients can be the early clinical manifestation of congenital anomalies of the kidney and urinary tract (CAKUT) or be related to bladder dysfunctions. E. coli is responsible for 80-90% of community-acquired acute pyelonephritis episodes, especially in children. Bacterial virulence factors and the innate host immune systems may contribute to the occurrence and severity of urinary tract infection. The clinical presentation of urinary tract infections in children is highly heterogeneous, with symptoms that can be quite obscure. Urine culture is still the gold standard for diagnosing urinary tract infection and methods of urine collection in individual centers should be determined based on the accuracy of voided specimens. The debate on the ideal imaging protocol is still ongoing and there is tendency of less use of prophylaxis. Alternative measures and management of risk factors for recurrent urinary tract infection should be emphasized. However, in selected patients, prophylaxis can protect from recurrent urinary tract infection and long-term consequences. According to population-based studies, hypertension and chronic kidney disease are rarely associated with urinary tract infection.

CONCLUSION

Many aspects regarding urinary tract infection in children are still matters of debate, especially imaging investigation and indication of antibiotic prophylaxis. Further longitudinal studies are needed to establish tailored approach of urinary tract infection in childhood.

Updated Italian recommendations for the diagnosis, treatment and follow-up of the first febrile urinary tract infection in young children

AIM

Our aim was to update the recommendations for the diagnosis, treatment and follow-up of the first febrile urinary tract infection in young children, which were endorsed in 2012 by the Italian Society of Pediatric Nephrology.

METHODS

The Italian recommendations were revised on the basis of a review of the literature published from 2012 to October 2018. We also carried out an ad hoc evaluation of the risk factors to identify children with high-grade vesicoureteral reflux or renal scarring, which were published in the previous recommendations. When evidence was not available, the working group held extensive discussions, during various meetings and through email exchanges.

RESULTS

Four major modifications have been introduced. The method for collecting urine for culture and its interpretation has been re-evaluated. We have reformulated the algorithm that guides clinical decisions to proceed with voiding cystourethrography. The suggested antibiotics have been revised, and we have recommended further restrictions of the use of antibiotic prophylaxis.

CONCLUSION

These updated recommendations have now been endorsed by the Italian Society of Pediatric Nephrology and the Italian Society for Pediatric Infectivology. They can also be used to compare other recommendations that are available, as a worldwide consensus in this area is still lacking.

A case of Raoultella ornithinolytica urinary tract infection in a pediatric patient

Raoultella ornithinolytica is a Gram-negative, non-motile, encapsulated, biofilm producing, facultative aerobic bacillus and is found in natural environment. Human infections with R.ornithinolytica is rare in children with only five cases having been reported previously. The present case report describes an urinary tract infection caused by R. ornithinolytica that was identified by MALDI-TOF MS and successfully treated with antibiotic therapy in a 6.5-year-old female child.

Urinary Tract Infection in Children

BACKGROUND

Urinary Tract Infection (UTI) is a common infection in children. Prompt diagnosis and appropriate treatment are very important to reduce the morbidity associated with this condition.

OBJECTIVE

To provide an update on the evaluation, diagnosis, and treatment of urinary tract infection in children.

METHODS

A PubMed search was completed in clinical queries using the key terms "urinary tract infection", "pyelonephritis" OR "cystitis". The search strategy included meta-analyses, randomized controlled trials, clinical trials, observational studies, and reviews. The search was restricted to English literature and the pediatric age group. Patents were searched using the key terms "urinary tract infection" "pyelonephritis" OR "cystitis" from www.google.com/patents, http://espacenet.com, and www.freepatentsonline.com.

RESULTS

Escherichia coli accounts for 80 to 90% of UTI in children. The symptoms and signs are nonspecific throughout infancy. Unexplained fever is the most common symptom of UTI during the first two years of life. After the second year of life, symptoms and signs of pyelonephritis include fever, chills, rigor, flank pain, and costovertebral angle tenderness. Lower tract symptoms and signs include suprapubic pain, dysuria, urinary frequency, urgency, cloudy urine, malodorous urine, and suprapubic tenderness. A urinalysis and urine culture should be performed when UTI is suspected. In the work-up of children with UTI, physicians must judiciously utilize imaging studies to minimize exposure of children to radiation. While waiting for the culture results, prompt antibiotic therapy is indicated for symptomatic UTI based on clinical findings and positive urinalysis to eradicate the infection and improve clinical outcome. The choice of antibiotics should take into consideration local data on antibiotic resistance patterns. Recent patents related to the management of UTI are discussed.

CONCLUSION

Currently, a second or third generation cephalosporin and amoxicillin-clavulanate are drugs of choice in the treatment of acute uncomplicated UTI. Parenteral antibiotic therapy is recommended for infants ≤ 2 months and any child who is toxic-looking, hemodynamically unstable, immunocompromised, unable to tolerate oral medication, or not responding to oral medication. A combination of intravenous ampicillin and intravenous/intramuscular gentamycin or a third-generation cephalosporin can be used in those situations. Routine antimicrobial prophylaxis is rarely justified, but continuous antimicrobial prophylaxis should be considered for children with frequent febrile UTI.