Urinary tract infections in infants and children: Diagnosis and management

Pediatric Urinary Tract Infections

Urinary tract infection (UTI) is frequent in the first year of life with bowel and bladder dysfunction, GU tract abnormalities, neurogenic bladder, and the intact prepuce conveying an increased risk. Urine culture is the gold standard for diagnosis. Antibiotics are tailored to resistance patterns. Guidelines have been established to direct the evaluation for GU anomalies but differ significantly. Bladder and bowel dysfunction is important to screen for and treat in potty-trained patients. Circumcised boys with febrile UTIs are more likely to have anatomic abnormalities than uncircumcised boys.

Characteristics of and cost of care for children with impaired development and acute appendicitis: A study of two national databases

BACKGROUND

Characteristics of children with impaired development who have acute appendicitis are not well described in the literature.

METHODS

We reviewed the National Surgical Quality Improvement Program-Pediatric and the multicenter Pediatric Health Information System for patients with acute appendicitis. Comparisons for demographics, clinical outcomes, and hospital charges between children with impaired development versus neurotypical children were made using independent t test or Wilcoxon rank sum tests. The multivariable logistic regression model estimated the odds of complicated acute appendicitis in impaired development patients. Based on correlation analyses, hierarchical linear modeling was used to examine the extent to which impaired development influenced resource use.

RESULTS

Patients with impaired development were younger, had higher comorbidities, and were more commonly male sex. In the National Surgical Quality Improvement Program-Pediatric database, impaired development was associated with higher rates of complicated acute appendicitis (33.6% vs 27.5, P < .001), particularly in older children, and higher usage of computed tomography at National Surgical Quality Improvement Program-Pediatric hospitals (23.1% vs 15.1%, P < .001). In the Pediatric Health Information System database, the adjusted odds of complicated acute appendicitis were significantly higher in patients with impaired development (1.20 [1.09-1.31]), low childhood opportunity level (1.39 [95% confidence interval: 1.31-1.47]), and Black race (1.25 [1.17-1.33]). Hierarchical adjusted linear modeling showed that impaired development was associated with significantly higher hospital charges (9% increase).

CONCLUSION

Management of acute appendicitis in children with impaired development remains a challenge to clinicians, as evidenced by the higher rate of perforated appendicitis in older children, diagnostic computed tomography use at National Surgical Quality Improvement Program-Pediatric hospitals, postoperative computed tomography use, and increased costs.

Incidence of febrile post-procedural urinary tract infection following voiding cystourethrography in children without prior urine culture

PURPOSE

Post-procedural urinary tract infections (ppUTIs) following voiding cystourethrography (VCUG) vary widely, with rates from 0 to 42%, though recent studies suggest rates typically below 5%. Verifying urine sterility before VCUG is traditionally done but questioned. This study assessed the 7-day ppUTI rate post-VCUG without prior urine sterility confirmation and identified associated risk factors.

METHODS

A retrospective review of VCUG cases in children under three years at a pediatric hospital over two years was conducted. Exclusions included neuropathic bladder, bladder exstrophy, pre-VCUG urine cultures, and lost-to-follow-up cases. Achieving a ppUTI rate below 5% would support safe VCUG practice without pre-urine culture.

RESULTS

Of 318 VCUGs performed on 300 children, 248 (78%) were males (8% circumcised) with a median age of 5 months. Retrograde VCUG was more common than suprapubic cystography (63% vs. 37%). Before the test, 33.6% received antibiotics, mostly prophylactically. Hydronephrosis was present in 66.4%, and 69% had a history of UTI. VCUG results were abnormal in 43% of cases: 85% had vesicoureteral reflux (VUR), 10% had posterior urethral valves (PUV), and 28% had other abnormalities. The 7-day ppUTI rate was 3.8%, with 67% of ppUTI cases having abnormal VCUG results versus 41% without ppUTI (p = 0.06). No significant risk factors for ppUTI were identified.

CONCLUSIONS

Omitting systematic urine culture before VCUG was not associated with a high ppUTI rate, even in children with pre-existing urologic conditions or a history of UTI, indicating that VCUG can be safely performed without prior urine sterility confirmation. No risk factors for ppUTI were identified.

Epidemiological trends of febrile infants presenting to the Paediatric Emergency department, in a tertiary care hospital, Karachi, Pakistan: a retrospective review

BACKGROUND

Understanding the epidemiological patterns of febrile infants can offer valuable insights for optimising management strategies and developing quality improvement initiatives, aiming to improve healthcare delivery in high-volume, low-resource emergency departments (EDs).

OBJECTIVES

To characterise the epidemiology of febrile infants presenting to the paediatric ED of a tertiary care hospital.

METHODS

A retrospective chart review of medical records was performed for febrile infants ≤1 year old, at paediatric ED, Indus Hospital and Health Network (IHHN), Karachi, Pakistan (1 January 2020-31 December 2020).

RESULTS

There were a total of 2311 patients in the study, with a male-to-female ratio of 1.4:1. The mean age of presentation was 4.9±2.7 months. Cough (n=1002, 43.2%) was the most frequent presenting symptom. The most common provisional ED diagnosis in ≤1 month of age was sepsis (n=98, 51%), bronchopneumonia (n=138, 28.6%) in 1.1-3 and 3.1-6 months (n=176, 36.45%); and upper respiratory tract illness (n=206, 47.4%) in 6.1-12 months of age. Age was significantly associated with provisional ED diagnosis and outcomes (p<0.001). Of 175 ED admissions (n=47, 26.8%), patients were discharged with a hospital diagnosis of bronchopneumonia and (n=27, 15.4) of sepsis. The infant mortality rate was 3/1000 live births.

CONCLUSIONS

This study is the first of its kind to explore the epidemiology of febrile infants in Pakistan, highlighting the burden and severity of respiratory illnesses and sepsis. It underscores the challenges of resource-limited settings, failing to meet the need for admission of febrile infants presenting to ED, IHHN. Moreover, it has highlighted the necessity to optimise the existing triage systems to effectively allocate resources and manage high patient volumes in low-resource EDs.

Decreasing Invasive Urinary Tract Infection Screening in a Pediatric Emergency Department to Improve Quality of Care

OBJECTIVES

Obtaining urine samples in younger children undergoing urinary tract infection (UTI) screening can be challenging in busy emergency departments (EDs), and sterile techniques, like catheterization, are invasive, traumatizing, and time consuming to complete. Noninvasive techniques have been shown to reduce catheterization rates but are variably implemented. Our aim was to implement a standardized urine bag UTI screening approach in febrile children aged 6 to 24 months to decrease the number of unnecessary catheterizations by 50% without impacting ED length of stay (LOS) or return visits (RVs).

METHODS

After forming an interprofessional study team and engaging key stakeholders, a multipronged intervention strategy was developed using the Model for Improvement. A urine bag screening pathway was created and implemented using Plan, Do, Study Act (PDSA) cycles for children aged 6 to 24 months being evaluated for UTIs. A urine bag sample with point-of-care (POC) urinalysis (UA) was integrated as a screening approach. The outcome measure was the rate of ED urine catheterizations, and balancing measures included ED LOS and RVs. Statistical process control methods were used for analysis.

RESULTS

During the 3-year study period from January 2019 to June 2022, the ED catheterization rate successfully decreased from a baseline of 73.3% to 37.7% and was sustained for approximately 2 years. Unnecessary urine cultures requiring microbiology processing decreased from 79.8% to 40.7%. The ED LOS initially decreased; however, it increased by 17 minutes during the last 8 months of the study. There was no change in RVs.

CONCLUSION

A urine bag screening pathway was successfully implemented to decrease unnecessary, invasive catheterizations for UTI screening in children with only a slight increase in ED LOS. In addition to the urine bag pathway, an ED nursing champion, strategic alignment, and broad provider engagement were all instrumental in the initiative's success.

Diagnostic Accuracy of Ureteric Jet Angle Measurement Using Color Doppler Ultrasonography in Children with Vesico-Ureteric Reflux: A Systematic Review

This systematic review evaluated accuracy of ureteric jet angles on color Doppler sonography in diagnosing vesico-ureteric reflux (VUR) in children, using voiding cystourethrogram as the reference standard. Six databases were searched, yielding 13 eligible studies of an initial 429, 7 with comparable data. Risk of bias and applicability were assessed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. Most studies demonstrated a correlation between increasing jet angle and VUR severity, but reporting and techniques varied, preventing meta-analysis. Ureteric jet angle sonography may have potential as a VUR triaging tool. Further investigations with rigorous methodology are required. Funding support was obtained from Queensland University of Technology. PROSPERO Registration CRD42020159799.

Urinary Tract Infections among Febrile Infants in Qatar: Extended-Spectrum-Beta-Lactamase (ESBL)-Producing Versus Non-ESBL Organisms

BACKGROUND

The escalating prevalence of ESBL-producing Enterobacteriaceae in Qatar's pediatric population, especially in community-onset febrile urinary tract infections (FUTIs), necessitates a comprehensive investigation into this concerning trend.

RESULTS

Over the course of one year, a total of 459 infants were diagnosed and subsequently treated for UTIs. Cases primarily occurred in infants aged over 60 days, predominantly non-Qatari females born from term pregnancies. Notably, E. coli and K. pneumoniae were the most frequently identified organisms, accounting for 79.7% and 9.8% in the ESBL group and 57.2% and 18.7% in the non-ESBL group, respectively. Interestingly, hydronephrosis emerged as the most prevalent urological anomaly detected in both ESBL (n = 10) and other organism (n = 19) groups.

METHODS

In this retrospective cohort study conducted in Qatar, we meticulously evaluated the prevalence of pediatric FUTIs. Our study focused on febrile infants aged less than 1 year, excluding those with urine samples not obtained through a catheter.

CONCLUSIONS

E. coli and K. pneumoniae prevailed as the predominant causative agents in febrile children in Qatar, with hydronephrosis being identified as the most common urological anomaly. Moreover, our findings suggested that gentamicin served as a viable non-carbapenem option for hospitalized ESBL cases, while oral nitrofurantoin showed considerable promise for uncomplicated ESBL UTIs.

Evaluating the requirement of ultrasonography for children with their first urinary tract infection

BACKGROUND

Management of urinary tract infection (UTI) in children remains important. It may be the first sign for a possible underlying congenital abnormalities for the kidney and urinary tract (CAKUT). This study examined whether performing renal and bladder ultrasonography (RBUS) only for children who have a pathogen other than E. coli during their first urinary tract infection (UTI), or who experience UTI recurrence, would result in more missed diagnoses of kidney anomalies.

METHODS

Patients aged between 2 months and 2 years who were seen in a tertiary pediatric hospital during a 2-year period and diagnosed with UTI were included. RBUS and voiding cystourethrography (VCUG) were performed according to American Academy of Pediatrics (AAP) guidelines. Afterwards, we looked back and evaluated how often we found kidney problems when we only did a RBUS on patients who had an atypical cause of their first UTI or who had multiple UTIs.

RESULTS

One hundred and seventy-eight patients who were followed up with UTI were included in this study. The isolated pathogen was E. coli in 104 cases (58.4 %) and atypical in 74 cases (41.6 %). VCUG was conducted on 40 patients, and vesicoureteral reflux (VUR) was discovered in 16 cases and ureteropelvic junction obstruction (UPJO) was discovered in 1 case. A different diagnostic approach that required the presence of an atypical pathogen at the first UTI or a fUTI recurrence to perform the RBUS would have missed just two severe kidney anomalies. It was observed that there could be a decrease of 40.4 % in RBUS and at least 20 % in VCUG.

CONCLUSIONS

A diagnostic approach that necessitates the presence of an abnormal pathogen during the initial UTI or a second UTI episode for the RBUS to be carried out would lead to fewer negative ultrasounds with minimal risk of overlooking kidney anomalies.

Piperacillin-Tazobactam versus Cefotaxime as Empiric Treatment for Febrile Urinary Tract Infection in Hospitalized Children

BACKGROUND

According to international pediatric urinary tract infection (UTI) guidelines, selecting ampicillin/sulbactam or amoxicillin/clavulanate is recommended as the first-line treatment for pediatric UTI. In Korea, elevated resistance to ampicillin and ampicillin/sulbactam has resulted in the widespread use of third-generation cephalosporins for treating pediatric UTIs. This study aims to compare the efficacy of piperacillin-tazobactam (TZP) and cefotaxime (CTX) as first-line treatments in hospitalized children with UTIs.

MATERIALS AND METHODS

The study, conducted at Jeju National University Hospital, retrospectively analyzed medical records of children hospitalized for febrile UTIs between 2014 and 2017. UTI diagnosis included unexplained fever, abnormal urinalysis, and the presence of significant uropathogens. Treatment responses, recurrence, and antimicrobial susceptibility were assessed.

RESULTS

Out of 323 patients, 220 met the inclusion criteria. Demographics and clinical characteristics were similar between TZP and CTX groups. For children aged ≥3 months, no significant differences were found in treatment responses and recurrence. Extended-spectrum beta-lactamase (ESBL)-positive strains were associated with recurrence in those <3 months.

CONCLUSION

In Korea, escalating resistance to empirical antibiotics has led to the adoption of broad-spectrum empirical treatment. TZP emerged as a viable alternative to CTX for hospitalized children aged ≥3 months with UTIs. Consideration of ESBL-positive strains and individualized approaches for those <3 months are crucial.

Urinary tract infections in very premature neonates: the definition dilemma

BACKGROUND AND OBJECTIVES

Data on urinary tract infections (UTIs) in very preterm neonates (VPTNs) are scarce. We aimed to (i) describe the characteristics of UTIs in VPTNs and (ii) compare the diagnostic practices of neonatal clinicians to established pediatric guidelines.

METHODS

All VPTNs (<29 weeks GA) with a suspected UTI at the CHU Sainte-Justine neonatal intensive care unit from January 1, 2014, and December 31, 2019, were included and divided into two definition categories: Possible UTI, and Definite UTI.

RESULTS

Most episodes were Possible UTI (87%). Symptoms of UTIs and pathogens varied based on the definition category. A positive urinalysis was obtained in 25%. Possible UTI episodes grew 2 organisms in 62% of cases and <50,000 CFU/mL in 62% of cases.

CONCLUSION

Characteristics of UTIs in VPTNs vary based on the definition category and case definitions used by clinicians differ from that of established pediatric guidelines.

Clinical relevance of blood urea nitrogen to serum albumin ratio for predicting bacteremia in very young children with febrile urinary tract infection

BACKGROUND

Urinary tract infections (UTIs) are one of the most common bacterial infections in febrile children and a common cause of hospitalization, especially in very young children. We examined the clinical characteristics and predictive factors of concomitant bacteremia in pediatric patients with febrile UTI aged ≤24 months.

METHODS

This retrospective multicenter study reviewed medical data from 2,141 patients from three centers from January 2000 to December 2019. Enrolled cases were classified into the bacteremic UTI and non-bacteremic UTI groups according to the presence of blood culture pathogens.

RESULTS

Among 2,141 patients with febrile UTI, 40 (1.9%) had concomitant bacteremia. All patients in the bacterial group were aged ≤6 months. Multivariate analysis revealed that younger age, lower blood lymphocyte counts and serum albumin levels, higher C-reactive protein (CRP) levels, blood urea nitrogen (BUN) levels, and BUN/serum albumin ratio were independent risk factors of concomitant bacteremia. The area under the receiver-operating characteristic curves predicting bacteremia were 0.668 for CRP, 0.673 for lymphocytes, and 0.759 for the BUN/albumin ratio.

CONCLUSION

The present study identified the BUN/albumin ratio and lower blood lymphocyte counts as novel predictive factors for bacteremia in young infants with febrile UTI in addition to the previously identified factors of younger age and higher CRP levels. Our findings could help to identify patients at high risk of bacteremia and benefit decision-making in the management of infants with febrile UTI.

Reducing Antibiotic Duration for Uncomplicated UTI in the Pediatric Emergency Department

BACKGROUND

Short-duration (3-5 days) antibiotic treatment of uncomplicated urinary tract infection (uUTI) in children >24 months of age is equivalent to longer-duration antibiotic treatment, with added benefits of antibiotic stewardship. At our pediatric emergency department (ED), 13% of 5- to 18-year-old patients discharged with uUTI received ≤5 days of antibiotics. We aimed to increase short-duration prescriptions in patients with uUTI from 13% to >50% over 12 months.

METHODS

This quality improvement project was conducted from January 2021 to August 2022. Complicated UTI was excluded. Interventions included education, practice feedback, and electronic health record changes. The outcome measure, the proportion of children treated with a short antibiotic duration, was studied by using p-charts. Antibiotic days saved were calculated. Revisits with UTI within 14 days of confirmed uUTI treated with short-duration antibiotics (balancing measure) were analyzed by using Fisher's exact test.

RESULTS

In 1292 (n = 363 baseline, 929 post-intervention) eligible patients treated for uUTI, shorter antibiotic duration increased from 13% to 91%. We met our 50% aim within 2 months, with continued improvement leading to an additional centerline shift. Consequently, 2619 antibiotic days were saved. Two of 334 (0.6%) patients returned (P = NS) within 14 days of the index visit with a culture-positive uUTI.

CONCLUSIONS

By using education, feedback, and electronic health record changes, we decreased antibiotic duration in children discharged from the ED for uUTI without a significant increase in return visits with UTI. These interventions can be expanded to wider age groups and other outpatient settings.

Comparison Between Urine Dipstick and Microscopic Examination Urinalysis With Urine Culture to Evaluate the Sensitivity and Specificity for Each in Diagnosing Urinary Tract Infection in Qassim Region, Saudi Arabia

BACKGROUND

Urinalysis is the most popular test for evaluating emergency room patients with possible urinary tract infections (UTIs). Due to their speed and inexpensive cost, urine dipsticks are frequently performed in the Emergency Room. Although a urine dipstick test may be less expensive and time-saving than a laboratory study, it may not be accurate. The study evaluated the sensitivity and specificity of urine dipstick and microscopic urinalysis with a urine culture.

METHODOLOGY

A prospective, observational study was conducted on adults who visited the Emergency Department at King Fahd Specialist Hospital in Buraydah and reported having dysuria, urine urgency, or frequency, as well as suprapubic or costovertebral angle soreness. Patients who could not give a trustworthy history, had symptoms of vaginal discharge, or had taken antibiotics within the previous 72 hours were excluded.

RESULTS

One hundred fifty-three urine samples were collected and examined using urinalysis and dipstick. In addition, 113 (73.86%) of 153 urine samples exhibited no growth in urine culture. With a count of nine, Escherichia coli (E. coli) was the most often isolated organism among the positive cultures (5.88%). Klebsiella pneumoniae was the second most common in our sample with eight (5.23%). The urine dipstick was shown to have an overall sensitivity of 0.79, specificity of 0.39, positive productive value (PPV) of 0.30, and negative productive value (NPV) of 0.85. Urinalysis exhibited a high sensitivity of 0.95 and a poor specificity of 0.21.

CONCLUSION

Our study showed that urine dipsticks may be more beneficial than urinalysis for ruling out urinary tract infections (UTIs), while urinalysis may be more helpful in verifying their presence.

A uretheral stone causing urinary obstruction in a paediatric patient

Urinary retention in pediatric patients is an uncommon presentation, particularly when attributed to urethral stones. We present the case of an 8 year old child who experienced acute urinary retention due to a urethral stone, an infrequent occurrence in this age group. Initial assessment revealed signs of obstructive voiding, prompting further investigation. Imaging studies confirmed the presence of a urethral stone causing complete obstruction. Management involved a multidisciplinary approach, incorporating surgical intervention. This case report underlines the need for awareness about the rare occurrence of urethral stones in pediatric age group which must be kept in mind while treating children.

Should you test for urinary tract infection in children with respiratory symptoms?

QUESTION

An 8-month-old boy presented to our clinic with a 3-day history of fever. He has had a cough and rhinorrhea since the onset of the fever, and his 4-year-old sibling has recently had cough and cold symptoms. I have heard that the presence of respiratory symptoms means that urinary tract infection (UTI) is less likely. In infants with fever and respiratory symptoms, who should have a sample collected for urinalysis for UTI?

ANSWER

The approach to diagnosing febrile infants who have respiratory symptoms varies by age. Urinalysis should be done for all febrile infants younger than 2 months of age, regardless of whether they have respiratory symptoms. Clinicians should assess risk factors for UTI in every infant between 2 and 24 months of age and should not exclude the diagnosis of UTI based on respiratory symptoms alone. Use of a predictive tool to estimate the pretest probability of UTI would aid decision making about patients in this population.

Risk Factors for Urinary Tract Infections in Children with Hematuria in the Emergency Department

INTRODUCTION

Hematuria is a worrisome symptom in children and is sometimes associated with urinary tract infections (UTIs). This study aimed to identify useful clinical factors that can predict UTIs in hematuria patients without pyuria in the pediatric emergency department (ED).

METHODS

We retrospectively recruited patients with hematuria from the pediatric ED. Clinical symptoms, urine biochemistry and microscopic examination results, and blood laboratory tests were analyzed to identify the predictors of UTIs. Patients were divided into the verbal group (age ≥ 2 years) and non-verbal group (age < 2 years) for identifying predictors of UTIs. Causes of hematuria were also investigated.

RESULTS

A total of 161 patients with hematuria without pyuria were evaluated. Among symptoms, dysuria was significantly correlated with UTIs. Regarding urine biochemistry data, urine esterase and urine protein > 30 mg/dl were found to be significant parameters for predicting UTIs, while urine esterase and urine nitrite showed significant differences in children with age < 2 years. In the urine microscopic examinations, urine red blood cells (RBC) > 373/µL in children aged ≥ 2 years and urine RBC > 8/µL in children aged < 2 years were associated with UTIs. In addition, UTIs and urinary tract stones were found to be the top two causes of hematuria.

CONCLUSIONS

Dysuria, urine esterase, urine nitrite, and urine protein may be useful parameters for predicting UTIs in pediatric patients with hematuria but no pyuria in the ED. In addition, a UTI was the most commonly identified etiology of hematuria without pyuria, followed by urinary tract stones.

Management of well-appearing febrile young infants aged ≤90 days

The evaluation and management of young infants presenting with fever remains an area of significant practice variation. While most well-appearing febrile young infants have a viral illness, identifying those at risk for invasive bacterial infections, specifically bacteremia and bacterial meningitis, is critical. This statement considers infants aged ≤90 days who present with a rectal temperature ≥38.0°C but appear well otherwise. Applying recent risk-stratification criteria to guide management and incorporating diagnostic testing with procalcitonin are advised. Management decisions for infants meeting low-risk criteria should reflect the probability of disease, consider the balance of risks and potential harm, and include parents/caregivers in shared decision-making when options exist. Optimal management may also be influenced by pragmatic considerations, such as access to diagnostic investigations, observation units, tertiary care, and follow-up. Special considerations such as temperature measurement, risk for invasive herpes simplex infection, and post-immunization fever are also discussed.

URINARY TRACT INFECTIONS IN PATIENTS YOUNGER THAN 60 DAYS OLD

The safety and efficacy of transitioning from parenteral to oral antibiotics in patients aged less than 60 days with urinary tract infections were assessed. Patients who transitioned to oral therapy had a lower mean length of stay with no significant difference in medically attended urinary tract infection symptoms within 30 days of treatment.

The long and the short of pediatric emergency department antibiotic prescribing: A retrospective observational study

BACKGROUND

Most antibiotics prescribed to children are provided in the outpatient and emergency department (ED) settings, yet these prescribers are seldom engaged by antibiotic stewardship programs. We reviewed ED antibiotic prescriptions for three common infections to describe current prescribing practices.

METHODS

Prescription data between 2018 and 2021 were extracted from the electronic records of children discharged from the Children's Hospital of Eastern Ontario ED with urinary tract infection (UTI), community acquired pneumonia (CAP), and acute otitis media ≥2 years of age (AOM). Antibiotic choice, duration, as well as the provider's time in practice and training background were collected. Antibiotic durations were compared with Canadian guideline recommendations to assess concordance. Provider-level prescribing practices were analyzed using k-means cluster analysis.

RESULTS

10,609 prescriptions were included: 2868 for UTI, 2958 for CAP, and 4783 for AOM. Guideline-concordant durations prescribed was generally high (UTI 84.9%, CAP 94.0%, AOM 52.8%), a large proportion of antibiotic-days prescribed were in excess of the minimally recommended duration for each infection (UTI 16.8%, 19.3%, AOM 25.5%). Cluster analysis yielded two clusters of prescribers, with those in one cluster more commonly prescribing durations at the lower end of recommended interval, and the others more commonly prescribing longer durations for all three infections reviewed. No statistically significant differences were found between clusters by career stage or training background.

CONCLUSIONS

While guideline-concordant antibiotic prescribing was generally high, auditing antibiotic prescriptions identified shifting prescribing towards the minimally recommended duration as a potential opportunity to reduce antibiotic use among children for these infections.

Conflicting views of physicians and surgeons concerning pediatric urinary tract infection: a comparative review

BACKGROUND

A first febrile urinary tract infection (UTI) is a common condition in children, and pathways of management have evolved over time.

OBJECTIVE

To determine the extent to which pediatricians and surgeons differ in their investigation and management of a first febrile UTI, and to evaluate the justifications for any divergence of approach.

MATERIALS AND METHODS

A literature search was conducted for papers addressing investigation and/or management following a first febrile UTI in children published between 2011 and 2021. Searches were conducted on Medline, Embase, and the Cochrane Controlled Trials Register. To be eligible for inclusion, a paper was required to provide recommendations on one or more of the following: ultrasound (US) and voiding cystourethrogram (VCUG), the need for continuous antibiotic prophylaxis and surgery when vesicoureteral reflux (VUR) was detected. The authorship required at least one pediatrician or surgeon. Authorship was categorized as medical, surgical, or combined.

RESULTS

Pediatricians advocated less imaging and intervention and were more inclined to adopt a "watchful-waiting" approach, confident that any significant abnormality, grades IV-V VUR in particular, should be detected following a second febrile UTI. In contrast, surgeons were more likely to recommend imaging to detect VUR (p<0.00001), and antibiotic prophylaxis (p<0.001) and/or surgical correction (p=0.004) if it was detected, concerned that any delay in diagnosis and treatment could place the child at risk of kidney damage. Papers with combined authorship displayed intermediate results.

CONCLUSION

There are two distinct directions in the literature regarding the investigation of an uncomplicated first febrile UTI in a child. In general, when presented with a first febrile UTI in a child, physicians recommend fewer investigations and less treatment, in contrast to surgeons who advocate extensive investigation and aggressive intervention in the event that imaging detects an abnormality. This has the potential to confuse the carers of affected children.

Short duration of parenteral antibiotics in infants with urinary tract infections

Objectives

Current guidelines by the Canadian Paediatric Society on treating urinary tract infections (UTIs) exclude infants ≤ 60 days old. There is considerable practice variability in this age group, especially around the optimal duration of parenteral antibiotics. The study aimed to assess local practice patterns, and the safety of a short course (≤3 days) of parenteral antibiotics in young infants.

Methods

In this retrospective cohort study, 95 infants (≤60 days) with confirmed UTIs were identified at British Columbia Children's Hospital. Patients receiving short (≤3 days) and long (>3 days) duration of parenteral antibiotics were compared. Outcomes of interest included urinary tract infection recurrence within 30 days, hospital length of stay (LOS), representation, and readmission.

Results

Twenty infants (21%) received a short course of parenteral antibiotics. These infants were older (median 47 days versus 28 days) and non-bacteremic. Urinary tract infection recurrence was identified in 8 patients (8%), of which 7 were treated with a long duration (P = 1.0). Patients treated with a short duration had a significantly shorter LOS, with a mean difference of 4.21 days [95% CI: 3.37 to 5.05] (P < 0.001). All five (5%) bacteremic patients were treated exclusively with parenteral antibiotics.

Conclusions

In a Canadian setting, a short course of parenteral antibiotics is safe in young, non-bacteremic infants with UTIs. Despite substantial evidence, local practice patterns suggest a tendency towards prescription of long courses, providing an opportunity for quality improvement.

Association between the imaging characteristics of renal abscess and vesicoureteral reflux

INTRODUCTION

Renal abscesses are rare in pediatric populations. We aimed to highlight the differences in the computed tomography (CT) imaging characteristics of renal abscesses in patients with and without vesicoureteral reflux (VUR).

MATERIALS AND METHODS

Thirteen children with renal abscesses were included and categorized into those with and without VUR. Blood and urine culture results were recorded as positive or negative. Imaging characteristics were recorded: with/without subcapsular fluid collection, with/without upper/lower pole involvement, and with single/multiple lesions in kidneys. Fisher's exact test was used for intergroup comparisons of the rate of positive pathogens and imaging characteristics.

RESULTS

Nine patients had VUR (45.9%). Blood and urine culture were positive in two (15.4%) and seven cases (53.8%), respectively. There was no significant difference in the rate of pathogen-positive blood and urine cultures (blood culture positive/negative status with VUR vs. that without VUR = 2/7 vs. 0/4, p > 0.999, urine culture positive/negative status with VUR vs. that without VUR = 4/5 vs. 3/1, p = 0.559). The two groups differed significantly regarding subcapsular fluid collection presence (with/without subcapsular fluid collection with VUR vs. that without VUR = 9/0 vs 1/3, p = 0.014). There was no significant difference in upper/lower pole involvement (with/without involving upper/lower pole with VUR vs. that without VUR = 8/1 vs 2/2, p = 0.203). Patients with VUR were non-significantly more likely to have multiple lesions compared to those without VUR.

CONCLUSIONS

VUR was associated with subcapsular fluid collection and possibly with multiple lesions, indicating the need for prompt detection of and specific treatment for VUR in cases with these findings.

Blood analysis for screening of electrolyte and kidney function alterations in patients with febrile urinary tract infection

AIM

To describe the prevalence, severity, risk factors, and clinical relevance of electrolyte disturbances and acute kidney injury (AKI) during febrile urinary tract infection (fUTI).

METHODS

Retrospective observational study of well/fair-appearing patients between 2 months and 16 years, with no previous relevant medical history, diagnosed with fUTI in the paediatric emergency department (PED) with subsequent microbiological confirmation. Analytical alteration (AA) data were considered: AKI (creatinine elevation × 1.5 the median for age), plasma sodium alteration (≤130 or ≥150 mEq/L), and potassium alteration (≤3 or ≥6 mEq/L).

RESULTS

We included 590 patients, 17.8% presented AA (13 hyponatremia, 7 hyperkalaemia, and 87 AKI). No patient presented severe analytic alterations or a higher frequency of symptoms potentially attributable to these alterations (seizures, irritability, or lethargy). Risk factors associated with these AA were clinical dehydration (OR = 3.5 95% CI: 1.04-11.7; p = 0.044) and presenting a temperature >39°C (OR = 1.9 95% CI: 1.14-3.1; p = 0.013).

CONCLUSIONS

Electrolyte and renal function disturbances are infrequent in the previously healthy paediatric population with a fUTI. If present, they are asymptomatic and not severe. Based on our results, performing systematic blood analysis to rule out AA appears no longer justified, especially in the absence of risk factors.

Kidney Ultrasonography After First Febrile Urinary Tract Infection in Children: A Systematic Review and Meta-analysis

Importance

Controversy exists on the clinical utility of kidney ultrasonography after first febrile urinary tract infection (UTI), and clinical practice guideline recommendations vary.

Objective

To determine the prevalence of urinary tract abnormalities detected on kidney ultrasonography after the first febrile UTI in children.

Data Sources

The MEDLINE, EMBASE, CINAHL, PsycINFO, and Cochrane Central Register of Controlled Trials databases were searched for articles published from January 1, 2000, to September 20, 2022.

Study Selection

Studies of children with first febrile UTI reporting kidney ultrasonography findings.

Data Extraction and Synthesis

Two reviewers independently screened titles, abstracts, and full texts for eligibility. Study characteristics and outcomes were extracted from each article. Data on the prevalence of kidney ultrasonography abnormalities were pooled using a random-effects model.

Main Outcomes and Measures

The primary outcome was prevalence of urinary tract abnormalities and clinically important abnormalities (those that changed clinical management) detected on kidney ultrasonography. Secondary outcomes included the urinary tract abnormalities detected, surgical intervention, health care utilization, and parent-reported outcomes.

Results

Twenty-nine studies were included, with a total of 9170 children. Of the 27 studies that reported participant sex, the median percentage of males was 60% (range, 11%-80%). The prevalence of abnormalities detected on renal ultrasonography was 22.1% (95% CI, 16.8-27.9; I2 = 98%; 29 studies, all ages) and 21.9% (95% CI, 14.7-30.1; I2 = 98%; 15 studies, age <24 months). The prevalence of clinically important abnormalities was 3.1% (95% CI, 0.3-8.1; I2 = 96%; 8 studies, all ages) and 4.5% (95% CI, 0.5-12.0; I2 = 97%; 5 studies, age <24 months). Study recruitment bias was associated with a higher prevalence of abnormalities. The most common findings detected were hydronephrosis, pelviectasis, and dilated ureter. Urinary tract obstruction was identified in 0.4% (95% CI, 0.1-0.8; I2 = 59%; 12 studies), and surgical intervention occurred in 1.4% (95% CI, 0.5-2.7; I2 = 85%; 13 studies). One study reported health care utilization. No study reported parent-reported outcomes.

Conclusions and Relevance

Results suggest that 1 in 4 to 5 children with first febrile UTI will have a urinary tract abnormality detected on kidney ultrasonography and 1 in 32 will have an abnormality that changes clinical management. Given the considerable study heterogeneity and lack of comprehensive outcome measurement, well-designed prospective longitudinal studies are needed to fully evaluate the clinical utility of kidney ultrasonography after first febrile UTI.

Management of febrile neutropenia in immunocompetent children and youth

Febrile neutropenia is a common clinical presentation in children that can be associated with invasive bacterial infection (IBI). However, in otherwise healthy children and youth with fever and neutropenia, the risk for IBI is low, with most cases being caused by viral infections. Well-appearing, non-oncologic, and presumed immunocompetent children aged 6 months to 18 years experiencing a first episode of neutropenia, with no additional risk factors, typically do not require empiric antibiotics. However, a thorough assessment, including complete history and physical exam, is indicated, and a blood culture should be performed when the absolute neutrophil count is <0.5 × 109/L. Close follow-up, a repeat complete blood count, and strong anticipatory guidance are recommended.

Individualised versus standard duration of antibiotic therapy in children with acute uncomplicated febrile urinary tract infection: a study protocol and statistical analysis plan for a multicentre randomised clinical trial

INTRODUCTION

Febrile urinary tract infection is one of the most common bacterial infections in children. Currently, recommended antibiotic duration is 10 days. However, recent evidence suggests that 90%-95% of children with febrile urinary tract infections are afebrile and clinically improved 48-72 hours after treatment initiation. Accordingly, individualised duration of antibiotic therapy, according to the recovery time, might be more beneficial than current recommendations, but no evidence exists.

METHODS AND ANALYSIS

An open-label randomised clinical trial equally randomising children aged 3 months to 12 years from eight Danish paediatric departments with uncomplicated febrile (≥38°C) urinary tract infection to either individualised or standard duration of antibiotic therapy. Children allocated to individualised duration of antibiotic therapy will terminate antibiotic therapy 3 days after clinical improvement with no fever, flank pain or dysuria. Children allocated to standard duration will receive 10 days of antibiotic therapy. Co-primary outcomes are non-inferiority for recurrent urinary tract infection or death within 28 days after the end of treatment (non-inferiority margin 7.5 percentage points) and superiority for the number of days with antibiotic therapy within 28 days after treatment initiation. Seven other outcomes will also be assessed. A total of 408 participants are needed to detect non-inferiority (one-sided alpha 2.5%; beta 80%).

ETHICS AND DISSEMINATION

This trial has been approved by the Ethics Committee (H-21057310) and the Data Protection Agency (P-2022-68) in Denmark. Regardless of the trial's findings (whether positive, negative or inconclusive), the results will be compiled into one or more manuscripts for publication in international peer-reviewed scientific journals and presented at conferences.

TRIAL REGISTRATION NUMBER

NCT05301023.

Elevated Urinary Hepcidin Level and Hypoferremia in Infants with Febrile Urinary Tract Infection: A Prospective Cohort Study

To evaluate the kinetics of serum and urinary hepcidin levels along with anemia-related parameters during the infection course of infants with febrile urinary tract infection (UTI), we enrolled febrile infants aged one to four months in this prospective study. Febrile patients with UTI were allocated into Escherichia coli (E. coli) or non-E. coli groups according to urine culture results. Septic workup, blood hepcidin, iron profile, urinalysis, and urinary hepcidin-creatinine ratio were collected upon admission and 3 days after antibiotic treatment. In total, 118 infants were included. On admission, the febrile UTI group showed a significant reduction in serum iron level and a significant elevation of urinary hepcidin-creatinine ratio compared to the febrile control counterpart. Moreover, urinary hepcidin-creatinine ratio had the highest odds ratio, 2.01, in logistics regression analysis. After 3 days of antibiotic treatment, hemoglobin and the urinary hepcidin-creatinine ratio were significantly decreased. Patients with an E. coli UTI had a significantly decreased urinary hepcidin-creatinine ratio after 3 days of antibiotics treatment, whereas the non-E. coli group showed insignificant changes. Our study suggested that the urinary hepcidin-creatinine ratio elevated during acute febrile urinary tract infection and significantly decreased after 3 days of antibiotics treatment, especially in E. coli UTI.

Urine collection methods in precontinent children treated at the paediatric emergency department

AIM

To describe the urine collection methods used in precontinent children presenting at the Paediatric Emergency Department (PED) and compare results and contamination rates.

METHODS

Retrospective observational cohort study that included 1678 urine cultures collected in infants <24 months of age between January 2016 and December 2019. Urine cultures were compared based on collection technique, sex and patient age.

RESULTS

In total, 60.4% of samples were collected by clean-catch urine collection (CCUC), 26.4% by urethral catheterisation (UC) and 13.2% by urine bag (UB). Contamination rates were 2.9% (95% CI 1.3, 4.4) for UC, 11.3% (95% CI 9.3, 13.2) for CCUC and 23.4% (95% CI 17.8, 29.0) for UB. Significant differences in contamination rates were found between UC and CCUC in the 6-12-month age group (1.9% [95% CI 0.0-4.0] versus 12.0% [95% CI 7.2-16.8] [p < 0.0009]), and between UC and UB for all ages.

CONCLUSIONS

CCUC is the most common method for urine culture collection in infants <24 months of age at the PED in our centre. UC has the lowest contamination rates, but significant differences were only observed between CCUC and UC in the 6-12-month age group. CCUC is a non-invasive alternative for urine collection in infants.

Trends in hospitalization for urinary tract infection in the paediatric age group in the 2000-2015 period in Spain

OBJECTIVE

To analyse the trends in hospital admissions related to urinary tract infection among children aged 0-14 years in Spain in the 2000-2015 period.

METHODS

We conducted a retrospective observational study using the minimum basic hospital discharge dataset system of Spain, which applies the International Classification of Diseases, version 9 (ICD-9) coding system. We included every hospitalisation due to cystitis, pyelonephritis and unspecified UTI among children aged less than 15 years. We collected data on patient sex and age, type of discharge, main diagnosis, comorbidities, length of stay and overall cost. We calculated crude hospitalization rates per 1000 inhabitants aged less than 15 years and performed a joinpoint regression analysis to identify temporal trends.

RESULTS

In the 2000-2015 period, there were 124 696 hospitalizations in children under 15 years. Of these patients, 72.97% were aged 0-1 year and 60.12% had a diagnosis of unspecified UTI, 39.27% of pyelonephritis, and 0.52% of cystitis. The crude rate of hospitalization due to UTI ranged from 1.24 in year 2000 to 0.98 in 2015. The rate of hospitalization was higher in female versus male patients. The joinpoint analysis found a decreasing trend in the rate of hospitalization due to UTI, with an average annual percent change (AAPC) of -1.5% (95% confidence interval [CI], -2.4 a -0.6). The largest decreases occurred in female patients (AAPC, -1.8; 95% CI, -2.5 a -1.0) and children aged 7-10 years (AAPC - 5.9; 95% CI, -6.7 a -5.2).

CONCLUSIONS

The rate of hospitalization related to UTI in Spain in patients aged up to 14 years decreased during the 2000-2015 period. The highest hospitalization rates occurred in female patients and in the 0-to-1 year age group.

Determining the effectiveness of the immature granulocyte percentage and systemic immune-inflammation index in predicting acute pyelonephritis

AIM

The most serious form of urinary tract infection (UTI) is acute pyelonephritis (APN), which can result in bacteremia and renal scarring. This study aims to show the roles that the systemic immune-inflammation index (SII) and the immature granulocyte (IG) percentage play in predicting APN in pediatric patients by comparing them with traditional infection markers. By illustrating a significant relationship between APN, the IG percentage, and the SII, the study's contributions to the differential diagnosis of UTI can promote a rapid and appropriate treatment of APN.

MATERIAL AND METHODS

The present study included 522 pediatric patients. The patients were divided into two groups: (I) an APN group (n = 236) and (II) a lower UTI group (n = 286).

RESULTS

The mean age of the sample was 5.05 ± 4.7 years. According to the most appropriate cutoff values, the findings showed that among all the parameters, C-reactive protein (CRP) and the IG percentage had the highest sensitivities, specificities, and predictive values for predicting APN.

CONCLUSION

This study emphasizes the support features of the IG percentage and the SII in the diagnosis of APN in pediatric patients, a topic that has recently attracted attention. The findings indicated that among all of the parameters behind CRP, the IG percentage and the SII had the highest sensitivities, specificities, and predictive values for forecasting APN. It is worth noting that these methods can be applied without additional costs or burdens to the patient.

Building nomogram plots for predicting urinary tract infections in children less than three years of age

BACKGROUND AND PURPOSE

Urinary tract infections (UTIs) are the most common bacterial infection in young children. This study aimed to formulate nomogram plots for clinicians to predict UTIs in children aged <3 years by evaluating the risk factors for UTIs in these children.

METHODS

This retrospective study was conducted at a tertiary medical center from December 2017 to November 2020. Children less than three years of age were eligible for the study if they had undergone both urine culture and urinalysis during the study period. Mixed-effects logistic regression models with a stepwise procedure were used to determine the relationship between outcome (positive/negative UTI) and covariates of interest (e.g., weight percentile, laboratory) for each patient. Nomogram plots were constructed on the basis of significant factors. We repeated the analysis thrice to adapt it to three different medical settings: medical centers, regional hospitals, and local clinics.

RESULTS

In the medical center setting, the two most significant factors were urine leukocyte count ≥100 (OR =8.87; 95% CI (Confidence Interval), 4.135-19.027) and urine nitrite level (OR =8.809; 95% CI, 5.009-15.489). The two factors showed similar significance at the regional hospital and local clinic settings. Abnormal renal echo findings were positively correlated with UTI in the medical center setting (OR =2.534; 95% CI 1.757-3.655). Three nomogram plots for the prediction of UTIs were drawn for medical centers, regional hospitals, and local clinics.

CONCLUSION

Using the three nomogram plots, frontline doctors can formulate the probabilities of pediatric UTIs for better decision-making.

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.

Risk factors for imaging abnormalities after the first febrile urinary tract infection in infants ≤3 months old: a retrospective cohort study

OBJECTIVES

To assess the association of clinical factors and investigation results (blood and urine) with imaging abnormalities (ultrasound of the kidneys, ureters and bladder; dimercaptosuccinic acid scan; and/or micturating cystourethrogram) and recurrent urinary tract infections (UTIs) in infants ≤3 months old presenting with their first febrile UTI.

METHODS

We conducted a retrospective cohort study of infants ≤3 months old with first febrile UTI admitted from 2010 to 2016. Multivariable logistic regression model was used to analyse the association of imaging abnormalities and recurrent UTI with covariates selected a priori: age at presentation, maximum temperature, duration of illness at presentation, interval between start of antibiotics and fever resolution, C-reactive protein, total white cell count on the full blood count, bacteraemia, white cell count on the urinalysis and non-Escherichia coli growth in the urine culture (non-E. coli UTI).

RESULTS

There were 190 infants but 12 did not undergo any imaging. Median age at presentation was 63 days (IQR 41-78). Twenty-four patients had imaging abnormalities. Non-E. coli UTI (adjusted OR (aOR) 5.01, 95% CI 1.65 to 15.24, p=0.004) was independently associated with imaging abnormalities, while bacteraemia (aOR 4.93, 95% CI 1.25 to 19.43, p=0.022) and non-E. coli UTI (aOR 5.06, 95% CI 1.90 to 13.48, p=0.001) were independently associated with recurrent UTI.

CONCLUSION

Non-E. coli UTI at the first febrile UTI in infants ≤3 months old may be useful in predicting imaging abnormalities while bacteraemia and non-E. coli UTI may be useful to predict recurrent UTI.

Urinary Tract Infection in Children

Symptoms of urinary tract infection (UTI) in young children are nonspecific and urine sampling is challenging. A safe and rapid diagnosis of UTI can be achieved with new biomarkers and culture of clean-catch urine, reserving catheterization or suprapubic aspiration for severely ill infants. Most guidelines recommend ultrasound assessment and use of risk factors to direct further management of children at risk of kidney deterioration. The increasing knowledge of the innate immune system will add new predictors and treatment strategies to the management of UTI in children. Long-term outcome is good for the majority, but individuals with severe scarring can develop hypertension and decline in kidney function.

Dexamethasone to prevent kidney scarring in acute pyelonephritis: a randomized clinical trial

BACKGROUND

Urinary tract infection (UTI) is one of the most common bacterial infections in childhood and is associated with long-term complications. We aimed to assess the effect of adjuvant dexamethasone treatment on reducing kidney scarring after acute pyelonephritis (APN) in children.

METHODS

Multicenter, prospective, double-blind, placebo-controlled, randomized clinical trial (RCT) where children from 1 month to 14 years of age with proven APN were randomly assigned to receive a 3-day course of either an intravenous corticosteroid (dexamethasone 0.30 mg per kg/day) twice daily or placebo. The late technetium 99 m-dimercaptosuric acid scintigraphy (> 6 months after acute episode) was performed to assess kidney scar persistence. Kidney scarring risk factors (vesicoureteral reflux, kidney congenital anomalies, or urinary tract dilatation) were also assessed.

RESULTS

Ninety-one participants completed the follow-up and were finally included (dexamethasone n = 49 and placebo n = 42). Both groups had similar baseline characteristics. Twenty participants showed persistent kidney scarring after > 6 months of follow-up without differences in incidence between groups (22% and 21% in the dexamethasone and placebo groups, p = 0.907). Renal damage severity in the early DMSA (β = 0.648, p = 0.023) and procalcitonin values (β = 0.065 p = 0.027) significantly modulated scar development. Vesicoureteral reflux grade showed a trend towards significance (β = 0.545, p = 0.054), but dexamethasone treatment showed no effect.

CONCLUSION

Dexamethasone showed no effect on reducing the risk of scar formation in children with APN. Hence, there is no evidence for an adjuvant corticosteroid treatment recommendation in children with APN. However, the study was limited by not achieving the predicted sample size and the expected scar formation.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT02034851. Registered in January 14, 2014. "A higher resolution version of the Graphical abstract is available as Supplementary information."

Management of Pediatric Urinary Tract Infections: A Delphi Study

Urinary tract infection (UTI) is one of the most common infectious diseases in the pediatric population and represents a major cause of antibiotic consumption and hospitalization in children. Considering the ongoing controversies on the management of pediatric UTI and the challenges due to increasing antimicrobial resistance, the aim of the present study was to evaluate the level of agreement on UTI management in pediatric age in Emilia-Romagna Region, Italy, and to assess on the basis of recent studies whether there is the need to change current recommendations used by primary care pediatricians, hospital pediatricians, and pediatric surgeons in everyday clinical practice to possibly improve outcomes. This consensus provides clear and shared indications on UTI management in pediatric age, based on the most updated literature. This work represents, in our opinion, the most complete and up-to-date collection of statements on procedures to follow for pediatric UTI, in order to guide physicians in the management of the patient, standardize approaches, and avoid abuse and misuse of antibiotics. Undoubtedly, more randomized and controlled trials are needed in the pediatric population to better define the best therapeutic management in cases with antimicrobial resistance and real usefulness of long-term antibiotic prophylaxis.

Decreasing Misdiagnoses of Urinary Tract Infections in a Pediatric Emergency Department

BACKGROUND AND OBJECTIVES

Urinary tract infection (UTI) is a common diagnosis in the emergency department (ED), often resulting in empirical antibiotic treatment before culture results. Diagnosis of a UTI, particularly in children, can be challenging and misdiagnosis is common. The aim of this initiative was to decrease the misdiagnosis of uncomplicated pediatric UTIs by 50% while improving antimicrobial stewardship in the ED over 4 years.

METHODS

By using the Model for Improvement, 3 interventions were developed: (1) an electronic UTI diagnostic algorithm, (2) a callback system, and (3) a standardized discharge antibiotic prescription. Outcome measures included the percentage of patients with UTI misdiagnosis (prescribed antibiotics, but urine culture results negative) and antibiotic days saved. As a balancing measure, positive urine culture results without a UTI diagnosis were reviewed for ED return visits or hospitalization. Statistical process control and run charts were used for analysis.

RESULTS

From 2017 to 2021, the mean UTI misdiagnosis decreased from 54.6% to 26.4%. The adherence to the standardized antibiotic duration improved from 45.1% to 84.6%. With the callback system, 2128 antibiotic days were saved with a median of 89% of patients with negative culture results contacted to discontinue antibiotics. Of 186 patients with positive urine culture results with an unremarkable urinalysis, 14 returned to the ED, and 2 were hospitalized for multiresistant organism UTI treatment.

CONCLUSIONS

A UTI diagnostic algorithm coupled with a callback system safely reduced UTI misdiagnoses and antibiotic usage. Embedding these interventions electronically as a decision support tool, targeted audit and feedback, reminders, and education all supported long-term sustainability.

Epidemiologic, microbiologic and imaging characteristics of urinary tract infections in hospitalized children < 2 years of age diagnosed with anatomic abnormalities of the urinary tract

BACKGROUND

To compare the epidemiologic, microbiologic and imaging characteristics of urinary tract infections (UTI) in children <2 years of age with and without anatomic urinary tract abnormalities (AA).

METHODS

All children hospitalized with UTI during 1.1.2005-31.12.2018 were included. The study group (patients with AA) included 76 patients. The control group (99 patients) included patients without AA.

RESULTS

1163 children were hospitalized. Age at diagnosis was younger in the study group vs. controls (5.2 ± 6.0 vs. 7.9 ± 7.5 months, P = 0.038). Uropathogens distribution was different (P = 0.007), with lower Escherichia coli (Ec) and Proteus mirabilis (Pm) percentages in the study group and higher percentages of Enterococcus spp. (Ent) in controls. In the study group, Ec nonsusceptibility rates to ampicillin, amoxicillin/clavulanic acid, cefazolin, cefuroxime, TMP/SMX and ceftriaxone were 58%, 40%, 14%, 14%, 12% and 10%, respectively, with no differences vs. controls. Ultrasound (US) was performed in 69/76 (98%) patients with AA (84.1%, abnormal); bilateral (39.7%) and unilateral (32.7%) ureteral dilatation were the most frequent findings. Voiding cystourethrography was performed in 46 patients (pathologic in 35, 76%); 31 (81.6%) patients had vesicoureteral reflux (VUR) (bilateral in 11, 35.5%; grade 4/5 in 7 patients). Uropathogens distribution in VUR patients differed between study and control groups, with lower Ec and Pm in the first group and higher Pseudomonas aeruginosa and Ent percentages in the control group.

CONCLUSION

Age at diagnosis was lower and pathogen distribution was different in patients with AA. Antibiotic susceptibility patterns of the main uropathogens were similar between patients with or without AA.

Assessing nephrology competence in general paediatrics—A survey of general paediatricians, paediatric nephrologists, residents, and program directors

Objective

The objective of this study was to identify nephrology topics of lowest perceived competency and importance for general paediatricians.

Methods

Surveys were distributed to general paediatricians, paediatric residents, paediatric residency program directors, and paediatric nephrologists. Perceived importance and competence were rated on a 5-point Likert scale. Means and 95% confidence intervals were calculated.

Results

Mean perceived competency from general paediatricians across all nephrology domains was 3.0, 95%CI (2.9 to 3.1) and mean importance was 3.2, 95%CI (3.1 to 3.3). Domains scoring below the means for competence and importance, respectively were kidney stones (2.5, 95%CI [2.2 to 2.7]) and 2.6, 95%CI [2.3 to 2.8]), acute kidney injury (2.5, 95%CI [2.2 to 2.8] and 2.4, 95%CI [2.1 to 2.8]), chronic kidney disease (1.9, 95%CI [1.7 to 2.2] and 2.1, 95%CI [1.8 to 2.4]), tubular disorders (1.8, 95%CI [1.6 to 2.0] and 2.0, 95%CI [1.8 to 2.3]), and kidney transplant (1.6, 95%CI [1.4 to 1.8] and 1.7, 95%CI [1.4 to 1.9]). Residents, program directors, and paediatric nephrologists agreed that stones, chronic kidney disease, tubular disorders, and transplant were of lower importance. However, acute kidney injury was the domain with the largest discrepancy in perceived importance between residents (4.4, 95%CI [4.2 to 4.6]), nephrologists (4.2, 95%CI [3.8 to 4.6]), and program directors (4.2, 95%CI [3.7 to 4.7]) compared to general paediatricians ([2.4, 95%CI [2.1 to 2.8]; P&lt;0.05).

Conclusion

Paediatricians did not believe acute kidney injury was important to their practice, despite expert opinion and evidence of long-term consequences. Educational interventions must address deficits in crucial domains of renal health in paediatrics.

Clinical management and outcomes of acute febrile illness in children attending a tertiary hospital in southern Ethiopia

Background

The management of febrile illnesses is challenging in settings where diagnostic laboratory facilities are limited, and there are few published longitudinal data on children presenting with fever in such settings. We have previously conducted the first comprehensive study of infectious aetiologies of febrile children presenting to a tertiary care facility in Ethiopia. We now report on clinicians’ prescribing adherence with guidelines and outcomes of management in this cohort.

Methods

We consecutively enrolled febrile children aged 2 months and under 13 years, who were then managed by clinicians based on presentation and available laboratory and radiologic findings on day of enrolment. We prospectively collected outcome data on days 7 and 14, and retrospectively evaluated prescribing adherence with national clinical management guidelines.

Results

Of 433 children enrolled, the most common presenting syndromes were pneumonia and acute diarrhoea, diagnosed in 177 (40.9%) and 82 (18.9%), respectively. Antibacterial agents were prescribed to 360 (84.7%) of 425 children, including 36 (34.0%) of 106 children without an initial indication for antibacterials according to guidelines. Antimalarial drugs were prescribed to 47 (11.1%) of 425 children, including 30 (7.3%) of 411 children with negative malaria microscopy. Fever had resolved in 357 (89.7%) of 398 children assessed at day 7, and in-hospital death within 7 days occurred in 9 (5.9%) of 153 admitted patients. Among children with pneumonia, independent predictors of persisting fever or death by 7 days were young age and underweight for age. Antibacterial prescribing in the absence of a guideline-specified indication (overprescribing) was more likely among infants and those without tachypnea, while overprescribing antimalarials was associated with older age, anaemia, absence of cough, and higher fevers.

Conclusion

Our study underscores the need for improving diagnostic support to properly guide management decisions and enhance adherence by clinicians to treatment guidelines.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-022-07424-0.

The position during urine sample collection from young precontinent children through a bag does not limit contamination rates: Results from a randomized controlled trial: Does infant position influence quality of urine collection?

AIM

Despite its limitation, bag collection is still widely used for a preliminary urine screening test in non-toilet-trained children suspected of febrile urinary tract infection. A previous study conducted by our group raised the hypothesis that the absence of direct contact between urine and the perinea during urine collection could limit urine contamination by perineal flora. The aim of this study was to evaluate the impact of the patient's position during urine collection (upright standing position versus free position) on the rate of contaminated urine samples in non-toilet-trained children with suspected febrile urinary tract infection.

METHODS

This prospective, randomized, controlled study took place in seven pediatric emergency departments. Two groups were compared: the intervention group (infants held in an upright standing position during urination) and the control group (free position during urination).

RESULTS

Among the 800 pediatric patients randomized to the study, 124 had a urine culture, 60 in the intervention group and 64 in the control group. Among the 124 urine cultures, 12 (9.7%) were contaminated: eight (13.3%) in the intervention group and four (6.3%) in the control group (p = 0.1824).

CONCLUSION

The results show that the patient's position does not have a significant impact on the quality of urine samples collected by bag.

Clinical guidelines of UTIs in children: quality appraisal with AGREE II and recommendations analysis

OBJECTIVE

To explore the current Chinese and English guidelines of urinary tract infection (UTI) in children and provide a summary of the recommendations of the guidelines.

METHODS

An electronic search was conducted on databases, including Pubmed, SinoMed, Wangfang Data, CHKD,VIP, NICE, WHO, GIN and Medliveto retrieve data of the clinical practice guidelines on UTI from the establishment of the database to June 2020. Four assessors assessed the quality of guidelines using the Appraisal of Guidelines for Research & Evaluation II (AGREE II) and evaluated the specific recommendations in guidelines.

RESULTS

(1) Nine guidelines including two from the USA (AAP and A guideline for the inpatient care of children with pyelonephritis) and the remaining from EAU/ESPU, SINEPE, KHA-CARI, CPS, ISPN, NICE and CMA-CSP were explored. (2) The AGREE II evaluation demonstrated higher scores of UTI guidelines in terms of 'scope and purpose' (72.99%±11.19%) and 'clarity of presentation' (75.62%±7.75%), whereas the average scores were lower in the aspect of 'stakeholder involvement' (35.49%±14.41%), 'rigour of development' (37.05%±10.05%), 'applicability' (37.75%±11.98%) and 'editorial independence' (43.06%±48.14%). The average scores of the guidelines were as follows: SINePe (72.57%), CMA-CSP (62.96%), EAU/ESPU (59.61%), AAP (56.86%), NICE (47.54%), CPS (40.93%), KHA-CARI (38.86%), ISPN (38.63%) and A guideline for the inpatient care of children with pyelonephritis (34.72%). (3) All the selected guidelines basically reached a consensus on urine sample retention methods in older children, the antibiotic treatment course and renal and bladder ultrasonography application but lacked a conclusion on the determination of urine culture results, the choice of voiding cystourethrography and Tc-99mdimercaptosuccinicacid, and antibiotic prophylaxis.

CONCLUSION

There remains a need to improve the quality of guidelinesfor UTI in clinical practice. Existing controversies on the current guidelines of UTI in some recommendations warrant further exploration to provide more evidence on formulating more unified and practical guidelines in the future.

ETHICS AND DISSEMINATION

No ethical approval is required for this research, as it did not include patients or patient data.

PREVALENCE OF ASYMPTOMATIC BACTERIURIA AND ITS DISTRIBUTION BY SEX AND AGE GROUPS IN CHILDREN COMING FOR ROUTINE IMMUNIZATION IN DISTRICT PESHAWAR, PAKISTAN

Background: Asymptomatic bacteriuria (ASB) in not an uncommon disease in children. It may lead to symptomatic infection and later on renal damage. The objectives of this study were to determine the prevalence of ASB and its distribution by sex and age groups in children coming for routine immunization in District Peshawar, Pakistan.Material and methods: This cross-sectional study was conducted in Department of Pediatrics, Khyber Girls Medical College, Peshawar, Pakistan form March 2017 to August 2017. 146 children presenting for routine immunization were selected. Sex, age groups, age in years and presence of ASB were variables. Sex, age groups and presence of ASB were analyzed by count and percentage with 80%CL. Age in years was analyzed by mean, SD and range with 95%CI.Results: Out of 146 children, 65 (44.52%) were males and 81 (55.48%) females, and 51 (34.93%) in age group ≤3 years, 52 (35.62%) in 3.0-6.50 years and 43 (29.45%) in 6.51-10 years. Mean age of sample was 4.82±2.81 (09-9.50, range 8.60) (95%CI 4.36-5.28) years. ASB was found in 16 (10.96%) cases. Prevalence of ASB was higher 4.11% in boys than 6.856% girls. It was highest 6.85% in age group 3.0-6.50 years, followed by 2.74% in 6.51-10 years and 1.37% in age group ≤3.0 years.Conclusion: Asymptomatic Bacteriuria is quite common in our children. It is a significant health risk especially among females, and we suggest more studies to find out the underlying factors and follow up studies on its complications.

Molecular Study of Escherichia albertii in Pediatric Urinary Tract Infections

Background:

There are insufficient data about the presence of E. albertii as a causative organism in urinary tract infection in pediatric patients. Objective: The present study aimed to detect E. albertii by polymerase chain reaction (PCR) for detection of uidA, mdh, and lysP genes among isolated E.coli from children with urinary tract infection.

Methods:

The present study was a cross-sectional retrograde study which was carried out on 100 isolates of phenotypically confirmed E.coli detected in urine samples of children suffering from urinary tract infection. The isolates were subjected to molecular identification by PCR for uidA, mdh, and lysP genes.

Results:

E. albertii was identified by PCR in 7% of the isolates and E.coli was identified in 93% of the isolates. Two mdh and lysP genes were detected for E. albertii and the uidA gene for E. coli. E. albertii isolates had marked resistance to gentamicin (71.4%), followed by resistance to ciprofloxacin (57.1%), meropenem and imipenem (42.9% each) and ESBL activity by double discs method was reported in 57.1% of the isolates. However, none of the isolates had shown resistance to nalidixic acid and only one isolate had resistance to norfloxacin. There was a statistically insignificant difference between resistance to the used antibiotics such as aztreonam (P=0.083), ampicillin/clavulanate (P=0.5), ciprofloxacin (P=0.69), gentamicin (P=0.3) and ceftazidime (P=1.00).

Conclusion:

The present study highlights the emergence of E. albertii as a pathogen associated with urinary tract infections in children. There is marked antibiotic resistance of this pathogen, especially toward extended spectrum beta-lactams antibiotics. The identification method depends mainly on genetic studies. Further longitudinal studies with large number of patients are required to verify the accurate prevalence of this bacterium.

Egyptian pediatric clinical practice guidelines for urinary tract infections in infants and children (evidence based)

Background

National evidence-based recommendations for diagnosis, treatment, imaging, and follow-up in urinary tract infection are crucial being a major health problem in pediatrics. Every region should follow international recommendations with respect to the disease local profile and available facilities for that area.

Methods

Based on AGREE II (the assessment tool of practice guidelines), Egyptian CGLs used *American Academy Pediatrics, *European Association Urology, European Society Pediatric Urology, and *Asian Association Urinary tract infections as its evidence-based references. Health questions were listed for evidence base answers adopted from selected CGLs after their permission. Key statements were approved by all members and further approved by the Egyptian Pediatric Guidelines Committee after local and international external peer reviewing.

Results

(1) Diagnosis recommendations: Urine culture with diagnostic colony counts is essential for diagnosis. Catheter samples are important for critical cases and non-toilet-trained cases especially when they show significant bacteriuria and pyuria. (2) Treatment plan included areas of debate as choice of antibiotic, oral versus intravenous, duration, antibiotic prophylaxis considering age, disease severity, recurrence, + risk factors, and imaging reports. (3) Imaging recommendations were tailored to suit our community. Renal bladder ultrasound is important for children with febrile UTI, due to the high prevalence of congenital anomalies of the kidney and urinary tract, paucity of prenatal ultrasound, and lack of medical documentation to reflect previously diagnosed UTI or US reports. We recommend renal isotopic scan and voiding cystography for serious presentation, high-risk factors, recurrence, and abnormal US. (4) Urological consultation is recommended: in urosepsis or obstruction, male infants < 6 months. Acute basal DMSA is recommended in congenital renal hypodysplasia. Six months post-infection, US and DMSA are recommended in severe pyelonephritis and vesico-ureteric reflux, where those with abnormal US or DMSA or both should have voiding cystography. (5) Follow-up recommendations include family orientation with hazards of noncompliance and monitoring at pregnancy.

Conclusion

Diagnosis and treatment show strong recommendations. Imaging depends on patient assessment. Referral to a pediatric nephrologist and urologist in complicated cases is crucial. Follow-up after the age of 16 years in adult clinics is important.

Urine collection methods for infants under 3 months of age in clinical practice

BACKGROUND

Methods of urine collection used in precontinent children are a controversial issue. Definitive diagnosis of urinary tract infection (UTI) requires an uncontaminated urine culture. We aimed to describe methods used to collect urine for culture in infants under 3 months of age and compare results and contamination rates.

METHODS

This retrospective observational cohort study included 721 urine cultures collected from infants <3 months of age at the Hospital Universitario Infanta Sofía, Madrid, between January 2016 and December 2019. Urine cultures were compared based on collection technique, sex, and patient age.

RESULTS

Median patient age was 36 days and 54.6% were male. In total, 592 (82.1%) samples were collected using clean-catch urine stimulation technique (CCUST), 77 (10.7%) by urethral catheterization (UC) and 52 (7.2%) by urine bag (UB). Positive cultures were obtained in 11.7% (95% confidence interval [CI] 9.1, 14.3) of CCUST samples and in 28.6% (95% CI 18.5, 38.7) of UC samples (p<0.001). The contamination rate was 13.7% (95% CI 10.9, 16.4] for CCUST, 23.1% (95% CI 11.6, 34.6) for UB and 5.2% (95% CI 0.2, 10.2) for UC, with statistically significant differences (p=0.007) between UB and UC collection.

CONCLUSIONS

CCUST is the most commonly used method in our hospital for collecting urine in infants younger than 3 months. The contamination rate of UC is lower but not significantly different to that of CCUST. Urine collection by CCUST serves as a non-invasive alternative to UC for diagnosis of UTI in infants under 3 months of age in routine clinical practice. Graphical abstract.