Urinary tract infection in febrile infants younger than eight weeks of Age

Prevalence, aetiology, antimicrobial susceptibility testing, and predictors of urinary tract infection among neonates with clinical sepsis: a cross-sectional study

Background

Urinary tract infection (UTI) is the most common and life-threatening bacterial infection among neonates. This study aimed to determine the prevalence, aetiology, and susceptible antimicrobial agents among neonates with UTI.

Methods

This was a cross-sectional analytical hospital-based study that included 152 neonates with clinical sepsis who were admitted at Dodoma regional referral hospital from January to June 2020. Bacterial growth of 1 × 103 colony forming units/mL of a single uropathogen was used to define the presence of UTI. Statistical analysis was performed using SPSS version 23.0 and multivariate analysis was used to determine the predicting factors of UTI. P <0.05 was regarded statistically significant.

Results

The prevalence of UTI was 18.4% (28/152). Klebsiella pneumoniae 64.3% (18/28) and Enterobacter spp. 35.7% (10/28) were the bacterial agents isolated. The bacterial isolates were 90%, and 60% sensitive to ciprofloxacin and amikacin, respectively. Low Apgar score (AOR = 12.76, 95% CI = 4.17–39.06, p<0.001), prolonged labour (AOR = 5.36, 95% CI = 1.28–22.52, p = 0.022), positive urine nitrite test (AOR = 26.67, 95% CI = 7.75–91.70, p<0.001), and positive leucocyte esterase test (AOR = 6.64, 95% CI = 1.47–29.97, p = 0.014) were potential predictors of UTI.

Conclusion

The prevalence of UTI confirmed by urine culture among neonates that were included in the present study indicates that this problem is common in the population where the study was conducted. Klebsiella pneumoniae and Enterobacter spp. were the uropathogens which were isolated. Ciprofloxacin, nitrofurantoin, and amikacin were sensitive to the isolated uropathogens.

Clinical and Epidemiological Analysis of Children's Urinary Tract Infections in Accordance with Antibiotic Resistance Patterns of Pathogens

The study was conducted to analyze urinary tract infections (UTI) in children by considering epidemiology and antibiotic resistance patterns of pathogens in accordance with inflammatory parameters. The research included 525 patients who demonstrated 627 episodes of UTI. The increasing resistance of bacteria was observed over the years covered by the study (p < 0.001). There was a significant increase of resistance to amoxicillin with clavulanic acid (p = 0.001), gentamicin (p = 0.017) and ceftazidime (p = 0.0005). According to the CART method, we managed to estimate C-reactive protein (CRP), procalcitonin (PCT) and white blood cell (WBC) values, in which antibiotic sensitivity was observed. In children with CRP > 97.91 mg/L, there was a high percentage of sensitive cases to amoxicillin with clavulanic acid (87.5%). Values of WBC above 14.45 K/µL were associated with E. coli more sensitivity to ampicillin. 100% of children with CRP > 0.42 mg/L and PCT ≤ 6.92 ng/mL had confirmed sensitivity to cefuroxime. Concerning sensitivity to gentamicin, the most optimal cut-off point of WBC was >7.80 K/µL, while in the case of nitrofurantoin, it was CRP value > 0.11 mg/L (which was presented in 98.50% of children). These results may guide us with antibiotic therapy and help to inhibit increasing antibiotic resistance.

Envisioning Future UTI Diagnostics

Urinary tract infections (UTIs) are among the most common bacterial infections in the United States and are a major driver of antibiotic use - both appropriate and inappropriate - across healthcare settings. UTI treatment has become complex due to antibacterial resistance; one quarter of urinary tract isolates of Escherichia coli in the United States in 2017 were resistant to fluoroquinolones and one third to trimethoprimsulfamethoxazole (1), agents with historically predictable activity against E. coli. As a result, more broad-spectrum antibiotics are being used to treat UTIs, contributing to selection of further antibiotic resistance.

Treatment of positive urine cultures in the neonatal intensive care unit: a guideline to reduce antibiotic utilization

BACKGROUND

The pediatric definition of bacterial urinary tract infection (UTI) is >50,000 colony forming units (CFU) of a single organism on catheterized culture or 10,000-50,000 CFU with pyuria on urinalysis.

LOCAL PROBLEM

The diagnosis of UTI in our NICU is clinician-dependent and not based on the accepted pediatric definition.

METHODS

A retrospective review of positive urine cultures between 2015 and 2017 was performed.

INTERVENTION

A treatment guideline for positive urine cultures was adopted and PDSA methodology utilized for incremental improvements.

RESULTS

For 909 pre-intervention neonates, 26 of 38 positive urine cultures were treated for UTI but only 23% (6/26) met the pediatric definition. For 644 post-guideline neonates, only 7 of 25 positive urine cultures were treated and 86% met guideline criteria with no increase in urosepsis.

CONCLUSIONS

A guideline to treat positive urine cultures resulted in a decreased rate of UTI diagnosis and thus prevented unnecessary antibiotic exposure.

Clinical manifestations, laboratory markers, and renal ultrasonographic examinations in 1-month to 12-year-old Iranian children with pyelonephritis: a six-year cross-sectional retrospective study

BACKGROUND

Upper urinary tract infection (UTI) or pyelonephritis may increase the pathogenesis rate and risk of severe complications in children due to kidney atrophy.

OBJECTIVE

A set of clinical symptoms, laboratory markers, and ultrasound findings were assessed to achieve the early diagnosis and prognosis of pyelonephritis in hospitalized pediatrics.

METHODS

A cross-sectional study with 104 Iranian children (95 girls and 9 boys) aged 1 month to 12 years with acute pyelonephritis during 2012-2018 was conducted. The ultrasound examination of kidneys and urinary tract during hospitalization, the incidence of clinical symptoms, and laboratory markers in blood and urine were monitored to identify the best predictive factors of early diagnosis of this bacterial infection.

RESULTS

Three-fourth of the patients had one of the four clinical symptoms of abdominal pain, constipation, dysuria, and vomiting, while others were asymptomatic. A much frequency of pyuria (88.46%), Escherichia coli in urine (92.31%), leukocytosis (81.73%), and high ESR (> 10 mm/h, 92.30%) and CRP (> 10 mg/L, 82.82%) was observed. The kidney and urinary tract ultrasonography only in 32.7% of children revealed findings in favor of pyelonephritis (cystitis, ureteral stones, and hydronephrosis).

CONCLUSION

There was a high frequency of clinical signs and laboratory markers associated with pyelonephritis. Ultrasound alone was not an efficient tool to track febrile UTI as most patients presented normal sonography.

Prostatic Abscess in a Neonate

Urinary tract infection (UTI) is the most commonly occurring serious bacterial infection in young infants. Uncircumcised male infants have a higher rate of UTI when compared with circumcised male infants and girls. A prostatic abscess is a very rare clinical variety of UTI, especially in neonates.

We present the case of a 15-day-old male neonate who developed a rare variety of urosepsis. The baby was evaluated and found to have a prostatic abscess. Ultrasound of the abdomen showed an enlarged prostate gland with diffuse heterogeneous hypoechogenicity. Magnetic resonance imaging (MRI) of the pelvis showed an enlarged, lobulated prostate with T2 hyperintense signal and T1 hypointense signal and diffusion restriction. The post-contrast images in the pelvis-MRI also showed peripheral rim enhancement suggestive of a prostatic abscess. Urine culture showed growth of methicillin-resistant Staphylococcus aureus (MRSA). The baby was treated with intravenous vancomycin, and pus was drained through a transurethral approach.

Phimosis can cause purulence in the prostate. Prostatic abscess usually has a good prognosis in neonates when diagnosed early and appropriate treatment was instituted.

Procalcitonin, C-reactive protein, and erythrocyte sedimentation rate for the diagnosis of acute pyelonephritis in children

BACKGROUND

In children with urinary tract infection (UTI), only those with pyelonephritis (and not cystitis) are at risk for developing long-term renal sequelae. If non-invasive biomarkers could accurately differentiate children with cystitis from children with pyelonephritis, treatment and follow-up could potentially be individualized. This is an update of a review first published in 2015.

OBJECTIVES

The objectives of this review were to 1) determine whether procalcitonin (PCT), C-reactive protein (CRP), erythrocyte sedimentation rate (ESR) can replace the acute DMSA scan in the diagnostic evaluation of children with UTI; 2) assess the influence of patient and study characteristics on the diagnostic accuracy of these tests, and 3) compare the performance of the three tests to each other.

SEARCH METHODS

We searched MEDLINE, EMBASE, DARE, Web of Science, and BIOSIS Previews through to 17th December 2019 for this review. The reference lists of all included articles and relevant systematic reviews were searched to identify additional studies not found through the electronic search.

SELECTION CRITERIA

We only considered published studies that evaluated the results of an index test (PCT, CRP, ESR) against the results of an acute-phase ⁹⁹Tc-dimercaptosuccinic acid (DMSA) scan (conducted within 30 days of the UTI) in children aged 0 to 18 years with a culture-confirmed episode of UTI. The following cut-off values were used for the primary analysis: 0.5 ng/mL for procalcitonin, 20 mg/L for CRP and 30 mm/hour for ESR.

DATA COLLECTION AND ANALYSIS

Two authors independently applied the selection criteria to all citations and independently abstracted data. We used the bivariate model to calculate pooled random-effects pooled sensitivity and specificity values.

MAIN RESULTS

A total of 36 studies met our inclusion criteria. Twenty-five studies provided data for the primary analysis: 12 studies (1000 children) included data on PCT, 16 studies (1895 children) included data on CRP, and eight studies (1910 children) included data on ESR (some studies had data on more than one test). The summary sensitivity estimates (95% CI) for the PCT, CRP, ESR tests at the aforementioned cut-offs were 0.81 (0.67 to 0.90), 0.93 (0.86 to 0.96), and 0.83 (0.71 to 0.91), respectively. The summary specificity values for PCT, CRP, and ESR tests at these cut-offs were 0.76 (0.66 to 0.84), 0.37 (0.24 to 0.53), and 0.57 (0.41 to 0.72), respectively.

AUTHORS' CONCLUSIONS

The ESR test does not appear to be sufficiently accurate to be helpful in differentiating children with cystitis from children with pyelonephritis. A low CRP value (< 20 mg/L) appears to be somewhat useful in ruling out pyelonephritis (decreasing the probability of pyelonephritis to < 20%), but unexplained heterogeneity in the data prevents us from making recommendations at this time. The procalcitonin test seems better suited for ruling in pyelonephritis, but the limited number of studies and the marked heterogeneity between studies prevents us from reaching definitive conclusions. Thus, at present, we do not find any compelling evidence to recommend the routine use of any of these tests in clinical practice.

Reporting and Categorization of Blood Culture Contaminants in Infants and Young Children: A Scoping Review

BACKGROUND

Blood cultures are obtained routinely for infants and young children for the evaluation for serious bacterial infection. Isolation of organisms that represent possible contaminants poses a management challenge. The prevalence of bacteremia reported in this population is potentially biased by inconsistent contaminant categorization reported in the literature. Our aim was to systematically review the definition and reporting of contaminants within the literature regarding infant bacteremia.

METHODS

A search of studies published between 1986 and mid-September 2016 was conducted using Medline/PubMed. Included studies examined children aged 0 to 36 months for whom blood culture was performed as part of a serious bacterial infection evaluation. Studies that involved children in an intensive care unit, prematurely born children, and immunocompromised children or those with an indwelling catheter/device were excluded. Data extracted included contaminant designation methodology, organisms classified as contaminants and pathogens, and contamination and bacteremia rates.

DISCUSSION

Our search yielded 1335 articles, and 69 of them met our inclusion criteria. The methodology used to define contaminants was described in 37 (54%) study reports, and 16 (23%) reported contamination rates, which ranged from 0.5% to 22.8%. Studies defined contaminants according to organism species (n = 22), according to the patient's clinical management (n = 4), and using multifactorial approaches (n = 11). Many common organisms, particularly Gram-positive cocci, were inconsistently categorized as pathogens or contaminants.

CONCLUSIONS

Reporting and categorization of blood culture contamination are inconsistent within the pediatric bacteremia literature, which limits our ability to estimate the prevalence of bacteremia. Although contaminants are characterized most frequently according to organism, we found inconsistency regarding the classification of certain common organisms. A standardized approach to contaminant reporting is needed.

Bacterial meningitis in febrile young infants acutely assessed for presumed urinary tract infection: a systematic review

Urinary tract infections, the most common severe bacterial infections in young infants, may be associated with co-existing meningitis. There is no consensus on when to perform a lumbar puncture in these infants. Our aim was to quantify the frequency of co-existing bacterial meningitis in febrile young infants acutely assessed for presumed urinary tract infections. We systematically reviewed PubMed, EMBASE, and the Cochrane Library for studies including infants ≤ 3 months with suspected/confirmed urinary tract infections, who underwent a lumbar puncture. Two investigators independently reviewed articles for inclusion and extracted relevant data. Our outcomes were culture-confirmed meningitis and identification of low-/high-risk criteria of meningitis. Overall 20/2079 studies, including 4191 infants, met inclusion criteria. A total of 11 infants had bacterial meningitis (frequency between 0 and 2.1% across studies) and were mostly neonates. Of 253 infants meeting the low-risk criteria (well-appearing, age > 21 days, procalcitonin ≤ 0.5 ng/ml, and C reactive protein ≤ 20 mg/L) none developed meningitis, but only 15 underwent lumbar puncture.Conclusion: Co-existing bacterial meningitis in febrile young infants with urinary tract infection is rare. In those meeting low-risk criteria, a lumbar puncture may not be indicated. A case by case assessment should be made in infants not meeting low-risk criteria.Trial registration: CRD42018105339 What is known: • When caring for febrile infants ≤ 3 months with urinary tract infections, clinicians may have uncertainty on whether to perform a lumbar puncture (LP) for possible co-existing meningitis What is new: • An up-to-date systematic review of 20 studies found the frequency of co-existing meningitis in this population to be between 0 and 2.1% • Despite limited data, an LP may not be indicated in infants meeting low-risk criteria (being well-appearing, age > 21 days, procalcitonin ≤ 0.5 ng/ml, C reactive protein ≤ 20 mg/L). Ill-appearance and neonatal age appear to be significant risk factors of co-existing meningitis.

Pediatric Genitourinary Infections and Other Considerations

Pediatric patients pose a unique host of challenges to the emergency provider across all complaints and ages, but this is particularly notable in the genitourinary (GU) system. The pediatric GU system is different from that of the adult in its etiology of symptoms, complications, and treatments. Based on age, there are variations in the anatomy. These differences result in symptoms and diagnoses that must be managed differently. Although in many respects management is similar to GU emergency conditions in adults, there are, occasionally subtle, differences between the care of children and adults, which can greatly impact outcomes.

Association of Diagnostic Criteria With Urinary Tract Infection Prevalence in Bronchiolitis: A Systematic Review and Meta-analysis

IMPORTANCE

Concomitant urinary tract infection (UTI) is a frequent concern in febrile infants with bronchiolitis, with a prior meta-analysis suggesting a prevalence of 3.3%. However, the definition of UTI in these studies has generally not incorporated urinalysis (UA) results.

OBJECTIVE

To conduct a systematic review and meta-analysis examining the prevalence of UTI in infants with bronchiolitis when positive UA results are incorporated into the UTI definition.

DATA SOURCES

Medline (1946-2017) and Ovid EMBASE (1976-2017) through August 2017 and bibliographies of retrieved articles.

STUDY SELECTION

Studies reporting UTI prevalence in bronchiolitis.

DATA EXTRACTION

Data were extracted in accordance with meta-analysis of observational studies in epidemiology guidelines via independent abstraction by multiple investigators. Random-effects models generated a weighted pooled event rate with corresponding 95% confidence intervals.

MAIN OUTCOMES AND MEASURES

Prevalence of UTI.

RESULTS

We screened 477 unique articles by abstract, with full-text review of 30 studies. Eighteen bronchiolitis studies reported a UTI prevalence and 7 of these reported UA data for inclusion in the meta-analysis. The overall reported prevalence of UTI in bronchiolitis from these 18 studies was 3.1% (95% CI, 1.8%-4.6%). With the addition of positive UA results (defined as the presence of pyuria or nitrites) as a diagnostic criterion, the prevalence of UTI as reported in the 7 studies in bronchiolitis was 0.8% (95% CI, 0.3%-1.4%). Sensitivity analyses yielded similar results, including for infants younger than 90 days. Heterogeneous definitions of UTI and UA criteria introduced uncertainty into prevalence estimates.

CONCLUSIONS AND RELEVANCE

When a positive UA result is added as a diagnostic criterion, the estimated prevalence of concomitant UTI is less than recommended testing thresholds for bronchiolitis.

Urine flow cytometry is an adequate screening tool for urinary tract infections in children

Diagnosing a urinary tract infection in children is often difficult due to non-specific symptoms and requires invasive and time-consuming procedures. Flow cytometry is a new and rapid method of analyzing urine to confirm or exclude UTIs. We have investigated the sensitivity and specificity of urine flow cytometry (Sysmex UF1000i) compared to conventional diagnostic techniques in a prospective study from January 1, 2014 until January 1, 2015. All children under 13 years of age with a suspicion of urinary tract infection were screened using both urine flow cytometry and urine culture. A urinary tract infection was defined as the combination of leukocyturia (≥ 25 leukocytes per μl) and a positive urine culture in the presence of clinical symptoms. A total number of 412 urine samples were collected, of which 63 cases (15.3%) were positive for a urinary tract infection. Receiver operating characteristic analysis showed an area under the curve of 0.97 (95% confidence interval h0.93-1.00) for the bacterial count. When using a cut-off value of 250 bacteria/μl in the presence of leukocyturia, the sensitivity for urinary tract infection is 0.97 with a negative predictive value of 97%, and the specificity is 0.91 with a positive predictive value of 90%.Conclusion: Flow cytometry-based bacterial and leukocyte count analysis is a time-efficient method of diagnosing or ruling out urinary tract infection in children, with a higher sensitivity and specificity than dipstick and microscopic analysis. What is known • Screening for urinary tract infections in children is difficult due to invasive and time-consuming procedures. • There is both over- and under-treatment of urinary tract infections due to the delays in accurate diagnosing. What is new • Flow cytometry is a rapid and accurate method to provide useful information in the diagnosis of urinary tract infection in children. When negative, flow cytometry can exclude urinary tract infection in children with a high degree of confidence. When flow cytometry is positive, the possibility of a urinary tract infection in children is increased.

Clinical and laboratory features of urinary tract infections in young infants

Introduction:

Urinary tract infection (UTI) is the most common serious bacterial infection in young infants. Signs and symptoms are often nonspecific.

Objectives:

To describe clinical, demographic and laboratory features of UTI in infants ≤ 3 months old.

Methods:

Cross-sectional study of infants ≤ 3 months old with UTI diagnosed in a pediatric emergency department, for the period 2010-2012. UTI was defined as ≥ 50,000 colony-forming units per milliliter of a single uropathogen isolated from bladder catheterization. Paired urinalysis and urine culture from group culture-positive and group culture-negative were used to determine the sensitivity and specificity of pyuria and nitrite tests in detecting UTI.

Results:

Of 519 urine cultures collected, UTI was diagnosed in 65 cases (prevalence: 12.5%); with male predominance (77%). The most common etiologies were Escherichia coli (56.9%), Klebsiella pneumoniae (18.5%) and Enterococcus faecalis (7.7%). Frequent clinical manifestations were fever (77.8%), irritability (41.4%) and vomiting (25.4%). The median temperature was 38.7°C. The sensitivity of the nitrite test was 30.8% (95%CI:19.9-43.4%), specificity of 100% (95%CI:99.2-100%). Pyuria ≥ 10,000/mL had a sensitivity of 87.7% (95%CI:77.2-94.5%), specificity of 74.9% (95%CI:70.6 -78.8%). The median peripheral white blood cell count was 13,150/mm³; C-reactive protein levels were normal in 30.5% of cases.

Conclusions:

The male: female ratio for urinary tract infection was 3.3:1. Non-Escherichia coli etiologies should be considered in empirical treatment. Fever was the main symptom. Positive nitrite is highly suggestive of UTI but has low sensitivity; whereas pyuria ≥ 10,000/mL revealed good sensitivity, but low specificity. Peripheral white blood cell count and C-reactive protein concentration have limited usefulness to suggest UTI.

Randomized Clinical Trial of Lidocaine Analgesia for Transurethral Bladder Catheterization Delivered via Blunt Tipped Applicator in Young Children

OBJECTIVE

Transurethral bladder catheterization (TUBC) is a painful, frequently performed procedure for collecting sterile urine. We sought to determine if administration of intraurethral lidocaine before TUBC using a blunt tipped syringe decreases procedural pain in young children in the pediatric emergency department.

METHODS

Randomized clinical trial of children 0 to 36 months old requiring TUBC for collection of urine in a pediatric emergency department was performed. Patients received intraurethral 2% lidocaine jelly or usual care (no analgesia). Randomization was stratified by sex. Intraurethral lidocaine jelly was administered via Uro-Jet, 5 minutes before TUBC. Baseline child state, lidocaine application, TUBC, and child state 1 minute post-TUBC were videotaped. Neither providers nor parents were blinded to study arm. Videos were scored by a trained, independent, blinded reviewer using the Faces, Legs, Arms, Cry, and Consolability (FLACC) and Modified Behavioral Pain Score scales. Pain scores were compared using the Wilcoxon rank sum test. Our primary outcome was difference in FLACC scores between groups.

RESULTS

Eighty children were enrolled in the study, and 73 had analyzable data. No differences were detected in pain by mean FLACC score between intervention (8; 95% confidence interval, 7-9) and control (9; 95% confidence interval, 8-10) groups. There were no differences between groups in mean FLACC score when stratified by age or sex or in mean Modified Behavioral Pain Score.

CONCLUSIONS

Intraurethral lidocaine for TUBC for urine collection using a blunt tipped applicator did not improve procedural pain scores. Pain scores were high across groups. Further study should be performed to improve analgesia for this highly painful procedure.

Diagnostic accuracy of urinary biomarkers in infants younger than 3 months with urinary tract infection

Purpose

The aim of this study was to evaluate the diagnostic accuracy of urinary biomarkers, such as neutrophil gelatinase-associated lipocalin (uNGAL) and β-2 microglobulin (uB2MG), in early detection of urinary tract infection (UTI) in infants aged <3 months with fever.

Methods

A total of 422 infants aged <3 months (male:female=267:155; mean age, 56.4 days), who were admitted for fever, were retrospectively included in this study. We compared uNGAL and uB2MG between the UTI and non-UTI groups at the time of admission. The sensitivity, specificity, accuracy, and area under the curve (AUC) of uNGAL and uB2MG for use in diagnosing UTI were assessed.

Results

Among 422 patients, 102 (24.2%) were diagnosed with UTI. Levels of uNGAL were higher in the UTI group than in the non-UTI group (366.6 ng/mL vs. 26.9 ng/mL, P<0.001). Levels of uB2MG were not different between the 2 groups. Multivariate analysis revealed that uNGAL was an independent predictive factor for UTI (P=0.033). The sensitivity, specificity, and accuracy were 90.2%, 92.5%, and 91.9% for uNGAL, and 48.0%, 43.8%, and 44.8% for uB2MG, respectively. AUC of uNGAL was 0.942 and that of uB2MG was 0.407.

Conclusion

Accuracy of uNGAL in the diagnosis of UTI is high in febrile infants aged <3 months. uNGAL can help in the early diagnosis and treatment of UTI in infants.

Late-onset sepsis due to urinary tract infection in very preterm neonates is not uncommon

Urinary tract infection (UTI) is a common cause of sepsis in infants. Premature infants hospitalized at a neonatal intensive care unit often have risk factors for infection. In this group, the risk of UTI is not clearly known, and guidelines for urine analysis are not unanimous. We aimed to identify the risk of UTI in premature infants with central lines, suspected of late-onset sepsis. We analyzed all 1402 infants admitted to our hospital between 2006 and 2014 with a gestational age less than 32 weeks. Six hundred sixty-two episodes of sepsis evaluations were found with an unknown source of infection based on clinical symptoms. In half of this group, urine analysis was performed identifying UTI in 11.3% (24/212). In 13 of these infants (54%) with a UTI, infection was due to Candida albicans. In at least four episodes, the diagnosis and treatment would have been delayed if urine analysis had not been performed.

CONCLUSION

Based on these findings, we conclude that in premature infants with central lines, urine analysis should be performed routinely when signs of infection occur beyond 72 h after birth. Urine collection should not be delayed and cultures should preferably be performed before the start of the antibiotic treatment. What is known: • In preterm infants, the presence of other risk factors for infection might make clinicians reluctant to obtain urine cultures during sepsis evaluation. • An internal survey demonstrated that there is no consensus within the NICUs in The Netherlands regarding urine analysis as part of LOS work-up. What is new: • The risk of UTI in the NICU population (11.3%) is comparable to term infants; therefore, urine analysis should be performed routinely when LOS is suspected. • Candida albicans was the most frequently (54%) detected pathogen causing UTI in this population.

Trends in Intravenous Antibiotic Duration for Urinary Tract Infections in Young Infants

OBJECTIVES

To assess trends in the duration of intravenous (IV) antibiotics for urinary tract infections (UTIs) in infants ≤60 days old between 2005 and 2015 and determine if the duration of IV antibiotic treatment is associated with readmission.

METHODS

Retrospective analysis of infants ≤60 days old diagnosed with a UTI who were admitted to a children's hospital and received IV antibiotics. Infants were excluded if they had a previous surgery or comorbidities, bacteremia, or admission to the ICU. Data were analyzed from the Pediatric Health Information System database from 2005 through 2015. The primary outcome was readmission within 30 days for a UTI.

RESULTS

The proportion of infants ≤60 days old receiving 4 or more days of IV antibiotics (long IV treatment) decreased from 50% in 2005 to 19% in 2015. The proportion of infants ≤60 days old receiving long IV treatment at 46 children's hospitals varied between 3% and 59% and did not correlate with readmission (correlation coefficient 0.13; P = .37). In multivariable analysis, readmission for a UTI was associated with younger age and female sex but not duration of IV antibiotic therapy (adjusted odds ratio for long IV treatment: 0.93 [95% confidence interval 0.52-1.67]).

CONCLUSIONS

The proportion of infants ≤60 days old receiving long IV treatment decreased substantially from 2005 to 2015 without an increase in hospital readmissions. These findings support the safety of short-course IV antibiotic therapy for appropriately selected neonates.

The Utility of Real-Time Quantitative Polymerase Chain Reaction Genotype Detection in the Diagnosis of Urinary Tract Infections in Children

Urinary tract infections (UTIs) are the most common serious bacterial infection in children with significant morbidity with delayed diagnosis. Polymerase chain reaction (PCR) is very accurate in detecting bacteria and widely available, but has never been evaluated to detect UTIs in children. To assess the utility of PCR as a rapid diagnostic tool, we conducted a prospective cohort study of 193 urine samples from children younger than 36 months undergoing evaluation for UTI in the emergency department over a 10-month period. A quantification cycle (Cq) threshold of 26.15 identified all Escherichia coli positive samples with sensitivity and specificity of 100% and 99.5%, respectively (95% CI = 71.5%-100% and 97.9%-99.5%, respectively). A Cq threshold of 19.03 identified E coli infections >100 000 colony forming units/mL with sensitivity and specificity of 100% (95% CI = 72.2%-100% and 98.6%-100%, respectively). PCR is very accurate in diagnosing E coli UTIs in young children and could be useful as a rapid diagnostic tool.

New markers of urinary tract infection

Urinary tract infection (UTI) is the most common bacterial infection independent of age. It is also one of the most common causes of hospitalizations for infections among elderly people and the most common indication for antibiotic prescriptions in primary care. Both diagnostics and management of lower and upper urinary tract infections provide challenges in clinical practice due to their high prevalence and recurrence, and worldwide increase of antibiotic resistance. The clinical symptoms of UTI are often uncharacteristic or asymptomatic. The accurate diagnosis and early treatment are crucial due to risk of septicaemia and long-term consequences. Currently the diagnosis of urinary tract infection is based on the presence of clinical symptoms in combination with the results of nitrite strip test indicating the presence of bacteria in urine and semi-quantitative measurement of white blood cells count in urine. Although urine culture is the gold standard in UTI diagnostics it is both time-consuming and costly. Searching for novel biomarkers of UTI has attracted much attention in recent years. The article reviews several promising serum and urine biomarkers of UTI such as leukocyte esterase, C-reactive protein, procalcitonin, interleukins, elastase alpha (1)-proteinase inhibitor, lactofferin, secretory immunoglobulin A, heparin-binding protein, xanthine oxidase, myeloperoxidase, soluble triggering receptor expressed on myeloid cells-1, α-1 microglobulin (α1Mg) and tetrazolium nitroblue test (TNB).

Evaluation of a New Strategy for Clean-Catch Urine in Infants

BACKGROUND AND OBJECTIVES

A new noninvasive bladder stimulation technique has been described to obtain clean-catch urine (CCU) in infants aged <30 days. Objectives were (1) to determine proportion and predictive factors for successful CCU collections using a stimulation maneuver technique among infants <6 months and (2) to determine the proportion of bacterial contamination with this method.

METHODS

A prospective cohort study was conducted in a tertiary pediatric emergency department among infants <6 months needing a urine sample. CCU samples were collected using a standardized stimulation technique. Invasive technique was performed after CCU for three specific conditions. Primary outcomes were proportions of successful CCU specimens and bacterial contamination. We determined associations between successful urine samples and 4 predictive factors (age, sex, low oral intake, and recent voiding).

RESULTS

A total of 126 infants were included (64 boys, median age: 55 days). The CCU procedure was effective in 62 infants (49%; median time: 45 seconds). Infants 0 to 29 days; 30 to 59 days, and 60 to 89 days had more successful procedures, compared with infants >89 days (odds ratios [95% confidence interval (CI)]: 4.3 [1.4 to 13.4]; 3.2 [1.2 to 8.4]; and 4.44 [1.5 to 13.3], respectively). The contamination proportion was 16% (95% CI: 8% to 27%) in the CCU group. This proportion was not statistically different compared with the invasive method group (6%, 95% CI: 3% to 15%).

CONCLUSIONS

The CCU procedure is a quick and effective noninvasive method in children aged <90 days. Contamination proportions were similar to those reported in the literature for urethral catheterization. Circumstances for which the CCU procedure could be performed are proposed.

Antimicrobial Resistance and Diagnostic Imaging in Infants Younger Than 2 Months Old Hospitalized With a First Febrile Urinary Tract Infection: A Population-based Comparative Study

BACKGROUND

Data on urinary tract infection (UTI) in infants ≤2 months of age are limited. We examined clinical characteristics, antimicrobial resistance, imaging findings and clinical outcomes in infants ≤2 months of age and children 2-24 months of age hospitalized with the first febrile UTI.

METHODS

Children ≤24 months of age hospitalized with their first-diagnosed febrile UTI were prospectively studied. Renal ultrasonography, Tc-dimercaptosuccinic acid scanning and voiding cystourethrography were performed in all children.

RESULTS

Of the 388 children analyzed (255 boys and 133 girls), 61 patients were ≤2 months of age, representing 15.7% of the whole population, whereas 327 patients were 2-24 months of age. Escherichia coli was the predominant bacterium, with similar antimicrobial resistance in the 2 groups, and associated E. coli bacteremia occurred in 9 patients (2.3%). Renal ultrasonography showed abnormal findings in 130 patients (33.5%), but there was no difference in the rate of abnormal findings between the groups. Vesicoureteral reflux (VUR) was present in 130 children (33.5%), including 93 (24%) with grades III-V VUR. VUR was more prevalent in the infants ≤2 months of age (P = 0.007), but there was no difference in the prevalence of grades III-V VUR between the groups. The incidence of renal scarring was 28.6% (111/388), and it did not differ between the groups.

CONCLUSIONS

There are similarities in clinical characteristics, antimicrobial resistance, imaging findings and clinical outcomes after a first UTI between the young infants ≤2 months and children 2-24 months of age. The same guidelines for the diagnosis and management after the first febrile UTI can be applied to children who are ≤24 months of age.

Meta-analysis to Determine Risk for Serious Bacterial Infection in Febrile Outpatient Neonates With RSV Infection

OBJECTIVES

This study aimed to analyze a large group of febrile neonates 28 days or younger who received outpatient sepsis evaluation and nasopharyngeal aspirate antigen testing (NPAT) for respiratory syncytial viral (RSV) infection to determine whether there is a clinically significant association between viral study results and risk for serious bacterial infection (SBI: bacterial meningitis, bacteremia, urinary tract infection, bacterial enteritis).

METHODS

We evaluated consecutive febrile neonates 28 days or younger presenting to our urban pediatric emergency department [Maimonides Medical Center (MMC)] during a 6-year period, all of whom received a sepsis evaluation (cerebrospinal fluid, blood, urine cultures) and RSV NPAT. To achieve adequate power (80%), the MMC data were combined with similar data reported from a prior prospective PEM-CRC study of like-aged febrile neonates who received similar evaluation.

RESULTS

From the MMC data of consecutively evaluated cases, the prevalence rate of +RSV in 387 febrile neonates was 6%. Of these, 378 (98%) received both a sepsis evaluation and RSV NPAT; +SBI occurred in 4/22 (18.1%) with +RSV versus 58/356 (16.2%) with -RSV (P = 0.77). Combined with the PEM-CRC cohort of 411 febrile neonates 28 days or younger who received similar evaluation, a total of 789 cases were analyzed using meta-analysis. Overall, there were 117 (14.8%) cases of +SBI and 104 (13.2%) cases of +RSV. The rate of +SBI was 11.5% in those with +RSV versus 15.3% in those with -RSV. Meta-analysis performed showed no significant difference in rates of +SBI between those with and without +RSV (odds ratio, 0.78; 95% confidence interval, 0.41-1.50; P = 0.46).

CONCLUSIONS

Rates of +SBI are not significantly different between febrile neonates 28 days or younger with and without +RSV. Respiratory viral infection status is not an accurate clinical determinant in distinguishing SBI risk in febrile neonates.

Early prediction of urinary tract infection in neonates with hyperbilirubinemia

Introduction: Hyperbilirubinemia is a common manifestation of infectious disorders during the neonatal period. Urinary tract infection (UTI) is one of the serious bacterial infections with hyperbilirubinemia among newborn infants.

Objectives: The aim of this study was to identify the early predictive risk factors of UTI in neonates with hyperbilirubinemia, to prevent its long-term complications.

Patients and Methods: A total of 95 neonatal hyperbilirubinemia were evaluated in 2 groups with (n = 40) and without UTI (n = 55).

Results: Mean age at diagnosis of UTI was 16.37 ± 8.86 days. Hyperbilirubinemia was detected in 70% of patients during the first week of life. There was a significant difference regarding the age at admission, duration of hyperbilirubinemia, serum bilirubin and creatinine, white blood cells (WBC) , and also Hgb levels between the 2 groups in univariate analysis. However, prolonged jaundice (OR = 10.3, P = 0.001) and serum bilirubin concentration (OR = 5.15, P = 0.001) were statistically associated with a positive urine culture in multivariate analysis.

Conclusion: Screening of UTI is recommended in neonates with prolonged unexplained jaundice, leukocytosis, and increased serum creatinine.

High prevalence and antimicrobial resistance of urinary tract infection isolates in febrile young children without localizing signs in Taiwan

BACKGROUND

Antimicrobial susceptibility and prevalence of pediatric urinary tract infection (UTI) is very useful for pediatricians in selecting effective antibiotics in time to improve outcomes in patients. This study aimed to determine the prevalence rate, bacterial distribution, and antimicrobial susceptibility of UTI in febrile young children at a teaching hospital in northern Taiwan.

METHODS

From January 2011 to December 2011, all urinary isolates from suspected cases of UTI in febrile young children aged from 1 day to 36 months visiting the Pediatric Emergency Room of Chang Gung Children's Hospital, Taoyuan, Taiwan were identified by conventional methods. Antibiotic susceptibility was determined according to the Clinical and Laboratory Standards Institute.

RESULTS

A total of 5470 (78%) from 7009 eligible children were enrolled in the study, and 619 (11.3%) had a diagnosis of UTI. The most prevalent bacterium was Escherichia coli (68%) followed by Klebsiella pneumoniae (8.1%) and Proteus mirabilis (6.8%). Ampicillin, piperacillin, and trimethoprim-sulfamethoxazole (TMP-SMX) showed a higher resistance rate in the three predominant bacteria. All tested bacteria showed higher resistance to ampicillin (79.3%) and TMP-SMX (44.1%), and lower resistance to cefazolin (17.7%) and gentamicin (13.0%). Fourteen percent of the isolates produced extended spectrum β-lactamase (ESBL), among which 93.33% were E. coli isolates.

CONCLUSION

The overall prevalence of UTI in this study was higher than previously reported in febrile children. Higher antimicrobial resistance was found in ampicillin and TMP-SMX. Among commonly used antibiotics, cefazolin and gentamicin are recommended to treat UTI in febrile children aged < 3 years without localizing signs.

Diagnostic accuracy of the urinalysis for urinary tract infection in infants <3 months of age

BACKGROUND

The 2011 American Academy of Pediatrics urinary tract infection (UTI) guideline suggests incorporation of a positive urinalysis (UA) into the definition of UTI. However, concerns linger over UA sensitivity in young infants. Infants with the same pathogenic organism in the blood and urine (bacteremic UTI) have true infections and represent a desirable population for examination of UA sensitivity.

METHODS

We collected UA results on a cross-sectional sample of 276 infants <3 months of age with bacteremic UTI from 11 hospital systems. Sensitivity was calculated on infants who had at least a partial UA performed and had ≥50 000 colony-forming units per milliliter from the urine culture. Specificity was determined by using a random sample of infants from the central study site with negative urine cultures.

RESULTS

The final sample included 245 infants with bacteremic UTI and 115 infants with negative urine cultures. The sensitivity of leukocyte esterase was 97.6% (95% confidence interval [CI] 94.5%-99.2%) and of pyuria (>3 white blood cells/high-power field) was 96% (95% CI 92.5%-98.1%). Only 1 infant with bacteremic UTI (Group B Streptococcus) and a complete UA had an entirely negative UA. In infants with negative urine cultures, leukocyte esterase specificity was 93.9% (95% CI 87.9 - 97.5) and of pyuria was 91.3% (84.6%-95.6%).

CONCLUSIONS

In young infants with bacteremic UTI, UA sensitivity is higher than previous reports in infants with UTI in general. This finding can be explained by spectrum bias or by inclusion of faulty gold standards (contaminants or asymptomatic bacteriuria) in previous studies.

Prevalence of upper urinary tract anomalies in hospitalized premature infants with urinary tract infection

OBJECTIVE

The 2011 American Academy of Pediatrics (AAP) guidelines address imaging after initial febrile urinary tract infection (UTI) in infants >2 months of age. We sought to determine the frequency of upper urinary tract anomalies (hydronephrosis and vesicoureteral reflux (VUR)) in hospitalized premature infants with UTI.

STUDY DESIGN

We retrospectively reviewed the electronic medical records of neonatal intensive care unit (NICU) admissions at a tertiary care children's hospital between 1 January 2006 and 31 December 2010. We queried the records for UTI, renal ultrasound (US) and voiding cystourethrogram (VCUG).

RESULT

We identified 3518 unique admissions. UTI occurred in 118 infants (3%). Sixty-nine (60%) had a normal US. Renal dilation was predominantly renal pelvic dilation (12%) and isolated caliectasis (22%). VUR was identified in 15 (14%) infants evaluated with a VCUG. VUR was identified in nine (12%) infants without and in seven (16%) with an abnormality on US. Reflux was identified in 7% of male and 38% of female infants with a UTI.

CONCLUSION

Anatomic abnormalities of the upper urinary tract are uncommon in premature infants with a UTI that occurs during neonatal hospitalization. In concordance with the AAP guidelines, a VCUG may not be required in all NICU infants under age 2 months after a single UTI.

Urinary tract infections in the infant

Urinary tract infection (UTI) in an infant may be the first indication of an underlying renal disorder. Early recognition and initiation of adequate therapy for UTI is important to reduce the risk of long-term renal scarring. Ampicillin and gentamicin are traditionally the empiric treatment of choice; however, local antibiotic resistance patterns should be considered. Maternal antibiotics during pregnancy also increase the risk of resistant pathogens during neonatal UTI. Long-term management after the first UTI in infants remains controversial because of lack of specific studies in this age group and the risk-benefit issues for antibiotic prophylaxis between reduced recurrent disease and emergent antibiotic resistance.

Procalcitonin, C-reactive protein, and erythrocyte sedimentation rate for the diagnosis of acute pyelonephritis in children

BACKGROUND

In children with urinary tract infection (UTI), only those with pyelonephritis (and not cystitis) are at risk for developing long-term renal sequelae. If non-invasive biomarkers could accurately differentiate children with cystitis from children with pyelonephritis, treatment and follow-up could potentially be individualized.

OBJECTIVES

The objectives of this review were to 1) determine whether procalcitonin, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR) can replace the acute DMSA scan in the diagnostic evaluation of children with UTI; 2) assess the influence of patient and study characteristics on the diagnostic accuracy of these tests, and 3) compare the performance of the three tests to each other.

SEARCH METHODS

We searched MEDLINE, EMBASE, DARE, Web of Science, and BIOSIS Previews for this review. The reference lists of all included articles and relevant systematic reviews were searched to identify additional studies not found through the electronic search.

SELECTION CRITERIA

We only considered published studies that evaluated the results of an index test (procalcitonin, CRP, ESR) against the results of an acute-phase DMSA scan (conducted within 30 days of the UTI) in children aged 0 to 18 years with a culture-confirmed episode of UTI. The following cutoff values were used for the primary analysis: 0.5 ng/mL for procalcitonin, 20 mg/L for CRP and 30 mm/h for ESR.

DATA COLLECTION AND ANALYSIS

Two authors independently applied the selection criteria to all citations and independently abstracted data. We used the bivariate model to calculate pooled random-effects pooled sensitivity and specificity values.

MAIN RESULTS

A total of 24 studies met our inclusion criteria. Seventeen studies provided data for the primary analysis: six studies (434 children) included data on procalcitonin, 13 studies (1638 children) included data on CRP, and six studies (1737 children) included data on ESR (some studies had data on more than one test). The summary sensitivity estimates (95% CI) for the procalcitonin, CRP, ESR tests at the aforementioned cutoffs were 0.86 (0.72 to 0.93), 0.94 (0.85 to 0.97), and 0.87 (0.77 to 0.93), respectively. The summary specificity values for procalcitonin, CRP, and ESR tests at these cutoffs were 0.74 (0.55 to 0.87), 0.39 (0.23 to 0.58), and 0.48 (0.33 to 0.64), respectively.

AUTHORS' CONCLUSIONS

The ESR test does not appear to be sufficiently accurate to be helpful in differentiating children with cystitis from children with pyelonephritis. A low CRP value (< 20 mg/L) appears to be somewhat useful in ruling out pyelonephritis (decreasing the probability of pyelonephritis to < 20%), but unexplained heterogeneity in the data prevents us from making recommendations at this time. The procalcitonin test seems better suited for ruling in pyelonephritis, but the limited number of studies and the marked heterogeneity between studies prevents us from reaching definitive conclusions. Thus, at present, we do not find any compelling evidence to recommend the routine use of any of these tests in clinical practice.

Diagnosis and management of urinary tract infection and vesicoureteral reflux in the neonate

Urinary tract infection (UTI) is the most common bacterial infection in febrile newborns, particularly those born prematurely and with a low birth weight. Vesicoureteral reflux (VUR) predisposes to UTI and renal scarring. Half of neonates with UTI may have only low-grade fever or no fever. Jaundice in the absence of any other symptoms or signs may be the only clinical manifestation of UTI in neonates. The urinalysis may be negative in a significant number of neonates with UTI. Newborns with UTI have a high incidence of congenital anomalies of kidney and urinary tract anomalies, and hence should undergo renal imaging.

Automated urinalysis and urine dipstick in the emergency evaluation of young febrile children

OBJECTIVE

The performance of automated flow cytometric urinalysis is not well described in pediatric urinary tract infection. We sought to determine the diagnostic performance of automated cell counts and emergency department point-of-care (POC) dipstick urinalyses in the evaluation of young febrile children.

METHODS

We prospectively identified a convenience sample of febrile pediatric emergency department patients <48 months of age who underwent urethral catheterization to obtain POC and automated urinalyses and urine culture. Receiver operating characteristic analyses were performed and diagnostic indices were calculated for POC dipstick and automated cell counts at different cutpoints.

RESULTS

Of 342 eligible children, 42 (12%) had urinary bacterial growth ≥ 50000/mL. The areas under the receiver operating characteristic curves were: automated white blood cell count, 0.97; automated bacterial count, 0.998; POC leukocyte esterase, 0.94; and POC nitrite, 0.76. Sensitivities and specificities were 86% and 98% for automated leukocyte counts ≥ 100/μL and 98% and 98% for bacterial counts ≥ 250/μL. POC urine dipstick with ≥ 1+ leukocyte esterase or positive nitrite had a sensitivity of 95% and a specificity of 98%. Combinations of white blood cell and bacterial counts did not outperform bacterial counts alone.

CONCLUSIONS

Automated leukocyte and bacterial counts performed well in the diagnosis of urinary tract infection in these febrile pediatric patients, but POC dipstick may be an acceptable alternative in clinical settings that require rapid decision-making.

Factors associated with bacteremia in young infants with urinary tract infection

BACKGROUND

Urinary tract infection (UTI) is the most frequent severe bacterial infection in infants. Up to 31% of infants with UTI have bacteremia.

METHODS

We retrospectively identified all infants aged 0-2 months who were managed in our hospital with UTI during a 1-year period. Those with bacteremia were compared with those without bacteremia, according to the following variables: ethnicity, age, gender, white blood cell and polymorphonuclear counts, C-reactive protein, urinalysis and blood creatinine values as related to age-appropriate norms, imaging and outcome.

RESULTS

We identified 81 infants with 82 episodes of UTI. Most occurred in males (72.8%) and 35 (42.7%) were in infants of non-Jewish origin. In 14/81 (17.3%) of episodes, Escherichia coli was cultured from blood. In multivariate analysis, increased blood creatinine levels (P = 0.004) and non-Jewish origin (P = 0.006) were associated with bacteremia. Time to defervescence was significantly longer in bacteremic versus nonbacteremic children (P = 0.018). Duration of hospitalization was longer in bacteremic infants-10 (7-17) days in bacteremic versus 7 (1-14) days in nonbacteremic children (P < 0.001).

CONCLUSIONS

In infants aged 0-2 months with UTI, increased blood creatinine value at admission was associated with bacteremia. This value provides an additional clue on admission, independent of personal judgment, to help identify infants at higher risk for bacteremia, prolonged hospitalization and possible complications.

Decreased concentrating capacity in children with febrile urinary tract infection and normal 99mTc-dimercaptosuccinic acid scan: does medullonephritis exist?

BACKGROUND

Although 99mTc-dimercaptosuccinic acid (DMSA) scan is considered the gold standard for the diagnosis of acute pyelonephritis (AP), sometimes it produces false results in children with clinical features of AP. There are no studies on the comparison of the sensitivity of DMSA and concentrating capacity test.

METHODS

Eighty-five infants with AP of less than one year old were studied to evaluate whether they had real AP or not. Data were compared between infants with an abnormal (group A, n=64) and those with a normal DMSA scan (group B, n=21) respectively. A DDAVP test was performed for each infant.

RESULTS

All the infants in both groups presented a high level of C-reactive protein and fever (≥38°C). There were no differences in clinical and analytical variables except C-reactive protein level in the two groups. Both groups exhibited a low urinary osmolality (87.5% in the group A vs. 85.7% in the group B). The patients with normal DMSA and decreased concentrating capacity have some renal parenchymal damage and not only a lower urinary infection. Of the infants with an abnormal DMSA scan, 33.9% showed renal scars after 6-12 months. No infant with a normal DMSA scan showed scars. The biochemical variables in both groups of infants were not related to vesicoureteral refl ux.

CONCLUSION

Infants with AP, normal DMSA scan and low concentrating capacity may be characterized by a localized infection in the medulla (medullonephritis) or by a false negative DMSA scan.

Urinary tract infection in outpatient febrile infants younger than 30 days of age: a 10-year evaluation

BACKGROUND

To determine the prevalence of outpatient-diagnosed urinary tract infection (UTI) in consecutive febrile neonates ≤ 30 days of age and correlate demographic, laboratory and radiographic imaging results with infectious etiology.

METHODS

Review of medical records of consecutive febrile infants ≤ 30 days of age presenting to an urban pediatric emergency department during a 10-year period, whose policy is to perform a sepsis evaluation (urine culture obtained by bladder catheterization) and hospitalize for parenteral antibiotic therapy pending culture results.

RESULTS

Of 670 febrile neonates ≤ 30 days of age evaluated for sepsis, urine culture was obtained in 651 cases (97%). Of 100 patients with UTI (15.4%), 73% were male; the most common uropathogens were Escherichia coli (71%), Enterococcus (10%) and Klebsiella sp. (10%). In all, 39% had a maximum documented fever ≥ 102 °F, and 40% had CBC total white blood cells count ≥ 15,000/mm(3). Urine dipstick test was positive for leukocyte esterase or nitrite in 79%. Renal ultrasound performed in 95 patients (95%) showed anatomic abnormalities in 47%; 5/26 (24%) with hydronephrosis had vesicoureteral reflux on voiding cystourethrogram. Four patients had urosepsis; none had bacterial meningitis and no patients died.

CONCLUSIONS

UTI affects approximately 1 in 6 febrile neonates ≤ 30 days of age. Males are affected 2.5-times greater than females. E. coli continues to be the predominant uropathogen. Clinical parameters like height of fever, CBC total white blood cell count and urine dipstick test lack sensitivity in identifying UTI risk in the outpatient setting. Only 4 infants had urosepsis (4%). Nearly half of neonates with UTI have a radiographically identified anatomic abnormality. All febrile young infants should receive performance of a urine culture; those with UTI require imaging.

Diagnostic markers of serious bacterial infections in febrile infants younger than 90 days old

BACKGROUND

The aim of this study was to assess correlations between demographic, clinical and laboratory characteristics and the risk of serious bacterial infection (SBI) in febrile <90-day-old infants.

METHODS

Medical records of all infants younger than 90 days old hospitalized at Dana-Dwek Children's Hospital (2006-2008) for evaluation of fever were retrospectively reviewed. Data on clinical, laboratory and demographic characteristics were retrieved and evaluated.

RESULTS

Forty-eight of the 401 study infants (12%) had SBI: most of them had urinary tract infection (43 infants; 90% of all SBI), three infants had bacteremia, one had bacterial pneumonia and one had bacterial meningitis. Significant independent clinical predictors for the diagnosis of SBI included duration of fever, absence of rhinitis and the absence of lung and skin manifestations. Significant independent laboratory predictors were absolute neutrophil count (ANC), platelets, blood urea nitrogen and C-reactive protein (CRP) level. On receiver operating characteristic curve analysis, the CRP area under the curve (0.819) was significantly superior to ANC and leukocyte count.

CONCLUSION

Of the clinical and laboratory variables selected for evaluation, qualitative CRP was the strongest independent predictor for diagnosing SBI and a significantly better diagnostic marker than clinical characteristics, ANC and white blood cell count.

Prevalence of urinary tract infection in acutely unwell children in general practice: a prospective study with systematic urine sampling

BACKGROUND

Urinary tract infection (UTI) in children may be associated with long-term complications that could be prevented by prompt treatment.

AIM

To determine the prevalence of UTI in acutely ill children ≤ 5 years presenting in general practice and to explore patterns of presenting symptoms and urine sampling strategies.

DESIGN AND SETTING

Prospective observational study with systematic urine sampling, in general practices in Wales, UK.

METHOD

In total, 1003 children were recruited from 13 general practices between March 2008 and July 2010. The prevalence of UTI was determined and multivariable analysis performed to determine the probability of UTI.

RESULT

Out of 597 (60.0%) children who provided urine samples within 2 days, the prevalence of UTI was 5.9% (95% confidence interval [CI] = 4.3% to 8.0%) overall, 7.3% in those < 3 years and 3.2% in 3-5 year olds. Neither a history of fever nor the absence of an alternative source of infection was associated with UTI (P = 0.64; P = 0.69, respectively). The probability of UTI in children aged ≥3 years without increased urinary frequency or dysuria was 2%. The probability of UTI was ≥5% in all other groups. Urine sampling based purely on GP suspicion would have missed 80% of UTIs, while a sampling strategy based on current guidelines would have missed 50%.

CONCLUSION

Approximately 6% of acutely unwell children presenting to UK general practice met the criteria for a laboratory diagnosis of UTI. This higher than previously recognised prior probability of UTI warrants raised awareness of the condition and suggests clinicians should lower their threshold for urine sampling in young children. The absence of fever or presence of an alternative source of infection, as emphasised in current guidelines, may not rule out UTI in young children with adequate certainty.

Performance characteristics of urinalyses for the diagnosis of pediatric urinary tract infection

PURPOSE

The purpose of this study is to determine whether point-of-care (POCT) urinalysis (UA) is as accurate as laboratory-performed UA in diagnosing urinary tract infections (UTIs) in the pediatric emergency department (PED).

BASIC PROCEDURES

This was a retrospective series of children (0-18 years old) seen at a tertiary care PED from July 2008 to December 2012 in whom UA and urine culture were obtained. Urinalyses were considered positive if leukocyte esterase and/or nitrites were positive. Performance characteristics for the 2 types of UAs were calculated using urine culture as the reference standard.

MAIN FINDINGS

A total of 43452 specimens were sent for laboratory-performed UA and culture, and 6492, for POCT UA and culture (in 2908 specimens, both UAs were performed). Sixty-four percent of specimens were from girls, 51% were catheterized, and 7.5% had UTIs. The sensitivity of POCT UAs and laboratory-performed UAs was 82.5% (confidence interval [CI], 79.4%-85.3%) and 89.1% (CI, 86.4%-88.8%), respectively. The superior performance of laboratory-performed UAs was driven by the sensitivity of microscopy. Laboratory-performed UAs were more sensitive than the POCT in girls (90.6% [CI, 89.4%-91.8%] vs 82.8% [79.4%-85.8%]).

PRINCIPAL CONCLUSIONS

Although POCT UAs offer more rapid turnaround times, the sensitivity is greater for laboratory-performed UAs. Given the difficulty in following up PED patients after discharge as well as the potential morbidity from untreated UTIs, the rapidity of the POCT UA must be balanced against the lower sensitivity of this assay. The benefit of more accurate diagnosis may outweigh the potentially longer PED length of stay associated with a laboratory-performed UA.

What is the risk of bacterial meningitis in infants who present to the emergency department with fever and pyuria?

OBJECTIVE

To determine the rate of bacterial meningitis among febrile infants in the emergency department (ED) who have pyuria detected in an initial catheterized urine specimen.

METHODS

This retrospective chart review, conducted at the Hospital for Sick Children, Toronto, Ont., involved all children aged 0 to 3 months who presented to the ED with fever and pyuria (>/=10 white blood cells/mm(3)) over a 3-year period. Cerebrospinal fluid (CSF) was evaluated using standard methods, and the rate of meningitis in children with pyuria was determined.

RESULTS

The study sample included 211 infants with fever and pyuria -- 79 of these under 1 month of age. Eighty-one percent (171/211) had positive urine cultures, and 143 underwent lumbar puncture to rule out meningitis. Of these, 140 CSF samples were culture negative and 3 grew coagulase negative Staphylococcus -- 2 because of contamination and 1 because of a ventriculo-peritoneal shunt infection. Both children with CSF contamination grew Escherichia coli in the urine. The rate of bacterial meningitis in the study sample was 0% (95% confidence interval, 0%-2.6%).

CONCLUSIONS

In this study of febrile children under 90 days of age with fever and pyuria, the incidence of concurrent meningitis was 0%. This suggests that recommendations for mandatory lumbar puncture in such children should be reconsidered. However, until larger prospective studies define a patient subset that does not require CSF analysis, it is prudent to rule out meningitis, administer parenteral antibiotics for urinary tract infection, and admit for close observation.

Impact of C-reactive protein test results on evidence-based decision-making in cases of bacterial infection

Background

C-reactive protein (CRP) is widely used to detect bacterial infection in children. We investigated the impact of CRP test results on decision-making and summarized the evidence base (EB) of CRP testing.

Methods

We collected information from the hospital records of 91 neonates with suspected sepsis and of 152 febrile children with suspected infection on the number of ordered CRP tests, the number of EB-CRP tests, and the impact of the test results on decision-making. CRP diagnostic accuracy studies focusing on pediatric infections were reviewed critically. The main outcomes were the proportion of CRP tests that were EB and the proportion of tests that affected decision-making. A secondary outcome was the overall one-year expenditure on CRP testing.

Results

The current EB for CRP testing in pediatric infections is weak and suggests that CRP is of low diagnostic value. Approximately 54.8% of tests performed for suspected neonatal sepsis and 28% of tests performed for other infections were EB; however, the results of only 12.9% of neonatal sepsis tests and of 29.9% of tests on children with other infections informed decision-making. The one-year overall cost for CRP testing and related health care was $26,715.9.

Conclusions

The routine ordering of CRP for children with infections is based on weak evidence. The impact of the CRP test results on decision-making is rather small, and CRP ordering may contribute to unnecessary health care expenditures. Better quality research is needed to definitively determine the diagnostic accuracy of CRP levels in children with infections.

The impact of therapeutic delay time on acute scintigraphic lesion and ultimate scar formation in children with first febrile UTI

We assessed the role of therapeutic delay time (TDT) in acute renal cortical scintigraphic lesion (ASL) and ultimate scar formation (USF) in children with first febrile UTI and whether it is affected by the presence of vesico-ureteral reflux (VUR). 230 children, 90 girls and 140 boys with first febrile UTI were included. Radiologic (USG, DMSA, and VCUG), clinical (age, gender, peak fever, therapeutic delay time) and laboratory (CBC with differential count, ANC (absolute neutrophil count), BUN, Creatinine, urine analysis, gram stain, culture, CRP and ESR) variables were analysed. DMSA was performed within 5 days and after six months. VCUG was performed after acute phase of UTI. The differences in TDT according to the presence of ASL, USF and VUR were assessed. And the correlation between ASL or USF with the duration of TDT was assessed. Of 230 patients enrolled, 142 patients had refluxing UTI and 88 patients had non-refluxing UTI. TDT was the risk factor associated with ASL and USF along with presence of VUR. TDT was longer in ASL positive group compared with the ASL negative group. Also USF group showed longer TDT compared with those without USF in both refluxing UTI and non refluxing UTI. The TDT was significantly shorter in USF group with the presence of VUR. Positive linear association was noted between prevalence of ASL and USF and duration of TDT. In conclusion, the impact of UTI on formation of USF may be enhanced by the presence of VUR with shorter duration of TDT.

The age-related risk of co-existing meningitis in children with urinary tract infection

Objective

The primary aim of this study was to determine age-stratified rates of co-existing bacterial meningitis in children with urinary tract infection (UTI). The secondary aims of this study were to determine the causative pathogens of UTI, and the clinical features and outcome of children with co-existing meningitis.

Methods

Analysis of data collected over a nine-year period at a tertiary pediatric hospital in Australia. Study population: children below 16 years of age with culture-confirmed UTI and a paired CSF sample.

Results

A total of 748 episodes in 735 cases were included in the final analysis. The commonest pathogens causing UTI were Escherichia coli (67.4%), Enterococcus faecalis (8.4%), Klebsiella oxytoca (3.5%) and Klebsiella pneumoniae (3.5%). Only two (1.2%; 95% CI: 0.15–4.36%) of 163 neonates (between 0 and 28 days of age) with UTI had co-existing meningitis. Both presented with pyrexia, irritability and lethargy, and recovered uneventfully with antibiotic treatment. There were no cases of co-existing meningitis among 499 infants (between 29 days and 12 months of age) with UTI (95% CI: 0.00–0.74%), or any of the 86 children aged 12 months or over (95% CI: 0.00–4.20%).

Conclusions

These findings indicate that clinicians should have a low threshold to perform a lumbar puncture in neonates with UTI, as the risk of co-existing meningitis is not insignificant in this age group. In contrast, beyond the neonatal period, the risk is small and a more selective approach is warranted.

Febrile urinary tract infections in 0- to 3-month-old infants: a prospective follow-up study

OBJECTIVE

To track the clinical evolution of febrile urinary tract infection (UTI) diagnosed in 0- to 3-month-old infants and characterize uropathogen frequencies, antimicrobial resistance rates, renal abnormalities, and differences in the sexes in this age group.

STUDY DESIGN

We observed prospectively 46 infants identified in a cohort of 209 children with first UTI diagnosed between July 2006 and July 2008 at the age of 0 to 3 months. Renal ultrasound scanning and voiding cystourethrography examinations were performed in all infants.

RESULTS

Infants < 3 months old represented 21% of all children with first UTI. Of these children, 26% were female and 74% were male. Escherichia coli was isolated in 88% of cases and had a high rate of resistance to ampicillin (71%) and to trimethoprim/sulfamethoxazole (47%); 21% of children had vesicoureteral reflux, which was of low-grade in 67% of cases, with spontaneous resolution before 2 years in all cases. In infants with normal ultrasound scanning results, a low-grade vesicoureteral reflux was subsequently found in 10% of cases.

CONCLUSION

Infants aged 0 to 3 months represent 21% of children treated for febrile UTI. Boys represent 74% of these cases. E coli is responsible for 88% of UTIs, with a high rate of resistance to antibiotics. When ultrasound scanning examination results are normal, the risk of missing a significant renal abnormality is expected to be extremely low.

Prevalence of renal anomalies after urinary tract infections in hospitalized infants less than 2 months of age

OBJECTIVE

Our aim was to determine the incidence of anatomical abnormalities after a urinary tract infection (UTI) in infants <2 months of age hospitalized in the neonatal intensive care unit (NICU).

STUDY DESIGN

This was a retrospective, single-center cohort study of infants <2 months of age in the NICU with a UTI and documented renal imaging.

RESULT

We identified 141 infants with UTIs. The mean gestational age and birth weight were 28 weeks and 1254 g, respectively. The most commonly identified pathogen was coagulase-negative Staphylococcus (28%, 44 of 156). A major abnormality was found on at least one imaging study for 4% (5 of 118) of infants. Major abnormalities were noted on 4% (5 of 114) of renal ultrasounds and 2% (2 of 82) of voiding cystourethrography examinations.

CONCLUSION

Among infants in the NICU <2 months of age at the time of a UTI, the prevalence of major anatomical abnormalities is <5%.

Implications of 99mTc-DMSA scintigraphy performed during urinary tract infection in neonates

OBJECTIVE

To evaluate prospectively whether normal scintigraphic results during urinary tract infections (UTIs) in neonates were predictive of the absence of dilating vesicoureteral reflux (VUR) (grade > or =III) and permanent renal damage (PRD).

METHODS

Term neonates with a first symptomatic, community-acquired UTI participated in the study. Urinary tract ultrasonography and technetium-99m-labeled dimercaptosuccinic acid ((99m)Tc-DMSA) scintigraphy were performed within 72 hours after diagnosis and voiding cystourethrography within 1 to 2 months. DMSA scintigraphy, to determine the development of PRD, was repeated 6 months after UTI.

RESULTS

Seventy-two neonates (144 renal units) were enrolled. Acute pyelonephritis was diagnosed through early DMSA scintigraphy in 19% of renal units, VUR in 22%, and grade > or =III VUR in 13%. The majority (71%) of renal units with grade > or =III VUR had normal early DMSA scintigraphic results. The sensitivity and specificity of abnormal early DMSA scintigraphic results to predict grade > or =III VUR were 29% (95% confidence interval: 11%-55%) and 82% (95% confidence interval: 74%-88%), respectively. PRD was found in 7% of renal units, all of which had abnormal early DMSA scintigraphic results. PRD was significantly more frequent among renal units with grade > or =III VUR than among nonrefluxing renal units (P < .05).

CONCLUSIONS

Normal early DMSA scintigraphic results for neonates with symptomatic UTIs were helpful in ruling out later development of PRD but were not predictive of the absence of dilating VUR. To rule out dilating VUR, voiding cystourethrography may be required.

Changing trend in antimicrobial resistance of pediatric uropathogens in Taiwan

BACKGROUND

There is growing concern regarding antimicrobial resistance worldwide, particularly of Escherichia coli, and the first choice of an antimicrobial agent for empiric treatment of pediatric urinary tract infection (UTI) is not well established.

METHODS

The medical records from January 1991 to December 2005 for all children under 18 years of age admitted to Tri-Service General Hospital, Taipei for their first UTI were reviewed. Two study periods, early (1991-2000) and late (2001-2005), were chosen during the 15 year period for evaluating the trend of antimicrobial resistance.

RESULTS

Of the 368 isolates, E. coli was the most common pathogen (81.0%), followed by Klebsiella pneumoniae (6.5%), Enterococcus spp. (6.0%), and Proteus mirabilis (3.5%). Of the 368 isolates, 77.4% were resistant to ampicillin, 44.6% to co-trimoxazole, 27.2% to cephalothin, 15.0% to gentamicin, and 8.4% to nitrofurantoin. In the early (1991-2000) and late (2001-2005) study periods, 199 isolates (54.1%) and 169 isolates (45.9%), respectively, were compared. The resistance to antimicrobial agents for overall pathogens in the early and late study periods, respectively, was as follows: 68.8% and 88.0% to ampicillin, 48.9% and 46.6% to co-trimoxazole, 26.8% and 28.9% to cephalothin, 16.2% and 19.8% to gentamicin, and 8.7% and 9.0% to nitrofurantoin.

CONCLUSION

Among commonly used antimicrobial agents for the treatment of pediatric UTI, there is a trend towards increasing resistance to ampicillin and a persistently low resistance rate to gentamicin, cephalosporin, and nitrofurantoin. Parenteral first-generation cephalosporins, gentamicin, and oral nitrofurantoin should be considered for first-line agents, given the resistance patterns of this study.

Prevalence of urinary tract infection in childhood: a meta-analysis

BACKGROUND

Knowledge of baseline risk of urinary tract infection can help clinicians make informed diagnostic and therapeutic decisions. We conducted a meta-analysis to determine the pooled prevalence of urinary tract infection (UTI) in children by age, gender, race, and circumcision status.

METHODS

MEDLINE and EMBASE databases were searched for articles about pediatric urinary tract infection. Search terms included urinary tract infection, cystitis, pyelonephritis, prevalence and incidence. We included articles in our review if they contained data on the prevalence of UTI in children 0-19 years of age presenting with symptoms of UTI. Of the 51 articles with data on UTI prevalence, 18 met all inclusion criteria. Two evaluators independently reviewed, rated, and abstracted data from each article.

RESULTS

Among infants presenting with fever, the overall prevalence (and 95% confidence interval) of UTI was 7.0% (CI: 5.5-8.4). The pooled prevalence rates of febrile UTIs in females aged 0-3 months, 3-6 months, 6-12 months, and >12 months was 7.5%, 5.7%, 8.3%, and 2.1% respectively. Among febrile male infants less than 3 months of age, 2.4% (CI: 1.4-3.5) of circumcised males and 20.1% (CI: 16.8-23.4) of uncircumcised males had a UTI. For the 4 studies that reported UTI prevalence by race, UTI rates were higher among white infants 8.0% (CI: 5.1-11.0) than among black infants 4.7% (CI: 2.1-7.3). Among older children (<19 years) with urinary symptoms, the pooled prevalence of UTI (both febrile and afebrile) was 7.8% (CI: 6.6-8.9).

CONCLUSIONS

Prevalence rates of UTI varied by age, gender, race, and circumcision status. Uncircumcised male infants less than 3 months of age and females less than 12 months of age had the highest baseline prevalence of UTI. Prevalence estimates can help clinicians make informed decisions regarding diagnostic testing in children presenting with signs and symptoms of urinary tract infection.

Urologic problems of the neonate: an update

During the last 2 decades of the twentieth century, maternal sonography became integrated into routine prenatal care. As a result, numerous anomalies are now detected in the fetus. This practice has had a profound influence on the presentation and natural history of urologic problems in the neonate. In an attempt to reflect the clinical scenario, this article is divided into two main parts: the first includes clinical questions raised by prenatally detected anomalies, abdominal masses, urosepsis, urinary retention, scrotal masses, and abnormal external genitalia; the second part is a discussion of specific anomalies with respect to evaluation and management, including controversies, and optimum timing for referral to a tertiary care center. Our knowledge regarding the pathophysiology and therefore treatment of these conditions is constantly expanding and changing.