Oral antibiotic treatment for 7-10 days works for most feverish children with uncomplicated urinary tract infection (UTI), reported Tej K. Mattoo, MD, of Wayne State University, Detroit, and associates.
A good clinical assessment supported by laboratory results using a clean urine specimen is crucial to accurately diagnosing UTI in children, Dr. Mattoo and colleagues reported in a state-of-the-art review article in Pediatrics.
The authors set out to summarize the current literature on UTI in children with the goal of guiding clinical management. They provide a thorough summary of the research on a wide range of issues, including pathogenesis of acute pyelonephritis and renal scarring, risk factors for UTI and renal scarring, diagnosis and common errors in diagnosis, complications of UTI and post-UTI renal imaging, antibiotics, antimicrobial prophylaxis, surgical interventions, and prevention of recurrent UTIs.
What key steps make all the difference?
To help guide practicing physicians through this wealth of information, Dr. Mattoo noted in an interview that, although the review article offers “many takeaway messages,” there are several issues of crucial importance. Notably, urine collection in young children who are not yet toilet trained can present considerable challenges in achieving an accurate assessment. A contaminated urine specimen leads to unnecessary antibiotic treatment, and in some cases unwarranted hospitalization, intravenous lines, renal imaging, and follow-up investigations, Dr. Mattoo said.
Ureteral catheterization or suprapubic bladder aspiration are the preferred methods of specimen collection, especially in cases where specimens collected with a perineal bag are dipstick positive, the authors explained. Midstream collection (known as the Quick-Wee method) can also be used following stimulation of the suprapubic area with cold fluid-soaked gauze.
Also of considerable importance is distinguishing bladder infections from kidney infections whenever possible, Dr. Mattoo noted. The antibiotic treatment, complications, and follow-up plans can be different for each, he cautioned. The authors have provided a helpful table within the article to help make this differentiation.
Timing is crucial
Prescribing treatment with an antibiotic within 48 hours of fever onset is essential for the prevention of renal scarring, Dr. Mattoo advised. The key is to treat with the goal of avoiding long-term complications. Although there are some exceptions, most cases of UTI can be treated with oral antibiotics and do not require hospitalization.
Some children with first UTI need additional testing, such as renal imaging, to ensure that there are no underlying risk factors for UTI. These children, in particular, can be at an increased risk of recurrent UTI and renal scarring, Dr. Mattoo explained.
Antibiotic resistance is a major emerging problem in patients with UTI at all ages and we should use antibiotics only in patients who truly have a UTI that requires such treatment, he urged.
In an interview, Timothy Joos, MD, a Seattle internist and pediatrician in private practice, noted: “In the words of the British novelist Tom Holt, ‘There are few moments of clarity more profound than those that follow the emptying of an overcharged bladder. The world slows down, the focus sharpens, the brain comes back online. Huge nebulous difficulties prove on close calm examination to be merely cloud giants.’ Thank you to Drs. Mattoo, Nelson, and Shaikh for providing this clarity of current UTI diagnosis and management,” Dr. Joos said.
“It bears repeating that because of the rare prevalence of grade 4 to 5 vesicoureteral reflux in children with their first UTI, current guidelines recommend that a voiding cystourethrogram can be reserved for children with an abnormal ultrasound, atypical pathogen, complicated clinical course, or known renal scarring,” added Dr. Joos.
The authors had no relevant disclosures. Dr. Joos is a member of the Pediatric News editorial advisory board but had no other disclosures.