MIAMI – A pediatric nephrologist shared her perspective, including positive aspects and potential pitfalls, in the months since the American Academy of Pediatrics released updated clinical practice guidelines for diagnosis and management of an initial urinary tract infection in febrile children aged 2-24 months.
"These are guidelines, not protocols. These are here to guide us. They are not intended to replace your clinical judgment, please remember this," Dr. Ana L. Paredes said at a pediatric update sponsored by Miami Children’s Hospital.
Dr. Paredes reviewed the guideline and its seven action statements, most of which address routine, non-complicated cases, she said (Pediatrics 2011;128:595-610). Diagnosis of urinary tract infection (UTI) based on both pyuria and at least 50,000 colonies of a single urinary pathogen in a specimen collected by catheterization or suprapubic aspiration is a new recommendation. "There is a consideration that if your lab only reports from 10,000 to 100,000 colonies, then 10,000 would make the diagnosis," Dr. Paredes said.
Also, culture of a urine sample collected via one of these two methods is required prior to antibiotic treatment if a bagged urine sample tests positive for leukocytes or nitrates, according to the guidelines.
If a clinician judges that antimicrobial treatment is warranted for an infant with no apparent source of infection, a urine specimen for urinalysis and culture is always required before starting treatment, the guidelines state. Clinical status of the patient guides the route of antimicrobial administration.
Close follow-up and monitoring for recurrent infection is warranted after completion of the recommended 7-14 days of antimicrobial therapy. Instruct parents to seek prompt medical attention at the onset of any new fever to facilitate quick diagnosis and treatment of any recurrence.
"These are guidelines, not protocols. These are here to guide us."
The AAP initially released the guidelines in 1999. The update is based on a meta-analysis of six randomized controlled trials. The guideline writers asked each of these study authors to provide raw data from their trials and then extracted information for infants aged 2-24 months ("AAP Updates Policy on First UTI in Febrile Infant," Pediatric News).
Although the meta-analysis included 1,091 infants, there were none with vesicoureter reflux grades IV and only 5 infants with grade V, Dr. Paredes said. A lack of more severe reflux in the meta-analysis is a potential limitation of the guidelines, she said.
The seven physician authors, all members of the AAP Subcommittee on Urinary Tract Infection, determined that antimicrobial prophylaxis is not warranted to prevent febrile recurrent UTI for infants who have no or grade I to IV vesicoureteral reflux.
"As per the AAP, a voiding cystourethrography [VCUG] is not routinely indicated after the first febrile UTI," said Dr. Paredes, pediatric nephrologist and director of renal research at Miami Children’s Hospital. She was not an author of the guidelines.
"A take-home message is perform a renal and bladder ultrasound" for febrile UTI in infants 2-24 months of age, Dr. Paredes said. "This is recommended during the first 2 days of treatment when clinical presentation is severe," such as during the first 48 hours of hospital admission.
If the renal and bladder ultrasound reveals hydronephrosis, scarring, or other evidence of high grade vesicoureteral reflux or obstructive uropathy, VCUG is indicated. "Also, VCUG is always indicated after a second febrile UTI," Dr. Paredes said.
A useful table in the guidelines lists risk factors for UTI by gender. For girls, white race; age less than 12 months; a fever lasting 2 days or longer; temperature of 39° C or greater; and absence of another source of infection increase the probability of a UTI. For boys, non–black race; temperature of 39° C or greater; fever lasting more than 24 hours; and, again, absence of another source of infection were risk factors identified.
Recommended oral antimicrobial agents include cephalosporins (cefixime, cefdinir, cefuroxime, and cephalexin), sulfonamides, or amoxicillin-clavulanate. Preferred parenteral antimicrobials include ceftriaxone, cefotaxime, ceftazidime, gentamicin, and tobramycin.
Dr. Paredes reported that she had no relevant financial disclosures.