Dr. Helman, in 2016, added the following to Episode 48 shownotes: “Update 2016! Justin Morgenstern publishes a great analysis of the most important pediatric UTI literature relevant to EM to date on First10EM. [Be sure to read it]
The following is from Episode 48 – Pediatric Fever Without A Source with Dr. Sarah Reid and Dr. Gina Neto (and Dr. Helman, Emergency Medicine Cases, guiding the discussion):
Pediatric Urinary Tract Infections
What are the risk factors for UTI in children?
- History of previous UTI
- Temp >39°C, and without an apparent source, >24h
- Ill appearance
- Supra-pubic tenderness, (or dysuria/frequency/low-back pain or new-onset incontinence in children old enough)
- Females, uncircumcised boys and non-black race
Who to test (see JAMA guideline article 3):
< 3 months: check urine in all babies with fever without source
3-24 month: check all girls, and boys if >1 risk factor, or if circumcised and >2 risk factors
>24 months: check all girls, all symptomatic uncircumcised boys, and circumcised boy who had several symptoms suggesting UTI
Consider checking the urine even in children who have had another source for their illness; in children <60 days old with bronchiolitis, many will also have a UTI! (4)
How to get the urine?
<2 months: obtain a sample by catheterization (and send every sample for culture, as the urinalysis may be normal in the presence of true infection)
>2 months of age to toilet trained: bag urine okay to screen by microscopy, however if it is positive (>10-20 white cells), a sterile culture needs to be obtained by catheter
Toilet-trained kids: obtain midstream urine.
Which children with UTI require admission? (Expert Opinion)
Generally children <2 months should be admitted.
Well appearing children >2 months can usually be discharged home on antibioitcs with good follow up, unless they are dehydrated or parents are unreliable.
Treatment of UTI
Antibiotic options depend on local antibiotic resistance patterns, however, in our experts’ catchment area,
In hospital: IV ampicillin and gentamicin
Oral: cephalexin for most, or cefixime for infants 2-6 months old, or those you are worried have a complicated UTI or urinary tract abnormalities.
Do all children with a first-time UTI need a renal ultrasound and voiding cystourethrography (VCUG)?
All need an ultrasound, and then only VCUG if there is hydronephrosis found on the ultrasound.
The following are the references from Episode 48 – Pediatric Fever Without A Source [which actually has much more then just Pediatric UTI. The entire post is full of practical wisdom.]
1) Baraff, L. Management of Infants and Young Children with Fever without Source. Pediatric Annals 37:10, October 2008. Free Full PDF
2) Subcommittee on Urinary Tract Infection, Steering Committee on Quality Improvement and Management Pediatrics. 2011;128:595-610.
3) Shaikh, N. Does This Child Have a Urinary Tract Infection? JAMA, December 26, 2007 Vol 298 No 24. Full Free PDF
4) Levine, D. Risk of Serious Bacterial Inection in Young Febrile Infants with Respiratory Syncytial Virus Infections. Pediatrics. 2004;113;1728. Full Text
5) Urinary Tract Infection: Clinical Practice Guideline for the Diagnosis and Management of the Initial UTI in Febrile Infants and Children 2 to 24 Months. Pediatrics 2011;128;595; originally published online August 28, 2011.Free Full PDF
6) Wilkinson, M. et al. Prevalence of occult bacteremia in children aged 3 to 36 months presenting to the emergency department with fever in the postpneumococcal conjugate vaccine era. Academic Emergency Medicine 2009; 16:220-225. Free Full PDF