Urinary tract infections in children.pdf

Urinary tract infections in children Straight to the point of care Last updated: May 29, 2024  Table of Contents Overview 3 Summary 3 Def...

Urinary tract infections in children Straight to the point of care Last updated: May 29, 2024  Table of Contents Overview 3 Summary 3 Definition 3 Theory 4 Epidemiology 4 Aetiology 4 Pathophysiology 4 Classification 5 Case history 7 Diagnosis 8 Approach 8 History and exam 13 Risk factors 14 Investigations 16 Differentials 19 Management 22 Approach 22 Treatment algorithm overview 26 Treatment algorithm 28 Emerging 43 Primary prevention 43 Secondary prevention 43 Patient discussions 44 Follow up 45 Monitoring 45 Complications 46 Prognosis 47 Guidelines 48 Diagnostic guidelines 48 Treatment guidelines 49 References 51 Images 61 Disclaimer 62 Urinary tract infections in children Overview Summary Urinary tract infections (UTIs) are common in children. Symptoms and signs may be non-specific, particularly in neonates and infants. Older children may have dysuria, urgency, or frequency with a lower urinary tract OVERVIEW infection, or fever, loin or back pain, and vomiting with upper UTI (pyelonephritis). An appropriately obtained urine specimen can confirm the diagnosis and pathogen; urine culture and antimicrobial susceptibility testing will define the appropriate antibiotic for treatment. Anatomical and functional abnormalities of the urinary tract and bowel may predispose children to recurrent UTIs. Further evaluation of children with recurrent UTIs is required to identify any treatable underlying cause. Recurrent UTIs may lead to renal scarring and renal insufficiency. Definition Paediatric urinary tract infection (UTI) is an illness caused by infection of the lower urinary tract (cystitis), the upper urinary tract (pyelonephritis), or both. The presence of pyuria and symptoms distinguishes UTI from asymptomatic bacteriuria. Asymptomatic bacteriuria is the presence of bacteria in urine obtained in asymptomatic children on routine screening or incidentally during other investigations. The prevalence of asymptomatic bacteriuria is 0.37% in boys and 0.47% in girls, with highest rates in uncircumcised boys younger than 1 year old and girls older than 2 years of age. Asymptomatic bacteriuria does not require treatment. Uncomplicated UTI occurs in a child who has a structurally and functionally normal urinary tract, normal renal function, and a competent immune system. Complicated UTI occurs in a child who has a structural or functional abnormality of the urinary tract. This PDF of the BMJ Best Practice topic is based on the web version that was last updated: May 29, 2024. BMJ Best Practice topics are regularly updated and the most recent version of the topics 3 can be found on bestpractice.bmj.com. Use of this content is subject to our disclaimer (. Use of this content is subject to our). © BMJ Publishing Group Ltd 2024. All rights reserved.  Urinary tract infections in children Theory Epidemiology UTI is one of most common childhood bacterial infections, affecting approximately 8% of children 20% are resistant to trimethoprim/sulfamethoxazole, which limits their use as initial therapy. Consult local guidelines and formularies. Adjust therapy to the nearest spectrum antibiotic following complete identification of the pathogen and susceptibility data. Cure rates with antibiotics exceed 95%. Renal function and aminoglycoside blood levels should be monitored in patients treated with aminoglycosides (e.g., gentamicin) for >48 hours. Uncomplicated UTI An uncomplicated UTI is one that occurs in a patient who has a structurally and functionally normal urinary tract, normal renal function, and a competent immune system. Uncomplicated UTIs generally involve the lower urinary tract (cystitis) rather than the upper urinary tract. MANAGEMENT Children may have mild pyrexia and mild dehydration, but do not have vomiting or any signs of sepsis, dehydration, or haemodynamic instability. 22 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: May 29, 2024. BMJ Best Practice topics are regularly updated and the most recent version of the topics can be found on bestpractice.bmj.com. Use of this content is subject to our disclaimer (. Use of this content is subject to our). © BMJ Publishing Group Ltd 2024. All rights reserved. Urinary tract infections in children Management Choice of empirical therapy is guided by local antimicrobial resistance patterns. Therapy should be reviewed when the organism and its antimicrobial sensitivities are confirmed by culture, and changed to a narrower-spectrum agent if appropriate. Oral therapy is usually appropriate for children with uncomplicated UTI. Options include a second- or third-generation cephalosporin (e.g., cefixime), amoxicillin/clavulanate, trimethoprim, trimethoprim/ sulfamethoxazole, or nitrofurantoin. Cefalexin or amoxicillin may be used second- line if culture results confirm susceptibility. Trimethoprim/sulfamethoxazole is active against multiple antibiotic-resistant bacteria, including extended-spectrum beta-lactamase (ESBL)-producing Enterobacterales such as E coli and AmpC-beta-lactamase-producing Enterobacterales such as Klebsiella species. Nitrofurantoin is active against cystitis caused by ESBL-producing Enterobacterales and AmpC-beta-lactamase-producing Enterobacterales. Treatment for penicillin-allergic patients depends on the age of the patient, history of drug allergy, and severity of illness. Consult a specialist for guidance on antibiotic selection in these patients. Allergy to penicillin is generally not a concern in neonates and young infants because they have not been challenged with penicillin before. Typical treatment course is 7-14 days. The American Academy of Pediatrics (AAP) recommends that oral antibiotic therapy for 7 to 10 days is adequate for uncomplicated febrile UTI that responds well to treatment. One systematic review found that a 2- to 4-day course of antibiotics was as effective as a 7- to 14-day course at eradicating lower UTI in children. A 3- to 5-day course may be considered. Complicated UTI A complicated UTI is one that occurs in a child who has a structural or functional abnormality of the urinary tract. Complicated UTIs generally involve the upper urinary tract (pyelonephritis) rather than the lower urinary tract. Children ≤2 months Neonates and infants aged ≤2 months are at high risk for serious bacterial infection and sepsis. Symptoms are non-specific in this age group, making it difficult to distinguish UTI from other causes of serious bacterial infection at initial evaluation. These children should be admitted to hospital for evaluation and most should receive empirical parenteral antibiotic therapy. See Sepsis in children for more information. Oral antibiotics may be appropriate for well-appearing, febrile, term infants aged 29-60 days who have positive urinalysis result and normal inflammatory markers. Choice of empirical therapy is guided by past infections and associated antibiotic susceptibility data from the past 6 months, antibiotic exposures within the past 30 days, and local antimicrobial resistance patterns. Suitable regimens include ampicillin plus gentamicin or ampicillin plus a third-generation cephalosporin (e.g., cefotaxime, cefepime, ceftriaxone). The UK National Institute for Health and Care Excellence (NICE) recommends a third-generation cephalosporin plus an antibiotic active against listeria (e.g., ampicillin) for infants aged 2 months with no structural renal disease The choice between oral and intravenous therapy depends on patient age, suspicion of sepsis, illness severity, hydration status, tolerance for oral medication, and whether there are complications of infection. NICE recommends intravenous antibiotics for children with pyelonephritis who are vomiting, unable to take oral antibiotics, or severely unwell. Choice of empirical therapy is guided by past infections and associated antibiotic susceptibility data from the past 6 months, antibiotic exposures within the past 30 days, and local antimicrobial resistance patterns. Therapy should be reviewed when the organism and its antimicrobial sensitivities are confirmed by culture, and changed to a narrower-spectrum agent if appropriate. Examples of suitable oral antibiotics include cefalexin, cefixime, and amoxicillin/clavulanate (if cultures confirm sensitivity). Cefuroxime, ceftriaxone, gentamicin (with or without ampicillin), amikacin, or tobramycin may be used if intravenous treatment is required. Ampicillin is added to cover Enterococci. Amikacin is active against ESBL-producing Enterobacterales such as E coli. Similarly to gentamicin, tobramycin is active against multiple antibiotic-resistant bacteria, including ESBL- producing Enterobacterales, AmpC-beta-lactamase-producing Enterobacterales such as Klebsiella species, and Pseudomonas aeruginosa with DTR. Treatment course is 7-14 days. Switching from parenteral to oral antibiotic treatment in a stepwise manner for hospitalised patients should be considered whenever possible. One systematic review reported no significant difference in microbiological eradication, renal scarring, clinical cure, re-infection, persistence of acute pyelonephritis, or re-infection in children who were switched to oral antibiotics after 5-10 days, compared with children who received intravenous antibiotics for 14 days. Children >2 months with structural renal disease Choice of empirical therapy is guided by past infections and associated antibiotic susceptibility data from the past 6 months, antibiotic exposures within the past 30 days, and local antimicrobial resistance patterns. Cefalexin or amoxicillin/clavulanate may be used as first-line oral antibiotics (if culture results are available and bacteria are susceptible). In patients with an underlying renal disorder who require broader gram-negative and Pseudomonas coverage and who are systemically stable at presentation, consider a fluoroquinolone such as oral ciprofloxacin. Ciprofloxacin is active against ESBL-producing Enterobacterales such as E coli and AmpC-beta-lactamase-producing Enterobacterales such as Klebsiella species. Systemic fluoroquinolone antibiotics, such as ciprofloxacin, may cause serious, disabling, and potentially long-lasting or irreversible adverse events. This includes, but is not limited to: tendinopathy/tendon rupture; peripheral neuropathy; arthropathy/arthralgia; aortic aneurysm and dissection; heart valve MANAGEMENT regurgitation; dysglycaemia; and central nervous system effects including seizures, depression, psychosis, and suicidal thoughts and behaviour. Prescribing restrictions apply to the use of fluoroquinolones, and these restrictions may vary between countries. In general, fluoroquinolones should be restricted for use in serious, life- 24 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: May 29, 2024. BMJ Best Practice topics are regularly updated and the most recent version of the topics can be found on bestpractice.bmj.com. Use of this content is subject to our disclaimer (. Use of this content is subject to our). © BMJ Publishing Group Ltd 2024. All rights reserved. Urinary tract infections in children Management threatening bacterial infections only. Some regulatory agencies may also recommend that they must only be used in situations where other antibiotics, that are commonly recommended for the infection, are inappropriate (e.g., resistance, contraindications, treatment failure, unavailability) Consult your local guidelines and drug formulary for more information on suitability, contraindications, and precautions. Consider second-line parenteral ampicillin plus gentamicin for patients with pre-existing structural renal disease and normal renal function. Alternative options include cefotaxime or ceftriaxone. Both oral and intravenous formulations of cephalosporins have been demonstrated to be effective. Special patient populations Consult a specialist for guidance on antibiotic selection in patients with penicillin allergy and those who are immunosuppressed, have renal impairment, or do not respond adequately to initial treatment. Therapy is individualised depending on patient factors, severity of illness, likely causative organisms, and local antimicrobial susceptibility patterns. Allergy to penicillin is generally not a concern in neonates and young infants because they have not been challenged with penicillin before. Nitrofurantoin should be avoided in children with renal impairment. Antifungal therapy may be required in immunosuppressed patients. Supportive care Some patients may require supportive care with intravenous fluids and/or an antipyretic (e.g., paracetamol). Lack of response to initial treatment Lack of response to initial therapy may indicate that the organism is not susceptible to the antimicrobial agent used, or indicate the development of pyonephrosis, renal abscess, or obstructed urine drainage. Culture results should be reviewed and urgent ultrasound performed. Recurrent UTI A recurrent UTI is defined as: ≥2 episodes of acute pyelonephritis, or 1 episode of acute pyelonephritis plus ≥1 episode of cystitis, or ≥3 episodes of cystitis. Recurrent UTIs may be due to unresolved infection (initial treatment is inadequate for elimination of bacteria in the urinary tract) or persistent infection (caused by re-emergence of bacteria in the urinary tract due to a site of persistent infection that cannot be eradicated [e.g., infected stones or fistulas]). The same pathogen is implicated in each recurrent infection. MANAGEMENT The American Urological Association recommends antibiotic prophylaxis for children aged 2 months uncomplicated UTI 1st oral antibiotics complicated UTI: no 1st oral or intravenous antibiotics structural renal disease adjunct supportive care adjunct antifungal therapy complicated UTI: 1st oral or intravenous antibiotics structural renal disease adjunct supportive care adjunct antifungal therapy Ongoing ( summary ) recurrent UTIs 1st consider prophylactic antibiotics adjunct optimise bladder and bowel function adjunct urology referral MANAGEMENT This PDF of the BMJ Best Practice topic is based on the web version that was last updated: May 29, 2024. BMJ Best Practice topics are regularly updated and the most recent version of the topics 27 can be found on bestpractice.bmj.com. Use of this content is subject to our disclaimer (. Use of this content is subject to our). © BMJ Publishing Group Ltd 2024. All rights reserved.  Urinary tract infections in children Management Treatment algorithm Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer Initial vesicoureteral reflux: no history of febrile UTIs 1st consider prophylactic antibiotics Primary options » nitrofurantoin: 1 mg/kg orally once daily at bedtime OR » trimethoprim: 2 mg/kg orally once daily at bedtime Secondary options » cefalexin: 10-15 mg/kg orally once daily at bedtime OR » trimethoprim/sulfamethoxazole: children ≥2 months of age: 1-2 mg/kg orally once daily at bedtime Dose refers to trimethoprim component. » The American Urological Association recommends antibiotic prophylaxis for children aged