Urinary Tract Infections in Young Children and Infants: Common Questions and Answers

 

Urinary tract infections (UTIs) are common in children and are associated with significant short- and long-term morbidity. They have a high recurrence rate and are associated with anatomic and functional abnormalities. The decision to test for UTI is based on risk factors and the child's age. Urinalysis is valuable to rule out UTI and to help decide when to start antibiotics; however, urine culture is needed for definitive diagnosis. Urine specimens collected via perineal bagging should not be used for culture because of high false-positive rates. Diagnosis of UTI requires pyuria and bacterial growth in the urine culture. Prompt treatment of UTIs reduces renal scarring. Antibiotic selection should be based on local sensitivity patterns and adjusted once culture results are available. In most cases, oral antibiotics are as effective as intravenous agents. When intravenous antibiotics are used, early transition to an oral regimen is as effective as longer intravenous courses. Kidney and bladder ultrasonography is helpful to identify acute complications and anatomic abnormalities. Voiding cystourethrography is indicated when ultrasound findings are abnormal and in cases of recurrent febrile UTIs. The use of antibiotic prophylaxis for recurrent UTIs is controversial. Identification and treatment of bowel and bladder dysfunction can prevent UTI recurrence.

Urinary tract infections (UTIs) are common in children and are associated with significant morbidity. Up to 7% of girls and 2% of boys have had a UTI by six years of age.1 The recurrence rate is 30%.2 One in six febrile neonates has a UTI,3 and it is the most common serious bacterial infection in children younger than three months.4 Short-term complications may include sepsis, renal abscess, and acute kidney injury 5; potential long-term sequelae include renal scarring, recurrent infection, impaired renal function, hypertension, end-stage renal disease, and preeclampsia.2,5 Prophylactic antibiotics are commonly prescribed, but their use has questionable benefit and contributes to microbial resistance.69

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Use risk stratification based on age and clinical findings to determine whether urine testing is needed in a child with suspected UTI.4,1015

C

Disease-oriented outcomes based on cohort studies and evidence-based guidelines

Do not use perineal bagging to collect urine for cultures because these specimens have high false-positive rates.10,11

C

Disease-oriented outcomes based on evidence-based guidelines

When clinically possible, use shorter courses of intravenous antibiotics followed by oral antibiotics.20,21

A

Patient-oriented outcomes based on a Cochrane review and cohort study

Order kidney and bladder ultrasonography for all children younger than 24 months after their first febrile UTI.10,11

C

Guidelines based partly on observational studies

Order voiding cystourethrography for children younger than 24 months10,11 (or younger than three years, according to one guideline22) if they have recurrent UTIs or abnormal ultrasound findings.

C

Guidelines based partly on randomized controlled trials and observational studies

Use antibiotic prophylaxis selectively to prevent recurrent UTIs; evidence of benefit is small at best, and this practice promotes antimicrobial resistance.69

B

Disease- and patient-oriented outcomes based on Cochrane reviews, a systematic review, and a randomized controlled trial

Evaluate for and treat bowel and bladder dysfunction when UTI is diagnosed to help prevent recurrence.2,11,27

C

Disease-oriented outcomes based on evidence-based guidelines and a cohort study


UTI = urinary tract infection.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

The Authors

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BRIAN VEAUTHIER, MD, is the program director of the University of Wyoming Family Medicine Residency Program, Casper....

MICHAEL V. MILLER, DO, is the associate program director of the University of Wyoming Family Medicine Residency Program.

Address correspondence to Brian Veauthier, MD, 1522 E. A St., Casper, WY 82601 (email: bveauthi@uwyo.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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