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This is an updated version of the article that appeared in print. See the Editor's Note for more details.

Am Fam Physician. 2020;102(5):278-285

Patient information: See related handout on urinary tract infections in children, written by the authors of this article.

This clinical content conforms to AAFP criteria for CME.

Author disclosure: No relevant financial affiliations.

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. (Am Fam Physician. 2020; 102(5):278–285. Copyright © 2020 American Academy of Family Physicians.)

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

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 CDisease-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 CDisease-oriented outcomes based on evidence-based guidelines
When clinically possible, use shorter courses of intravenous antibiotics followed by oral antibiotics.20,21 APatient-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 CGuidelines 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.CGuidelines 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 BDisease- 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 CDisease-oriented outcomes based on evidence-based guidelines and a cohort study
RecommendationSponsoring organization
Avoid ordering follow-up urine cultures after treatment for an uncomplicated urinary tract infection (UTI) in patients that show evidence of clinical resolution of infection.American Academy of Pediatrics – Section on Nephrology and the American Society of Pediatric Nephrology
Do not perform voiding cystourethrography routinely for a first febrile UTI in children aged two to 24 months.American Academy of Family Physicians

Which Children Should Be Tested for a UTI?

A urine sample should be obtained for testing before antibiotic therapy is initiated in clinically unstable children who do not have a clear source of infection. In other children, age and clinical findings can be used to determine the need for testing. The physician's overall clinical impression for UTI often misses the diagnosis.

EVIDENCE SUMMARY

Because antibiotics can rapidly sterilize urine and thereby limit the ability to diagnose UTI, a urine sample should be obtained using an age-appropriate method before antibiotic therapy is initiated.2,10,11 For children who do not require urgent antibiotic therapy, clinical characteristics can identify those at higher risk of UTI who require testing (Figure 1).13,5,1015

Urine testing is indicated for all acutely ill infants (both febrile and afebrile) who are younger than three months.4,12 For febrile children two to 24 months of age, the 2011 American Academy of Pediatrics (AAP) guideline recommended basing testing decisions on risk factors and absence of alternative sources of infection. However, this guideline was retired in 2021 because of improper use of race as a risk factor and potential for missed diagnoses in Black and non-White children.10,16,17.The UTICalc, a tool developed by the University of Pittsburgh (https://uticalc.pitt.edu), uses similar risk factors (excluding race) to estimate the risk of UTI in febrile children two to 23 months of age. Testing is recommended when the risk is 2% or greater.

Two observational studies in the United Kingdom raise concern for UTI in unwell but afebrile children. In one study of 597 children younger than five years, absence of fever did not sufficiently rule out UTI.12 A particularly high rate of UTIs was noted in infants younger than three months (12.5%); thus, the authors recommend that all acutely ill children in this age group be tested regardless of symptoms. A second observational study of 2,740 children younger than five years found that the following clinical findings were associated with an increased risk of UTI: pain or crying with urination, malodorous urine, history of UTI, absence of cough, severe illness, lack of ear abnormalities, and abdominal tenderness on examination.14 Lack of fever was not useful for ruling out UTI. This study was limited by underrepresentation of children younger than two years, who comprised only 6.5% of the study population.

A study evaluating the diagnostic accuracy of UTI symptoms found that the decision to perform urine testing in verbal children older than 24 months should be based on sex, circumcision status, and symptoms.15 In girls and uncircumcised boys with urinary frequency, dysuria, abdominal pain or tenderness, back pain, or new-onset incontinence, the probability of UTI is 18% to 30%, and urine testing should be performed. If these symptoms are not present, the probability of UTI is low, and testing is not indicated. The baseline probability of UTI in circumcised boys is less than 1%, and testing is indicated only when at least three of these symptoms are present.

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