The diagnosis of a UTI is confirmed by a positive urine culture, but this does not distinguish between upper tract andlower tract infection. Localization of a UTI is importantbecause upper UTI is associated more frequently with bacteremia and with anatomic abnormalities than is uncomplicated cystitis. The clinical manifestations of UTI do notreliably distinguish the site of infection in neonates, infants,and toddlers. Fever and abdominal pain may occur with either lower or upper UTI, although high fever, costovertebral tenderness, high erythrocyte sedimentation rate, leukocytosis, and bacteremia each suggest upper tract involvement.DMSA scan is sensitive for detecting acute pyelonephritisbut not commonly used.
The manifestations of UTI overlap with signs of sepsis seen in young children and with enteritis, appendicitis, mesenteric lymphadenitis, and pneumonia in older children. Dysuria may indicate pinworm infection, hypersensitivity to soaps or detergents, vaginitis, or sexual abuse and infection.
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Empirical therapy should be initiated for symptomatic children and for all children with a urine culture confirming UTI. For an older child who does not appear ill but has a positive urine culture, oral antibiotic therapy should be initiated. For a child with suspected UTI who appears toxic, appears dehydrated, or is unable to retain oral fluids, initial antibiotic therapy should be administered parenterally, and hospitalization should be considered.
is uncertainty about diagnosis of UTI in a younger child or Neonates with UTI are treated for 10 to 14 days with par-infant, urine can be collected by the most convenient method enteral antibiotics because of the higher rate of bacteremia. for urinalysis and if suggestive of infection, collect urine by Older children with UTI are treated for 7 to 14 days. Initial catheterization prior to starting antibiotics. treatment with parenteral antibiotics is determined by clinical status. Parenteral antibiotics should be continued until there is clinical improvement (typically 24 to 48 hours). Specificantibiotic therapy should be guided by the local antimicrobial susceptibility patterns and the results of the patient’surine cultures because of increasing problems related to antimicrobial resistance. Commonly used parenteral antibiotics include ceftriaxone or gentamicin. Oral regimens include acephalosporin, amoxicillin plus clavulanic acid, or trimethoprim sulfamethoxazole. Infants and children who do notshow the expected clinical response within 2 days of startingantimicrobial therapy should be re-evaluated, have anotherurine specimen obtained for culture, and undergo imagingpromptly.
The degree of toxicity, dehydration, and ability to retain oral intake of fluids should be assessed carefully. Restoring or maintaining adequate hydration, including correction of electrolyte abnormalities that are often associated with vomiting or poor oral intake, is important.
Bacteremia occurs in 2% to 5% of episodes of pyelonephritis and is more likely in infants than in older children. Focal renal abscesses are an uncommon complication.
The relapse rate of UTI is approximately 25% to 40%. Most relapses occur within 2 to 3 weeks of treatment. Parents should be counseled to follow up for evaluation for subsequent fevers to evaluate for the possibility of a recurrence of UTI. If a recurrent UTI is diagnosed, further imaging studies (VCUG) are indicated to evaluate the possibility of vesicoureteral reflux (see Chapter 167).