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EUROPEAN UROLOGY XXX (2014) XXXXXX
available at www.sciencedirect.com
journal homepage: www.europeanurology.com
Division of Paediatric Urology, Department of Urology, Mainz University Medical Centre, Johannes Gutenberg University, Mainz, Germany;
Hacettepe
University, Faculty of Medicine, Department of Urology, Division of Paediatric Urology, Ankara, Turkey; c Department of Urology, Ghent University Hospital,
Gent, Belgium;
e
Department of Urology, General Teaching Hospital in Praha, and Charles University 1st Faculty of Medicine, Praha, Czech Republic;
Department of Urology, Division of Pediatric Urology, University of Groningen, Groningen, The Netherlands; f Department of Urology, Medical University of
Article info
Abstract
Article history:
Accepted November 5, 2014
Context: In 30% of children with urinary tract anomalies, urinary tract infection (UTI)
can be the first sign. Failure to identify patients at risk can result in damage to the upper
urinary tract.
Objective: To provide recommendations for the diagnosis, treatment, and imaging of
children presenting with UTI.
Evidence acquisition: The recommendations were developed after a review of the
literature and a search of PubMed and Embase. A consensus decision was adopted
when evidence was low.
Evidence synthesis: UTIs are classied according to site, episode, symptoms, and complicating factors. For acute treatment, site and severity are the most important. Urine
sampling by suprapubic aspiration or catheterisation has a low contamination rate and
conrms UTI. Using a plastic bag to collect urine, a UTI can only be excluded if the
dipstick is negative for both leukocyte esterase and nitrite or microscopic analysis is
negative for both pyuria and bacteriuria. A clean voided midstream urine sample after
cleaning the external genitalia has good diagnostic accuracy in toilet-trained children. In
children with febrile UTI, antibiotic treatment should be initiated as soon as possible to
eradicate infection, prevent bacteraemia, improve outcome, and reduce the likelihood of
renal involvement. Ultrasound of the urinary tract is advised to exclude obstructive
uropathy. Depending on sex, age, and clinical presentation, vesicoureteral reux should
be excluded. Antibacterial prophylaxis is benecial. In toilet-trained children, bladder
and bowel dysfunction needs to be excluded.
Conclusions: The level of evidence is high for the diagnosis of UTI and treatment in
children but not for imaging to identify patients at risk for upper urinary tract damage.
Patient summary: In these guidelines, we looked at the diagnosis, treatment, and
imaging of children with urinary tract infection. There are strong recommendations
on diagnosis and treatment; we also advise exclusion of obstructive uropathy within
24 h and later vesicoureteral reux, if indicated.
# 2014 Published by Elsevier B.V. on behalf of European Association of Urology.
Keywords:
Urinary tract infection
Children
Urine sampling
Diagnosis
Treatment
Antibacterial treatment
Ultrasound
Follow-up imaging
Renal scar
guidelines
EAU
ESPU
http://dx.doi.org/10.1016/j.eururo.2014.11.007
0302-2838/# 2014 Published by Elsevier B.V. on behalf of European Association of Urology.
Please cite this article in press as: Stein R, et al. Urinary Tract Infections in Children: EAU/ESPU Guidelines. Eur Urol (2014), http://
dx.doi.org/10.1016/j.eururo.2014.11.007
1.
Introduction
Background
Methodology
4.
Classification
Diagnostic work-up
5.1.
Medical history
Please cite this article in press as: Stein R, et al. Urinary Tract Infections in Children: EAU/ESPU Guidelines. Eur Urol (2014), http://
dx.doi.org/10.1016/j.eururo.2014.11.007
Physical examination
Urine sampling
5.4.2.
Urine analysis
Please cite this article in press as: Stein R, et al. Urinary Tract Infections in Children: EAU/ESPU Guidelines. Eur Urol (2014), http://
dx.doi.org/10.1016/j.eururo.2014.11.007
Table 1 Criteria for urinary tract infections in children from the EAU guidelines on urological infections
Urine specimen from suprapubic
bladder puncture
Any number of CFU per millilitre
(at least 10 identical colonies)
Urine culture
Blood test
Ultrasound
6.
Therapy
Asymptomatic bacteriuria
Please cite this article in press as: Stein R, et al. Urinary Tract Infections in Children: EAU/ESPU Guidelines. Eur Urol (2014), http://
dx.doi.org/10.1016/j.eururo.2014.11.007
6.5.
Antimicrobial agents
Prophylaxis
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dx.doi.org/10.1016/j.eururo.2014.11.007
Table 2 Frequently used antibacterial agents for treatment of paediatric urinary tract infections
Chemotherapeutics
Daily dosage
Application
012 yr
Parenteral cephalosporins
Group 3a (eg, cefotaxime)
Group 3b (eg, ceftazidime)
Ceftriaxone
Oral cephalosporins
Group 3 (eg, ceftibuten)
Group 3 (eg, cexime)
Group 2 (eg, cefpodoxime proxetil)
Group 2 (eg, cefuroxime axetil)
Group 1 (eg, cefaclor)
TMP
or
TMP/Sulfamethoxazole
Ampicillin
Amoxicillin
Adolescents,
if different
100200 mg/kg
100150 mg/kg
75 mg/kg
36 g
26 g
IV in 23 D
IV in 23 D
IV in 1 D
9 mg/kg
812 mg/kg
810 mg/kg
2030 mg/kg
50100 mg/kg
56 mg/kg
0.4 g
0.4 g
0.4 g
0.51.0 g
1.54.0 g
PO
PO
PO
PO
PO
PO
320 mg
36 g
1.56.0 g
60100 mg/kg
3.66.6 g
PO in 2 D
IV in 34 D
PO in 23 D*
IV in 3 D
IV in 3 D
PO in 3 D
PO in 3 D;
IV in 34 D
Piperacillin
Tobramycin
Gentamicin
Ciprooxacin
Nitrofurantoin
Comments
35 mg/kg;
maximum: 0.4 g
5 mg/kg
35 mg/kg;
maximum: 0.4 g
Children and adolescents (117 yr): 2030 mg/kg
(maximum dose: 400 mg) (parenterally)
Children and adolescents (117 yr): 2040 mg/kg
(maximum dose: 750 mg) (PO)
35 mg
in
in
in
in
in
in
12 D
12 D
2D
3D
23 D
2D
IV in 1 D
Drug monitoring
IV in 1 D
IV in 3 D
PO in 2 D
PO in 2 D
D = doses per day; IV = intravenous; PO = oral; TMP = trimethoprim; UTI = urinary tract infection.
Infants: 2 D; children 112 yr: 3 D; adolescents: 23 D.
Modied with permission from the European Association of Urology [75].
Patients at risk
8.
Imaging
8.1.
Ultrasound
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dx.doi.org/10.1016/j.eururo.2014.11.007
Table 3 Recommendations for calculated antibacterial therapy of pyelonephritis dependent on age and severity of infection*
Diagnosis
Uncomplicated pyelonephritis
(without dilatation or known reux)
after 6 mo of age
Complicated pyelonephritis
(with dilatation/reux; severe bladder
dysfunction?) and/or urosepsis (all ages)
Proposal
Application
Duration
of therapy
Level of
evidence
10 (to 14) d
Newborns:
1421 d
7 (to 10) d
1b
1014 d
Cephalosporin
group 3y
Ceftazidime and
ampicillin*
or aminoglycoside
and ampicillin*
Chemotherapeutics
Oral cephalosporins
Group 1 (eg, cefaclor)
Group 1 (eg, cephalexin)
Group 2 (eg, cefuroximaxetil)
Group 2 (eg, cefpodoxime proxetil)
Group 3 (eg, ceftibuten)
TMP
TMP/Sulfamethoxazole
Amoxicillin/Clavulanic acid
Nitrofurantoin
Application
PO
PO
PO
PO
PO
PO
PO
PO
PO
in
in
in
in
in
in
in
in
in
23 D
34 D
2D
2D
1D
2D
3D
3D
2D
The first-choice antibacterials are nitrofurantoin, trimethoprim, and trimethoprim/sulfamethoxazole; in exceptional cases, oral cephalosporin can be used.
In Germany, ceftibuten is not approved for infants <3 mo old.
Modified with permission from the European Association of Urology [75]. Modified according to Craig et al [80].
Renal scintigraphy
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dx.doi.org/10.1016/j.eururo.2014.11.007
renal units with VUR grade III had normal early DMSA
scanning [101].
8.3.
Voiding cystourethrography
Table 6 General and specific recommendations in children with febrile urinary tract infection
General recommendations
Medical history
Anomalies in the pre- or postnatal US
Recurrent UTI
Family history
Clinical investigation
Exclusion of other sources of fever
Complete physical examination
Urine sampling
Suprapubic bladder aspiration
(most sensitive method)
Bladder catheterisation
Clean-catch urine collection
Plastic bag (useful only if negative
for both pyuria and bacteriuria)
Blood sample
Depending on clinical symptoms/
complicated UTI
Imaging
US to exclude upper tract dilatation
within 24 h, depending on the
clinical situation and medical
history
AB therapy/administration route
In uncomplicated UTI, oral AB therapy
is possible and gives the same
results as parenteral AB treatment
Duration of therapy
Parenteral AB therapy should be
continued until the child is
afebrile, followed by oral
AB for 714 d
If the child remains febrile,
reconsider the administration
route and choice of drug,
or repeat the US (upper tract
dilatation/abscess formation)
Follow-up imaging
Exclusion of VUR by VCUG
and/or DMSA scan
Follow-up therapy
Consider prophylaxis
<1 yr of age,
specic
>1 yr of age,
girl specic
>1 yr of age,
boy specic
Toilet trained,
girl specic
Toilet trained,
boy specic
Symptoms of LUTS/BBD
Symptoms of LUTS/BBD
Exclusion of LUTS/BBD
Exclusion of LUTS/BBD
Exclusion of VUR only
if there is a suspicion
Treatment of BBD/
LUTS with or without
treatment of VUR
Consider treatment
of phimosis
Electrolyte
Blood cell count
Creatinine
C-reactive protein
Procalcitonin
Infants <2 mo
of age:
parenteral
AB therapy
Exclusion
of VUR
Exclusion
of VUR
Exclusion of
VUR after recurrent
febrile UTIs
With or without
Consider treatment of
treatment of VUR phimosis with or
without treatment
of VUR
Treatment of BBD/
LUTS with or without
treatment of VUR
AB = antibiotic; BBD = bladder and bowel dysfunction; DMSA scan = (technetium Tc 99 labelled) dimercaptosuccinic acid scan; LUTS = lower urinary tract
symptoms; US = ultrasound; UTI = urinary tract infection; VCUG = voiding cystourethrogram; VUR = vesicoureteral reux.
Please cite this article in press as: Stein R, et al. Urinary Tract Infections in Children: EAU/ESPU Guidelines. Eur Urol (2014), http://
dx.doi.org/10.1016/j.eururo.2014.11.007
Fig. 1 Algorithm for assessment and treatment of first febrile urinary tract infection.
BBD = Bladder Bowel Dysfunction; DMSA = dimercaptosuccinic acid; IV = intravenous; MRI = magnetic resonance imaging; UTI = urinary tract infection;
VCUG = voiding cystourethrography; VUR = vesicoureteral reflux.
BBD is a risk factor for which every child with UTI should be
screened at presentation. Correction of lower urinary tract
dysfunction is important to decrease the rate of UTI
recurrence. If there are signs of BBD during infection-free
intervals, further diagnosis and effective treatment are
strongly recommended [111114]. Treatment of constipation leads to a decrease in UTI recurrence [115117]. Exclusion of BBD is therefore strongly recommended in any child
with febrile and/or recurrent UTI, and, if present, treatment
of BBD is necessary [118].
Author contributions: Raimund Stein had full access to all the data in the
study and takes responsibility for the integrity of the data and the
accuracy of the data analysis.
Study concept and design: Stein, Dogan, Hoebeke, Kocvara, Nijman,
Radmayr, Tekgul.
Acquisition of data: Stein, Dogan, Hoebeke, Kocvara, Nijman, Radmayr,
Tekgul.
10.
Conclusions
Please cite this article in press as: Stein R, et al. Urinary Tract Infections in Children: EAU/ESPU Guidelines. Eur Urol (2014), http://
dx.doi.org/10.1016/j.eururo.2014.11.007
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