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Urinary Tract Infection: Clinical Practice Guideline for
the Diagnosis and Management of the Initial UTI in
Febrile Infants and Children 2 to 24 Months
urinary tract infection, infants, children, vesicoureteral reflux,
OBJECTIVE: To revise the American Academy of Pediatrics practice
voiding cystourethrography parameter regarding the diagnosis and management of initial urinary
ABBREVIATIONS tract infections (UTIs) in febrile infants and young children.
SPA—suprapubic aspiration METHODS: Analysis of the medical literature published since the last
AAP—American Academy of Pediatrics
UTI—urinary tract infection
version of the guideline was supplemented by analysis of data provided
RCT—randomized controlled trial by authors of recent publications. The strength of evidence supporting
CFU—colony-forming unit each recommendation and the strength of the recommendation were
VUR—vesicoureteral reflux
WBC—white blood cell
assessed and graded.
RBUS—renal and bladder ultrasonography RESULTS: Diagnosis is made on the basis of the presence of both
VCUG—voiding cystourethrography
pyuria and at least 50 000 colonies per mL of a single uropathogenic
This document is copyrighted and is property of the American organism in an appropriately collected specimen of urine. After 7 to 14
Academy of Pediatrics and its Board of Directors. All authors
have filed conflict of interest statements with the American days of antimicrobial treatment, close clinical follow-up monitoring
Academy of Pediatrics. Any conflicts have been resolved through should be maintained to permit prompt diagnosis and treatment of
a process approved by the Board of Directors. The American recurrent infections. Ultrasonography of the kidneys and bladder
Academy of Pediatrics has neither solicited nor accepted any
commercial involvement in the development of the content of
should be performed to detect anatomic abnormalities. Data from the
this publication. most recent 6 studies do not support the use of antimicrobial prophy-
The recommendations in this report do not indicate an exclusive laxis to prevent febrile recurrent UTI in infants without vesicoureteral
course of treatment or serve as a standard of medical care. reflux (VUR) or with grade I to IV VUR. Therefore, a voiding cystoure-
Variations, taking into account individual circumstances, may be thrography (VCUG) is not recommended routinely after the first UTI;
VCUG is indicated if renal and bladder ultrasonography reveals hydro-
All clinical practice guidelines from the American Academy of
Pediatrics automatically expire 5 years after publication unless
nephrosis, scarring, or other findings that would suggest either high-
reaffirmed, revised, or retired at or before that time. grade VUR or obstructive uropathy and in other atypical or complex
clinical circumstances. VCUG should also be performed if there is a
recurrence of a febrile UTI. The recommendations in this guideline do
not indicate an exclusive course of treatment or serve as a standard of
care; variations may be appropriate. Recommendations about antimi-
crobial prophylaxis and implications for performance of VCUG are
based on currently available evidence. As with all American Academy of
Pediatrics clinical guidelines, the recommendations will be reviewed routinely and incorporate new evidence, such as data from the Ran-
domized Intervention for Children With Vesicoureteral Reflux (RIVUR)
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2011 by the American Academy of Pediatrics CONCLUSIONS: Changes in this revision include criteria for the diag-
COMPANION PAPERS: Companions to this article can be found
nosis of UTI and recommendations for imaging. Pediatrics 2011;128:
on pages 572 and e749, and online at 595–610
doi/10.1542/peds.2011-1818 and

PEDIATRICS Volume 128, Number 3, September 2011 595
Downloaded from by guest on April 29, 2017

Ne. brile infants” is used to indicate febrile 24 months of age and some did not terization or suprapubic aspiration infants and young children 2–24 provide specific data according to [SPA]). months of age applies to children ommendations. This clinical practice guideline is a re. dren with VUR. in the remain. occult bactere. (eg. mine whether the evidence gener. 2 in algorithm form in the Appendix. this children with VUR. The cian would use them when evaluating guideline was reviewed by multiple METHODS and treating a febrile infant.) The lower and upper grade of 24-month-old chil.4°F). or therapy to prevent recurrence of fe- mia has been the major focus of con. there has been increasing appre. who have no obvious neurologic or an. the literature search was creases in bacteremia and meningi. this definition committee members. a surveillance of Medline-listed tended to be a sole source of guidance Canada. To explore this par- (which have resulted in dramatic de. revision focuses on the diagnosis and ticular issue. which are presented line. With the introduc. The AAP ated from studies of infants 2 to 24 The subcommittee formulated 7 rec- funded the development of this guide. strength of the recommendation were ademic general pediatrics. tended to replace clinical judgment or to 596 FROM THE AMERICAN ACADEMY OF PEDIATRICS Downloaded from by guest on April 29. which the recommendations are ing body of evidence questioning the tion of effective conjugate vaccines based are included in a companion effectiveness of antimicrobial prophy- against Haemophilus influenzae type technical report. according to grade of VUR. ment or placebo treatment for chil- terial infections. diagnosis and treatment may months of age. The guideline is intended view of the literature on the effective. pediatric nephrol. emergency department. and 9 sections) and 5 external literature searches were conducted. there are special considerations in ing each recommendation and the cians with expertise in the fields of ac. management of initial urinary tract in. cording to AAP policy5 (Fig 1). pediatric radi. The infants who have no recognizable summary of the analysis. The quality of evidence support- and Management that included physi. fections (UTIs) in febrile infants and since 1993 in which antimicrobial pro- ciation of the urinary tract as the most young children (2–24 months of age) phylaxis was compared with no treat- frequent site of occult and serious bac. cians in decision-making.4 laxis to prevent recurrent febrile UTI in b and Streptococcus pneumoniae Like the 1999 practice parameter. Data are insufficient to deter. the authors of the 6 RCTs be delayed. plication of evidence derived from assessed by the committee member ogy and informatics. (For simplicity.0°C and meta-analyses were provided to lished by the American Academy of (ⱖ100. expanded to include trials published tis). raised and discussed until consensus oped by a subcommittee of the Steer. onates and infants less than 2 was reached regarding recommenda- ing Committee on Quality Improvement months of age are excluded. This text is a with vesicoureteral reflux (VUR). 1 To provide evidence for the guideline. ology. clinical practice guideline is not in- organizations in the United States and that is. The guideline will be reviewed literature over the past 10 years for for the treatment of febrile infants with and/or revised in 5 years. hospital) by clinicians who treat in. als (RCTs) of the effectiveness of pro- for culture cannot be obtained without der of this guideline the phrase “fe. fever was de. was published and a systematic re. pediatric practice. fined as temperature of at least 38. Rather. accordingly. treatment of pyelonephritis increase and have documented that the preva. Issues were Pediatrics (AAP) in 1999. of fever is used in this guideline. Most experimental and age limits were selected because stud. and pediatric urology. Results from the literature searches vision of the practice parameter pub. it is intended to assist clini- evidence emerges that warrants revi. unless new significant changes since the guideline UTIs. 2017 . The data on latter was based on the new and grow- source of infection.3 It was devel. dren. epidemiol. none of the participants had any more than 24 months of age. This council. Meta- the risk of renal damage. epidemiology and were graded ac- ogy. group. all provided raw data clinical data support the concept that ies on infants with unexplained fever from their studies specifically ad- delays in the institution of appropriate generally have used these age limits dressing infants 2 to 24 months of age. most experienced in informatics and infectious diseases. this age group that may limit the ap.2 lence of UTI is high (⬃5%) in this age analysis of these data was performed.INTRODUCTION for use in a variety of clinical settings ness of prophylactic antimicrobial Since the early 1970s. Because the clinical atomic abnormalities known to be as. in the text in the order in which a clini- financial conflicts of interest. office. because tions. In those studies. brile UTI/pyelonephritis in children cern for clinicians evaluating febrile fants and young children. phylaxis included children more than invasive methods (urethral cathe. were contacted. It is not in- sion sooner. as well as groups within the AAP (7 committees. Because all except 1 of presentation tends to be nonspecific in sociated with recurrent UTI or renal the recent randomized controlled tri- infants and reliable urine specimens damage. pediatric the studies of 2.

Therefore.9.6–8 nostic studies on relevant populations). cause of ill appearance or another When ultrasonographic guidance is pressing reason. and many parents and phy. it is important to fects the diagnostic process regarding UTI. 2017 . technique has limited risks. dition to seeking an explanation for the The techniques required for catheter- ● Value judgments: Once antimicro- fever. antimicrobial therapy have shown ture of urine collected in a bag vere phimosis or girls with tight la.10 The ● Benefits: A missed diagnosis of UTI should ensure that a urine speci. sterilized. Cultures of urine specimens collected in a bag applied to the perineum have an unacceptably high false-positive rate and are valid only when they yield negative results. have the most-accurate test for UTI degree of illness warrants immediate tion for the procedure may stimulate performed initially. the first few drops should be erences for bag versus catheterized SPA before antimicrobial agents are allowed to fall outside the sterile con. but tech. clini. recommendation).6. Urine obtained through catheteriza. compared ● Benefit-harms assessment: Prepon- the degree of illness or toxicity. ● Harms/risks/costs: Catheterization When evaluating febrile infants. However. because they may be contami- nated by bacteria in the distal urethra. ization and SPA are well described.12 derance of benefit over harm. catheter- If a clinician decides that a febrile method for obtaining urine that is un. If the clinician determines that the urine specimen.2%. Once an- specimen needs to be obtained unacceptably invasive. there portunity to make a definitive cause the diagnosis of UTI cannot may be no acceptable alternative to diagnosis is lost.11. lead to overtreatment and unneces- bial agent is administered. strong bial adhesions. urine. FROM THE AMERICAN ACADEMY OF PEDIATRICS tainer. Whether the urine is ● Role of patient preferences: There is specimen suitable for culture should obtained through catheterization or is no evidence regarding patient pref- be obtained through catheterization or voided. September 2011 597 Downloaded from by guest on April 29. antimicrobial therapy. cians make a subjective assessment of and a specificity of 99%. For febrile boys. Vari. in cases in which antimicro- Action Statement 1 SPA has been considered the standard bial therapy will be initiated. SPA for boys with moderate or se. success rates improve. the diagnosis of UTI. multiple studies of be established reliably through cul. the rate of false-positive re- establish an exclusive protocol for the administered. can lead to renal scarring if left un- men is obtained for both culture nical expertise and experience are treated. bial agents commonly prescribed in with a prevalence of UTI of 0. the fever requires antimicrobial able success rates for obtaining urine ● Aggregate quality of evidence: A (diag- therapy to be administered be. the clinician used. This clinical assessment deter. then a urine the child to void.14–16 With a preva- lence of UTI of 5% and a high rate of false-positive results (specificity: ⬃63%). ization or SPA is required to establish infant with no apparent source for contaminated by perineal flora. care of all children with this condition. with that obtained through SPA. tion for culture has a sensitivity of 95% is invasive. be. required.13 bial therapy has begun. false-positive result 88% of the time. a “positive” culture result for FIGURE 1 urine collected in a bag would be a AAP evidence strengths. bladder tap has PEDIATRICS Volume 128. DIAGNOSIS obscure the diagnosis of UTI. that the urine may be rapidly (evidence quality: A. because the antimicro. the op- through catheterization or SPA. the clinician should have a nity to make a definitive diagnosis is should be initiated promptly and af- sterile container ready to collect a lost.7. sults is 95%. the sicians perceive the procedure as sary and expensive imaging. with catheterization. Number 3. for circumcised boys. the such situations would almost certainly rate of false-positive results is 99%. have been reported (23%–90%). compared timicrobial therapy is initiated. Therefore. overdiagnosis of UTI can and urinalysis before an antimicro. with a prevalence of UTI of 2%. the opportu- mines whether antimicrobial therapy When catheterization or SPA is being attempted. because the prepara. However. in ad.

ficiently high to warrant urine culture. then the it is reasonable to monitor the clin. the overall preva. with no apparent source for the fever urine yields negative leukocyte es. aProbability of UTI exceeds 1% even with no risk factors other than being uncircumcised. 11. Option 2 is to obtain a cumcised boys is 4 to 20 times higher of another source of infection. Probability of UTI Among Febrile Infant Girls28 and Infant Boys30 According to Number of Findings Present. of girls with no identifiable or microscopic analysis results In a survey asking. Gorelick. Action Statement 2a If the clinician determines that the de. with sensitivity of convenient means and to perform a rate of UTI is only 0. no source for their fever evident on the dicates the number of risk factors as- basis of history or physical examina. not produce an absolute percentage. white race. age less than 12 tain a urine specimen through cath. among febrile infant girls is more than namely. The prevalence of UTI fant girls on the basis of 5 risk factors. For ex- esterase test results or nitrite test hood of UTI by one-half. This urine specimen through the most than that for circumcised boys. 67. can be obtained at a later time) and com- cient (evidence quality: A. be obtained through catheteriza. ● Intentional vagueness: The basis of the determination that antimicro- bial therapy is needed urgently is not specified. FIGURE 2 and the literature provides only gen. then practitioners considered the yield suf- diate antimicrobial therapy. permits urinalysis. then clinical follow-up likelihood of UTI should be assessed. twice that among febrile infant boys months. whose prediction rule. con- siderations for individual patients. temperature of at least 39°C. strong likelihood. Therefore. because variability in clinical judgment is expected. than 1% for 10. Fig 2 in- recommendation).18 of UTI of at least 1% and at least 2%. negative urinalysis results do not old that warrants a urine culture) does rule out a UTI with certainty. 2017 .7% of as not being so ill as to require imme. and absence urinalysis.5% of academicians and 45. a low-likelihood group (Fig 2). eterization or SPA for culture and (relative risk: 2.7% for practitioners26.19–24 The 88% and specificity of 30%.4%. strong lence of UTI in febrile infants who have fort with diagnostic uncertainty. clinician should assess the likelihood of ical course without initiating anti. eral guidance. then the dence that contact will be maintained (see text). quired to warrant urine culture in fe. pending on factors such as their confi- infant to have a low likelihood of UTI diate antimicrobial therapy. fever for at least 2 days.4% of academicians and Action Statement 2 tion or SPA and cultured. source of infection. sociated with threshold probabilities Action Statement 2b tion results is approximately 5%. clinicians will choose a threshold de- If the clinician determines the febrile gree of illness does not require imme. then a urine specimen should brile infants?. attempting to operational- UTI (see below for how to assess microbial therapy. Shaw. if urinaly.17. through the illness (so that a specimen monitoring without testing is suffi. then there are 2 and some with lower-than-average dated a prediction rule for febrile in- choices (evidence quality: A. terase and nitrite test results. Option 1 is to ob. ● Policy level: Strong recommendation. The rate for uncir. febrile infant is not in a low-risk with higher-than-average likelihood and colleagues27–29 derived and vali- group (see below). may enter into the decision. those who are non- positive for leukocytes or bacte.25 ample. recommendation).2% to 0. such as availability of follow-up care. As noted previously. recognizing that ize “low likelihood” (ie. ● Exclusions: None. when the If a clinician assesses a febrile infant sis of fresh (<1 hour since void) threshold was increased to 1% to 3%. If the urinalysis results presence of another. below a thresh- likelihood). been shown to be more painful than urethral catheterization.” the threshold was less with a recent onset (⬍2 days) of low- 598 FROM THE AMERICAN ACADEMY OF PEDIATRICS Downloaded from by guest on April 29. “What yield is re. If the clinician determines that the but it is possible to identify groups In a series of studies.27). white and more than 12 months of age ria). clinically obvious some infant girls to be considered in suggest a UTI (positive leukocyte source of infection reduces the likeli.

Many clinicians think that this timely identification and treatment General Considerations collection technique has a low contam. ination rate under the following cir. quality: C. to ensure sensitivity and quires culture of a specimen collected ● Exclusions: Because it depends on a specificity of the urinalysis. and the ● Role of patient preferences: The in tests that may predict the results of specimen is refrigerated or processed choice of option 1 or option 2 and the urine culture and enable presump- immediately.4. ● Harms/risks/costs: A small propor- men is desired. Urinalysis cannot substitute for urine ● Benefit-harms assessment: Prepon. pensive imaging. the specimen the 2 groups at highest risk of UTI. the ● Value judgments: There is a risk of with culture. PEDIATRICS Volume 128. clinicians should require both uri- ability of UTI can be estimated on the ba- nostic studies on relevant populations). fever ● Benefits: Accurate diagnosis of UTI tion (pyuria and/or bacteriuria) can prevent the spread of infection and the presence of at least 50 000 for more than 24 hours. perineum. the major definitive urine specimen through Action Statement 3 risk factor for febrile infant boys is catheterization initially. nonblack race. however. Alone and in Combination 1% probability of UTI. ● Aggregate quality of evidence: A (diag. recommendation). that some Leukocyte esterase or 93 (90–100) 72 (58–91) of the factors (eg. of a uropathogen cultured from a If the clinician determines that the in. It Leukocyte esterase test 83 (67–94) 78 (64–92) Nitrite test 53 (15–82) 98 (90–100) should be noted. obtained through cath. (Table 1). then often a urine tion of febrile infants. The tests through catheterization or SPA. the precise tion are biochemical analyses of leu- waiting for the infant to void and a sec. or prompting testing as described in microscopy positive action statement 2a. A a bag urine sample yields negative urinalysis results) versus timely must be fresh (⬍1 hour after voiding “positive” culture result from a speci. may be necessary if the the clinician but is below 3%. formed on any specimen. Be. range of patient. nalysis results that suggest infec- sis of 4 risk factors. colony-forming units (CFUs) per mL another source of infection. hours. taining a urine specimen is left to rapid dipstick method and urine eterization. % risk factor increases the probability. and absence of and renal scarring. ture or ⬍4 hours after voiding with re- to document a UTI. UTI but needs to be used in conjunction properly cleansed and rinsed before application of the collection bag. blood cells (WBCs) and bacteria UTI. each additional Test Sensitivity (Range).and physician- that have received the most atten- cause there may be substantial delay specific considerations. 99. there may be significant con. will not receive is used. obtaining a urine specimen may be encounter. avoiding overdi. treatment and unnecessary and ex. However. % Specificity (Range). WBCs 73 (32–100) 81 (45–98) Microscopy. whether they are circumcised. duration of fever) nitrite test positive may change during the course of the Microscopy. September 2011 599 Downloaded from by guest on April 29. microscopic examination for white urinalysis suggests the possibility of ● Intentional vagueness: None. many clinicians prefer to obtain a ● Policy level: Strong recommendation. Even if contamination the threshold risk of UTI warranting tive therapy to be initiated at the first from the perineal skin is minimized.30 agnosis of UTI can prevent over.8 (99–100) 70 (60–92) low-likelihood designation and nitrite test. catheterization or SPA (evidence microbial therapy and a urine speci. excluding the infant from a Leukocyte esterase test. sults are not available for at least 24 urine bag is removed promptly after ther evaluation. culture to document the presence of cumstances: the patient’s perineum is derance of benefit over harm. considered at collection bag affixed to the perineum Urinalysis low likelihood of UTI. frigeration). As demonstrated in Fig 2. Urinalysis can be per- however. there is considerable interest urine is voided into the bag. 2017 . bacteria 81 (16–99) 83 (11–100) illness. confirmation re. urine specimen obtained through fant does not require immediate anti. FROM THE AMERICAN ACADEMY OF PEDIATRICS grade fever (⬍39°C) have less than a TABLE 1 Sensitivity and Specificity of Components of Urinalysis. The prob. threshold risk of UTI warranting ob- kocyte esterase and nitrite through a ond specimen. including tamination from the vagina in girls or influenced by parents’ preference to avoid urethral catheterization (if one collected from a bag applied to the the prepuce in uncircumcised boys. of their UTIs. Because urine culture re- UTI sufficiently low to forestall fur. To establish the diagnosis of UTI. Number 3. temperature of at least 39°C. with maintenance at room tempera- evaluation (obtaining a definitive men collected in a bag cannot be used specimen through catheterization). namely.

The presence of bacteria in a fresh. standard method of assessing pyuria based systems use flow imaging terase test is 94% when it used in the has been centrifugation of the urine analysis technology and software to context of clinically suspected UTI. however. The test is helpful clude contaminated specimens. the results of leukocyte esterase tests chamber is used. More likely expla- tive value than does the standard urinal- have little value in ruling out UTI. nalysis are now being used in many Leukocyte Esterase Test nition of pyuria has been at fault. rather than very young infants. viduals with asymptomatic bacteriuria dard method does not. gen. bacteriuria is the presence of pyuria. guished. They indi. threshold of 5 WBCs per high-power urine specimens rapidly. Automated Urinalysis are few false-positive results). Gram-stained specimen of uncentri- The absence of pyuria in children with tion used for positive urine culture fuged urine correlates with 105 CFUs true UTIs is rare.36 The key to distin- bacteria in the urine). Image- The sensitivity of the leukocyte es. In a study of infants 2 to they provide rapid results. results should be interpreted with cau. If a counting correlate well with manual methods. such as with is an advantage of the test. A nitrite test is not a sensitive marker old of at least 1 Gram-negative rod in for children. because studies suggest that converted from dietary nitrates in the ing from other conditions (eg. and squamous epithelial cells. and after vigorous exercise. There. there tomatic bacteriuria. with a thresh- duces both fever and pyuria.7% of afebrile girls quire microscopy. The hospitals and laboratories. including fever result. trite tests vary according to the defini. The conversion of ease). were related to culture results without of at least 10 WBCs per ␮L in uncentri. because false-positive results are be easily confused with true UTI in a terase (as a surrogate marker for common.34 Culture a limitation. a finding of pyuria by no means bladder. positive leukocyte esterase test 105 CFUs per mL of a single uropatho- Improvement Amendments. not all urinary pathogens reduce culture in the absence of pyuria in- urinalysis when appropriate equipment nitrate to nitrite. cause of fever should already have sitivity. quires approximately 4 hours in the fore. has greater sen- empty their bladders frequently. Urine specimens terase test (average: 72% [range: and older girls. nations for significant bacteriuria in ysis33 and is the preferred method of over. The absence of be more sensitive33 and performs well method by which urinalysis is per- leukocyte esterase in the urine of indi. in clinical situations in which the stan. specificity. It is theoret- results.37 An “enhanced uri- ically possible if a febrile child is as- population being studied. and are eligible for specificity of pyuria in general. chamber assessment of pyuria noted sponse has developed. Accord. the age and symptoms of the per mL in culture. WBCs may be found in the urine.32 when true UTI has been reported to oc. and microscopic analysis. In the exclusion of individuals with asymp. bacteriuria. With numerous conditions febrile infant but needs to be distin- pyuria) and urinary nitrite (which is other than UTI.26 Asymptomatic bacteriuria can cate the presence of leukocyte es. however.31 The performance characteris. when the result is positive. the reported sensitivity in var. Automated methods to perform uri- cur in the absence of pyuria. Asymptomatic bacteriuria sults in addition to evidence of pyuria The specificity of the leukocyte es. harm than good. insen- and personnel are available. tion.” combining the counting sessed before the inflammatory re- method of urine collection. who children who are being evaluated be- 10 oil immersion fields. because field (⬃25 WBCs per ␮L). and the nalysis. In most cases. 0. WBCs. the sensitivity. 2017 . because 64%–92%]) generally is not as good as during infancy. and asymp- because it is highly specific (ie. because it distinguishes An important cause of bacteriuria in The diagnosis of UTI is made on the ba- individuals with asymptomatic bacte. often is associated with school-aged and/or bacteriuria.38 Results ious studies is lower (83%). with a classify particles in uncentrifuged Overall. antimicrobial treatment may do more presence of most Gram-negative enteric coccal infections or Kawasaki dis. and positive predic- Therefore. therefore. strepto.Urine dipsticks are appealing. this may be the most common tomatic bacteriuria. Microscopic Analysis for Bacteriuria confirms that an infection of the uri- tics of both leukocyte esterase and ni. More. formed in laboratories. particularly infants. guishing true UTI from asymptomatic dietary nitrates to nitrites by bacteria re. the defi. sitive criteria for pyuria.35 but it can be present should be processed as expediently as 600 FROM THE AMERICAN ACADEMY OF PEDIATRICS Downloaded from by guest on April 29. do not re. however. fuged urine has been demonstrated to future. the absence of pyuria is asymptomatic sis of quantitative urine culture re- riuria from those with true UTI. but the previously with Gram staining of drops Nitrite Test inflammatory response to a UTI pro- of uncentrifuged urine. negative nitrite test results WBCs in their urine. 24 months of age. the finding especially for red blood cells. nary tract is present. which reflects the non. had 3 successive urine cultures with a waiver under the Clinical Laboratory ingly.

and to reduce the bacteriuria “significant” in infants and treatment and unnecessary and ex. false-positive results) over a very Urine culture results are considered small chance of missing a UTI. The time the be in the range of 87% to 100%. The clinician urine resides in the bladder (bladder specificity is reported to be 92% to should base the choice of agent on incubation time) is an important deter. then it should be re. ceive an antimicrobial agent parenter- PEDIATRICS Volume 128. ● Aggregate quality of evidence: C (ob. may have a place in the of. however. Initiating treat- negative culture results are opera. to eliminate the acute infection. in which the propor.39 In most instances. The clinician should choose 7 to 14 clinically to have pyelonephritis. such as route of administration on practi- der urine. A prop.40 (Organisms such as sis of UTI in infants with asymptom. Definitions of positive and dipslides. These criteria dren can be treated orally. specificity. terns (if available) and should ad- ties. would seem to increase the sensitivity ● Value judgments: Treatment of tation to another site for processing of culture at the expense of decreased asymptomatic bacteriuria may be should be transported on ice. healthy. CFUs per mL to 50 000 CFUs per mL derance of benefit over harm. for the same rea. specimens that require transpor. strong recommendation). out symptoms. and Corynebacterium specimens. urine from adult women. a low colony count may be sis of UTI and whether the organism is present in a specimen obtained When initiating treatment.41 Practices that use dipslides just the choice according to sensi- count. son. number of CFUs that grow on the cul- ture medium. whom clinicians judge to be “toxic” or pathogen. colony counts with regard to the than 100 000 CFUs per mL.) number of UTIs. and equally efficacious. September 2011 601 Downloaded from by guest on April 29. 10 000. vant urine isolates for otherwise nostic criteria may miss a small frigerated to prevent the growth of or. coagulase-negative atic bacteriuria or contaminated (including medications) should re- staphylococci. 1000 to ● Intentional vagueness: None. was based on morning collections of and sensitivity testing or. sensitivity is reported to ment orally or parenterally is tional and not absolute. infants with “positive” sume that parents prefer no action will allow identification of urinary tract culture results alone will be recog. may need to per- ison of specimens from women with- form “test of cure” cultures after 24 Action Statement 4b out symptoms and women considered hours of treatment. fice setting. 10 000 to 100 000. erly collected urine specimen should posed criteria for UTI now include evi- dence of pyuria in addition to positive ● Role of patient preferences: We as- be inoculated on culture medium that culture results. ceeded the proportion of women with. an and renal scarring. Action Statement 4a therefore. with compar- sence of such results.42–44 Patients 50 000 CFUs per mL of a single urinary reduce the likelihood of overdiagno. If the specimen is not pro. the transition range. through voiding or catheterization cian should base the choice of when bacteria are not present in blad. 98%. ganisms that can occur in urine at Reducing the threshold from 100 000 ● Benefit-harms assessment: Prepon- room temperature. FROM THE AMERICAN ACADEMY OF PEDIATRICS possible. results in the 10 000 to 100 000 MANAGEMENT the distal urethra and periurethral CFUs per mL range need to be evalu- area are commonly colonized by the Action Statement 4 ated in context. In such method of collection considers that cases. because the pro- harmful. Some labo- positive or negative on the basis of the ratories report growth only in the ● Exclusions: None. spp are not considered clinically rele. Alternative culture methods. to pre- appropriate threshold to consider agnosis of UTI can prevent over. therapy (evidence quality: B. and more ● Policy level: Recommendation. but dipslides cannot specify the local antimicrobial sensitivity pat- minant of the magnitude of the colony organism or antimicrobial sensitivi. in the ab. 2017 . who are unable to retain oral intake Lactobacillus spp. ● Benefits: Accurate diagnosis of UTI recommendation). servational studies). likelihood of renal damage. cal considerations. Number 3. Most chil- children is the presence of at least pensive imaging. such as whether the same bacteria that may cause UTI. in the absence of a UTI (avoiding pathogens. 24-month-old children. nized as having asymptomatic bacteri. urinalysis findings support the diagno. ● Harms/risks/costs: Stringent diag- cessed promptly. vent complications. days as the duration of antimicrobial tion of women with pyelonephritis ex. The concept that more than should do so in collaboration with a tivity testing of the isolated 100 000 CFUs per mL indicates a UTI certified laboratory for identification uropathogen (evidence quality: A. avoiding overdi. the clini- a recognized uropathogen.36 Definition of significant following categories: 0 to 1000. was 10 000 to 100 000 can prevent the spread of infection The goals of treatment of acute UTI are CFUs per mL. uria rather than a true UTI.

allowable. yet been well defined. nal parenchyma and an assessment of tial to know local patterns of suscepti. least amount of medication that en- possibility of a structural abnormality sures effective treatment. be. There is evidence only 3 (1%) were deemed too ill to be that 1. tomic survey (with measurements). such as nitrofurantoin. recommendation). The usual choices ● Benefits: Adequate treatment of UTI tomic abnormalities that require fur- for oral treatment of UTIs include can prevent the spread of infection ther evaluation. Outcomes of aging or urologic consultation. antimicrobial choice and duration findings is relatively low. rectly were not found. agent also should be considered when sonography (RBUS) (evidence ● Aggregate quality of evidence: A/B quality: C. ● Harms/risks/costs: There are mini. therefore. the minimal administration of an antimicrobial undergo renal and bladder ultra- duration selected should be 7 days. and 14 days di- study of 309 febrile infants with UTIs. renal size that can be used to monitor bility of coliforms to antimicrobial mal harm and minor cost effects of renal growth. 2017 . UTIs. Whether the initial route of administra. per d in 2 doses divided every 6–8 h Sulfisoxazole 120–150 mg/kg per d in 4 doses Ceftazidime 100–150 mg/kg per d. but ● Policy level: Strong recommendation/ ministered fluids and medications.46 Wide- sulfamethoxazole and cephalexin. The yield of actionable agents. and the range is improvement. are inferior to courses in the recom- teral or oral treatment. evidence. based duration. In a data comparing 7. The purpose of RBUS is to detect ana- orally is uncertain. should erable variability in the timing and sary treatment. hours. or trimethoprim. every 24 h Trimethoprim-sulfamethoxazole 6–12 mg/kg trimethoprim and 30-60 mg/kg sulfamethoxazole Cefotaxime 150 mg/kg per d.TABLE 2 Some Empiric Antimicrobial Agents TABLE 3 Some Empiric Antimicrobial Agents for Oral Treatment of UTI for Parenteral Treatment of UTI Antimicrobial Agent Dosage Antimicrobial Dosage Amoxicillin-clavulanate 20–40 mg/kg per d in 3 doses Agent Sulfonamide Ceftriaxone 75 mg/kg. obstructive uropathy in infants. but the ● Value judgments: Adjusting antimi- crobial agent before sensitivity results consequences of prenatal screening crobial choice on the basis of avail- are available. particularly trimethoprim. Cephalosporin divided every 8 h Cefixime 8 mg/kg per d in 1 dose Gentamicin 3-day courses for febrile UTIs Action Statement 5 assigned randomly to either paren.5 mg/kg per d. unless the study was a detailed ana- tion of the antimicrobial agent is oral ● Exclusions: None. malities in infants with UTIs have not best evidence will minimize cost and peutic concentrations in the blood. those of 7. The committee attempted to 7 vs 10 vs 14 days. RBUS clavulanic acid. Agents that are excreted with respect to the risk of renal abnor- able data and treating according to in the urine but do not achieve thera. not be used to treat febrile infants with quality of prenatal ultrasonograms. amoxicillin plus and renal scarring. divided every 6–8 h the total course of therapy should be 7 distinguishes the benefit of treating ally (Table 2) until they exhibit clinical to 14 days. because parenchymal and serum ● Role of patient preferences: It is as- and the report of “normal” ultrasono- antimicrobial concentrations may be sumed that parents prefer the graphic results cannot necessarily be insufficient to treat pyelonephritis or most-effective treatment and the relied on to dismiss completely the urosepsis. 10. compliance with obtaining an antimi- crobial agent and/or administering it (RCTs). It is essen. Cefuroxime axetil 20–30 mg/kg per d in 2 doses divided every 8 h Cephalexin 50–100 mg/kg per d in 4 doses Piperacillin 300 mg/kg per d. recommendation. and are able to retain orally ad. preferred. prevalence of previously unsuspected account during selection of an antimi. or parenteral (then changed to oral). There is consid- consequences of failed or unneces- stream. spread application of prenatal ultra- cause there is substantial geographic ● Benefit-harms assessment: Prepon. of therapy. such as additional im- a cephalosporin.45. sonography clearly has reduced the variability that needs to be taken into derance of benefit over harm. rather than a range. short courses (1–3 d) are inferior to also provides an evaluation of the re- sulfamethoxazole (Table 3). generally within 24 to 48 identify a single. ● Intentional vagueness: No evidence was performed during the third tri- 602 FROM THE AMERICAN ACADEMY OF PEDIATRICS Downloaded from by guest on April 14-d courses.42 Parenteral Febrile infants with UTIs should mended range. Cefpodoxime 10 mg/kg per d in 2 doses divided every 8 h Cefprozil 30 mg/kg per d in 2 doses Tobramycin 5 mg/kg per d.

The radiation dose to for development of pyelonephritis. formed. the patient during dimercaptosuccinic then the rationale for performing acid scanning is generally low (⬃1 ● Intentional vagueness: None. September 2011 603 Downloaded from by guest on April 29. 2017 . been challenged in the past decade. however. tions of this modality that were de. even with recognition of the limita. the total exposure for the other atypical or complex clinical clinical improvement is not occurring. rences of infection were not prevented sessment of renal growth. not beneficial and VUR is not required first febrile UTI. RBUS is recom. because it judged sufficiently important to tip VUR cannot be demonstrated. and 1% to 2% will have ab- malities in which recurrent UTI could parenchyma attributable to edema normalities that would lead to ac- increase renal damage. was who develop pyelonephritis in whom ning is useful in research. tion as prophylaxis and surgical inter- acute infection to be a true baseline leading to unnecessary and invasive vention if VUR was persistent or recur- study for later comparisons in the as. imaging does not need ation is a major advantage of RBUS. The sive and poses minimal risk. Management included ities makes it inappropriate to con. of the potentially correctable abnor- curred. PEDIATRICS Volume 128.51–55 If prophylaxis is. derance of benefit over harm. routine evaluation of infants with their condition. or obstruction. B. and the ensures that all subjects in a study the scales in favor of testing. scarring. additional evaluation. structive uropathy. the strategy to could be confused with hydronephro- ● Benefits: RBUS in this population protect the kidneys from further dam- sis. ani. as well as in ness is unusually severe or substantial Moreover. in fact. scribed previously. digital fluoroscopy) and is related di- gest either high-grade VUR or ob- structive uropathy when the clinical ill. laxis for patients who have VUR has permits assessment of later renal cause ultrasonography is noninva. which servational studies).49 although it may be increased in ● Policy level: Recommendation. onstrate substantial clinical improve. VCUG is indicated if RBUS re- ment to identify serious complications. VCUG when both studies are per- routinely after the first febrile mended during the first 2 days of treat. and VCUG is used tion. we as. UTI must be questioned. coupled with are a significant number of infants cystourethrography (VCUG). some have advocated surgical labeled dimercaptosuccinic acid has intervention to correct high-grade re- ● Value judgments: The seriousness greater sensitivity for detection of flux even when infection has not re- acute pyelonephritis and later scar. Further evaluation should be con- tion and can even be misleading. or surgery). brile UTI (evidence quality: X. Several studies have suggested that findings on nuclear scans rarely affect sume that parents will prefer RBUS prophylaxis does not confer the de- acute clinical management. ferral. recommendation). ● Harms/risks/costs: Between 2% continuous antimicrobial administra- sider RBUS performed early during and 3% will be false-positive results. ducted if there is a recurrence of fe- mal studies demonstrate that Esche. Action Statement 6 preted by qualified individuals. acute and follow-up studies are ob. richia coli endotoxin can produce recommendation). ● Aggregate quality of evidence: C (ob- dilation during acute infection. The lack of exposure to radi- ment. The scan. it is clear that there ring than does either RBUS or voiding malities in 1% to 2%. to detect this. evaluations. re- mon of these is VUR. However. The most com- also are common during acute infec. VCUG routinely after an initial febrile mSv).50 The radiation dose from UTI. child will be increased when both circumstances (evidence quality For febrile infants with UTIs who dem. the absence of physical harm. For the past 4 decades. and was performed and inter. imen. however.47 The radiation dose from dimercapto- Action Statement 6a The timing of RBUS depends on the succinic acid is additive with that of VCUG should not be performed clinical situation. Action Statement 6b to occur early during the acute infec. effectiveness of antimicrobial prophy- have pyelonephritis to start with and it ● Role of patient preferences: Be. with an antimicrobial prophylaxis reg- ● Benefit-harms assessment: Prepon- Nuclear scanning with technetium. VCUG depends on the equipment that veals hydronephrosis. over taking even a small risk of sired benefit of preventing recurrent and are not recommended as part of missing a serious and correctable febrile UTI. such as renal or perirenal abscesses is used (conventional versus pulsed or other findings that would sug- or pyonephrosis associated with ob. scarring as an outcome measure. tained. The presence of these abnormal. children with reduced renal function.48 age after an initial UTI has been to de- Changes in the size and shape of the will yield abnormal results in ⬃15% tect childhood genitourinary abnor- kidneys and the echogenicity of renal of cases. rectly to the total fluoroscopy time. FROM THE AMERICAN ACADEMY OF PEDIATRICS mester. tion (eg. Number 3. pyonephrosis. ● Exclusions: None.

604 FROM THE AMERICAN ACADEMY OF PEDIATRICS Downloaded from by guest on April 29. ommendation. expense. TABLE 4 Recurrences of Febrile UTI/Pyelonephritis in Infants 2 to 24 Months of Age With and Without Antimicrobial Prophylaxis. Unfortunately. and some did not provide com. It is the judgment of the to VCUG (Fig 4). The position brile UTIs is small. of VUR.00 meta-analyses. and discomfort. or IV VUR (Table 4 and Fig 3). ing high-grade reflux is still in some ditional important data58 (see Areas sufficient to justify routinely subject. attempts have ● Aggregate quality of evidence: B ter the second UTI.29 IV 16 55 21 49 . laxis seems to be ineffective in pre- Vesicoureteral Reflux study) is cur. Data adapted from abnormalities until their second UTI. To minimize any harm Action Statement 6a committee that VCUG is indicated af- incurred by that infant. With a practice of wait- over. a data set with data for 1091 infants 2 grade VUR. More. there are no radiation exposure (of particular to 24 months of age according to grade clinical or laboratory indicators that concern near the ovaries in girls). Because the benefit of identify- UTI. the predictive value of any of the malities is delayed. doubt. ● Exclusions: None. without reflux or those with grades I. ing all infants with an initial febrile UTI considered. the new evidence demonstrating anti.51–56 All com.15 These 2 factors have compromised I 2 37 2 35 1. To ensure direct com. A ␹2 analysis (2-tailed) and a have been demonstrated to identify in. (It child is receiving antimicrobial pro- also is possible that the 1 infant with chance of benefit is both small and phylaxis. formal meta-analysis did not detect a fants with high-grade VUR. which permitted the creation of greatest likelihood of having high. 99 do not. elonephritis for the vast majority of fects of a prophylactic antimicrobial ditional potential harm to an infant infants. None 7 210 11 163 .14 6 researchers who had conducted the most recent RCTs and requested raw data from their studies. In some cases. those who have the ● Benefits: This avoids. therefore. treatment of a febrile UTI recurrence exposure. been made to identify. No. majority of febrile infants with UTIs. data for insufficient at the time of the 1999 ated with radiation (plus the ex- those infants are not included in Table practice parameter to receive a rec. the committee contacted the III 31 140 40 145 . Antimicrobial prophy- grade V VUR might have been identified domized Intervention for Children With after the first UTI on the basis of abnor. The level of evidence supporting rou- tine imaging with VCUG was deemed ● Value judgments: The risks associ- cluded in the RCTs. of the current subcommittee reflects current studies (Table 5) indicate that. pense and discomfort of the proce- 4 or Fig 3.) Data to quantify ad. for the vast plied. play. II 11 133 10 124 . ● Benefit-harms assessment: Prepon- III. of Total N No. because VCUG is an uncomfort- VUR. According to Grade of VUR laxis performed to date generally in- Reflux Prophylaxis No Prophylaxis P cluded children more than 24 months Grade of age.RCTs of the effectiveness of prophy. prompt diagnosis and effective able procedure involving radiation ing for a second UTI to perform VCUG. ● Role of patient preferences: The of a hypothetical cohort of 100 infants microbial prophylaxis not to be effec. indications for VCUG proposed in this manner is not known. parents only 10 of the 100 would need to un. these preferences should be for Research). 2017 . at the time of (RCTs). judgment of parents may come into with febrile UTIs. and it is anticipated to provide ad- but suggest that the increment is in. infants with grade V VUR were in. venting recurrence of febrile UTI/py- mal RBUS results that prompted VCUG rently in progress to identify the ef- to be performed. the initial UTI. may be of greater importance regard- dergo the procedure and the 1 with may prefer to subject their children less of whether VUR is present or the to the procedure even when the grade V VUR would be identified. outweigh the risk of delaying the de- the subcommittee was to “strongly en- grade VUR among all infants with fe. but the consensus of dure) for the vast majority of infants The proportion of infants with high. for VCUG have been proposed on the small number of cases of high- phylaxis in preventing recurrence of basis of consensus in the absence of grade reflux and correctable abnor- febrile UTI/pyelonephritis in infants data57. only 1 has grade V tive as presumed previously. Some parents may want to regimen for children 2 months to 6 who is not revealed to have high-grade avoid VCUG even after the second years of age who have experienced a VUR until a second UTI are not precise UTI. A national study (the Ran. II.95 parisons. Only 5 derance of benefit over harm. Indications ● Harms/risks/costs: Detection of a statistically significant benefit of pro. tection of the few with correctable courage” imaging studies. of Total N Recurrences Recurrences plete data according to grade of VUR. uncertain.

data provided by Drs likely in the near future. Further pyelonephritis in 285 infants 2 to 24 months of age with grade III VUR. ● Benefit-harms assessment: Prepon- FIGURE 3 derance of benefit over harm. ● Benefits: VCUG after a second UTI should identify infants with very high-grade reflux. Adapted from Jodal. data provided by Drs Craig. because the Brandström. Recurrences of febrile UTI/pyelonephritis in 373 infants 2 to 24 months of age without VUR. September 2011 605 Downloaded from by guest on April 29. including to the ovaries of girls. with and without antimicrobial prophylaxis (based on 5 studies. Recurrences of febrile UTI/pyelonephritis in 257 infants 2 to 24 grade reflux and other abnormali- months of age with grade II VUR. Craig. with and without antimicrobial prophylaxis (based on 3 studies. Montini. and studies of treatment for grade V Roussey-Kesler). Craig. Action Statement 6b ● Aggregate quality of evidence: X (ex- ceptional situation). judged that patients with high- with and without antimicrobial prophylaxis (based on 4 studies. and Roussey-Kesler). Garin. Montini. % After First After UTI Recurrence (N ⫽ 100) (N ⫽ 10) No VUR 65 26 Grades I–III VUR 29 56 Grade IV VUR 5 12 Grade V VUR 1 6 FIGURE 4 Relationship between renal scarring and num- ber of bouts of pyelonephritis. condition is uncommon and ran- domization of treatment in this group generally has been consid- ered unethical. and Mon. ● Harms/risks/costs: VCUG is an un- comfortable. and Pennesi). and Roussey-Kesler). FROM THE AMERICAN ACADEMY OF PEDIATRICS TABLE 5 Rates of VUR According to Grade in Hypothetical Cohort of Infants After First UTI and After Recurrence Rate. Pennesi.59 ● Intentional vagueness: None. M-H indicates Mantel-Haenszel. data ties may benefit from interventions provided by Drs Craig. E. Garin. data provided by Drs Brandström. C. Pennesi. costly procedure that involves radiation. Number 3. ● Value judgments: The committee tini). with and without antimicrobial prophylaxis (based on 3 studies. ● Policy level: Recommendation. PEDIATRICS Volume 128. data provided by Drs Craig. B. Garin. with and without antimicrobial prophylaxis (based on 6 studies. Garin. CI. A. D. Recurrences of febrile UTI/pyelonephritis in 104 infants 2 to 24 months of age with VUR are not underway and are un- grade IV VUR. Montini. Recurrences of febrile UTI/pyelonephritis in 72 infants 2 to 24 months of age with grade I VUR. 2017 . Recurrences of febrile UTI/ to prevent further scarring. confidence interval.

Ultrasonography of would permit an alternative to inva- have sustained a febrile UTI should the kidneys and bladder should be per. 2017 . 2. indicated if RBUS reveals hydrone- parents may come into play. to the clinician for evaluation of uncertain. It is the ● Exclusions: None. til urine culture and urinalysis results at several steps. age has not been conducted and is treatment of infants and young chil- pending on the findings. valuable for general use. seek medical care. VCUG is tioned previously. of VUR remain unproven. Strategies for diag- scope of this guideline. In some cases. VUR or obstructive uropathy. with able. pathogen in an appropriately collected recognized the same limitations. but the AREAS FOR RESEARCH point estimates suggest a small po. Special at- onset of subsequent febrile illnesses. number of recurrences increase (Fig prompt diagnosis and treatment of re. able for assessment of the effects treated promptly (evidence qual. close clinical follow-up the imaging techniques now avail- Early treatment limits renal damage monitoring should be maintained. ● Benefits: Studies suggest that early phrosis. all infants who current infections. consultation). first UTI is not recommended. ● Benefit-harms assessment: Prepon- derance of benefit over harm. fication of areas in which evidence is the second UTI. estimates of undesirable unexplained fever. 1. The relationship between UTIs in in- judgment of the committee that ● Intentional vagueness: None. outcomes in adulthood. duced renal function in adults has UTI. fants and young children and re- VCUG is indicated after the second ● Policy level: Recommendation. imaging tools avail- infections can be detected and does not provide a definitive diagnosis. it may be possible to identify better than late treatment. such as nosis and treatment depend on ● Policy level: Recommendation. CONCLUSIONS well characterized in quantitative ● Intentional vagueness: Further eval. The ideal prospective cohort The committee formulated 7 key action uation will likely start with VCUG but study from birth to 40 to 50 years of statements for the diagnosis and may entail additional studies de. the relationship of scarring to re- risk of renal scarring increases as the quent febrile episodes to permit nal impairment and hypertension. urinalysis alone Until recently. One of the major values of a compre- tential benefit. Diagnosis is based on subject to bias and error. been established but is not ● Exclusions: None. or other findings cause VCUG is an uncomfortable treatment of UTI reduces the risk of that would suggest either high-grade procedure involving radiation expo. Routine VCUG after the cause urethral catheterization may 606 FROM THE AMERICAN ACADEMY OF PEDIATRICS Downloaded from by guest on April 29.● Role of patient preferences: As men. The benefits of treatment fever. The details unlikely to be conducted. each of which is nician should instruct parents or are available. ● Aggregate quality of evidence: C (ob. to ensure that recurrent specimen of urine. be. additional imaging or urologic girls and uncircumcised boys. ences should be considered. are based on the mathe- Action Statement 7 matical product of probabilities mediately or can be delayed safely un- After confirmation of UTI. whether the clinician determines that hypertension and end-stage renal antimicrobial therapy is warranted im. treatment. as well as sure. sive sampling and culture would be have a urine specimen obtained at the formed to detect anatomic abnormali. The following 8 areas are pre- of identifying high-grade reflux is will ultimately make the judgment to sented in an order that parallels the still in some doubt. scarring.1. be- treated promptly. these prefer. VCUG also should be additional costs and inconvenience the procedure even when the performed if there is a recurrence of to parents with more-frequent visits chance of benefit is both small and febrile UTI. The development of techniques that 4). parents may in other atypical or complex clinical ● Harms/risks/costs: There may be prefer to subject their children to circumstances. Because the benefit ● Role of patient preferences: Parents lacking. renal scarring.59 For these reasons. recommendation). There- dren 2 to 24 months of age with UTI and of further evaluation are beyond the fore. parents hensive literature review is the identi- may want to avoid VCUG even after ● Value judgments: None. thoughtful literature review have hours) for future febrile ill. terms. Similarly. previous discussion.2 and the evaluation of the urine during subse. disease. nesses. Other guardians to seek prompt medical the presence of pyuria and at least attempts at decision analysis and evaluation (ideally within 48 50 000 CFUs per mL of a single uro. After 7 to 14 days of antimicrobial of UTIs have been insensitive. the judgment of servational studies). ties that require further evaluation tention should be given to infant so that a UTI can be diagnosed and (eg. With ity: C. the cli.

Downs SM. Downs. Wald. 2011. Marco Pennesi.”60. Practice urinary tract infection in febrile infants and 2. MS phylaxis is of benefit for individuals rolled in the Randomized Interven- S. 4. 2009 –2011 sumption that antimicrobial pro. creased scarring. Barriers to the ef. bial treatment has not been deter- ity to replace culture. Finnell SM. Commit. MS with VUR to prevent recurrences of tion for Children With Vesi. Retro. plausibility. MD. A urinary 8. VUR. IMPROVEMENT AND MANAGEMENT. fending uropathogen. rather than an antimi. ited and would be useful for predic. of VUR. because it could be taken parisons of various duration would VCUG) is incompletely understood. Acquired renal scars in chil. This guideline is limited to the initial Jonathan Craig. The optimal duration of antimicro- the desired sensitivity and specific. Committee on Quality Improvement and fection. among Hispanic individuals are lim. September 2011 607 Downloaded from by guest on April 29. Maria E. regimen. taminated specimens and SPA now these issues. Number 3. Michael Zerin. J Urol. Steering ring associated with reflux and urinary in. tion in febrile infants and young children. Better understanding of the ge- that progressive renal scarring nome (human and bacterial) may LEAD AUTHOR provide insight into risk factors Kenneth B.61 and multiple investiga. SUBCOMMITTEE ON URINARY TRACT demonstrated VUR. results in delayed parents would need sufficient edu. ness with a well-tolerated. VUR (defined through VCUG) and 5. crobial agent. 5. and renal scar- rently is the subject of the Random. The role of VUR (and therefore of desirable. will be retained from children en. safe or other abnormalities. Roberts. some will be identified as having VUR is not commonly performed. STAFF tinguish the contribution of congeni. Gio- ated with the various agents. Pediatrics. Alton DJ. Caryn Davidson. and the potential for emergence of anti. MD. cording to grade of VUR to be com- phylaxis are adherence to a daily tion rules. the concept has biological ACKNOWLEDGMENTS attributable to UTI.52. Finnell. enabling clinicians to It is recognized that pyelonephritis bacteria would develop resistance. Carroll AE. and search addressing the optimal culture process. Hardy BE. Shortliffe.53 The pre. would be particularly mined. tee on Quality Improvement. 1983. recurrent UTI. BMJ. Blood specimens INFECTION. Roberts. Eduardo Garin. MA vention of UTI has not been demon- tal dysplasia from acquired scarring strated. 2017 . Classifying recommenda- PEDIATRICS Volume 128. American Academy of Pediatrics. MD data from recent studies and cur. microbial resistance. MD is not supported by the aggregate of J. which is inherent in the product would be required. FROM THE AMERICAN ACADEMY OF PEDIATRICS be difficult and can produce con. MD. piled. and young children. Data regarding rates to permit the data set with data for concentrations. Studies may also be able to dis. cation to understand the value and uations would be valuable. REFERENCES 1. Smellie JM. The committee gratefully acknowl- bial agents used to treat or to pre.308(6938):1193–1196 Pediatrics. Incu. Technical Churchill BM. treatment. infants 2 to 24 months of age. ring. One of the factors used to assess edges the generosity of the research- vent infections of the urinary tract the likelihood of UTI in febrile in. Some of Gwenaelle Roussey-Kesler. 3. MD UTI or the development of renal scars coureteral Reflux study. 7. that is. Chair Stephen M. 6. evidence of effective. 1091 infants aged 2 to 24 months ac- fectiveness of antimicrobial pro. 1994. ers who graciously shared their data are excreted in the urine in high fants is race. Drs Per Brandström. Poulton A. Winter AL. indefinitely without concern that be valuable. Stanley Hellerstein.58 search to identify a genetic basis for 2009 –2011 4. MD examination of genetic determinants Ellen R. Vesicoureteral Reflux study. ment on the basis of tests that lack importance of adherence. Prescod NP. Arbus GS.58 VUR is recognized to “run in OVERSIGHT BY THE STEERING ized Intervention for Children With families.129(6):1190 –1194 on Urinary Tract Infection. Another possible strategy might be what is needed to eradicate the of- phy) can occur in the absence of the use of probiotics. MD (defined through cortical scintigra- phy) can occur in the absence of (VUR and others) that lead to in.103(4):843– 852 Management. antiseptic. Kenneth B.128(3):e749 spective study of children with renal scar. et al. Subcommittee report: diagnosis and management of an initial dren. 1999. limit antimicrobial exposure to (defined through cortical scintigra. To overcome the infants will have recurrent UTIs. parameter: the diagnosis. evaluation of the initial urinary tract infec. Further re- bation time. Virtually all antimicro. RCTs of head-to-head com- 3. American Academy of Pediatrics. COMMITTEE ON QUALITY tors are currently engaged in re. adverse effects associ. course of management in specific sit- treatment or presumptive treat. for future Linda D. Although the effectiveness of anti- microbial prophylaxis for the pre. and management of the first UTI in febrile vanni Montini.

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nice. Health and Clinical Excellence. Lancet. Is sults from a prospective randomized study. controlled trial. 2006. and Long-term 350(9075):396 – 400 PEDIATRICS Volume 128. Antibiotic 59. 2008. Accessed March Med. part III: uri. London. Radiation dosimetry of ized. Abbott GD. Hansson S. Mol Genet. 14. 2009. Hoberman A. Lambert pyelonephritis: a multicenter. Eccles MR. J Nucl Pediatrics. ized. 57. controlled. Keren R. voiding cystourethrography. Craig J. Infect Dis Clin North Am. coureteral Reflux (RIVUR) study. Jodal U. Avail- Gordon I. Patient dose reduction during Antibiotic prophylaxis for the prevention of 58. Zucchetta P. Carpenter MA. September 2011 609 Downloaded from by guest on April 29. 55. random. Peratoner L. 1996. Number 3. recurrent urinary tract infection in children Rationale and design issues of the Random- 2006.pediatrics. Management: NICE Clinical Guideline 54. Bailey RR. ized Intervention for Children With Vesi- 51. Esbjorner E. Treatment. Evans K. Urinary Tract Infection in Children: familial ureteric reflux. 2008. FROM THE AMERICAN ACADEMY OF PEDIATRICS teral malfunction induced by bacteria. Coulthard MG. 53.122(5):1064 –1071 11819/36032/36032. Herthelius M. fection in technetium-99m-DMSA in children. Montini G. Clinical signifi- nary tract infection pattern.pdf. Pediatr Radiol. Scott JE.36(suppl 2):168 –172 with low grade vesicoureteral reflux: re. Garcia Nieto V. 2017 . Pediatrics. Williams G. prophylaxis and recurrent urinary tract in- childhood. Pennesi M. J Urol. 626 – 632 Diagnosis. Smith T. Hum ciano B.122(suppl 5):S240 –S250 coureteral reflux effective in preventing py. 1997. 1987. et al. Anderson PJ. National Institute for Health and Clinical Ex. Swerkersson S. et al. Lythgoe MF. Brandström P. Swallow V. In. 2011 50. Pediatrics. reflux: a common familial disorder. et al. Pro.179(2):674 – 679 2008. Pediatrics. antibiotic prophylaxis in children with vesi. 1975. Available at: www. 1(4):713–729 121(6). The Unravelling the genetics of vesicoureteric 361(18):1748 –1759 cgi/content/full/121/6/e1489 60. 56. England: National Institute for 49. vest Urol. Ward VL. 1996.):1425–1429 cance of primary vesicoureteral reflux and urinary antibiotic prophylaxis after acute 184(1):286 –291 61. HJ. Valen- Swedish Reflux Trial in Children. Screening of newborn babies for controlled study. Travan L. The natural history of bacteriuria in elonephritis and renal scars? A random. Sullivan MJ. Rigon L. Garin EH. noninferiority trial. Olavarria F. 2010. 2008. randomized. Idres N. Campos A. fection in children? A multicenter.117(3): cellence. Simpson J. Young L. et N Engl J Med. J Urol.37(8):1336 –1342 54. Gadjos V. 2007. Jodal U.5(Spec No. Roussey-Kesler G.13(2):117–120 phylaxis after first febrile urinary tract in. Lee RE. able at: www.

APPENDIX Clinical practice guideline algorithm. 610 FROM THE AMERICAN ACADEMY OF PEDIATRICS Downloaded from by guest on April 29. 2017 .

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