+ MODEL
Journal of Pediatric Urology (2017) xx, 1e7
a
Department of Pediatrics with
Clinical Assessment Unit,
Medical University of Warsaw,
Poland
b
Department of Pediatrics and
Nephrology, Medical University
of Bialystok, Poland
Correspondence to:
M. Okarska-Napierała,
Department of Pediatrics with
Clinical Assessment Unit,
Samodzielny Publiczny
Dziecie
˛cy Szpital Kliniczny, ul.
_
Zwirki i Wigury 63A, Warszawa
02-091, Poland, Tel.: þ48 503
065 849; fax: þ48 22 317 92 32
magda.okarska@gmail.com
(M. Okarska-Napierała)
Keywords
Congenital anomaly of the kid-
neys and urinary tract, CAKUT;
Urinary tract infection, UTI;
Voiding cystourethrogram,
VCUG; Recommendations
Received 21 May 2017
Accepted 29 July 2017
Available online xxx
http://dx.doi.org/10.1016/j.jpurol.2017.07.018
1477-5131/ª 2017 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Okarska-Napierała M, et al., Urinary tract infection in children: Diagnosis, treatment, imaging e
Comparison of current guidelines, Journal of Pediatric Urology (2017), http://dx.doi.org/10.1016/j.jpurol.2017.07.018
Review Article
Urinary tract infection in children:
Diagnosis, treatment, imaging e
Comparison of current guidelines
M. Okarska-Napierała a, A. Wasilewska b, E. Kuchar a
Summary
Background and objective
Urinary tract infection (UTI) is a frequent disorder of
childhood, yet the proper approach for a child with
UTI is still a matter of controversy. The objective of
this study was to critically compare current guide-
lines for the diagnosis and management of UTI in
children, in light of new scientific data.
Methods
An analysis was performed of the guidelines from:
American Academy of Pediatrics (AAP), National
Institute for Health and Care Excellence (NICE),
Italian Society of Pediatric Nephrology, Canadian
Paediatric Society (CPS), Polish Society of Pediatric
Nephrology, and European Association of Urology
Introduction
UTI is the most common bacterial infection in
children aged <2 years [1], and it may be the
first symptom of congenital anomaly of the
kidneys and urinary tract (CAKUT), with VUR
being the most prevalent. The assumption that
recurrent UTIs in patients with VUR lead to
renal scarring and consecutive chronic kidney
disease (CKD) had been the indication for ac-
curate diagnosis and specific treatment of
VUR. However, recently, this aggressive
approach has been questioned, due to
numerous studies undermining the clinical
importance and effectiveness of VUR treat-
ment [2]. Damage to the kidney tissue, which
was previously attributed to UTIs or reflux
nephropathy, has been found to be congenital
in nature [3,4]. Similarly, antibiotic prophy-
laxis in CAKUT has also been recently chal-
lenged [5]. The current review summarized
current knowledge and recommendations
concerning UTI in children.
The first document included in the review
was the National Institute for Health and
(EAU)/European Society for Pediatric Urology
(ESPU).
Separate aspects of the approach for a child with
UTI, including diagnosis, treatment and further im-
aging studies, were compared, with allowance for
recent research in each field.
Conclusions
The analyzed guidelines tried to reconcile recent
reports about diagnosis, treatment, and further di-
agnostics in pediatric UTI with prior practices and
opinions, and economic capabilities. There was still
a lack of sufficient data to formulate coherent, un-
equivocal guidelines on UTI management in chil-
dren, with imaging tests remaining the main area of
controversy. As a result, the authors formulated
their own proposal for UTI management in children.
Care Excellence (NICE) guideline: Urinary
tract infection in under 16s: diagnosis and
management [6]. This was followed by
American Academy of Pediatrics (AAP)
guideline: Urinary Tract Infection: Clinical
Practice Guideline for the Diagnosis and
Management of the Initial UTI in Febrile In-
fants and Children 2e24 Months, which was
published in 2011 [7]. In the same year, the
Italian Society of Pediatric Nephrology pub-
lished: Febrile urinary tract infections in
young children: recommendations for diag-
nosis, treatment and follow-up [8]. In 2014,
the Canadian Pediatric Society (CPS) released
its guideline: Urinary tract infection in in-
fants and children: Diagnosis and manage-
ment [9]. In 2015, the Polish Society of
Pediatric Nephrology Guidelines concerning
management of UTI in children was published
[10]. The newest paper included in this
analysis was: Urinary Tract Infections in
Children: EAU/ESPU Guidelines, which was
published in 2016 by the European Associa-
tion of Urology (EAU) and European Society
for Pediatric Urology (ESPU) [11].
 + MODEL
2 M. Okarska-Napierała et al.
The guidelines substantially differ in rating evidence
quality and strength of recommendations. The NICE authors
revised evidence using separate criteria for interventions
and diagnostic test accuracy, but they did not rate their
recommendations. Similarly, neither CPS nor EAU/ESPU
guidelines included any rating system for strength of rec-
ommendations. The AAP guidelines are graded according to
AAP policy; the Italian authors used Strength of Recommen-
dation Taxonomy (SORT) criteria, whereas Polish guidelines
were based on Grades of Recommendation Assessment,
Development and Evaluation (GRADE) system. Thus, the
strength of recommendations was unsuitable for
comparison.
Definitions
A few guidelines included definitions of atypical/compli-
cated or recurrent UTI. According to NICE, atypical UTI
include: seriously ill patients, children with poor urine flow,
abdominal or bladder mass, elevated serum creatinine,
septicemia, failure to respond to treatment with suitable
antibiotics within 48 h, and infections with non-Escherichia
coli organisms. In both CPS and Polish guidelines, almost
identical characteristics are listed as features of complicated
UTI, and both latter guidelines cite NICE as a reference.
In addition, the NICE guideline separately lists risk factors
for serious underlying pathology, which include: poor urine
flow, history of previous UTI, recurrent fever of uncertain
origin, antenatal diagnosis of renal abnormality, family
history of VUR or renal disease, constipation, dysfunctional
voiding, enlarged bladder, abdominal mass, evidence of
spinal lesion, poor growth, and high blood pressure.
Italian guidelines similarly define risk factors for CAKUT
as follows: prenatal or postnatal ultrasonographic abnor-
malities, family history of VUR, septicemia, renal insuffi-
ciency, male infants aged <6 months, suspected non-
compliant family, micturition abnormalities or thickened
bladder wall, absence of a clinical response to antibiotics
within 72 h, and pathogens other than E. coli.
A recurrent UTI is defined in the NICE guideline as two or
more episodes of pyelonephritis, or one episode of pyelo-
nephritis plus one or more episodes of cystitis, or three or
more episodes of cystitis. The other guidelines provide no
other definition of recurrent UTI.
Most of the risk factors listed above seem to be based on
experts’ opinion, which explains the slight differences be-
tween the guidelines. Scientific data on risk factors pre-
dicting CAKUT in children with a first-time UTI are scarce
and conflicting. Male gender, young age, positive family
history [12], fever of 38  C, elevated CRP [13], high
neutrophil ratio [14], pathogens other than E. coli, and
positive blood culture [15,16] were all found to predict VUR
in children with UTI. However, a recent study by Yılmaz
evaluated 300 children with their first UTI, and no clinical
or laboratory data were found to correlate with the pres-
ence of VUR [17]. On the other hand, Ristola et al., in a
study evaluating 282 children with their first UTI, found
that non-E. coli UTIs correlated with abnormal kidney ul-
trasound, whereas risk factors predicting VUR included
abnormal ultrasound, atypical infection, non-E. coli infec-
tion, and recurrent infections [18].
Please cite this article in press as: Okarska-Napierała M, et al., Urinary tract infection in children: Diagnosis, treatment, imaging e
Comparison of current guidelines, Journal of Pediatric Urology (2017), http://dx.doi.org/10.1016/j.jpurol.2017.07.018
Diagnosis
All guidelines agree that UTI in children may be difficult to
diagnose, especially in children aged <2e3 years, because
symptoms and signs in this age group are non-specific. For
this reason, urine tests are warranted not only in children
with typical UTI symptoms, but also in cases of unexplained
fever. This approach was reinforced by an AAP technical
report from 2011, which stated that among children aged
2e24 months with fever of unknown origin, 5% had a UTI [19].
In addition, AAP, CPS, Polish and EAU/ESPU guidelines
state that urine tests must be performed before antimi-
crobial treatment is introduced, whereas CPS guidelines
emphasize that in cases of fever with a known source (e.g.
diarrhea or rhinitis), urine tests should not be performed.
In toilet-trained children, the method of choice for
diagnosing a UTI is a clean voided midstream urine sample
[20]. The difficulty is obtaining a urine sample from a child
who does not control voiding. There are four techniques for
collecting a urine sample in those children. Non-invasive
techniques include a bag applied to the perineum and
clean catch midstream void, whereas invasive methods
include bladder catheterization and suprapubic aspiration
(SPA). The NICE guidelines recommend a clean catch sam-
ple as the method of choice, but they also permit a urine
collection bag. However, an AAP technical report states
that up to 85% of positive culture results obtained by using a
collection bag can be false positives [19]. For this reason,
most guidelines published since 2011 agree that a urine
sample collected in a bag applied to the perineum is only
reliable when negative. Most guidelines recommend clean
catch void as the preferred method, although, according to
AAP, only invasive techniques may be used to confirm
diagnosis of a UTI. The reason for this is probably that AAP
guidelines relate to children aged up to 24 months, in whom
mid-stream void has a high contamination rate of up to 26%
[21], and is technically difficult and time-consuming. The
CPS guidelines also recommend invasive techniques in
children up to 24 months of age.
Some guidelines also suggest that invasive urine sam-
pling methods are particularly appropriate in children who
appear ill or have poor general health when there is an
urgent need for antimicrobial treatment. The AAP technical
report also states that SPA has higher pain scores and lower
success rates than bladder catheterization, which in turn
presents 95% sensitivity and 99% specificity in comparison
with SPA [19]. This suggests catheterization as a preferred
invasive urine sampling method.
Urinalysis
Urinalysis is a quick dipstick test for nitrite and leukocyte
esterase, and microscopic examination for white blood
cells (WBC) and bacteria. The nitrite dipstick test repre-
sents the conversion of dietary nitrate by Gram-negative
bacteria, and has high specificity (98%) for UTI [22]. Its
major limitation is that it gives negative results when the
bladder is emptied frequently or if the underlying pathogen
is Gram-positive [23]. Therefore, most guidelines agree
that a urine dipstick test is not recommended for the
youngest children who void frequently. Leukocyte esterase,
 + MODEL
Urinary tract infection in children
a surrogate marker of pyuria, has sensitivity of 79% and
specificity of 87% for UTIs [22].
White blood cells present in the urine on microscopic ex-
amination are a useful indicator of inflammation associated
with UTI, although there is no standardized definition of
pyuria in the literature. In the microscopic analysis of
centrifuged urine, five WBCs per high-power field is a usual
threshold for pyuria. Another method is automatic counting
in uncentrifuged urine, with 10 WBCs being a threshold value.
Cultures
The definition of significant bacteriuria varies slightly be-
tween guidelines. According to AAP, significant bacteriuria
is defined as 5  104 colony forming units (CFU) per milli-
liter (CFU/ml) of urine obtained by catheterization. This
definition is derived from a study published in 1956. Urine
cultures from women with and without pyelonephritis
symptoms revealed that the threshold range, in which the
proportion of patients with symptomatic UTI exceeded
those without symptoms, was between 104 and 105 CFU/ml
[24]. Hoberman et al. confirmed this threshold value in
children with UTI in a study in which urine culture results
were verified by a renal scan with DMSA [25]. Other
guidelines present broader definitions considering the urine
collection method; they are presented in Table 1.
The definition included in EAU/ESPU guidelines is based
on the finding that pyelonephritis may also be present with
lower CFU counts on cultures. In 2016, Swerkersson et al.
published an interesting study evaluating 430 infants with
first-time UTI, diagnosed by SPA, revealing that 19% of
children had low bacterial counts of <104 CFU/ml. The
authors suggested that UTI with low bacterial count might
be a separate entity, associated with non-E. coli etiology
and low inflammatory response, but with the same risk of
VUR and renal scarring [26]. In another study, it was found
that 19% of infants with UTI diagnosed by SPA had bacte-
riuria <105 CFU/ml in clean catch voided urine [27] and
could have been missed with a higher cut-off value. These
arguments suggest that the EAU/ESPU bacteriuria defini-
tions are probably the most appropriate for diagnosing UTI.
Children with positive urine culture and normal urinal-
ysis, without symptoms, are regarded as having asymp-
tomatic bacteriuria that, in otherwise healthy subjects, is
not an indication for any intervention. This applies to all
guidelines analyzed in the current review.
Management
The varying approaches to management of UTI included in
guidelines are summarized in Table 1. The AAP authors
stated that there is no difference in efficacy between oral
and intravenous treatment of UTI, which has been proven in
numerous studies both in children and adults [28,29]. Thus,
most children with a UTI can be treated orally. Parenteral
treatment is only required in children who are severely ill
or unable to retain oral intake; however, sequence treat-
ment is recommended even in those children.
The AAP guidelines suggest that pyelonephritis treat-
ment should last 7e14 days. This broad range is due to the
lack of sufficient data identifying optimal treatment dura-
tion [30]. There is evidence that a 1e3-day regimen for
Please cite this article in press as: Okarska-Napierała M, et al., Urinary tract infection in children: Diagnosis, treatment, imaging e
Comparison of current guidelines, Journal of Pediatric Urology (2017), http://dx.doi.org/10.1016/j.jpurol.2017.07.018
3
febrile children with a UTI is less effective than a 7-day
regimen, which is the reason for the recommended mini-
mum treatment duration of 7 days.
The choice of antibiotic should be based on locally
developed current resistance patterns of urinary patho-
gens. The AAP guidelines state that antibiotics excreted in
the urine, which do not reach therapeutic concentrations in
the blood (e.g. nitrofurantoin), should not be used in py-
elonephritis treatment. Another issue to be considered in
the treatment of UTI is the increasing frequency of in-
fections with extended-spectrum beta-lactamases (ESBL)-
producing pathogens, which is reported to be 20% and is
more common in younger children [19].
Further diagnostics
Further diagnostics in children with febrile UTI is undoubt-
edly the most controversial issue. The general tendency is
to restrict indications to VCUG and DMSA scintigraphy. Sig-
nificant radiation exposure, the risk of catheter-induced
UTI, stress for a young patient and their parents, and the
cost of the imaging techniques must be considered. The
main objective of performing imaging tests following a
UTI is to identify children with CAKUT, mainly VUR, who
may be more susceptible to recurrent UTI and further renal
scarring. Some of those patients may benefit from surgical
interventions. They may also benefit from antimicrobial
prophylaxis, which used to be routinely administered
in children with CAKUT, and had been proven effective in
reducing the risk of recurrent UTI in the Prevention of
Recurrent Urinary Tract Infection in Children with Ves-
icoureteric Reflux and Normal Renal Tracts (PRIVENT) study
[31]. This approach, however, has recently been chall-
enged by several studies demonstrating that antimicrobial
prophylaxis in those children neither avoids subsequent
infections nor influences further renal scarring [5,32].
Roussey-Kesler et al. found no benefit from antimicrobial
prophylaxis in children with grade IeIII VUR, excluding boys
with grade III VUR in whom it may avoid further UTI [33],
whereas a Swedish reflux study revealed that in a group of
infant girls with grade III or IV VUR, antimicrobial prophy-
laxis is effective in preventing renal scarring [34]. On the
other hand, the recent Randomized Intervention for Chil-
dren with Vesicoureteral Reflux (RIVUR) trial has proven
that antimicrobial prophylaxis reduces risk of UTI recur-
rence, but not of renal scarring in children with VUR [35].
The benefit of diagnosing VUR has also been questioned
for other reasons. Several studies have stated that the risk
of VUR in children with UTI is similar to the rest of the
population at around 30% [19,36]. Moreover, a large pro-
portion of children with UTI and VUR, particularly low-
grade, reach spontaneous resolution without medical
intervention [37] and mild/moderate VUR does not increase
the risk of recurrent UTI or renal scarring [38]. The question
is: how to identify those children with VUR who would
benefit from surgical treatment?
Abdominal ultrasound
Abdominal ultrasound (US) is the least invasive, and rela-
tively inexpensive, diagnostic tool in evaluating children
 Table 1 Comparison of the guidelines.

4
Comparison of current guidelines, Journal of Pediatric Urology (2017), http://dx.doi.org/10.1016/j.jpurol.2017.07.018
Please cite this article in press as: Okarska-Napierała M, et al., Urinary tract infection in children: Diagnosis, treatment, imaging e

NICE 2007 AAP 2011 ISPN 2011 CPS 2014 PSPN 2015 EAU/ESPU 2016 Our proposal References
of recommendation
Urine collection Clean catch Bladder Bladder No Any method for Clean catch Bladder Finnell 2011
in non-toilet- mid-stream void catheterization catheterization recommendation, urinalysis mid-stream void, catheterization Tosif 2012
trained Alternatively: or SPA (relates (in poor general but bladder Clean catch bladder or clean catch
children collection bag to children aged health) or clean catheterization mid-stream catheterization mid-stream void
<2 years) catch mid-stream or clean catch void, bladder or SPA for diagnosis Collection bag
void (method of mid-stream void catheterization Collection bag only as a method
choice) are the preferred or SPA for only as a method of exclusion
Collection bag is methods culture of exclusion
acceptable for
urinalysis, not
for culture
Significant Not included Catheterization: Catheterization: Catheterization: >5  104 or Catheterization: Catheterization: Hoberman
bacteriuria 5  104 CFU/ml >104 CFU/ml >104 CFU/ml (depending on the 103e105 CFU/ml 103 CFU/ml 1994
Clean voided laboratory standard) Clean voided Clean voided Swerkersson
urine: >105 Clean voided urine: >105 CFU/ml urine: >104 CFU/ml urine: >104 2016
CFU/ml SPA: any growth of bacteria with symptoms CFU/ml with
Urinary bag: OR >105 without symptoms OR >105

+
>105 CFU/ml symptoms without symptoms

MODEL
SPA: any growth SPA: any growth of
of bacteria bacteria
Route of Parenteral in all Parenteral only Parenteral only Parenteral only in Parenteral in Parenteral in all Parenteral only Hoberman
antibiotic children <3 in children unable in children unable children unable to most children children <2 months in children unable 1999
administration months and in to eat and/or in to eat and/or in eat and/or in poor <3 months and and in those who to eat and/or in Pohl 2007
those who are poor general health poor general health general health in those who are unable to poor general
unable to eat Parenteral Parenteral are unable to eat and/or in health
and/or in poor antibiotics should antibiotics should eat and/or in poor general Parenteral
general health be switched to be switched to poor general health antibiotics should
Parenteral oral as soon as oral after 2e4 health be switched to
antibiotics should clinical days oral as soon
be switched to improvement is as clinical
oral after observed improvement is
2e4 days observed

M. Okarska-Napierała et al.
Oral in Oral in all Oral in all Oral in all Oral in all Oral in all Oral in all
other children other patients other patients other patients, other patients other patients other patients
>3 months but children <3
months; need
close monitoring
Treatment Upper UTI: 7e10 7e14 days 7e14 days Upper UTI: 7e14 Upper UTI: Upper UTI: 7e14 Upper UTI: 7e10 Strohmeier
duration days days 7e10 days days days 2014
Lower UTI: 3 days Lower UTI: 2e4 Lower UTI: Lower UTI: at Lower UTI: 3
days 3e5 days least 3e5 days days
SPA e suprapubic aspiration; CFU e colony forming units.
 + MODEL
Urinary tract infection in children 5

with UTI. It is usually readily available and can detect
hydronephrosis, hydroureters, bladder wall abnormalities,
and acute complications of UTI (e.g. renal or perirenal ab-
scesses). On the other hand, US has limited sensitivity in
detecting VUR and is highly observer-dependent. According
to NICE, US is indicated in all children with UTI and aged <6
months, whereas in older children responding well to ther-
apy, routine US is not needed. This restrictive approach is
definitely cost-effective [39] but carries a risk of missing a
significant number of patients who may benefit from CAKUT
diagnosis [40]. According to most of the remaining guide-
lines, US is indicated in those children with UTI who are aged
<2 years or present with additional risk factors (Table 2).
VCUG
VCUG is a gold standard for the diagnosis and grading of
VUR [41]. It is also useful in visualizing the anatomy of the
urethra and bladder. The disadvantages of this method
include radiation exposure, the risk of inducing a UTI, the
high cost and discomfort for the patient. According to most
of the analyzed guidelines, VCUG is not routinely indicated
and should only be performed if US reveals abnormalities
suggesting CAKUT, or in other specific clinical circum-
stances (Table 2). The EAU/ESPU, on the contrary, indicates
that US alone misses up to 33% of patients at risk and thus
recommends one of two further approaches: the bottom-up
method (VCUG and, if positive, DMSA scan) or the top-down
method (DMSA scan and, if positive, VCUG) in all patients
with febrile UTI and aged <1 year. In older children,
exclusion of VUR is warranted in all girls, and in those boys
who have recurrent UTI. Bottom-up and top-down ap-
proaches were compared by Routh et al., who revealed that
the top-down method results in a higher radiation dose,
higher cost and lower sensitivity compared with the
bottom-up approach, which may not outweigh its benefits
(fewer urethral catheterizations and fewer diagnoses of
insignificant VUR) [39]. This is in contradiction to CPS
guidelines, which recommend DMSA as a first choice diag-
nostic test in girls, and follow-up modality in both sexes.
DMSA scan
A DMSA scan is reliable in detecting both acute pyelone-
phritis and late renal parenchymal scarring. However, it
usually does not affect acute clinical management. A DMSA
scan is an expensive technique that exposes the patient to
radiation. Mantadakis et al. studied the accuracy of acute
phase DMSA scans in identifying children with VUR, and
revealed that DMSA scans have limited ability to replace
VCUG in the diagnosis of VUR [42]. Indications for DMSA
scans vary considerably between guidelines, which are
probably due to their unclear role in further clinical de-
cisions (Table 2). Moreover, EAU/ESPU guidelines recom-
mend considering treatment of phimosis in uncircumcised
boys, who are at significantly higher risk of recurrent UTI.

Table 2 Comparision of further diagnostics.

Age of patients Ultrasound (US) VCUG DMSA
NICE <6 months All children Atypical/recurrent UTI Atypical/recurrent UTI
6 monthse3 years Atypical/recurrent UTI Atypical/recurrent UTI Atypical/recurrent UTI
AND specific featuresa
>3 years Atypical/recurrent UTI Not indicated Recurrent UTI
AAP 24 months All children Abnormal US or other e
specific circumstances
Italian 36 months All children Abnormal US or risk factorsb Abnormal US or VUR
CPS <2 years All children Abnormal US; recurrent Only when diagnosis of
>2 yrs. Not specified UTI in children <2 years UTI is in doubt
Polish <2 years All children Atypical/recurrent RECURRENT pyelonephritis,
>2 years Pyelonephritis, febrile UTI; abnormal US; VUR III-V
atypical/recurrent positive family history for VUR
UTI or risk factors
for recurrent UTIc
EAU/ESPU All children Either VCUG or DMSA is
indicated in bottom-up
or top-down approach
Our proposal <2 years All children Recurrent febrile UTI; Recurrent pyelonephritis,
>2 years CAKUT risk factors abnormal USG; other VUR IIIeV, high risk of
CAKUT risk factors renal scarring
NICE e National Institute for Health and Care Excellence; AAP e American Academy of Pediatrics; CPS e Canadian Paediatric Society;
EAU e European Association of Urology; ESPU e European Society for Pediatric Urology; US e ultrasonography; VCUG e voiding
uretherocystography; DMSA e dimercaptosuccinic acid scintigraphy; VUR e vesicoureteral reflux; CAKUT e congenital anomalies of the
kidney and urinary tract.
a
Dilatation on ultrasound, poor urine flow, non-E. coli infection, family history of VUR.
b
First degree relative with VUR, septicemia, chronic kidney disease, age <6 months in a male infant, likely non-compliance of the
family, abnormal bladder emptying, no clinical response to correct antibiotic treatment within 72 h, bacteria other than E. coli.
c
Abnormal US in past, positive family history of UTI or CAKUT, bladder catheterization, abnormal voiding, abnormal defecation or
sexual activity in girls.

Please cite this article in press as: Okarska-Napierała M, et al., Urinary tract infection in children: Diagnosis, treatment, imaging e
Comparison of current guidelines, Journal of Pediatric Urology (2017), http://dx.doi.org/10.1016/j.jpurol.2017.07.018
 + MODEL
6 M. Okarska-Napierała et al.
Conclusions
The guidelines on UTI in children try to reconcile recent
reports on diagnosis, treatment, and further diagnostics
with prior practices and opinions, and costs. As stated
above, many studies concerning UTI in children are con-
flicting, and there is still a lack of sufficient data to
formulate coherent, indubitable guidelines, with imaging
diagnostics remaining the main area of controversy. In light
of these analyzed guidelines, it is recommended that urine
tests be performed both in children with typical UTI
symptoms and in children with unexplained fever. Urine
tests should be performed before administration of anti-
microbials. In toilet-trained children, a clean voided
midstream urine sample is the method of choice for diag-
nosing a UTI, while catheterization is a preferred invasive
method of urine sampling in infants and small children.
Urine sample collected in a bag applied to the perineum
can be used as a UTI exclusion method.
Both positive urinalysis and significant bacteriuria are
necessary to diagnose a UTI. Children with positive urine
culture and negative urinalysis, without symptoms, are
regarded as having asymptomatic bacteriuria, which, in
otherwise healthy subjects is not an indication for any
intervention.
It is recommended that the diagnosis of a UTI be
dependent on the urine collection method, and that it is
defined by significant bacteriuria as >104 CFU/ml in clean
voided urine with symptoms, 103 CFU/ml by catheteri-
zation (depending on the laboratory standard), and any
growth of bacteria by SPA.
Since there is no difference in efficacy between oral and
intravenous UTI treatment, parenteral treatment is only
required in children who are severely ill or unable to retain
oral intake. Parenteral antibiotics should be switched to
oral as soon as clinical improvement is observed, usually
within 24e48 h. In children aged >3 months, the differen-
tiation between upper and lower UTI guides the treatment.
Upper UTI treatment should last 7e10 days, whereas in
lower urinary tract infection this should be 3 days. The
choice of antibiotic should be based on local epidemiology
and susceptibility patterns.
It is recommend that an abdominal US be performed on
all patients aged <2 years of age and older children with
CAKUT risk factors. VCUG remains a gold standard for the
diagnosis and grading of VUR and should be performed in
children with abnormal abdominal US, recurrent UTI, or
other risk factors (recommendation strength 1C).
The bottom-up method is recommended in evaluating
children with UTI: VCUG and, if positive, a DMSA scan. DMSA
scans should be performed 4e6 months after UTI in children
with recurrent UTI, VUR grade IIIeV, and those who have
high risk of renal scarring (i.e. scarring visible on US or
clinical symptoms: hypertension, albuminuria).
Nevertheless, clinicians treating children with a UTI
should be aware of the existing controversy in order to
make good decisions.
Conflict of interest/funding
None.
Please cite this article in press as: Okarska-Napierała M, et al., Urinary tract infection in children: Diagnosis, treatment, imaging e
Comparison of current guidelines, Journal of Pediatric Urology (2017), http://dx.doi.org/10.1016/j.jpurol.2017.07.018
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