Clinical Practice Guideline

In the Approach And Treatment of Urinary Tract Infection In Children

In The Philippine Setting

THE CHILD WITH PROBABLE URINARY TRACT INFECTION

I. The SUSPECT
1. The neonates presenting with the clinical signs and symptoms as presented in
table 1.
2. Febrile infants (>38 C) below 2 years of age.
3. Older children manifesting symptoms referable to urinary tract.

Table 1 : Signs and Symptoms Associated with UTI

Clinical Signs and Symptoms Neonates Older Infants School Age

Adolescents
 Septic [+]
 Temperature instability [+]
 Poor feeding [+]
 Vomiting [+] [+]
 Lethargy/Irritability [+]
 Jaundice [+]
 Fever [+] [+] [+]
 Poor weight gain [+] [+] [+]
 Diarrhea [+]
 Abdominal Pain [+] [+]
 Frequency, dribbling, [+] [+]
urgency, dysuria
 Weak urinary stream [+] [+]
 Malodorous urine [+]
 Enuresis [+]
 Flank pains
II. THE FOLLOWING IS AN ALGORITHM ON THE DIAGNOSIS, WORK-UP,
TREATMENT AND FOLLOW-UP OF CHILDREN WITH URINARY TRACT
INFECTION

SUSPECTED URINARY TRACT INFECTION

History Urinalysis (suggestive of UTI)

(+) Leukocyte esterase or Nitrite Test

Bacteria present in unspun
Gram-stained specimen
Pyuria ≥ WBC/hpf or 10/mm3
(+) Urine culture of a properly
Collected urine specimen
Physical
Examination

FEVER ≥ 38.5 C

ABSENT PRESENT

CBC (CRP, ESR)

BUN, Creatinine
Optimal CRP,
ESR, Blood C/S

Oral Antibiotics Admit to hospital

Parenteral Antibiotics
KUB Ultrasound, pre
and post void KUB Ultrasound, pre and
post void

Urology consult as needed

 GOOD RESPONSE POOR RESPONSE GOOD RESPONSE

After 48-72 hours After 48-72 hours After 48-72 hours

Complete 7-14 days of Reassess May shift to oral

of treatment Repeat urine culture Complete 7-14 days
Use appropriate antibiotics
Based on initial urine C/S
Complete 7-14 days of treatment

Antibiotic Prophylaxis

Renal Work-up: Voiding Cystourethrogram

Or nuclear cystogram

When needed: Radionuclide renal scan (DMSA/DTPA)

Intravenous Pyelography
Other imaging techniques

Urology follow-up as needed

Nephrology follow-up
Monitor Blood Pressure
Urinalysis every 4-6 weeks
Urine Culture
GFR (Creatinine)
III. DIAGNOSIS

i. HISTORY
- History of previous proven UTI, constipation, voiding disorders such
as incontinence, previous surgeries especially pelvic surgeries.

ii. PHYSICAL EXAMINATON

- Thorough physical examination is a must.
- The examiner should look for congenital defects that coexists.
- Back examination such as presence of dimples, hair tufts in the
lumbosacral area indicating probable neurogenic bladders.
- Lower extremities must also be examined.
- Though neurologic examination must be included.
- Rectal examination is part of the examination.

iii. URINALYSIS
 Proper Collection of Urine: This is the cornerstone of the algorithm.
>> Requirement
a. For infants below one year of age, a suprapubic tap is
recomended.
b. A catheterized urine is good alternative to obtain urine
specimen.
c. Midstream urine collection for cooperative patients – older
girls, circumcised boys and older boys whose foreskin is easily
retracted.

iv. URINE CULTURE

- THE GOLD STANDARD IS ANY BACTERIAL GROWTH AFTER A
SUPRAPUBIC TAP.
 URINE CULTURE: INTERPRETATION OF UTI

METHOD OF COLLECTION QUANTITATIVE CULTURE

 SUPRAPUBIC ASPIRATION
 CATHETERIZATION
 MIDSTREAM CLEAN-VOID
 MIDSTREAM CLEAN-VOID
Growth of urinary pathogen in any
number (exception is up to 2-3 X 103
CFU/ml of coagulase negative
staphylococci
Febrile infants or children usually have
50,000 CFU/ml evidence of a single
urinary pathogen, but infection may be
present with count from > 1,000
CFU/ml
Symptomatic patients usually have 105
CFU/ml of a single urinary pathogen
Asymptomatic patients at least two
specimens on different days with 105
CRU of the same pathogen

IV. WORK-UP
- Ultrasonography alone as a work-up for patients with proven urinary
tract infection is inadequate.
- The use of voiding cystourethrography (or nuclear cystogram)
evaluates the presence or absence of vesicoureteral reflux.

V. TREATMENT

 Some Antimicrobials for Oral Treatment of UTI

- Amoxicillin 20-40mg/kg/day in 3 doses
- TMP-SMX 6-12mg TMP
30-60 SMX/kg/day in 2 doses
- Sulfisoxazole 120-150mg/kg/day in 4 doses
- Cefixime 8mg/kg/day in 2 doses
- Cephalexin 50-100mg/kg/day in 4 doses
- Cefpdoxime 10mg/kg/day in 2 doses
- Cefprozil 30mg/kg/day in 2 doses
- Loracarbef 150mg/kg/day in 2 doses
 Some Antibiotics for Parenteral Treatment of UTI
- Ceftriaxone 75mg/kg every 24 hours
- Cefotaxime 150mg/kg/day divided every 6 hrs
- Ceftazidime 150mg/kg/day divided every 6 hrs
- Cefazolin 50mg/kg/day divided every 8 hrs
- Gentamycin 7.5mg/kg/day divided every 8 hrs
- Tobramycin 5mg/kg/day divided every 8 hrs
- Ticarcillin 300mg/kg/day divided every 6 hrs
- Ampicillin 100mg/kg/day divided every 6 hrs

 Some Antimicrobial for Prophylaxis of UTI

- TMP-SMX
- Nitrofurantoin
- Sulfisoxazole
- Nalidixic Acid
- Methenamine mandelate
2mg TMP,10mg SMX per kg as single
Bedtime dose
1-2mg/kg as single daily dose
10-20mg/kg divided every 12 hrs
30mg/kg divided every 12 hours
75mg/kg divided every 12 hours

Reference: Philippine Pediatric Society

 Western Visayas Medical Center
Department of Pediatrics

Clinical Practice Guideline

In The Approach And Treatment Of

Urinary Tract Infection In Children In The
Philippine Setting