Clinical Pediatrics

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Diagnosis and Management of Urinary Tract Infections in Neonates and Young Infants
Jonathan D Santoro, Vanessa G Carroll and Russell W Steele
CLIN PEDIATR 2013 52: 111
DOI: 10.1177/0009922812471713

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Commentary
Diagnosis and Management of Urinary
Tract Infections in Neonates and Young
Infants
Jonathan D. Santoro, MD1,Vanessa G. Carroll, MD1,
and Russell W. Steele, MD1
Introduction
The American Academy of Pediatrics (AAP) recently
issued guidelines for the diagnosis and management of
urinary tract infections (UTIs) in children 2 months to 2
years of age.1 This publication, however, did not address
the management of younger infants and neonates with
suspected or documented UTIs.
Neonates With Fever
Neonates 28 days of age or less with fever routinely
undergo a sepsis workup, which should include 2 blood
cultures, complete blood count with differential, cere-
brospinal fluid analysis, urinalysis, and urine culture.
This recommendation has been supported by a large
number of clinical studies.2-4 Patients are then typically
hospitalized and begun on empirical antibiotics pending
results of the cultures. There is therefore little need for
risk assessment prior to hospitalization and treatment in
this age range. However, a definition of UTI based on
the presence of pyuria, colony count of the urine cul-
ture, or other criteria has not been established for neo-
nates.
Young Infants With Fever
Several publications have made recommendations for
the diagnostic and therapeutic management of febrile
infants from 29 days, to 56 to 60 days of age referred to
as the Philadelphia, Boston, Milwaukee, and Rochester
protocols.5-8 The use of laboratory-based stratification
in these high-risk young infants is critical for identify-
ing at-risk patients because physical examination alone
has been shown to be quite insensitive.6,7,9 The criteria
established at the Children’s Hospital of Philadelphia5
stratified infants between the ages of 29 and 60 days of
age into categories at low and high risk for developing
a serious bacterial infection (Table 1). This criterion set
reported a sensitivity of 98% and negative predictive
value of 99.7%, which is excellent for this vulnerable
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Clinical Pediatrics
52(2) 111­–114
© The Author(s) 2012
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DOI: 10.1177/0009922812471713
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patient population. Additionally, some experts feel that
these criteria could be used to lower the age threshold
for immediate hospitalization to less than 28 days, as is
recommended by several institutions.10
UTIs in Young Infants
Among neonates and young infants presenting with
febrile illness in the first few weeks of life, UTI is the
most commonly diagnosed serious bacterial infection,
with incidence as high as 7.5% in various reports.11
Because it is so common, many studies have examined
potential risk factors for UTIs. A major risk factor in this
population is male gender. This is surprising, given that
UTIs are much more common in girls later in infancy
and childhood. Others include prematurity, a tempera-
ture greater than 102°F, and white race. The greatest risk
factor for boys is lack of circumcision, which has been
reported to increase the risk of UTIs by nearly 10-fold.11
In pediatric patients 29 to 60 days of age, diagnosis
and management of suspected UTIs are problematic pri-
marily because, as with neonates, the definition of a UTI
has not been established. Criteria proposed in the recent
guidelines for older infants and children do not apply to
these patients because literature reviewed for this publi-
cation did not include this age group.1 Pediatricians,
therefore, must use empirical criteria for the diagnosis
and management of these febrile patients when there is
no evidence of pyuria or when urine cultures have fewer
than 50 000 colonies/mL. If criteria for older infants are
fulfilled, that is, there is evidence of pyuria plus a bacte-
rial culture with a single organism colony count >50
000/mL, decisions are obviously easier.
1
Ochsner Children’s Health Center and Tulane University School of
Medicine, New Orleans, LA, USA
Corresponding Author:
Jonathan Santoro, Department of Pediatrics, Ochsner Children’s
Health Center and Tulane University School of Medicine, 4207
Fontainebleau Drive, New Orleans, LA 70125, USA
Email: jsantoro@tulane.edu
112 Clinical Pediatrics 52(2)

Table 1. Boston, Milwaukee, Philadelphia, and Rochester Criteria for Risk Stratification in Febrile Infants Between 29 and 89
Days of Age; All Patients Have Otherwise Unremarkable Physical Examinations

Boston Criteria Milwaukee Criteria Philadelphia Criteria Rochester Criteria

Age range 28-89 Days 28-56 Days 29-60 Days ≤60 Days
Temperature ≥38.0°C ≥38.0°C ≥38.2°C ≥38.0°C
Medical history No recent immunizations ND ND Term infant
or antibiotics in last
48 hours
  Not dehydrated No perinatal antibiotics
  No underlying disease
  Not hospitalized longer
than mother
Laboratory findings CSF <10/mm3 CSF <10/mm3 CSF <8/mm3 WBC >5000 and <15
000/mm3
  WBC < 20 000/mm3 WBC < 15 000/mm3 WBC < 15 000/mm3 ABC < 1500
  UA <10 WBC/hpf UA <5-10 WBC/hpf UA <10 WBC/hpf UA ≤ 10 WBC/hpf
without bacteria and
negative leukocyte
esterase
  CXR: no infiltrate CXR: no infiltrate Urine Gram stain Stool: WBC ≤ 5/hpf on
if taken if taken negative smear when indicated
  CSF Gram stain negative  
  CXR: no infiltrate  
  Stool: no blood with few  
or no WBC on smear
  Band-neutrophil ratio  
<0.2
Management for low risk Outpatient follow-up Outpatient follow-up Outpatient follow-up Outpatient follow-up
with oral empirical within 24 hours and IM without antibiotics without antibiotics
antibiotics ceftriaxone 50 mg/kg
Management for high risk Hospitalize and ND Hospitalize and Hospitalize and
administer empirical administer empiric administer empirical
antibiotics antibiotics antibiotics

Abbreviations: ND, not defined; CSF, cerebrospinal fluid; WBC, white blood cell count; hpf, high-power field; UA, urinalysis; CXR, chest X-ray;
ABC, absolute band count; IM, intramuscular.

Risk of UTI a renal ultrasound and another 2% of patients who had

The AAP guidelines for UTI management in infants
older than 60 days use a calculated percentage likeli-
hood of UTI based on risk factors.1 Physicians must
first decide what probability of infection, <1%, 1% to
2%, or >2%, warrants more extensive evaluation and
perhaps empirical therapy prior to culture results being
available (Table 2). Such guidelines for younger patients
may not be acceptable because of the higher morbidity
in infants younger than 60 days of age. Most important,
with delayed diagnosis and treatment of UTIs, bactere-
mia is known to occur in 21% to 36% of cases.12
Moreover, these children are more likely to have ana-
tomical defects. In a recent study of children less than 2
months old with a UTI, the incidence of major ana-
tomical abnormalities was found in 4% of patients with
a follow-up voiding cystourethrogram.13,14
Laboratory Diagnosis of UTI
Laboratory diagnosis of UTI in children less than 60
days of age should take into account both evidence of
pyuria and documentation of bacteriuria. Most clinical
laboratories report white blood cells (WBCs) in urine
as the average number per high-power field (hpf) of
centrifuged urine. With this methodology, pyuria is
generally defined as 5 or more WBCs/hpf. Several
studies have demonstrated that in patients less than 8
weeks of age, the sensitivity of this standard urinalysis
in predicting UTI (defined with a positive culture) is as
low as 30%, which is significantly lower than what is
reported in older infants.15

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Santoro et al 113

Table 2. Current AAP Guidelines for Probability of UTI Development in Febrile Infants1

Individual Risk Factors: Girls Individual Risk Factors: Boys  

White race Nonblack race  
Temperature ≥ 39.0°C Temperature ≥ 39.0°C  
Fever ≥ 2 days Fever ≥ 24 hours  
Absence of another source of infection Absence of another source of infection  
Age < 12 months  
Probability of UTI (Girls) Number of Factors Present  
<1% No more than 1 factor  
<2% No more than 2 factors  

Probability of UTI (boys) Factors if Uncircumcised Factors if Circumcised

<1% a No more than 2
<2% None No more than 3

Abbreviations: AAP, American Academy of Pediatrics; UTI, urinary tract infection.

Another methodology generally referred to as an mL hypothetically increases sensitivity but lowers

“enhanced urinalysis” utilizes uncentrifuged urine and
a counting chamber, reporting WBCs as the average
number per microliter. Most investigators use 10 or
more WBCs/µL to define pyuria. This enhanced uri-
nalysis reduces the variability of results by avoiding the
concentration and resuspension of solid elements
required when small samples are centrifuged. Using
this methodology in older age groups and defining a
UTI as bacterial colony counts of >50 000 colony form-
ing units (CFUs)/mL, sensitivity improved to 84.5%
with a positive predictive value of 93.1%.15 Thus, many
experts conclude that in febrile infants less than 8 weeks
of age, hemocytometer WBC counts should be used
along with urine culture to diagnose UTI.15-17
The low yield of standard urinalysis in this age group
has led to examination of other laboratory studies that
may help diagnose UTI in infants younger than 60 days.
Lin et al15 determined that a CRP (C-reactive protein)
of >20 and ESR (erythrocyte sedimentation rate) >30
were clinically significant predictive factors for UTI,
but a WBC count >15 000/µL was not. Although the
specificities of elevated CRP and ESR were high (90%
and 78%, respectively), their sensitivities were lower
than desired (59% and 73%, respectively), indicating
that they are limited as predictors for identifying UTI in
this population.
If the urine WBC count is not taken into consider-
ation and only a urine bacterial colony count of >100
000 CFU/mL is used to define UTI, it is estimated that
approximately 20% of true UTIs would be missed.18 A
lower bacterial count is, therefore, favored given the
risks associated with a false negative diagnosis. Using
a cutoff bacterial colony count as low as 10 000 CFU/
specificity, yet studies reported no change in the diag-
nosis of UTI.11 Urine bacterial counts between 10 000
and 50 000 CFU/mL have previously demonstrated a
high likelihood of asymptomatic bacteriuria when used
alone as diagnostic criteria for UTI.11 Although unstud-
ied, adding the additional condition of 10 WBC/µL to
diagnostic criteria would theoretically decrease the
detection of lone asymptomatic bacteriuria while
increasing the recognition of UTI in this patient
population.
Contamination of cultures and asymptomatic bacte-
riuria are additional factors that complicate a clear
diagnosis of UTI. Asymptomatic bacteriuria of course
does not require treatment. To reduce the likelihood of
contamination, catheterization or suprapubic aspiration
to obtain urine cultures are mandatory in all infants and
neonates.19,20
Conclusion
Clinical and laboratory assessment of possible UTIs in
neonates and young febrile infants is complex. Although
rates of confounding factors range greatly across hospi-
tals, geography, and gender, in a population with such a
high risk for bacteremia and renal damage, a conserva-
tive definition of UTI is warranted.
The current standard of care for neonates, which
includes hospitalization and a workup for sepsis should
be maintained. Beyond the neonatal age range, clinical
and laboratory criteria can be used to make decisions for
inpatient or outpatient management. For neonates and
infants younger than 60 days of age, we suggest the fol-
lowing criteria to define a UTI:

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114 Clinical Pediatrics 52(2)
1. Pyuria as determined with an “enhanced uri-
nalysis” (hemocytometer counting chamber)
of ≥10 WBC/µL
2. A urine culture colony count of ≥10 000 CFU/
mL for a single organism
Finally, selection of antibiotics is based on the sus-
ceptibility pattern of the organism, and duration of
therapy is the same as with older infants, that is, 7 to 14
days. All these young patients should also undergo renal
and bladder ultrasonography and voiding cystoure-
thrography to assess for genitourinary abnormalities,
given the correlation of these abnormalities with UTI in
this age group.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The authors received no financial support for the research,
authorship, and/or publication of this article.
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