Chapter 553  ◆  Urinary Tract Infections  2789
Fig. 553.1  Acute pyelonephritis seen as an area of decreased perfusion
Chapter 553  Pyelonephritis
Urinary Tract Infections
Karen E. Jerardi and Elizabeth C. Jackson
PREVALENCE AND ETIOLOGY
Urinary tract infections (UTIs) commonly occur in children of all ages,
though the prevalence varies with age. UTIs are most common in children
under age 1 yr; the prevalence of afebrile symptomatic UTIs in children
over age 1 yr is ~8%; the prevalence in febrile infants is 7%. During the
first yr of life, the male:female ratio is 2.8 : 5.4. Beyond 1-2 yr, there is
a female preponderance, with a male:female ratio of 1 : 10. In males,
most UTIs occur during the first year of life; UTIs are much more
common in uncircumcised males, especially in the first yr of life, where
Downloaded for Ahmed Manfy (manfy54@gmail.com) at Egyptian Knowledge Bank from ClinicalKey.com by Elsevier on November 21, 2019.
For personal use only. No other uses without permission. Copyright ©2019. Elsevier Inc. All rights reserved.
by CT scan done for abdominal pain and fever in a child who subsequently
was shown to have no reflux by VCUG.
the rate is 20% in febrile uncircumcised males under age 1 yr. In females,
the first UTI usually occurs by the age of 5 yr, with peaks during infancy,
toilet training, and onset of sexual activity.
UTIs are caused primarily by colonic bacteria. Escherichia coli (see
Chapter 227) causes 54–67% of all UTIs, followed by Klebsiella spp.
and Proteus spp., Enterococcus, and Pseudomonas (see Chapter 129).
Other bacteria known to cause UTIs include Staphylococcus saprophyticus,
group B streptococcus, and, less commonly, Staphylococcus aureus,
Candida spp., and Salmonella spp.
UTIs have been considered a risk factor for the development of renal
insufficiency or end-stage renal disease in children, although some have
questioned the importance of UTI as an isolated risk factor, because
only 2% of children with renal insufficiency report a history of UTI.
Furthermore, many children receive antibiotics for fever without a
specific diagnosis (e.g., treating a questionable otitis media), resulting
in a partially treated UTI. Some children with end-stage renal disease
diagnosed as reflux nephropathy actually have dysplasia associated with
reflux rather than scarring caused by infection and reflux.
CLINICAL MANIFESTATIONS AND CLASSIFICATION
The two basic forms of UTIs (defined as symptoms and a positive culture)
are pyelonephritis and cystitis. Focal pyelonephritis (lobar nephronia)
and renal abscesses are less common.
Pyelonephritis is characterized by any or all of the following: abdominal,
back, or flank pain; fever; malaise; nausea; vomiting; and, occasionally,
diarrhea. Fever may be the only manifestation; particular consideration
should occur for a temperature > 39°C without another source lasting
more than 24 hr for males and more than 48 hr for females. Newborns
can show nonspecific symptoms, such as poor feeding, irritability,
jaundice, and weight loss. Pyelonephritis is the most common serious
bacterial infection in infants younger than 24 mo of age who have fever
without an obvious focus (see Chapters 202 and 203). Involvement of
the renal parenchyma is termed acute pyelonephritis (Figs. 553.1 and
553.2), whereas if there is no parenchymal involvement, the condition
may be termed pyelitis. Acute pyelonephritis can result in renal injury,
termed pyelonephritic scarring.
Acute lobar nephronia (acute lobar nephritis) is a localized renal
parenchymal mass caused by acute focal infection without liquefaction;
2789.e2  Part XXIII  ◆  Urologic Disorders in Infants and Children

Keywords
Asymptomatic bacteriuria
bowel–bladder dysfunction
cystitis
hemorrhagic cystitis
lobar nephronia
perinephric abscess
pyelonephritis
renal abscess
urinary tract infection (UTI)

Downloaded for Ahmed Manfy (manfy54@gmail.com) at Egyptian Knowledge Bank from ClinicalKey.com by Elsevier on November 21, 2019.
For personal use only. No other uses without permission. Copyright ©2019. Elsevier Inc. All rights reserved.
2790  Part XXIII  ◆  Urologic Disorders in Infants and Children

it more commonly occurs in older children. It may be an early stage
in the development of a renal abscess (Fig. 553.3). Manifestations are
identical to those of pyelonephritis and include fever and flank pain.
The epidemiology of the causative organism is also similar to that of
pyelonephritis. Renal abscess typically occurs following hematogenous
spread with S. aureus or can occur following a pyelonephritic infection
caused by the usual uropathogens. Most abscesses are unilateral and
right sided and can affect children of all ages (Fig. 553.4). Both acute
lobar nephronia and renal abscess are associated with an increased risk
of renal scarring. Perinephric abscess (see Fig. 553.3) can occur secondary
to contiguous infection in the perirenal area (e.g., vertebral osteomyelitis,
psoas abscess) or pyelonephritis that dissects to the renal capsule. It
differs from renal abscess in that it is diffuse throughout the capsule
and is not walled off, although it can develop septations. As with renal
abscesses, the most common organisms are S. aureus and E. coli. A
perinephric abscess may not communicate with the collecting system,
and, thus, abnormal findings may not be seen on urinalysis or culture.
Xanthogranulomatous pyelonephritis is a rare type of renal infection
characterized by granulomatous inflammation with giant cells and foamy
histiocytes. It can manifest clinically as a renal mass or an acute or
chronic infection. Renal calculi, obstruction, and infection with Proteus
spp. or E. coli contribute to the development of this lesion, which usually
requires total or partial nephrectomy.
Cystitis
Cystitis indicates that there is only bladder involvement; symptoms
include dysuria, urgency, frequency, suprapubic pain, incontinence, and
possibly malodorous urine. Cystitis does not cause high fever and does
not result in renal injury. Malodorous urine is not specific for a UTI.
Acute hemorrhagic cystitis, though uncommon in children, is often
caused by E. coli; it also has been attributed to adenovirus types 11 and
21. Adenovirus cystitis is more common in boys; it is self-limiting, with
hematuria lasting approximately 4 days. Patients receiving immunosup-
pressive therapy (e.g., solid-organ or bone marrow transplantation) are
at higher risk for hemorrhagic cystitis; adenoviruses and polyomaviruses
(i.e., JC virus and BK virus) are important causes in immunocompromised
populations (see Chapter 301). Other rare types of cystitis that may be
confused with infection include eosinophilic cystitis or interstitial cystitis.
Eosinophilic cystitis may present with hematuria, whereas interstitial
cystitis may present with irritative voiding symptoms but a negative
urine culture.
PATHOGENESIS AND PATHOLOGY
Nearly all UTIs are ascending infections. The bacteria arise from the
fecal flora, colonize the perineum, and enter the bladder via the urethra.
In uncircumcised males, the bacterial pathogens arise from the flora
beneath the prepuce. In some cases, the bacteria causing cystitis ascend

Fig. 553.2  Acute pyelonephritis with focal mass formation. The kidney
shows a rounded heterogeneous mass (arrow) with a poorly defined
margin. Inflammatory changes in the adjacent perinephric fat and renal
fascial thickening (arrowheads) are also present. (From Haaga JR, Boll
DT [eds]: CT and MRI of the whole body, 6th ed, Philadelphia 2017,
Elsevier; Fig. 54-131, p. 1833.)
Fig. 553.3  Right renal abscess (arrow) shows a thick wall and low
density (30 HU). Inflammatory stranding is present in the perinephric
fat. (From Haaga JR, Boll DT [eds]: CT and MRI of the whole body,
6th ed, Philadelphia, 2017, Elsevier; Fig. 54-133, p. 1834.)

A B
Fig. 553.4  A, Renal sonogram, 19 mo old girl with perirenal abscess secondary to methicillin-resistant Staphylococcus aureus. B, CT scan
demonstrates extensive perinephric and focal intrarenal abscess. Patient underwent incision and drainage.

Downloaded for Ahmed Manfy (manfy54@gmail.com) at Egyptian Knowledge Bank from ClinicalKey.com by Elsevier on November 21, 2019.
For personal use only. No other uses without permission. Copyright ©2019. Elsevier Inc. All rights reserved.
 Chapter 553  ◆  Urinary Tract Infections  2791

Table 553.1  Risk Factors for Urinary Tract Infection

Female gender Constipation
Uncircumcised male Anatomic abnormality (labial
Vesicoureteral reflux adhesion)
Toilet training Neuropathic bladder
Voiding dysfunction Sexual activity
Obstructive uropathy Pregnancy
Urethral instrumentation
Sources of external irritation
(such as tight clothing,
pinworm infestation)

PROTECTIVE POTENTIATING

Urolithiasis

Unobstructed Intrarenal reflux

urine transport 1. Compound papillae
2. Acquired

Vesicoureteral reflux
Unidirectional

Ascent of infection
urine flow Obstructive uropathy
(any level)

Defective urothelial
defense
Operative antimicrobial Imbalanced voiding
urothelial activity
Fig. 553.5  Scarred kidney from recurrent pyelonephritis. 1. Neurogenic bladder-
infrequent, incomplete
Regular, complete voiding
bladder emptying 2. Constipation, inflammation

Normal perineal Diverticula

resistance
Periurethral colonization
1. Soilage (diaper, encopresis)
2. Inflammation
a. diaper rash
b. tub baths with chemical
irritant:
-bubble bath
-harsh soaps
(shampoo)
3. Phimosis
Fig. 553.7  Host factors that protect the urinary tract from infection
and abnormalities that potentiate the establishment of invasive bacterial
infection. (From Holcomb III GW, Murphy JP, Ostlie DJ [eds]: Ashcraft’s
pediatric surgery, 6th ed, Philadelphia, 2014, Elsevier; Fig. 55-3, p. 735.)

Fig. 553.6  CT scan showing an area of parenchymal thinning corre-

sponding to an underlying calyx, characteristic of pyelonephritic scarring
or reflux nephropathy.
to the kidney to cause pyelonephritis. Rarely, renal infection occurs by
hematogenous spread, as in endocarditis or in some bacteremic neonates.
If bacteria ascend from the bladder to the kidney, acute pyelonephritis
can occur. Normally, the simple and compound papillae in the kidney
have an antireflux mechanism that prevents urine in the renal pelvis
from entering the collecting tubules. However, some compound papillae,
typically in the upper and lower poles of the kidney, allow intrarenal
reflux. Infected urine stimulates an immunologic and inflammatory
response, causing renal injury and scarring (Figs. 553.5 and 553.6).
Children of any age with a febrile UTI can have acute pyelonephritis
and subsequent renal scarring, but the risk is highest in those younger
than 2 yr of age.
Table 553.1 and Fig. 553.7 outline the host risk factors for UTI.
Vesicoureteral reflux (VUR) is discussed in Chapter 554. If there is
grade III, IV, or V VUR and a febrile UTI, 90% have evidence of acute
pyelonephritis on renal scintigraphy or other imaging studies. In females,
UTIs often occur at the onset of toilet training because of bowel–bladder
dysfunction that occurs at that age. The child is trying to retain urine
to stay dry, yet the bladder may have uninhibited contractions forcing
urine out. The resulting high-pressure, turbulent urine flow and
incomplete bladder emptying both increase the likelihood of bacteriuria.
Bowel–bladder dysfunction can arise in school-age children who refuse
to use the school bathroom, creating a state of urinary retention.
Obstructive uropathy resulting in hydronephrosis increases the risk of
UTI because of urinary stasis. Specifically, patients who require clean
intermittent catheterization due to neurogenic bladder dysfunction are
at high risk for UTI, often from organisms with more antibiotic resistance.
Constipation with fecal impaction can increase the risk of UTI because
it can cause bladder dysfunction.
The pathogenesis of UTI is based in part on the presence of bacterial
pili or fimbriae on the bacterial surface. There are two types of fimbriae,
type I and type II. Type I fimbriae are found in most strains of E. coli.
Because attachment to target cells can be blocked by D-mannose, these
fimbriae are referred to as mannose sensitive. They have no role in
pyelonephritis. The attachment of type II fimbriae is not inhibited by
mannose, and these are known as mannose resistant. These fimbriae
are expressed by only certain strains of E. coli. The receptor for type II
fimbriae is a glycosphingolipid that is present on both the uroepithelial

Downloaded for Ahmed Manfy (manfy54@gmail.com) at Egyptian Knowledge Bank from ClinicalKey.com by Elsevier on November 21, 2019.
For personal use only. No other uses without permission. Copyright ©2019. Elsevier Inc. All rights reserved.
2792  Part XXIII  ◆  Urologic Disorders in Infants and Children
Table 553.2  Sensitivity and Specificity of Components of Urinalysis, Alone and in Combination
TEST
Leukocyte esterase test
Nitrite test
Leukocyte esterase or nitrite positive
Microscopy (white blood cells)
Microscopy (bacteria)
Leukocyte esterase test, nitrite, or microscopy positive
From Subcommittee on Urinary Tract Infection, Steering Committee on Quality Improvement and Management: Clinical practice guideline. Urinary tract infection:
clinical practice guideline for the diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months. Pediatrics 128:595-610, 2011.
cell membrane and red blood cells. The Gal 1-4 Gal oligosaccharide
fraction is the specific receptor. Because these fimbriae can agglutinate
by P blood group erythrocytes, they are known as P fimbriae. Bacteria
with P fimbriae are more likely to cause pyelonephritis. Between 76%
and 94% of pyelonephritogenic strains of E. coli have P fimbriae, compared
with 19–23% of cystitis strains.
Other host factors for UTI include anatomic abnormalities precluding
normal micturition, such as a labial adhesion. This lesion acts as a
barrier and causes vaginal voiding. A neuropathic bladder can predispose
to UTIs if there is incomplete bladder emptying and/or detrusor–sphincter
dyssynergia or a resultant need for frequent catheterization. Sexual
activity is associated with UTIs in females, due to introduction of bacteria
near the urinary tract that can be exacerbated in part because of urethral
irritation and incomplete bladder emptying following intercourse. The
incidence of UTI in infants who are breastfed is lower than in those
fed with formula.
The first step in an E. coli UTI is attachment of the bacteria to the
mannose receptor on the umbrella cells, the cells lining the bladder.
These bladder-lining cells may take the E. coli into the cell, where the
bacteria replicate in the nutrient-rich environment, forming intracellular
bacterial communities (IBCs). Within the IBCs, some of the E. coli fail
to divide, becoming filamentous. Part of the bladder’s defense against
infection is to shed the lining cells with the IBCs; however, some IBCs
break out from the cell and repopulate the urine. The filamentous forms
can evade attack by polymorphonuclear white blood cells (WBCs) in
the urine. When the lining of the bladder is shed, E. coli may be taken
up in the cells of the bladder wall, where they form quiescent intracellular
reservoirs (QIRs). The dormant QIRs are completely protected from
antibiotics and may be a source of recurrent infections. Much current
research is attempting to prevent the initial attachment of bacteria to
the bladder wall that can lead to the IBCs and QIRs.
DIAGNOSIS
UTIs may be suspected based on symptoms or findings on urinalysis,
or both; a urine culture is necessary for confirmation and appropriate
therapy. There are several ways to obtain a urine sample; some are more
accurate than others. In toilet-trained children, a midstream urine sample
usually is satisfactory; the introitus should be cleaned before obtaining
the specimen. In uncircumcised males, the prepuce must be retracted;
if the prepuce is not retractable, a voided sample may be unreliable and
contaminated with skin flora. According to the 2011 American Academy
of Pediatrics (AAP) Clinical Guideline for children 2-24 mo, in children
who are not toilet trained, a catheterized or suprapubic aspirate urine
sample should be obtained. Alternatively, the application of an adhesive,
sealed, sterile collection bag after disinfection of the skin of the genitals
can be useful only if the urinalysis or culture is negative; the negative
predictive value for urinalysis from a “bag” specimen is 99%. However,
a positive culture can result from skin contamination, particularly in
females and uncircumcised males. If treatment is planned immediately
after obtaining the urine culture, a bagged specimen should not be the
method because of a high rate of contamination, often with mixed
organisms. A suprapubic aspirate generally is unnecessary.
Downloaded for Ahmed Manfy (manfy54@gmail.com) at Egyptian Knowledge Bank from ClinicalKey.com by Elsevier on November 21, 2019.
For personal use only. No other uses without permission. Copyright ©2019. Elsevier Inc. All rights reserved.
SENSITIVITY (RANGE) % SPECIFICITY (RANGE) %
83 (67–94) 78 (64–92)
53 (15–82) 98 (90–100)
93 (90–100) 72 (58–91)
73 (32–100) 81 (45–98)
81 (16–99) 83 (11–100)
99.8 (99–100) 70 (60–92)
Nitrites and leukocyte esterase are often positive in infected urine.
Bacteria generally require 4 hr for metabolism of nitrates to nitrites.
Nitrites may not be detected in cases of UTI if the organism does not
convert nitrates to nitrites (most notably enterococcus) or if the child
has urinary frequency, where there may not be enough time for the
conversion to nitrites (Table 553.2). In febrile infants less than 60 days
old, the presence of pyuria, nitrites, or leukocyte esterase has a high
sensitivity and specificity for a UTI.
Microscopic hematuria is common in acute cystitis, but microhe-
maturia alone does not suggest UTI. WBC casts in the urinary sediment
suggest renal involvement, but in practice these are rarely seen. If the
child is asymptomatic and the urinalysis result is normal, it is unlikely
that there is a UTI. However, if the child is symptomatic, a UTI is
possible, even if the urinalysis result is negative, and the urine culture
should be monitored.
Pyuria (leukocytes on urine microscopy) suggests infection, but infec-
tion can occur in the absence of pyuria; this finding is more confirmatory
than diagnostic (see Table 553.2). A WBC count on urinalysis above
3-6 WBCs/high-power-field is indicative of infection with a likelihood
ratio of 10 in a symptomatic child. Conversely, pyuria can be present
without UTI. Asymptomatic bacteriuria can also have pyuria.
Sterile pyuria (positive leukocytes, negative culture) may occur in
partially treated bacterial UTIs, viral infections, urolithiasis, renal
tuberculosis, renal abscess, UTI in the presence of urinary obstruction,
urethritis as a consequence of a sexually transmitted infection (see
Chapter 146), inflammation near the ureter or bladder (appendicitis,
Crohn disease), Kawasaki disease (Chapter 471.1), schistosomiasis,
neoplasm, renal transplant rejection, or interstitial nephritis (eosinophils).
Prompt plating of the urine sample for culture is important, because if
the urine sits at room temperature for more than 60 min, overgrowth
of a minor contaminant can suggest a UTI when the urine might not
be infected. Refrigeration is a reliable method of storing the urine until
it can be cultured.
If the culture shows > 50,000 colony-forming units/mL of a single
pathogen (suprapubic or catheter sample) and the urinalysis has pyuria
or bacteriuria in a symptomatic child, the child is considered to have
a UTI. In a bag sample, if the urinalysis result is positive and the patient
is symptomatic, a catheter sample should be obtained for culture.
With acute renal infection, leukocytosis and neutrophilia are noted
on the complete blood count (CBC); an elevated serum erythrocyte
sedimentation rate, procalcitonin level, and C-reactive protein are
common. However, these are all nonspecific markers of inflammation,
and their elevation does not prove that the child has acute pyelonephritis.
Bacteremia in the setting of pyelonephritis is reported to occur in 3–20%
of patients and is most common in infants less than 90 days old (with
rates decreasing with increasing age in the first 90 days) and in any
child with obstructive uropathy. For these high-risk groups, particularly
if the patient appears to be ill at presentation, blood cultures should be
drawn before starting antibiotics, if possible.
Among children 2-24 mo, risk factors for females include white race,
age younger than 12 mo, temperature > 39°C (102.2°F), fever for longer
than 2 days, and absence of another source of infection. Risk factors

for males include nonblack race, temperature > 39°C (102.2°F), fever
for longer than 24 hr, and absence of another source of infection. Atypical
features include failure to respond within 48 hr of appropriate antibiotics,
poor urine flow, an abdominal flank or suprapubic mass, non–E. coli
pathogen, urosepsis, and an elevated creatinine level.
IMAGING FINDINGS
Imaging is not needed to make the clinical diagnosis of UTI or pyelo-
nephritis. If there is concern about acute lobar nephronia or renal abscess,
imaging should be considered. Ultrasound is the first-line type of imaging
for screening and will likely demonstrate an enlarged kidney with a
possible mass in the case of acute lobar nephronia or renal abscess. CT
scan is more sensitive and specific for lobar nephronia and will typically
show a wedge-shaped, lower-density area after contrast administration.
The more frequent use of imaging in patients with possible pyelonephritis
is thought to be contributing to the increasing frequency of acute lobar
nephronia diagnoses.
TREATMENT
Acute cystitis should be treated promptly to prevent possible progression
to pyelonephritis. If the symptoms are severe, presumptive treatment
is started pending results of the culture. If the symptoms are mild or
the diagnosis is doubtful, treatment can be delayed until the results
of culture are known, and the culture can be repeated if the results
are uncertain. If treatment is initiated before the results of a culture
and sensitivities are available, a 3- to 5-day course of therapy with
trimethoprim-sulfamethoxazole (TMP-SMX) (6-12 mg TMP/kg/day in
2 divided doses) or trimethoprim is effective against many strains of
E. coli. Nitrofurantoin (5-7 mg/kg/24 hr in 3-4 divided doses) also is
effective and has the advantage of being active against Klebsiella and
Enterobacter organisms. Amoxicillin (50 mg/kg/24 hr in 2 divided
doses) also may be effective as initial treatment but has a high rate of
bacterial resistance.
In acute febrile UTIs, the clinical symptoms of UTI and pyelonephritis
are difficult to differentiate. Given this, it is reasonable to consider that
given the presence of systemic symptoms, the infection has likely
progressed to the kidneys and the patient should be treated for pyelo-
nephritis. A course of antibiotics for 7-14 days that is capable of reaching
significant tissue levels is preferable for pyelonephritis; oral and parental
routes are equally efficacious. Children who are dehydrated, are vomiting,
are unable to drink fluids, have complicated infection, or in whom
urosepsis is a possibility should be admitted to the hospital for intravenous
(IV) rehydration and IV antibiotic therapy. Local antimicrobial sensitivity
patterns should be considered when selecting empirical antibiotic
treatment. For hospitalized children, parenteral treatment with ceftriaxone
(50 mg/kg/24 hr, not to exceed 2 g) or cefepime (100 mg/kg/24 hr
q 12 h) or cefotaxime (100-150 mg/kg/24 hr in 3-4 divided doses) (when
available) is a reasonable choice until culture results are back to determine
whether a narrower-spectrum antibiotic can be used. If prior urine
culture results have grown resistant or atypical organisms, other antibiotic
choices may be prudent on a case-by-case basis.
Oral 3rd-generation cephalosporins such as cefixime are as effective
as parenteral ceftriaxone against a variety of Gram-negative organisms
other than P. aeruginosa, and these medications are considered by some
authorities to be the treatment of choice for oral outpatient therapy.
Cephalexin may also be considered given the increasing resistance of
Gram-negative organisms to amoxicillin. Nitrofurantoin should not be
used routinely in children with a febrile UTI, because it does not achieve
significant renal tissue levels. The oral fluoroquinolone ciprofloxacin is
an alternative agent for resistant microorganisms, particularly P.
aeruginosa, in patients older than 17 yr; however, evidence suggests
that the potential side effects of fluoroquinolones should be weighed
against the benefits of this antibiotic selection. It also has been used on
occasion for short-course therapy in younger children with P. aeruginosa
UTIs. Levofloxacin is an alternative quinolone with a good safety profile
in children. However, clinical treatment with fluoroquinolones in children
should be used with caution because of potential cartilage damage. In
some children with a febrile UTI, intramuscular injection of a loading
dose of ceftriaxone followed by oral therapy with a third-generation
Downloaded for Ahmed Manfy (manfy54@gmail.com) at Egyptian Knowledge Bank from ClinicalKey.com by Elsevier on November 21, 2019.
For personal use only. No other uses without permission. Copyright ©2019. Elsevier Inc. All rights reserved.
Chapter 553  ◆  Urinary Tract Infections  2793
cephalosporin is effective. This may be especially useful in children
with vomiting or to allow families time to obtain the oral medication.
A repeat urine culture after the termination of treatment of a UTI is not
routinely needed. Urine cultures are typically negative within 24 hr of
initiation of antibiotic therapy, and therefore a urine culture during
treatment is almost invariably negative.
Acute Lobar Nephronia, Renal Abscess,
and Perinephric Abscess
Acute lobar nephronia is treated with the same antibiotics as pyelone-
phritis. The duration of treatment is recommended for 14-21 days; one
study suggested higher treatment failure in the group treated for the
shorter duration. Children with a renal or perirenal abscess or with
infection in obstructed urinary tracts can require surgical or percutaneous
drainage in addition to antibiotic therapy and other supportive measures
(see Fig. 553.4). Percutaneous drainage is typically attempted prior to
surgical intervention. Immediate percutaneous drainage has been recom-
mended when the abscess is larger than 3-5 cm; however, some patients
have been managed successfully with IV antibiotics only. A 48-hr trial
of IV antibiotics first before surgical drainage may be warranted in
otherwise stable children. Small abscesses, less than 3 cm, may initially
be treated with antibiotics alone. Few studies address the role of oral
antibiotic therapy for renal abscess. Traditionally, patients received 10-14
days of IV antibiotics, followed by 2-4 wk of oral antibiotic therapy
targeted against the known organism (or the likely causes of E. coli and
S. aureus if the organism was unknown). The increasing use of oral
antibiotics for other serious infections (e.g., osteomyelitis) suggests that
an earlier transition to oral therapy for renal abscess is likely feasible.
Kidney loss is reported to occur in 10–20% of cases of renal abscess.
Perinephric abscesses may be managed with IV antibiotics alone or
with percutaneous drainage if the area is large, causing impaired kidney
function. Identification of a causative organism can be an additional
advantage of percutaneous drainage of a perinephric abscess because
the infection may remain isolated from the collecting system based on
the location.
Other Potential Treatment or Prevention Options
There is interest in probiotic therapy, which replaces urogenital flora,
as well as cranberry juice to prevent UTIs. Studies are beginning in
the United States with a non-uropathogenic E. coli called Nissle 1917
already available in Europe. These bacteria may inhibit growth of other
bacteria. Cranberry juice may prevent bacterial adhesion and biofilm
formation, hypothesized to be via proanthocyanidin (PAC). Currently
there is insufficient evidence regarding the use of these therapies to
reduce UTIs.
The main consequences of chronic renal damage caused by pyelo-
nephritis are arterial hypertension and end-stage renal insufficiency;
when they are found, they should be treated appropriately (see Chapters
472 and 550). Even without chronic renal damage, the consequences
of infections include lost days from school and work, uncomfort-
able symptoms, and exposure to antibiotics that change the healthy
microbiome.
IMAGING STUDIES IN CHILDREN WITH
A FEBRILE UTI
The goal of imaging studies in children with a UTI is to identify anatomic
abnormalities that predispose to infection, determine whether there is
active renal involvement, and assess whether renal function is normal
or at risk.
There are two historical approaches to imaging, the traditional
“bottom-up” and “top-down” approaches.
1. The “bottom-up” method was a renal sonogram plus a voiding cysto-
urethrogram (VCUG), which will identify upper and lower urinary
tract abnormalities, including VUR, bladder–bowel dysfunction, and
bladder abnormalities, such as a paraureteral diverticulum.
2. The “top-down” approach was intended to reduce the number of
VCUG examinations. It begins with a dimercaptosuccinic acid (DMSA)
renal scan, to identify areas of acute pyelonephritis (Fig. 553.8). The
DMSA scan in younger children generally requires sedation. On
2794  Part XXIII  ◆  Urologic Disorders in Infants and Children

DMSA, involved areas of the kidney are photopenic and the kidney
is enlarged. Among children with a febrile UTI, approximately 50%
have a positive DMSA scan; the proportion with acute pyelonephritis
is 80–90% among those with dilating grades of reflux (III, IV, V). Of
those with a positive scan, approximately 50% develop renal scarring
in the areas of acute pyelonephritis. If the DMSA scan is positive, a
VCUG is performed (Fig. 553.9) because 90% of children with dilating
LPO RPO
Fig. 553.8  DMSA renal scan showing bilateral photopenic areas
indicating acute pyelonephritis and renal scarring. LPO, left posterior
oblique; RPO, right posterior oblique.
Fig. 553.9  Intrarenal reflux. VCUG in an infant boy with a history of
a UTI. Note the right VUR with ureteral dilation, with opacification of
the renal parenchyma representing intrarenal reflux.
reflux have a positive DMSA scan. If reflux is identified, treatment
is based on the perceived long-term risk of the reflux to the child
(see Chapter 554).
The AAP practice parameter recommends initial ultrasound of the
kidneys, ureters, and bladder for children 2-24 mo with a first episode
of UTI. VCUG is indicated only if the ultrasound study indicates
hydronephrosis, scarring or other findings suggestive of reflux or
obstructive uropathy, or if the patient has other atypical complex
features. Further, they recommend VCUG if the child has a recurrent
febrile UTI (Table 553.3). This recommendation minimizing VCUG use
highlights the importance of parental education to return for evaluation
of subsequent fevers, so that the child can be promptly evaluated for
a recurrent febrile UTI. The rate of renal scarring increases between
days 2 and 3 of fever; this makes the prompt evaluation and appropri-
ate treatment of a recurrent UTI important. The risk of scarring also
increases with the number of episodes of pyelonephritis and with the
grade of reflux.
The AAP guidelines address only febrile infections in children
between the ages of 2 and 24 mo. Given the discomfort associated
with imaging, other causes of infection in children older than 2 yr of
age, and unclear optimal management of reflux in other age-groups,
shared decision making with parents or guardians and the child, when
appropriate, should be considered for children outside the ages of the
guideline.
In children with a history of cystitis (dysuria, urgency, frequency,
suprapubic pain), imaging is usually unnecessary. Instead, assessment
and treatment of bladder and bowel dysfunction is important. This
evaluation is also recommended in recurrent upper tract infections.
The AAP recommendation has resulted in a significant decrease in
the number of VCUGs performed. However, the pediatric urologic
community has raised numerous concerns regarding the recommenda-
tions. One concern is that many primary care physicians may generalize
these recommendations, which were intended for children 2-24 mo, to
all children. Further, there is concern that the premise on which the
AAP recommendations were made was that prophylaxis did not reduce
the frequency of UTIs but that the Randomized Intervention for Children
with Vesicoureteral Reflux (RIVUR) showed a significant reduction in
febrile UTIs in children with reflux on prophylaxis. However, given
that the rates of renal scarring were unchanged in those receiving
prophylaxis, the AAP reaffirmed the recommendations in 2016.
Similarly, in 2007, the NICE (National Institute for Health and Clinical
Excellence, UK) guidelines for diagnosis, management, and imaging after
UTI were released (Table 553.4). These recommendations divided children
into those younger than 6 mo, 6 mo to 3 yr, and older than 3 yr of age.
An initial ultrasound is recommended for children younger than 6 mo,
and a VCUG is recommended only in children younger than age 6 mo
with atypical features (non-E. coli, significant family history), recurrent
UTI, or abnormal ultrasound findings. For children age 6 mo to 3 yr, an
ultrasound and VCUG are recommended for those patients with atypical
features or recurrent UTIs. No imaging is suggested for first-time, typical
UTIs in this age-group. These recommendations are controversial because
the methodology was not based on evidence but on expert opinion. In
addition, there was no retrospective or prospective assessment of the

Table 553.3  Guideline Recommendations for Diagnostic Evaluation Following a Febrile Urinary Tract Infection in Infants
GUIDELINE ULTRASONOGRAPHY VCUG LATE DMSA SCAN
National Institute for Health and (see Table 553.4)
Care Excellence (NICE)*
American Academy of Pediatrics Yes If abnormal ultrasonogram or febrile recurrence No
Italian Society for Paediatric Yes If abnormal ultrasonogram or if risk factors are If abnormal ultrasonogram
Nephrology (ISPN) present† or VUR
*Upper urinary tract dilation on ultrasonography, poor urinary flow, infection with organism other than E. coli, or family history of vesicoureteral reflux.
†
Abnormal antenatal ultrasonogram of fetal urinary tract, family history of reflux, septicemia, renal failure, age younger than 6 mo in a male infant, likely family
noncompliance, incomplete bladder emptying, no clinical response to appropriate antibiotic therapy within 72 hr, or infection with organism other than E. coli.
VCUG, voiding cystourethrogram; DMSA, dimercaptosuccinic acid; VUR, vesicoureteral reflux.

Downloaded for Ahmed Manfy (manfy54@gmail.com) at Egyptian Knowledge Bank from ClinicalKey.com by Elsevier on November 21, 2019.
For personal use only. No other uses without permission. Copyright ©2019. Elsevier Inc. All rights reserved.
 Chapter 553  ◆  Urinary Tract Infections  2795

Table 553.4  Recommended Imaging Schedule for Children With Urinary Tract Infection
TYPE OF INFECTION
RESPONDS WELL TO TREATMENT
CHILD AGE AND TESTS WITHIN 48 HR ATYPICAL INFECTION RECURRENT INFECTION
CHILDREN YOUNGER THAN 6 MO OLD
Ultrasound scan during acute infection No Yes Yes
Ultrasound scan within 6 wk of infection Yes No No
DMSA scan 4-6 mo after acute infection No Yes Yes
Micturating cystograms Consider if ultrasound scan abnormal Yes Yes
CHILDREN 6 MO TO 3 YR OLD
Ultrasound scan during acute infection No Yes No
Ultrasound scan within 6 wk of infection No No Yes
DMSA scan 4-6 mo after acute infection No Yes Yes
Micturating cystograms No Not routine; consider if dilation on ultrasound, poor
urine flow, non–E. coli infection, or family history of
vesicoureteric reflux
CHILDREN OLDER THAN AGE 3 YR
Ultrasound scan during acute infection No Yes No
Ultrasound scan within 6 wk of infection No No Yes
DMSA scan 4-6 mo after acute infection No Yes Yes
Micturating cystograms No No No
DMSA, dimercaptosuccinic acid.
Adapted from National Institute for Health and Clinical Excellence. Urinary tract infection in children: diagnosis, treatment, and long-term management. NICE
clinical guidelines, no. 54. London, 2007, RCOG Press, Tables 6-13, 6-14, and 6-15.

potential of this approach to identify significant uropathology. There

is evidence that a significant number of children with uropathology
would not have been identified under these guidelines.

PREVENTION OF RECURRENCES
In a child with recurrent UTIs, identification of predisposing factors is
beneficial. Bowel and bladder dysfunction is a very important contributor
to recurrent UTIs and is one of the main reasons for an increase in
UTIs around the time of toilet training. Some children with UTIs may
also have constipation (see Chapter 358.1). Behavioral modification,
with treatment of constipation as described in Chapter 558, often is
effective. The first UTI gives the pediatrician a chance to investigate
constipation. The Rome III criteria for constipation in the pediatric
age-group standardize the definition of constipation.
Bladder dysfunction manifested by urgency, wetting, and especially
“Vincent’s curtsy” (females squat on their heels in response to an
uninhibited bladder contraction) can predispose to UTI.
In toilet-trained children, a thorough history and use of urodynamic
studies and measurement of postvoid residual volumes may be helpful
in identifying children with bladder dysfunction that may contribute
to UTIs. Tightening the pelvic floor during urination can sometimes
be seen on a VCUG as a spinning-top urethra (Fig. 553.10). An ultrasound
may document residual urine and possibly a thick bladder wall. Uro-
dynamics may show an intermittent stream with increased activity in
the pelvic floor muscles.
The RIUVR study was a randomized trial of TMP-SMX prophylaxis
for patients with a history of UTI and diagnosed VUR. Although the
UTI recurrence rate was decreased by half from 30% in the group not Fig. 553.10  This VCUG shows contraction of the pelvic floor and
receiving prophylaxis to 15% in those receiving prophylaxis, rates of external sphincter during voiding, leading to a dilated posterior urethra
renal scarring were the same in both groups. Additionally, the rates of and bilateral reflux.
UTI caused by resistant organisms increased in the group receiving
prophylaxis. Taken together, although the use of prophylaxis can decrease
rates of recurrence, the increase in antibiotic resistance, need for daily
medication in children, and no change in renal scarring prevent firm from long-term antibiotic prophylaxis include neuropathic bladder,
recommendations for prophylaxis. The AAP does not recommend urinary tract stasis and obstruction, severe VUR (see Chapter 554), and
routine use of antibiotic prophylaxis in children with a first episode urinary calculi.
of pyelonephritis in an otherwise anatomically normal urinary tract.
Urologic conditions that can cause recurrent UTIs that might benefit Bibliography is available at Expert Consult.

Downloaded for Ahmed Manfy (manfy54@gmail.com) at Egyptian Knowledge Bank from ClinicalKey.com by Elsevier on November 21, 2019.
For personal use only. No other uses without permission. Copyright ©2019. Elsevier Inc. All rights reserved.