Urinary Tract Infections in Infants and Children Older Than One Month - Clinical Features and Diagnosis - UpToDate

20/10/23, 17:50 Urinary tract infections in infants and children older than one month: Clinical features and
inical features and diagnosis - UpToDate
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Urinary tract infections in infants and children older than

one month: Clinical features and diagnosis
Authors: , Nader Shaikh, MD, Alejandro Hoberman, MD
SECTION EDITORS: Morven S Edwards, MD, Tej K Mattoo, MD, DCH, FRCP
DEPUTY EDITOR: Diane Blake, MD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Sep 2023.

This topic last updated: Dec 07, 2021.
INTRODUCTION
Urinary tract infections (UTIs) are a common and important problem in children. Acute
pyelonephritis may lead to renal scarring, hypertension, and end-stage kidney disease.
The clinical features and diagnosis of UTI in children will be discussed here. The epidemiology,
risk factors, and management of UTI in children, acute cystitis in children older than two years,
and UTI in neonates (<1 month of age) are discussed separately:
● (See "Urinary tract infections in children: Epidemiology and risk factors".)
● (See "Urinary tract infections in infants older than one month and children less than two
years: Acute management, imaging, and prognosis".)
● (See "Urinary tract infections in children: Long-term management and prevention".)
● (See "Acute infectious cystitis: Clinical features and diagnosis in children older than two
years and adolescents" and "Acute infectious cystitis: Management and prognosis in
children older than two years and adolescents".)
● (See "Urinary tract infections in neonates".)
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20/10/23, 17:50 Urinary tract infections in infants and children older than one month: Clinical features and diagnosis - UpToDate
TERMINOLOGY
UTI is best defined as significant bacteriuria of a clinically relevant uropathogen in a

symptomatic patient. Most patients with UTI also have pyuria, although there are exceptions.
(See 'Special circumstances' below.)
In this topic, we define UTI broadly, without attempting to distinguish cystitis from
pyelonephritis. Although children with pyelonephritis tend to present with fever, it is often
difficult to distinguish cystitis from pyelonephritis clinically, particularly in children younger than
two years [1].
CLINICAL PRESENTATION
Younger children
● Symptoms and signs – In infants and young children, UTI usually presents with
nonspecific symptoms and signs (eg, fever, irritability) [2]. Parental report of foul-smelling
urine or gastrointestinal symptoms (eg, vomiting, diarrhea, poor feeding) is generally not
helpful in diagnosing UTI [3-5].
Fever may be the sole manifestation of UTI in infants and children <2 years of age [6-8]. In
observational studies, UTI is more common among infants and young children with
maximum temperatures ≥39°C (102.2°F) than in those with lower fevers (16 versus 7
percent for infants ≤60 days and 4 versus 2 percent for children <2 years) [7-9]. (See
"Urinary tract infections in children: Epidemiology and risk factors", section on
'Prevalence'.)
Although fever >24 hours is associated with increased risk of UTI, evaluation for UTI
should not be delayed in children who present with possible UTI and fever for ≤24 hours'
duration [10]. The risk of renal scarring increases with increased duration of fever before
initiation of antibiotics. In a retrospective cohort study of 482 children with febrile UTI, the
risk of renal scarring was approximately 5 percent in children with fever duration of one to
two days, 8 percent in children with fever duration of two to three days, and 14 percent in
children with duration of fever of >3 days before initiation of antibiotics [11].
Having another source of fever identified (eg, upper respiratory tract infection, acute otitis
media, acute gastroenteritis) decreases the risk of UTI but does not eliminate it [9]. In
observational studies of young children who presented to the emergency department with
fever, the prevalence of UTI ranged from 2 to 3 percent in children with and 6 to 8 percent
in those without another source of fever [7,12]. This highlights the importance of
obtaining urine cultures in febrile infants and young children without a definite source for
fever. (See 'Decision to obtain urine sample' below.)
● Predictors of culture-confirmed UTI – Clinical and demographic factors associated with

increased risk of culture-confirmed UTI were identified in a nested case-control study of
febrile (>38°C [100.4°F]) children age 2 through 23 months who were evaluated for UTI in
the emergency department of a tertiary care children's hospital [9]. They include:
• Age <12 months
• Maximum reported temperature ≥39°C (102.2°F)
• Female child
• Male child who is uncircumcised
• No other source of fever identified (eg, acute otitis media; upper respiratory tract
infection, gastroenteritis, bronchiolitis, or other viral syndrome; pneumonia,
meningitis)
Additional factors that increase the risk of UTI in young children include history of UTI and
duration of fever ≥48 hours [13,14]. These factors have been used to develop a calculator
to estimate the probability of UTI in children age 2 through 23 months ( UTICalc,
available from the University of Pittsburgh).
Older children — Symptoms and signs of UTI in older children include fever, urinary symptoms
(dysuria, urgency, frequency, new-onset incontinence), abdominal pain, suprapubic tenderness,
and costovertebral angle tenderness [15-17]. The constellation of fever, chills, and flank pain is
suggestive of pyelonephritis in older children [2].
In a meta-analysis of the diagnostic accuracy of the clinical findings of UTI in verbal children, the
following findings were the most helpful in identifying children with UTI [3]:
● Abdominal pain
● Back pain
● Dysuria, frequency, or both
● New-onset urinary incontinence
CLINICAL EVALUATION
Children with UTI symptoms should be evaluated promptly. Prompt recognition and treatment
of UTI may be important in the prevention of renal scarring. (See "Urinary tract infections in
children: Epidemiology and risk factors", section on 'Risk factors for renal scarring'.)
History — The history of the acute illness should include documentation of the height and
duration of fever, urinary symptoms (dysuria, frequency, urgency, incontinence), abdominal
pain, suprapubic discomfort, back pain, recent illnesses, antibiotics administered, and, if
applicable, sexual activity.
The past medical history should include risk factors for UTI, including:
● Chronic urinary symptoms – Incontinence, lack of proper stream, frequency, urgency,

withholding maneuvers (suggestive of bladder dysfunction)
● Bowel and bladder dysfunction, including chronic constipation
● Previous UTI or previous undiagnosed febrile illnesses in which urine culture was not
obtained
● Vesicoureteral reflux (VUR)
● Family history of frequent UTI, VUR, and other genitourinary abnormalities
● Antenatally diagnosed renal abnormality
● Sexually activity, particularly if barrier contraception with spermicidal agents is used (such
methods predispose to UTI by altering the normal vaginal flora [18-20])
(See "Urinary tract infections in children: Epidemiology and risk factors", section on 'Host
factors'.)
Physical examination — Important aspects of the physical examination in the child with
suspected UTI include [3,21,22]:
● Documentation of blood pressure and temperature
• Temperature ≥39°C (102.2°F) is associated with acute pyelonephritis that may cause
renal scarring (odds ratio 2.3, 95% CI 1.6-3.3) [23]
• Elevated blood pressure may be an indication of renal scarring
● Growth parameters
• Poor weight gain may be an indication of chronic renal failure due to renal scarring
● Abdominal and flank examination [21]
• Suprapubic and costovertebral angle tenderness is associated with UTI
• Enlarged bladder or kidney may indicate urinary obstruction and palpable stool in the
colon may indicate constipation, both of which predispose to UTI
● Examination of the external genitalia for anatomic abnormalities (eg, phimosis,

hypospadias ( picture 1), or labial adhesions ( picture 2)) and signs of vulvovaginitis,
vaginal foreign body, or sexually transmitted infections, which may predispose to UTI (see
"Vulvovaginitis in the prepubertal child: Clinical manifestations, diagnosis, and treatment"
and "Overview of vulvovaginal conditions in the prepubertal child")
● Evaluation of the lower back for signs of occult myelomeningocele (eg, midline
pigmentation, lipoma, vascular lesion, sinus, tuft of hair), which may be associated with a
neurogenic bladder and recurrent UTI (see "Closed spinal dysraphism: Clinical
manifestations, diagnosis, and management", section on 'Clinical manifestations')
● Evaluation for other sources of fever; another source of fever decreases the risk of UTI but
does not eliminate it altogether [7,12]
LABORATORY EVALUATION AND DIAGNOSIS
The laboratory evaluation for suspected UTI includes urine dipstick and microscopic analysis
( table 1) and urine culture.
Decision to obtain urine sample — The decision to obtain a urine sample for urinalysis and
culture is made on a case-by-case basis, considering medical history, age, sex, circumcision
status, and presenting signs and symptoms ( table 2) [13,14,24-26].
The indications for obtaining urine samples described below are for children without urinary
tract abnormalities ( table 2). Indications to obtain urine samples in children with urinary tract
abnormalities vary with the type of abnormality and are discussed separately. For example, (see
"Myelomeningocele (spina bifida): Urinary tract complications", section on 'Urinary tract
infections' and "Management of vesicoureteral reflux", section on 'Follow-up').
In children younger than two years, UTI may present with nonspecific symptoms; fever may be
the sole manifestation. UTICalc can be used to estimate the probability of UTI in febrile
(temperature ≥38°C [100.4°F]) children age 2 through 23 months according to clinical
characteristics [13,14]. We obtain a urine sample in febrile children <2 years of age with a
pretest probability of UTI ≥2 percent (ie, approximately 10 children need to be tested for every
UTI detected) [9,13,14]. Other considerations include the feasibility of follow-up, parental views
toward catheterization (if catheterization is necessary), potential harm of not diagnosing an
episode of UTI, harm of incorrectly diagnosing UTI, cost and availability of testing, and benefits
of early treatment. These considerations are particularly important when the probability of UTI
is close to 2 percent. (See "Urinary tract infections in infants older than one month and children
less than two years: Acute management, imaging, and prognosis", section on 'Overview'.)
● Age <1 month – Indications for urine samples in infants age <1 month are provided
separately. (See "Urinary tract infections in neonates", section on 'Diagnosis'.)
● Age 1 to <2 months – Fever ≥38°C (100.4°F).
● Females and uncircumcised males age 2 through 23 months
• Age 2 through 11 months – Fever ≥38°C (100.4°F)
• Age 12 through 23 months – Any of the following combinations:
- Fever ≥38°C (100.4°F) and history of UTI (documented UTI or UTI reported by
caregiver)
- Fever ≥38°C (100.4°F) and no other source of fever
Other source of fever includes (but is not limited to) acute otitis media; pneumonia;
meningitis; upper respiratory tract infection, gastroenteritis, bronchiolitis, or
another viral syndrome.
- Maximum fever ≥39°C (102.2°F) and fever ≥48 hours
● Circumcised males age 2 through 23 months
• Age 2 through 11 months – Fever ≥38°C (100.4°F) and any of the following
combinations:
- No other source of fever and history of UTI (documented or reported by caregiver)
- No other source of fever, maximum fever ≥39°C (102.2°F), and duration of fever
≥48 hours
- Other source of fever, history of UTI, maximum fever 39°C (102.2°F), and duration
of fever ≥48 hours
• Age 12 through 23 months – The combination of no other source of fever, maximum

fever ≥39°C (102.2°F), history of UTI, and fever ≥48 hours
● Age ≥24 months – We obtain urine samples in children ≥24 months of age with the clinical
findings listed below (one or more clinical findings for females or uncircumcised males;
two or more clinical findings for circumcised males):
• Dysuria
• Frequency
• New-onset incontinence
• Abdominal pain
• Back pain
• Fever ≥39°C (102.2°F) if no other cause is identified
How to obtain urine sample
● Children who are not toilet trained – Catheterization or suprapubic aspiration is the
preferred method of urine collection for dipstick analysis, microscopic examination, and
culture of the urine in infants and young children who are not toilet trained [27].
Urine obtained in a sterile collection bag should not be used for culture. Although we
prefer not to use bag urine specimens for dipstick or microscopic analysis, others suggest
that bag urine samples can be used as a first step to determine whether a catheterized
urine sample should be obtained for culture in young children. This approach is discussed
separately. (See "Urine collection techniques in infants and children with suspected urinary
tract infection", section on 'Specimen for urine dipstick or urinalysis'.)
● Children who are toilet trained – A clean-voided specimen is the preferred method of
urine collection for dipstick analysis, microscopic examination, and culture of the urine in
children who are toilet trained. (See "Urine collection techniques in infants and children
with suspected urinary tract infection", section on 'Selection of technique'.)
All urine specimens should be examined as soon as possible after collection. A delay of even a
few hours at room temperature increases both the false-positive and false-negative rates
substantially [26].
Rapidly available tests
● Use in determining probability of UTI – The results of urine dipstick and microscopic
analysis are rapidly available. These results can be combined with clinical features to
estimate the probability of UTI in an individual child to guide decisions about antimicrobial
therapy. For children 2 through 23 months of age, UTICalc, available through the
University of Pittsburgh, can be used for this estimation.
The sensitivity and specificity of the components of the urinalysis in predicting significant
bacteriuria on culture has been evaluated in systematic reviews and meta-analyses
( table 1) [28-30].
● Dipstick analysis – Dipstick tests are convenient, inexpensive, and require little training
for proper usage; they may be the only test available in some settings. They are at best 88
percent sensitive ( table 1) and will likely miss some children with UTI [29].
• Leukocyte esterase – Positive leukocyte esterase on dipstick analysis is suggestive of

UTI but is nonspecific. White blood cells (WBCs) may be present in the urine in other
conditions (eg, Kawasaki disease). (See 'Diagnostic criteria' below.)
• Nitrite – Positive nitrites on dipstick analysis indicate that UTI is likely [31]. The nitrite
test is highly specific, with a low false-positive rate ( table 1). False-negative results
are common because urine must remain in the bladder for at least four hours to
accumulate a detectable amount of nitrite [32]. Thus, a negative nitrite test does not
exclude a UTI [33].
Although a dilute urine sample has been associated with decreased accuracy of dipstick
nitrites, retrospective analysis of urinalysis and urine culture results from children <24
months who underwent bladder catheterization indicated that inclusion of urine
specific gravity (SG) in the decision-making process would not have appreciably
affected the care of children with UTI [34].
● Microscopic examination – Microscopic examination requires more equipment and

training than dipstick tests. If available, we prefer enhanced microscopy to standard or
automated microscopy, particularly for detection of bacteriuria.
• Standard microscopy – In standard microscopy, a centrifuged sample of unstained

urine is examined for WBCs and bacteria.
With standard microscopy, pyuria is defined as ≥5 WBC/high-power field (hpf) and

bacteriuria as any bacteria per hpf. The sensitivity, specificity, and likelihood ratios are
summarized in the table ( table 1).
• Enhanced microscopy – Enhanced microscopy (or enhanced urinalysis), available at

some academic centers, refers to examination of an uncentrifuged urine specimen
using a hemocytometer (results reported as WBC/mm3) and a Gram-stained smear
[28,29,35].
With enhanced urinalysis, pyuria is defined as ≥10 WBC/mm3 and bacteriuria as any
bacteria per 10 oil immersion fields of a Gram-stained smear. In young children in
whom the prompt diagnosis and treatment of UTI are paramount, the enhanced
urinalysis offers the best combination of sensitivity and specificity ( table 1)
[28,36,37]. However, enhanced urinalysis is not available in many outpatient settings.
• Automated microscopy – Many hospital laboratories have replaced manual

microscopy with automated microscopy, which uses flow cytometry and microscopic
analyzers to detect WBC and bacteria [38]. The definitions of pyuria and bacteriuria
vary with the automated microscopy system.
Although automated microscopy appears to be comparable to manual microscopy for

pyuria, Gram-stained smear of uncentrifuged urine is better for the detection of
bacteriuria [37,38]. In a prospective study, automated and enhanced manual
microscopy for pyuria were similarly sensitive (80 and 84 percent, respectively) and
specific (90 and 94 percent, respectively) in predicting positive urine culture. However,
for bacteriuria, automated microscopy was less sensitive (73 versus 84 percent) and
specific (85 versus 96 percent) than enhanced manual microscopy [37].
Although SG may influence the accuracy of the WBC count with enhanced or
automated microscopy [34,39,40], retrospective analysis of urinalysis and urine culture
results from children <24 months who underwent bladder catheterization indicated
that inclusion of urine SG in the decision-making process would not have appreciably
affected the care of children with UTI [34].
Urine culture — Quantitative urine culture is required for the diagnosis of UTI.
● Children <2 years of age – We routinely perform urine culture in children <2 years in whom
UTI is a diagnostic consideration and in whom a sample for urinalysis or dipstick is
collected, even if the dipstick and standard and/or automated microscopic examination
are negative for WBCs and bacteria because the sensitivity of these tests is <90 percent
( table 1) [41,42]. (See 'Decision to obtain urine sample' above and 'How to obtain urine
sample' above and 'Significant bacteriuria without pyuria' below.)
● Older children – For verbal children ≥2 years of age who are toilet trained and afebrile, the
results of the dipstick or microscopic analysis can be used to decide whether to obtain a
urine culture [43].
Urine obtained for culture should be processed as soon as possible after collection. A delay of
even a few hours at room temperature increases both the false-positive and false-negative rates
substantially [26].
Other laboratory tests — Other laboratory tests are not particularly helpful in the diagnosis of
UTI and are not routinely necessary in children with suspected UTI. (See "The febrile infant (29
to 90 days of age): Outpatient evaluation" and "Fever without a source in children 3 to 36
months of age: Evaluation and management".)
● Markers of inflammation – We do not routinely obtain markers of inflammation (eg,

erythrocyte sedimentation rate [ESR], C-reactive protein [CRP], or procalcitonin [PCT]) in
the evaluation of children with suspected UTI.
Although markers of inflammation are associated with pyelonephritis, they do not reliably
differentiate between cystitis and pyelonephritis because of their low sensitivity and/or
specificity. In a meta-analysis of studies evaluating the accuracy of PCT, CRP, and ESR in
predicting dimercaptosuccinic acid-confirmed pyelonephritis in children with culture-
confirmed UTI, sensitivity ranged from 81 to 93 percent and specificity from 37 to 76
percent [44]. Although CRP <20 mg/L (2 mg/dL) appeared to be helpful in excluding
pyelonephritis and PCT >0.5 ng/mL (0.5 mcg/L) appeared to be helpful in confirming
pyelonephritis, methodologic limitations (eg, small number of studies, unexplained
heterogeneity) prevented definitive conclusions.
Although elevated CRP has been associated with increased risk of renal scarring, it adds
little to a prediction model that includes clinical features that do not require venipuncture
(eg, temperature, pathogen, results of renal bladder ultrasonography) [23]. (See "Urinary
tract infections in children: Epidemiology and risk factors", section on 'Prediction of renal
scarring after first UTI'.)
● Serum creatinine – Measurement of serum creatinine is not routinely necessary in

children with suspected UTI. However, we suggest that serum creatinine be measured in
children with a history of multiple UTI and suspected renal involvement or if acute kidney
injury due to dehydration or sepsis is suspected.
● Blood culture – We do not routinely obtain a blood culture in children older than two
months of age who have UTI and do not require blood culture for other reasons. (See "The
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febrile infant (29 to 90 days of age): Outpatient evaluation" and "Fever without a source in
children 3 to 36 months of age: Evaluation and management".)
Bacteremia occurs in 4 to 9 percent of infants with UTI [45-51]. Fever in bacteremic infants
with UTI persists, on average, one day longer than in nonbacteremic infants with UTI [52].
Nonetheless, a positive blood culture rarely alters management because the same
organism usually is isolated from the blood and urine.
● Lumbar puncture – Given the low prevalence of bacterial meningitis in infants age 29 to
90 days with UTI (0.25 percent, 95% CI 0.09-0.70 percent in pooled analysis of 20 studies),
lumbar puncture generally is not warranted in infants and children >1 month of age with
UTI but should be assessed on a case-by-case basis [53]. (See "Bacterial meningitis in
children older than one month: Clinical features and diagnosis".)
Lumbar puncture in infants younger than one month with UTI is discussed separately. (See
"Urinary tract infections in neonates".)
Diagnostic criteria — UTI is best defined as significant bacteriuria of a clinically relevant

uropathogen in a symptomatic patient ( table 3). Pyuria is present in most cases. However, in
approximately 10 to 20 percent of children with UTI, pyuria may be absent. (See 'Special
circumstances' below.)
Significant bacteriuria
● Quantitative threshold – What constitutes significant bacteriuria depends upon the

method of collection and the identification of the isolated organism [26].
Our thresholds for significant bacteriuria according to method of collection are as follows:
• Clean-voided sample – Growth of ≥100,000 colony forming units (CFU)/mL of a single

uropathogen, or ≥100,000 CFU/mL of one uropathogen and <50,000 CFU/mL of a
second uropathogen; growth of a second uropathogen with ≥50,000 CFU/mL or growth
of >2 organisms is considered contamination.
This is the same as the standard definition for significant bacteriuria on clean-catch
specimens in adults, which is based upon studies from the 1950s [54].
• Catheter sample – Growth of ≥50,000 CFU/mL of a single uropathogen, or ≥50,000

CFU/mL of one uropathogen and <10,000 CFU/mL of a second uropathogen [26,55];
growth of a second uropathogen with ≥10,000 CFU/mL or growth of >2 organisms is
considered contamination. Although we generally use ≥50,000 CFU/mL as the
threshold for catheter samples, growth of ≥10,000 CFU/mL of a single uropathogen

may be considered sufficient to diagnose a UTI in cases where the pretest probability of
UTI is high.
In a prospective study of febrile children <24 months of age, catheterized urine

samples with 10,000 to 50,000 CFU/mL were more likely than specimens with ≥50,000
CFU/mL to yield gram-positive organisms (excluding enterococci) or mixed organisms
(65 versus 17 percent) [56].
We suggest that children who have growth of 10,000 to 50,000 CFU/mL of a single
uropathogen from an initial catheterized specimen have a repeat urine culture. We
consider such children to have UTI if the second culture grows ≥10,000 CFU/mL and
pyuria is present on dipstick or microscopic urinalysis.
• Suprapubic sample – Growth of ≥1000 CFU/mL of an uropathogen.
● Clinically relevant uropathogens – Clinically relevant uropathogens in children include

Escherichia coli, Klebsiella spp, Proteus spp, Enterobacter spp, Citrobacter spp, Serratia
marcescens, Staphylococcus saprophyticus, Enterococcus spp, Streptococcus agalactiae, and
Pseudomonas aeruginosa.
● Clinically irrelevant uropathogens – Lactobacillus spp, coagulase-negative staphylococci,

and Corynebacterium spp are not considered clinically relevant uropathogens [26].
Pyuria — For the diagnosis of UTI in children, pyuria is defined by one of the following
(irrespective of urine SG):
● Positive leukocyte esterase (≥trace) on dipstick analysis

● ≥5 WBC/hpf with standardized or automated microscopy
● ≥10 WBC/mm3 on a hemocytometer with an enhanced urinalysis
The presence of WBC in the urine is not specific for UTI. Other causes of pyuria in children with
symptoms that mimic UTI include appendicitis, group A streptococcal infection, and Kawasaki
disease. (See 'Differential diagnosis' below.)
Special circumstances
Significant bacteriuria without pyuria — Pyuria is absent in approximately 10 to 20 percent

of children with UTI [22,41,57,58]. The approach to diagnosis of UTI in children with significant
bacteriuria without pyuria varies with the uropathogen that is isolated.
● Significant growth of Enterococcus spp, Klebsiella spp, or P. aeruginosa – UTI may be

diagnosed in the absence of pyuria in children with symptoms of UTI and significant
growth of Enterococcus spp, Klebsiella spp, or P. aeruginosa [41,59-61].
In a retrospective review of 1181 children (<18 years of age) with UTI who had a
microscopic urinalysis for pyuria (≥5 WBC/hpf or ≥10 WBC/mm3), 13 percent did not have
pyuria [41]. UTI was defined by growth of a single uropathogen at a concentration of
≥50,000 CFU/mL from a catheterized specimen or ≥100,000 CFU/mL from a clean-voided
specimen in a child with symptoms of UTI. Only 54 percent of children with Enterococcus
UTI, 74 percent of children with Klebsiella UTI, and 62 percent of children with P. aeruginosa
UTI had pyuria, compared with 89 percent of children with E. coli UTI. However, given that
E. coli was the most frequently isolated uropathogen (85 percent), most of the children
with UTI without pyuria had an E. coli UTI (107 of 150 children without pyuria).
● Significant growth of other uropathogens – Although children with growth of

Enterococcus spp, Klebsiella spp, or P. aeruginosa are more likely to lack pyuria on urinalysis
than children with other pathogens, given the high proportion of UTI caused by E. coli,
most cases of bacteriuria without pyuria are observed in children with E. coli. It is not clear
why bacteriuria occurs without pyuria in children with E. coli UTI, but it may occur [26,59]:
• Early in the course of a UTI (ie, before the local inflammatory response develops).
• If the dipstick leukocyte esterase test or microscopic analysis is falsely negative (these
tests are at best 90 percent sensitive ( table 1)).
• In children with colonization of the urinary tract (ie, asymptomatic bacteriuria with
symptoms due to another non-specific illness).
In symptomatic children with bacteriuria without pyuria, we recommend antibiotic therapy

for those with any of the following characteristics:
• Age <2 years

• Fever >38°C (100.4°F)
• History of febrile UTI or urinary tract abnormality
• Clinical worsening or lack of improvement
We recommend antibiotic therapy for these children because the prevalence of bacteriuria
without pyuria far exceeds the prevalence of asymptomatic bacteriuria [62]. In preverbal
febrile children in whom the urine sample was obtained by bladder catheterization, one
study estimated that up to 12 children with true UTIs would be missed to protect one child
with asymptomatic bacteriuria from receiving antibiotics [62].
For other children, repeating the urinalysis and urine culture can help to distinguish
between early infection and colonization, particularly if the urine is obtained through
catheterization or suprapubic aspiration to minimize contamination [12].
• Pyuria and bacteriuria on the second sample is suggestive of UTI.
• The absence of pyuria and bacteriuria on the second sample is suggestive of bacterial
contamination of the initial sample.
• Bacteriuria without pyuria on the second sample may be due to true infection or
asymptomatic bacteriuria.
Pyuria without significant bacteriuria — In children with symptoms of UTI and pyuria on
dipstick or microscopic urinalysis, the absence of significant bacteriuria does not absolutely
exclude a diagnosis of UTI. Failure to meet the threshold for significant bacteriuria (ie, false-
negative urine culture) may occur under the following circumstances [12,56]:
● A bacteriostatic antimicrobial agent is present in the urine

● Rapid rate of urine flow with reduced incubation time
● Obstruction of the ureter that interferes with the discharge of bacteria into the bladder
When false-negative urine culture is suspected, renal scintigraphy may be helpful in

establishing the diagnosis of acute pyelonephritis. (See "Urinary tract infections in infants older
than one month and children less than two years: Acute management, imaging, and
prognosis", section on 'Kidney scintigraphy'.)
DIFFERENTIAL DIAGNOSIS
Other considerations in the differential diagnosis in a child with suspected UTI depend upon the
presenting symptoms and signs and results of the urinalysis. Quantitative urine culture results,
results of cultures or other microbiologic tests from other sites, and associated clinical features
distinguish UTI from these conditions.
● Fever without a source – Although occult UTI is the main consideration in the differential
diagnosis of fever without a source in children age 3 to 36 months, other considerations
include occult pneumonia and occult bacteremia (rare in the conjugate vaccine era). (See
"Fever without a source in children 3 to 36 months of age: Evaluation and management".)
● Fever, abdominal pain, and pyuria – Considerations include:
• Group A streptococcal infection (see "Group A streptococcal tonsillopharyngitis in

children and adolescents: Clinical features and diagnosis")
• Appendicitis (see "Acute appendicitis in children: Clinical manifestations and diagnosis")
• Kawasaki disease (see "Kawasaki disease: Clinical features and diagnosis")
● Urinary symptoms (eg, urgency, frequency, dysuria) with bacteriuria (with or without
pyuria) – Considerations include (see "Etiology and evaluation of dysuria in children and
adolescents"):
• Nonspecific vulvovaginitis, irritant or chemical urethritis (eg, due to bubble bath), and
vaginal foreign body (see "Vulvovaginitis in the prepubertal child: Clinical
manifestations, diagnosis, and treatment" and "Overview of vulvovaginal conditions in
the prepubertal child")
• Urethritis secondary to a sexually transmitted infection, particularly chlamydia (see

"Clinical manifestations and diagnosis of Chlamydia trachomatis infections")
• Urinary calculi (see "Kidney stones in children: Clinical features and diagnosis")
● Urinary symptoms without bacteriuria
• Bowel and bladder dysfunction is frequently overlooked in children with urinary

symptoms and a negative urine culture, although it also contributes to the
pathogenesis of UTI. (See "Urinary tract infections in children: Epidemiology and risk
factors", section on 'Bladder and bowel dysfunction'.)
● Asymptomatic bacteriuria – Asymptomatic bacteriuria in a child with nonspecific

symptoms (eg, fever, abdominal pain) caused by a condition other than UTI (eg, viral
gastroenteritis) is a consideration in the differential diagnosis of UTI in children.
Asymptomatic bacteriuria (ie, colonization of the urinary tract with bacteria in the absence
of symptoms) is rare. The prevalence of asymptomatic bacteriuria is substantially lower
than the prevalence of UTI. In a meta-analysis of 14 studies (49,806 children <19 years of
age), the prevalence of asymptomatic bacteriuria was 0.47 percent in females and 0.37
percent in males [62]. The bacteria tend to be of low virulence, and spontaneous
resolution is common; antibiotic treatment is not recommended [63-66]. A meta-analysis
of three randomized trials found the evidence insufficient to determine the risks and
benefits but concluded that antibiotic therapy is unlikely to benefit children in the long
term [67].
SOCIETY GUIDELINE LINKS
Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Urinary tract infections
in children".)
INFORMATION FOR PATIENTS
UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics."
The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading
level, and they answer the four or five key questions a patient might have about a given
condition. These articles are best for patients who want a general overview and who prefer
short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more
sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading
level and are best for patients who want in-depth information and are comfortable with some
medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print
or email these topics to your patients. (You can also locate patient education articles on a
variety of subjects by searching on "patient education" and the keyword[s] of interest.)
● Basics topic (see "Patient education: Urinary tract infections in children (The Basics)")
● Beyond the Basics topic (see "Patient education: Urinary tract infections in children
(Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
● Clinical features – In infants and young children, UTI may present with nonspecific
symptoms and signs (eg, fever, irritability, poor feeding, poor weight gain); fever may be
the only sign. Older children may have urinary symptoms (eg, dysuria, frequency, new-
onset urinary incontinence, abdominal pain, back pain, fever). (See 'Clinical presentation'
above.)
● History and examination – Important aspects of the history in a child with suspected UTI
include features of the acute illness (eg, fever, urinary symptoms) and risk factors for UTI
(eg, previous UTI, bowel and bladder dysfunction, vesicoureteral reflux). (See 'History'
above.)
The examination of the child with suspected UTI should include (see 'Physical examination'
above):
• Measurement of temperature, blood pressure, and growth parameters

• Abdominal examination for tenderness or mass
• Assessment of suprapubic and costovertebral tenderness
• Examination of the external genitalia
• Evaluation of the lower back for signs of occult myelomeningocele
• Evaluation for other sources of fever
● Laboratory evaluation and diagnosis – The laboratory evaluation for suspected UTI
includes urine dipstick and microscopic analysis ( table 1) and urine culture. (See
'Laboratory evaluation and diagnosis' above.)
• The decision to obtain a urine sample is made on a case-by-case basis, considering age,
sex, circumcision status, and presenting signs and symptoms ( table 2). UTICalc
can be used to estimate the probability of UTI in febrile (temperature ≥38°C [100.4°F])
children age 2 through 23 months according to clinical characteristics. (See 'Decision to
obtain urine sample' above.)
• Catheterization or suprapubic aspiration is the preferred method of urine collection for

infants and children who are not toilet trained. A clean-voided specimen is the
preferred method for toilet-trained children. Urine obtained in a sterile bag should not
be used for culture. (See 'How to obtain urine sample' above.)
• We routinely perform urine culture in children <2 years with suspected UTI if a sample
for urinalysis or dipstick test is collected, even if the dipstick and microscopic
examination are negative for white blood cells and bacteriuria because the sensitivity
of dipstick and microscopic examination is <90 percent ( table 1).
For verbal children ≥2 years of age who are toilet trained and afebrile, the results of the
dipstick or microscopic analysis can be used to decide whether to obtain a urine
culture. (See 'Urine culture' above.)
• UTI is best defined as significant bacteriuria of a clinically relevant uropathogen in a

symptomatic patient. Although pyuria is usually present, it may be absent in 10 to 20
percent of children with UTI ( table 3). (See 'Diagnostic criteria' above.)
● Differential diagnosis – Quantitative urine culture results, results of cultures or other

microbiologic tests from other sites, and associated clinical features distinguish UTI from
other conditions in the differential diagnosis (eg, asymptomatic bacteriuria, occult
bacteremia [rare], occult pneumonia, group A streptococcal infection, appendicitis,
Kawasaki disease, nonspecific vulvovaginitis, urethritis, nephrolithiasis, and bowel and
bladder dysfunction). (See 'Differential diagnosis' above.)
Use of UpToDate is subject to the Terms of Use.
REFERENCES
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infants. J Pediatr 1993; 123:17.
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young children in the emergency department. Pediatrics 1998; 102:e16.
8. Zorc JJ, Levine DA, Platt SL, et al. Clinical and demographic factors associated with urinary
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Estimating the Probability of Urinary Tract Infection in Young Febrile Children. JAMA Pediatr
2018; 172:550.
10. Marquez L, Palazzi DL. Antibiotic Treatment for Febrile Urinary Tract Infection: The Clock Is
Ticking. JAMA Pediatr 2016; 170:834.
11. Shaikh N, Mattoo TK, Keren R, et al. Early Antibiotic Treatment for Pediatric Febrile Urinary
Tract Infection and Renal Scarring. JAMA Pediatr 2016; 170:848.
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1997; 16:11.
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15. Winberg J, Andersen HJ, Bergström T, et al. Epidemiology of symptomatic urinary tract
infection in childhood. Acta Paediatr Scand Suppl 1974; :1.
16. Majd M, Rushton HG, Jantausch B, Wiedermann BL. Relationship among vesicoureteral
reflux, P-fimbriated Escherichia coli, and acute pyelonephritis in children with febrile
urinary tract infection. J Pediatr 1991; 119:578.
17. SMELLIE JM, HODSON CJ, EDWARDS D, NORMAND IC. CLINICAL AND RADIOLOGICAL
FEATURES OF URINARY INFECTION IN CHILDHOOD. Br Med J 1964; 2:1222.
18. Hooton TM, Scholes D, Stapleton AE, et al. A prospective study of asymptomatic bacteriuria
in sexually active young women. N Engl J Med 2000; 343:992.
19. Scholes D, Hooton TM, Roberts PL, et al. Risk factors for recurrent urinary tract infection in
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20. Hooton TM, Scholes D, Hughes JP, et al. A prospective study of risk factors for symptomatic
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23. Shaikh N, Craig JC, Rovers MM, et al. Identification of children and adolescents at risk for
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data. JAMA Pediatr 2014; 168:893.
24. Wald ER. To bag or not to bag. J Pediatr 2005; 147:418.
25. Shaw KN, Gorelick MH. Urinary tract infection in the pediatric patient. Pediatr Clin North
Am 1999; 46:1111.
26. Subcommittee on Urinary Tract Infection, Steering Committee on Quality Improvement and
Management, Roberts KB. 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 2011; 128:595.
27. Breinbjerg A, Mohamed L, Yde Nielsen S, et al. Pitfalls in Diagnosing Urinary Tract Infection
in Children below the Age of 2: Suprapubic Aspiration vs Clean-Catch Urine Sampling. J Urol
2021; 206:1482.
28. Huicho L, Campos-Sanchez M, Alamo C. Metaanalysis of urine screening tests for

determining the risk of urinary tract infection in children. Pediatr Infect Dis J 2002; 21:1.
29. Gorelick MH, Shaw KN. Screening tests for urinary tract infection in children: A meta-
analysis. Pediatrics 1999; 104:e54.
30. Finnell SM, Carroll AE, Downs SM, Subcommittee on Urinary Tract Infection. Technical
report—Diagnosis and management of an initial UTI in febrile infants and young children.
Pediatrics 2011; 128:e749.
31. Liang T, Schibeci Oraa S, Rebollo Rodríguez N, et al. Predicting Urinary Tract Infections With
Interval Likelihood Ratios. Pediatrics 2021; 147.
32. Powell HR, McCredie DA, Ritchie MA. Urinary nitrite in symptomatic and asymptomatic
urinary infection. Arch Dis Child 1987; 62:138.
33. Coulthard MG. Using urine nitrite sticks to test for urinary tract infection in children aged <
2 years: a meta-analysis. Pediatr Nephrol 2019; 34:1283.
34. Shaikh N, Shope MF, Kurs-Lasky M. Urine Specific Gravity and the Accuracy of Urinalysis.
Pediatrics 2019; 144.
35. Hoberman A, Wald ER, Penchansky L, et al. Enhanced urinalysis as a screening test for
urinary tract infection. Pediatrics 1993; 91:1196.
36. Herr SM, Wald ER, Pitetti RD, Choi SS. Enhanced urinalysis improves identification of febrile
infants ages 60 days and younger at low risk for serious bacterial illness. Pediatrics 2001;
108:866.
37. Shah AP, Cobb BT, Lower DR, et al. Enhanced versus automated urinalysis for screening of
urinary tract infections in children in the emergency department. Pediatr Infect Dis J 2014;
33:272.
38. Chaudhari PP, Monuteaux MC, Bachur RG. Microscopic Bacteriuria Detected by Automated
Urinalysis for the Diagnosis of Urinary Tract Infection. J Pediatr 2018; 202:238.
39. Chaudhari PP, Monuteaux MC, Bachur RG. Urine Concentration and Pyuria for Identifying
UTI in Infants. Pediatrics 2016; 138.
40. Nadeem S, Badawy M, Oke OK, et al. Pyuria and Urine Concentration for Identifying Urinary
Tract Infection in Young Children. Pediatrics 2021; 147.
41. Shaikh N, Shope TR, Hoberman A, et al. Association Between Uropathogen and Pyuria.
Pediatrics 2016; 138.
42. Friedman A. Management of UTI in Children: Murky Waters. Pediatrics 2016; 138.
43. National Institute for Health and Care Excellence. Urinary tract infection in under 16s: Diag
nosis and management (2017 revisions). Available at: https://www-nice-org-uk.juanncorpa
s.proxybk.com/guidance/cg54 (Accessed on August 13, 2019).
44. Shaikh KJ, Osio VA, Leeflang MM, Shaikh N. Procalcitonin, C-reactive protein, and
erythrocyte sedimentation rate for the diagnosis of acute pyelonephritis in children.
Cochrane Database Syst Rev 2020; 9:CD009185.
45. Smellie JM, Poulton A, Prescod NP. Retrospective study of children with renal scarring
associated with reflux and urinary infection. BMJ 1994; 308:1193.
46. Hoberman A, Wald ER, Hickey RW, et al. Oral versus initial intravenous therapy for urinary
tract infections in young febrile children. Pediatrics 1999; 104:79.
47. Bachur R, Caputo GL. Bacteremia and meningitis among infants with urinary tract
infections. Pediatr Emerg Care 1995; 11:280.
48. Schnadower D, Kuppermann N, Macias CG, et al. Febrile infants with urinary tract infections
at very low risk for adverse events and bacteremia. Pediatrics 2010; 126:1074.
49. Dayan PS, Hanson E, Bennett JE, et al. Clinical course of urinary tract infections in infants
younger than 60 days of age. Pediatr Emerg Care 2004; 20:85.
50. Velasco-Zúñiga R, Trujillo-Wurttele JE, Fernández-Arribas JL, et al. Predictive factors of low
risk for bacteremia in infants with urinary tract infection. Pediatr Infect Dis J 2012; 31:642.
51. Hernández-Bou S, Trenchs V, Alarcón M, Luaces C. Afebrile very young infants with urinary
tract infection and the risk for bacteremia. Pediatr Infect Dis J 2014; 33:244.
52. Honkinen O, Jahnukainen T, Mertsola J, et al. Bacteremic urinary tract infection in children.
Pediatr Infect Dis J 2000; 19:630.
53. Nugent J, Childers M, Singh-Miller N, et al. Risk of Meningitis in Infants Aged 29 to 90 Days
with Urinary Tract Infection: A Systematic Review and Meta-Analysis. J Pediatr 2019;
212:102.
54. KASS EH. Asymptomatic infections of the urinary tract. Trans Assoc Am Physicians 1956;
69:56.
55. SUBCOMMITTEE ON URINARY TRACT INFECTION. Reaffirmation of AAP Clinical Practice

Guideline: The Diagnosis and Management of the Initial Urinary Tract Infection in Febrile
Infants and Young Children 2-24 Months of Age. Pediatrics 2016; 138.
56. Hoberman A, Wald ER, Reynolds EA, et al. Pyuria and bacteriuria in urine specimens
obtained by catheter from young children with fever. J Pediatr 1994; 124:513.
57. Schroeder AR, Chang PW, Shen MW, et al. Diagnostic accuracy of the urinalysis for urinary
tract infection in infants <3 months of age. Pediatrics 2015; 135:965.
58. Williams GJ, Macaskill P, Chan SF, et al. Absolute and relative accuracy of rapid urine tests
for urinary tract infection in children: a meta-analysis. Lancet Infect Dis 2010; 10:240.
59. Hoberman A, Wald ER. Treatment of urinary tract infections. Pediatr Ann 1999; 28:688.
60. Lubell TR, Schnadower D, Freedman SB, et al. Comparison of Febrile Infants With
Enterococcal and Gram-negative Urinary Tract Infections. Pediatr Infect Dis J 2016; 35:943.
61. Forster CS, Shaikh N, Hoberman A, Jackson E. Uropathogens and Pyuria in Children With
Neurogenic Bladders. Pediatrics 2018; 141.
62. Shaikh N, Osio VA, Wessel CB, Jeong JH. Prevalence of Asymptomatic Bacteriuria in
Children: A Meta-Analysis. J Pediatr 2020; 217:110.
63. Sequelae of covert bacteriuria in schoolgirls. A four-year follow-up study. Lancet 1978;
1:889.
64. Lindberg U, Claesson I, Hanson LA, Jodal U. Asymptomatic bacteriuria in schoolgirls. VIII.
Clinical course during a 3-year follow-up. J Pediatr 1978; 92:194.
65. Hansson S, Martinell J, Stokland E, Jodal U. The natural history of bacteriuria in childhood.
Infect Dis Clin North Am 1997; 11:499.
66. Nicolle LE, Gupta K, Bradley SF, et al. Clinical Practice Guideline for the Management of
Asymptomatic Bacteriuria: 2019 Update by the Infectious Diseases Society of America. Clin
Infect Dis 2019; 68:e83.
67. Fitzgerald A, Mori R, Lakhanpaul M. Interventions for covert bacteriuria in children.

Cochrane Database Syst Rev 2012; :CD006943.
Topic 5990 Version 55.0
GRAPHICS
Degrees of hypospadias
Composite of cases demonstrating increasing severity of

hypospadias. A through D show standard hypospadias, and E
through F show severe hypospadias. The risk of differences of sex
development is increased for cases of severe hypospadias and
isolated standard hypospadias accompanied by micropenis and/or
cryptorchidism (unilateral or bilateral). Refer to UpToDate content on
evaluation and management of hypospadias.
Note the progressive severity of the location of the ectopic urethral

meatus from coronal margin.
(A, B, C) Distal penile shaft.
(D) Mid-penile shaft.
(E) Scrotum.
(F) Perineum.
Courtesy of Laurence S Baskin, MD, FAAP.
Graphic 58046 Version 13.0
Partial labial adhesion in a prepubertal female
This picture shows fused labia minora (arrowheads) and a residual vaginal
opening (arrow) in a prepubertal female with labial adhesions.
Reproduced with permission from: Emans SJ. Vulvovaginal problems in the prepubertal child.
In: Emans, Laufer, and Goldstein's Pediatric and Adolescent Gynecology, 6 th ed, Emans SJ,
Laufer MR (Eds), Lippincott Williams & Wilkins, Philadelphia 2011. Copyright © 2011 Lippincott
Williams & Wilkins. www-lww-com<.juanncorpas.proxybk.com/a>. This image was republished
in Emans, Laufer, Goldstein's Pediatric and Adolescent Gynecology, 7 th Ed (2019).
Test characteristics of tests used to diagnose urinary tract infections in

children
Positive Negative
Sensitivity Specificity likelihood likelihood
ratio* ratio ¶
Dipstick
LE 84% 78% 4 0.2
Nitrite 50% 98% 25 0.5
Nitrite or LE 88% 93% 13 0.1
Nitrite and LE 72% 96% 18 0.3
Microscopy
Uncentrifuged
Pyuria 77% 89% 7 0.4

(>10/mm 3 )
(all ages)
Pyuria 90% 95% 18 0.1

(>10/mm 3 )
(<2 years)
Bacteriuria 93% 95% 19 0.1

(Gram-
stained)
Overall 85% 99.9% 85 0.1

(P+B) =
enhanced
Overall (P 95% 89% 9 0.1

or B)
Centrifuged
Pyuria 67% 79% 3 0.4

(>5/hpf)
Bacteriuria 81% 83% 5 0.2
Overall 66% 99% 7 0.4

(P+B)
LE: leukocyte esterase; P: pyuria; B: bacteriuria; hpf: high-power field.
* Positive likelihood ratio: The positive likelihood ratio is the probability that a child with a UTI will
have a positive test divided by the probability that a child without a UTI will have a positive test (eg,
true positive rate/false positive rate). The higher the positive likelihood ratio, the better the test.
¶ Negative likelihood ratio: The negative likelihood ratio is the probability that a child with a UTI will
have a negative test divided by the probability that a child without a UTI will have a negative test (eg,
false negative rate/true negative rate). The lower the negative likelihood ratio, the better the test (a
perfect test has a negative likelihood ratio of zero).
References:
1. Gorelick MH, Shaw KN. Screening tests for urinary tract infection in children: A meta-analysis. Pediatrics 1999;
104:e54.
2. Huicho L, Campos-Sanchez M, Alamo C. Metaanalysis of urine screening tests for determining the risk of urinary tract
infection in children. Pediatr Infect Dis J 2002; 21:1.
3. Finnell SM, Carroll AE, Downs SM, the Subcommittee on Urinary Tract Infection. Technical report--Diagnosis and
management of an initial UTI in febrile infants and young children. Pediatrics 2011; 128:e749.
Indications for urinalysis and urine culture in febrile children age ≥1 month
with suspected UTI and no abnormalities of the urinary tract [1,2]
Age, sex, and circumcision status Indications for urine sample
1 to <2 months
Females and males (circumcised or Fever ≥38°C

uncircumcised)
2 through 11 months
Females and uncircumcised males Fever ≥38°C
Circumcised males Fever ≥38°C and any of the following

combinations:
No other source of fever* and history of
UTI ¶
No other source of fever*, maximum fever
≥39°C, and fever ≥48 hours
Other source of fever*, history of UTI ¶ ,
maximum fever ≥39°C, and fever ≥48
hours
12 through 23 months
Females and uncircumcised males Any of the following combinations:

Fever ≥38°C and history of UTI ¶ Δ
Fever ≥38°C and no other source of fever*
Maximum fever ≥39°C and fever ≥48
hours
Circumcised males The combination of no other source of fever*,

maximum fever ≥39°C, history of UTI ¶ , and
fever ≥48 hours
≥24 months
Females and uncircumcised males: ≥1 Clinical findings:

clinical finding Dysuria
Circumcised males: ≥2 clinical findings Frequency
New-onset incontinence
Abdominal pain
Back pain
Fever ≥39°C if no other source of fever is
identified*
This table is meant for use with UpToDate content on UTI in children. The indications for obtaining
urine samples correspond to a pretest probability of UTI ≥2% (ie, approximately 10 children need to
be tested for every UTI detected, which are the thresholds used in UTICalc, available from the
University of Pittsburgh). [1] Thresholds may vary depending on duration of symptoms, feasibility of
follow-up, and parental views toward catheterization.
UTI: urinary tract infection.
* Other source of fever includes (but is not limited to) acute otitis media; pneumonia; meningitis;
upper respiratory tract infection, gastroenteritis, bronchiolitis, or other viral syndrome.
¶ Documented UTI or UTI reported by caregiver.
Δ Although the pretest probability is <2% for female or uncircumcised children age 12 through 23
months with a history of UTI, maximum temperature <39°C, and fever <48 hours, children with a
history of febrile UTI are at increased risk for renal scarring with recurrent UTI and we obtain a urine
sample for urinalysis and urine culture in such children.
References:
1. University of Pittsburgh. UTICalc version 3.0. Available at: https://uticalc-pitt-edu.juanncorpas.proxybk.com/ (Accessed
on July 28, 2021).
2. Shaikh N, Hoberman A, Hum SW, et al. Development and validation of a calculator for estimating the probability of
urinary tract infection in young febrile children. JAMA Pediatr 2018; 172:550.
Definition of urinary tract infection in children
Diagnostic criteria Definition (any of the following)
Significant bacteriuria ≥100,000 CFU/mL of a single uropathogen from a clean-catch

specimen
≥50,000 CFU/mL of a single uropathogen from a catheterized
specimen
≥1000 CFU/mL of uropathogenic bacteria from a suprapubic
aspirate
Clinically relevant Escherichia coli

uropathogen* Klebsiella spp
Proteus spp
Enterobacter spp
Citrobacter spp
Serratia marcescens
Staphylococcus saprophyticus
Enterococcus spp
Streptococcus agalactiae
Pseudomonas aeruginosa
Symptomatic patient Symptoms in infants and young children:

Fever
Irritability
Symptoms in older children:

Dysuria
Frequency
New-onset incontinence
Abdominal pain
Back pain
Fever
Pyuria (usually present) ¶ Positive leukocyte esterase (≥trace) on dipstick analysis

≥5 WBC/high-power field on standardized microscopy
≥10 WBC/mm 3 on a hemocytometer
Pyuria according to automated microscopy
This table is meant for use with the UpToDate topic on UTI in infants and children older than 1
month. Refer the UpToDate topic for additional details, including indications for obtaining urine
samples for dipstick analysis, microscopic analysis, and urine culture.
UTI: urinary tract infection; CFU: colony forming units; WBC: white blood cells.
* Lactobacillus spp, coagulase-negative staphylococci, and Corynebacterium spp are not clinically
relevant uropathogens.
¶ UTI may be diagnosed in the absence of pyuria in children with symptoms of UTI. Lack of pyuria is
particularly prevalent when the uropathogen isolated is Enterococcus spp, Klebsiella spp, or P.
aeruginosa. However, given the high proportion of UTI caused by E. coli, most cases of bacteriuria
without pyuria are observed in children with E. coli. We provide antimicrobial therapy for these
symptomatic children despite the lack of pyuria.
Contributor Disclosures
Nader Shaikh, MD No relevant financial relationship(s) with ineligible companies to disclose. Alejandro
Hoberman, MD No relevant financial relationship(s) with ineligible companies to disclose. Morven S
Edwards, MD Other Financial Interest: Texas State University personal services agreement [Chagas
disease]. All of the relevant financial relationships listed have been mitigated. Tej K Mattoo, MD, DCH,
FRCP Consultant/Advisory Boards: Alnylam Pharmaceuticals [Primary hyperoxaluria]. All of the relevant
financial relationships listed have been mitigated. Diane Blake, MD No relevant financial relationship(s)
with ineligible companies to disclose.
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must
conform to UpToDate standards of evidence.
Conflict of interest policy

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20/10/23, 17:50 Urinary tract infections in infants and children older than one month: Clinical features and

inical features and diagnosis - UpToDate

Official reprint from UpToDate®

Urinary tract infections in infants and children older than

Literature review current through: Sep 2023.

● (See "Urinary tract infections in children: Epidemiology and risk factors".)

● (See "Urinary tract infections in children: Long-term management and prevention".)

● (See "Urinary tract infections in neonates".)

UTI is best defined as significant bacteriuria of a clinically relevant uropathogen in a

● Predictors of culture-confirmed UTI – Clinical and demographic factors associated with

• Age <12 months

• Maximum reported temperature ≥39°C (102.2°F)

• Male child who is uncircumcised

● Chronic urinary symptoms – Incontinence, lack of proper stream, frequency, urgency,

● Bowel and bladder dysfunction, including chronic constipation

● Vesicoureteral reflux (VUR)

● Family history of frequent UTI, VUR, and other genitourinary abnormalities

● Antenatally diagnosed renal abnormality

● Documentation of blood pressure and temperature

• Elevated blood pressure may be an indication of renal scarring

● Abdominal and flank examination [21]

• Suprapubic and costovertebral angle tenderness is associated with UTI

● Examination of the external genitalia for anatomic abnormalities (eg, phimosis,

LABORATORY EVALUATION AND DIAGNOSIS

● Age 1 to <2 months – Fever ≥38°C (100.4°F).

● Females and uncircumcised males age 2 through 23 months

• Age 2 through 11 months – Fever ≥38°C (100.4°F)

• Age 12 through 23 months – Any of the following combinations:

- Fever ≥38°C (100.4°F) and no other source of fever

- Maximum fever ≥39°C (102.2°F) and fever ≥48 hours

● Circumcised males age 2 through 23 months

- No other source of fever and history of UTI (documented or reported by caregiver)

• Age 12 through 23 months – The combination of no other source of fever, maximum

How to obtain urine sample

Rapidly available tests

• Leukocyte esterase – Positive leukocyte esterase on dipstick analysis is suggestive of

● Microscopic examination – Microscopic examination requires more equipment and

• Standard microscopy – In standard microscopy, a centrifuged sample of unstained

With standard microscopy, pyuria is defined as ≥5 WBC/high-power field (hpf) and

summarized in the table ( table 1).

• Enhanced microscopy – Enhanced microscopy (or enhanced urinalysis), available at

• Automated microscopy – Many hospital laboratories have replaced manual

Although automated microscopy appears to be comparable to manual microscopy for

● Markers of inflammation – We do not routinely obtain markers of inflammation (eg,

● Serum creatinine – Measurement of serum creatinine is not routinely necessary in

Diagnostic criteria — UTI is best defined as significant bacteriuria of a clinically relevant

● Quantitative threshold – What constitutes significant bacteriuria depends upon the

• Clean-voided sample – Growth of ≥100,000 colony forming units (CFU)/mL of a single

• Catheter sample – Growth of ≥50,000 CFU/mL of a single uropathogen, or ≥50,000

threshold for catheter samples, growth of ≥10,000 CFU/mL of a single uropathogen

In a prospective study of febrile children <24 months of age, catheterized urine

• Suprapubic sample – Growth of ≥1000 CFU/mL of an uropathogen.

● Clinically relevant uropathogens – Clinically relevant uropathogens in children include

● Clinically irrelevant uropathogens – Lactobacillus spp, coagulase-negative staphylococci,

● Positive leukocyte esterase (≥trace) on dipstick analysis

Significant bacteriuria without pyuria — Pyuria is absent in approximately 10 to 20 percent

● Significant growth of Enterococcus spp, Klebsiella spp, or P. aeruginosa – UTI may be

● Significant growth of other uropathogens – Although children with growth of

In symptomatic children with bacteriuria without pyuria, we recommend antibiotic therapy

• Age <2 years

• Pyuria and bacteriuria on the second sample is suggestive of UTI.

● A bacteriostatic antimicrobial agent is present in the urine

When false-negative urine culture is suspected, renal scintigraphy may be helpful in