Best treatment of urinary tract infection (UTI) in children 2024

URINARY TRACT INFECTION CLINICAL MANIFESTATION

Urinary tract infection should be suspected in all infants and young children with unexplained fever, fever, and congenital urinary tract anomalies.

The symptoms and signs markedly varied with age.
Neonates may present with failure to thrive, feeding problems, and fever

Infants 1 month to 2 years of age may present with feeding problems, failure to thrive, diarrhea, vomiting, or unexplained fever. The symptoms may mimic gastrointestinal illness, with colic, irritability, and excessive crying.

After 2 years of age, children present with classic signs of UTI, such as urgency, dysuria, frequency, and abdominal or back pain.

The diagnosis of UTI in infants and young children requires the presence of both pyuria and at least 50,000 CFU/mL of a single pathogenic organism.

For older children and adolescents, more than 100,000 CFU/mL indicates infection.

Q-How to collect samples?
For older children and adolescents, It is appropriate to obtain urine cultures by midstream, a clean-catch technique, whereas, for younger children and infants, transurethral catheterization or suprapubic bladder aspiration is the appropriate method

NOTE: Perineal bags for urine collection are prone to contamination and are not recommended for urine collection for culture.
If there is uncertainty about the diagnosis of UTI in a younger child or infant, urine can be collected by the most convenient method for urinalysis, and if suggestive of infection, collect urine by catheterization prior to starting antibiotics.

Q-How to interpret routine examination of urine in UTI?
Urinalysis showing pyuria (leukocyturia of >10 white blood cells [WBCs]/mm3) suggests infection but is also consistent with urethritis, vaginitis, nephrolithiasis, glomerulonephritis, and interstitial nephritis.

Other urinalysis findings suggestive of urinary tract infection include
1)Any bacteria per high-powered field in the unstained uncentrifuged urinary sediment,
2)positive urinary leukocyte esterase test, and
3) positive urinary nitrite test.
Combined testing for leukocyte esterase, nitrite, and microscopic bacteria has almost 100% sensitivity for detecting UTI by the positivity of one or more of the three tests.
The negative predictive value of urinalysis is about 100% if all three tests are negative and may obviate the need for culture except in neonates, where urinalysis results are less reliable predictors of infection.

Indication of ultrasonography
Ultrasonography of the bladder and kidneys is recommended for infants and non–toilet-trained children with first-time febrile UTIs to exclude structural abnormalities or detect hydronephrosis.
Indication of VCUG
If the ultrasound is abnormal (hydronephrosis, scarring, or other abnormalities suggesting blockage or congenital abnormality), a voiding cystourethrogram (VCUG) is advised . Vesicoureteral reflux is the most common abnormality found and is ranked from grade I to grade V

A positive urine culture confirms the diagnosis of a UTI but does not differentiate between an upper or lower tract infection.
Localization of a UTI is important because pyelonephritis is associated more frequently with bacteremia and anatomic abnormalities than is uncomplicated cystitis.
In newborns, babies, and toddlers, the clinical signs of UTI do not consistently identify the infection location.
Both lower and upper UTIs can cause fever and abdominal pain, but upper tract involvement is more likely to be the cause of high fever, vomiting, costovertebral tenderness, leukocytosis on complete blood count (CBC), and bacteremia.
In younger children, the symptoms of UTI are similar to those of sepsis; in older children, they are similar to those of enteritis, appendicitis, mesenteric lymphadenitis, and pneumonia.
Dysuria may be a sign of vaginitis, pinworm infection, intolerance to soaps or detergents, sexual abuse, or other conditions..

Therapy should be initiated for symptomatic children and for all children with a urine culture confirming UTI.
Oral antibiotic therapy
For infants and children who do not appear ill but have a positive urine culture, oral antibiotic therapy should be initiated.
Parenteral antibiotic therapy
For all young infants and any child with suspected UTI who appears toxic, appears dehydrated, or is unable to retain oral fluids, initial antibiotic therapy should be administered parenterally.
Neonates are treated initially with parenteral antibiotics because UTIs in this age group are assumed to occur from hematogenous spread regardless of blood culture results. Often, if there is rapid clinical improvement and initial blood cultures are negative, patients can eventually be transitioned to enteral antibiotics to complete a 14-day total course of therapy.
Duration of antibiotics
Older children with febrile UTI are treated for 7–14 days of enteral antibiotics or a combination of parenteral followed by enteral antibiotic therapy.

Initial treatment with parenteral antibiotics in this age group is determined by clinical status. Parenteral antibiotics should be continued until there is clinical improvement (typically 24–48 hours), defined as resolution of fever and improved oral intake.

Empirical antibiotic therapy should be guided by the local antimicrobial susceptibility patterns and the results of the patient’s prior urine cultures because of increasing problems related to antimicrobial resistance.
Commonly used empirical parenteral antibiotics include cefazolin, ceftriaxone, or ampicillin plus gentamicin.
Oral regimens include cephalexin, amoxicillin plus clavulanic acid, trimethoprim-sulfamethoxazole, or fluoroquinolones (for older children only).
Definitive antibiotic therapy should be guided by the patient’s urine culture results.
Infants and children who do not show the expected clinical response within 2–3 days of starting antimicrobial therapy should be re-evaluated, have another urine specimen obtained for culture, and undergo imaging promptly to evaluate for renal abscess.
The degree of toxicity, dehydration, and ability to retain oral intake of fluids should be assessed carefully. Restoring or maintaining adequate hydration, including correction of electrolyte abnormalities that are often associated with vomiting or poor oral intake, is important.

About 5% of people with pyelonephritis develop bacteremia, and newborns are more prone to have it than older children. Focal renal abscesses are a rare complication. Parents should be advised to follow up for examination if their child develops any further fevers in order to establish whether a UTI might return. If a recurring UTI is identified, further imaging tests (VCUG) are recommended to determine whether vesicoureteral reflux may be present.

Primary prevention
1) encouraging healthy genital hygiene
2) addressing underlying risk factors for UTI, such as encopresis, chronic constipation, and daytime and nighttime incontinence.
There is evidence that antibiotic prophylaxis may help avoid more serious symptoms of repeated infections, although the benefit is limited and linked to the emergence of resistant bacteria.
It is unknown how secondary prophylaxis to avoid kidney scarring may affect things.
It is not advised to use cranberry juice alone to acidify the urine in order to avoid UTIs in children who are at high risk.