From the Guidelines
The recommended workup for a first urinary tract infection in a child under 2 years old includes a thorough history and physical examination, urinalysis, and urine culture before starting antibiotics, with renal and bladder ultrasonography performed to identify structural abnormalities, but voiding cystourethrography (VCUG) is not routinely recommended after the first UTI unless there are atypical or complex clinical circumstances. The diagnosis of UTI is made on the basis of the presence of both pyuria and at least 50,000 colonies per mL of a single uropathogenic organism in an appropriately collected specimen of urine 1. Urine collection should be done via catheterization or suprapubic aspiration to avoid contamination. Empiric antibiotic therapy should be initiated promptly with amoxicillin-clavulanate (30-40 mg/kg/day divided every 8 hours) or cefixime (8 mg/kg/day divided every 12-24 hours) for 7-10 days. For febrile UTIs, consider initial parenteral therapy with ceftriaxone (50-75 mg/kg/day) or gentamicin (5-7.5 mg/kg/day). Some key points to consider in the workup and treatment of UTIs in children under 2 years old include:
- The role of imaging is to guide treatment by identifying patients who are at high risk to develop recurrent UTIs or renal scarring 1
- The effectiveness of current management of UTIs is put into question, with prospective studies failing to demonstrate significant decrease in renal scarring in patients with febrile UTI who were treated with prophylactic antibiotics 1
- The incidence of acute pyelonephritis in the absence of documented VUR is much too high to be explained only by intermittent VUR 1
- Renal and bladder ultrasonography should be performed to identify structural abnormalities, preferably within 2-4 weeks of diagnosis 1
- VCUG is indicated if renal and bladder ultrasonography reveals hydronephrosis, scarring, or other findings that would suggest either high-grade VUR or obstructive uropathy and in other atypical or complex clinical circumstances 1
- Parents should be educated about UTI prevention strategies including proper hygiene, adequate hydration, regular voiding, and avoiding bubble baths. It is essential to note that the recommendations for the workup and treatment of UTIs in children under 2 years old are based on the most recent and highest quality evidence available, with a focus on minimizing the risk of morbidity, mortality, and reducing the impact on quality of life 1.
From the Research
Workup for First UTI in Child Less Than 2 Years Old
- The recommended workup for a first urinary tract infection (UTI) in a child under 2 years old includes collecting an uncontaminated urine specimen for accurate diagnosis 2.
- A renal ultrasound examination is advised in all young children with first febrile UTI 2.
- Voiding cystourethrogram (VCUG) may be considered after the first UTI in children with abnormal renal and bladder ultrasound examination or a UTI caused by atypical pathogen, complex clinical course, or known renal scarring 2.
Treatment
- Oral antibiotic therapy for 7 to 10 days is adequate for uncomplicated cases that respond well to the treatment 2.
- Antibiotics such as cefixime or amoxycillin/clavulanic acid can be used to treat febrile UTIs in children for 10 to 14 days 3.
- Amoxycillin-clavulanic acid combination can be considered a first choice treatment of urinary tract infections in children 4.
- Narrow-spectrum antibiotics, such as first-generation cephalosporins, can be used for uncomplicated UTI 5.
Prevention of Recurrent UTI and Renal Scarring
- Long-term antibiotic prophylaxis is used selectively in high-risk patients 2.
- Treatment of acute pyelonephritis with an appropriate antibiotic within 48 hours of fever onset and prevention of recurrent UTI lowers the risk of renal scarring 2.
- The role of antibiotic prophylaxis in preventing recurrent UTI and renal scarring is still being studied, and more research is needed to answer these questions 6.