Should a 6-year-old with dysuria and a history of vesicoureteral (VU) reflux be treated for a urinary tract infection (UTI)?

Management of UTI in a 6-Year-Old with History of Vesicoureteral Reflux

A 6-year-old child with dysuria and history of vesicoureteral reflux should be treated for a urinary tract infection, as children with VUR have an increased risk of recurrent UTIs and potential renal scarring. 1

Rationale for Treatment

• Children with a history of VUR have an increased prevalence of UTIs, with frequency increasing from 35% to 74% in those with recurrent UTIs 1
• The presence of VUR increases the risk of upper tract infection and damage when a bladder infection occurs 1
• Dysuria is a classic symptom of UTI, and in a child with known VUR, this symptom should be taken seriously to prevent potential renal scarring 2

Diagnostic Approach

• Obtain a urine culture before starting antibiotics to confirm the diagnosis and guide treatment 3
• While awaiting culture results, empiric treatment should be initiated promptly to prevent potential progression to pyelonephritis 2
• Ultrasound of the kidneys and bladder may be considered based on clinical judgment, though routine imaging is not necessary for every UTI episode in children >6 years with known VUR 1

Treatment Recommendations

• Start with an appropriate oral antibiotic that covers common uropathogens, particularly E. coli 3
• First-line options include:
  • Trimethoprim-sulfamethoxazole (if local resistance patterns permit) 4
  • Amoxicillin-clavulanate (Augmentin) for broader coverage if local resistance patterns indicate 3
• Avoid fluoroquinolones like ciprofloxacin as first-line therapy in pediatric patients due to increased risk of adverse events related to joints and surrounding tissues 5
• Treatment duration should be 7-10 days for a child with VUR to ensure complete eradication of the infection 3, 2

Special Considerations for VUR

• The child's history of VUR increases their risk for upper tract involvement and potential renal scarring 1, 2
• Monitor response to treatment closely; failure to respond within 48 hours may indicate an atypical infection requiring further evaluation 1
• If the child has recurrent UTIs (defined as ≥2 episodes of upper tract UTI or ≥3 episodes of lower tract UTI), consider referral to pediatric urology for reassessment of VUR status 2

Long-term Management

• After treating the acute infection, consider whether continuous antibiotic prophylaxis (CAP) is appropriate:
  • Recent evidence suggests limited benefit of CAP in preventing recurrent UTIs in children with VUR 6
  • The decision to use CAP should be based on VUR grade, frequency of recurrent UTIs, and risk of renal scarring 1
• Educate parents about symptoms of UTI to ensure prompt recognition and treatment of future episodes 2
• Address any underlying issues that might contribute to UTIs, such as constipation or dysfunctional voiding 7

Pitfalls to Avoid

• Don't delay treatment while awaiting culture results in a symptomatic child with history of VUR, as this increases risk of upper tract involvement 2
• Don't assume all dysuria in children with VUR is due to UTI; confirm with appropriate cultures before prolonged antibiotic treatment 7
• Don't routinely order imaging studies for every UTI episode in children >6 years with known VUR, as this provides limited additional information 1
• Don't use fluoroquinolones as first-line therapy due to risk of adverse effects on developing joints 5