Chapter 67
Urinary Tract Infections in Children
Nicholas G. Larkins,
Jonathan C. Craig,
Nicholas G. Larkins
Department of Nephrology, Perth Children's Hospital, Nedlands, Western Australia, Australia
School of Paediatrics and Child Health, University of Western Australia, Nedlands, Western Australia, Australia
Search for more papers by this authorJonathan C. Craig
College of Medicine and Public Health Flinders University, Adelaide, Australia
Search for more papers by this authorNicholas G. Larkins,
Jonathan C. Craig,
Nicholas G. Larkins
Department of Nephrology, Perth Children's Hospital, Nedlands, Western Australia, Australia
School of Paediatrics and Child Health, University of Western Australia, Nedlands, Western Australia, Australia
Search for more papers by this authorJonathan C. Craig
College of Medicine and Public Health Flinders University, Adelaide, Australia
Search for more papers by this authorBook Editor(s):Jonathan C. Craig MBChB, DipCH, MMed(Clin Epi), PhD, FAHMS,
Donald A. Molony MD,
Giovanni F.M. Strippoli MD, PhD, MPH, MM (Epi),
Jonathan C. Craig MBChB, DipCH, MMed(Clin Epi), PhD, FAHMS
Matthew Flinders Distinguished Professor Vice President and Executive Dean
College of Medicine and Public Health, Flinders University, Adelaide, Australia
Search for more papers by this authorDonald A. Molony MD
Professor of Medicine Distinguished Teaching Professor of the University of Texas System
Division of Renal Diseases and Hypertension AND Center for Clinical Research and Evidence-based Medicine, McGovern Medical School University of Texas, Houston, TX, USA
Search for more papers by this authorGiovanni F.M. Strippoli MD, PhD, MPH, MM (Epi)
Professor of Nephrology Adjunct Professor of Epidemiology
Department of Emergency and Organ Transplantation – University of Bari, Bari, Italy
School of Public Health, University of Sydney, Sydney, NSW, Australia
Search for more papers by this authorFirst published: 18 November 2022
Summary
Urinary tract infections (UTIs) are a common and potentially serious infection among children. This chapter reviews the epidemiology of UTIs among children, presentation and treatment of acute infection, risk factors and approaches to managing recurrent infection, the role of diagnostic imaging, and long-term outcomes. Most infections are caused by ascending coliform bacteria, with both host and pathogenic factors contributing to the development and sequalae of UTI. Young children and infants often have difficulty localizing symptoms. The diagnosis of UTI first requires the collection of an uncontaminated urine sample. Confirmation of UTI requires the growth of a potentially causative organism from an uncontaminated sample. Multiple, well-designed, randomized trials have been conducted comparing antibiotic prophylaxis to placebo for the prevention of recurrent UTI. Another important component of treatment is the management of lower urinary tract dysfunction, which is a strong predictor of recurrent infections and kidney damage.
References
- Hultcrantz , M. , Rind , D. , Akl , E.A. et al. ( 2017 ). The grade working group clarifies the construct of certainty of evidence . J. Clin. Epidemiol. 87 : 4 – 13 . https://doi.org/10.1016/j.jclinepi.2017.05.006 .
- Hellstrom , A. , Hanson , E. , Hansson , S. et al. ( 1991 ). Association between urinary symptoms at 7 years old and previous urinary tract infection . Arch. Dis. Child. 66 : 232 – 234 . https://doi.org/10.1136/adc.66.2.232 .
-
Mårild , S.
and
Jodal , U.
(
2007
).
Incidence rate of first-time symptomatic urinary tract infection in children under 6 years of age
.
Acta Paediatr.
87
:
549
–
552
.
https://doi.org/10.1111/j.1651-2227.1998.tb01502.x
.
10.1111/j.1651?2227.1998.tb01502.x Google Scholar
- Singh-Grewal , D. , Macdessi , J. , and Craig , J. ( 2005 ). Circumcision for the prevention of urinary tract infection in boys: a systematic review of randomised trials and observational studies . Arch. Dis. Child. 90 : 853 – 858 . https://doi.org/10.1136/adc.2004.049353 .
-
Ellison , J.S.
,
Dy , G.W.
,
Fu , B.C.
et al. (
2018
).
Neonatal circumcision and urinary tract infections in infants with hydronephrosis
.
Pediatrics
https://doi.org/10.1542/peds.2017-3703
.
10.1542/peds.2017?3703 Google Scholar
- Lutter , S.A. , Currie , M.L. , Mitz , L.B. , and Greenbaum , L.A. ( 2005 ). Antibiotic resistance patterns in children hospitalized for urinary tract infections . Arch. Pediatr. Adolesc. Med. 159 : 924 – 928 . https://doi.org/10.1001/archpedi.159.10.924 .
- Pauchard , J.Y. , Chehade , H. , Kies , C.Z. et al. ( 2017 ). Avoidance of voiding cystourethrography in infants younger than 3 months with Escherichia coli urinary tract infection and normal renal ultrasound . Arch. Dis. Child. 102 : 804 – 808 . https://doi.org/10.1136/archdischild-2016-311587 .
- Friedman , S. , Reif , S. , Assia , A. et al. ( 2006 ). Clinical and laboratory characteristics of non- E. coli urinary tract infections . Arch. Dis. Child. 91 : 845 – 846 . https://doi.org/10.1136/adc.2005.080721 .
- Jantunen , M.E. , Siitonen , A. , Ala-Houhala , M. et al. ( 2001 ). Predictive factors associated with significant urinary tract abnormalities in infants with pyelonephritis . Pediatr. Infect. Dis. J. 20 : 597 – 601 .
- Raman , G. , McMullan , B. , Taylor , P. et al. ( 2018 ). Multiresistant E. coli urine infections in children: a case-control study . Arch. Dis. Child. 103 : 336 – 340 . https://doi.org/10.1136/archdischild-2017-312831 .
- Bryce , A. , Hay , A.D. , Lane , I.F. et al. ( 2016 ). Global prevalence of antibiotic resistance in paediatric urinary tract infections caused by Escherichia coli and association with routine use of antibiotics in primary care: systematic review and meta-analysis . BMJ 352 : i939 . https://doi.org/10.1136/bmj.i939 .
- Shaikh , N. , Ewing , A.L. , Bhatnagar , S. , and Hoberman , A. ( 2010 ). Risk of renal scarring in children with a first urinary tract infection: a systematic review . Pediatrics 126 : 1084 – 1091 . https://doi.org/10.1542/peds.2010-0685 .
- Shaikh , N. , Craig , J.C. , Rovers , M.M. et al. ( 2014 ). Identification of children and adolescents at risk for renal scarring after a first urinary tract infection: a meta-analysis with individual patient data . JAMA Pediatr. 168 : 893 – 900 . https://doi.org/10.1001/jamapediatrics.2014.637 .
- Shaikh , N. , Mattoo , T.K. , Keren , R. et al. ( 2016 ). Early antibiotic treatment for pediatric febrile urinary tract infection and renal scarring . JAMA Pediatr. 120 : e922 – e928 . https://doi.org/10.1001/jamapediatrics.2016.1181 .
- Panaretto , K.S. , Craig , J.C. , Knight , J.F. et al. ( 1999 ). Risk factors for recurrent urinary tract infection in preschool children . J. Paediatr. Child Health 35 : 454 – 459 . https://doi.org/10.1046/j.1440-1754.1999.355417.x .
- Craig , J.C. , Simpson , J.M. , Williams , G.J. et al. ( 2009 ). Antibiotic prophylaxis and recurrent urinary tract infection in children . N. Engl. J. Med. 361 : 1748 – 1759 . https://doi.org/10.1056/NEJMoa0902295 .
- Keren , R. , Shaikh , N. , Pohl , H. et al. ( 2015 ). Risk factors for recurrent urinary tract infection and renal scarring . Pediatrics 136 : e13 – e21 . https://doi.org/10.1542/peds.2015-0409 .
- Connell , I. , Agace , W. , Klemm , P. et al. ( 1996 ). Type 1 fimbrial expression enhances Escherichia coli virulence for the urinary tract . Proc. Natl. Acad. Sci. USA. 93 : 9827 – 9832 . https://doi.org/10.1073/pnas.93.18.9827 .
- Tullus , K. , Jacobson , S.H. , Katouli , M. , and Brauner , A. ( 1991 ). Relative importance of eight virulence characteristics of pyelonephritogenic Escherichia coli strains assessed by multivariate statistical analysis . J. Urol. 146 : 1153 – 1155 .
- Zaffanello , M. , Malerba , G. , Cataldi , L. et al. ( 2010 ). Genetic risk for recurrent urinary tract infections in humans: a systematic review . J. Biomed. Biotechnol. 2010 : 321082 . https://doi.org/10.1155/2010/321082 .
- Lebowitz , R.L. , Olbing , H. , Parkkulainen , K.V. et al. ( 1985 ). International system of radiographic grading of vesicoureteric reflux . Pediatr. Radiol. 15 : 105 – 109 . https://doi.org/10.1007/bf02388714 .
- Kelly , H. , Molony , C.M. , Darlow , J.M. et al. ( 2007 ). A genome-wide scan for genes involved in primary vesicoureteric reflux . J. Med. Genet. 44 : 710 – 717 . https://doi.org/10.1136/jmg.2007.051086 .
- Zaffanello , M. , Tardivo , S. , Cataldi , L. et al. ( 2011 ). Genetic susceptibility to renal scar formation after urinary tract infection: a systematic review and meta-analysis of candidate gene polymorphisms . Pediatr. Nephrol. 26 : 1017 – 1029 . https://doi.org/10.1007/s00467-010-1695-7 .
- Numazaki , Y. , Shigeta , S. , Kumasaka , T. et al. ( 1968 ). Acute hemorrhagic cystitis in children. Isolation of adenovirus type ii . N. Engl. J. Med. 278 : 700 – 704 . https://doi.org/10.1056/NEJM196803282781303 .
- Al-Orifi , F. , McGillivray , D. , Tange , S. , and Kramer , M.S. ( 2000 ). Urine culture from bag specimens in young children: are the risks too high? J. Pediatr. 137 : 221 – 226 . https://doi.org/10.1067/mpd.2000.107466 .
- McGillivray , D. , Mok , E. , Mulrooney , E. , and Kramer , M.S. ( 2005 ). A head-to-head comparison:“clean-void” bag versus catheter urinalysis in the diagnosis of urinary tract infection in young children . J. Pediatr 147 : 451 – 456 .
- Whiting , P. , Westwood , M. , Bojke , L. et al. ( 2006 ). Clinical effectiveness and cost-effectiveness of tests for the diagnosis and investigation of urinary tract infection in children: a systematic review and economic model . 10 : 1 – 154 .
- Kaufman , J. , Fitzpatrick , P. , Tosif , S. et al. ( 2017 ). Faster clean catch urine collection (quick-wee method) from infants: randomised controlled trial . BMJ 357 : j1341 . https://doi.org/10.1136/bmj.j1341 .
- Williams , G.J. , Macaskill , P. , Chan , S.F. et al. ( 2010 ). Absolute and relative accuracy of rapid urine tests for urinary tract infection in children: a meta-analysis . Lancet Infect. Dis. 10 : 240 – 250 . https://doi.org/10.1016/s1473-3099(10)70031-1 .
- Mori , R. , Yonemoto , N. , Fitzgerald , A. et al. ( 2010 ). Diagnostic performance of urine dipstick testing in children with suspected UTI: a systematic review of relationship with age and comparison with microscopy . Acta Paediatr. 99 : 581 – 584 . https://doi.org/10.1111/j.1651-2227.2009.01644.x .
- Verrier Jones , K. , Asscher , A.W. , Verrier Jones , E.R. et al. ( 1982 ). Glomerular filtration rate in schoolgirls with covert bacteriuria . BMJ 285 : 1307 – 1310 . https://doi.org/10.1136/bmj.285.6351.1307 .
- Wettergren , B. , Hellström , M. , Stokland , E. , and Jodal , U. ( 1990 ). Six year follow up of infants with bacteriuria on screening . BMJ (Clinical Research Ed.) 301 : 845 – 848 .
-
Shaikh , N.
,
Borrell , J.L.
,
Evron , J.
, and
Leeflang , M.M.G.
(
2015
).
Procalcitonin, c-reactive protein, and erythrocyte sedimentation rate for the diagnosis of acute pyelonephritis in children
.
Cochrane Database Syst. Rev
.
https://doi.org/10.1002/14651858.CD009185.pub2
.
10.1002/14651858.CD009185.pub2 Google Scholar
- Toffolo , A. , Ammenti , A. , and Montini , G. ( 2012 ). Long-term clinical consequences of urinary tract infections during childhood: a review . Acta Paediatr. 101 : 1018 – 1031 . https://doi.org/10.1111/j.1651-2227.2012.02785.x .
- Pope , J. , Brock , J. , Adams , M. et al. ( 1999 ). How they begin and how they end classic and new theories for the development and deterioration of congenital anomalies of the kidney and urinary tract, CAKUT . J. Am. Soc. Nephrol. 10 : 2018 – 2028 .
- Montini , G. , Tullus , K. , and Hewitt , I. ( 2011 ). Febrile urinary tract infections in children . N. Engl. J. Med. 365 : 239 – 250 .
- Craig , J.C. , Irwig , L.M. , Knight , J.F. , and Roy , L.P. ( 2000 ). Does treatment of vesicoureteric reflux in childhood prevent end-stage renal disease attributable to reflux nephropathy? Pediatrics 105 : 1236 – 1241 . https://doi.org/10.1542/peds.105.6.1236 .
- Ardissino , G. , Dacco , V. , Testa , S. et al. ( 2003 ). Epidemiology of chronic renal failure in children: data from the ItalKid project . Pediatrics 111 : e382 – e387 .
- Clayton P , Hurst K . Anzdata registry report 2016 . 2016 . Australia and New Zealand Dialysis and Transplant Registry, Adelaide, Australia . 2017. Available at: http://www.anzdata.org.au .
- Craig , J.C. and Williams , G.J. ( 2011 ). Denominators do matter: It's a myth–urinary tract infection does not cause chronic kidney disease . Pediatrics 128 : 984 – 985 . https://doi.org/10.1542/peds.2011-2631 .
- Hoberman , A. , Greenfield , S.P. , Mattoo , T.K. et al. ( 2014 ). Antimicrobial prophylaxis for children with vesicoureteral reflux . N. Engl. J. Med. 370 : 2367 – 2376 . https://doi.org/10.1056/NEJMoa1401811 .
- Holmdahl , G. , Brandstrom , P. , Lackgren , G. et al. ( 2010 ). The Swedish reflux trial in children: Ii. Vesicoureteral reflux outcome . J. Urol. 184 : 280 – 285 . https://doi.org/10.1016/j.juro.2010.01.059 .
-
Strohmeier , Y.
,
Hodson , E.M.
,
Willis , N.S.
et al. (
2014
).
Antibiotics for acute pyelonephritis in children
.
Cochrane Database Syst. Rev
.: CD003772.
https://doi.org/10.1002/14651858.CD003772.pub4
.
10.1002/14651858.CD003772.pub4 Google Scholar
-
Fitzgerald , A.
,
Mori , R.
,
Lakhanpaul , M.
, and
Tullus , K.
(
2012
).
Antibiotics for treating lower urinary tract infection in children
.
Cochrane Database Syst. Rev
.: CD006857.
https://doi.org/10.1002/14651858.CD006857.pub2
.
10.1002/14651858.CD006857.pub2 Google Scholar
- Tran , D. , Muchant , D.G. , and Aronoff , S.C. ( 2001 ). Short-course versus conventional length antimicrobial therapy for uncomplicated lower urinary tract infections in children: a meta-analysis of 1279 patients . J. Pediatr. 139 : 93 – 99 . https://doi.org/10.1067/mpd.2001.114698 .
- Kronenberg , A. , Butikofer , L. , Odutayo , A. et al. ( 2017 ). Symptomatic treatment of uncomplicated lower urinary tract infections in the ambulatory setting: randomised, double blind trial . BMJ 359 : j4784 . https://doi.org/10.1136/bmj.j4784 .
- Gagyor , I. , Bleidorn , J. , Kochen , M.M. et al. ( 2015 ). Ibuprofen versus fosfomycin for uncomplicated urinary tract infection in women: randomised controlled trial . BMJ 351 : h6544 . https://doi.org/10.1136/bmj.h6544 .
-
Tzimenatos , L.
,
Mahajan , P.
,
Dayan , P.S.
et al. (
2018
).
Accuracy of the urinalysis for urinary tract infections in febrile infants 60 days and younger
.
Pediatrics
https://doi.org/10.1542/peds.2017-3068
.Pediatric Emergency Care Applied Research Network
10.1542/peds.2017?3068 Google Scholar
- Westwood , M.E. , Whiting , P.F. , Cooper , J. et al. ( 2005 ). Further investigation of confirmed urinary tract infection (UTI) in children under five years: a systematic review . BMC Pediatr. 5 : 2 . https://doi.org/10.1186/1471-2431-5-2 .
- Dick , P. ( 2002 ). Routine imaging does not benefit children with a first uncomplicated UTI . Pediatr. Res. 51 : 213A – 213A .
-
Passerotti , C.C.
,
Kalish , L.A.
,
Chow , J.
et al. (
2011
).
The predictive value of the first postnatal ultrasound in children with antenatal hydronephrosis
.
Int. Braz. J. Urol.
37
:
557
–
557
.
https://doi.org/10.1590/S1677-55382011000400031
.
10.1590/S1677?55382011000400031 Google Scholar
- Montini , G. , Zucchetta , P. , Tomasi , L. et al. ( 2009 ). Value of imaging studies after a first febrile urinary tract infection in young children: data from Italian renal infection study 1 . Pediatrics 123 : e239 – e246 . https://doi.org/10.1542/peds.2008-1003 .
- Lee , H.-y. , Soh , B.H. , Hong , C.H. et al. ( 2009 ). The efficacy of ultrasound and dimercaptosuccinic acid scan in predicting vesicoureteral reflux in children below the age of 2 years with their first febrile urinary tract infection . Pediatr. Nephrol. (Berlin, Germany) 24 : 2009 – 2013 . https://doi.org/10.1007/s00467-009-1232-8 .
- Shaikh , N. , Spingarn , R.B. , and Hum , S.W. ( 2016 ). Dimercaptosuccinic acid scan or ultrasound in screening for vesicoureteral reflux among children with urinary tract infections . Cochrane Database Syst. Rev. 7 : CD010657. https://doi.org/10.1002/14651858.CD010657.pub2 .
- McTaggart , S. , Danchin , M. , Ditchfield , M. et al. ( 2015 ). KHA-CARI guideline: diagnosis and treatment of urinary tract infection in children . Nephrology 20 : 55 – 60 . https://doi.org/10.1111/nep.12349 .
- Agrawalla , S. , Pearce , R. , and Goodman , T.R. ( 2004 ). How to perform the perfect voiding cystourethrogram . Pediatr. Radiol. 34 : 114 – 119 . https://doi.org/10.1007/s00247-003-1073-8 .
-
Williams , G.
,
Wei , L.
,
Lee , A.
, and
Jc , C.
(
2011
).
Long-term antibiotics for preventing recurrent urinary tract infection in children (review)
.
Cochrane Database Syst. Rev.
16
:
10
–
12
.
https://doi.org/10.1002/14651858.CD001534.pub3.Copyright
.
10.1002/14651858.CD001534.pub3.Copyright Google Scholar
- Hewitt , I.K. , Pennesi , M. , Morello , W. et al. ( 2017 ). Antibiotic prophylaxis for urinary tract infection–related renal scarring: a systematic review . Pediatrics 139 : e20163145 . https://doi.org/10.1542/peds.2016-3145 .
-
Nagler , E.V.
,
Williams , G.
,
Hodson , E.M.
, and
Craig , J.C.
(
2011
).
Interventions for primary vesicoureteric reflux
.
Cochrane Database Syst. Rev
.: CD001532.
https://doi.org/10.1002/14651858.CD001532.pub4
.
10.1002/14651858.CD001532.pub4 Google Scholar
- Smellie , J.M. , Tamminen-Mobius , T. , Olbing , H. et al. ( 1992 ). Five-year study of medical or surgical treatment in children with severe reflux: radiological renal findings . Pediatr. Nephrol. 6 : 223 – 230 . https://doi.org/10.1007/BF00878353 .
- ( 1987 ). Prospective trial of operative versus non-operative treatment of severe vesicoureteric reflux in children: five years' observation. Birmingham Reflux Study Group . BMJ 295 : 237 – 241 . https://doi.org/10.1136/bmj.295.6592.237 .
- Altan , M. , Citamak , B. , Bozaci , A.C. et al. ( 2017 ). Is there any difference between questionnaires on pediatric lower urinary tract dysfunction? Urology 103 : 204 – 208 . https://doi.org/10.1016/j.urology.2016.12.055 .
- van Gool , J.D. , de Jong , T.P. , Winkler-Seinstra , P. et al. ( 2014 ). Multi-center randomized controlled trial of cognitive treatment, placebo, oxybutynin, bladder training, and pelvic floor training in children with functional urinary incontinence . Neurourol. Urodyn. 33 : 482 – 487 . https://doi.org/10.1002/nau.22446 .
- Fazeli , M.S. , Lin , Y. , Nikoo , N. et al. ( 2015 ). Biofeedback for nonneuropathic daytime voiding disorders in children: a systematic review and meta-analysis of randomized controlled trials . J. Urol. 193 : 274 – 279 . https://doi.org/10.1016/j.juro.2014.07.097 .
- Sureshkumar , P. , Bower , W. , Craig , J.C. , and Knight , J.F. ( 2003 ). Treatment of daytime urinary incontinence in children: a systematic review of randomized controlled trials . J. Urol. 170 : 196 – 200 . discussion 200. doi: https://doi.org/10.1097/01.ju.0000072341.34333.43 .
- Kajbafzadeh , A.M. , Baradaran , N. , Sadeghi , Z. et al. ( 2010 ). Vesicoureteral reflux and primary bladder neck dysfunction in children: urodynamic evaluation and randomized, double-blind, clinical trial on effect of alpha-blocker therapy . J. Urol. 184 : 2128 – 2133 . https://doi.org/10.1016/j.juro.2010.06.132 .
- Nayir , A. ( 2001 ). Circumcision for the prevention of significant bacteriuria in boys . Pediatr. Nephrol. 16 : 1129 – 1134 . https://doi.org/10.1007/s004670100044 .
- Jagannath , V.A. , Fedorowicz , Z. , Sud , V. et al. ( 2012 ). Routine neonatal circumcision for the prevention of urinary tract infections in infancy . Cochrane Database Syst. Rev. 11 : CD009129. https://doi.org/10.1002/14651858.CD009129.pub2 .
- Jepson , R.G. , Williams , G. , and Craig , J.C. ( 2012 ). Cranberries for preventing urinary tract infections . Cochrane Database Syst. Rev. 10 : CD001321. https://doi.org/10.1002/14651858.CD001321.pub5 .
- Dechartres , A. , Trinquart , L. , Boutron , I. , and Ravaud , P. ( 2013 ). Influence of trial sample size on treatment effect estimates: meta-epidemiological study . BMJ (Clinical Research Ed.) 346 : f2304 – f2304 . https://doi.org/10.1136/bmj.f2304 .
-
Schwenger , E.M.
,
Tejani , A.M.
, and
Loewen , P.S.
(
2015
).
Probiotics for preventing urinary tract infections in adults and children
.
Cochrane Database Syst. Rev
.: CD008772.
https://doi.org/10.1002/14651858.CD008772.pub2
.
10.1002/14651858.CD008772.pub2 Google Scholar
- Lee , T. , Ellimoottil , C. , Marchetti , K.A. et al. ( 2017 ). Impact of clinical guidelines on voiding cystourethrogram use and vesicoureteral reflux incidence . J. Urol. 199 : 831 – 836 . https://doi.org/10.1016/j.juro.2017.08.099 .
-
Ramirez , D.C.
,
Courchia , B.
,
Roberts , K.B.
, and
Rauch , D.A.
(
2017
).
Changes in UTI hospitalizations after the 2011 AAP UTI guidelines
.
Pediatrics
140
:
35
.
https://doi.org/10.1542/peds.140.1_MeetingAbstract.35
.
10.1542/peds.140.1_MeetingAbstract.35 Google Scholar
