Elsevier

European Urology

Volume 67, Issue 3, March 2015, Pages 546-558
European Urology

Guidelines
Urinary Tract Infections in Children: EAU/ESPU Guidelines

https://doi.org/10.1016/j.eururo.2014.11.007Get rights and content

Abstract

Context

In 30% of children with urinary tract anomalies, urinary tract infection (UTI) can be the first sign. Failure to identify patients at risk can result in damage to the upper urinary tract.

Objective

To provide recommendations for the diagnosis, treatment, and imaging of children presenting with UTI.

Evidence acquisition

The recommendations were developed after a review of the literature and a search of PubMed and Embase. A consensus decision was adopted when evidence was low.

Evidence synthesis

UTIs are classified according to site, episode, symptoms, and complicating factors. For acute treatment, site and severity are the most important. Urine sampling by suprapubic aspiration or catheterisation has a low contamination rate and confirms UTI. Using a plastic bag to collect urine, a UTI can only be excluded if the dipstick is negative for both leukocyte esterase and nitrite or microscopic analysis is negative for both pyuria and bacteriuria. A clean voided midstream urine sample after cleaning the external genitalia has good diagnostic accuracy in toilet-trained children. In children with febrile UTI, antibiotic treatment should be initiated as soon as possible to eradicate infection, prevent bacteraemia, improve outcome, and reduce the likelihood of renal involvement. Ultrasound of the urinary tract is advised to exclude obstructive uropathy. Depending on sex, age, and clinical presentation, vesicoureteral reflux should be excluded. Antibacterial prophylaxis is beneficial. In toilet-trained children, bladder and bowel dysfunction needs to be excluded.

Conclusions

The level of evidence is high for the diagnosis of UTI and treatment in children but not for imaging to identify patients at risk for upper urinary tract damage.

Patient summary

In these guidelines, we looked at the diagnosis, treatment, and imaging of children with urinary tract infection. There are strong recommendations on diagnosis and treatment; we also advise exclusion of obstructive uropathy within 24 h and later vesicoureteral reflux, if indicated.

Introduction

In 30% of children with urinary tract anomalies, urinary tract infection (UTI) can be the first sign [1]. If we fail to identify patients at risk, damage to the upper urinary tract may occur. Up to 85% of infants and children with febrile UTI have visible photon defects on technetium Tc 99–labelled dimercaptosuccinic acid (DMSA) scanning, and 10–40% of these children have permanent renal scarring [2], [3], [4] that may lead to poor renal growth, recurrent pyelonephritis, impaired glomerular function, early hypertension, end-stage renal disease, and preeclampsia [5], [6], [7], [8], [9], [10].

Identifying children at risk of renal parenchymal damage and follow-up imaging after UTI is controversial. In these guidelines, we provide recommendations for the diagnosis, treatment, and imaging of children presenting with UTI based on evidence, and when this is lacking, based on expert consensus.

Section snippets

Background

UTI is the most common bacterial infection in childhood [11], [12], [13], [14], and up to 30% of infants and children experience recurrent infections during the first 6–12 mo after initial UTI [15], [16]. In very young infants, symptoms of UTI differ in many ways from those in older infants and children. The prevalence is higher in the first age group, with a male predominance. Most infections are caused by Escherichia coli, although in the first year of life Klebsiella pneumoniae, Enterobacter

Methodology

Several guidelines on dealing with specific subgroups of UTI are currently available, some of which are driven by economic and health care issues [20], [21], [22]. The recommendations in these guidelines were developed by the European Association of Urology (EAU)/European Society for Paediatric Urology (ESPU) Paediatric Guidelines Committee after a review of the literature and a search of PubMed and Embase for UTI and newborn, infants, preschool, school, child, and adolescent. A consensus

Classification

The four widely used infection classification systems depend on the site, episode, symptoms, and complicating factors. For acute treatment, the site and severity are the most important.

Medical history

The site, episode, symptoms, and complicating factors are identified by taking the patient's history. This includes questions on primary (first) or secondary (recurring) infection, febrile or nonfebrile UTIs; malformations of the urinary tract (eg, pre- or postnatal ultrasound [US] screening), previous operations, drinking, and voiding habits; family history; whether there is constipation or the presence of lower urinary tract symptoms; and sexual history in adolescents.

Clinical signs and symptoms

Fever may be the only

Therapy

Before any antibiotic therapy is started, a urine specimen should be obtained for urinalysis and urine culture. In febrile children with signs of UTI (clinical signs, positive dipstick and/or positive microscopy), antibiotic treatment should be initiated as soon as possible to eradicate the infection, prevent bacteraemia, improve clinical outcome, diminish the likelihood of renal involvement during the acute phase of infection, and reduce the risk of renal scarring [31], [59], [60], [61]. In

Monitoring of urinary tract infection

With successful treatment, urine usually becomes sterile after 24 h, and leucocyturia normally disappears within 3–4 d. Normalisation of body temperature can be expected within 24–48 h after the start of therapy in 90% of cases. In patients with prolonged fever and failing recovery, treatment-resistant uropathogens or the presence of congenital uropathy or acute urinary obstruction should be considered. Immediate US examination is necessary, if not performed initially as recommended.

Procalcitonin

Ultrasound

Renal and bladder US is advised in all children with febrile UTI to exclude dilatation or anomalies of the upper and lower urinary tract if no improvement is seen within 24 h because some conditions are life threatening. It can be delayed in those with a previous normal US examination, depending on the clinical situation. Abnormal results are found in approximately 15% of cases, and 1–2% have abnormalities that require prompt action (eg, additional evaluation, referral, diversion, or surgery)

Bladder and bowel dysfunction

BBD is a risk factor for which every child with UTI should be screened at presentation. Correction of lower urinary tract dysfunction is important to decrease the rate of UTI recurrence. If there are signs of BBD during infection-free intervals, further diagnosis and effective treatment are strongly recommended [111], [112], [113], [114]. Treatment of constipation leads to a decrease in UTI recurrence [115], [116], [117]. Exclusion of BBD is therefore strongly recommended in any child with

Conclusions

Figure 1 and Table 6 summarise the general recommendations:

  • Classification of a UTI is made according to the site, episode, symptoms, and complicating factors. For acute treatment, the site and severity are of the most importance.

  • Immediate US of the kidney and bladder are necessary in patients with febrile UTI to exclude underlying uropathy.

  • Treatment of patients with febrile UTIs should be initiated after urine analysis and culture to confirm the diagnosis.

  • SPA and catheterisation have the lowest

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