AAP Issues Guidelines for UTI Management in Children

Laurie Barclay, MD

August 30, 2011

August 30, 2011 — An American Academy of Pediatrics (AAP) Clinical Practice Guideline and technical report published online August 29 and will appear in the September issue of Pediatrics address diagnosis and management of an initial urinary tract infection (UTI) in febrile infants and young children.

"The diagnosis and management of ...UTIs in young children are clinically challenging," write S. Maria E. Finnell, MD, MS, and colleagues from the AAP Subcommittee on Urinary Tract Infection who coauthored the Technical Report. "This report was developed to inform the revised, evidence-based, clinical guideline regarding the diagnosis and management of initial UTIs in febrile infants and young children, 2 to 24 months of age.... The conceptual model presented in the 1999 technical report was updated after a comprehensive review of published literature."

Clinical Characteristics, New Urinalysis Methods

On the basis of a review of recent literature and meta-analyses on the effectiveness of antimicrobial prophylaxis to prevent recurrent UTI, the report authors concluded that specific clinical characteristics and new methods of urinalysis may help clinicians determine which febrile children are at very low risk for UTI. Their findings include the following:

  • Compared with parenteral therapy, oral antimicrobial therapy is as effective in treating UTI.

  • Evidence from published, randomized controlled trials suggests that when voiding cystourethrography (VCUG) shows vesicoureteral reflux (VUR), antimicrobial prophylaxis is not recommended to prevent febrile UTI.

  • The sensitivity of urinary tract ultrasonography after the first UTI is poor.

  • The risk for renal damage from UTI may be reduced by early antimicrobial therapy.

"Recent literature agrees with most of the evidence presented in the 1999 technical report, but meta-analyses of data from recent, randomized controlled trials do not support antimicrobial prophylaxis to prevent febrile UTI," the report authors write. "This finding argues against ...VCUG after the first UTI."

AAP Recommendations

On the basis of this technical report and its underlying evidence, Kenneth B. Roberts, MD, and colleagues from the AAP Subcommittee on Urinary Tract Infection who coauthored the new Clinical Practice Guideline, issued recommendations for the diagnosis and management of the first UTI in febrile infants and children 2 to 24 months old. Changes from the previous AAP guidelines include criteria for the diagnosis of UTI and recommendations for imaging.

Specific recommendations in the new Clinical Practice Guideline include the following:

  • Diagnosis of UTI is made from an appropriately collected urine specimen based on the presence of pyuria as well as 50,000 colonies per mL or more of a single uropathogenic organism.

  • To facilitate prompt diagnosis and treatment of recurrent UTIs, close clinical follow-up monitoring should be maintained after 7 to 14 days of antimicrobial therapy.

  • To diagnose anatomic abnormalities, ultrasonography of the kidneys and bladder should be performed.

  • Because evidence from the most recent 6 studies does not support the use of antimicrobial prophylaxis to prevent febrile recurrent UTI in infants without VUR or with grade 1 to 4 VUR, VCUG is not recommended routinely after the first UTI.

  • However, VCUG is indicated if renal and bladder ultrasonography results show hydronephrosis, scarring, or other evidence of high-grade VUR or obstructive uropathy, as well as in other atypical or complex clinical circumstances.

  • Infants and children who have recurrence of a febrile UTI should also undergo VCUG.

Additional Clinical Questions

In an accompanying editorial, Thomas B. Newman, MD, MPH, from the Division of Clinical Epidemiology, Department of Epidemiology and Biostatistics, and Division of General Pediatrics, Department of Pediatrics at the University of California, San Francisco, calls the new recommendations "a long-awaited update" and "an exceptionally evidence-based guideline."

He makes additional comments in response to the 5 clinical questions addressed in the guideline and technical report, including the following:

  1. Which children should have their urine tested? The new guideline recommends selective urine testing based on the prior probability of UTI, which Dr. Newman states is an important improvement vs the 1999 practice parameter recommending urine testing for all children aged 2 months to 2 years with unexplained fever.

  2. How should the urine sample be obtained? Dr. Newman applauds the new guideline for continuing to offer the option of noninvasively obtaining urine for urinalyses, but he is not convinced that the bag urine can never be used for culture, because the prior probability may sometimes be in a range where the bag culture will be useful.

  3. How should UTIs be treated? Dr. Newman agrees with the guideline's recommendation that regional variation in antimicrobial susceptibility patterns should dictate the choice of initial treatment. However, he suggests adjusting the choice based on the clinical course rather than on sensitivity testing of the isolated uropathogen, as recommended in the guideline.

  4. What imaging and follow-up are recommended after a diagnosis of UTI? "The recommendation most dramatically different from the 1999 guideline is that a VCUG not be routinely performed after a first febrile UTI," Dr. Newman writes. "The main reason for this change is the accumulation of evidence casting doubt on the benefit of making a diagnosis of ...VUR. To put these data in historical perspective, operative ureteral reimplantation was standard treatment for VUR until randomized trials found it to be no better than prophylactic antibiotics at preventing renal scarring."

  5. How should children be monitored after a UTI has been diagnosed? Dr. Newman concurs with the guideline authors in not recommending prophylactic antibiotics to prevent UTI recurrences, because meta-analyses have revealed no significant reduction in symptomatic UTI from such prophylaxis regardless of whether VUR was present.

"I salute the authors of the new AAP UTI guideline and the accompanying technical report," Dr. Newman concludes. "Both publications represent a significant advance that should be helpful to clinicians and families dealing with this common problem."

Dr. Newman has disclosed no relevant financial relationships.

Pediatrics. 2011;128:595-610, 572-575, e749-e770.


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