COMMENTARY

UTIs in Infants: Reviewing the Guidelines

Michael C. Carr, MD, PhD

Disclosures

June 24, 2013

Editorial Collaboration

Medscape &

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I'm Michael Carr, the Associate Director of Pediatric Urology at Children's Hospital in Philadelphia. Today, I wanted to talk to you about the guidelines that have recently been published by the American Academy of Pediatrics (AAP) concerning urinary tract infection (UTI) in a febrile infant between the age of 2 and 24 months. These guidelines, published in August of 2011, have certainly sparked a lot of controversy. I think it is important to go through those 7 guidelines that the AAP came up with in terms of the management of these infants with febrile UTI.

The first guideline is that if a febrile infant is to be treated with an antimicrobial therapy, a urine specimen should be obtained. That urine specimen should be obtained either with a suprapubic aspirate or urethral catheterization. Why? Because it is very important before beginning therapy to obtain the best, most accurate, urine culture on which to base your therapy.

The second guideline states that if the clinician determines that an infant does not require antibiotic therapy, a bag urine specimen can be obtained. If the bag urine specimen is negative, that is assurance that the infant does not have a UTI. On the other hand, if the bag urine specimen is positive, then a catheterized urine specimen would be necessary in order to determine appropriate treatment.

The third guideline states that establishing the diagnosis of UTI requires the presence of both pyuria and bacteria on a urine dipstick.

The fourth guideline states that when initiating treatment, the clinician should base the choice of therapy and the route of administration upon the infant's clinical condition. In fact, data demonstrate that oral antibiotic therapy can be effective, even in an infant. Clinicians should look at local or regional sensitivity patterns to determine the appropriate antibiotic for that infant.

The fifth guideline states that infants with a UTI should have renal and bladder ultrasonography. We know that ultrasonography may not be the ideal screening tool, but it can detect the presence of abnormalities in the urinary tract, which would then allow further evaluation to be done. On the other hand, if you find that renal bladder ultrasonography is normal, that gives you fairly good assurance that this infant does not need further evaluation at this point in time.

Now the next guideline, which has sparked the most controversy, states that following a first febrile UTI, infants should not undergo a voiding cystourethrogram (VCUG) study. The reason for this recommendation is that randomized controlled studies in children demonstrated that even in those with existing vesicoureteral reflux, antibiotic therapy does not change the incidence of a subsequent febrile UTI. So in other words, if your treatment or management of that patient is not going to change the outcome, it does not make sense to diagnose reflux in that individual infant. On the other hand, if renal and bladder ultrasonography shows some abnormality, such as dilation within the kidney or ureteral dilation, or something that seems abnormal, such as a suggestion of potential renal scarring, then a VCUG study should be performed.

Finally, the last guideline states that following confirmation of a UTI, the clinician should instruct the parent to seek prompt medical attention if that infant develops another febrile illness. In other words -- and what I think is most important -- is that as clinicians, we need to educate our families about what should be done. If their infant has an unexplained fever, they need to go to the emergency department or to the clinician's office to be evaluated promptly. At that time, a determination will be made as to whether a urine culture should be obtained.

In my practice, I think it is best to begin antibiotic therapy while waiting for the results of the urine culture rather than waiting for the culture result to come back and then instituting antibiotic therapy, because oftentimes it is 48 hours before you get the results. It is much better to then stop antibiotics rather than start them later and allow that child to potentially languish for 48 hours.

In the end we, as clinicians, really need to educate our families about what is most important when their child, their infant, has a febrile UTI. Remember, these guidelines are only for infants between the age of 2 and 24 months. There are no guidelines, as yet, established for older patients, because a number of the issues that lead to these older children developing UTIs are quite different.

Thank you very much for your attention.

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