COMMENTARY

Febrile UTIs in Infants: A Talk With the Author of the AAP Guideline

Christopher J. Chiu, MD; Justin L. Berk, MD, MPH, MBA

Disclosures

November 30, 2020

This transcript has been edited for clarity.

Christopher J. Chiu, MD: Welcome. I'm Chris Chiu with The Cribsiders. As always, I'm joined by my co-host, Dr Justin Berk.

Justin L. Berk, MD, MPH, MBA: We're here to recap our podcast episode with Kenneth B. Roberts, MD, professor emeritus of pediatrics at University of North Carolina and an author of the American Academy of Pediatrics' (AAP) 2011 Guidelines on urinary tract infections (UTIs) in febrile Infants. We learned a lot about all of the AAP guidelines in addition to the diagnosis, management, and treatment of UTIs in infants.

Chiu: The first pearl I'd like to share is that any level of leukocyte esterase in a urinalysis represents pyuria and the presence of an inflammatory response. This inflammatory response is what causes renal scarring. Also, remember that bowel and bladder dysfunction are common causes of UTIs, especially in recurrent cases.

Berk: We also talked about when to do imaging. Any febrile infant under 2 years old who has a UTI should undergo a renal and bladder ultrasound. This can help us identify severe reflux but also any type of structural abnormality. Admittedly, since 2011, a lot of these abnormalities may be picked up by a prenatal ultrasound, but it's still worth making sure that we're not missing anything. This is based on the most recent guidelines.

Obtain a voiding cystourethrogram (VCUG) anytime you see an abnormality in the ultrasound. The VCUG helps us look for the grade of reflux to determine whether a surgical intervention is necessary. If a patient under the age of 2 years has recurrent UTIs, that can be a sign that we may be missing something. Anytime there's a recurrence of UTI, there's a higher likelihood of urinary reflux, and that warrants VCUG.

Chiu: Generally speaking, patients with recurrent UTIs do not get antibiotics for prophylaxis, but you can consider a bowel regimen to prevent these recurrences.

Berk: For the diagnosis of a UTI, the guidelines include specific risk factors for determining the likelihood or risk of UTI. These include age, how high the fever is, sex (girls are more likely than boys to have UTIs), uncircumcised status, and also race.

We talked more about race as a risk factor in a companion episode to this podcast, where we discuss how incorporating race into clinical decision-making can be problematic at times. So if you want to take a deeper dive, a follow-up episode is available on all of our podcast streams.

Chiu: Yes. Make sure you check out the UTI episode and the companion episode anywhere you download podcasts. And as always, check out The Cribsiders website.

Chris Chiu, MD, is assistant professor at The Ohio State University, where he is also the physician lead at OSU's Outpatient Care East Clinic and serves as the assistant clinical director for the internal medicine residency. He is an Air Force veteran and a self-proclaimed gadget geek. Follow him on Twitter

Justin Berk, MD, MPH, MBA, is assistant professor of medicine and pediatrics at the Warren Alpert School of Medicine at Brown University. He is a clinical educator active in ambulatory and inpatient care and pediatrics. He enjoys coffee, thinking about hiking, and being a generalist. Follow him on Twitter

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