Urinary Tract Infection In Children: Emergency Department Diagnostics And Interventions

Table of Contents

 

1. Abstract
2. Case Presentation
3. Introduction
4. Critical Appraisal Of The Literature
5. Etiology And Pathophysiology
6. Differential Diagnosis
7. Prehospital Care
8. Emergency Department Evaluation
   1. Preverbal Infants
      1. History Of Present Illness
      2. Physical Examination
   2. Verbal Patients
      1. History Of Present Illness
      2. Physical Examination
9. Diagnostic Studies
   1. Urinalysis And Urine Culture
   2. Hematuria Testing
   3. Procalcitonin
   4. Additional Testing Based On Clinical Suspicion
10. Treatment
    1. Intravenous Versus Oral Therapy
    2. Length Of Treatment Required
11. Special Populations
12. Controversy And Cutting Edge
    1. Use Of Procalcitonin Testing
    2. Risk Of Significant Renal Damage
    3. Day Treatment Centers
13. Disposition
14. Summary
15. Clinical Pathway For Management Of Pediatric Urinary Tract Infection
16. Risk Management Pitfalls For Pediatric Urinary Tract Infections
17. Time- And Cost-Effective Strategies
18. Case Conclusions
19. Tables and Figures
    1. Table 1. Signs And Symptoms For Evaluation Of Pediatric Urinary Infection
    2. Table 2. Risk Stratification Prior To Testing For Urinary Tract Infection In Febrile Infants
    3. Table 3. Sensitivity And Specificity Of Different Urinary Test For Diagnosis Of Urinary Tract Infection
    4. Table 4. Comparison Of Previous And Updated Practice Guidelines From The American Academy Of Pediatrics
20. References

Abstract

Pediatric patients represent a significant portion of patients in the emergency department, and they often present with nonspecific complaints (such as fussiness, decreased oral intake, crying, or fever), which can pose a diagnostic dilemma. One serious cause for these complaints that should be considered is a urinary tract infection. Approximately 7% of fevers in pediatric patients presenting to the ED are caused by a bacterial infection of the normally sterile urinary system, and there is a litany of ways in which a young patient can manifest a urinary tract infection. This review will discuss the epidemiology, natural history, and pathophysiology of urinary tract infections in children. Pertinent history and physical examination findings as well as the diagnostic and treatment modalities will be examined, with the goal of providing updated evidence on the varied options in managing a patient once diagnosed. Controversies in the exact diagnosis of a urinary tract infection as well as a review of novel concepts in the management of this condition will also be presented.

Case Presentation

Two anxious parents arrive at the ED with an 8-month-old male who has a chief complaint of tactile fever lasting 2 days. They state that he has been drinking less than normal and that his urine has a distinct odor. His parents deny any cough, coryza, vomiting, diarrhea, or rash. He stools daily, and he last moved his bowels a small amount the previous day. The triage vital signs are: temperature, 39.7°C; heart rate, 160 beats/min; respiration, 25 breaths/min; and oxygen saturation, 98%. Physical examination reveals a well-appearing male with moist mucous membranes, no respiratory distress, a mildly distended abdomen, and an uncircumcised penis. Examination of the head, ears, eyes, nose, and throat is normal. A straight-catheterized urine sample is positive for nitrites. You wonder if there are any other tests that should be ordered, and if the child should be admitted. You further question if there are any predisposing factors to UTI that also need to be addressed.

An 18-year-old female presents to the ED complaining of 3 days of lower abdominal discomfort with mild dysuria. Her mother tells the triage nurse she just wants an antibiotic for her daughter’s bladder infection and indicates that they need to get in and out quickly. The teenager is afebrile and has normal vital signs. She takes no medicines except birth control pills and is otherwise healthy. While the mother is asking about the antibiotics, you wonder if history alone is sufficient to diagnose and treat UTI. Should you talk to the patient outside the presence of her mother? Can you just dip her urine and rapidly discharge her?

A 9-week-old child with fever to 40°C presents to the ED with her parents. She is slightly lethargic initially and has dry mucous membranes, but she improves with IV fluids and acetaminophen. She has a cough with scattered rales and wheezing on lung examination. Chest x-rays show mild hyperinflation with some peribronchial cuffing. She is breathing comfortably, but is still not tolerating liquids orally. Rapid RSV test is positive. At this point, you question whether any further testing is required and if the patient can be sent home with close follow-up.

Introduction

A urinary tract infection (UTI) results from bacterial colonization of any part of the genitourinary tract, which is a normally sterile system. UTI is one of the most common infections in children, with a cumulative incidence of 3% to 7% in females and 1% to 2% in males.^1,2 UTIs result in > 1.1 million physician visits and 500,000 emergency department (ED) visits per year in the United States, accounting for 0.7% of all physician visits and approximately 7% of febrile presentations in the ED.^1,3,4 Before the advent of antimicrobials in the 1930s, febrile UTI carried a 20% mortality rate in children.⁵ This has greatly decreased with antibiotics, but UTI is still considered a significant source of serious bacterial infections, causing bacteremia in 2% to 4% of cases, and carrying the risk of sepsis.^6,7 Historically, there has been concern for significant long-term risks of having a UTI (such as renal scarring and the subsequent development of hypertension, chronic kidney disease, and preeclampsia);^8,9,10 however, a more recent systemic review highlighted that, while there is a significant risk of renal scarring (affecting 1 in 7 children), there is a great disparity in evidence demonstrating how often subsequent pathology from the scarring occurs.¹¹ The emergency clinician plays an important role in the diagnosis and management of UTI in children. In this issue, we will discuss key points regarding the diagnosis, treatment, and disposition of pediatric UTIs, issues that may arise under special circumstance, and several new developments in the management of UTIs.

Critical Appraisal Of The Literature

A literature search was performed using the PubMed, OVID, and Cochrane databases. Searches were limited to those studies published in English involving human subjects dating back to 1990. Search terms included: pediatric, urinary tract infection, UTI, pyelonephritis, vesicoureteral reflux, fever, circumcision, and urinalysis. Articles deemed relevant were read, and references within were reviewed. The Cochrane Database of Systematic Reviews was searched for any pertinent systematic reviews or meta-analyses. The American Academy of Pediatrics (AAP) practice parameters and previously published guidelines were also utilized. The Infectious Diseases Society of America has no guidelines regarding pediatric urinary tract infections. The total body of literature included systematic reviews, meta-analyses, randomized controlled trials, prospective trials, retrospective analyses, and case reports. A total of 1286 studies were scrutinized, using abstracts, when available, and then were determined applicable based on their relevance to the scope of this article.

Risk Management Pitfalls For Pediatric Urinary Tract Infections

1. “The patient never made urine, so I just empirically treated for UTI.” It is vital to obtain an appropriate urine specimen, both for diagnosis and for later antibiotic- sensitivity assessment. If the patient has no urine, even on bladder catheterization, then significant dehydration and possibly a more serious infection should be considered.
2. “I prescribed an antibiotic, so I’m not sure why the patient returned with sepsis.” Not only is it vital to make sure that the patient’s bacterial agent is sensitive to your antibiotic, you must make sure that he or she can actually tolerate oral intake before discharge and has not had difficulty with oral medications in the past.
3. “The patient’s mom didn’t want her child to have an intravenous line, so I thought oral antibiotics were the right choice.” While it is prudent to minimize trauma and harm to the child, there are certain indications that warrant intravenous antibiotics, including sepsis, inability to tolerate oral intake, evidence of pyelonephritis, and significant dehydration.
4. “I treated the patient with locally-susceptible antibiotics. I don’t know why her condition did not improve.” While verifying local susceptibilities is important, assessing the patient for risk factors (such as pediatric intensive care unit stay, immunosuppression, renal transplant, recurrent UTIs, or genitourinary deformities) is also necessary in determining the proper pharmacologic agent.
5. “The adolescent girl complained of dysuria and was certain it was a UTI because her mom had recurrent cystitis. I treated it, even though the urinalysis was unremarkable.” In adolescent females, sexually transmitted diseases must be on the differential for complaints of dysuria, and, in the presence of any uncertainty, a pelvic examination is necessary. Asking the parent to leave the room in order to obtain a more detailed history is always warranted, especially in this age population. It is also not uncommon for urine WBCs or LE to be elevated in a patient with sexually transmitted urethritis or cervicitis. Risk Management Pitfalls For Pediatric Urinary Tract Infections
6. “The patient was afebrile in the ED, so I didn’t consider UTI.” It is important in pediatric populations to note in the history the patient’s objective or even subjective febrile temperatures before presentation to the ED, especially as the child may have received anti-inflammatory medications prior to arrival. Additionally, it is important to remember that not all UTIs present with fever.
7. “I didn’t check for a UTI because the patient is a boy.” In male patients aged < 2 years and, especially male patients aged < 6 months, UTI is not uncommon and approaches the prevalence of this condition in females. For male patients aged> 2 years, circumcision status should be sought, as uncircumcised males still have a higher prevalence of UTIs.
8. “The patient’s father didn’t want us to catheterize his newborn baby, so we placed an adhesive bag. When the UA showed bacteria, I treated it.” In all infants and toddlers who are not toilet-trained, an adhesive bag, regardless of perineal cleansing, is not as specific as a straight catheterization. Contaminated specimens from a bag may result in unnecessary treatment or a missed diagnosis.
9. “The 3-month-old looked great. I can’t believe his dad is threatening to sue because I didn’t admit him.” New guidelines suggest that infants aged > 2 months who appear well can be sent home on oral antibiotics. Additionally, new studies have shown that patients “on the cusp” can obtain effective treatment in facilities that provide daily ambulatory intravenous antibiotics.
10. “I treated the otherwise healthy girl who had positive nitrites and LE on dipstick with an antibiotic. How would I have known that it was not a sensitive antibiotic?” While it is acceptable to treat a patient with a strongly positive urine dipstick, sending the urine for a formal culture is recommended to ensure a correct diagnosis and to confirm that the antibiotic choice was appropriate.

Tables and Figures

References

Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study will be included in bold type following the reference, where available.

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