a SLACK Incorporated newspaper
January 1999
"Certain signs and symptoms might suggest to the practitioner that a patient is experiencing infection of the urinary tract. Some of these symptoms are specific, and some are nonspecific," said Ellen R. Wald, MD, professor of pediatrics and otolaryngology at Children's Hospital of Pittsburgh and a member of the Infectious Diseases in Children editorial board.
According to Wald, the specific symptoms of bladder infection or cystitis are frequency, urgency and dysuria, while the nonspecific symptoms are irritability and fever.
The specific symptoms of kidney infections are flank pain and costovertebral angle tenderness. "In children with acute pyelonephritis, we find high fever, rigors and chills," added Wald, here at the recent annual meeting of the American Academy of Pediatrics.
Of course, the key to diagnosis of UTIs is collecting a specimen of urine and then submitting that specimen to the laboratory for culture. "The definition of UTIs varies according to the method of collection of the urine. This takes into account that, although we know that the bladder's urine is usually a sterile body fluid, any urine that is collected after passing through the urethra has an opportunity to become contaminated," she explained.
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In children, more than 95% of the cases of UTI are caused by gram-negative organisms. "Far and away the most prominent organism is Escherichia coli," she said.
Once UTI has been diagnosed, practitioners must decide whether to treat intravenously or with an oral antibiotic. "In general, oral antimicrobial therapy has been deemed quite acceptable for the management of children who present with cystitis and even for the management of older children who present with acute pyelonephritis, especially if they are non-toxic in appearance and have no history of vomiting," she said.
However, when deciding to treat with an oral antibiotic, it is important to make sure that the parents will be able to watch the child and report any worsening conditions. Also, it is important to make sure parents are compliant with administering the medication.
"The more complex issue has been how to manage the young infant with acute pyelonephritis, and the tradition historically has been for that child to be admitted to the hospital for parenteral antimicrobials," Wald said.
"Another alternative that works quite well for the management of urinary tract infection is the combination treatment trimethoprim-sulfamethoxazole. It has become a tradition that the test of cure is now within 24 hours after antimicrobials have been started," she said. "Urine is collected and sent to the laboratory to ensure that it is sterile. In virtually 100% of the cases, the urine will be sterile. In fact, the urine sterilizes in most children after only a single dose of therapy."
Several choices are also available if you need to select a parenteral antimicrobial for patient management. A combination of ampicillin and sulbactam (Unasyn, Pfizer) can be used or a second- or third-generation cephalosporin can be prescribed.
"You could also consider an aminoglycoside, such as gentamicin. When a parenteral antimicrobial is used, it is conventional to continue treatment until a patient becomes afebrile, and then for a period after afebrility results. My preference is to continue the IV parenteral treatment for 24 or 48 hours beyond the point that the patient becomes afebrile. I'll then change the patient to an oral antimicrobial and complete a 10-day course of therapy," Wald said.
For your information:
- Wald ER, Hoberman A. Urinary tract infection in infants, children and adolescents. Presented at the Annual Meeting of the American Academy of Pediatrics. Oct. 17-21. San Francisco.
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