ELK GROVE VILLAGE, Ill. - The American Academy of Pediatrics (AAP) recently developed new recommendations for the diagnosis, management and follow-up of infants and young children with unexplained fever who are found to have urinary tract infections (UTIs).
The 11 recommendations proposed by the AAP focus on children 2 months to 2 years of age. Infants and young children with UTIs in this age group have the greatest risk of renal damage because the diagnosis is frequently challenging, the clinical presentation tends to be nonspecific and valid urine specimens cannot be obtained without invasive methods, according to the AAP.
"This particular age group was studied because this is the age at which improvement is most likely to be seen," said David A. Bergman, MD, chairman of the AAP Committee on Quality Improvement.
Identification, treatment and evaluation of children who are at risk for kidney damage are better performed when an accurate UTI diagnosis is made, Bergman added.
Correctly diagnosing UTIs is also important to avoid unnecessary treatment and unnecessary evaluation of children who are not at risk. Intervention is costly, potentially harmful and provides no benefit to this population, according to the AAP.
UTIs are highly prevalent in young children and may cause few recognizable signs and symptoms other than fever. These infections also have great potential to cause renal damage in infants and children younger than 2 years. As a result, the AAP recommended that children in this age group who have unexplained fever be considered to have UTIs.
The degree of toxicity, dehydration and ability to retain oral intake must be carefully assessed in these children and the AAP recommended that a subjective assessment of the degree of illness or toxicity be made in addition to seeking an explanation for the fever.
A urine specimen should be obtained by suprapubic aspiration (SPA) or transurethral bladder catheterization in children assessed as being sufficiently ill enough to warrant antimicrobial therapy. Urine obtained by these methods is unlikely to be contaminated; therefore, specimens taken by these methods are preferred for documenting UTIs, the AAP suggested.
If a child does not require immediate antimicrobial therapy, culture a urine specimen collected by SPA or transurethral bladder catheterization or obtain a urine specimen by the most convenient means and perform a urinalysis, the recommendations stated.
Diagnosis of UTIs requires a culture of the urine. To prevent growth of organisms in the urine at room temperature, the specimens should be processed or refrigerated quickly. The standard UTI urine culture is a quantitative urine culture. According to the recommendations, no urinalysis element or combination of elements is as sensitive and specific as quantitative urine culture.
If a UTI patient is assessed as toxic, dehydrated or unable to retain oral intake, initial antimicrobial therapy should be administered parenterally and hospitalization should be considered. Treatment goals are to eliminate the acute infection, prevent urosepsis and reduce likelihood of renal damage.
If a patient who does not appear ill has a culture confirming the presence of UTI, the AAP recommended proceeding with antimicrobial therapy. If the expected clinical response is not achieved after two days, the patient should be reevaluated and another urine specimen should be cultured.
A seven- to 10-day antimicrobial course is recommended for patients whose treatment was administered parenterally. According to the AAP, when long-term therapy was compared with short-term, results were better with long-term duration of treatment. After a seven- to 14-day course of antimicrobial therapy and sterilization of the urine, the AAP recommended that antimicrobials in therapeutic dosages be given until the imaging studies are completed.
If the expected clinical response is not achieved within two days of antimicrobial therapy, perform ultrasonography. Also perform voiding cystourethrography (VCUG) or radionuclide cystography (RNC) as early as possible. A sonogram and either VCUG or RNC should be performed as soon as possible if the patient had the expected clinical response, according to the new recommendations.
UTIs in young children are markers for abnormalities of the urinary tract. Because of this, the AAP recommends imaging every febrile infant or young child with a first UTI to identify abnormalities that predispose to renal damage.
Infants and young children with UTIs warrant special attention because of the opportunity to prevent kidney damage. The UTI may bring a child with an obstructive anomaly or severe vesicoureteral reflux to a clinician's attention.
The urinary tract is a relatively common site of infection in infants and young children. UTIs cause acute morbidity and may result in long-term medical problems, including hypertension and reduced renal failure.
The 11 recommendations made by the AAP focus on febrile infants and young children 2 months to 2 years of age but exclude those children with obvious neurologic or anatomic abnormalities known to be associated with recurrent UTI and renal damage.
For more information:
- AAP. Committee on Quality Improvement. Subcommittee on Urinary Tract Infections. Practice parameter: The diagnosis, treatment, and evaluation of the initial urinary tract infection in febrile infants and young children. Pediatrics 1999;103(4):843-853.
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