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Diagnosis and management of urinary tract infection (UTI) in febrile infants are challenging for several reasons: Obtaining a sterile urine sample requires either inserting a urethral catheter or performing a suprapubic aspirate, both the route and duration of antibiotics are not standardized, and follow-up evaluation often includes voiding cystourethrography (VCUG) that involves irradiation of the pelvis. The American Academy of Pediatrics Subcommittee on UTI extensively reviewed studies published during the past 10 years on UTI in young children and developed sensible, updated evidence-based guidelines to direct practitioners in the diagnosis and management of febrile UTI in children aged 2 to 24 months. The seven key action statements are as follows:
1. If a febrile patient with no known source of fever is deemed ill enough to require immediate antibiotic therapy, obtain urine culture by either catheterization or suprapubic aspiration before initiating treatment.
2. Assess the likelihood of UTI. Risk factors for UTI are female sex, not being circumcised, no other source of fever, and fever ≥39°C. Additional risk factors in girls are white race, age <12 months, and fever for >2 days. Additional risk factors in boys are nonblack race and fever for ≥24 hours.
Low-risk patients can be followed clinically without urine evaluation.
In patients who are not low risk, obtain a urine culture by either catheterization or suprapubic aspiration for urinalysis and culture, or obtain a urine specimen for urinalysis followed by culture if positive.
3. Establish UTI diagnosis. Diagnosis requires both abnormal urinalysis (pyuria, bacteriuria, or both) and urine culture with >50,000 CFU/mL of a urinary pathogen.
4. Oral therapy and parenteral therapy are both efficacious, and decisions should be based on practical considerations (e.g., the patient's ability to take oral medication). Adjust antibiotics according to sensitivity patterns. Minimal duration of therapy is 7 days. No differences in efficacy have been documented among 7-, 10-, and 14-day regimens.
5. Evaluation after a first febrile UTI should include renal and bladder ultrasound. Increasing evidence indicates that antibiotic prophylaxis for low-grade reflux does not improve outcomes. Therefore, routine VCUG is not recommended after a first UTI.
6. VCUG should be performed in patients with a first UTI only if ultrasound suggests high-grade vesicoureteral reflux. VCUG is indicated for recurrent febrile UTI.
7. Following a confirmation of UTI, physicians should instruct parents to seek prompt care for future unexplained febrile illness.
Subcommittee on Urinary Tract Infection. Urinary tract infection: Clinical practice guideline for the diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months. Pediatrics 2011 Sep; 128:595.
Comment
In the era of conjugated vaccines for Haemophilus influenzae and Streptococcus pneumoniae, bacteria that cause UTI have become one of the most common causes of serious bacterial infection in infants aged 2 to 24 months. This extremely clear document outlines a systematic approach to diagnosis and management that minimizes harm, maximizes benefit, and optimizes the use of lab tests and procedures in patients who are most likely to receive benefit.