37 Urinary Tract Infection in Infants and Children

Abstract

The presence of fever, in the setting of an appropriately collected urine specimen and positive urine culture, reasonably distinguishes between cystitis (lower tract) and pyelonephritis (upper tract) infections (moderate evidence). Pyelonephritis, and hence renal scarring, can occur with or without the existence of vesicoureteric reflux (VUR) (strong evidence). Infants and children with their first febrile UTI should undergo imaging workup to detect congenital anomalies or high-grade VUR [with US and voiding cystourethrography (VCUG)] that increase the risk of renal scar and later dysfunction (limited evidence). Higher grades of upper urinary tract obstruction alone, without complicating factors such as stones or infection, may lead to progressive, focal renal damage, and progressive loss of renal function (moderate evidence). Unrelieved bladder outlet obstruction, caused by posterior urethral valves or neurogenic bladder, predisposes to infection and may result in progressive voiding dysfunction, VUR, renal scarring, and dysplasia (strong evidence). Low-grade VUR (grades I–III), in the absence of infection, is unlikely to result in progression of renal scarring (moderate evidence). High-grade VUR (grades IV–V) is more likely than low-grade VUR to be associated with renal cortical scarring and with recurrent UTI (moderate evidence). There is insufficient evidence that early detection of urinary tract obstruction, VUR, and/or renal scarring after UTI in infants and children, and instigation of therapy, either medical or surgical, minimizes or prevents further scarring (insufficient evidence). There is insufficient evidence that instigation of low-dose prophylactic antibiotic therapy, after identification of urinary tract obstruction, lower grades of VUR, and/or renal scarring prevents development of recurrent infection and further scars (insufficient evidence). In addition, antibiotic prophylaxis leads to higher rates of resistant infections (limited to moderate evidence). There is insufficient evidence that elimination of VUR with surgical reimplantation or endoscopic introduction of antireflux agents prevents development of recurrent infection and further scars (insufficient evidence).