Urinary Tract Infection In Febrile Infants Research Articles

Diagnostic test accuracy of dipstick urinalysis for diagnosing urinary tract infection in febrile infants attending the emergency department

ObjectiveTo report the diagnostic test accuracy of dipstick urinalysis for the detection of urinary tract infections (UTIs) in febrile infants aged 90 days or less attending the emergency department (ED).DesignRetrospective...

High incidence of abnormal imaging findings in circumcised boys diagnosed with urinary tract infections

The American Academy of Pediatrics guidelines recommend delaying voiding cystourethrogram (VCUG) until the second febrile urinary tract infection (UTI). Similarly, the NICE Guidelines do not recommend VCUG after the first febrile UTI in infants and children under three years of age. Currently, there is no good clinical indicator to determine which patients would benefit from an earlier cystogram. Here, we sought to identify clinical and bacteriologic findings that are associated with an increased risk of urinary tract anatomic anomalies in pediatric males presenting to the Emergency Department with a UTI. A retrospective review was performed of all urine cultures from the Emergency Department at our institution between 2006 and 2015. Males under 18 years of age with ≥50,000CFU/mL of Proteus, Klebsiella, Escherichia coli, Staphylococcus, Streptococcus and Enterococcus were included. Clean catch, catheterized and suprapubic aspiration specimens were included. Bagged specimens and specimens from patients on intermittent catheterization were excluded. Ultrasound and cystogram images were reviewed when available. Univariate and multivariable Poisson regression with robust variance was used to calculate and compare prevalence ratios. Statistical analysis was performed with Stata software, version 15.1MP (Stata Corporation, College Station, Texas, USA). We reviewed 1585 urine cultures, of which 812 met eligibility criteria including 619 (76.2%) E. coli, 84 (10.3%) Proteus, 55 (6.8%) Klebsiella, 29 (3.6%) Staphylococcus, 13 (1.6%) Enterococcus and 12 (1.5%) Streptococcus. Median age was six months (2.4-36 months IQR). After adjusting for age, ethnicity and bacterial species, the prevalence of dilating vesicoureteral reflux (VUR, defined as grades III-V) was 5.3 times higher in circumcised males compared to uncircumcised males (95% CI: 2.4-11.4, p=0.001). Circumcised males had a 3.1 times increased prevalence of high-grade hydronephrosis (defined as SFU grades 3 and 4) compared to uncircumcised males (prevalence ratio: 3.1, 95% CI: 1.0-10.0, p=0.05). Among bacterial pathogens, no patients with Proteus UTI had high-grade hydronephrosis or dilating VUR. In contrast, Staphylococcal infections were associated significantly with dilating VUR (prevalence ratio 10.1, 95% CI: 2.3, 44.8; p=0.002) and high-grade hydronephrosis (prevalence ratio 8.1, 95% CI: 1.7, 39.7; p=0.010). Circumcision status is an independent predictor of structural urinary anomalies of the bladder and upper tracts in pediatric males with UTI, therefore circumcised males should be considered for early imaging, including VCUG, after their first UTI. Furthermore, Staphylococcal infections were associated with an even higher prevalence of high-grade hydronephrosis and dilating VUR and therefore warrant early investigation with VCUG. In contrast, none of the Proteus infections, which were seen almost exclusively in uncircumcised males, were associated with dilating VUR or hydronephrosis, making initial observation more appropriate in these patients.

Evaluation of bladder stimulation as a non-invasive technique for urine collection to diagnose urinary tract infection in infants under 6\u2009months: a randomized multicenter study (\u201cEE-Sti.Ve.N\u201d)

BackgroundFebrile urinary tract infection (UTI) is common in infants and needs to be diagnosed quickly. However, the symptoms are non-specific, and diagnosis can only be confirmed after high quality urinalysis. The American Academy of Pediatrics recommends suprapubic aspiration (1–9% contamination) and urinary catheterization (8–14% contamination) for urine collection but both these procedures are invasive. Recent studies have shown a new non-invasive method of collecting urine, bladder stimulation, to be quick and safe. However, few data about bacterial contamination rates have been published for this technique. We hypothesize that the contamination rate of urine collection by bladder stimulation to diagnose febrile UTI in infants under 6 months is equivalent to that of urinary catheterization.Methods/designThis trial aims to assess equivalence in terms of bacterial contamination of urinary samples collected by urinary catheterization and bladder stimulation to diagnose UTI. Seven hundred seventy infants under 6 months presenting with unexplained fever in one of four Pediatric Emergency Departments in France will be enrolled. Each child will be randomized into a bladder stimulation or urinary catheterization group. The primary endpoints will be the validity of the urine sample assessed by the presence of contamination on bacterial culture.ConclusionA high recruitment rate is achievable due to the high prevalence of suspected UTIs in infants. The medical risk is the same as that for routine clinical care as we analyze patients with isolated fever.If our hypothesis holds true and the rate of urine contamination collected by bladder stimulation is acceptable, the infants included in the study will have benefited from a non-invasive and reliable means of collecting urine.Trial registrationClinicalTrials.gov, NCT03801213. Registered on 11 January 2019.

Urine dipstick low sensitivity for UTI diagnosis in febrile infants*

Background: Urine cultures are usually obtained from 0- to 2-month-old febrile infants, while in older children they are obtained more selectively. In 3- to 23-month-old children, urinary tract infection (UTI) diagnosis requires both positive culture and dipstick, but data are scarce regarding 0- to 2-month-old infants. We assessed dipstick performance for UTI diagnosis in 0–2 vs. 3- to 23-month-old children.Methods: A case–control study, conducted between 2015 and 2016, in southern Israel. Sensitivity and specificity of urine dipstick for diagnosing UTI were assessed. We compared dipstick false-negative (FN) and true-positive (TP) groups; high FN rate indicates low sensitivity.Results: Overall, 434 positive and 571 sterile urine culture episodes were included. Dipstick sensitivity was 63% in 0-2 month old children; 93% for supra-pubic aspiration (SPA), and ∼50% for non-SPA sampling method. However, sensitivity was >90% for 3–5 and 6- to 23-month-old children. In univariate analysis, younger age, hospitalization, lower temperature, short fever duration, lower leukocyte blood levels, neutrophils, stabs and C-reactive protein, and absent future UTI within <1 year were associated with FN compared with TP. In multivariate analysis, among positive culture episodes, age 0–2 months (odds ratio, OR = 6.60) and non-SPA sampling method (OR = 8.39) were associated with FN episodes.Conclusions: Dipstick lower sensitivity for diagnosing UTI in febrile infants 0–2 months old vs. their older counterparts, was associated with non-SPA sampling method, lower inflammatory markers, lower temperature and low risk for future UTI. This suggests that positive culture in negative dipstick episodes may not reflect a true UTI.

Assessing the Utility of Urine Testing in Febrile Infants 2 to 12 Months of Age With Bronchiolitis.

The utility of testing for urinary tract infection (UTI) in febrile infants with bronchiolitis is indeterminate. The objective of this study was to investigate if the incidence of UTIs in febrile infants 2 to 12 months of age with bronchiolitis is higher than the presumed incidence of asymptomatic bacteriuria and determine risk factors associated with UTIs in this population. This prospective multicenter cross-sectional study was conducted in the emergency departments of 6 children's hospitals between November 2011 and June 2015. We obtained a convenience sample of febrile infants with bronchiolitis 2 to 12 months of age who were tested for UTI. Patient characteristics analyzed included age, maximum temperature, duration of fever, ethnicity, sex, and circumcision status. A total of 442 patients (including 86 from a previously published pilot study) were enrolled. Mean age was 5.5 months, 65.2% were Latino, 50.9% were male, and 27.6% of male infants were circumcised. Urinary tract infections were found in 33 patients (7.69%, binomial; 95% confidence interval [CI], 5.19%-10.33%). Urinary tract infections were not related to age, height of temperature, duration of fever, or ethnicity. Uncircumcised males were significantly more likely to have UTIs than circumcised males (7.64% vs 0%, P = 0.03). Odds ratios (ORs) were lower for circumcised males but not uncircumcised males when compared with females (OR, 0.12; CI, 0.0-0.71; P = 0.01 vs OR, 0.77; CI, 0.33-1.74; P = 0.64). Febrile infants 2 to 12 months of age with bronchiolitis have a clinically significant incidence of UTI, suggesting that UTI evaluation should be considered in these patients.

The Diagnosis of UTI: Colony Count Criteria Revisited.

* Abbreviations: AAP — : American Academy of Pediatrics CFU — : colony-forming unit SPA — : suprapubic aspiration UA — : urinalysis UTI — : urinary tract infection Urinalysis (UA) is valuable in allowing clinicians to make a presumptive diagnosis of urinary tract infection (UTI) and initiate appropriate empirical antimicrobial treatment.1 The American Academy of Pediatrics (AAP) UTI Clinical Practice Guideline for infants and children 2 months to 2 years of age advocates a definition of significant bacteriuria as ≥50 000 colony-forming units (CFU) per milliliter and endorses the finding of inflammation on UA as a necessary component of the diagnosis of UTI.2,3 However, reports of the accuracy and application of UA in the diagnosis of UTI in infants <2 months of age have been somewhat variable. In this issue of Pediatrics , Tzimenatos et al4 (for the Pediatric Emergency Care Applied Research Network) substantiate the excellent sensitivity and high specificity of the aggregate UA for diagnosing UTIs in febrile infants 60 days and younger with and without concurrent bacteremia, extending the use of this laboratory test to those younger than the age addressed in the AAP guideline. Along with UA, the authors applied the criterion of ≥50 000 CFU/mL for the diagnosis of UTI but also evaluated ≥10 000 CFU/mL, raising the important issue of what threshold should be used to define significant bacteriuria. Before the 1950s, the number of bacteria associated with UTIs was described in vague terms, such as “numerous.”5 In his 1956 landmark study of adult women, Kass6 proposed that 100 000 CFU/mL be considered the diagnostic threshold, a criterion that was accepted quickly and widely. Fifteen years later, Pryles and Lustik,7 while acknowledging that data … Address correspondence to Kenneth B. Roberts, MD, Department of Pediatrics, University of North Carolina School of Medicine, 3005 Bramblewood Dr, Mebane, NC 27302. E-mail: kenrobertsmd{at}gmail.com

The Role of Quantitative C-Reactive Protein, White Blood Cell Count and Pyuria in Predicting Urinary Tract Infection among Febrile Infants and Children

Introduction: Urinary tract infection (UTI) is among the commonest bacterial infections in infants and children that warrants early detection and management to prevent long term consequences in kidney causing significant morbidity. The prevalence of UTI varies according to age, gender, race, circumcision status of children but it occurs in 1% of boys and 1 to 3% of girls. There have been studies that have highlighted the importance of C-reactive as an inflammatory marker involved during urinary tract infection in children.Objectives: To find out how Quantitative C-reactive protein level, white blood cell count and pus cells in urine are associated in febrile infants and children with UTI. To find out the antibiotic sensitivity pattern of UTI.Methodology: A prospective cross sectional study was conducted to evaluate febrile infants and children of 2 months to 13 years of age with suspected UTI for a period of six months. Venous blood samples were sent for Quantitative estimation of CRP, White blood cell count and urine samples were sent for urine microscopy and culture sensitivity. Statistical analysis of data was done using SPSS software version 16.Results: Among 210 infants and children enrolled in the study, 62 (29.55%) had positive urine culture, representing 31.2% and 28.6% of female and male populations respectively. The sensitivity, specificity, positive predictive value(PPV) and negative predictive(NPV) value of CRP (with cut off of 1mg/dl) was 77%,81%, 63% &amp; 90% respectively and that of WBC Count (with cut off of &gt; 12000/ml ) were 56%, 88%, 66% &amp; 83% respectively. Similarly for pyuria (with cut off of &gt;10/HPF) using urine culture as gold standard were 63%, 91%,74% and 85% respectively. The most common organism found in urine culture was E. coli 49(79%). Highest number of isolates were sensitive to Nitrofurantoin(96%) and Amikacin(94%) whereas Amoxycillin was resistant to all the organism tested that was the resistance of 100%.The next common antibiotics found to be resistant was cotrimoxazole (70%).Conclusion: Quantitative C- reactive protein and White blood cell count in blood are very useful markers to predict UTI in febrile infants and children. E coli is the commonest pathogen to cause UTI and Pyuria(pus cells &gt; 10/HPF) has high predictive value for UTI. Birat Journal of Health SciencesVol.2/No.3/Issue 4/Sep- Dec 2017, Page: 296 - 299

Management of UTI in Children: Murky Waters.

* Abbreviations: AAP — : American Academy of Pediatrics UTI — : urinary tract infection Over the course of the last 2 decades, the approach to the management of urinary tract infections (UTIs) in children has undergone considerable reconsideration. Areas such as screening urinalysis, method of urine collection, definition of a positive culture, imaging assessment after the diagnosis of UTI in children, medications for treatment, and mode of administration are examples of such reassessment. In 2011, American Academy of Pediatrics (AAP) guidelines for the diagnosis and management of UTI in febrile infants and young children were published.1 The guidelines were for children 2 to 24 months. However, the guidelines also provide a framework for … Address correspondence to Aaron Friedman, MD, 125 North Hamilton St, #905, Madison, WI 53703. E-mail: alfried{at}umn.edu

Renal ultrasound and DMSA screening for high-grade vesicoureteral reflux.

Selection of the appropriate radiologic investigation in a child after first febrile urinary tract infection (UTI) remains a contentious issue. This report investigated the effectiveness of renal bladder ultrasound (RBUS) and late 6 month dimercaptosuccinic acid (DMSA) renal scan in the detection of high-grade vesicoureteral reflux (VUR) after first febrile UTI in infants aged <1 year. A total of 387 infants aged <1 year with first febrile UTI who completed diagnostic follow up consisting of RBUS, voiding cystourethrogram (VCUG) and late 6 month DMSA scan were enrolled in the study. The effectiveness of RBUS and DMSA scan in the detection of high-grade VUR, including cost and benefit were assessed. Abnormal RBUS was identified in 95 infants (24.5%). VUR was identified on VCUG in 79 (20.4%), of whom eight (2.1%) had high-grade VUR (grade IV-V). Abnormal renal parenchyma was identified on late 6 month DMSA scan in 22 infants (5.7%). The sensitivity of abnormal RBUS and of late 6 month DMSA scan in the prediction of high-grade VUR was 50% and 87.5%, and the proportion of infants who avoided unnecessary VCUG was 75.5% and 94.3%, respectively. Fifty percent of high-grade VUR was not identified on RBUS screening after first febrile UTI. Although late 6 month DMSA scan had higher sensitivity in the detection of high-grade VUR, with the added benefit of detection of renal scars, the practical application of this method was limited due to its high cost, radiation exposure and the associated delay in decision making.

Urinary Tract Infection in Children: An Update

The 2011 American Academy of Pediatrics (AAP) Urinary Tract Infection (UTI):Clinical Practice Guideline for the Diagnosis and Management of the Initial UTI in Febrile Infants and Children 2-24 Months guideline addressed “areas for research” identifying multiple areas where evidence at the time of the publication was lacking. This review discussed the evidence development in those identified areas. In this paper, I will review the latest literature on UTI in children and focus on those areas of research suggested in these guidelines. I will also summarize the related literature since September 2011. Literature related to first UTI in children have contributed important new knowledge since the publication of the 2011 AAP guideline; 1) additional research has failed to clarify the relationship between childhood UTI and adult renal function. 2) High grade vesicoureteral reflux (VUR) has been established as a clear risk factor for scarring, but the condition is rare. Abnormal ultrasound, and fever in combination with non-E coli infection are other important predictors of scarring. 3) Antimicrobial prophylaxis appear to decrease UTI recurrences, but a large amount of antibiotics has to be administrated to prevent one UTI and the prevention works best in children with low grade, not high grade, VUR, 4) cranberry juice may prevent UTI, and 5) new, less aggressive guidelines, seem not to have negative consequences for pediatric patients measured as missed true pathology. Future guidelines would benefit from incorporating this new information.

Urinary tract infections in newborns

The incidence of neonatal urinary tract infection (UTI) varies from 0.1 to 1% of all infants, and its frequency is inversely proportional to birth weight [1]. Neonatal UTI presents different features than those observed in other age groups for several reasons, including higher prevalence, male sex predominance, and most importantly higher risk of urosepsis [2]. As the symptoms of a UTI in a neonate, such as irritability, poor feeding and vomiting are generalized, the clinician should have a high index of suspicion. The best correlates of infection in infants with UTI were found to be a body temperature greater than 38 o C and uncircumcised males [3]. Escherichia coli is the most likely pathogen, but Klebsiella pneumoniae, Enterobacter spp., Enterococcus spp., Pseudomonas spp., Candida spp. and coagulase-negative staphylococci have to be considered in nosocomial UTI as well [1-3]. A positive blood culture is reported in 12.4% of cases, and nosocomial UTI is nearly twice likely to result in urosepsis compared with community-acquired UTI [2]. Bladder puncture or transurethral catheter is recommended for urine sampling in neonates to avoid urinary contamination. Parenteral antibiotic regimen, including a combination of a third-generation cephalosporin or aminoglycoside with ampicillin for a total of 7-14 days should be commenced urgently in the suspicion of pyelonephritis following urine sampling for culture. Vancomycin and an aminoglycoside should be considered for nosocomial UTI. In the light of the results of sensitivity testing, a single-antibiotic coverage, if possible, should be considered [1-3]. The presence of high-grade reflux, severe urinary obstruction, and recurrent pyelonephritis mandates antibacterial prophylaxis, however its efficiency has not yet been proven [2]. Radiological studies have to be undertaken once a diagnosis of UTI has been made. An abnormal renal ultrasound is reported in around one third of cases, and vesicoureteral reflux is observed in nearly one fourth during voiding cystourethrogram (VCUG). The urine should be sterile while performing a VCUG [2, 3]. Gram-negative antibiotic resistance is emerging worldwide and outbreaks have occurred in neonatal units due to multi-resistant gram-negative bacteria [4]. To overcome this problem in the case of a UTI, urine cultures should be appropriately obtained, and the treatment should be tailored based on sensitivity results; antibiotic prophylaxis should be spared to aforementioned high-risk groups, while emphasizing the importance of compliance; and pediatric-specific antibiograms should be used [5]. Finally, evidence-based guidelines for the diagnosis and management of UTI in febrile infants aged less than 2 months are lacking, and urgently required [2].

Comparison of Urinary Tract Infection Rates Among 2- to 12-Month-Old Febrile Infants With RSV Infections Using 1999 and 2011 AAP Diagnostic Criteria

Infants with RSV infections have been found to have a clinically significant rate of urinary tract infections (UTIs). The American Academy of Pediatrics (AAP) published a revised Clinical Practice Guideline on UTIs in 2011, which includes major changes in diagnostic criteria for UTIs. Past research has been done using previous diagnostic criteria. The objective of the study is to assess the rate of UTIs in febrile infants with respiratory syncytial virus (RSV) infections according to the 2011 revised AAP Diagnostic Criteria and compare the rate of UTIs against the 1999 AAP Diagnostic Criteria. A retrospective comparative study of febrile infants (2-12 months) with RSV infections admitted to the Inpatient Pediatric unit of Lincoln Medical and Mental Center, Bronx, NY, from September through April 2006 to 2012. We applied the AAP's 1999 and 2011 diagnostic criteria for UTIs separately to assess the rates of UTIs. A total of 359 RSV-positive febrile patients who were investigated for UTIs were enrolled. Pyuria was found in 11.1% (40/359), positive urine culture 10 000 to 50 000 was found in 1.4% (5/359) and ≥50 000 in 4.7% (17/359). The rate of UTIs using AAP's 1999 criteria was 6.1% (22/359), and using the 2011 criteria the rate was 1.1% (4/359). The rate of UTIs was significantly different between the 2 groups (odds ratio [confidence interval] = 0.17 [0.05, 0.5], P = .001). The rate of UTIs in RSV-positive febrile infants is very low (1.1%) with the 2011 AAP diagnostic criteria. Previously described increased risk of UTIs may represent asymptomatic bacteriuria or contaminated specimens.

A diagnostic predictive scale for urinary tract infection in febrile infants without an apparent focus

Urinary tract infection (UTI) is the most frequent bacterial infection in infants with nonspecific clinical manifestations. To validate a predictive scale for UTI in febrile infants without apparent source and hospitalized in a neonatal unit. A nested case-control study was conducted on 158 infants with febrile UTI, culture-confirmed, and on 346 febrile infants without apparent focus in whom UTI was ruled out, and also, hospitalized in a neonatal unit. The analysis was performed using Stata® 11. Associations were determined using odds ratio (OR) with 95% confidence interval. To find the predictive scale, multivariate analysis was performed using logistic regression and establishing major and minor criteria according to regression coefficient. Yield was calculated by sensitivity, specificity and area under ROC curve. The new predictive scale was validated by 108 new febrile neonates. The major criteria to predict UTI were abnormal urinalysis and Gram positive cells without centrifugation, and among the minor criteria, male, age at time of fever, previous neonatal hospitalization, abnormal temperature (38.5°C or more, persistent fever, hypothermia) and 1.7 mg/dL C reactive protein or higher, resulting positive with the presence of one mayor or three minor criteria. It showed good performance with 100% sensitivity (CI 95%:98.3-100%), 92.3% specificity (CI 95%: 85.8-98.9%) and 0.962 area under ROC (95% CI: 0.932-0.991) when validated on 108 new febrile neonates without focus. The new predictive scale allows predicting UTI with good yield in infants with fever without an identified source.

New AAP Guidelines for Diagnosis and Management of Febrile UTI in Infants and Young Children

Diagnosis and management of urinary tract infection (UTI) in febrile infants are challenging for several reasons: Obtaining a sterile urine sample

Diagnosis and Management of an Initial UTI in Febrile Infants and Young Children

The diagnosis and management of urinary tract infections (UTIs) in young children are clinically challenging. This report was developed to inform the revised, evidence-based, clinical guideline regarding the diagnosis and management of initial UTIs in febrile infants and young children, 2 to 24 months of age, from the American Academy of Pediatrics Subcommittee on Urinary Tract Infection. The conceptual model presented in the 1999 technical report was updated after a comprehensive review of published literature. Studies with potentially new information or with evidence that reinforced the 1999 technical report were retained. Meta-analyses on the effectiveness of antimicrobial prophylaxis to prevent recurrent UTI were performed. Review of recent literature revealed new evidence in the following areas. Certain clinical findings and new urinalysis methods can help clinicians identify febrile children at very low risk of UTI. Oral antimicrobial therapy is as effective as parenteral therapy in treating UTI. Data from published, randomized controlled trials do not support antimicrobial prophylaxis to prevent febrile UTI when vesicoureteral reflux is found through voiding cystourethrography. Ultrasonography of the urinary tract after the first UTI has poor sensitivity. Early antimicrobial treatment may decrease the risk of renal damage from UTI. Recent literature agrees with most of the evidence presented in the 1999 technical report, but meta-analyses of data from recent, randomized controlled trials do not support antimicrobial prophylaxis to prevent febrile UTI. This finding argues against voiding cystourethrography after the first UTI.

Urinary Tract Infection: Clinical Practice Guideline for the Diagnosis and Management of the Initial UTI in Febrile Infants and Children 2 to 24 Months

To revise the American Academy of Pediatrics practice parameter regarding the diagnosis and management of initial urinary tract infections (UTIs) in febrile infants and young children. Analysis of the medical literature published since the last version of the guideline was supplemented by analysis of data provided by authors of recent publications. The strength of evidence supporting each recommendation and the strength of the recommendation were assessed and graded. Diagnosis is made on the basis of the presence of both pyuria and at least 50,000 colonies per mL of a single uropathogenic organism in an appropriately collected specimen of urine. After 7 to 14 days of antimicrobial treatment, close clinical follow-up monitoring should be maintained to permit prompt diagnosis and treatment of recurrent infections. Ultrasonography of the kidneys and bladder should be performed to detect anatomic abnormalities. Data from the most recent 6 studies do not support the use of antimicrobial prophylaxis to prevent febrile recurrent UTI in infants without vesicoureteral reflux (VUR) or with grade I to IV VUR. Therefore, a voiding cystourethrography (VCUG) is not recommended routinely after the first UTI; VCUG is indicated if renal and bladder ultrasonography reveals hydronephrosis, scarring, or other findings that would suggest either high-grade VUR or obstructive uropathy and in other atypical or complex clinical circumstances. VCUG should also be performed if there is a recurrence of a febrile UTI. The recommendations in this guideline do not indicate an exclusive course of treatment or serve as a standard of care; variations may be appropriate. Recommendations about antimicrobial prophylaxis and implications for performance of VCUG are based on currently available evidence. As with all American Academy of Pediatrics clinical guidelines, the recommendations will be reviewed routinely and incorporate new evidence, such as data from the Randomized Intervention for Children With Vesicoureteral Reflux (RIVUR) study. Changes in this revision include criteria for the diagnosis of UTI and recommendations for imaging.

Febrile UTI in Infants 0–3 Months: Importance of Normal Renal US

Research Article| April 01 2011 Febrile UTI in Infants 0–3 Months: Importance of Normal Renal US AAP Grand Rounds (2011) 25 (4): 39. https://doi.org/10.1542/gr.25-4-39 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Facebook Twitter LinkedIn MailTo Tools Icon Tools Get Permissions Cite Icon Cite Search Site Citation Febrile UTI in Infants 0–3 Months: Importance of Normal Renal US. AAP Grand Rounds April 2011; 25 (4): 39. https://doi.org/10.1542/gr.25-4-39 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search toolbar search search input Search input auto suggest filter your search All PublicationsAll JournalsAAP Grand RoundsPediatricsHospital PediatricsPediatrics In ReviewNeoReviewsAAP NewsAll AAP Sites Search Advanced Search Topics: fever, kidney, urinary tract infections Source: Ismaili K, Lolin K, Damry N, et al. Febrile urinary tract infections in 0- to 3-month-old infants: a prospective follow-up study. J Pediatr. 2011; 158(1): 91-94; doi: https://doi.org/10.1016/j.jpeds.2010.06.053Google Scholar Belgian investigators reviewed data collected prospectively on infants 0 to 3 months of age with a first febrile urinary tract infection (UTI) in order to characterize pathogens, antimicrobial resistance, renal abnormalities, gender predilection, and recurrences. Urine was collected using suprapubic aspiration or bladder catheterization. UTI was defined as growth of at least 100,000 colony-forming units/ml or any growth from urine collected by aspiration. Patients with multiple pathogens or nosocomial UTI were excluded. All infants were treated according to a protocol that included initial parenteral antibiotics and hospitalization. All infants underwent renal ultrasound (US) during hospitalization and a voiding cystourethrogram (VCUG) at least one month after the UTI. All patients were followed for at least one year. Of 209 children treated for a first episode of proved febrile UTI, 43 (21%) were infants 0 to 3 months of age. All infants had antenatal US of which 6 (14%) were known to be abnormal. Of the 43 infants, 32 (74%) were male. All boys were uncircumcised. Escherichia coli comprised 88% of the pathogens, Klebsiella pneumoniae 7%, and Enterobacter species and Staphylococcus aureus occurred once each. E coli resistance to ampicillin and trimethoprim-sulfamethoxazole was 71% and 47% respectively. Bacteremia accompanied the UTI in three infants (7%). Sixty-seven percent of the US results were normal. Nine infants (21%; 6 boys) had vesicoureteral reflux (VUR); six infants had low grade VUR (I-III) and all of these resolved spontaneously within two years. US was abnormal in three of the six infants with low grade VUR. All three infants with high grade VUR (IV, V) had US demonstrating hydronephrosis, signs of dysplasia, or both. Six infants (four girls) had recurrent UTI during follow-up. Three of those patients had urinary tract abnormalities. The authors conclude that 21% of children with a first febrile UTI are 0 to 3 months of age; there is a male preponderance in this age group; E coli is the most common pathogen and shows high rates of resistance to ampicillin and trimethoprim-sulfamethoxazole; and when US is normal in this population the incidence of high grade VUR is extremely low. Dr Garber has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device. Controversy exists over the current management of UTI in infants and children. AAP Grand Rounds has addressed the issues of imaging and antibiotic prophylaxis at least 13 times in the past decade. Guidelines vary from country to country, and there is considerable practice variation within the United States.1 The 1999 AAP practice parameter2 recommends renal US and VCUG on every patient 2 months to 2 years of age with a first febrile UTI, and antibiotic prophylaxis for those with an abnormal urinary tract.... You do not currently have access to this content.

Evaluation of Uricult Trio Test as a Rapid Screening of UTI in Children with Fever

Purpose : The Dipslide culture test is a rapid method for diagnosis of urinary tract infection (UTI). The aim of this study is to determine the diagnostic availability of a urine Dipslide test for evaluation of UTI in febrile children. Methods : Urine specimens from 151 febrile infants were inoculated by a routine blood agar urine culture method and the Dipslide test at the same time. Following incubation for 16-24 hours, the results of the Dipslide test were read at the next visit. Both results of Dipslide and those of routine culture were compared. Results : The mean age of subjects was 1510.6 months. There were 150 infants (99.3%) who had fever with a mean duration of 2.62.6 days. Thirty two infants (21.2%) were diagnosed as having UTI. Sensitivity and specificity of Uricult Trio CLED medium were 59.4% and 84.8%, respectively. Sensitivity and specificity of Uricult Trio E. coli medium were 60.0% and 96.2%, respectively. The Pearson correlation coefficient between results of Uricult Trio CLED medium and urine culture was 0.438 (P=0.01). Correlation between results of Uricult Trio E. coli medium and urine culture was 0.617 (P=0.01). Conclusion : The Dipslide test requires only 16-24 hours with high specificity in terms of UTI caused by E. coli without the problems associated with specimen delay. This test seems to be helpful for exclusion of UTI in febrile infants and it may reduce unnecessary hospitalization and antibiotic use. However, further studies are required before the product can be recommended as a routine diagnostic tool.

Clinical and Demographic Factors Associated With Urinary Tract Infection in Young Febrile Infants

Previous research has identified clinical predictors for urinary tract infection (UTI) to guide urine screening in febrile children <24 months of age. These studies have been limited to single centers, and few have focused on young infants who may be most at risk for complications if a UTI is missed. The objective of this study was to identify clinical and demographic factors associated with UTI in febrile infants who are < or =60 days of age using a prospective multicenter cohort. We conducted a multicenter, prospective, cross-sectional study during consecutive bronchiolitis seasons. All febrile (> or =38 degrees C) infants who were < or =60 days of age and seen at any of 8 pediatric emergency departments from October through March 1999-2001 were eligible. Clinical appearance was evaluated using the Yale Observation Scale. UTI was defined as growth of a known bacterial pathogen from a catheterized specimen at a level of (1) > or =50000 cfu/mL or (2) > or =10000 cfu/mL in association with a positive dipstick test or urinalysis. We used bivariate tests and multiple logistic regression to identify demographic and clinical factors that were associated with the likelihood of UTI. A total of 1025 (67%) of 1513 eligible patients were enrolled; 9.0% of enrolled infants received a diagnosis of UTI. Uncircumcised male infants had a higher rate of UTI (21.3%) compared with female (5.0%) and circumcised male (2.3%) infants. Infants with maximum recorded temperature of > or =39 degrees C had a higher rate of UTI (16.3%) than other infants (7.2%). After multivariable adjustment, UTI was associated with being uncircumcised (odds ratio: 10.4; bias-corrected 95% confidence interval: 4.7-31.4) and maximum temperature (odds ratio: 2.4 per degrees C; 95% confidence interval: 1.5-3.6). Factors that were reported previously to be associated with risk for UTI in infants and toddlers, such as white race and ill appearance, were not significantly associated with risk for UTI in this cohort of young infants. Being uncircumcised and height of fever were associated with UTI in febrile infants who were < or =60 days of age. Uncircumcised male infants were at particularly high risk and may warrant a different approach to screening and management.

Urinary tract infection must be excluded in febrile infants less than 3 months of age with positive respiratory syncytial virus antigen test

Study objectives: The prevalence of significant bacterial infections in young infants who have respiratory syncytial virus (RSV) is unknown in the era after the introduction of <i>Haemophilus influenzae</i> and <i>Streptococcus pneumoniae</i> vaccinations. The evaluation of these infants remains controversial. We hypothesize that infants with fever and RSV are at low risk for secondary bacterial infection and may not require extensive and invasive laboratory evaluations. Methods: This was a prospective evaluation; all infants younger than 3 months from October 1998 to December 2003 who had a sepsis evaluation for fever and an RSV antigen test performed were eligible. Infants excluded were those with previous antibiotic use and immunosuppression. Results: There were 128 infants in the study; 50 (39%) were RSV positive, and 78 (61%) infants were RSV negative. Median age in the RSV-positive group was 44.3±19.4 days and in the RSV-negative group, 43.6±19.2 days. In the RSV-positive group, there were 30 (60%) boys, 11 (22%) whites, 29 (58%) blacks, and 10 (20%) Hispanics. In the RSV-negative group, there were 42 (53.8%) boys, 12 (15.3%) whites, 54 (69.2%) blacks, and 10 (12.8%) Hispanics. In the RSV-positive group, median temperature was 38.6±0.6°C, whereas in the RSV-negative group it was 38.5±0.5°C. In the RSV-positive group, mean pulse rate was 170.7±18.5 beats/min, with a pulse rate greater than 160 beats/min in 27 (54%) patients. In the RSV-negative group, mean pulse rate was 165.9±21.1 beats/min, with a pulse rate greater than 160 beats/min in 37 (47.4%) patients. In the RSV-positive group, mean respiratory rate was 48.2±18 breaths/min, with a respiratory rate greater than 60 breaths/min in 10 (20%) patients. In the RSV-negative group, mean respiratory rate was 44.2±15.9 breaths/min, with a respiratory rate greater than 60 breaths/min in 8 (10.2%) infants. There was no significant difference in vital signs between groups. There were more upper respiratory infection symptoms and coughing in the RSV-positive group (<i>P</i><.05). The number of patients admitted in the RSV-positive group was 38 (76%) versus 62 (79.4%) in the RSV-negative group. There were 6 (12%) infants admitted to the pediatric ICU in the RSV-positive group versus 1 (1.2%) in the RSV-negative group. The laboratory evaluation in the RSV-positive group included a CBC count of 46 (92%), urinalysis and culture 44 (88%), blood culture 45 (90%), chest radiograph 21 (62%), and CSF fluid analysis 22 (44%). In the RSV-negative group, the laboratory evaluation included a CBC count of 71 (91%), urinalysis and urine culture 71 (91%), blood culture 73 (93.5%), chest radiograph 36 (46.1%), and CSF fluid analysis 53 (67.9%). There were more chest radiographs performed in the RSV-positive group (<i>P</i><.05). There were 7 (14%) significant infections in the RSV-positive group versus 8 (10.2%) in the RSV-negative group. In the RSV-positive group, there were 5 (10%) instances of pneumonia and 1 (2%) instance of urinary tract infection (UTI). There were no significant positive blood culture results in the RSV-positive group, but there were 4 (8%) contaminant results. In the RSV-negative group, there were 4 (5.1%) instances of pneumonia, 3 (2.5%) of UTI, 1 (1.2%) of bacteremia with group B streptococcus, and 1 (1.2%) of meningitis with enterococcus. Conclusion: The risk of serious bacterial infection is low in the RSV-positive group, especially if one excludes pneumonias. There were no cases of bacteremia or meningitis; however, UTIs still are significant. Therefore, it may be prudent to exclude a UTI in febrile infants with a positive RSV antigen test. Further studies with greater numbers are needed to validate these results.