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Pneumonia in children: Inpatient treatment

Author
William J Barson, MD
Section Editors
Morven S Edwards, MD
George B Mallory, MD
Deputy Editor
Mary M Torchia, MD
Disclosures: William J Barson, MD Grant/Research/Clinical Trial Support: Pfizer [S. pneumoniae (Pneumococcal
conjugate vaccine (13-valent))]. Morven S Edwards, MD Grant/Research/Clinical Trial Support: Novartis Vaccines
[Group B Streptococcus]. Consultant/Advisory Boards: Novartis Vaccines [Group B streptococcal vaccine
development]. George B Mallory, MD Nothing to disclose. Mary M Torchia, MDEmployee of UpToDate, Inc.
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed
by vetting through a multi-level review process, and through requirements for references to be provided to support the
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evidence.
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All topics are updated as new evidence becomes available and our peer review process is
complete.
Literature review current through: Sep 2014. | This topic last updated: Jun 30, 2014.
INTRODUCTION Community-acquired pneumonia (CAP) is defined as an acute infection of the
pulmonary parenchyma in a patient who has acquired the infection in the community, as
distinguished from hospital-acquired (nosocomial) pneumonia. CAP is a common and potentially
serious illness with considerable morbidity.
The Pediatric Infectious Diseases Society/Infectious Diseases Society of America and the British
Thoracic Society have developed clinical practice guidelines for the treatment of CAP in children
[1,2].
The inpatient treatment of pneumonia in children will be reviewed here. The outpatient treatment of
CAP is discussed separately, as are the epidemiology, etiology, clinical features, and diagnosis.
(See "Community-acquired pneumonia in children: Outpatient treatment" and "Pneumonia in
children: Epidemiology, pathogenesis, and etiology" and "Community-acquired pneumonia in
children: Clinical features and diagnosis".)
HOSPITALIZATION
Indications The decision to hospitalize a child with community-acquired pneumonia (CAP) is
individualized based upon age, underlying medical problems, and clinical factors including severity
of illness (table 1) [1-3]. Hospitalization generally is warranted for infants younger than three to six
months of age, unless a viral etiology or Chlamydia trachomatis is suspected and they are
normoxemic and relatively asymptomatic. Hospitalization is also warranted for a child of any age
whose family cannot provide appropriate care and assure compliance with the management plan.
Additional indications for hospitalization include [1,2]:
Hypoxemia (oxygen saturation [SpO
2
] <90 percent in room air at sea level)
Dehydration, or inability to maintain hydration orally; inability to feed in an infant
Moderate to severe respiratory distress: Respiratory rate >70 breaths/minute for infants <12
months of age and >50 breaths per minute for older children; retractions; nasal flaring;
difficulty breathing; apnea; grunting
Toxic appearance (more common in bacterial pneumonia and may suggest a more severe
course) [4]
Underlying conditions that may predispose to a more serious course of pneumonia (eg,
cardiopulmonary disease, genetic syndromes, neurocognitive disorders), may be worsened by
pneumonia (eg, metabolic disorder) or may adversely affect response to treatment (eg,
immunocompromised host)
Complications (eg, effusion/empyema)
Suspicion or confirmation that CAP is due to a pathogen with increased virulence, such as
Staphylococcus aureus or group A streptococcus
Failure of outpatient therapy (worsening or no response in 48 to 72 hours)
Indications for intensive care The decision to treat a child with pneumonia in an intensive care
setting is individualized, based upon clinical, laboratory, and radiologic findings. Treatment in an
intensive care setting generally is warranted for children who manifest [1,2]:
The need for ventilatory support beyond that which can be provided outside the intensive
care unit (eg, mechanical ventilation, noninvasive positive pressure ventilation, failure to
maintain oxygen saturation [SpO
2
] >92 percent in FiO
2
>0.5)
Signs of impending respiratory failure (lethargy, increasing work of
breathing, and/or exhaustion with or without hypercarbia)
Recurrent apnea or slow irregular respirations
Cardiovascular compromise with progressive tachycardia and/or hypotension that requires or
is refractory to fluid management
Care in the intensive care unit also may be warranted for children with two or more of the following
[1]:
Respiratory rate >70 breaths/minute for infants <12 months of age and >50 breaths per
minute for older children
Apnea
Increased work of breathing (retractions, dyspnea, nasal flaring, grunting)
PaO
2
/FiO
2
ratio <250
Multilobar infiltrates
Altered mental status
Hypotension
Pleural effusion
Comorbid condition (eg, sickle cell disease, immune deficiency, immunosuppression)
Unexplained metabolic acidosis
Pediatric Early Warning Score >6 [5]
Infection control CAP can be caused by a variety of microbial agents requiring a variety of
infection-control measures [6]. If possible, rapid diagnostic tests should be performed at the time of
admission, to facilitate decisions regarding appropriate precautions. (See "Community-acquired
pneumonia in children: Clinical features and diagnosis", section on 'Rapid diagnostic tests'.)
Hand washing is the single most important procedure to prevent the spread of infection. Additional
infection control measures depend upon the likely pathogen(s), as follows [6,7]:
Respiratory syncytial and parainfluenza viruses gown and gloves (ie, contact precautions)
Influenza virus, group A streptococcus (for the first 24 hours of treatment), methicillin-
susceptible S. aureus, Bordetella pertussis (until patient has received five days of effective
therapy), and Mycoplasma pneumoniae mask within 3 feet (ie, droplet precautions)
Adenovirus contact and droplet precautions
Methicillin-resistant S. aureus and other multidrug resistant organisms special organism
precautions; contact and droplet precautions and dedicated patient equipment
These precautions are discussed separately. (See "General principles of infection control".)
Guidelines for hand hygiene in healthcare settings can be accessed through the Centers for
Disease Control and Prevention.
SUPPORTIVE CARE Supportive care includes ensuring adequate antipyresis, analgesia,
respiratory support, and hydration.
Antipyresis and analgesia Children hospitalized with pneumonia usually have fever and may
have pleuritic chest pain, which can lead to shallow breathing and impaired ability to cough.
Administration of antipyretics and/or analgesics can be used to keep the child comfortable.
Adequate pain control may promote coughing, which facilitates airway clearance. Antitussives
should be avoided as none have been found to be effective in pneumonia [8]. Symptomatic
treatment of cough is discussed separately. (See "The common cold in children: Treatment and
prevention", section on 'Cough'.)
Respiratory support Children hospitalized with pneumonia should receive ventilatory support as
indicated by their clinical condition [1,2]. A supported sitting position may help to expand the lungs
and improve respiratory symptoms [2].
We suggest that children with oxygen saturation [SpO
2
] <95 percent in room air be treated with
supplemental oxygen to maintain oxygen saturation 95 percent while they are in respiratory
distress. Different thresholds for supplemental oxygen are suggested by other experts (eg, the
British Thoracic Society guidelines suggest supplemental oxygenation to maintain oxygenation
saturation >92 percent) [2]. Gentle bulb suction of the nares may be helpful in infants and children
whose nares are blocked with secretions. Minimal handling seems to reduce oxygen requirements.
(See "Continuous oxygen delivery systems for infants, children, and adults".)
In children who are severely ill, it may be necessary to monitor carbon dioxide tension via blood gas
analysis in addition to oxygen saturation (SpO
2
) by oximetry. Hypercarbia is an important sign of
impending respiratory failure, particularly in the young infant who is tiring but may have preserved
oxygenation.
Fluid management Children who cannot maintain adequate fluid intake because of
breathlessness, fatigue, or risk of aspiration [9] may require intravenous fluid therapy. Nasogastric
(NG) tubes should be avoided if possible because they may compromise breathing; if necessary,
the smallest NG tube possible should be used [2]. (See "Maintenance fluid therapy in children".)
Children with pneumonia are at risk for inappropriate secretion of antidiuretic hormone (SIADH)
[10,11]. Serum electrolytes should be monitored if there is clinical suspicion of SIADH [11].
(See "Pathophysiology and etiology of the syndrome of inappropriate antidiuretic hormone secretion
(SIADH)", section on 'Pulmonary disease'.)
Chest physiotherapy Chest physiotherapy is not beneficial for children with uncomplicated
community-acquired pneumonia (CAP) [2]. In randomized and observational studies in children and
adults, chest physiotherapy had no conclusive effect on length of hospital stay, duration of fever, or
radiographic resolution [12-17].
EMPIRIC THERAPY
Overview The initial treatment of children who are hospitalized with pneumonia is empiric (table
2). Factors that must be considered include the spectrum of likely pathogens, antimicrobial
susceptibility, simplicity, tolerability, palatability, safety, and cost [18].
The recommendations of most guidelines are based on in vitro susceptibilities of the most likely
pathogen or pathogens, rather than evidence of the superiority of one antibiotic over another.
Clinical response to empiric therapy and results of microbiologic studies, when available, help to
determine whether additional evaluation or changes in therapy are necessary [1,2].
(See "Community-acquired pneumonia in children: Clinical features and diagnosis", section on
'Microbiology' and 'Specific therapy' below and 'Response to therapy' below.)
There are few randomized controlled trials to guide the choice of empiric antibiotics in children with
community-acquired pneumonia (CAP). Decisions regarding empiric therapy are complicated by the
substantial overlap in the clinical presentation of bacterial and nonbacterial pneumonias [19-21].
Treatment decisions usually are based upon algorithms that include patient age, epidemiologic and
clinical information, and diagnostic laboratory and imaging studies (table 2) [4]. The scope of
empiric therapy (ie, narrow or broad) depends upon the severity of illness and presence of
complications. Agents other than those suggested in the table may be more appropriate if there are
clinical or epidemiologic features strongly suggestive of a specific cause (eg, mediastinal or hilar
lymphadenopathy, residence in the central United States, and exposure to caves and/or bat guano
suggestive of pulmonary histoplasmosis) [22].
Consultation with a specialist in infectious disease may be helpful in children with medication
allergies, comorbid conditions, failure of outpatient therapy, or multiple-drug-resistant organisms.
Consultation with a pediatric pulmonologist may be helpful in children with recurrent pneumonia.
(See "Community-acquired pneumonia in children: Clinical features and
diagnosis" and "Community-acquired pneumonia in children: Outpatient treatment", section on
'Treatment failure'.)
Etiologic clues Certain clinical and epidemiologic features can be used to determine the most
likely pathogen(s) to aid in decisions regarding empiric therapy. Because these features often
overlap, they cannot be used with complete confidence, but are helpful in guiding empiric therapy
until results of microbiologic tests are available (table 3). These features are discussed in greater
detail separately. (See "Community-acquired pneumonia in children: Clinical features and
diagnosis", section on 'Clues to etiology' and "Community-acquired pneumonia in children: Clinical
features and diagnosis", section on 'Etiologic clues'.)
Neonates The treatment of neonatal pneumonia is discussed separately. (See "Neonatal
pneumonia".)
Viral pneumonia Most children younger than three to five years of age who are admitted to the
hospital with pneumonia have viral pneumonia (eg, respiratory syncytial virus). This is particularly
true in the absence of lobar (or lobular) infiltrate and pleural effusion [4]. Viral pneumonia does not
require antibiotic therapy, unless a mixed infection or secondary bacterial infection is suspected.
(See "Respiratory syncytial virus infection: Treatment", section on 'Overview' and "Respiratory
syncytial virus infection: Clinical features and diagnosis", section on 'Clinical manifestations'.)
No effective antivirals are available for most viral pneumonias, with the exception of influenza.
Influenza pneumonia Initiation of antiviral treatment for influenza (eg, oseltamivir) as soon as
possible is recommended for children hospitalized with presumed influenza pneumonia; laboratory
confirmation should not delay initiation of antiviral therapy. The diagnosis and treatment of influenza
in children are discussed separately. (See "Seasonal influenza in children: Prevention and
treatment with antiviral drugs", section on 'Antiviral therapy' and "Seasonal influenza in children:
Clinical features and diagnosis", section on 'Diagnosis'.)
For children with influenza pneumonia in whom secondary bacterial pneumonia is suspected,
empiric antibiotic therapy should include coverage for S. aureus, including methicillin-resistant S.
aureus (MRSA). Coinfection with S. aureus may be particularly severe and rapidly fatal.
(See "Seasonal influenza in children: Clinical features and diagnosis", section on 'S. aureus'.)
Uncomplicated bacterial pneumonia Streptococcus pneumoniae is the most common bacterial
cause of pneumonia in children of all ages [4,23]. Other potential bacterial pathogens that may
need to be included in empiric therapy for hospitalized children include S. aureus, including
methicillin-resistant S. aureus (MRSA), S. pyogenes (group A streptococcus),Haemophilus
influenzae type b (if unimmunized), nontypeable H. influenzae, and Moraxella catarrhalis [2,4,23-
28].
The Table provides several suggested parenteral empiric antibiotic regimens
for uncomplicated bacterial pneumonia in hospitalized children when S. aureus is not a
consideration (table 2) [4,29,30]. The treatment of complicated CAP and severe CAP (particularly
when S. aureus is a consideration) are discussed below. (See 'Complicated CAP' below
and 'Severe CAP requiring ICU admission' below.)
Ampicillin or penicillin G generally provides adequate coverage for the fully immunized child (table
4) in communities without substantial prevalence of penicillin-resistant S. pneumoniae[1,31]. We
suggest a third-generation cephalosporin (eg, cefotaxime, ceftriaxone) for children younger than 12
months and those who are not fully immunized because third-generation cephalosporins provide
coverage for the beta-lactamase producing pathogens (eg, H. influenzae and M. catarrhalis) that
may occur in these children. We also suggest third-generation cephalosporins for children with
more severe illness (table 1) because third-generation cephalosporins provide coverage for a
broader range of pathogens, including penicillin-resistantS. pneumoniae, than ampicillin [1,32,33].
A macrolide may be added (table 2) if M. pneumoniae, C. pneumoniae, or legionellosis is
suspected. (See 'Atypical pneumonia' below.)
We suggest that children who require hospitalization for treatment of CAP be treated initially with
parenteral antibiotics. However, oral amoxicillin may be an alternative for children older than six
months with uncomplicated pneumonia that is not thought to be due to S. aureus. In a multicenter
randomized trial, treatment with amoxicillin was equivalent to treatment withpenicillin G in children
with CAP who required hospital admission but did not have wheezing, hypotension, chronic
pulmonary conditions (other than asthma), immunodeficiency, pleural effusion requiring drainage, or
oxygen saturations <85 percent in room air [34]. The British Thoracic Society guidelines suggest
that oral antibiotics are safe and effective even for children with severe pneumonia as long as they
are able to tolerate oral fluids, are not vomiting, and do not have signs of septicemia or complicated
pneumonia [2].
Atypical pneumonia Atypical bacterial pathogens include C. trachomatis in afebrile infants,
and M. pneumoniae and C. pneumoniae in older children and adolescents. The Table provides
several suggested empiric regimens for atypical bacterial pneumonia in hospitalized children (table
2) [4,29].
For children older than four months with presumed atypical bacterial pneumonia, ampicillin or a
second- or third-generation cephalosporin may be added if there is strong evidence of a bacterial
cause (eg, white blood cell count >15,000/microL, CRP >35 to 60 mg/L (3.5 to 6 mg/dL), chills, no
response to outpatient therapy with a macrolide or doxycycline) [4,35].
Fluoroquinolones (eg, levofloxacin, moxifloxacin) may be reasonable empiric therapy for the older
child and adolescent with suspected atypical pneumonia, who could actually have pneumococcal
pneumonia. The fluoroquinolones also may be used in the older child or adolescent who has a type
1 hypersensitivity (table 5) to beta-lactam antibiotics. In addition to their excellent gram-negative
spectrum, the fluoroquinolones are active against a number of the pathogens responsible for CAP,
including beta-lactam-susceptible and nonsusceptible S. pneumoniae, M. pneumoniae (including
macrolide-resistant M. pneumoniae), and C. pneumoniae [36]. However, S. pneumoniae resistant to
levofloxacin have been identified [37].
Severe CAP Children with severe CAP that does not require admission to the intensive care unit
(table 1) may benefit from combination empiric therapy with a macrolide and a beta-lactam antibiotic
(eg, penicillin or third-generation cephalosporin) (table 2). Combination therapy improves coverage
for resistant organisms and mixed bacterial/atypical bacterial infections. Antimicrobial therapy can
be adjusted as necessary when results of microbiologic testing become available. Invasive
diagnostic testing, including bronchoscopy with bronchoalveolar lavage, may be necessary for
specific microbiologic diagnosis. (See 'Uncomplicated bacterial pneumonia' above and 'Atypical
pneumonia' above and "Community-acquired pneumonia in children: Clinical features and
diagnosis", section on 'Invasive studies'.)
Severe CAP requiring ICU admission Children who are admitted to the intensive care unit for
serious or life-threatening infections require broad-spectrum empiric coverage that addresses
potential beta-lactam resistance and community-associated methicillin-resistant S. aureus (CA-
MRSA). A suggested regimen for such children may include (table 2) [38-40]:
Vancomycin 60 mg/kg per day IV in four divided doses up to a maximum of 4 g/day, and
A third-generation cephalosporin (cefotaxime 150 mg/kg per day IV in four divided doses up
to a maximum of 10 g/day or ceftriaxone 100 mg/kg per day IV in two divided doses up to a
maximum dose of 4 g/day), and
Azithromycin 10 mg/kg once per day IV for two days (maximum 500 mg/day), followed by
5 mg/kg once per day IV (maximum 250 mg/day), and possibly
Nafcillin or oxacillin 150 mg/kg per day IV in four divided doses; maximum 12 g/day if S.
aureus is likely (methicillin-susceptible S. aureus is more rapidly killed by nafcillin than
byvancomycin), and possibly
Antiviral therapy for influenza, if the child is hospitalized during influenza season; laboratory
confirmation of influenza should not delay initiation of antiviral therapy. (See "Seasonal
influenza in children: Prevention and treatment with antiviral drugs", section on 'Antiviral
therapy'.)
This combination is necessary because of reports of treatment failure resulting from treatment of
nonsusceptible S. pneumoniae with beta-lactams, increasing clindamycin resistance among S.
pneumoniae, and concern for MRSA [38]. Virtually all strains of MRSA are susceptible
to vancomycin [39]. (See "Methicillin-resistant Staphylococcus aureus in children: Treatment of
invasive infections", section on 'Pneumonia'.)
When treating with vancomycin, renal function and serum trough levels or dosing to achieve
an AUC/MIC ratio >400 should be monitored in an attempt to assure therapeutic efficacy and limit
toxicity. In adults, vancomycin trough levels between 15 and 20 microgram/mL have been
suggested to improve clinical outcomes for complicated infections due to S. aureus [40-42]. Studies
evaluating the safety of such levels in children are inconsistent [42-46].
Linezolid is an oxazolidinone antibiotic with activity against gram-positive cocci, including beta-
lactam-resistant S. pneumoniae and MRSA. Linezolid could be substituted
for vancomycinand nafcillin in the above regimen. The dose for linezolid is 10 mg/kg per dose
(maximum 600 mg); it is administered every eight hours in children younger than 12 years and
every 12 hours in children 12 years and older.
Complicated CAP Complicated CAP (eg, parapneumonic effusion, lung abscess) requires a
broader spectrum of antibiotic coverage if etiologies other than S. pneumoniae are being
considered. The expanded spectrum should include coverage for beta-lactam-resistant isolates and
community-associated methicillin-resistant S. aureus (CA-MRSA). Coverage for anaerobes and
gram-negative organisms also may be necessary for children with lung abscess [47]. Antimicrobial
therapy can be adjusted as necessary when results of microbiologic testing become available.
(See "Community-acquired pneumonia in children: Clinical features and diagnosis", section on
'Complications' and "Management and prognosis of parapneumonic effusion and empyema in
children".)
Complicated CAP requires a prolonged course of antimicrobial therapy, usually initiated parenterally
[22]. Appropriate regimens may include [29]:
Ceftriaxone 100 mg/kg intravenously (IV) in two divided doses up to a maximum dose of
4 g/day, OR cefotaxime 150 mg/kg per day IV in four divided doses up to a maximum of
10g/day, PLUS clindamycin 30 to 40 mg/kg per day IV in three or four divided doses to a
maximum of 1 to 2 g/day if S. aureus or anaerobes are a consideration.
Vancomycin 40 to 60 mg/kg per day IV in three or four divided doses up to a maximum of
4 g/day is an alternative to clindamycin if the patient is allergic to clindamycin or if clindamycin-
resistant S. aureus is prevalent in the community. The threshold prevalence of clindamycin-
resistant MRSA (constitutive plus inducible) for choosing vancomycin varies from center to
center, usually ranging from 10 to 25 percent, trying to balance the benefit of definitive therapy
for the patient with the risk of increasing vancomycin resistance in the community. Additional
considerations in the decision to choose vancomycin include the prevalence of MRSA in the
community, the severity of illness, and the turn-around time for susceptibilities. When treating
with vancomycin, renal function and serum trough levels or dosing to achieve
an AUC/MIC ratio of >400 should be monitored in an attempt assure therapeutic efficacy and
limit toxicity. In adults, vancomycin trough levels between 15 and 20 microgram/mL have been
suggested to improve clinical outcomes for complicated infections due to S. aureus [40-
42]. Studies evaluating the safety of these levels in children are inconsistent [42-
46]. (See "Methicillin-resistant Staphylococcus aureus in children: Treatment of invasive
infections", section on 'MRSA infections'.)
Ampicillin-sulbactam 150 to 200 mg/kg per day of the ampicillin component IV in four divided
doses; maximum 12 g/day alone may be effective if a lung abscess is thought to be secondary
to an aspiration event. (See 'Aspiration pneumonia' below.)
The duration of therapy and other considerations in the management of complicated pneumonia
depend upon the type of complication:
Parapneumonic effusion/empyema The treatment of parapneumonic effusion and
empyema is discussed in detail separately. (See "Management and prognosis of
parapneumonic effusion and empyema in children".)
Necrotizing pneumonia Treatment of necrotizing pneumonia requires a prolonged course
of antibiotic therapy. The duration is determined by the clinical response but is usually a total
of four weeks or two weeks after the patient is afebrile and has improved clinically.
Interventional procedures (eg, percutaneous drainage catheter placement) should be
performed cautiously in children with necrotizing pneumonia; such procedures increase the
risk of complications, such as the development of bronchopleural fistulae [47-50].
Lung abscess Treatment of lung abscess requires a prolonged course of antibiotic
therapy. The duration is determined by the clinical response, but is usually a total of four
weeks or two weeks after the patient is afebrile and has clinical improvement. The average
duration of fever is four to eight days [22]. Eighty to 90 percent of lung abscesses in children
resolve with antibiotic therapy alone and spontaneous drainage through the tracheobronchial
tree, provided that bronchial obstruction is removed [51].

In cases that fail to resolve with antibiotics alone, needle aspiration or percutaneous catheter
drainage may provide diagnostic information and therapeutic benefit without the increased risk
of complications that occurs in children with necrotizing pneumonia [47,48,52,53].
Percutaneous drainage may be warranted in children with lung abscess whose condition fails
to improve or worsens after 72 hours of antibiotic therapy [47]. At least three weeks of IV
antibiotic therapy should be delivered before lobectomy is considered for treatment failure
[54].
Pneumatocele Most pneumatoceles involute spontaneously [55-57]. However, on
occasion, pneumatoceles result in pneumothorax [58].
Nosocomial pneumonia Empiric treatment of nosocomial (hospital-acquired) pneumonia should
include coverage for S. aureus, Enterobacteriaceae, Pseudomonas aeruginosa, and anaerobes.
Acceptable broad spectrum regimens usually include an aminoglycoside (for gram-negative
pathogens) and another agent to address gram-positive pathogens and anaerobes (table 2):
Aminoglycoside (usually gentamicin; amikacin if extended spectrum or Amp C beta-
lactamase producing gram-negative rods are possible etiologies) plus:
Ticarcillin-clavulanate 300 mg/kg per day IV in four divided doses up to a maximum of
24 g/day, or
Piperacillin-tazobactam 300 mg/kg per day IV in four divided doses up to a maximum of
12 g/day, or
Meropenem 60 mg/kg per day IV in three divided doses, up to a maximum of 6 g/day if
extended-spectrum or Amp C beta-lactamase-producing gram-negative rods are possible
etiologies, or
Ceftazidime 125 to 150 mg/kg per day in three divided doses; maximum of 6 g/day, or
Cefepime 150 mg/kg per day in three divided doses; maximum of 4 g/day
The combination of amikacin and meropenem should be used if extended-spectrum or Amp C beta-
lactamase-producing gram-negative rods are possible etiologies.
Thecephalosporin/aminoglycoside combination lacks anaerobic coverage so should NOT be used
when aspiration pneumonia is a possibility. (See 'Aspiration pneumonia' below.)
Vancomycin should be added to the empiric regimen if methicillin-resistant S. aureus is a
consideration.
Patients with true beta-lactam hypersensitivity (ie, type 1 hypersensitivity reaction) (table 5) can be
treated with a combination of clindamycin and an aminoglycoside.
Aspiration pneumonia Empiric antibiotic regimens for community-acquired aspiration
pneumonia must cover oral anaerobes. Appropriate antibiotic regimens for hospitalized children
include [47]:
Ampicillin-sulbactam 150 to 200 mg/kg per day of the ampicillin component IV in four divided
doses; maximum 12 g/day, or
Clindamycin 30 to 40 mg/kg per day IV in three or four divided doses to a maximum of 1 to
2 g/day if MRSA etiology is suspected.
Vancomycin 40 to 60 mg/kg per day IV in three or four divided doses up to a maximum of
4 g/day is an alternative to clindamycin if the patient is allergic to clindamycin or if clindamycin-
resistant S. aureus is prevalent in the community. The threshold prevalence of clindamycin-
resistant MRSA (constitutive plus inducible) for choosing vancomycin varies from center to
center, usually ranging from 10 to 25 percent, trying to balance the benefit of definitive therapy
for the patient with the risk of increasing vancomycin resistance in the community. Additional
considerations in the decision to choose vancomycin include the prevalence of MRSA in the
community, the severity of illness, and the turn-around time for susceptibilities.
(See "Methicillin-resistant Staphylococcus aureus in children: Treatment of invasive
infections", section on 'Pneumonia'.)
In neurologically compromised older adolescents prone to aspiration events, empiric treatment for
CAP with a fluoroquinolone like moxifloxacin (400 mg once daily) may be reasonable. Moxifloxacin
has activity against anaerobic bacteria, as well as the usual treatable causes of CAP (S.
pneumoniae, M. pneumoniae, and C. pneumoniae).
Appropriate antibiotic regimens for children with nosocomial aspiration who are known to be
colonized with unusual gram-negative pathogens (eg, Klebsiella pneumoniae) include:
Ticarcillin-clavulanate 300 mg/kg per day IV in four divided doses up to a maximum of
24 g/day, or
Piperacillin-tazobactam 300 mg/kg per day IV in four divided doses up to a maximum of
12 g/day, or
Meropenem 60 mg/kg per day IV in three divided doses, up to a maximum of 6 g/day
Vancomycin should be added to the empiric regime if methicillin-resistant S. aureus (MRSA) is a
consideration.
Patients with true beta-lactam hypersensitivity (ie, type 1 hypersensitivity reaction) (table 5) can be
treated with a combination of clindamycin and an aminoglycoside.
Immunocompromised host Empiric treatment for pneumonia in immunocompromised hosts
also requires broad-spectrum gram-positive and gram-negative coverage, similar to that required for
nosocomial pneumonia, with the addition of vancomycin if methicillin-resistant staphylococcus is
considered, and possibly trimethoprim-sulfamethoxazole for Pneumocystis jirovecii (formerly P.
carinii). Empiric regimens may need to be modified once results of cultures and antibiotic
susceptibility testing are available. Invasive testing may be required to obtain a satisfactory
specimen in such patients. (See "Community-acquired pneumonia in children: Clinical features and
diagnosis", section on 'Invasive studies'.) Treatment of CAP in the immunocompromised host
should occur in consultation with an infectious disease specialist.
An aggressive approach to specific microbial diagnosis is indicated in immunocompromised hosts
with clinically significant pneumonias. For patients with an endotracheal tube in place, specific
microbial diagnosis may involve early flexible bronchoscopy for bronchoalveolar lavage with viral,
fungal, and bacterial cultures. Although the protected specimen brush technique has been utilized
in some settings, quantitative bacterial cultures are more commonly used to differentiate
colonization from true lower respiratory tract infection. (See "Flexible bronchoscopy: Indications and
contraindications", section on 'Diagnostic indications' and "Clinical presentation and diagnosis of
ventilator-associated pneumonia", section on 'Diagnostic evaluation'.)
SPECIFIC THERAPY Once results of microbiologic tests are available, antimicrobial therapy can
be directed toward the responsible pathogen or pathogens. Specific antibiotic therapy for bacterial
CAP is summarized in the table (table 6). Specific antimicrobial and/or supportive therapy for the
pathogens that commonly cause CAP in children is discussed in the topic reviews listed below.
S. pneumoniae (see "Pneumococcal pneumonia in children", section on 'Specific therapy')
M. pneumoniae (see "Mycoplasma pneumoniae infection in children", section on 'Treatment')
C. pneumoniae (see "Pneumonia caused by Chlamydophila (Chlamydia) species in
children")
Methicillin-sensitive S. aureus Methicillin-susceptible S. aureus pneumonia may be treated
with oxacillin, nafcillin, or cefazolin [1,4]
Methicillin-resistant S. aureus (MRSA) (see "Methicillin-resistant Staphylococcus aureus in
children: Treatment of invasive infections", section on 'Definitive therapy')
Respiratory syncytial virus (see "Respiratory syncytial virus infection: Treatment")
Influenza (see "Seasonal influenza in children: Prevention and treatment with antiviral drugs",
section on 'Antiviral therapy')
Parainfluenza (see "Parainfluenza viruses in children", section on 'Treatment')
Adenovirus (see "Diagnosis and treatment of adenovirus infection", section on 'Treatment')
Human metapneumovirus (see "Human metapneumovirus infections", section on
'Treatment')
DURATION OF TREATMENT
Parenteral therapy There are few data to guide decisions about the duration of parenteral
therapy for community-acquired pneumonia (CAP) [2]. It is common to switch to oral therapy in
patients who have received parenteral antibiotics when the patient has become afebrile for 24 to 48
hours and is not having emesis [59].
Total duration There are few randomized controlled trials to guide decisions about the
appropriate duration of antimicrobial therapy for radiographically confirmed childhood pneumonia
[2]. Current practice assigns duration of therapy according to the host, causative agent, and
severity.
Uncomplicated cases The usual duration of combined parenteral and oral therapy for
uncomplicated pneumonia is 7 to 10 days [1,2]. Some authorities suggest continuing oral therapy at
least one week beyond resolution of fever; others suggest treating until the erythrocyte
sedimentation rate falls below 20 mm/hour. Some data from trials in adults suggest that a shorter
course may be equivalent to a 7- to 10-day course, but additional controlled studies are necessary
before this practice can be recommended routinely for children [47,60,61].
Complicated cases Treatment of complications, such as necrotizing pneumonia and lung
abscess, requires a prolonged course of antibiotic therapy, usually initiated parenterally. The
duration is determined by the clinical response, but usually is either a total of four weeks or a total
of two weeks after the patient is afebrile and has improved clinically. (See'Complicated
CAP' above.)
RESPONSE TO THERAPY The following clinical parameters can be monitored to assess
response to treatment [1,2]:
Temperature
Respiratory rate
Heart rate
Oxygen saturation (SpO
2
)
Work of breathing (eg, retractions, nasal flaring, grunting)
Chest examination (extent of abnormal or absent breath sounds; extent of dullness to
percussion)
Mental status
Ability to maintain oral intake and hydration
The frequency of monitoring depends upon the severity of illness. In patients who are receiving
oxygen supplementation, oxygen saturation should be evaluated regularly. Evaluation for
hypercarbia may be necessary in children with severe respiratory distress, as oxygenation may be
preserved.
The respiratory status of children with community-acquired pneumonia (CAP) who are appropriately
treated should improve within 48 to 72 hours [1]. However, fevers may persist for several days after
initiation of appropriate therapy [47].
Treatment failure In children who fail to improve as anticipated, the following possibilities must
be considered [1,2,62,63]:
Alternative or coincident diagnoses (eg, foreign body aspiration) (see "Community-acquired
pneumonia in children: Clinical features and diagnosis", section on 'Differential diagnosis')
Ineffective antibiotic coverage (lack of coverage for the actual etiology or resistant organism)
Development of complications (see "Community-acquired pneumonia in children: Clinical
features and diagnosis", section on 'Complications')
Underlying immunodeficiency condition
The history should be reviewed with special attention to the possibility of foreign body aspiration
and geographic or environmental exposures associated with pathogens not treated by the empiric
regimen (table 7).
Changes in laboratory parameters (eg, peripheral white blood cell count, inflammatory markers (if
obtained initially)) may provide information about disease progression. Repeat radiographs or
additional imaging studies can help to assess the degree of parenchymal involvement and evaluate
for complications or anatomic abnormalities [1]. (See "Community-acquired pneumonia in children:
Clinical features and diagnosis", section on 'Complications' and "Pneumonia in children:
Epidemiology, pathogenesis, and etiology", section on 'Etiologic agents'.)
Depending upon the severity of illness, more aggressive attempts may need to be made to
establish a microbiologic diagnosis (eg, induced sputum [64], bronchoscopy with bronchoalveolar
lavage, percutaneous needle aspiration, or lung biopsy). In children with lung abscess whose
condition fails to improve or worsens after 72 hours of antibiotic therapy, needle aspiration or
percutaneous catheter drainage may provide diagnostic information and therapeutic benefit
[47,48,52,53]. (See "Community-acquired pneumonia in children: Clinical features and diagnosis",
section on 'Invasive studies'.)
DISCHARGE CRITERIA Discharge criteria for children who have been admitted to the hospital
with community-acquired pneumonia (CAP) have not been standardized, but typically include
[1,47]:
Improvement of vital signs
Ability to maintain adequate fluid and nutrition orally
Ability to maintain oxygen saturation 90 percent in room air
Improvement in respiratory distress (tachypnea, retractions, nasal flaring, use of accessory
muscles)
Overall clinical improvement including level of activity, appetite, and decreased fever for at
least 12 to 24 hours
Stable and/or baseline mental status
Parents ability to administer and childs ability to comply with home antibiotic regimen
Safe and compliant home environment
Outpatient parenteral antibiotic therapy Outpatient parenteral antimicrobial therapy (OPAT) is
an option for selected patients who require prolonged treatment (usually for complicated CAP that
for some reason cannot be treated with an oral antibiotic) and have stabilized clinically [47,65,66].
Eligibility for OPAT requires a suitable home environment and a pharmacologic agent with a
reasonable dosing schedule [67]. Decisions regarding OPAT should involve the caregivers, an
infectious disease specialist (or clinician knowledgeable about the use of antimicrobial agents in
OPAT), a hospital pharmacist, and the primary care provider. The services of a visiting nurse may
be required for home visits, education and observation of caregiver administration, and/or obtaining
blood samples for therapeutic monitoring.
FOLLOW-UP
Clinical course Children with pneumonia should be seen by their primary care provider soon
after discharge to ensure that clinical improvement continues and antibiotic therapy is being taken
as prescribed [47]. Decisions regarding the timing of clinical follow-up should involve the child's
primary care provider and the clinical status of the child at the time of discharge.
Children who are appropriately treated for pneumonia should gradually improve with time. Cough
may persist for as long as three to four months after viral pneumonia or pertussis. Children who are
recovering from typical or atypical bacterial pneumonia may continue to cough for several weeks
and have moderate dyspnea on exertion for two to three months [68]. Symptomatic treatment of
cough is discussed separately. (See "The common cold in children: Treatment and prevention",
section on 'Cough'.)
Radiographs Follow-up radiographs are not necessary in asymptomatic children with
uncomplicated community-acquired pneumonia (CAP). However, in children with complicated
community-acquired pneumonia or CAP that required intervention, follow-up radiographs help to
ensure resolution [2,69]. Follow-up radiographs also may be helpful in children with recurrent
pneumonia, persistent symptoms, severe atelectasis, unusually located infiltrates, or round
pneumonia [2,47,70]. Conditions that must be considered if a round pneumonia fails to resolve on
follow-up imaging include congenital lung sequestration, metastatic Wilms tumor, cavitary necrosis,
pleural pseudocyst, and primary lung carcinoma [70-74]. When follow-up radiographs are indicated,
they should be obtained two to three weeks after hospital discharge [47,75].
Several studies have evaluated the utility of follow-up radiographs in cohorts of children with acute
radiologically proven CAP [76-81]. Three of the studies included clinical as well as radiologic follow-
up at three to seven weeks after initial diagnosis [76-79]. In each of these studies, follow-up
radiographs were normal or improved in asymptomatic children. Residual findings, even when
present, did not result in additional therapy.
PROGNOSIS Most otherwise healthy children with pneumonia recover without sequelae, even if
the pneumonia is complicated [47,49,50,82]. Although some data suggest that nearly one-half of
children who are hospitalized for viral pneumonia have symptoms of asthma five years after
hospitalization, it is not clear whether this is related to unrecognized asthma at the time of
presentation with pneumonia or a tendency to develop asthma after community-acquired viral
pneumonia [83,84].
The overall pneumonia mortality rate in developed countries is <1 per 1000 per year [85].
Pneumococcal pneumonia case fatality rates (not adjusted for comorbid conditions) for children in
the United States were estimated to be 4 percent in children younger than two years and 2 percent
in children 2 to 17 years [86].
INFORMATION FOR PATIENTS UpToDate offers two types of patient education materials, The
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Here are the patient education articles that are relevant to this topic. We encourage you to print or
e-mail these topics to your patients. (You can also locate patient education articles on a variety of
subjects by searching on patient info and the keyword(s) of interest.)
Basics topics (see "Patient information: Pneumonia in children (The Basics)")
SUMMARY AND RECOMMENDATIONS
The decision to hospitalize a child with community-acquired pneumonia (CAP) must be
individualized and is based upon age, underlying medical problems, and severity of illness
(table 1). (See 'Indications' above.)
CAP can be caused by a variety of microbial agents requiring a variety of infection-control
measures. (See 'Infection control' above.)
Supportive care for children hospitalized with pneumonia includes provision of adequate
respiratory support, hydration, antipyresis, and analgesia. (See 'Supportive care' above.)
Children with CAP who are hospitalized are treated empirically until information from the
microbiologic evaluation is available to direct therapy toward a specific pathogen. Decisions
regarding empiric antimicrobial therapy for CAP in children are usually based upon age unless
there are other overriding epidemiologic or clinical factors to suggest a specific etiologic agent
(table 2). (See 'Overview' above and "Pneumonia in children: Epidemiology, pathogenesis,
and etiology", section on 'Etiologic agents'.)
We recommend that empiric antibiotic therapy for presumed bacterial pneumonia in
hospitalized children include coverage for Streptococcus pneumoniae (table 2) (Grade 1B).
(See'Uncomplicated bacterial pneumonia' above.)
Extended empiric coverage may be indicated for children with complicated or severe
pneumonia, particularly those who require admission to an intensive care unit (table 2).
(See'Complicated CAP' above and 'Severe CAP requiring ICU admission' above.)
When results of microbiologic tests are available, antibiotic therapy can be directed toward
the specific pathogen recovered (table 6). (See 'Specific therapy' above.)
Oral therapy typically is initiated when the patient has been afebrile for 24 to 48 hours and
can tolerate oral intake. The total duration of antibiotic therapy is usually 7 to 10 days for
uncomplicated CAP and up to four weeks in complicated CAP. (See 'Duration of
treatment' above.)
The respiratory status of children receiving appropriate therapy for CAP should improve
within 48 to 72 hours. Children who fail to improve as anticipated may be receiving inadequate
antibiotic therapy, have developed complications, or have an alternative or coincident
diagnosis. (See 'Treatment failure' above.)
Children recovering from CAP may continue to have cough for several weeks to four months,
depending upon the etiology. Those recovering from typical or atypical bacterial pneumonia
may have moderate dyspnea on exertion for two to three months. (See 'Clinical
course' above.)
Follow-up radiographs are not necessary in asymptomatic children with uncomplicated CAP.
However, in children with complicated CAP or CAP that required intervention, follow-up
radiographs help to ensure resolution. Follow-up radiographs two to three weeks after
completion of therapy may be helpful in children with recurrent pneumonia, persistent
symptoms, severe atelectasis, round pneumonia, or unusually located infiltrates.
(See 'Radiographs' above.)
Most otherwise healthy children who develop pneumonia recover without any long-term
sequelae. (See 'Prognosis' above.)
ITU CHUILDREN
All topics are updated as new evidence becomes available and our peer review process is
complete.
Literature review current through: Sep 2014. | This topic last updated: Feb 25, 2014.
INTRODUCTION Urinary tract infections (UTI) are a common and important clinical problem in
childhood. Upper urinary tract infections (ie, acute pyelonephritis) may lead to renal scarring,
hypertension, and end-stage renal disease. Although children with pyelonephritis tend to present
with fever, it is often difficult on clinical grounds to distinguish cystitis from pyelonephritis,
particularly in young children (those younger than two years) [1]. As a result, we have defined UTI
broadly here without attempting to distinguish cystitis from pyelonephritis. Acute cystitis in older
children is discussed separately. (See "Acute cystitis: Clinical features and diagnosis in children
older than two years and adolescents".)
The clinical features and diagnosis of UTI in children will be discussed here. The epidemiology, risk
factors, and management of UTI in children and UTI in newborns (younger than one month of age)
are discussed separately. (See "Urinary tract infections in children: Epidemiology and risk
factors" and "Urinary tract infections in infants and children older than one month: Acute
management, imaging, and prognosis" and "Urinary tract infections in children: Long-term
management and prevention" and "Urinary tract infections in newborns".)
CLINICAL PRESENTATION Urinary tract infections (UTI) may present with nonspecific
symptoms and signs, particularly in infants and young children.
Younger children In a meta-analysis of the diagnostic accuracy of the symptoms and signs of
UTI in children younger than two years, the following symptoms and signs were the most helpful in
identifying children with UTI (table 1) [2]:
History of UTI (likelihood ratio [LR] 2.3)
Temperature >40C (LR 3.2)
Suprapubic tenderness (summary LR 4.4)
Lack of circumcision (summary LR 2.8)
Combinations of signs and symptoms were more useful than individual signs for identifying children
with and without UTI [2]:
Temperature >39C for 48 hours in absence of another source for fever (LR 4.0)
Temperature <39C, presence of another source for fever (LR 0.37)
Likelihood ratios are discussed separately. (See "Evaluating diagnostic tests", section on 'What are
the positive and negative likelihood ratios?'.)
Fever Several prospective studies have shown that infants and children younger than two
years can present with fever as the sole manifestation of UTI [3-5].

The prevalence of UTI is greater among infants and young children with maximum
temperatures 39C than in those with lesser degrees of fever (16 versus 7 percent for infants
60 days, and 4 versus 2 percent for children <2 years) [4,5]. (See "Urinary tract infections in
children: Epidemiology and risk factors", section on 'Prevalence'.)

The presence of another potential source of fever (upper respiratory tract infection, acute otitis
media, acute gastroenteritis) does not rule out the possibility of UTI. In studies of UTI in young
children who presented to the emergency department with fever, the prevalence of UTI in
children with and without another potential source of fever on examination ranged from 2 to 3
percent and 6 to 8 percent, respectively [4,6]. This highlights the importance of obtaining urine
cultures in febrile infants and young children without a definite source for fever. (See "Fever
without a source in children 3 to 36 months of age" and "Evaluation and management of fever
in the neonate and young infant (younger than three months of age)".)
Other symptoms Less common symptoms of UTI in infants include conjugated
hyperbilirubinemia (in those <28 days), irritability, poor feeding, or failure to thrive [7].
(See "Urinary tract infections in newborns".)

Parental reporting of foul-smelling urine or gastrointestinal symptoms (vomiting, diarrhea, and
poor feeding) is generally not helpful in diagnosing UTI [2,8,9].
Older children Symptoms of UTI in older children may include fever, urinary symptoms (dysuria,
urgency, frequency, incontinence, macroscopic hematuria), and abdominal pain [10-12]. The
constellation of fever, chills, and flank pain is suggestive of pyelonephritis in older children [7].
Occasionally, older children may present with short stature, poor weight gain, or hypertension
(calculator 1 and calculator 2) secondary to renal scarring from unrecognized UTI earlier in
childhood [13]. Suprapubic tenderness and costovertebral angle tenderness may be present on
examination of older children with UTI.
In a meta-analysis of the diagnostic accuracy of the symptoms and signs of UTI in verbal children,
the following symptoms and signs were the most helpful in identifying children with UTI [2]:
Abdominal pain (LR 6.3)
Back pain (LR 3.6)
Dysuria, frequency, or both (LR 2.2)
New-onset urinary incontinence (LR 4.6)
Likelihood ratios are discussed separately. (See "Evaluating diagnostic tests", section on 'What are
the positive and negative likelihood ratios?'.)
CLINICAL EVALUATION Children with urinary tract infection (UTI) symptoms should be
evaluated promptly. Prompt recognition and treatment of UTI is an important factor in the prevention
of renal scarring. (See "Urinary tract infections in children: Epidemiology and risk factors", section
on 'Risk factors for renal scarring'.)
History The history of the acute illness should include documentation of the height and duration
of fever, urinary symptoms (dysuria, frequency, urgency, incontinence), abdominal pain, suprapubic
discomfort, back pain, vomiting, recent illnesses, antibiotics administered, and in females, sexual
activity (if applicable).
Information from the past medical history should include (see "Urinary tract infections in children:
Epidemiology and risk factors", section on 'Host factors'):
Chronic urinary symptoms Incontinence, lack of proper stream, frequency, urgency,
withholding maneuvers
Chronic constipation
Previous UTI
Vesicoureteral reflux (VUR)
Previous undiagnosed febrile illnesses
Family history of frequent UTI, VUR, and other genitourinary abnormalities
Antenatally diagnosed renal abnormality
Elevated blood pressure
Poor growth
In sexually active girls, whether barrier contraception with spermicidal agents is used (such
methods predispose to UTI by altering the normal vaginal flora [14])
Physical examination Important aspects of the physical examination in the child with suspected
UTI include [2,15,16]:
Documentation of blood pressure and temperature
Growth parameters (poor weight gain and/or failure to thrive may be an indication of chronic
or recurrent UTI)
Abdominal examination for tenderness or mass (eg, enlarged bladder or enlarged kidney
secondary to urinary obstruction, palpable stool in colon) [15]
Assessment of suprapubic and costovertebral tenderness
Examination of the external genitalia for anatomic abnormalities (eg, phimosis or labial
adhesions) and signs of vulvovaginitis, vaginal foreign body, sexually transmitted diseases
(STDs) (see "Vulvovaginal complaints in the prepubertal child")
Evaluation of the lower back for signs of occult myelodysplasia (eg, midline pigmentation,
lipoma, vascular lesion, sinus, tuft of hair), which may be associated with a neurogenic
bladder
Evaluation for other sources of fever (see "Fever without a source in children 3 to 36 months
of age" and "Evaluation and management of fever in the neonate and young infant (younger
than three months of age)")
LABORATORY EVALUATION The laboratory evaluation for the child with suspected urinary
tract infection (UTI) includes obtaining a urine sample for a dipstick and/or microscopic evaluation
and urine culture. Pyuria and significant bacteriuria on urine culture are necessary to make the
diagnosis. (See 'Diagnosis of UTI' below.)
Urine sample
Decision to obtain The decision to obtain a urine sample for culture is best made on a case-by-
case basis, taking into consideration the age, sex, circumcision status, and the presenting signs
and symptoms (table 2 and table 1 and algorithm 1A-C).
Other considerations include the feasibility of follow-up, parental views toward catheterization (if
catheterization is necessary), potential harm of not diagnosing an episode of UTI, harm of
incorrectly diagnosing UTI, cost and availability of testing, and benefits of early treatment.
(See "Urinary tract infections in infants and children older than one month: Acute management,
imaging, and prognosis", section on 'Overview'.)
The clinician can use the patient's demographic and clinical characteristics to estimate the
probability of UTI. As an example, consider a nine-month-old, well-appearing white girl with a
temperature of 39.2C and no definite source. The clinician can inform the parents that their
daughter has an approximately 1 in 5 chance of having a serious but treatable infection (table 2),
and recommend that a catheterized urine specimen be obtained.
Urine samples for urinalysis (dipstick and microscopic examination) and culture are generally
indicated in the following patients [2,17-19]:
Girls and uncircumcised boys younger than two years with at least one risk factor for UTI
(history of UTI, temperature >39C, fever without apparent source [particularly if the child will
be treated with antibiotics], ill appearance, suprapubic tenderness, fever >24 hours, or
nonblack race)
Circumcised boys younger than two years with suprapubic tenderness or at least two risk
factors for UTI (history of UTI, temperature >39C, fever without apparent source [particularly
if the child will be treated with antibiotics], ill appearance, suprapubic tenderness, fever >24
hours, or nonblack race)
Girls and uncircumcised boys older than two years with any of the following urinary
symptoms: abdominal pain, back pain, dysuria, frequency, high fever, or new-onset
incontinence
Circumcised boys older than two years with multiple urinary symptoms (abdominal pain, back
pain, dysuria, frequency, high fever, or new-onset incontinence)
Febrile infants and children with abnormalities of the urinary tract or family history of urinary
tract disease
How to obtain Catheterization or suprapubic aspiration is the preferred method of urine
collection for dipstick, microscopic examination, and culture of the urine in infants and young
children who are not toilet-trained. A clean-voided specimen is the preferred method of collection in
toilet-trained children. (See "Urine collection techniques in children".)
All urine specimens should be examined as soon as possible after collection. A delay of even a few
hours increases both the false-positive and false-negative rates substantially [20].
We generally suggest catheterized urine samples for children who are not toilet-trained; the
sensitivity and specificity of catheterized specimens for urine culture are 95 and 99 percent,
respectively, when compared with suprapubic specimens [20]. Nonetheless, suprapubic aspiration
is a relatively straightforward procedure, and complications are rare. We specifically recommend a
suprapubic aspirate when:
Catheterization is not feasible (eg, severe phimosis or penile adhesions in boys; labial
adhesions in girls)
Results from a catheterized specimen are inconclusive (eg, repeated contaminated
specimen or repeated low colony counts)
We recommend that urine obtained in a sterile bag not be used for culture. Up to 85 percent of
positive cultures from bag urine specimens represent false-positive results [20]; results of urine
cultures from bag specimens are useful only if they are negative. The high false-positive rate of bag
specimens can lead to unnecessary and even harmful interventions [21]. (See"Urine collection
techniques in children".)
We also suggest that bag urine specimens not be used for dipstick or microscopic analysis.
However, others suggest that bag urine samples can be used as a first step to determine whether a
catheterized urine sample should be obtained for culture in young children [17,19]. This approach is
not recommended in ill-appearing patients or in patients who require antibiotics immediately after
the urine specimen is collected [16].
Rapidly available tests The accuracy of the various diagnostic tests in predicting significant
bacteriuria on culture has been the subject of two meta-analyses [22,23]. The sensitivity, specificity,
and likelihood ratios of rapidly available tests to diagnose UTI in children are summarized in the
table (table 3).
Dipstick analysis Dipstick tests are convenient, inexpensive, and require little training for proper
usage; they may be the only test available in some settings. However, they will likely miss some
children with UTI (at best they are 88 percent sensitive) (table 3) [23]. Because the sensitivity of
dipstick analysis is less than 100 percent, we suggest that a urine culture be obtained in children
with suspected UTI who have a negative dipstick test. (See 'Urine culture' below.)
Leukocyte esterase Positive leukocyte esterase on dipstick analysis is suggestive of UTI.
However, a positive leukocyte esterase test does not always signal a true UTI because WBCs
may be present in the urine in other conditions (eg, Kawasaki disease). (See 'Pyuria' below.).
In a two-year-old circumcised boy with a positive leukocyte esterase test, for example, the
probability of UTI is <4 percent, based upon the following calculation:

Post-test probability = Pretest probability x the positive likelihood ratio

In this example, the pretest probability is <1 percent (table 2) and the positive likelihood ratio is
4 (table 3), which results in a post-test probability of <4 percent. Likelihood ratios are
discussed separately. (See "Evaluating diagnostic tests", section on 'What are the positive and
negative likelihood ratios?'.)
Nitrite A child with a positive nitrite test is likely to have a UTI. The nitrite test is highly
specific, with a low false-positive rate (table 3). However, false-negative tests are common,
because urine needs to remain in the bladder for at least four hours to accumulate a
detectable amount of nitrite. Thus, a negative nitrite test does not exclude a UTI (table 3).
Microscopic exam Microscopic examination requires more equipment and training than dipstick
tests. In standard microscopy, a centrifuged sample of unstained urine is examined for white blood
cells (WBC) and bacteria. When performed in this way, pyuria is defined as 5 WBC/high power
field (hpf) and bacteriuria as the presence of any bacteria per hpf. The sensitivity, specificity, and
likelihood ratios are summarized in the table (table 3). Because the sensitivity of the standard
microscopic examination conducted using a centrifuged urine specimen is at best 81 percent, we
suggest that a urine culture be obtained in children with suspected UTI who have a negative
standard microscopic examination. (See 'Urine culture'below.)
The accuracy of microscopic analysis is improved by using [22-24]:
An uncentrifuged specimen
A hemocytometer (results reported as WBC/mm
3
)
A Gram-stained smear
Examination of a catheterized urine sample using these three techniques, which are available at
some academic centers, has been called an "enhanced urinalysis" [24]. When using the enhanced
urinalysis, pyuria is defined by 10 WBC/mm
3
and bacteriuria by any bacteria per 10 oil immersion
fields of a Gram-stained smear.
In young children in whom the prompt diagnosis and treatment of UTI are paramount, the enhanced
urinalysis offers the best combination of sensitivity and specificity (table 3) [22,25,26]. However,
enhanced urinalysis is not available in many outpatient settings.
Urine culture Urine culture is the standard test for the diagnosis of UTI. We suggest that urine
culture be performed routinely for all children in whom UTI is a diagnostic consideration and in
whom a sample for urinalysis or dipstick is collected. (See 'Decision to obtain' above.)
Urine obtained for culture should be processed as soon as possible after collection. A delay of even
a few hours increases both the false-positive and false-negative rates substantially [20].
Other laboratory tests Other laboratory tests are not particularly helpful in the diagnosis of UTI
and are not routinely necessary in children with suspected UTI. (See "Evaluation and management
of fever in the neonate and young infant (younger than three months of age)" and "Fever without a
source in children 3 to 36 months of age".)
Markers of inflammation We do not routinely obtain markers of inflammation in the
evaluation of children with suspected UTI. Elevated peripheral WBC, erythrocyte
sedimentation rate (ESR), C-reactive protein (CRP), and procalcitonin (PCT) are indicators of
an acute inflammatory process. Although some studies have shown that these markers are
associated with upper tract infection, because of their low sensitivity and/or specificity, these
tests do not reliably differentiate between children with cystitis and children with
pyelonephritis.

As an example, approximately 30 percent of children with a normal CRP have pyelonephritis
by 99m technetium-dimercaptosuccinic acid (DMSA) [27]. Similarly, although PCT appears to
be the most accurate marker of pyelonephritis to date [28,29], its predictive value is too low for
use as a screening test. A meta-analysis of children with culture-proven UTI examined the
sensitivity and specificity of PCT in differentiating cystitis from pyelonephritis [28]. The 10
studies included in this meta-analysis were relatively small and suffered from important
methodological limitations. There was significant heterogeneity in the results; sensitivity of
PCT ranged from 60 to 100 percent, and specificity ranged from 25 to 98 percent. Until larger,
more definitive studies are conducted, measurement of PCT does not appear to be clinically
indicated.
Serum creatinine Measurement of serum creatinine is not routinely necessary in children
with suspected UTI. However, we suggest that serum creatinine be measured in children with
a history of multiple UTI and suspected renal involvement.
Blood culture Bacteremia occurs in 4 to 9 percent of infants with UTI [13,30-34]. Fever in
bacteremic infants with UTI persists, on average, one day longer than in non-bacteremic
infants with UTI [35]. However, a positive blood culture does not alter management in the vast
majority of children because usually the same organism is isolated from the blood and urine.

Accordingly, we do not routinely obtain a blood culture in children older than two months of
age who have UTI and do not require blood culture for other reasons. (See "Evaluation and
management of fever in the neonate and young infant (younger than three months of
age)" and "Fever without a source in children 3 to 36 months of age".)
Lumbar puncture Lumbar puncture generally is not warranted in infants and children older
than one month with UTI. Lumbar puncture in infants younger than one month with UTI is
discussed separately. (See "Urinary tract infections in newborns".)
DIAGNOSIS OF UTI
Overview Quantitative urine culture is the standard test for the diagnosis of UTI. UTI is best
defined as significant bacteriuria in a patient with pyuria (ie, evidence of an inflammatory
response).
Significant bacteriuria What constitutes significant bacteriuria depends upon the method of
collection and the identification of the isolated organism [19]. Lactobacillus spp, coagulase-negative
staphylococci, and Corynebacterium spp are not considered clinically relevant uropathogens [19].
Clean voided sample We define significant bacteriuria from a clean voided urine specimen
in children as growth of 100,000 colony forming units (CFU)/mL of a uropathogenic bacteria.
This is the same as the standard definition for significant bacteriuria on clean catch specimens
in adults, which is based upon studies from the 1950s [36].
Catheter sample We define significant bacteriuria from catheterized specimens in children
as growth of 50,000 CFU/mL of a uropathogenic bacteria [19]. In a prospective study of
febrile children <24 months of age, catheterized urine samples with 10,000 to
50,000 CFU/mL were more likely than specimens with 50,000 CFU/mL to yield gram-positive
organisms (excluding enterococci) or mixed organisms than those with 50,000 CFU/mL (65
versus 17 percent) [37].

We suggest that children who have growth of 10,000 to 50,000 CFU/mL from an initial
catheterized specimen have a repeat urine culture. We consider such children to have UTI if
the second culture grows 10,000 CFU/mL and pyuria is present on dipstick or microscopic
urinalysis.
Suprapubic sample We define significant bacteriuria from suprapubic aspiration specimens
as the growth of any uropathogenic bacteria (the growth of one colony on the plate is
equivalent to 1000 CFU/mL).
False negatives False-negative results in children with UTI (eg, failure to meet the definitions of
significant bacteriuria described above) may occur under the following circumstances [6,37]:
A bacteriostatic antimicrobial agent is present in the urine
Rapid rate of urine flow with reduced incubation time
Obstruction of the ureter that interferes with the discharge of bacteria into the bladder
In such cases, when the urine culture will not provide definitive results, renal scintigraphy may be
helpful in establishing the diagnosis of acute pyelonephritis. (See "Urinary tract infections in infants
and children older than one month: Acute management, imaging, and prognosis", section on 'Renal
scintigraphy'.)
Pyuria The presence of WBC in the urine is not specific for UTI. However, true UTI without
pyuria (eg, positive leukocyte esterase on dipstick analysis, 5 WBC/hpf with standardized
microscopy, or 10 WBC/mm3 on a hemocytometer with an enhanced urinalysis) is unusual [16].
The absence of pyuria in the presence of significant bacteriuria may occur under the following
circumstances [19,38]:
Early in the course of UTI (before the local inflammatory response develops)
Colonization of the urinary tract (eg, asymptomatic bacteriuria)
In children who are suspected of having UTI but in whom pyuria is not detected on dipstick or
microscopic analysis, repeating the urinalysis and urine culture can help to distinguish between
early infection and colonization (algorithm 2) [6]:
Pyuria and bacteriuria on the second sample is suggestive of UTI
The absence of pyuria and bacteriuria on the second sample is suggestive of bacterial
contamination of the initial sample
Bacteriuria without pyuria on the second sample is suggestive of asymptomatic bacteriuria
DIFFERENTIAL DIAGNOSIS
Asymptomatic bacteriuria Asymptomatic bacteriuria (ie, colonization of the urinary tract with
bacteria in the absence of inflammation) occurs in 1 to 3 percent of infants and preschool age
children, and approximately 1 percent of older children [39,40]. The bacteria tend to be of low
virulence and are easily eliminated by antibiotics. However, in most children, asymptomatic
bacteriuria resolves spontaneously without causing renal scarring, decreased filtration rate, or
interfering with renal growth [41-43].
We do not recommend antibiotic treatment of asymptomatic bacteria in children. A meta-analysis of
three randomized trials found the evidence insufficient to determine the risks and benefits, but
concluded that antibiotic therapy is unlikely to benefit children in the long-term [44].
Other considerations The differential diagnosis in a child with suspected urinary tract infection
(UTI) depends upon the presenting symptoms and signs.
The differential diagnosis of a well-appearing infant who has fever without a definite source is
extensive, but most commonly includes UTI and occult bacteremia. In children vaccinated
against Haemophilus influenzae and Streptococcus pneumoniae, the probability of UTI (7
percent) is much higher than the probability of occult bacteremia (<1 percent) [2,45-47].
(See "Fever without a source in children 3 to 36 months of age".)
Urinary symptoms (eg, urgency, frequency, dysuria) and bacteriuria may be caused by
nonspecific vulvovaginitis, irritant (or chemical) urethritis (eg, bubble baths), urinary calculi,
urethritis secondary to a sexually transmitted disease (STD) (particularly Chlamydia), and
vaginal foreign body. (See "Evaluation of dysuria in children and
adolescents" and"Vulvovaginal complaints in the prepubertal child" and "Clinical features and
diagnosis of nephrolithiasis in children".)
Patients with group A streptococcal infection, appendicitis, and Kawasaki disease may
present with fever, abdominal pain, and pyuria. (See "Acute appendicitis in children: Clinical
manifestations and diagnosis" and "Kawasaki disease: Clinical features and diagnosis".)
Bowel and bladder dysfunction is a frequently overlooked diagnosis in children with urinary
symptoms and a negative urine culture. (See "Urinary tract infections in children:
Epidemiology and risk factors", section on 'Bowel and bladder dysfunction'.)
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(Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
Fever may be the only sign of urinary tract infection (UTI) in infants and young children.
Older children may have urinary symptoms (table 1). (See 'Clinical presentation' above.)
Important aspects of the history in a child with suspected UTI include features of the acute
illness (eg, fever, urinary symptoms) and risk factors for UTI (table 2). (See 'History' above
and "Urinary tract infections in children: Epidemiology and risk factors", section on 'Host
factors'.)
The examination of the child with suspected UTI should include measurement of blood
pressure, temperature, and growth parameters; abdominal examination for tenderness or
mass; assessment of suprapubic and costovertebral tenderness; examination of the external
genitalia; evaluation of the lower back for signs of occult myelodysplasia; and a search for
other sources of fever. (See 'Physical examination' above.)
The laboratory evaluation for the child with suspected UTI includes obtaining a urine sample
for a dipstick and/or microscopic evaluation and urine culture (table 3). Urine culture is
necessary to make the diagnosis. (See 'Laboratory evaluation' above.)
We suggest that urine samples be obtained for urinalysis and culture in the following patients
(algorithm 1A-C) (see 'Decision to obtain' above):
Girls and uncircumcised boys younger than two years with at least one risk factor for
UTI (history of UTI, temperature >39C, fever without apparent source [particularly if the
child will be treated with antibiotics], ill appearance, suprapubic tenderness, fever >24
hours, or nonblack race).
Circumcised boys younger than two years with suprapubic tenderness or at least two
risk factors for UTI (history of UTI, temperature >39C, fever without apparent source, ill
appearance, suprapubic tenderness, fever >24 hours, or nonblack race).
Girls and uncircumcised boys older than two years with any of the following urinary or
abdominal symptoms (abdominal pain, back pain, dysuria, frequency, high fever, or new-
onset incontinence).
Circumcised boys older than two years with multiple urinary symptoms (abdominal pain,
back pain, dysuria, frequency, high fever, or new-onset incontinence).
Febrile infants and children with abnormalities of the urinary tract or family history of
urinary tract disease.
Catheterization is the preferred method of urine collection for infants and young children who
are not toilet-trained. Clean catch is the preferred method of collection for toilet-trained
children. We recommend that urine obtained in a sterile bag not be used for culture.
(See 'How to obtain' above.)
We suggest that urine culture be performed routinely for all children in whom UTI is a
diagnostic consideration and in whom a sample for urinalysis or dipstick is collected.
(See'Urine culture' above.)
The diagnosis of UTI requires laboratory confirmation. UTI is best defined as significant
bacteriuria in a patient with pyuria on dipstick or microscopic urinalysis. We define significant
bacteriuria as recovery of 100,000 CFU/mL of a uropathogen from a clean catch specimen,
50,000 CFU/mL of a uropathogen from a catheterized specimen, and any uropathogenic
bacteria from a suprapubic aspirate. (See 'Significant bacteriuria' above.)
Urinary tract infections in infants and children older than one month: Acute management,
imaging, and prognosis
Authors
Nader Shaikh, MD
Alejandro Hoberman, MD
Section Editors
Morven S Edwards, MD
Tej K Mattoo, MD, DCH, FRCP
Deputy Editor
Mary M Torchia, MD
Disclosures: Nader Shaikh, MD Nothing to disclose. Alejandro Hoberman, MD Nothing to disclose. Morven S
Edwards, MD Grant/Research/Clinical Trial Support: Novartis Vaccines [Group B Streptococcus].
Consultant/Advisory Boards: Novartis Vaccines [Group B streptococcal vaccine development]. Tej K Mattoo, MD,
DCH, FRCP Nothing to disclose. Mary M Torchia, MD Employee of UpToDate, Inc.
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed
by vetting through a multi-level review process, and through requirements for references to be provided to support the
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All topics are updated as new evidence becomes available and our peer review process is
complete.
Literature review current through: Sep 2014. | This topic last updated: Aug 20, 2014.
INTRODUCTION Urinary tract infections (UTI) are a common and important clinical problem in
childhood. Upper urinary tract infections (ie, acute pyelonephritis) may lead to renal scarring,
hypertension, and end-stage renal dysfunction. Although children with pyelonephritis tend to
present with fever, it can be difficult on clinical grounds to distinguish cystitis from pyelonephritis,
particularly in young children (those younger than two years) [1]. Thus, we have defined UTI broadly
here without attempting to distinguish cystitis from pyelonephritis. Acute cystitis in older children is
discussed separately. (See "Acute cystitis: Clinical features and diagnosis in children older than two
years and adolescents".)
The acute management and prognosis of UTI in children will be reviewed here. The epidemiology,
risk factors, clinical features, diagnosis, long-term management, and prevention of UTI in children
and UTI in newborns are discussed separately. (See "Urinary tract infections in children:
Epidemiology and risk factors" and "Urinary tract infections in infants and children older than one
month: Clinical features and diagnosis" and "Urinary tract infections in children: Long-term
management and prevention" and "Urinary tract infections in newborns".)
OVERVIEW
Goals The goals of treatment for urinary tract infections (UTI) include [2,3]:
Elimination of infection and prevention of urosepsis
Prevention of recurrence and long-term complications including hypertension, renal scarring,
and impaired renal growth and function
Relief of acute symptoms (eg, fever, dysuria, frequency)
Acute management of UTI in children consists of antimicrobial therapy to treat the acute infection
and evaluation for possible predisposing factors (eg, urologic abnormalities). Long-term
management centers on prevention of recurrence and complications; it is discussed separately.
(See "Urinary tract infections in children: Long-term management and prevention".)
Decision to hospitalize Most infants older than two months with UTI can be safely managed as
outpatients as long as close follow-up is possible [3-5].
Usual indications for hospitalization and/or parenteral therapy include [3,6]:
Age <2 months
Clinical urosepsis (eg, toxic appearance, hypotension, poor capillary refill)
Immunocompromised patient
Vomiting or inability to tolerate oral medication
Lack of adequate outpatient follow-up (eg, no telephone, live far from hospital, etc)
Failure to respond to outpatient therapy (see 'Response to therapy' below)
ANTIBIOTIC THERAPY The effectiveness of antimicrobial therapy for urinary tract infections
(UTI) is demonstrated by the change in mortality between the pre- and post-antibiotic eras. The
mortality of UTI was as high as 20 percent in the preantibiotic era. In contrast, when UTI are
appropriately treated with antibiotics, acute complications (eg, renal abscess, death) are uncommon
[7]. (See 'Prognosis' below.)
Antimicrobial therapy for children with presumed UTI depends upon a number of factors, including
the age of the child, severity of illness, presence of vomiting, duration of fever before presentation,
underlying medical and/or urologic problems, and the antimicrobial resistance patterns in the
community.
Empiric therapy Early and aggressive antibiotic therapy (eg, within 72 hours of presentation) is
necessary to prevent renal damage. Delayed therapy has been associated with increased severity
of infection and greater likelihood of renal damage in experimental, retrospective, prospective, and
small randomized studies [8-15].
Decisions regarding the initiation of empiric antimicrobial therapy for UTI are best made on a case-
by-case basis based upon the probability of UTI, which is determined by demographic and clinical
factors [16].
We suggest that empiric antimicrobial therapy be initiated immediately after appropriate urine
collection in children with suspected UTI and a positive urinalysis. This is particularly true for
children who are at increased risk for renal scarring if UTI is not promptly treated, including children
who present with:
Fever (especially >39C [102.2F] or >48 hours)
Ill appearance
Costovertebral angle tenderness
Known immune deficiency
Known urologic abnormality
Choice of agent A Gram-stained smear of the urine, if readily available, can help guide
decisions regarding empiric therapy. The ultimate choice of antimicrobial therapy is based upon the
susceptibilities of the organism isolated.
Escherichia coli is the most common bacterial cause of UTI; it accounts for approximately 80
percent of UTI in children [17]. Other gram-negative bacterial pathogens
include Klebsiella,Proteus, Enterobacter, and Citrobacter. Gram-positive bacterial pathogens
include Staphylococcus saprophyticus, Enterococcus, and, rarely, Staphylococcus aureus.
(See "Urinary tract infections in children: Epidemiology and risk factors", section on 'Microbiology'.)
We recommend that empiric therapy for UTI in infants and children include an antibiotic that
provides adequate coverage for E. coli. The agent of choice should be guided by local resistance
patterns.
Approximately 50 percent of E. coli are resistant to amoxicillin or ampicillin [18-21]. In addition,
increasing rates of E. coli resistance to first-generation cephalosporins (eg, cephalexin),amoxicillin-
clavulanate or ampicillin-sulbactam, and trimethoprim-sulfamethoxazole (TMP-SMX) have been
reported in some communities [17-25]. Increased resistance to extended-spectrum cephalosporins
(cefotaxime, ceftazidime, cefepime), has been reported in children receiving prophylactic antibiotics
[26-28]. (See 'Recent antibiotic exposure' below.)
Third-generation cephalosporins
(eg, cefpodoxime, cefixime, cefdinir, ceftibuten, cefotaxime, ceftriaxone) and aminoglycosides
(eg, gentamicin, amikacin) are appropriate first-line agents for empiric treatment of UTI in children.
However, these drugs are not effective in treating Enterococcus and should not be used as
monotherapy for patients in whom enterococcal UTI is suspected (eg, those with a urinary catheter
in place, instrumentation of the urinary tract, or an anatomical abnormality). In such
patients, amoxicillin or ampicillin should be added. Hydration status and renal function should be
assessed in patients who are treated with aminoglycosides.
Oral therapy Most children older than two months of age who are not vomiting can be treated
with orally administered antimicrobials [3,29]. Close contact with the family should be maintained for
the first two to three days of therapy; the seriousness of the infection and the need for completion of
the entire course of therapy should be stressed.
We suggest a third-generation cephalosporin (eg, cefixime cefdinir, ceftibuten) as the first-line oral
agent in the treatment of UTI in children without genitourinary abnormalities [4,5,30,31]. In a
randomized, controlled trial of 306 children 1 to 24 months of age with a febrile UTI, oral therapy
with cefixime for 14 days was as effective as intravenous therapy with cefotaxime for three days
followed by oral therapy with cefixime [4]. The rates of symptom resolution (mean time to
defervescence approximately 24 hours), sterilization of the urine (100 percent), reinfection (4.6 and
7.2 percent), and renal scarring at six months (9.8 and 7.2 percent) did not differ between groups.
A similar trial in children 6 months to 16 years, albeit limited by imbalances in treatment group
comparability at baseline and high drop-out rates, found once-daily therapy with ceftibuten to be
comparable to initial therapy with ceftriaxone followed by ceftibuten [30]. Oral amoxicillin-
clavulanate (50 mg/kg per day in three divided doses) also was shown to be as effective as
parenteral therapy followed by oral therapy in a multicenter, randomized trial [32].
However, amoxicillin-clavulanate is associated with increasing rates of resistance. In a child with a
penicillin and cephalosporin allergy, treatment with trimethoprim-sulfamethoxazole (TMP-SMX),
or ciprofloxacin (if the local resistance rates to TMP-SMX are known to be high) and close follow-up
of the antimicrobial sensitivity results is a reasonable strategy.
Cefixime, cefdinir, and ceftibuten are dosed as follows:
Cefixime (16 mg/kg by mouth on the first day, followed by 8 mg/kg once daily to complete
therapy) (see 'Duration of therapy' below)
Cefdinir (14 mg/kg by mouth once daily)
Ceftibuten (9 mg/kg by mouth once daily)
Other third-generation cephalosporins that may be used for oral therapy
include cefpodoxime (10 mg/kg once daily) [3]. However, no large trials have specifically examined
the efficacy of these agents for pediatric UTI.
Amoxicillin and ampicillin are not routinely recommended for empiric therapy because of the high
rate of resistance of E. coli. Similarly, amoxicillin-clavulanate, first-generation cephalosporins
(eg, cephalexin), and TMP-SMX should be used with caution because of the increasing rates of
resistance to these drugs in some communities [17-25].
Fluoroquinolones (eg, ciprofloxacin) are effective for E. coli, and resistance is rare. However, the
safety of quinolones in children is still under study [33]. In addition, the widespread use of
fluoroquinolones is leading to increased resistance among other bacteria [34-36]. Ciprofloxacin
should not be used as a first-line agent. The American Academy of Pediatrics (AAP) Committee on
Infectious Diseases recommends that the use of ciprofloxacin for UTI in children be limited to UTI
caused by Pseudomonas aeruginosa or other multidrug-resistant, gram-negative bacteria [33].
Oral agents that are excreted in the urine but do not achieve therapeutic serum concentrations (eg,
nalidixic acid, nitrofurantoin) should not be used to treat UTI in febrile infants and young children in
whom renal involvement is likely because parenchymal and serum concentrations may be
insufficient to treat pyelonephritis or urosepsis [3].
Parenteral therapy Third- or fourth-generation cephalosporins
(eg, cefotaxime, ceftriaxone, cefepime) and aminoglycosides (eg, gentamicin) are appropriate first-
line parenteral agents for empiric treatment of UTI in children. Definitive therapy is based upon the
results of urine culture and sensitivities.
Acceptable inpatient treatment regimens include the combination of ampicillin and gentamicin;
gentamicin alone; or a third- or fourth-generation cephalosporin [7,37,38]. Ampicillin should be
included if enterococcal UTI is suspected. (See 'Recent antibiotic exposure' below.)
The doses are as follows [3,39]:
Ampicillin (100 mg/kg/day IV divided in four doses)
Gentamicin (7.5 mg/kg/day IV divided in three doses)
Cefotaxime (150 mg/kg per day IV divided in three or four doses)
Ceftriaxone (50 to 75 mg/kg per day IV)
Cefepime (100 mg/kg per day divided in two doses for children weighing 40 kg, maximum
daily dose 1 g; 500 mg twice per day for children weighing >40 kg)
Parenteral antibiotics should be continued until the patient is clinically improved (eg, afebrile) and
able to tolerate oral liquids and medications [3].
Outpatient parenteral therapy Once-daily parenteral administration
of gentamicin or ceftriaxone in a day treatment center may avoid the need for hospital admission in
select patients (eg, children who are 3 months old who are unable to tolerate oral therapy and are
nontoxic appearing, well hydrated, without urologic abnormalities, and whose caretakers will be
able to adhere to the outpatient regimen) [40-42].
Recent antibiotic exposure Recent exposure to antibiotics, whether for treatment of an
infection or as antimicrobial prophylaxis, is an important consideration in the choice of empiric
antibiotic therapy [26-28,43,44].
Recurrent UTI Review of the antimicrobial susceptibilities of the most recent urinary pathogens
can be helpful in choosing empiric therapy for children with recurrent UTI.
Duration of therapy In a systematic review, short course antimicrobial therapy (two to four days)
was as effective as standard duration (7 to 14 days) therapy in eradicating bacteria in children with
suspected lower urinary tract infection (ie, afebrile children) [45]. However, little evidence is
available to guide duration of antimicrobial therapy in children with febrile UTIs. A multicenter trial,
sponsored by the National Institutes of Health, is being conducted to determine the efficacy of
short-course therapy for UTI in children. If efficacious, short-course therapy may enable clinicians to
limit the duration of exposure to antimicrobials to that needed to eradicate the offending
uropathogen, reducing the likelihood of adverse events and the emergence of bacterial resistance.
In the meantime, we suggest a longer course of therapy for febrile children (usually 10 days) and a
short course of therapy (three to five days) for immune competent children presenting without fever.
Response to therapy
Clinical response The clinical condition of most patients improves within 24 to 48 hours of
initiation of appropriate antimicrobial therapy [46].
The mean time to resolution of fever is 24 hours, but fever may persist beyond 48 hours [4]. In a
review of 288 children younger than two years who were admitted to a tertiary-care children's
hospital with febrile UTI, 89 percent were afebrile within 48 hours of antimicrobial therapy [46]. No
differences were noted between those who remained febrile >48 hours and those who were afebrile
within 48 hours with respect to bacteremia (42 and 35 percent, respectively), hydronephrosis (3 and
8 percent, respectively) and significant vesicoureteral reflux (VUR) (19 and 14 percent,
respectively).
In children whose clinical condition (other than persistent fever) worsens or fails to improve as
expected within 48 hours of initiation of antimicrobial therapy, broadening antimicrobial therapy may
be indicated if the culture and sensitivity results are not yet available. Most of the empiric regimens
suggested above do not provide adequate coverage for Enterococcus.
In addition, in children who worsen or fail to improve within 48 hours, renal and bladder
ultrasonography (RBUS) should be performed as soon as possible (to evaluate the presence of a
renal abscess or surgically correctable anatomic abnormalities or obstruction) [3,47,48].
(See 'Imaging' below.)
Repeat urine culture Several observational studies suggest there is little utility in repeating the
urine culture in children with UTI who are treated with an antibiotic to which their uropathogen is
susceptible [46,49,50].
Accordingly, it is not necessary to routinely obtain repeat urine cultures during antimicrobial therapy
to document sterilization of the urine, provided that the child has had the expected clinical response
and the uropathogen is susceptible to the antibiotic that is used for treatment [46,49-51]. However,
urine cultures should be performed after 48 hours of therapy if the patient fails to respond clinically
or if the uropathogen is not susceptible (intermediate or resistant) to the antibiotic that is being used
for treatment. It is important to routinely perform susceptibility testing on the isolated uropathogens
to avoid unnecessary delay in administration of appropriate therapy.
Prophylactic antibiotics Decisions regarding prophylactic antibiotics for children following initial
febrile UTI should be made on a case-by-case basis.
Antibiotic prophylaxis for children who have undergone VCUG and have documented VUR
(of any grade) is discussed separately (see 'Voiding cystourethrogram' below
and"Management of vesicoureteral reflux")
For children who have undergone VCUG and do not have VUR or
other renal/urologic abnormalities, we generally do not suggest prophylactic antibiotics after
the first febrile UTI
For children with a first febrile UTI and for whom a decision is made to defer VCUG pending
recurrence (but who may have VUR), factors to consider include (see 'Voiding
cystourethrogram' below):
The decreased risk of febrile or symptomatic UTI recurrence in children with VUR,
particularly in those with bowel and bladder dysfunction, and febrile first UTI [52]
Family history of VUR, which increases the risk of VUR (see "Presentation, diagnosis,
and clinical course of vesicoureteral reflux", section on 'Genetics')
Age, sex, and race/ethnicity, all of which affect the probability of VUR (increased in
children <2 years, girls, and white versus black children) (see "Presentation, diagnosis,
and clinical course of vesicoureteral reflux", section on 'Epidemiology')
Severity of the UTI
The importance the parents place on prevention of recurrence (which may result in
alarming symptoms, hospitalization, and loss of work)
Ability to adhere to prophylaxis
Parental concern about development of antimicrobial resistance and potential impact on
the microbiome
Whether administration of prophylactic antibiotics after initial febrile UTI prevents recurrent urinary
tract infection or renal scarring in children (with and without VUR) has been controversial.
Randomized trials evaluating this question have had inconsistent results [53-58]. A meta-analysis of
individual data in infants and young children (2 to 24 months) without VUR and with VUR of grades
I to IV did not detect a benefit for prophylaxis in preventing recurrence [3]. However, some of the
included trials had methodologic problems potentially biasing results toward no effect (eg,
insufficient power; lack of blinding; non-stringent diagnostic criteria; inclusion of uncircumcised
boys, which limits generalizability to populations where most boys are circumcised; and
misclassification of asymptomatic bacteriuria as recurrent UTIs) [59].
Two large, well-designed trials, one included in the meta-analysis [54], and one published
subsequently (the Randomized Intervention for Vesicoureteral Reflux [RIVUR] trial) [52],
demonstrate that antimicrobial prophylaxis prevents recurrent UTI in children with VUR. The RIVUR
trial evaluated the efficacy of trimethoprim-sulfamethoxazole (TMP-SMX) prophylaxis
3mg/kg of trimethoprim plus 15 mg/kg of sulfamethoxazole daily in preventing febrile or
symptomatic urinary tract infection recurrences (primary outcome) in 607 children (two months to
six years) who were diagnosed with grade I to IV VUR after a first or second febrile or symptomatic
UTI and were followed for two years. Renal scarring, treatment failure (a composite of recurrences
and scarring), and antimicrobial resistance were secondary outcomes. Key findings were as follows:
Fewer children who received TMP-SMX had recurrent febrile or symptomatic UTI (13 versus
25 percent), reducing the risk of recurrent febrile or symptomatic UTI by 50 percent (hazard
ratio [HR], 0.50, 95% CI 0.34-0.74).
In subgroup analysis, antibiotic prophylaxis was most effective in children with bowel and
bladder dysfunction (hazard ratio 0.21, 95% CI 0.08-0.58) and children whose first UTI was
febrile (HR 0.41, 95% CI 0.26-0.64).
TMP-SMX prophylaxis did not reduce the incidence of renal scarring (11.9 and 10.2 percent),
severe renal scars (4.0 and 2.6 percent), or new renal scars (8.2 and 8.4 percent), as
assessed by renal scintigraphy at baseline, one-year follow-up, and two-year follow-up.
Compared to children in the placebo group, children treated with TMP-SMX who had a first
recurrent E. coli UTI infection during the follow-up period had increased risk of TMP-SMX
resistance (63 versus 19 percent).
The 2011 AAP practice guideline does not recommend prophylactic antimicrobials following the first
febrile UTI in children 2 to 24 months [3]. The United Kingdoms National Institute for Health and
Care Excellence (NICE) guideline for UTI in children indicates that antibiotic prophylaxis should not
be routinely recommended in infants and children following their first UTI, but may be warranted
after recurrent UTI [51]. (See "Urinary tract infections in children: Long-term management and
prevention", section on 'Prophylaxis'.)
ADJUNCTIVE THERAPIES Renal parenchymal inflammation during urinary tract infections (UTI)
may lead to renal scarring, although the predisposing factors are not well understood [60]. The role
of renal parenchymal inflammation in the development of renal scars, and the potential role of anti-
inflammatory agents in preventing renal scars has been evaluated in several studies [61-63]. An
observational study demonstrated that dexamethasone decreased urinary levels of interleukin-6
and interleukin-8 in children, suggesting a possible role for glucocorticoids in the prevention of scar
formation [62]. This hypothesis was supported by a trial in which 84 children <16 years with first
episode of acute pyelonephritis and high risk of renal scar formation were randomly assigned to
receive oral methylprednisolone or placebo in addition to antibiotic therapy (19 in the
methylprednisolone group and 65 in the placebo group) [63]. Treatment with methylprednisolone
was associated with decreased renal scarring at six months (33 versus 60 percent in the
methylprednisolone and placebo groups, respectively) without significant adverse effects, relapse,
or recurrence.
Results of this small study are difficult to generalize because enrollment required 1) performance of
a renal scintigram within 48 hours of diagnosis, which was not conducted in all patients, and 2)
severe renal involvement in children who were all hospitalized. Additional studies are necessary to
confirm these results and to determine the optimum glucocorticoid regimen before adjunctive
glucocorticoids are routinely recommended in the treatment of UTI in children. A large randomized
trial sponsored by the National Institutes of Health is being conducted to answer these questions
[64].
IMAGING
Rationale The rationale for imaging in young children with urinary tract infections (UTI) is to
identify abnormalities of the genitourinary tract that require additional evaluation or management
(eg, obstructive uropathies, dilating vesicoureteral reflux [VUR]). If such abnormalities are detected,
steps can be taken to modify the risk of subsequent renal damage (eg, surgical intervention or
antibiotic prophylaxis to prevent recurrent UTI).
The ultimate value of detecting anatomic or functional abnormalities of the urinary tract depends
upon the effectiveness of the interventions designed to prevent recurrent UTI and renal scarring
[65,66]. Evidence to support the utility of routine imaging in reducing long-term sequelae (renal
scarring, hypertension, renal failure) is limited [67-70], and there is a lack of consensus about the
optimal imaging strategy [3,51,71-73].
Ultrasonography Renal and bladder ultrasonography (RBUS) is a non-invasive test that can
demonstrate the size and shape of the kidneys, the presence of duplication and dilatation of the
ureters, and the existence of gross anatomic abnormalities. RBUS can also identify renal or
perirenal abscess or pyonephrosis in children with acute UTI who fail to improve with antimicrobial
therapy. It is not reliable in detecting renal scarring or VUR [74,75]. (See "Presentation, diagnosis,
and clinical course of vesicoureteral reflux".)
RBUS is estimated to yield management-altering abnormalities (ie, requiring additional evaluation,
surgery) in only 1 to 2 percent of cases of first febrile UTI in young children 2 to 24 months of age
[1,3,53,76,77]. The false positive rate is between 2 and 3 percent [3]. The major advantage of
RBUS is the lack of exposure to radiation.
Indications Given the potentially large benefit of detecting correctible malformations for a small
number of children and the low risk of harm, we suggest RBUS for the following children:
Children younger than two years of age with a first febrile UTI
Children of any age with recurrent febrile UTIs
Children of any age with a UTI who have a family history of renal or urologic disease, poor
growth, or hypertension (calculator 1 and calculator 2)
Children who do not respond as expected to appropriate antimicrobial therapy
However, many women have prenatal ultrasonography after 30 to 32 weeks of gestation a time at
which the urinary tract is fully developed; we may elect not to perform RBUS (in children of any age)
if prenatal ultrasonography that was performed at a reputable center was normal and the study
results are accessible [78,79].
The American Academy of Pediatrics (AAP) recommends RBUS for all infants and children 2 to 24
months following their first febrile UTI [3]. The United Kingdoms National Institute for Health and
Care Excellence (NICE) guideline on UTI in children recommends RBUS for infants younger than
six months and for children older than six months who have atypical or recurrent UTI [51]. They
define atypical UTI as serious illness, poor urine flow, abdominal or bladder mass; elevated
creatinine, septicemia, infection with an organism other than E. coli, and failure to respond to
antibiotics within 48 hours; they define recurrence as 2 episodes of upper UTI, one episode of
upper UTI plus 1 episode of lower UTI, or 3 episodes of lower UTI.
Timing When the RBUS should be performed depends upon the clinical situation [3]. In infants
and young children with unusually severe illness or failure to improve as expected after initiation of
antimicrobial therapy, RBUS should be performed as soon as possible during the acute phase of
illness to identify complications (eg, renal or perirenal abscess, pyonephrosis). However, for infants
and young children who respond as expected to appropriate antimicrobial therapy, RBUS should be
performed after the acute phase (to reduce the risk of false positive results secondary to renal
inflammation during the acute episode) [3,51]. The decision to treat with prophylactic antibiotics
pending results of imaging is discussed above. (See 'Prophylactic antibiotics' above.)
Voiding cystourethrogram The voiding cystourethrogram (VCUG) is the test of choice to
establish the presence and degree of vesicoureteral reflux (VUR). VUR is the retrograde passage of
urine from the bladder into the upper urinary tract. Approximately 40 percent of young children with
a first febrile UTI have VUR [4]. (See "Presentation, diagnosis, and clinical course of vesicoureteral
reflux".)
VCUG involves catheterization to fill the bladder with a radiopaque or radioactive liquid and
recording of VUR during voiding. VCUG is expensive, invasive, and may miss a significant portion
of children who are at risk for renal scarring [66]. The radiation exposure depends upon the
technique and equipment used (the pediatric effective dose estimate ranges from 0.03 to 0.3 mSV)
[80]. (See "Presentation, diagnosis, and clinical course of vesicoureteral reflux", section on
'Diagnosis' and "Radiation-related risks of imaging studies".)
Indications Decisions about performing a VCUG in infants and children with UTI must take into
consideration the factors described above, namely likelihood of VUR, severity of UTI, importance
parents place in preventing recurrences, cost and discomfort of the VCUG, perceived likelihood of
adherence to prophylaxis, and concerns about resistance. (See 'Prophylactic antibiotics' above.)
Pending results of ongoing cost-effectiveness analysis of the Randomized Intervention for
Vesicoureteral Reflux (RIVUR) data, we suggest performance of a VCUG to diagnose VUR in:
Children of any age with two or more febrile UTIs.
Children of any age with a first febrile UTI who have any anomalies on renal ultrasound or a
family history of renal or urologic disease; and children with poor growth or hypertension
(calculator 1 and calculator 2).
These children are more likely to have VUR and VCUG findings are more likely to influence
management. (See "Presentation, diagnosis, and clinical course of vesicoureteral
reflux" and"Management of vesicoureteral reflux".)
For children with a first febrile UTI and without abnormalities on renal ultrasonography, family
history of renal or urologic disease, poor growth, and hypertension, a strategy of watchful waiting
(ie, observation and performance of VCUG with recurrence) seems reasonable [81], particularly if
the family would prefer to avoid prophylactic antibiotics. These children are less likely to have VUR
and VCUG results are less likely to affect management.
It remains uncertain whether the benefits of detection and treatment of VUR after the first UTI
outweigh the risks [66]. The uncertainty centers on the changing view of the role of VUR in the
development of renal damage and progressive kidney disease and the lack of clarity regarding the
effectiveness of medical or surgical management of VUR in reducing the risk of renal scarring [66].
Although the risk of renal scarring is increased in children with VUR compared with children without
VUR (41 versus 17 percent in a systematic review) and increases with increasing grades of VUR,
VUR is neither necessary nor sufficient for the development of renal scars. (See "Presentation,
diagnosis, and clinical course of vesicoureteral reflux".)
Early trials comparing antireflux surgery with antimicrobial prophylaxis in children with VUR showed
no differences in rates of recurrent UTI or renal scarring [82-85], but the lack of a placebo or
observation group precluded determination that either treatment was more effective than no
treatment [82-85]. Subsequent randomized trials comparing antimicrobial prophylaxis with no
treatment or placebo had inconsistent results regarding recurrence of UTI, but most of these trials
were not blinded [53-57,59].
(See "Management of vesicoureteral reflux", section on 'Choice of therapy'.)
The RIVUR trial addressed many of these issues. It evaluated the efficacy of trimethoprim-
sulfamethoxazole (TMP-SMX) prophylaxis in preventing febrile or symptomatic urinary tract
infection recurrences (primary outcome) in 607 children (two months to six years) who were
diagnosed with grade I to IV VUR after a first or second febrile or symptomatic UTI and were
followed for two years [52]. Renal scarring, treatment failure (a composite of recurrences and
scarring), and antimicrobial resistance were secondary outcomes. The RIVUR trial demonstrated
unequivocally that prophylactic antibiotics decrease the risk of febrile, recurrent UTI (HR 0.50, 95%
CI 0.34 to 0.74) [52]. Nearly twice as many children receiving placebo than children receiving
prophylaxis were categorized as treatment failures (defined by two febrile UTIs, one febrile UTI and
three symptomatic UTIs, four symptomatic UTIs, or new or worsening renal scarring). However,
antibiotic prophylaxis did not reduce the risk of scarring, and was associated with antimicrobial
resistance. (See 'Prophylactic antibiotics' above.)
The 2011 AAP clinical practice guideline recommends postponing VCUG until the second febrile
UTI in children 2 to 24 months of age unless there are atypical or complex clinical circumstances or
the RBUS reveals hydronephrosis, scarring, or other findings suggestive of high-grade (IV or V)
VUR or obstructive uropathy [3]. According to the guideline, the benefit of avoiding radiation
exposure and discomfort in the majority of patients outweighs delayed detection of a small number
of cases of high-grade reflux or surgically correctible abnormalities. However, the guideline
acknowledges that parent preferences may play a role in the decision to perform VCUG.
The United Kingdoms NICE guideline suggests VCUG for infants <6 months with atypical or
recurrent UTI [51]. They define atypical UTI as serious illness, poor urine flow, abdominal or bladder
mass; elevated creatinine, septicemia, infection with an organism other than E. coli, and failure to
respond to antibiotics within 48 hours; they define recurrence as 2 episodes of upper UTI, one
episode of upper UTI plus 1 episode of lower UTI, or 3 episodes of lower UTI. The NICE
guidelines also suggest that VCUG may be warranted for children six months to three years with
atypical or recurrent UTI and dilation on ultrasonography, poor urine flow, non-E. coli infection, or
family history of VUR. They define atypical UTI as serious illness, poor urine flow, abdominal or
bladder mass; elevated creatinine, septicemia, infection with an organism other than E. coli, and
failure to respond to antibiotics within 48 hours; they define recurrence as 2 episodes of upper UTI,
one episode of upper UTI plus 1 episode of lower UTI, or 3 episodes of lower UTI.
Timing Although VCUG is often scheduled several weeks after UTI, it may be performed as
soon as the patient is asymptomatic [86]. Early imaging (as early as the first week) does not appear
to falsely increase the detection of VUR [87-90]. To avoid the use of prophylactic antibiotics in
children without VUR, we prefer to conduct VCUGs during the last days of antimicrobial therapy or
immediately after completion of antimicrobial therapy for UTI.
Renal scintigraphy Renal scintigraphy using dimercaptosuccinic acid (DMSA) can be used to
detect acute pyelonephritis and renal scarring in the acute and chronic settings, respectively
[1,3,91]. DMSA is injected intravenously, and uptake by the kidney is measured two to four hours
later. Areas of decreased uptake represent pyelonephritis or scarring. DMSA scans are expensive,
invasive, and expose children to radiation (the pediatric effective dose estimate ranges from 0.3 to 3
mSV) [80]. (See "Radiation-related risks of imaging studies".)
The role of renal scintigraphy in the management of children with acute UTI is controversial.
Scintigraphy at the time of an acute UTI provides information about the extent of renal parenchymal
involvement. In addition, DMSA will identify most (>70 percent) children with moderate to severe
VUR (grade III or higher) [92-94]. This observation has prompted some experts to suggest that
DMSA be used as the initial imaging test to identify children at higher risk for renal scarring (the top
down approach) [95].
However, using DMSA as the initial test to identify high-risk children is more expensive, and
involves greater exposure to radiation [96]. Furthermore, since most young febrile children with UTI
have pyelonephritis and a positive DMSA, this strategy may lead to identification of a large number
of children who may or may not be at risk for future UTI [1,66]. In a systematic review of 33 studies,
approximately 60 percent of children with initial UTI had DMSA scans consistent with acute
pyelonephritis in the acute phase of illness, but only 15 percent had renal scarring at follow-up [66].
It is unclear how to best manage children with positive acute-phase DMSA scan. Careful clinical
follow-up of all children with UTI may obviate the need for routine DMSA. (See 'Follow-up' below.)
We suggest not using DMSA in the routine evaluation of children with first UTI. This is consistent
with the AAP and NICE guidelines [3,51].
Some experts recommend DMSA 6 to 12 months after acute infection to detect the formation of
scarring which would require follow-up [97,98]. The NICE guidelines recommend DMSA four to six
months after acute infection for children younger than three years with atypical or recurrent UTI and
for children older than three years with recurrent UTI [51]. They define atypical UTI as serious
illness, poor urine flow, abdominal or bladder mass; elevated creatinine, septicemia, infection with
an organism other than E. coli, and failure to respond to antibiotics within 48 hours; they define
recurrence as 2 episodes of upper UTI, one episode of upper UTI plus 1 episode of lower UTI, or
3 episodes of lower UTI.
FOLLOW-UP Recurrent urinary tract infection (UTI) is a risk factor for renal scarring. Parents of
infants and young children who have been treated for a febrile UTI and children with bowel and
bladder dysfunction (a risk factor for recurrent UTI) should be instructed to seek prompt evaluation
for subsequent febrile illnesses to ensure prompt recognition and treatment of recurrent UTI
[3,51,59]. The evaluation of these episodes should include urinalysis and urine culture [1]. Among
children younger than six years, the risk of recurrence appears to be increased in those who are
white (hazard ratio [HR], 2.0), age three to five years (HR ~2.5), and those with grade IV to V VUR
(HR 4.38) [43].
Prompt diagnosis and effective treatment of recurrent febrile UTI and treatment of bowel and
bladder dysfunction that predisposes many children to UTI may be more important than identifying
anatomic or functional genitourinary abnormalities after the first febrile UTI in preventing renal
scarring [3]. The risk of renal scarring increases with recurrent episodes of pyelonephritis, from
approximately 5 percent after the first episode to 10 percent after the second, 20 percent after the
third, 40 percent after the fourth, and 60 percent after the fifth [99].
Primary care follow-up for infants and young children who have had a febrile UTI should include
regular monitoring of height, weight, and blood pressure. (See "Clinical presentation and evaluation
of chronic kidney disease in children", section on 'Clinical presentation'.)
INDICATIONS FOR REFERRAL Potential indications for referral to a nephrologist or urologist
with expertise in children include [51]:
Dilating vesicoureteral reflux (Grades III to V) or obstructive uropathy
Renal abnormalities
Impaired kidney function
Elevated blood pressure
Bowel and bladder dysfunction refractory to primary care measures (see "Urinary tract
infections in children: Long-term management and prevention", section on 'Children with
bowel and bladder dysfunction')
PROGNOSIS The short-term outcome of first urinary tract infection (UTI) in children (<19 years)
was described in a systematic review of 33 studies, including 4891 children [66]:
Twenty-five percent had vesicoureteral reflux (VUR); 2.5 percent had grade IV or V VUR
VUR was associated with an increased risk of developing acute pyelonephritis (relative risk
[RR] 1.5, 95% CI 1.1-1.9) and renal scarring (RR 2.6, 95% CI 1.7-3.9); grade III VUR was
associated with increased risk of renal scarring compared with lower grades (RR 2.1, 95% CI
1.4-3.2)
Fifteen percent (95% CI 11-18 percent) of children had evidence of renal scarring on follow-
up dimercaptosuccinic acid (DMSA) scan (5 to 24 months later); the long-term significance of
scarring, as identified by DMSA, remains to be determined
Eight percent (95% CI 5-11 percent) of children had at least one recurrence
Risk factors for recurrence among children younger than six years include white race (hazard ratio
[HR], 2.0), age three to five years (HR ~2.5), and grade IV to V VUR (HR 4.38) [43].
Predicting which children with UTI will develop long-term sequelae remains difficult. A systematic
review of the literature found only four prospective, relatively small studies addressing this question
[100]. The large majority of children with UTI have no long-term sequelae, as illustrated by the
following studies:
In a study of 111 high-risk girls who were followed for 6 to 32 years after their initial UTI, only
seven (6 percent) had decreased glomerular filtration rate (GFR), and none developed chronic
kidney disease [101].
In another study of 68 children with history of urographic renal scarring who were followed for
16 to 26 years after their index UTI, median GFR [67] and mean 24-hour ambulatory blood
pressure [102] were no different in children with and without urographic renal scarring. No
child developed chronic kidney disease.
In a study of 226 children with UTI followed for one to 41 years, two developed chronic
kidney disease that appeared to be attributable to the UTIs [103].
The prognosis for children with nonfebrile UTI is discussed separately. (See "Acute cystitis:
Management and prognosis in children older than two years and adolescents", section on
'Prognosis'.)
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Here are the patient education articles that are relevant to this topic. We encourage you to print or
e-mail these topics to your patients. (You can also locate patient education articles on a variety of
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Basics topic (see "Patient information: Urinary tract infections in children (The Basics)")
Beyond the Basics topic (see "Patient information: Urinary tract infections in children
(Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
Most children with urinary tract infection (UTI) can be managed as outpatients. Indications for
hospitalization may include age <2 months, clinical urosepsis, immunocompromised patient,
vomiting or inability to tolerate oral medication, lack of outpatient follow-up, and failure to
respond to outpatient therapy. (See 'Decision to hospitalize' above.)
Empiric antimicrobial therapy immediately after appropriate urine collection is warranted in
children with suspected UTI and a positive urinalysis. This is particularly true for young
children with fever (especially if >39C [102.2F] or >48 hours), ill appearance, costovertebral
angle tenderness, known immune deficiency, or known urologic abnormality. (See'Empiric
therapy' above.)
We recommend that empiric therapy for UTI in children include an antibiotic that provides
adequate coverage for Escherichia coli (Grade 1B). The agent of choice should be guided by
local resistance patterns. Definitive therapy is based upon the results of urine culture and
sensitivities. (See 'Choice of agent' above.)
We suggest a third-generation cephalosporin (eg, cefixime, cefdinir, ceftibuten) as the
first-line oral agent in the treatment of UTI in children without genitourinary abnormalities
(Grade 2A). Amoxicillin or ampicillin should be added if enterococcal infection is
suspected. (See 'Oral therapy' above.)
Third- or fourth-generation cephalosporins (eg, cefotaxime, ceftriaxone, cefepime) and
aminoglycosides (eg, gentamicin) are appropriate first-line parenteral agents for empiric
treatment of UTI in children. (See 'Parenteral therapy' above.)
The duration of therapy depends upon the age of the child and the clinical scenario.
(See 'Duration of therapy' above.)
Febrile children are usually treated for 10 days
Afebrile children are usually treated for shorter periods (3 to 5 days) (see 'Duration of
therapy' above and "Acute cystitis: Clinical features and diagnosis in children older than
two years and adolescents")
The clinical condition of most patients improves within 24 to 48 hours of initiation of
appropriate antimicrobial therapy. (See 'Clinical response' above.)
In children whose clinical condition worsens or fails to improve as expected within 24 to 48
hours of initiation of antimicrobial therapy, broadening of empiric therapy may be indicated.
Renal bladder ultrasonography (RBUS) should be performed as soon as possible to evaluate
the presence of renal abscess or surgically correctable anatomic abnormalities or obstruction.
(See 'Clinical response' above.)
We obtain routine RBUS after first febrile UTI in children younger than two years who did not
have normal prenatal ultrasonography at a reputable center at >30 to 32 weeks of gestation.
We also obtain RBUS for children of any age with recurrent febrile UTIs and children of any
age with a first UTI who have poor growth, hypertension, or a family history of renal or urologic
disease. (See 'Ultrasonography' above.)
We obtain voiding cystourethrogram (VCUG) to evaluate possible vesicoureteral reflux
(VUR) for children of any age with 2 febrile UTIs or a first febrile UTI who have any
anomalies on renal ultrasound or a family history of renal or urologic disease; and children
with poor growth or hypertension. (See 'Voiding cystourethrogram' above.)
The majority of children with UTI have no long-term sequelae. Prediction of long-term
sequelae in children with UTI remains difficult. (See 'Prognosis' above.)