Paeds · infectious-diseases
Urinary tract infection and pyelonephritis
Also known as Paediatric UTI · Febrile UTI · Acute pyelonephritis · Cystitis in children · Recurrent urinary tract infection · Vesicoureteral reflux with infection
Fellowship guide to paediatric urinary tract infection and pyelonephritis: the febrile infant as the great trap, reliable urine sampling by age, urinalysis and culture interpretation, oral versus intravenous therapy, the imaging and prophylaxis debate after a first febrile UTI, vesicoureteral reflux and the RIVUR evidence, and the prevention of renal scarring.
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Target exams
Red flags
- A febrile infant under three months whose urine is positive for pyuria and leucocyte esterase
- Fever with vomiting, flank or abdominal pain, and systemic toxicity suggesting pyelonephritis
- A toxic, lethargic, or poorly perfused child with suspected sepsis from a urinary source
- Recurrent febrile UTI, especially with voiding dysfunction, constipation, or a family history of reflux
- Failure to defervesce within 48 hours of appropriate antibiotics, suggesting obstruction or resistant organism
- Atypical infection with raised creatinine, hypertension, or a poor response mandating urgent imaging
- Urosepsis with shock or a neonate with jaundice and poor feeding as the only clue to UTI
Life stages
Care settings
Clinical exam formats
Board mappings
- Recognises UTI as a common and treatable cause of fever in infants and young children
- Selects the correct urine sampling method by age and obtains it before antibiotics
- Initiates appropriate empiric oral or intravenous antibiotics for suspected UTI
- Justifies the choice of antibiotic, route, and duration using current guideline evidence
- Applies the selective imaging strategy after a first febrile UTI
- Manages recurrent UTI, vesicoureteral reflux, and the prevention of renal scarring
- Empiric management of suspected UTI in a febrile infant or child
- Interpretation of urinalysis and urine culture, including contamination
- Counselling families about imaging, prophylaxis, and prognosis after UTI
- Bedside assessment of the febrile child with suspected UTI or pyelonephritis
- Urine sampling technique, indications for catheterisation, and culture interpretation
- Communication of the imaging plan, antibiotic course, and follow-up
- Level 1: Evaluates a febrile child and suspects UTI
- Level 2: Investigates and manages a first febrile UTI with selective imaging
- Level 3: Manages recurrent UTI, reflux, and complex or atypical infection
- Urine sampling methods and contamination risk by age
- Urinalysis and culture criteria for UTI diagnosis
- Imaging strategy and prophylaxis after a first febrile UTI
- History and examination of the child with suspected pyelonephritis
- Communication of diagnosis, antibiotic plan, and follow-up imaging
- Assessment of recurrent UTI and voiding dysfunction
- Diagnosis of UTI in febrile infants using catheter or suprapubic aspirate samples
- Empiric antibiotic selection and the oral versus intravenous decision
- Selective imaging and management of vesicoureteral reflux
- Recognition and management of UTI and pyelonephritis in children
- Appropriate urine sampling and interpretation of culture results
- Antibiotic stewardship, duration, and prevention of recurrence
- Canadian Paediatric Society approach to UTI in febrile children
- Selective imaging after a first febrile UTI
- Long-term follow-up for renal scarring, hypertension, and chronic kidney disease
Overview & Definition
A urinary tract infection is bacterial infection of the bladder, the collecting system, or the renal parenchyma, and it is one of the most common serious bacterial infections of childhood. In infants the presentation is usually non-specific fever alone, which makes UTI the diagnosis that must not be missed in any febrile child under two years. Pyelonephritis is the upper tract form, involving the kidney itself, and it carries the burden of fever, systemic illness, and the risk of permanent renal scarring. [2]
The reason this topic dominates paediatric exams is that the consequences of a missed or delayed diagnosis fall on the youngest patients. Renal scarring after pyelonephritis in a small child can lead to hypertension and chronic kidney disease decades later, so the threshold to sample urine in a febrile infant is deliberately low. The clinician's task is to obtain a reliable urine specimen before antibiotics, confirm the diagnosis with urinalysis and culture, treat promptly, and then decide selectively about imaging and prophylaxis. [1]
References12ShowHide
- [1]Roberts KB Urinary tract infection: clinical practice guideline for the diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months. Pediatrics, 2011.PMID 21873693
- [2]Mattoo TK Contemporary Management of Urinary Tract Infection in Children. Pediatrics, 2021.PMID 33479164
- [3]Hoberman A Antimicrobial prophylaxis for children with vesicoureteral reflux. N Engl J Med, 2014.PMID 24795142
- [4]Williams G Long-term antibiotics for preventing recurrent urinary tract infection in children. Cochrane Database Syst Rev, 2019.PMID 30932167
- [5]Hoberman A Imaging studies after a first febrile urinary tract infection in young children. N Engl J Med, 2003.PMID 12529459
- [6]Hoberman A Oral versus initial intravenous therapy for urinary tract infections in young febrile children. Pediatrics, 1999.PMID 10390264
- [7]Shaikh N Prevalence of urinary tract infection in childhood: a meta-analysis. Pediatr Infect Dis J, 2008.PMID 18316994
- [8]Shaikh N Identification of children and adolescents at risk for renal scarring after a first urinary tract infection: a meta-analysis with individual patient data. JAMA Pediatr, 2014.PMID 25089634
- [9]Morello W Acute pyelonephritis in children. Pediatr Nephrol, 2016.PMID 26238274
- [10]Montini G Prophylaxis after first febrile urinary tract infection in children? A multicenter, randomized, controlled, noninferiority trial. Pediatrics, 2008.PMID 18977988
- [11]Keren R Risk Factors for Recurrent Urinary Tract Infection and Renal Scarring. Pediatrics, 2015.PMID 26055855
- [12]Williams G Prevention of recurrent urinary tract infection in children. Curr Opin Infect Dis, 2009.PMID 19532083