Work-up of Pediatric Urinary Tract Infection

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Key points

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    Given the high false-positive rate of urinary tests it is important to test a population with a high pretest probability of infection.

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    The sensitivity and specificity of a catheterized specimen is significantly better than those of a bagged sample, and has a specificity of 83% to 89% compared with a suprapubic sample; in samples with greater than 100,000 colony-forming units/mL approaches 99%.

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    Comparing a positive urine dipstick and positive microscopic analysis showed no difference between the

History and physical

Clinicians must have a high index of suspicion for UTI in the pediatric population, especially in infants and children less than 2 years of age. The evaluation must include a thorough history and the importance of the physical examination in pediatric patients cannot be overstated.

Adolescent girls and urinary tract infection

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    Adolescent girls with urinary symptoms often present with a UTI, STI, or both. Statistics on STI rates vary, with a prospective study finding that 29% of adolescent girls with urinary symptoms had had an STI.14 Among sexually active girls with urinary symptoms, history of STI, more than 1 partner in the last 3 months, and urinalysis with blood and leukocyte esterase were predictive of STI.

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    No specific symptoms or history findings have been shown to reliably predict which adolescent girls with

Adolescent boys and urinary tract infection

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    Although the prevalence of UTI in this age group is low, several risk factors have been identified, including sexual activity and lack of circumcision.18

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    In adolescent boys with urinary symptoms it is also important to evaluate for balanitis xerotica obliterans, with nearly 35% incidence reported globally.19, 20 In pubertal boys, prostatitis can also present with symptoms of voiding dysfunction.21

Urine testing

Clinical and demographic factors should be used to determine the probability of an infection and guide the decision-making process to obtain a specimen for analysis. Given the high false-positive rate of urinary tests it is important to test a population with a high pretest probability of infection.22, 23

Bag Specimen

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    The simplest method of using a taped sterile bag to collect the urine is the least reliable, and has been consistently shown to have the greatest contamination rate.24, 25, 26

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    A positive urine culture from a bag specimen has up to a 75% rate of false-positives, with periurethral organisms being isolated more than 98% of the time. Given its low positive predictive value, this method of collection has the lowest diagnostic utility in the clinical setting.

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    If a bag specimen is negative, this can be

Dipstick Urinalysis

This is the most clinically available, affordable, and accessible urine test, and the most widely used in the outpatient setting. The most clinically useful findings are the presence or absence of leukocyte esterase and nitrite in the urine specimen.22, 31, 32

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    Positive leukocyte esterase is suggestive of inflammation in the urine and the presence of white blood cells (WBC). False-positives include other inflammatory conditions, such as Kawasaki disease; appendicitis; gastroenteritis; and

Imaging

There is no consensus on the need and optimal strategy for imaging in the setting of UTI in the pediatric population. The role and timing of imaging to evaluate for anatomic abnormalities and renal scarring, after a febrile UTI, is an area of debate. Renal bladder ultrasonography (RBUS), voiding cystourethrogram (VCUG), and dimercaptosuccinic acid (DMSA) scan are the most commonly used imaging modalities in this population; however, their role in diagnosis and management is controversial.

Treatment

Pediatric UTIs are treated with 2 goals: to eliminate the infection and prevent severe systemic illness; and to reduce possible long-term complications, such as renal scarring and hypertension.41

The decision to initiate empiric treatment should be based on clinical suspicion of infection based on history and physical examination and positive urinalysis on an appropriately collected urine specimen. Most patients can be treated as outpatients if the child appears nontoxic, can tolerate oral

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      The study was performed in 50 samples that were considered normal according to their negative results of dipstick chemical analysis, except for 6 samples presented positive results for leukocyte esterase test, the principle of leukocyte detection in dipsticks for urinalysis. Although this test display good sensitivity, specificity and positive predictive value for urinary tract infection diagnosis (around 80%) [37, 38, 39]. This observation isolated is not necessarily suggestive of urinary tract infection since false positive may result from the presence of bacteria from vaginal fluid, leukocyturia may continue even if an infectious process has been resolved, and in up to 37% of the cases the cause is unknown [39, 40, 41, 42].

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      The incidence of pediatric UTI is at least 2% in boys and 7% in girls, in the first 6 years of life. Escherichia coli is the most common pathogen, in pediatric UTI [8] as well as R. ornithinolytica is an unusual pathogen [5]. In English literature, only five cases of R. ornithinolytica infections are reported in childhood up to now.

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      The clinician should base the choice of agent on local antimicrobial sensitivity patterns (if available) and should adjust the choice according to sensitivity testing of the isolated uropathogen.69 Most patients can be treated in an outpatient basis with oral therapy, if the child has a nontoxic appearance, can tolerate oral medications, and the family complies with recommendations.73 On the other hand, inpatient parenteral therapy should be considered for acutely ill children, children who cannot tolerate oral therapy, or when adherence with the prescribed regimen is in question.6

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    Disclosures: The authors have nothing to disclose.

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