Review article
Urinary tract infections in infants and children

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Clinical manifestations

Young children with UTI often do not present with specific urinary tract symptoms (dysuria, urgency, or urinary frequency). The physical examination also is of limited value in detecting UTI because findings, such as reproducible suprapubic or costovertebral angle tenderness, are not reliable signs of UTI in the young child. Smellie et al [1] documented that the symptoms of infection in 200 children (3 days to 12 years of age) with UTI varied depending on the age of the child. The most common

Diagnosis

The clinician's major goal for the young child with a UTI is early diagnosis to allow identification of urinary tract abnormalities and preservation of renal function in the growing kidney. A urine specimen for culture is necessary to document a UTI in a young child [34], [35]. Urine specimens may be obtained by suprapubic bladder aspiration, urethral catheterization, or by the bag technique in the non–toilet-trained child and by voided midstream technique in the toilet-trained child. Cleansing

Management

The goals of management are (1) prompt diagnosis of concomitant bacteremia or meningitis, particularly in the infant less than 2 months of age; (2) prevention of progressive renal disease by eradication of the bacterial pathogen, identification of abnormalities of the urinary tract, and prevention of recurrent infections; and (3) resolution of the acute symptoms of the infection. Delay in initiation of antimicrobial therapy is associated with an increased risk of renal scarring [49].

Imaging

Urinary tract infection in young children is a marker for abnormalities of the urinary tract. Imaging studies are recommended for any boy or girl under 3 to 5 years of age with a positive urine culture obtained from an appropriate urine specimen [56], [62], [63], [64]. Imaging studies should also be considered in school-age or adolescent girls with recurrent pyelonephritis or hypertension. The goal in obtaining these studies is early identification and correction of congenital or acquired

Outcome

Renal scarring is found in approximately 10% of children after UTI [11], [69]. Although the mechanisms responsible for renal scarring are unclear, scarring has been associated with obstructive malformations of the urinary tract, VUR, recurrent UTI, and delay in antibiotic treatment of UTI. Wennerstrom et al [70] studied 74 children with renal scarring and no obstruction. Renal scarring in boys was largely congenital and associated with severe reflux and parenchymal damage. In contrast girls had

Prevention

Prevention of recurrent UTI focuses on detection and correction, if possible, of urinary tract abnormalities, such as posterior urethral valves or ureterovesicular obstruction. Patients with significant urinary tract abnormalities or frequent symptomatic UTI may benefit from prophylactic antibacterials [73]. Drugs of choice are nitrofurantoin and cotrimoxazole. This practice is based on a study conducted by Smellie et al [74] who examined the effect of antimicrobial prophylaxis in children with

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