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Urinary tract infection (UTI) is a common infection in children and infants all over the world
.
Currently, most of the existing guidelines for urinary tract infections in children come from Western countries
.
The Asian Association of Urinary Tract Infections and Sexually Transmitted Infections (AAUS) expert group formulated guidelines for the treatment of urinary tract infections in children in Asia in 2015, and through continuous collection of opinions and suggestions, the expert group recently revised and improved the guidelines based on the latest developments.
, And published in the Journal of Infection and Chemotherapy
.
This article sorts out some key contents for your reference
.
Figure UTI Risk Factors and Treatment Epidemiology The incidence of UTI urinary tract infections is 1% in boys under 10 years old and 3% in girls
.
At 3 months of age, the incidence of boys is higher than that of girls
.
According to reports, the total recurrence rate of UTI in the neonatal period is 25%, and the recurrence rate of children receiving toilet training is 30%-50%
.
Among them, more than 80% of UTIs are caused by Escherichia coli.
The most common mechanism of infection is retrograde rise, while hospital and systemic infections are rare
.
The classification of urinary tract infections in children UTI can be based on the site of infection (lower urinary tract/upper urinary tract), number of attacks (initial/recurrence), severity (mild/severe), symptoms (absent/present), or complex factors (simple infection) /Complex infection) for classification
.
This classification can reflect the severity of the infection
.
In actual clinical applications, the site of infection, number of attacks, severity and complex factors are more often used as the basis for evaluation (level of evidence LE: 2, grade of recommendation GR: B)
.
The first diagnosis 01 clinical symptoms and signs of UTI in infants and children are more non-specific symptoms in young children
.
Unexplained fever may be the only manifestation of young children, and it is also an important sign of renal parenchymal involvement
.
Other common non-specific symptoms include: sepsis, lethargy, prolonged jaundice, hematuria, poor feeding, vomiting, diarrhea, abdominal pain, irritability, stunted growth, cloudy or foul urine, and crying when urinating
.
The symptoms and signs of UTI in older children are more specific
.
Pyelonephritis mainly manifests as fever, chills, vomiting, back pain or abdominal pain, and rib percussive pain
.
Symptoms of lower urinary tract infection mainly include suprapubic pain, dysuria, frequent urination, urgency, dampness during the day, cloudy urine, and new enuresis at night
.
02 Medical history and physical examination When diagnosing UTI, the siblings or parents’ constipation, UTI or vesicoureteral reflux (VUR) history, and recent antibiotic use should be determined
.
Children should undergo a complete physical examination to rule out other possible causes of fever and pyuria
.
For children with febrile urethritis, the physical examination should also include genital abnormalities (phimosis in male patients, labial adhesions or vulvovaginitis in female patients), tenderness of the flanks or suprapubic bone, spina bifida, and basic neurological examinations As well as palpation of the abdominal mass
.
03 Urinalysis The focus of urinalysis is the analysis of leukocyte esterase and nitrite in urine, and the microscopic examination of pyuria and bacteriuria
.
The sensitivity of leukocyte esterase is about 79%, and the specificity is 87%.
The sensitivity of nitrite is low (about 50%), but the specificity is high (98%)
.
Therefore, a negative test for nitrite cannot rule out UTI, and a positive means that UTI is more likely
.
The combination of leukocyte esterase and nitrite test has a high degree of sensitivity and specificity
.
The enhanced urine analysis by the red blood cell counter has higher sensitivity and specificity than the standard analysis
.
04 Urine culture collection and interpretation Urine culture is the gold standard for diagnosis of UTI
.
However, the results may be affected by fecal bacterial contamination that colonizes the perineum and distal urethra
.
Suprapubic aspiration can avoid contamination, so it has been considered as the standard method for urinary culture in young children
.
For children who have undergone urination training, mid-stage urine can be collected for cultivation (LE: 3, GR: A)
.
The cut-off value of positive or negative culture results is related to the method of urine collection, not absolute
.
If the urine culture proves the growth of a single bacteria with the following colony counts, it is considered positive: (1) any growth from suprapubic suction, (2) urethral catheterization >5 × 104 CFU/ml, or ( 3) Collect >105 CFU/ml (LE: 3, GR: B) through mid-section urine
.
05 Asymptomatic bacteriuria Asymptomatic bacteriuria in infants is not easy to distinguish from real urinary tract infections
.
The 2011 AAP guidelines revised the definition of UTI, indicating that the final diagnosis of urinary tract infection is only based on the positive results of quantitative urine culture and urinalysis (LE: 3, GR: B)
.
Pyuria is a symptom of urinary tract infection, so whether pyuria is present can also help distinguish the two
.
Antibacterial treatment of UTI The antibacterial treatment of UTI depends on the site of infection (upper or lower urinary tract infection), the age of the patient, the severity of symptoms, and the antibiotic resistance of the community
.
For children with suggestive clinical symptoms and a positive urine test, they should begin empirical antibiotic therapy (LE: 2, GR: A) after obtaining a suitable urine specimen for culture
.
Common urinary tract pathogens include Escherichia coli (accounting for more than 80% of urinary tract infections in children), Klebsiella, Proteus, Enterobacter, Enterococcus, Citrobacter and Staphylococcus saprophyticus
.
The empirical use of antibiotics is guided by the local antibiotic resistance situation, and E.
coli is generally regarded as the main pathogen
.
Some experts recommend the use of third-generation cephalosporin as the initial treatment, but because the third-generation cephalosporin is a broad-spectrum drug, abuse may increase the resistance rate of urinary tract pathogens
.
When the susceptibility result of urine culture is clear, the treatment should be adjusted to the narrowest spectrum antibiotic
.
Oral quinolone antibiotics (such as ciprofloxacin) that are not approved for use in prepubertal children are very effective against most urinary tract pathogens, so these drugs are suitable for multidrug-resistant pathogens
.
Traditional first-line antibiotics for urinary tract infections in children, such as co-trimoxazole, have a resistance rate of over 50% in Taiwan and are no longer applicable
.
Common choices for oral antibiotics include first-generation cephalosporin or amoxicillin-clavulanic acid
.
Drugs that do not reach therapeutic levels in the blood (such as nalidixic acid or nitrofurantoin) should not be used to treat children with febrile urinary tract infections
.
When intravenous treatment is needed, the initial combination of ampicillin or ampicillin-sulbactam and aminoglycosides (such as gentamicin) or cephalosporin can achieve excellent therapeutic effects
.
Approximately 90% of febrile UTI infants will stop fever within 48 hours of starting appropriate parenteral therapy
.
Antibiotics can be administered parenterally for 2-4 days and then changed to oral
.
Long-term fever is more common in older children or children who suffer from lobar nephropathy, renal abscess, pyelonephritis, immunodeficiency, and infections caused by multi-drug resistant bacteria
.
Regardless of the route of administration, the entire course of antibiotic treatment should be 7 to 14 days
.
For more serious renal parenchymal infections, such as acute lobar nephropathy or renal abscess, the course of antibiotics needs to be extended to more than 14 days
.
For children with non-febrile bacterial cystitis, oral antibiotics for 2-4 days are usually the same as antibiotics for 7-14 days
.
For simple febrile UTI, regardless of the duration of fever, recurrence rate, and subsequent incidence of kidney damage, oral and parenteral administration routes are equally effective (LE: 2: GR: A)
.
For children with acute pyelonephritis, oral medications can be taken if they are tolerated.
According to the literature, experts recommend a treatment duration of 7-14 days
.
30%-50% of children with symptomatic UTI may have recurrent urinary tract infections after continuous preventive antibacterial treatment, and the recurrence rate is directly related to the number of previous UTI episodes
.
The sensitivity of recurrence within 2 to 6 months after UTI is the highest, and the benefits and risks are balanced.
For patients who are highly sensitive to UTI and have the risk of acquired renal damage (including high-grade VUR, recurrent pyelonephritis, or obvious urinary tract Obstruction) can consider long-term prophylactic use of antibiotics
.
Antibiotics selected for prevention should meet the following requirements: (1) effective against most urinary tract pathogens; (2) cause the most serious side effects; (3) cause the least resistance to bacteria; (4) against the local bacterial flora The ecological impact is small
.
The dose of preventive antibiotics taken every night before going to bed should usually be one-fourth of the conventional therapeutic dose
.
The commonly used trimethoprim or compound trimethoprim and nitrofurantoin are not allowed in early infants in many countries, so oral cephalosporin is the first choice for this age group
.
Diagnosis and management of bladder bowel dysfunction (BBD) BBD refers to lower urinary tract dysfunction with/without constipation/fecal contamination.
It is an important risk factor for the occurrence and recurrence of UTI in children, as well as one of the important factors for the progression of scarred kidneys (LE : 2)
.
Babies with febrile UTI may develop BBD when they grow up
.
Early diagnosis and recognition of BBD is very important to prevent UTI (LE: 2, GR: A)
.
Diagnosis and treatment should begin after infection control
.
01 Diagnosis of lower urinary tract dysfunction The diagnosis of infant LUTD can be obtained by observing urination for 4 hours.
Interruption of urination is defined as urination again within 5 minutes
.
Residual urine after urination (PVR)>10 ml or 20% bladder volume can be considered as an increase in PVR, which is related to the recurrence of febrile UTI in infants
.
The definition of over-inflated bladder is that the bladder volume (empty volume + PVR) is greater than 115% of the expected bladder volume (EBC), or the empty volume>100% EBC
.
When the bladder volume reaches over-inflated, more than one-third of urination can lead to abnormal urine flow patterns and PVR >20ml
.
02 The relationship between LUTD and UTI LUTD is considered an important risk factor for the occurrence and recurrence of UTI in children
.
About 20%-50% of children with UTI and VUR have urinary dysfunction
.
03LUTD management behavior modification or urinary tract treatment should be the first step in the treatment of LUTD.
At the same time, a good toilet posture can relax the pelvic floor muscles optimally, thereby reducing urinary dysfunction and PVR.
Pelvic floor biofeedback relaxation is helpful To improve the urinary symptoms and urodynamic parameters of children with urinary dysfunction
.
The basic principle of VUR for timely diagnosis and proper treatment of VUR in children with febrile urinary tract infection is to prevent recurrent pyelonephritis and its potential consequences
.
01 Bladder and bowel dysfunction is usually associated with VUR, VUR, UTI and BBD
.
Approximately half of VUR children have BBD, which reduces the spontaneous regression rate of VUR
.
The results suggest that bladder function is an important predictor of spontaneous reflux regression, susceptibility to pyelonephritis and kidney damage
.
This understanding has enlightening significance for the conservative treatment of VUR
.
Currently, for low-grade VUR, prophylactic antibiotics and surgical treatment are not recommended
.
For high-level VUR, BBD should be studied and processed first
.
For recurrent febrile UTI, surgical intervention can be used to treat VUR, because the current literature has shown that open surgery can reduce the incidence of recurrent pyelonephritis
.
.
Currently, most of the existing guidelines for urinary tract infections in children come from Western countries
.
The Asian Association of Urinary Tract Infections and Sexually Transmitted Infections (AAUS) expert group formulated guidelines for the treatment of urinary tract infections in children in Asia in 2015, and through continuous collection of opinions and suggestions, the expert group recently revised and improved the guidelines based on the latest developments.
, And published in the Journal of Infection and Chemotherapy
.
This article sorts out some key contents for your reference
.
Figure UTI Risk Factors and Treatment Epidemiology The incidence of UTI urinary tract infections is 1% in boys under 10 years old and 3% in girls
.
At 3 months of age, the incidence of boys is higher than that of girls
.
According to reports, the total recurrence rate of UTI in the neonatal period is 25%, and the recurrence rate of children receiving toilet training is 30%-50%
.
Among them, more than 80% of UTIs are caused by Escherichia coli.
The most common mechanism of infection is retrograde rise, while hospital and systemic infections are rare
.
The classification of urinary tract infections in children UTI can be based on the site of infection (lower urinary tract/upper urinary tract), number of attacks (initial/recurrence), severity (mild/severe), symptoms (absent/present), or complex factors (simple infection) /Complex infection) for classification
.
This classification can reflect the severity of the infection
.
In actual clinical applications, the site of infection, number of attacks, severity and complex factors are more often used as the basis for evaluation (level of evidence LE: 2, grade of recommendation GR: B)
.
The first diagnosis 01 clinical symptoms and signs of UTI in infants and children are more non-specific symptoms in young children
.
Unexplained fever may be the only manifestation of young children, and it is also an important sign of renal parenchymal involvement
.
Other common non-specific symptoms include: sepsis, lethargy, prolonged jaundice, hematuria, poor feeding, vomiting, diarrhea, abdominal pain, irritability, stunted growth, cloudy or foul urine, and crying when urinating
.
The symptoms and signs of UTI in older children are more specific
.
Pyelonephritis mainly manifests as fever, chills, vomiting, back pain or abdominal pain, and rib percussive pain
.
Symptoms of lower urinary tract infection mainly include suprapubic pain, dysuria, frequent urination, urgency, dampness during the day, cloudy urine, and new enuresis at night
.
02 Medical history and physical examination When diagnosing UTI, the siblings or parents’ constipation, UTI or vesicoureteral reflux (VUR) history, and recent antibiotic use should be determined
.
Children should undergo a complete physical examination to rule out other possible causes of fever and pyuria
.
For children with febrile urethritis, the physical examination should also include genital abnormalities (phimosis in male patients, labial adhesions or vulvovaginitis in female patients), tenderness of the flanks or suprapubic bone, spina bifida, and basic neurological examinations As well as palpation of the abdominal mass
.
03 Urinalysis The focus of urinalysis is the analysis of leukocyte esterase and nitrite in urine, and the microscopic examination of pyuria and bacteriuria
.
The sensitivity of leukocyte esterase is about 79%, and the specificity is 87%.
The sensitivity of nitrite is low (about 50%), but the specificity is high (98%)
.
Therefore, a negative test for nitrite cannot rule out UTI, and a positive means that UTI is more likely
.
The combination of leukocyte esterase and nitrite test has a high degree of sensitivity and specificity
.
The enhanced urine analysis by the red blood cell counter has higher sensitivity and specificity than the standard analysis
.
04 Urine culture collection and interpretation Urine culture is the gold standard for diagnosis of UTI
.
However, the results may be affected by fecal bacterial contamination that colonizes the perineum and distal urethra
.
Suprapubic aspiration can avoid contamination, so it has been considered as the standard method for urinary culture in young children
.
For children who have undergone urination training, mid-stage urine can be collected for cultivation (LE: 3, GR: A)
.
The cut-off value of positive or negative culture results is related to the method of urine collection, not absolute
.
If the urine culture proves the growth of a single bacteria with the following colony counts, it is considered positive: (1) any growth from suprapubic suction, (2) urethral catheterization >5 × 104 CFU/ml, or ( 3) Collect >105 CFU/ml (LE: 3, GR: B) through mid-section urine
.
05 Asymptomatic bacteriuria Asymptomatic bacteriuria in infants is not easy to distinguish from real urinary tract infections
.
The 2011 AAP guidelines revised the definition of UTI, indicating that the final diagnosis of urinary tract infection is only based on the positive results of quantitative urine culture and urinalysis (LE: 3, GR: B)
.
Pyuria is a symptom of urinary tract infection, so whether pyuria is present can also help distinguish the two
.
Antibacterial treatment of UTI The antibacterial treatment of UTI depends on the site of infection (upper or lower urinary tract infection), the age of the patient, the severity of symptoms, and the antibiotic resistance of the community
.
For children with suggestive clinical symptoms and a positive urine test, they should begin empirical antibiotic therapy (LE: 2, GR: A) after obtaining a suitable urine specimen for culture
.
Common urinary tract pathogens include Escherichia coli (accounting for more than 80% of urinary tract infections in children), Klebsiella, Proteus, Enterobacter, Enterococcus, Citrobacter and Staphylococcus saprophyticus
.
The empirical use of antibiotics is guided by the local antibiotic resistance situation, and E.
coli is generally regarded as the main pathogen
.
Some experts recommend the use of third-generation cephalosporin as the initial treatment, but because the third-generation cephalosporin is a broad-spectrum drug, abuse may increase the resistance rate of urinary tract pathogens
.
When the susceptibility result of urine culture is clear, the treatment should be adjusted to the narrowest spectrum antibiotic
.
Oral quinolone antibiotics (such as ciprofloxacin) that are not approved for use in prepubertal children are very effective against most urinary tract pathogens, so these drugs are suitable for multidrug-resistant pathogens
.
Traditional first-line antibiotics for urinary tract infections in children, such as co-trimoxazole, have a resistance rate of over 50% in Taiwan and are no longer applicable
.
Common choices for oral antibiotics include first-generation cephalosporin or amoxicillin-clavulanic acid
.
Drugs that do not reach therapeutic levels in the blood (such as nalidixic acid or nitrofurantoin) should not be used to treat children with febrile urinary tract infections
.
When intravenous treatment is needed, the initial combination of ampicillin or ampicillin-sulbactam and aminoglycosides (such as gentamicin) or cephalosporin can achieve excellent therapeutic effects
.
Approximately 90% of febrile UTI infants will stop fever within 48 hours of starting appropriate parenteral therapy
.
Antibiotics can be administered parenterally for 2-4 days and then changed to oral
.
Long-term fever is more common in older children or children who suffer from lobar nephropathy, renal abscess, pyelonephritis, immunodeficiency, and infections caused by multi-drug resistant bacteria
.
Regardless of the route of administration, the entire course of antibiotic treatment should be 7 to 14 days
.
For more serious renal parenchymal infections, such as acute lobar nephropathy or renal abscess, the course of antibiotics needs to be extended to more than 14 days
.
For children with non-febrile bacterial cystitis, oral antibiotics for 2-4 days are usually the same as antibiotics for 7-14 days
.
For simple febrile UTI, regardless of the duration of fever, recurrence rate, and subsequent incidence of kidney damage, oral and parenteral administration routes are equally effective (LE: 2: GR: A)
.
For children with acute pyelonephritis, oral medications can be taken if they are tolerated.
According to the literature, experts recommend a treatment duration of 7-14 days
.
30%-50% of children with symptomatic UTI may have recurrent urinary tract infections after continuous preventive antibacterial treatment, and the recurrence rate is directly related to the number of previous UTI episodes
.
The sensitivity of recurrence within 2 to 6 months after UTI is the highest, and the benefits and risks are balanced.
For patients who are highly sensitive to UTI and have the risk of acquired renal damage (including high-grade VUR, recurrent pyelonephritis, or obvious urinary tract Obstruction) can consider long-term prophylactic use of antibiotics
.
Antibiotics selected for prevention should meet the following requirements: (1) effective against most urinary tract pathogens; (2) cause the most serious side effects; (3) cause the least resistance to bacteria; (4) against the local bacterial flora The ecological impact is small
.
The dose of preventive antibiotics taken every night before going to bed should usually be one-fourth of the conventional therapeutic dose
.
The commonly used trimethoprim or compound trimethoprim and nitrofurantoin are not allowed in early infants in many countries, so oral cephalosporin is the first choice for this age group
.
Diagnosis and management of bladder bowel dysfunction (BBD) BBD refers to lower urinary tract dysfunction with/without constipation/fecal contamination.
It is an important risk factor for the occurrence and recurrence of UTI in children, as well as one of the important factors for the progression of scarred kidneys (LE : 2)
.
Babies with febrile UTI may develop BBD when they grow up
.
Early diagnosis and recognition of BBD is very important to prevent UTI (LE: 2, GR: A)
.
Diagnosis and treatment should begin after infection control
.
01 Diagnosis of lower urinary tract dysfunction The diagnosis of infant LUTD can be obtained by observing urination for 4 hours.
Interruption of urination is defined as urination again within 5 minutes
.
Residual urine after urination (PVR)>10 ml or 20% bladder volume can be considered as an increase in PVR, which is related to the recurrence of febrile UTI in infants
.
The definition of over-inflated bladder is that the bladder volume (empty volume + PVR) is greater than 115% of the expected bladder volume (EBC), or the empty volume>100% EBC
.
When the bladder volume reaches over-inflated, more than one-third of urination can lead to abnormal urine flow patterns and PVR >20ml
.
02 The relationship between LUTD and UTI LUTD is considered an important risk factor for the occurrence and recurrence of UTI in children
.
About 20%-50% of children with UTI and VUR have urinary dysfunction
.
03LUTD management behavior modification or urinary tract treatment should be the first step in the treatment of LUTD.
At the same time, a good toilet posture can relax the pelvic floor muscles optimally, thereby reducing urinary dysfunction and PVR.
Pelvic floor biofeedback relaxation is helpful To improve the urinary symptoms and urodynamic parameters of children with urinary dysfunction
.
The basic principle of VUR for timely diagnosis and proper treatment of VUR in children with febrile urinary tract infection is to prevent recurrent pyelonephritis and its potential consequences
.
01 Bladder and bowel dysfunction is usually associated with VUR, VUR, UTI and BBD
.
Approximately half of VUR children have BBD, which reduces the spontaneous regression rate of VUR
.
The results suggest that bladder function is an important predictor of spontaneous reflux regression, susceptibility to pyelonephritis and kidney damage
.
This understanding has enlightening significance for the conservative treatment of VUR
.
Currently, for low-grade VUR, prophylactic antibiotics and surgical treatment are not recommended
.
For high-level VUR, BBD should be studied and processed first
.
For recurrent febrile UTI, surgical intervention can be used to treat VUR, because the current literature has shown that open surgery can reduce the incidence of recurrent pyelonephritis
.
