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Evaluation

General considerations and risk factors

• UTI is cause of 7% febrile infections in infants, 8% if > 24mo
• Bacteremia present in 7-13% with fever
• If < 24mo, fever > 40, hx UTI, SP tenderness, and uncircumcised penis are most predictive of UTI in a febrile child
• Age/gender: 2.7% boys vs 0.7% have a UTI during 1st year, then 0.03%-0.2% boys vs 1-3% girls per year after 1st year
• Circumcision in 1st 6mo of life decreases rates x10 - 111 otherwise-normal boys need to be circumcised to prevent one UTI, but only 11 if hx UTI, only 4 if hx high grade VUR
• Other risk factors: vesicoureteral reflux, neurogenic bladder, bowel/bladder dysfunctoin

Imaging for UTI

• Renal US: obtain if febrile UTI, < 6mo, or > 6mo and atypical UTI
• VCUG: obtain if abnormal RUS, 2+ febrile UTI, UTI in circumcised boy, or abnormal UTI, can perform as soon as asymptomatic and urine is sterile, cycling study recommended (more sensitive)
• DMSA scan: consider if atypical UTI, may need to wait 1-2yrs to assess scarring

Treatment

Treatment considerations

• Indications for inpatient management: age < 1mo (some say < 2-6mo), toxic appearance, not tolerating PO intake, concerns for antibiotic compliance
• Consider renal US if no improvement within 48hrs
• Duration: treat for 7-14 days, longer for severe infections
• Age considerations: avoid TMP/SMX if < 6 weeks, avoid nitrofurantoin if < 3mo

Other Infections

• Viral cystitis: more common in immunosuppressed situations, can have 50-80% mortality rate without treatment
• Funguria: more common with catheterization or prior antibiotic therapy, consider imaging to assess for fungal balls

Antibiotics for UTI

Antibiotic	Dosing	N/V/D	Rash	Other side effects
Nitrofurantoin	3-5mg/kg/d, BID	Yes	No	Hyperbilirubinemia if given < 3mo old
TMP/SMX	8-10mg/kg/d (trimethoprim), BID		Yes	Photosensitivity
Augmentin	20-40mg/kg/d, TID			No
Cephalexin	50-100mg/kg/d, QID			Headache, diarrhea
Cefprozil	20mg/kg/d, BID