August 30, 2011.
An American Academy of
Pediatrics (AAP) Clinical Practice Guideline and technical report published
online August 29 and will appear in the September issue of Pediatrics
address diagnosis and management of an initial urinary tract infection (UTI)
in febrile infants and young children.
"The diagnosis and management
of ...UTIs in young children are clinically challenging," write S. Maria E.
Finnell, MD, MS, and colleagues from the AAP Subcommittee on Urinary Tract
Infection who coauthored the Technical Report. "This report was developed to
inform the revised, evidence-based, clinical guideline regarding the
diagnosis and management of initial UTIs in febrile infants and young
children, 2 to 24 months of age.... The conceptual model presented in the
1999 technical report was updated after a comprehensive review of published
Clinical Characteristics, New Urinalysis Methods
On the basis of a review of recent literature and meta-analyses on the
effectiveness of antimicrobial prophylaxis to prevent recurrent UTI, the
report authors concluded that specific clinical characteristics and new
methods of urinalysis may help clinicians determine which febrile children
are at very low risk for UTI. Their findings include the following:
Compared with parenteral therapy, oral antimicrobial therapy is as effective
in treating UTI.
Evidence from published, randomized controlled trials
suggests that when voiding cystourethrography (VCUG) shows vesicoureteral
reflux (VUR), antimicrobial prophylaxis is not recommended to prevent
The sensitivity of urinary tract ultrasonography after the
first UTI is poor.
The risk for renal damage from UTI may be reduced by
early antimicrobial therapy.
"Recent literature agrees with most of
the evidence presented in the 1999 technical report, but meta-analyses of
data from recent, randomized controlled trials do not support antimicrobial
prophylaxis to prevent febrile UTI," the report authors write. "This finding
argues against ...VCUG after the first UTI."
On the basis of this technical report and its underlying evidence,
Kenneth B. Roberts, MD, and colleagues from the AAP Subcommittee on Urinary
Tract Infection who coauthored the new Clinical Practice Guideline, issued
recommendations for the diagnosis and management of the first UTI in febrile
infants and children 2 to 24 months old. Changes from the previous AAP
guidelines include criteria for the diagnosis of UTI and recommendations for
Specific recommendations in the new Clinical Practice
Guideline include the following:
Diagnosis of UTI is made from an
appropriately collected urine specimen based on the presence of pyuria as
well as 50,000 colonies per mL or more of a single uropathogenic organism.
To facilitate prompt diagnosis and treatment of recurrent UTIs, close
clinical follow-up monitoring should be maintained after 7 to 14 days of
To diagnose anatomic abnormalities,
ultrasonography of the kidneys and bladder should be performed.
evidence from the most recent 6 studies does not support the use of
antimicrobial prophylaxis to prevent febrile recurrent UTI in infants
without VUR or with grade 1 to 4 VUR, VCUG is not recommended routinely
after the first UTI.
However, VCUG is indicated if renal and bladder
ultrasonography results show hydronephrosis, scarring, or other evidence of
high-grade VUR or obstructive uropathy, as well as in other atypical or
complex clinical circumstances.
Infants and children who have recurrence
of a febrile UTI should also undergo VCUG.
In an accompanying editorial, Thomas B. Newman, MD, MPH,
from the Division of Clinical Epidemiology, Department of Epidemiology and
Biostatistics, and Division of General Pediatrics, Department of Pediatrics
at the University of California, San Francisco, calls the new
recommendations "a long-awaited update" and "an exceptionally evidence-based
He makes additional comments in response to the 5
clinical questions addressed in the guideline and technical report,
including the following:
Which children should have their urine
tested? The new guideline recommends selective urine testing based on the
prior probability of UTI, which Dr. Newman states is an important
improvement vs the 1999 practice parameter recommending urine testing for
all children aged 2 months to 2 years with unexplained fever.
the urine sample be obtained? Dr. Newman applauds the new guideline for
continuing to offer the option of noninvasively obtaining urine for
urinalyses, but he is not convinced that the bag urine can never be used for
culture, because the prior probability may sometimes be in a range where the
bag culture will be useful.
How should UTIs be treated? Dr. Newman agrees
with the guideline's recommendation that regional variation in antimicrobial
susceptibility patterns should dictate the choice of initial treatment.
However, he suggests adjusting the choice based on the clinical course
rather than on sensitivity testing of the isolated uropathogen, as
recommended in the guideline.
What imaging and follow-up are recommended
after a diagnosis of UTI? "The recommendation most dramatically different
from the 1999 guideline is that a VCUG not be routinely performed after a
first febrile UTI," Dr. Newman writes. "The main reason for this change is
the accumulation of evidence casting doubt on the benefit of making a
diagnosis of ...VUR. To put these data in historical perspective, operative
ureteral reimplantation was standard treatment for VUR until randomized
trials found it to be no better than prophylactic antibiotics at preventing
How should children be monitored after a UTI has been
diagnosed? Dr. Newman concurs with the guideline authors in not recommending
prophylactic antibiotics to prevent UTI recurrences, because meta-analyses
have revealed no significant reduction in symptomatic UTI from such
prophylaxis regardless of whether VUR was present.
"I salute the
authors of the new AAP UTI guideline and the accompanying technical report,"
Dr. Newman concludes. "Both publications represent a significant advance
that should be helpful to clinicians and families dealing with this common
Dr. Newman has disclosed no relevant financial
Pediatrics. 2011;128:595-610, 572-575, e749-e770.