This document was amended in July 2023 to reflect literature that was released since the original publication of this content in May 2012. This document will continue to be periodically updated to reflect the growing body of literature related to this topic.

Pediatric Urinary Tract Infections

Key Words: Cystitis, vesicoureteral reflux (VUR), dysuria, hematuria, pyelonephritis, hydronephrosis, UTI

Learning Objectives:

At the end of this unit, the medical student will be able to:

1. Describe the differences in clinical presentation of UTIs in infants and older children
2. Describe the differences in clinical presentation of cystitis and pyelonephritis
3. Identify modifiable and non-modifiable risk factors associated with bacterial, viral, and fungal UTIs in children
4. Describe variations in urologic anatomy that are associated with pediatric UTIs
5. Describe the anatomic, physiologic, and clinical sequelae of repeated and untreated pediatric UTIs
6. Summarize the diagnostic evaluation of pediatric UTIs
7. Outline the operative and non-operative management options for pediatric UTIs

Introduction and Epidemiology

Pediatric urinary tract infections (UTI) are common, accounting for nearly 1.1  million visits to health care providers annually, and over $180 million in spending directed toward inpatient hospital costs.(1)  During ages 0-12 months, UTIs are more common in boys (3.7%), with an intact foreskin being a common risk factor, than in girls (2%).(2) However, during the prepubertal ages, there is a greater annual incidence in girls than in boys (3% and 1%, respectively).(2) The risk of UTI recurrence within 6-12 months of the initial occurrence is 12-30%.(2)

Clinical Presentation

Children, particularly infants, may present with nonspecific UTI symptoms. Infants in particular may present with fever, lethargy, decreased oral intake, or signs of dehydration.(3),(4) Older children may complain of dysuria, irritative bladder symptoms (urinary urgency and frequency, with or without incontinence), a sensation of incomplete emptying, and flank or abdominal pain.(2) Children of any age may also present with blood in the urine (hematuria), strong-smelling urine, vomiting, or with changes in bowel habits (constipation and/or diarrhea).(2),(5) Importantly, while the presence of fever and systemic symptoms raises concern for pyelonephritis, a fever is not pathognomonic for kidney infection; in some cases, children may present with cystitis and fever, while others may have renal involvement and present with normo- or even hypothermia.

Pathophysiology

Bacteria or fungi (including yeast) can enter the urinary tract through ascending (urethra or bladder) or hematogenous (bloodborne) routes. The most common bacterium isolated in pediatric UTIs is E. Coli, accounting for over 80% of pediatric UTIs, which is commonly found in stool.(2) The ascent of bacteria from the bladder to the kidneys may be mediated by congenital anomalies of the kidneys and urinary tract, such as vesicoureteral reflux, genitourinary surgery, recent antibiotic use or by bacterial virulence factors such as pili that enable the bacteria to “climb” toward the kidneys even in the absence of anatomic anomalies.(2),(6)

Fungal UTIs occur in immunosuppressed children, in those with indwelling catheters, in those with urinary obstruction and in those with prolonged antibiotic exposure.(2) Patients in the Neonatal Intensive Care Unit (NICU) are also at increased risk, as these patients often have multiple invasive lines and tubes and have received broad-spectrum antibiotics for prolonged periods.(7) “Fungal balls” may obstruct the collecting system and necessitate percutaneous drainage.(8) Fungal UTIs may not have significant pyuria, but catheterized urine samples will show fungal growth; this can make the clinical differentiation of fungal colonization and infection difficult.(6) Treatment consists of limiting risk factors (removing or changing indwelling lines and tubes, limiting antibiotic use when possible) and administering antifungal agents (fluconazole or amphotericin B).(7),(8)

Like fungal UTIs, viral UTIs typically occur in immunocompromised children in whom normally dormant viruses are activated.(6) Viral UTIs are common in children following organ transplantation or oncology-related immunosuppression, and viral infection can also be associated with hemorrhagic cystitis. Common viruses include BK virus, adenovirus, and cytomegalovirus (CMV).(6) Limiting immunosuppression when possible and considering antiviral therapy (e.g., ribavirin, cidofovir) can be helpful.(6),(9)

Sterile pyuria is often seen with UTIs caused by acid-fast bacilli such as Mycobacterium tuberculosis.(2)

Table 1. Uropathogen Prevalence by Sex and Visit Setting (10)

*Based on national data from TSN (The Surveillance Network). Prevalence will vary based on region.

Sequelae

In the acute setting, children with UTIs are at increased risk for dehydration, electrolyte abnormalities, and febrile seizures.(2) Untreated, UTIs may develop into systemic illness (urosepsis, a complication more often seen with gram-negative pathogens) and cause permanent damage to organs.(2) Examples of complications from spread into adjacent organs include epididymitis and orchitis. Chronic infection of the renal parenchyma (pyelonephritis) has been associated with late effects including renal scarring(which can be evaluated with nuclear renal scans that show differential uptake within the renal parenchyma), poor renal function, and high blood pressure.(2) Renal scarring is most likely in young children with pyelonephritis, and is often seen in children with vesicoureteral reflux.(2) One study following children with pyelonephritis-associated scarring for 27 years found a 21% prevalence of hypertension and 10% prevalence of end-stage renal disease.(11) A rare, but severe, consequence of chronic renal infection and inflammation is xanthogranulomatous pyelonephritis (XGP), which is characterized by renal suppuration.(12) While improvements in radiological imaging have facilitated the conservative management of XGP, nephrectomy is often necessary.(12)   Prompt treatment of suspected UTI in children has been shown to decrease the likelihood of renal involvement, with the odds of renal scarring 74% lower in children treated with antibiotics within 24 hours of fever onset as compared to those who initiated treatment > 72 hours of fever onset.(13) . Treatment should be started as early as possible, and ideally within 24-72 hours of symptom onset.(2)

Evaluation and Management of the Child with Suspected UTI

A full history and physical examination should be performed. Onset and duration of symptoms, as well as the presence or absence of systemic symptoms (e.g. fever, vomiting, diarrhea) should be recorded. Caregivers should be asked about the child’s pre- and post-natal history as well as any current medications, ill contacts, and family history of urogenital anomalies. In children with suspected urinary tract infection, urine should be collected and evaluated for infection. Urine collection using bags in infants is discouraged due to a high risk of contamination, high potential for misdiagnosis, and high false negative rate.(2) Suspected infection on a bagged specimen should be confirmed by collecting urine through suprapubic aspiration or urethral catheterization. In older, toilet-trained children, midstream urine specimens are acceptable options, though care must be taken to adequately cleanse the perineum before voiding and to ensure that midstream urine is collected. Laboratory tests such as complete blood count, basic metabolic panel, C-reactive protein, erythrocyte sedimentation rate, and blood cultures should be performed at the physician’s discretion.(2)

In children aged 2-24 months of age, the current AAP UTI Clinical Practice Guideline supports the diagnosis of UTI in children with >50,000 cfu/cc of a single pathogen on appropriately collected urine.(3),(4) However, a diagnosis of UTI can be considered in children who have lower cfu/cc in conjunction with findings of inflammation (e.g. pyuria) or fever.(3),(4) A 2022study showed that about one in ten children with symptoms of UTI and a positive urine culture had no pyuria.(14) In those children, Enterococcus and Klebsiella were more likely to be identified as the causative organisms.(14) Fungal UTIs may also present with relatively few white cells in the urine.(7) The presence of leukocyte esterase or nitrites also supports the diagnosis of a UTI, and if urinalysis of fresh urine (< 1 hour since void) is negative for these markers, then it is reasonable to monitor a febrile infant without starting antimicrobials.(4) .

In children in whom the urine suggests infection, early initiation of antibiotic therapy is critical to minimizing the deleterious effects of infection on the upper tracts. Empiric antibiotic selection is based on the suspected pathogen and local resistance patterns, although it is noteworthy that many hospitals do not have antibiograms specific to pediatric patients. A majority of urinary pathogens are resistant to amoxicillin, but sensitive to third-generation cephalosporins. (15) In children who are afebrile, additional options include first-generation cephalosporins, trimethoprim-sulfamethoxazole, and nitrofurantoin.(15) Factors such as ease of use (e.g. taste and number of daily doses) as well as cost should also be considered in efforts to increase adherence. While most children older than 2 months of age can tolerate oral antibiotics, inpatient treatment should be considered in children who are unable to tolerate oral therapy.(2)

Families should be made aware that antibiotics may be changed based on final culture growth and antibiotic sensitivity; these data are typically available 48-72 hours following urine collection.(2) The duration of antimicrobial therapy is dictated by the age and medical complexity of the child..(2) Readout from the SCOUT trial demonstrated that halting antimicrobial therapy in children who exhibited clinical improvement after 5 days and continuing for an additional 5 days both resulted in high success rates (96% for short course vs. 99% for longer course).(16)  In general, treatment courses of 7-14 days for most children.(2) When nitrofurantoin is selected as the antibiotic of choice, the minimum duration of therapy should be 7 days. Parents and caregivers should be made aware that, in the setting of pyelonephritis or renal abscess, fevers may persist even in the setting of observed clinical improvement.(2)

The AAP Clinical Practice Guidelines support obtaining a renal-bladder ultrasound (RBUS) in all children aged 2-24 months after the first febrile UTI.(3) The RBUS can be obtained after the UTI has resolved, although earlier use may be warranted in severe illness to rule out renal abscess or occult obstruction.(3) However, recent literature suggests that the cost-effectiveness of screening with a renal-bladder ultrasound may be increased if sonography is limited to children with a second febrile UTI.(17) Additional testing, such as voiding cystourethrogram, should be obtained if the screening ultrasound demonstrates evidence of collecting system dilatation or renal parenchymal abnormality, if there is an atypical causative pathogen, or if there is known renal scarring.(2)

The role of antibiotic prophylaxis in the management of urinary tract infections remains an area of active investigation. In the setting of high-grade (grade 4-5) vesicoureteral reflux, prophylactic antibiotics appear to decrease the risk of recurrent urinary tract infection. The benefit of antibiotic prophylaxis in lower-grade, “nondilating” (grades 1-3) reflux is less clear. The PRIVENT and RIVUR studies found that antibiotic prophylaxis with trimethoprim-sulfamethoxazole was associated with a decreased risk of developing a recurrent UTI in children with VUR.(18),(19) Combined results of the RIVUR and CUTIE studies show that toilet-trained children with both VUR and bowel-bladder dysfunction (BBD) exhibit the greatest benefit from antimicrobial prophylaxis, as these children are at higher risk for recurrence than those with VUR or BBD alone.(20) However, several other randomized studies and meta-analyses show mixed results on the efficacy of antibiotic prophylaxis.(2) Of note, a potential explanation for the disparate findings is a low compliance rate among pediatric patients prescribed antibiotic prophylaxis.(21) Furthermore, no study has demonstrated a beneficial effect of prophylaxis on preventing renal scarring.(2) Given the high risk of antimicrobial resistance seen with prophylaxis, particularly with long-term use of prophylactic agents, a clear endpoint for prophylaxis should be planned and families should be counseled on the risks and benefits of antibiotic prophylaxis, including the possible need for periodic laboratory tests.

Antibiotic stewardship is critical to limit the adverse effects of antibiotic for both individual patients and the community at large. Deaths attributable to or associated with antimicrobial resistance pose a significant global burden, with many of the causative bacteria being implicated in UTIs.(22) Ultimately, the choice of prophylactic antibiotic should be based on the child’s age, any comorbidities, local resistance patterns, and ease of use (e.g. cost, number of daily doses, taste, need for refrigeration). In otherwise healthy term infants, amoxicillin 20 mg/kg daily is frequently used; in infants older than two months, trimethoprim (TMP)-sulfamethoxazole at a dose of 2 mg TMP/kg once daily may be used.(2) Providers are encouraged to review local antibiograms to identify pertinent susceptibility and resistance patterns.

Associated Conditions

Upper tract abnormalities

Vesicoureteral reflux (VUR)

Vesicoureteral reflux (VUR) occurs when urine flows backward from the bladder towards the kidney, increasing the exposure of the upper tracts to bacterial pathogens.(23) In high-grade VUR (grades 4 and 5) VUR, the risk of UTI is further elevated due to the presence of a pseudoresidual volume of urine in the bladder after reflux.(24) Low grade VUR, however, is generally not associated with an increased risk of urinary tract infections in the absence of other anomalies (ie. UPJ obstruction).(25),(26)

In 2011, the AAP released a recommendation (reaffirmed in 2016) that voiding cystourethrogram (VCUG) should be reserved for children with a second febrile urinary tract infection or those in whom the screening ultrasound found sonographic abnormalities in the renal parenchyma or collecting system.(25) In older children with afebrile UTIs, VCUG is generally considered low-yield for the identification of anatomic abnormalities in the absence of other sonographic or physical findings.(27)

A VCUG (see figure) delineates the anatomy within the collecting system, inclusive of the ureters, bladder, and urethra. It identifies children with VUR and posterior urethral valves. In some cases, ureteroceles and ureteral ectopia may be diagnosed as filling defects and contour abnormalities. While variations in VCUG technique can lead to differences in radiographic findings, the most significant observed difference is typically in observed bladder capacity rather than the proportion of children with detected VUR. Nevertheless, differences in technique should be acknowledged, as the timing of VUR onset during the filling/voiding cycle is a prognostic factor for calculating the likelihood of spontaneous resolution. Recent research has also identified the distal ureteral diameter normalized to the height of a vertebral body as an important predictive factor.(28)

The following AUA guideline Management and screening of primary vesicoureteral reflux in children is a detailed resource for clinicians.(29)

Ureteropelvic junction obstruction (UPJO)

Ureteropelvic junction obstruction (UPJO) is the most common form of CAKUT that describes a blockage of the flow of urine from the renal pelvis into the ureter.(30) Obstructions may be "intrinsic" (associated defect in the muscular or intimal layers of the ureter or a "high insertion" wherein the ureteropelvic junction is not dependent) or "extrinsic" (usually associated with vascular compression from a lower pole accessory renal artery). Before the widespread use of prenatal ultrasonography, UPJO was commonly diagnosed when patients presented with hematuria, UTI, intermittent flank pain, nausea, and vomiting, often after increased fluid intake or diuresis.(30) Persistent pressure on the renal parenchyma from the dilated renal pelvis may be associated with an ipsilateral decrease in renal function.(31) Renal function (estimated renal plasma flow) and drainage can be assessed using MAG-3 nuclear medicine renal scans.(31),(32) Symptomatic patients and those with demonstrated obstruction may be considered for surgical intervention with open or minimally invasive pyeloplasty.(33)

Lower tract and voiding abnormalities

Ectopic ureter and ureteroceles

Ureteral ectopia, occurring in about 0.05% of children, happens when the ureteric bud emerges too proximally in the Wolffian system. This leads to the ureteral orifice opening not in an orthotopic position in the bladder but at or distal to the bladder neck.(34) In girls, the ureter may also drain to the perineum or into the vagina (via a ruptured Gartner’s duct cyst). In boys, the ureter may drain into any remnant of the Wolffian system, such as the vas deferens or seminal vesicle, but does not drain to the perineum. Ureteral ectopia can expose the upper tract to bacteria because of the absence of the antireflux mechanism generated by tunneling the ureter at the ureterovesical junction and also because of the relative proximity of the ectopic ureteral orifice to the perineum.

Ureteroceles are a cystic dilatation of the distal ureter and may be associated with obstruction or, less commonly, reflux into the affected ureter. Ureteroceles may predispose children to the development of urinary tract infections by obstructing the bladder outlet during voiding, leading to elevated post-void residuals, or by trapping infected urine in the obstructed ureterocele. Children in whom ectopia or ureterocele is thought to increase UTI risk may benefit from definitive surgical treatment.(35)

Posterior urethral valves & myogenic bladder

Posterior urethral valves (PUV) are excess tissue in the membranous urethra, just distal to the verumontanum, creating obstruction during voiding and contributing to the development of secondary vesicoureteral reflux and upper tract damage.(36) Improvements in antenatal screening have enabled many of these boys with this condition can now be identified prenatally through antenatal screening. At present, no differences in long term renal function, but these advancements may enable early therapeutic intervention (bladder decompression followed by endoscopic valve ablation).(37),(38) Currently, half of boys with PUV will develop renal insufficiency within the first decade, and one in six may develop end-stage renal disease.(36)

In the setting of outlet obstruction, the voiding and storage dynamics will be altered by differences in the composition and function of the bladder (specifically collagen and muscle components). These variations, termed the "myogenic bladder," should be managed according to the underlying abnormalities in bladder function.

Neurogenic bladder

Patients with damage to the nerves that innervate the bladder, pelvic floor, or external sphincter often have abnormal bladder capacity, difficulty voiding at low pressures, and incomplete bladder emptying. Neurogenic bladder is commonly seen in children with spinal dysraphism (e.g., myelomeningocele, sacral agenesis) but can also result from spinal cord injuries due to trauma, surgery, tumor, or vascular accidents. Children with neurogenic bladder may exhibit functional deficits such as difficulty ambulating, lower extremity pain, and abnormal voiding and stooling habits. Skin abnormalities, such as variable pigmentation or hair distribution over the lower spine, deep sacral dimples, or deviations in the gluteal cleft, may also be observed in some cases. The exact functional abnormalities associated with neurogenic bladder vary depending on the nerves involved. Given that lower tract function abnormalities can increase the risk of upper tract damage, children with neurogenic bladders must be carefully monitored.

Voiding dysfunction and constipation

The relationship between bladder-bowel dysfunction and urinary tract infections is well-documented in toilet-trained children. Changes in urodynamic and rectal manometric parameters have been described, including increased voiding pressures and increased post-void residual urine in the setting of increased rectal distension.(39),(40) Additionally, the stool serves as a reservoir of bacteria, and functional constipation is associated with lower urinary tract symptoms. Frequent (every 2-3 hours) voiding, management of constipation, and increased fluid intake may help to decrease lower urinary tract symptoms and UTIs in these children.(41) Children with symptoms refractory to behavioral modification should be evaluated for pelvic floor dysfunction, and may benefit from biofeedback or physical therapy.

Eagle-Barrett (Prune Belly or Triad Syndrome)

Eagle-Barrett syndrome consists of the triad of deficient or absent anterior abdominal wall musculature (giving the abdomen its characteristic wrinkled appearance), dilated and tortuous ureters, and intra-abdominal undescended testes typically located at the level of the iliac vessels. Even after abdominal wall and urinary tract reconstruction, children with this condition often have urinary stasis, and so instrumentation of the urinary tract should be limited to reduce the risk of introducing pathogens.

Additional Considerations

Urolithiasis

The cumulative incidence of renal and ureteral stones has increased in recent years in children.(42),(43) Although kidney stones are generally not an independent risk factor for UTIs, stones traveling down the ureter can cause obstruction and prevent the antegrade flow of infected urine. Struvite stones are associated with urea-splitting bacteria (e.g., Proteus spp). Bladder stones may serve as a nidus for bacteria and should be considered in children who present with recurrent or persistent bacterial infections despite appropriate therapy. Bladder stones are most commonly seen in children with concentrated urine and in those who do not completely empty the bladder, such as children who perform intermittent catheterization and those with a bladder augmented with a mucus-producing bowel patch.

While upper tract urolithiasis is not directly implicated in the development of urinary tract infections, there is considerable overlap in the risk factors (decreased fluid intake, increased dietary salt intake) for both conditions. The presence of a diverse community of bacteria in the intestines (intestinal microbiome) and the discovery of bacteria in urine (urinary microbiome) might play a role in kidney stone formation and urinary colonization.(44)

Sexual abuse

Estimates of the prevalence of pediatric sexual abuse vary widely, with some series finding that nearly four in ten children have experienced sexual violence.(45) The signs and symptoms of sexual abuse may be subtle, and physicians must maintain a high index of suspicion for abnormal physical examination findings (e.g., genital abrasions or lacerations), inappropriate demeanor (unexplained fear of the examiner), or patient statements. Physicians must report suspected sexual abuse to Child Protective Services.

Summary

1. UTIs are common in children and have substantial clinical and economic sequelae.
2. Children with bacterial UTIs may have coexisting conditions, including structural abnormalities of the urinary tract, elimination disorders, or an experience of sexual abuse.
3. Risk factors for fungal UTIs include immunosuppression, broad-spectrum antibiotics, and invasive vascular and urinary devices.
4. Bacterial pyelonephritis is associated with increased risk of renal scarring and later renal insufficiency and hypertension.
5. The most common initial radiologic study for children with UTI is renal and bladder ultrasound. Some children may benefit from VCUG.
6. Antibiotic stewardship, including selection of the proper treatment spectrum and duration, is critical for both treatment and prophylactic antibiotic regimens.
7. Prompt treatment for presumed or proven UTI may decrease the risk of renal scarring and later sequelae.

References

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18. Craig JC, Simpson JM, Williams GJ, et al. Antibiotic prophylaxis and recurrent urinary tract infection in children [published correction appears in N Engl J Med. 2010 Apr 1;362(13):1250]. N Engl J Med. 2009;361(18):1748-1759.
19. RIVUR Trial Investigators, Hoberman A, Greenfield SP, et al. Antimicrobial prophylaxis for children with vesicoureteral reflux. N Engl J Med. 2014;370(25):2367-2376.
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Authors

2023
Kathleen Kieran, MD
Seattle, WA
Disclosures: Nothing to disclose

Nityam Rathi
Cleveland, OH
Disclosures: Nothing to disclose

Maria Antony
Farmington, CT
Disclosures: Nothing to disclose

2020
Kathleen Kieran
Seattle, WA
Disclosures: Nothing to Disclose

2012-2016
David Hatch, MD
Issaquah, WA
Disclosures: Pfizer, Scientific Study or Trial

William Hulbert, MD
Rochester, NY
Disclosures: Nothing to disclose

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