Practice Parameter for UTI under age 2 years
Russell Steele, MD: AAP
Controversial questions addressed by
AAP practice parameters:
1. Q: When should a UTI be ruled out in a child with fever under
age two:
A: Whenever a fever is unexplained - true for males and females
2. Q: How should specimen be obtained?
A: By cath or suprapubic; bag specimen give 85% false positive results
3. Q: What is a significant colony count by these methods of
collection:
A: Suprapubic: > 100 colonies/ml urine
Cath : > 5,000 colonies/ml urine
Clean void : > 100,000
colonies/ml urine
4. Q: What organisms most commonly cause UTIs in this age group?
A: E. Coli -80%; Klebsiella 6%; Staph Saprophyticus 5%; Proteus 1%;
Pseudomonas 1%
5. Q: Which antibiotics should be used for treating Pyelonephritis,
other UTIs?
A:
Pyelo: Ceftriaxone, Cefotaxime, Gentamycin, Tobramycin,
Ticarcillin, Ampicillin. Treat for an average of 7-10 days; treat
systemically until fever gone x 48 hours then switch to po meds. Studies
of shorter duration of treatment show less good results
UTI: other than pyelonephritis: po meds: use Septra,
Gantrisin, Suprax, Vantin, Cefzil, Keflex, or Lorabid in that order.
Amoxicillin is less used because of resistance E.Coli
Antibiotics should be continued until the radiologic workup is
completed.
6. Q: When should workup be done, and what should it consist of?
A: All documented UTIs in the first two years of life should be worked
up with a renal ultrasound, and a VCUG. Timing of VCUG can
be anytime that is convenient. There is no need to wait until weeks have
passed.
7. Q: What is the role of the DMSA scan in the workup of these
children?
A: This scan, which identifies renal scarring, should be obtained when
there are recurrent UTIs or if definitive abnormalities of anatomy are
discovered by U/S and VCUG. This test should not be done routinely. It
is expensive ($600/test) and does not affect our treatment
8. Q: If GU reflux is identified, when should the child be
referred to an urologist?
A: GI and GII (calyces normal) should be taken care of by pediatrician;
GIV and V by urologist; GIII (blunted calyces) by either.
9. Q: If pediatrician to follow child, how should that be done?
A: The answer will depend on whether or not reflux has been identified:
|
Reflux (+/-) |
1 month |
3 month |
6 month |
1 year |
|
No reflux |
urine culture |
urinalysis |
Urinalysis |
Urinalysis |
|
G I-III reflux |
urine culture
antibiotic px |
urine culture
antibiotic px |
Urine culture
Antibiotic px, repeat x-rays |
Urine culture
Antibiotic px, repeat x-rays |
10. Q: How long should antibiotic prophylaxis be continued?
A: Until reflux disappears or until age five years.
11. Q: How approach the problem of asymptomatic bacteruria?
A: Unlikely this infection will have any significant changes on
x-rays. Treat conservatively.
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