Tim Horeczko over at the excellent Pediatric Emergency Medicine Playbook just posted his latest monthly review (including podcast) – this time on urinary tract infections. I love the approach – simple, straightforward and focused on common questions in the ED. Some highlights;
- The risk factors for UTI include age ≤12 months, fever ≥39C, fever >24 hours and absence of another source of infection.
- Always cath – unless you want to do a suprapubic bladder aspiration – which is totally a viable way to get urine
- Per the AAP the “standard definition of a urinary tract infection is the presence of BOTH pyuria AND at least 50,000 colonies per mL of a single uropathogen.” It is interesting that a recent study by Shaikh called into question the utility of pyuria in certain uropathogens.
- Bactrim is acquiring resistance, therefore consider other treatment options in the well appearing child including cephalexin or cefdinir.
- Generally admit anyone under 2 months with a febrile UTI
Tim also highlights the Urine Rule of 10s, which I think is a neat way to conceptualize things.
- 10% of young febrile children without a source will have a UTI
- 10% of UAs will show no evidence of pyuria
- Routine urine culture in all children with suspected or confirmed UTI up to about age 10
Finally, he makes the following salient points – which I couldn’t agree more with;
- If a child over 3 months of age is well, has no comorbidities, has a low grade fever “in the 38s” (38-38.9 °C) without a source, especially if less than 24 hours, you are very safe to do watchful waiting at home without obtaining urine.
- An otherwise well child with an obvious upper respiratory tract infection has a source of his fever.
- If your little patient has risk factors for UTI, or you are otherwise concerned, send the UA and send the culture. You can opt out of the culture by middle school in the otherwise healthy child.
- Make sure the child follows up with their primary care doctor.
Oh, and the title was a pun, and you know how much I love puns!
Check out all of the great content at PEMPlaybook.org
Subcommittee on Urinary Tract Infection, Steering Committee on Quality Improvement and Management, Roberts KB. Urinary tract infection: clinical practice guideline for the diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months. Pediatrics. 2011 Sep;128(3):595-610.