You could go ahead and pick out a good book this summer. But why waste time on formulaic plots and slapdash characterizations when you could be reading great articles relevant to the Pediatric Emergency Department. Here’s another paper from the PEMBlog Summer Reading List!
American Academy of Pediatrics Clinical Practice Guideline
PEDIATRICS Volume 128, Number 3, September 2011
What this article is about?
Obviously this is an updated guideline for diagnosis and management of UTI in infants and toddlers. Questions that it may help you answer include;
- On which patients should I obtain urinalysis and culture?
- What is the best empiric treatment for suspected UTI?
I won’t address VCUG, prophylaxis or other issues not directly related to the Emergency Department, but know that this CPG does include information on post UTI imaging and more.
Why is it important?
Febrile infants between two and twenty-four months have an overall prevalence of UTI as high as 5%. Some children have higher risks than others, as detailed in Figure 2. These risks should be kept in mind when deciding who to test and empirically treat.
How you can use it in your practice
When it comes to testing first determine the pre-test probability for UTI in the febrile patient you are evaluating:
- The overall prevalence is 5%, but girls have 2x the prevalence of boys. This is partly due to the shorter urethra that allows passage of bacteria into the bladder in girls
- Uncircumcised boys have a rate between 4 and 20 times that of circumcised boys, whose rate of UTI in fever without a source is only 0.2-0.4%
- Another clinically obvious infection reduces the risk of UTI by at least 50% – sometimes more, like in bronchiolitis where the risk is only 1/33
- The factors in Figure 2 above have a sensitivity of 88% and a specificity of 30%
When you do test be aware of the characteristics of urinalysis, but know that culture is the gold standard – >50,000 CFU/mL:
Treatment depends on age and overall appearance:
- Infants under 2-3 months basically have pyelonephritis and should be admitted. IV ceftriaxone is a great option. Note that the concomitant risk of meningitis is low in well-appearing infants with UTI. See this great synopsis from Best Bets for more.
- There is limited evidence on treatment length. Overall 7, 10 and 14 days were studied. We do know that outcomes of short (1-3day) courses are inferior for 2-24 month olds.
Antibiotic options are varied, see the following tables for more:
What this article is about?
Obviously this is an updated guideline for diagnosis and management of UTI in infants and toddlers. Questions that it may help you answer include;
- On which patients should I obtain urinalysis and culture?
- What is the best empiric treatment for suspected UTI?
I won’t address VCUG, prophylaxis or other issues not directly related to the Emergency Department, but know that this CPG does include information on post UTI imaging and more.
Why is it important?
Febrile infants between two and twenty-four months have an overall prevalence of UTI as high as 5%. Some children have higher risks than others, as detailed in Figure 2. These risks should be kept in mind when deciding who to test and empirically treat.
How you can use it in your practice
When it comes to testing first determine the pre-test probability for UTI in the febrile patient you are evaluating:
- The overall prevalence is 5%, but girls have 2x the prevalence of boys. This is partly due to the shorter urethra that allows passage of bacteria into the bladder in girls
- Uncircumcised boys have a rate between 4 and 20 times that of circumcised boys, whose rate of UTI in fever without a source is only 0.2-0.4%
- Another clinically obvious infection reduces the risk of UTI by at least 50% – sometimes more, like in bronchiolitis where the risk is only 1/33
- The factors in Figure 2 above have a sensitivity of 88% and a specificity of 30%
When you do test be aware of the characteristics of urinalysis, but know that culture is the gold standard – >50,000 CFU/mL:
Treatment depends on age and overall appearance:
- Infants under 2-3 months basically have pyelonephritis and should be admitted. IV ceftriaxone is a great option. Note that the concomitant risk of meningitis is low in well-appearing infants with UTI. See this great synopsis from Best Bets for more.
- There is limited evidence on treatment length. Overall 7, 10 and 14 days were studied. We do know that outcomes of short (1-3day) courses are inferior for 2-24 month olds.
Antibiotic options are varied, see the following tables for more:
