Urinary Tract Infection in Children: Indian Academy of Pediatrics Guidelines

Urinary tract infection (UTI) is a common bacterial infection in young children. Delay in diagnosis and treatment can lead to irreversible and long-term damage to the developing kidneys. It may result in renal scarring, hypertension, and renal insufficiency. Diagnosis of UTI in young children is made in presence of: ; Symptoms such as fever, dysuria, urgency, frequency, abdominal/flank pain in older children and fever, vomiting, diarrhea, and poor weight gain in infants; PLUS  Positive dipstick for leukocyte esterase and nitrite (as a screening tool) ; Abnormal urinalysis with significant pyuria and bacteriuria and ; Isolation of single species of microorganism in significant number in a properly collected urine sample prior to starting antimicrobial therapy and tested for urine culture (gold standard)

The Indian Academy of Pediatrics (IAP) has released Standard Treatment Guidelines 2022 for Urinary tract infection in children. The lead author for these guidelines on Urinary tract infection in children is Dr Sudha Ekambaram along with co-author Dr Afsana Jahan and Dr Kiran P Sathe. The guidelines come Under the Auspices of the IAP Action Plan 2022, and the members of the IAP Standard Treatment Guidelines Committee include Chairperson Remesh Kumar R, IAP Coordinator Vineet Saxena, National Coordinators SS Kamath, Vinod H Ratageri, Member Secretaries Krishna Mohan R, Vishnu Mohan PT and Members Santanu Deb, Surender Singh Bisht, Prashant Kariya, Narmada Ashok, Pawan Kalyan.

Following are the major recommendations of guidelines:

Bacteriuria:

Asymptomatic bacteriuria is considered in presence of ; Significant bacteriuria in absence of pyuria or symptoms ; More common in girls compared to boys ; Often associated with nonvirulent Escherichia coli colonization ; Ideally should not be treated with unnecessary antimicrobials. Significant bacteriuria: It is based on the colony count in the urine culture and method of collection: Colony count in the urine culture and methods of collection. Method of collection Colony count (per mL) Suprapubic aspiration Any number Urethral catheterization >104 Midstream void >105.

Risk Factors:

Risk factors for UTI in young children (look for presence of any of these in your patient) ; Poor perineal hygiene and unnecessary use of diapers ; Congenital anomalies of kidney and urinary tract (CAKUT) such as vesicoureteric reflux, pelvic ureteric junction obstruction, obstructive uropathy, abnormal communication between urinary tract and gastrointestinal tract, phimosis in boys, vulvar synechiae in girls, and renal stones ; Bowel bladder dysfunction (BBD) presenting with features of urinary urgency, frequency, dysuria, voiding postponement during the toilet training age group, incontinence, and constipation ; Almost 50% children with recurrent UTI and 10% children presenting with a single UTI have an associated urological abnormality ; Fungal UTI is more common in immunocompromised patients, intensive care unit (ICU) setting, prolonged antibiotic usage, and in presence of indwelling catheters.

Common organisms:

Common organisms causing UTI are: E. coli in >70% cases ; Uncommon organisms—non-E. Coli bacteria and fungi.

Sample Collection:

Ideal sample of urine for urine culture for diagnosis of UTI in young children ; Toilet-trained children: Midstream collected urine by clean catch method (most preferred, noninvasive practical method). Genital area should be cleaned properly with soap and water before collecting midstream urine sample. ; Non-toilet-trained children: Simple urethral catheterization or Suprapubic aspiration Note: Urine sample should never be collected from urobag or minicom in neonates, infants, and older children. Urine sample should be processed as soon as possible ideally within 30 minutes of collecting the sample to avoid contamination and incorrect result.

Common antimicrobials for treatment of UTI in children are presented :

• Oral:

Cefixime 10 in two divided doses: Good effective empirical broad spectrum agent

Amoxicillin or co-amoxiclav 30–50 in two divided doses May consider for uncomplicated

Cephalexin 30–50 in three divided doses UTI

Cefadroxil 30–40 in two divided doses

• Parenteral:

Amikacin 10–15 in one to two divided doses Once a day dosing is effective

Gentamicin 5–6 in one to two divided doses

Cefotaxime 100 in two to three divided doses Safe and effective as monotherapy

Ceftriaxone 75–100 in one to two divided doses

• Prophylaxis -once a day:

Cotrimoxazole 1–2 of trimethoprim; Nitrofurantoin 1–2: Avoid below 3 months and in glucose-6-phosphate dehydrogenase (G6PD) deficiency

Cephalexin 10 Safer option in infancy

Cefadroxil 3–5

Follow-up and Monitoring:

Further follow-up and monitoring ; Aim for symptomatic improvement, complete and sustained resolution of fever, and return of normal well being ; Document normal urine analysis at the end of treatment of current UTI ; Do not repeat urine culture unless there is a new UTI/breakthrough UTI ; Periodic monitoring of growth ; Urine analysis during further febrile episodes in presence of a known risk factor for UTI ; Blood pressure evaluation once in 6–12 months ; Assess renal function once a year in a child who had severe complicated UTI or recurrent UTI ; Watch for proteinuria after successful treatment of UTI, it may be associated with pyelonephritis renal scarring and would need medical intervention.

Further readings:

Indian Society of Pediatric Nephrology, Vijayakumar M, Kanitkar M, Nammalwar BR, Bagga A. Revised statement on management of urinary tract infections. Indian Pediatr. 2011;48(9):709-17.

The guidelines can be accessed on the official site of IAP: https://iapindia.org/standard-treatment-guidelines/