An 18-month-old girl is brought to the emergency department due to fever and abdominal pain. Yesterday she began to cry while urinating. Today her parents saw a small amount of blood in the urine, and the urine was malodorous. The patient was born at term and has no chronic medical conditions. Temperature is 38.9 C (102 F), blood pressure is 96/62 mm Hg, pulse is 130/min, and respirations are 20/min. Physical examination shows suprapubic tenderness and left costovertebral angle tenderness. Complete blood count reveals leukocytosis. Serum creatinine and electrolytes are normal. Catheterized urinalysis results are as follows:
| Blood | moderate |
| Leukocyte esterase | positive |
| Nitrites | positive |
| Bacteria | moderate |
| White blood cells | 50+/hpf |
| Red blood cells | 20-30/hpf |
| Casts | none |
A urine culture grows 100,000 colony-forming units/mL of Escherichia coli. Antibiotics are administered, and her fever and pain resolve on the second day of hospitalization. In addition to completing the current course of antibiotics, which of the following is the best next step in management of this patient?
Urinary tract infection (UTI) in children | |
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RBUS = renal & bladder ultrasound; VCUG = voiding cystourethrogram; WBCs = white blood cells. | |
This patient with abdominal pain, dysuria, and Escherichia coli on urine culture has a first febrile urinary tract infection (UTI). The costovertebral tenderness also suggests possible renal involvement. Pyuria (≥5 white blood cells/hpf) and bacteriuria (≥50,000 colony-forming units/mL from a catheterized specimen) are diagnostic of UTI, and positive nitrites (suggestive of infection with Enterobacteriaceae, including E coli) and leukocyte esterase (produced by white blood cells) support the diagnosis. Hematuria is also commonly associated, as in this patient.
Children age <2 years are at increased risk of complications from UTIs (eg, renal scarring/damage, hypertension) and should be treated with 1-2 weeks of antibiotics (eg, third-generation cephalosporin). In addition, all children age <2 with a first febrile UTI should undergo a renal and bladder ultrasound to evaluate for any anatomic abnormalities (eg, urinary obstruction, vesicoureteral reflux) that might predispose them to UTIs. The ultrasound should be performed after fever and symptoms have resolved to minimize false positive results from acute inflammation. If the patient has persistent or worsening symptoms, an ultrasound should be performed immediately to assess for renal abscess.
(Choice A) Daily prophylactic antibiotics can be considered in patients with recurrent UTIs or evidence of high-grade vesicoureteral reflux. They are generally not indicated in children with a first febrile UTI.
(Choice B) Children age >2 and adults generally do not need further evaluation of a first-time UTI due to the lower likelihood of predisposing anatomic issues, lower risk of complications, and lower risk of recurrent UTI.
(Choice C) A voiding cystourethrogram is appropriate if hydronephrosis or scarring is seen on renal ultrasound. It is also indicated in children with recurrent UTIs or a first febrile UTI from an organism other than E coli.
(Choice E) Repeat blood work and urine culture should be performed only in children who fail to improve after 2-3 days of appropriate antibiotics. These studies are not indicated to prove a cure in patients with obvious symptomatic improvement.
Educational objective:
Children age <2 years with a first febrile urinary tract infection (UTI) should receive 1-2 weeks of antibiotics and a renal and bladder ultrasound to evaluate for abnormalities that may lead to recurrent UTIs.