UPDATE ON DIAGNOSIS AND

MANAGEMENT OF PEDIATRIC UTI

Donald McLaren, MD

  Seventh International Symposium in Continuing Nursing Education/March

2014

OBJECTIVES Discuss latest AAP guidelines for

diagnosis and treatment of UTIs in febrile infants

Discuss UTI symptoms, diagnosis and treatment in children of all ages except newborns

To discuss some causes recurrent UTI and prevention of UTI and kidney damage in children with recurrent UTI

GENERAL COMMENTS In febrile infants and small children, the

urinary tract is the most common site of bacterial infection – about 5% of children 2-24 months will get at least one UTI

Some recommend UC in all 2-24 mo girls and uncircumcised males with fever >39o with no source and < 6 moa for a circumcised male (their risk much lower) (2-4 % vs. 10-25%)

AAP CLINICAL PRACTICE GUIDELINES The AAP periodically has put out

guidelines for diagnosis and management of UTI in children.

The 2011 guidelines updating the 1999 guidelines: “Urinary Tract Infection: Clinical Practice Guideline for the Diagnosis and Management of the Initial UTI in Febrile Infants and Children 2-24 months” found at: http://pediatrics.aappublications.org/content/early/2011/08/24/peds.2011-1330

AAP GUIDELINES CONTINUED This has significant recommendation

changes concerning diagnosis and evaluation of febrile UTIs in this age group.

We will discuss these guidelines. While there has been some controversy, the guidelines are very useful for us on the field as we work with children with possible UTI. They will decrease the amount of travel required for work-up after the initial febrile UTI in this age group over the 1999 guidelines

A LITTLE HISTORY I presented this topic in 2009. At that time

the recommendation was that children with a first time febrile UTI needed an evaluation including a Renal Bladder US (RBUS) and VCUG (Voiding cystourethrogram)

This was because 33% had an underlying condition or vesicoureteral reflux (VUR) to explain the UTI AND

It was felt that repeated febrile UTIs in someone with VUR would result in significant sequelae – renal scarring, HTN, and eventual RF and as evidence see the next 2 slides

AMERICAN ACADEMY OF PEDIATRICS: PRACTICE PARAMETER: THE DIAGNOSIS, TREATMENT, AND EVALUATION OF THE INITIAL URINARY TRACT INFECTION IN FEBRILE INFANTS AND YOUNG CHILDREN. PEDIATRICS. 1999;103:843-852

When 1999 guidelines written, belief was that renal scarring occurred with UTI ONLY if VUR allowed infected urine reflux back up to the kidneys

But some then were already questioning whether this was true? Was this aggressive approach really indicated? I ended with this:Medicine is fun, exhilarating, maddening,

frustrating, challenging, ever changingWe in the profession must keep up as best

we can to offer our patients the best care. What is dogma now may become wrong

tomorrowWe often don’t know what we don’t know.

So, as I present the 2011 guidelines, realize there is some controversy – some still think a first time UTI in a febrile child needs to be evaluated with a RUS and VCUG

But these new guidelines give us some much needed guidance for patients living overseas in deciding who needs to travel for further evaluation. They providing excellent guidance for diagnosis, treatment and work-up of UTI in this group of children.

DISCLAIMER IN ARTICLE WITH GUIDELINES “This clinical practice guideline is not

intended to be the sole source of guidance for the treatment of febrile infants with UTIs. Rather, it is intended to assist clinicians in decision making. It is not intended to replace clinical judgment or to establish an exclusive protocol for the care of all children with this condition.”

ACTION STATEMENT 1 – EVIDENCE QUALITY A, STRONG RECOMMENDATION Action Statement 1: If a clinician

decides that a febrile infant with no apparent source for the fever requires antimicrobial therapy because of ill appearance or another pressing reason, the clinician should ensure that a urine specimen is obtained for UA AND UC by catheterization or SPA (suprapubic urine) before antimicrobials given.

BUT DON’T FORGET THE URINE

http://pedemmorsels.com/hyperpyrexia-2/hyperpyrexia-2/

Pediatric EM Morsels © 2010-2014

HOW TO COLLECT THE URINE To tx first would obscure diagnosis of UTI SPA gold standard but many consider it

invasive and is more painful. May be only option in some (phimosis, labial adhesions)

Catheterization urine culture 95% sensitive, 99% specific compared to SPA

A bagged urine specimen not adequate in this age - has very high false positive rate (88% false + rate) and is only useful if negative

ACTION STATEMENT 2 – EVIDENCE QUALITY A; STRONG REC If a clinician assesses a febrile

infant with no apparent source for fever as not being so ill as to require immediate antimicrobial therapy, then the clinician should assess the likelihood of UTI

2a If clinician determines the febrile infant to have a low likelihood of UTI, then clinical follow-up monitoring without testing is sufficient

2B EVIDENCE QUALITY C; RECOMMENDATION 2b If clinician determines that the

febrile infant not in a low-risk group then either: Option 1 is to obtain a urine specimen

through cath or SPA for UA and UC. OROption 2: Obtain urine specimen by most

convenient means and perform UA. If the UA results suggest UTI (+ leukocyte esterase or nitrite test; + microscopic analysis for leukocytes or bacteria), obtain the urine by cath or SPA for UA and UC (fresh < 1 hour old specimen or if refrigerated < 4 hours old)

DETERMINING RISK OF UTI UTI prevalence among febrile girls > 2X that

of infant boys. Rate for uncircumcised boys 4-20X that of

circumcised boys who only have 0.2-0.4% risk

Presence of another source (i.e. OM) lowers risk by half.

New guidelines has a system based on studies to determine if risk is < 1% or at least 2%

Risk grid not absolute – if patient unlikely to keep F/U or lives in a remote location it is wise to check for UTI even if risk very low

PROBABILITY OF UTI: INFANT GIRLS

Individual FactorsProbability of

UTI# of Factors

Present

• Race: White• Age: <12 months• Temperature: ≥39⁰C• Fever: ≥2 days• Absence of another

source of infection

≤1% No more than 1

≤2% No more than 2

PROBABILITY OF UTI: INFANT BOYS

Individual FactorsProbability

of UTI

# of Factors Present

• Race: Nonblack• Temperature: ≥39⁰C• Fever: >24 hours• Absence of another

source of infection

CircumcisedNo Yes

≤1% * No more than 2

≤2% None No more than 3

*Probability of UTI exceeds 1% even with no risk factors other than being uncircumcised.

ACTION STATEMENT 3: EVIDENCE QUALITY C; RECOMMENDATION To establish the diagnosis of UTI,

clinicians should require both UA results suggesting infection (pyuria and/or bacteriuria) and the presence of at least 50 000 colony-forming units (CFUs) per mL of a uropathogen cultured from a urine specimen obtained through catheterization or SPA

URINALYSIS + UA AND UC now considered essential to

diagnosis – UA essential, not sufficient alone

If only a + UC with - UA, considered to be either asymptomatic bacteriuria or contamination as inflammation should lead to an abnormal UA also

Asymptomatic bacteriuria known to occur in older children. 0.7% of afebrile girls had 3 cultures with a single uropathogen

Lack of pyuria distinguishes true UTI from asymptomatic bacteriuria

WHAT IS NEEDED TO CONSIDER A UA POSITIVE FOR UTI? Dipstick

Positive leukocyte esterase is a marker for pyuria Sensitivity 94% in context of clinically

suspected UTI Reported as 83% in other studies Specificity much less – 64-92% - false positives

Positive Nitrite (converted from dietary nitrates in presence of most gram negative bacteria but requires 4 hours in bladder) Not sensitive but very few false positives

(specific) so if positive almost certainly have bacteria in the urine

URINE MICRO AND CULTURE > 5 WBC / hpf (25 WBC / microliter) > 10 WBC/microliter in counting

chamber Unspun gram stained urine – 1 gm –

bacteria / 10 hpf = 105 bacteria UC of fresh or refrigerated specimen

Significant > 50,000 CFUs/ml of a single urinary pathogen

Lower number for SPA (> 1000 CFU/ml)Always do sensitivity if grows urinary

pathogen

http://www.impactednurse.com/?p=2144

http://library.aua.edu.ag/webpath/webpath/tutorial/urine/urine.htm

ACTION STATEMENT 4A: QUALITY A; STRONG RECOMMENDATION Action Statement 4a When initiating

treatment, the clinician should base the choice of route of administration on practical considerations. Oral and parenteral are equally efficacious. The choice of agent should be based on local antimicrobial sensitivity patterns (if available) and should adjust the choice according to sensitivity testing of the uropathogen

4B: EVIDENCE QUALITY B; RECOMMENDATION 4b One can choose 7 to 14 days as

the duration of antimicrobial therapy

TREATMENT Goals of treatment

Eliminate infection and relieve symptomsPrevent complicationsReduce likelihood of renal damage

“Most experimental and clinical data support the concept that delays in the institution of appropriate treatment of pyelonephritis increase the risk of renal damage.”

TREATMENT Most can be treated orally

Treat parenterally if toxic appearingOr if cannot hold down meds due to N/VPossibly if not responding or cannot get F/U

Duration of treatment 7-14 daysData comparing 7,10,14 days not availableEvidence 1-3 days of treatment inferior

CHOICE OF ANTIBIOTICS Based on local resistance patterns if

possible Must cover E. coli (80% of UTIs in this

age) and other gram negative organisms

Significant degree of resistance in many places to TMP-SMP and Cephalexin

Those with multiple previous episodes of UTI often seem to be resistant to more drugs

© 2013 Answers in Genesis www.AnswersInGenesis.org.

ORAL ANTIBIOTIC OPTIONS Amoxicillin/clavulanate 20-40 mg/kg/day

q8hr Sulfisoxazole or TMP-SMX: 6-12 mg/kg

TMP and 30-60 mg/kg SMX daily in 2 doses

Cephalosporins Cefixime – 8 mg/kg/ day in 1 dose Cefpodoxime – 10 mg/kg/day in 2 doses Cefprozil – 30 mg/kg/day in 2 doses Cefuroxime axetil – 20-30 mg/kg/day in 2

doses Cephalexin – 50-100 mg/kg/day in 4 doses

PARENTERAL ANTIBIOTIC CHOICES Ceftriaxone 75 mg/kg every 24 hours Cefotaxime 150 mg/kg/day divided q 6-

8 hr Ceftazidime 100-150 mg/kg/day divided

q 8 hr Gentamycin 7.5 mg/kg/day divided q 8

hours Tobramycin 5 mg/kg/day divided q 8

hours Pipercillin 300 mg/kg/day, divided q 6-8

hours

ACTION STATEMENT 5: EVIDENCE QUALITY C; RECOMMENDATION Febrile infants with UTIs should

undergo renal and bladder ultrasonography (RBUS)

RBUS While not super useful, helpful in some

cases Non-invasive and no radiation To detect anatomic abnormalities that

require further evaluation and abscesses

Evaluate renal parenchyma Assess renal size as baseline so as to

monitor Less useful now as many already had

RBUS as prenatal screening (but often uncertain timing and quality of US during pregnancy)

RBUS TIMING Timing of RBUS within 2 days if severe

or not improving Otherwise, later better as 2 days into a

UTI would not be a true baseline as E-coli endotoxin can cause edema

DMSA scan shows if patient has pyelonephritis much better but rarely changes initial treatment. Not recommended at early stage

© 2014 RemakeHealth Inc.™ All Rights Reserved. http://www.remakehealth.com

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ACTION STATEMENT 6A: EVIDENCE QUALITY B; RECOMMENDATION Action Statement 6a: VCUG should not

be performed routinely after the first febrile UTI; VCUG is indicated if there is hydronephrosis, scarring or other findings that would suggest high grade VUR or obstructive uropathy on RBUS as well as in other atypical or complex clinical circumstances

Action Statement 6b: Further evaluation should be conducted if there is a recurrence of febrile UTI (evidence quality: X; recommendation).

SIGNIFICANT CHANGE IN RECOMMENDATIONS Strategy for 40 years

Prevent further damage after initial UTI by determining which had treatable GU abnormalities which would increase risk of renal damage with recurrent UTI

Antimicrobial prophylaxis with Bactrim or Nitrofurantoin to prevent further UTI if VUR

Or if high grade VUR or failed trial of prophylactic antibiotics, VUR surgery

However several studies have shown that one can get renal scarring/damage without VUR

Some studies indicate that antibiotic prophylaxis is not effective except in grade V reflux

If prophylaxis is not usually helpful AND one can get pyelonephritis, renal damage without VUR, then rationale for VCUG is questionable for VUR grades I-IV.

Grade V is not common among those with UTI (1/100) so by waiting reduce need for invasive VCUG testing after first febrile by UTI 90%

Study now underway to determine effects of prophylaxis in children 2 months – 6 years “The Randomized Intervention for Children with VUR study” (TMP-SMX in 607 children with grade I-V VUR following UTI)

RECURRENCE RATE OF FEBRILE UTI BY REFLUX GRADE, 1,091 INFANTS 2–24 MONTHS

0%

20%

40%

60%

80%

100%

None Grade I Grade II Grade III Grade IV

Prophylaxis

No Prophylaxis

Pediatric Care OnlineTM ©American Academy of Pediatrics

N=373 N=100 N=257 N=285 N=104

NS NS NS

NS

NS

RECURRENCE RATE OF FEBRILE UTI BY REFLUX GRADE, 1,091 INFANTS 2–24 MONTHS

0

50

100

150

200

250

None Grade I Grade II Grade III Grade IV

Prophylaxis

No Prophylaxis

Pediatric Care OnlineTM ©American Academy of Pediatrics

After First UTI(N=100)

After Recurrence(N=10)

No VUR 65 (65%) 2.6 (26%)

Grade I–III VUR 29 (29%) 5.6 (56%)

Grade IV VUR 5 (5%) 1.2 (12%)

Grade V VUR 1 (1%) 0.6 (6%)

Pediatric Care OnlineTM ©American Academy of Pediatrics

N=103 “By restricting urinary tract imaging after an initial

febrile UTI [based on NICE guidelines, 2007], rates of voiding cystourethrography and prophylactic antibiotic use decreased substantially without increasing the risk of UTI recurrence within 6 months and without an apparent decrease in detection of high-grade VUR.”

Schroeder AR, Abidari JM, Kirpekar R, et al. Impact of a more restrictive approach to urinary tract imaging after febrile urinary tract infection. Arch Pediatr Adolesc Med. 2011;165(11):1027–1032

Impact of a More Restrictive Approach to Urinary Tract Imaging After Febrile Urinary Tract Infection

EVIDENCE QUALITY C; RECOMMENDATION Action statement 7: After confirmation

of first UTI, parents should be instructed to seek prompt (ideally within 48 hours) for future febrile illnesses to ensure that recurrent infections are detected and treated promptly.Why? (Early treatment limits renal damage

better than late treatment and risk of renal scarring increases with number of recurrences)

AREAS FOR RESEARCH (8)1. Relationship between UTIs and

reduced renal function / hypertension

2. Alternatives to invasive collection of urine and culture

3. Role of VUR (and, thus, VCUG)4. Role of prophylaxis (RIVUR study)5. Genetics6. Hispanics7. Further treatment: What and for

whom?8. Duration of treatment

AAP Guideline for theDiagnosis and Management

of UTIs in Febrile InfantsUnanswered Questions and Unquestioned

Answers

Kenneth B. Roberts, MD, FAAP Professor of Pediatrics (Emeritus) University of North Carolina

TM

Roberts KB. “AAP Guideline for the Diagnosis and Management of UTIs in Febrile infants.” Pediatric Care Online Accessed 1/17/2014 at www2.aap.org/pcorss/webinars/pco/AAP%20Webinar_UTI-Roberts-Final.ppt

UTI – BACTERIOLOGY AND CAUSE 80% E. coli but also Klebsiella, Proteus,

Enterobacter, Citrobacter, etc. Gram + rare.

Non-E.coli more common with anomalies of UT, younger age, previous tx with antibiotic

Few bacteremic except newborns. Beyond newborn period due to bacteria

ascending up urethra to bladder Newborn hematogenous or ascending Most UTIs due to UPEC (uropathogenic E.

Coli); most E. Coli pyelo have P. pili fimbriae.

RISK FACTORS (UTD) Younger age, Being female, white race Lack of circumcision Genetic factors Urinary tract obstruction or VUR Bowel/bladder dysfunction Sexual activity Bladder catheterization Risk of renal scarring: recurrent UTI,

delay in treatment of acute UTI, bladder/bowel dysfunction, obstruction, VUR, ? young age

SYMPTOMS IN YOUNGER CHILDREN Very non-specific in younger children First 2 months high fever, jaundice,

apnea, many more – often with sepsis After 1-2 months: fever (especially > 39o

and if >48 hours) and suprapubic tenderness

Some irritability or fussiness and other non-specific signs: poor feeding, FTT

Foul smelling urine and GI symptoms not found to be helpful in diagnosis

SYMPTOMS IN OLDER CHILDREN Classic sx: fever and urinary symptoms

(frequency, dysuria, urgency, incontinence, hematuria, abd. pain)

For pyelonephritis in older children fever, chills, flank pain and abdominal pain

Not all with sx have UTI: ddx of urethritis include vulvovaginitis, irritant or chemical, urethritis, urinary calculi, STD, vaginal FB

In past it was said and I always presume if UTI + fever = pyelonephritis. Not always true but cannot do a DMSA scan in all of them

http://nutravize.com

IMPORTANT HISTORY AND PHYSICAL FINDINGS History -Determine if chronic symptoms,

constipation, previous UTIs or undiagnosed febrile illnesses, VUR, FH, antenatally diagnosed renal abnormality, high Bp, poor growth, sexual activity and spermicides

Physical: Bp, Temp, growth parameters, tenderness of abdomen, external genitalia, low back exam, other sources of fever

LAB Lab – Need + UA AND UC to confirm UTI Usually no need for BC after 2 months No need for creatinine unless recurrent If potty trained can do CCUA specimen

> 100,000 CFU/ml for CCUA> 1000 CFU/ml for SP>50,000 CFU/ml for cath culture

If 10-50,000 repeat If same result of same and only one uropathogen

treat

TREATMENT 50% E. Coli resistant to Amoxicillin, Amp;

increasing resistance to TMP-SMX,cephalexin, Amoxacillin-clavulanate, Amp-sulbactam

If suspect enterococcus don’t use monotherapy – add Ampicillin (urinary catheter, anatomical abnormality)

3rd gen. cephalosporins best starting drug. Oral as good as IV for time to symptom

resolution, sterilization of urine, reinfection rate, renal scarring at 6 months

TREATMENT FLQs effective but increasing resistance. ?

safety in children - limit to Pseudomonas and multidrug resistant gram negative organisms

Should improve within 24-48 hours. No need to reculture unless not improving 24

hr Studies conflict on whether prophylaxis

useful for recurrent UTI – some say only if grade V reflux – others if III-V reflux

Would try after 2nd UTI + VUR as trial Study ongoing to see if steroids prevent

renal damage with UTI

WORK-UP AFTER UTI RBUS: Children < 2 with 1st UTI, any age with

recurrent febrile UTIs, children with FH of kidney issues, HTN, poor antibiotic response.

VCUG if < 2 yo with 2 or more febrile UTIs, FH of renal/urological disease, poor growth or HTN, perhaps those with organism other than E.Coli and prophylaxis if grade > III VUR

DMSA not routine – shows pyelonephritis, most VUR III or higher, as well as scarring.

F/u with growth, weight and Bp – not UA, UC

WHEN TO REFER Refer if dilating VUR (III-V) or obstructive

uropathy, renal abnormalities, impaired kidney function, elevated Bp, bowel or bladder dysfunction that is refractory to primary care measures

PROGNOSIS Most have no long term sequelae < 19 with first UTI – 25% had VUR, 2.5%

had grade IV or V reflux. VUR increases risk of acute

pyelonephritis and renal scarring and 15% showed evidence of renal scarring at F/U

8% had at least one recurrence

LONG TERM MANAGEMENT 8-30% have > one symptomatic reinfections. Evaluate for, tx bowel/bladder dysfunction No need for F/U cultures Inform parents after febrile UTI they need to

seek care soon if symptoms or fever develop Consider prophylaxis for those without VUR if

3 febrile UTIs in 6 months or 4 in year. With VUR grade 3-5 after second febrile UTI.

TMP-SMX 2 mg TMP/kg or Nitrofurantoin 1-2 mg/kg

6 months and if no UTIs can stop and resume if another recurrence

ACUTE CYSTITIS IN CHILDREN 2 YEARS THROUGH ADOLESCENCE 90% E. coli (then other gm - organisms) >100,000 CFU/ml uropathogen Ddx- bladder dysfunction, vaginal FB, drug,

chemical, nonspecific vulvovaginitis, cervicitis, urethritis, prostatitis, epididymo-orchitis, nephrolithiasis, urethral stricture, interstitial (autoimmune), neoplasm

Treat empirically If > 13, uncomplicated include coverage for

staph saprophyticus – TMP-SMX or cephalosporin

In older children if not complicated treat 5-7 days. If younger or complicated 7-14 days

VESICO-URETERAL REFLUX (VUR)

© 2005-2014 All Rights Reserved http://www.childrenshospital.org

VUR Retrograde passage of urine into upper

urinary tract from the bladder 1% newborns; 30-45% young children with

UTI Most common urological finding in children Can be primary or secondary due to

abnormally high pressures in bladder More common in whites, girls, younger. Strong genetic component Diagnose by VCUG or radionuclide

cystogram (RNC)

30-60% of those with IV or V reflux have primary renal scarring – may be developmental issue

? if scarring result of developmental issue or due to infections ascending up to kidney due to VUR; many continue to believe latter

> ½ resolve on their own – more likely with milder degrees (I-II 80% resolve in 5 years)

High grade rarely resolve on own Evaluate all with VUR and F/U for renal

status, growth parameters, Bp, creatinine (initially) and UA for pyuria and proteinuria

MANAGEMENT OF VUR Unknown benefits of treatment. UpToDate

management based on available data, prevention of pyelonephritis, likelihood of renal scarring and of spontaneous resolution of VUR, and patient/family preference Screen for voiding dysfunction III-V either treat (prophylaxis) or surveillance and

prompt treatment if UTI I,II observation vs. antibiotic prophylaxis with

family inputTrials so far display no difference in

outcome between antibiotic prophylaxis, surgical VUR repair - get family input

VUR MANAGEMENT CONTINUED

Surgery recommended if unlikely to resolve (family input); Grade V reflux + scarring, Grade V > 6 YOA, III-V with failed medical tx

Dx and tx promptly if symptoms or febrile illness.

Yearly RBUS. DMSA if RBUS suggests renal scarring, poor renal growth, those with recurrent UTI and with Grade III-V VUR

F/u yearly growth, Bp and UA

BLADDER OR VOIDING DYSFUNCTION Essential to determine in children with

UTI or VUR if have bladder dysfunction - problems with bladder filling or emptying which can predispose to repeated infections.

Can be from neurogenic, anatomic (ectopic ureter, obstruction) or functional causes

WHEN TO EVALUATE FOR BLADDER/BOWEL DYSFUNCTION Hx, Px, UA, UC – Suspect if:

Daytime urinary incontinence in school age or previously toilet trained children

Urinary sx: urgency, dribbling, dysuria, daytime frequency, nocturia, hesitancy, holding maneuvers to avoid voiding, abnormal or intermittent flow or stream, incontinence, abdominal straining, holding maneuvers, post void residual, if VUR or recurrent infections

Dysfunctional Voiding Symptoms Survey questionnaire or voiding diary very helpful

R/O neurological or anatomical causes

http://fmymind.com/urine-trouble/

Many types beyond scope of talk. Will discuss only daytime wetting due to dysfunctional voiding - occurs in 20% of 4-6 years old- causesOveractive bladder (urgency)Voiding postponement and underactive

bladder (Valsalva to urinate large volume post void residual)

Dysfunctional voiding (Inability to relax urethral sphincter and/or pelvic floor musculature during voiding. Detrusor contractions during voiding against a closed external urinary sphincter. Get interrupted staccato flow pattern, prolonged voiding time)

Other

DYSFUNCTIONAL VOIDING

http://www.vcu.edu/urology/patients/conditions/peds_urology/dys_voiding.html

TREATMENT OF DYSFUNCTIONAL VOIDING Can reduce symptoms in as many as 40-

70% Take care of constipation Explain to parents, patient if appropriate Voiding behavior modification if age

appropriate Educate family including how child’s voiding

patterns deviate from normal Timed voiding schedule and 72 hr voiding diary Frequent voiding q 2-3 hours all day Try to empty bladder fully and use double voids Reward for following program, not for staying

dry

REFERRAL FOR DYSFUNCTIONAL VOIDING If not working refer to urologist MD for

testing and treatment which might include RBUS, VCUG, MRI, urinary flow measurement,

urodynamic testing Medication Pelvic floor relaxation techniques Biofeedback Electrical stimulation therapy, botox injection,

surgery,, intermittent clean catheterization If not treated risk high pressures, complications

thereof – some feel all need urologist

SOURCES Subcommittee on Urinary Tract Infection and

Steering Committee on Quality Improvement and Management. “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 accessed 1/20/2014 at http://pediatrics.aappublications.org/content/early/2011/08/24/peds.2011-1330

Allen HA. “Fever without a source in children 3 to 36 months of age.” UpToDate accessed 1/17/2014 http://www.uptodate.com/contents/fever-without-a-source-in-children-3-to-36-months-of-age?source=search_result&search=fever+without+a+source&selectedTitle=1%7E15

McLorie G, Herrin JT. “Management of vesicoureteral reflux. UpToDate accessed 1/16/2014 at http://www.uptodate.com/contents/management-of-vesicoureteral-reflux?source=search_result&search=Management+of+vesicoureteral&selectedTitle=1%7E68

McLorie G, Herrin JT. “Presentation, diagnosis and clinical course of vesicoureteral reflux.” UpToDate accessed 1/16/2014 at http://www.uptodate.com/contents/presentation-diagnosis-and-clinical-course-of-vesicoureteral-reflux?source=search_result&search=presentation%2C+diagnosis+adn+clinical+course+of+vesicoureteral+reflux&selectedTitle=1%7E150

Nepple KG, Cooper CS. “Etiology and clinical features of bladder dysfunction in children.” UpToDate accessed 1/16/2014 at http://www.uptodate.com/contents/etiology-and-clinical-features-of-bladder-dysfunction-in-children?source=search_result&search=bladder+dysfunction&selectedTitle=3%7E150

Nepple KG, Cooper CS. “Evaluation and diagnosis of bladder dysfunction in children.” UpToDate accessed 1/16/2014 at http://www.uptodate.com/contents/evaluation-and-diagnosis-of-bladder-dysfunction-in-children?source=search_result&search=bladder+dysfunction&selectedTitle=4%7E150

Nepple KG, Cooper CS. “Management of bladder dysfunction in children.” Uptodate accessed 1/16/2014 at http://www.uptodate.com/contents/management-of-bladder-dysfunction-in-children?source=search_result&search=bladder+dysfunction&selectedTitle=6%7E150

O’Donovan DJ. “Urinary tract infections in newborns.” Uptodate accessed 1/20/2014 at http://www.uptodate.com/contents/urinary-tract-infections-in-newborns?source=search_result&search=urinary+tract+infection+in+newborns&selectedTitle=1%7E150

Palazzi DL and Campbell JR. “Acute cystitis in children older than two years and adolescents.” UpToDate accessed 1/20/2014 at http://www.uptodate.com/contents/acute-cystitis-in-children-older-than-two-years-and-adolescents?source=search_result&search=acute+cystitis&selectedTitle=2%7E74

Roberts KB. “AAP Guideline for the Diagnosis and Management of UTIs in Febrile infants.” Pediatric Care Online Accessed 1/17/2014 at www2.aap.org/pcorss/webinars/pco/AAP%20Webinar_UTI-Roberts-Final.ppt

Shaikh N, Hoberman A. “Urinary tract infections in Infants and children older than one month: acute management, imaging, and prognosis.” UpToDate accessed 1/20/2014 at http://www.uptodate.com/contents/urinary-tract-infections-in-infants-and-children-older-than-one-month-acute-management-imaging-and-prognosis?source=search_result&search=uti+in+children&selectedTitle=1%7E150

Shaikh N, Hoberman A. “Long-term management and prevention of urinary tract infections in children. UpToDate accessed 1/20/2014 at http://www.uptodate.com/contents/long-term-management-and-prevention-of-urinary-tract-infections-in-children?source=search_result&search=uti+in+children&selectedTitle=5%7E150

Shaikh N, Hoberman A. “Urinary tract infections in infants and children older than one month: clinical features and diagnosis.” UpToDate Accessed 1/20/2014 at http://www.uptodate.com/contents/urinary-tract-infections-in-infants-and-children-older-than-one-month-clinical-features-and-diagnosis?source=search_result&search=uti+in+children&selectedTitle=2%7E150

Shaikh N, Hoberman A. “Urinary tract infections in children: epidemiology and risk factors.” UpToDate accessed 1/20/2014 at http://www.uptodate.com/contents/urinary-tract-infections-in-children-epidemiology-and-risk-factors?source=search_result&search=uti+in+children&selectedTitle=3%7E150

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