Clinical Practice Guideline In the Approach And Treatment of Urinary Tract Infection In Children In The Philippine Setting

THE CHILD WITH PROBABLE URINARY TRACT INFECTION I. The SUSPECT

1. The neonates presenting with the clinical signs and symptoms as presented in table 1. 2. Febrile infants (>38 C) below 2 years of age. 3. Older children manifesting symptoms referable to urinary tract.

Table 1 : Signs and Symptoms Associated with UTI

Clinical Signs and Symptoms Septic Temperature instability Poor feeding Vomiting Lethargy/Irritability Jaundice Fever Poor weight gain Diarrhea Abdominal Pain Frequency, dribbling, urgency, dysuria Weak urinary stream Malodorous urine Enuresis Flank pains Neonates [+] [+] [+] [+] [+] [+] [+] [+] Older Infants School Age Adolescents

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II.

THE FOLLOWING IS AN ALGORITHM ON THE DIAGNOSIS, WORK-UP, TREATMENT AND FOLLOW-UP OF CHILDREN WITH URINARY TRACT INFECTION SUSPECTED URINARY TRACT INFECTION
History Urinalysis (suggestive of UTI) (+) Leukocyte esterase or Nitrite Test Bacteria present in unspun Gram-stained specimen Pyuria WBC/hpf or 10/mm3 (+) Urine culture of a properly Collected urine specimen Physical Examination

FEVER 38.5 C

ABSENT

PRESENT

CBC (CRP, ESR) BUN, Creatinine Optimal CRP, ESR, Blood C/S

Oral Antibiotics KUB Ultrasound, pre and post void

Admit to hospital Parenteral Antibiotics KUB Ultrasound, pre and post void Urology consult as needed

GOOD RESPONSE After 48-72 hours

POOR RESPONSE After 48-72 hours

GOOD RESPONSE After 48-72 hours

Complete 7-14 days of of treatment

Reassess May shift to oral Repeat urine culture Complete 7-14 days Use appropriate antibiotics Based on initial urine C/S Complete 7-14 days of treatment

Antibiotic Prophylaxis Renal Work-up: Voiding Cystourethrogram Or nuclear cystogram Radionuclide renal scan (DMSA/DTPA) Intravenous Pyelography Other imaging techniques Urology follow-up as needed Nephrology follow-up Monitor Blood Pressure Urinalysis every 4-6 weeks Urine Culture GFR (Creatinine)

When needed:

III.

DIAGNOSIS i. HISTORY
History of previous proven UTI, constipation, voiding disorders such as incontinence, previous surgeries especially pelvic surgeries.

ii.

PHYSICAL EXAMINATON
Thorough physical examination is a must. The examiner should look for congenital defects that coexists. Back examination such as presence of dimples, hair tufts in the lumbosacral area indicating probable neurogenic bladders. Lower extremities must also be examined. Though neurologic examination must be included. Rectal examination is part of the examination.

iii.

URINALYSIS
Proper Collection of Urine: This is the cornerstone of the algorithm. >> Requirement a. For infants below one year of age, a suprapubic tap is recomended. b. A catheterized urine is good alternative to obtain urine specimen. c. Midstream urine collection for cooperative patients older girls, circumcised boys and older boys whose foreskin is easily retracted.

iv.

URINE CULTURE
THE GOLD STANDARD IS ANY BACTERIAL GROWTH AFTER A SUPRAPUBIC TAP.

URINE CULTURE: INTERPRETATION OF UTI

METHOD OF COLLECTION SUPRAPUBIC ASPIRATION QUANTITATIVE CULTURE Growth of urinary pathogen in any number (exception is up to 2-3 X 103 CFU/ml of coagulase negative staphylococci Febrile infants or children usually have 50,000 CFU/ml evidence of a single urinary pathogen, but infection may be present with count from > 1,000 CFU/ml Symptomatic patients usually have 105 CFU/ml of a single urinary pathogen Asymptomatic patients at least two specimens on different days with 105 CRU of the same pathogen

CATHETERIZATION

MIDSTREAM CLEAN-VOID MIDSTREAM CLEAN-VOID

IV.

WORK-UP
Ultrasonography alone as a work-up for patients with proven urinary tract infection is inadequate. The use of voiding cystourethrography (or nuclear cystogram) evaluates the presence or absence of vesicoureteral reflux.

V.

TREATMENT

Some Antimicrobials for Oral Treatment of UTI

Amoxicillin TMP-SMX Sulfisoxazole Cefixime Cephalexin Cefpdoxime Cefprozil Loracarbef 20-40mg/kg/day in 3 doses 6-12mg TMP 30-60 SMX/kg/day in 2 doses 120-150mg/kg/day in 4 doses 8mg/kg/day in 2 doses 50-100mg/kg/day in 4 doses 10mg/kg/day in 2 doses 30mg/kg/day in 2 doses 150mg/kg/day in 2 doses

 Some Antibiotics for Parenteral Treatment of UTI - Ceftriaxone 75mg/kg every 24 hours - Cefotaxime 150mg/kg/day divided every 6 hrs - Ceftazidime 150mg/kg/day divided every 6 hrs - Cefazolin 50mg/kg/day divided every 8 hrs - Gentamycin 7.5mg/kg/day divided every 8 hrs - Tobramycin 5mg/kg/day divided every 8 hrs - Ticarcillin 300mg/kg/day divided every 6 hrs - Ampicillin 100mg/kg/day divided every 6 hrs

Some Antimicrobial for Prophylaxis of UTI - TMP-SMX Nitrofurantoin Sulfisoxazole Nalidixic Acid Methenamine mandelate

2mg TMP,10mg SMX per kg as single Bedtime dose 1-2mg/kg as single daily dose 10-20mg/kg divided every 12 hrs 30mg/kg divided every 12 hours 75mg/kg divided every 12 hours

Reference: Philippine Pediatric Society

Western Visayas Medical Center Department of Pediatrics

Clinical Practice Guideline

In The Approach And Treatment Of Urinary Tract Infection In Children In The Philippine Setting