Urinary Tract Infections in Children

URINARY TRACT INFECTIONS IN CHILDREN

Urinary tract infections in children may be difficult to diagnose because children rarely complain of symptoms such as dysuria (burning when passing urine) or frequency. Occasionally a mother’s complaint that the child cries each time he or she passes urine may lead to a proven UTI. Most other cases of UTI are found on

• Checking urine for patients with fever with no obvious cause
• Children investigated for failure to thrive. Hidden urinary tract infections are an important cause of failure to thrive and so always check urine for UTI if there is no clear cause for failure to thrive.

It is important to follow a urine microscopy that suggests UTI with a culture and sensitivity test on urine to prove the UTI if possible. That is because pyuria may occur with any fever and the diagnosis of UTI has important follow up tests needed. To get a specimen suitable for culture, urine should be obtained by a clean catch in to a sterile container. Or by a suprapubic puncture or catheterisation using paediatric NG tubes, both of which can be safely done in a primary health centre. Bag urine obtained by a bag or test tube stuck on are not suitable for a culture and sensitivity test but can be used for dipstick tests.

Proven or suspected UTI in children under 5: what to do in a health centre?

1. Treat the acute infection with appropriate antibiotics such as cephalexin or a quinolone (despite theoretical objections to quinolones in children). Sick individuals will need parenteral antibiotics including gentamicin.
2. On completion of successful treatment start preventive treatment with cotrimoxazole. The preventive doses of cotrimoxazole is the same as the treatment dose in antibiotic doses but given only once a day and not twice a day (i.e. half the dose). Give B complex and folic acid also to those who need preventive treatment. 6 months of treatment is needed and the child should be entered in the chronic follow up register.
3. All these children should have growth monitoring as a routine follow up if not already done.
4. Do an ultrasound scan of renal tract if possible. If ultrasound is difficult to get, consider doing it only on those who had (1) failure to thrive at presentation or follow up after treatment and (2) those who get further UTI during prophylaxis or after prophylaxis is stopped.
5. Those who have no changes on ultrasound need to have only prophylaxis for 6 months or a further 6 months if UTI recurred after or during prophylaxis.
6. Those who have ultrasound scans that suggest blockage, scarring or swollen kidneys should be referred to a paediatrician. Those who continue to have infection after the antibiotic treatment for 6 months may need referral also but if their ultrasound scan is normal they could be considered for another 6 months preventive treatment. In those who have scarred kidneys who cannot be referred to a specialists, antibiotic prevention may be given until 5 years age.