AAP reaffirms Guideline on Diagnosis, Management of Initial UTI in Febrile Infants,Young Children

The diagnosis and management of urinary tract infections (UTIs) in young children are clinically challenging. . Certain clinical findings and new urinalysis methods can help clinicians identify febrile children at very low risk of UTI

In November 2016, AAP came out with the Reaffirmation of AAP Clinical Practice Guideline on The Diagnosis and Management of the Initial Urinary Tract Infection in Febrile Infants and Young Children 2–24 Months of Age as a part of its five yearly update.

Following are its major recommendations on the issue

Action Statement 1

If a clinician decides that a febrile infant with no apparent source for the fever requires antimicrobial therapy to be administered because of ill appearance or another pressing reason, the clinician should ensure that a urine specimen is obtained for both culture and urinalysis before an antimicrobial is administered; the specimen needs to be obtained through catheterization or suprapubic aspiration (SPA), because the diagnosis of UTI cannot be established reliably through culture of urine collected in a bag (evidence quality: A; strong recommendation).

Action Statement 2

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

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  Action Statement 2a. If the clinician determines the febrile infant to have a low likelihood of UTI (see text), then clinical follow-up monitoring without testing is sufficient (evidence quality: A; strong recommendation).

  
  


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  Action Statement 2b. If the clinician determines that the febrile infant is not in a low-risk group (see below), then there are 2 choices (evidence quality: A; strong recommendation).

  
  


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  Option 1 is to obtain a urine specimen through catheterization or SPA for culture and urinalysis.

  
  


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  Option 2 is to obtain a urine specimen through the most convenient means and to perform a urinalysis. If the urinalysis results suggest a UTI (positive leukocyte esterase test results or nitrite test or microscopic analysis results for leukocytes or bacteria), then a urine specimen should be obtained through catheterization or SPA and cultured; if urinalysis of fresh (less than 1 hour since void) urine yields negative leukocyte esterase and nitrite results, then it is reasonable to monitor the clinical course without initiating antimicrobial therapy, recognizing that a negative urinalysis does not rule out a UTI with certainty.

  
  

Action Statement 3

To establish the diagnosis of UTI, clinicians should require both urinalysis results that suggest infection (pyuria and/or bacteriuria) and the presence of at least 50 000 colony-forming units (cfu) per milliliter of a uropathogen cultured from a urine specimen obtained through transurethral catheterization or SPA (evidence quality: C; recommendation).

Action Statement 4

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  Action Statement 4a. When initiating treatment, the clinician should base the choice of route of administration on practical considerations: initiating treatment orally or parenterally is equally efficacious. The clinician should base the choice of agent on local antimicrobial sensitivity patterns (if available) and should adjust the choice according to sensitivity testing of the isolated uropathogen (evidence quality: A; strong recommendation).

  
  


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  Action Statement 4b. The clinician should choose 7 to 14 days as the duration of antimicrobial therapy (evidence quality B; recommendation).

  
  

Action Statement 5

Febrile infants with UTIs should undergo renal and bladder ultrasonography (RBUS) (evidence quality: C; recommendation).

Action Statement 6

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  Action Statement 6a. Voiding cystourethrography (VCUG) should not be performed routinely after the first febrile UTI; VCUG is indicated if RBUS reveals hydronephrosis, scarring, or other findings that would suggest either high-grade VUR or obstructive uropathy, as well as in other atypical or complex clinical circumstances (evidence quality B; recommendation).

  
  


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

  
  

Action Statement 7

After confirmation of UTI, the clinician should instruct parents or guardians to seek prompt medical evaluation (ideally within 48 hours) for future febrile illnesses to ensure that recurrent infections can be detected and treated promptly (evidence quality: C; recommendation).

You can read the full Guideline by clicking on the link :

http://pediatrics.aappublications.org/content/early/2016/11/24/peds.2016-3026