A complicated urinary tract infection, whether localized to the lower or upper tract, is associated with an underlying condition that increases the risk of failing therapy. These conditions are summarized above. (See'Definitions' above.)
●The microbial spectrum of complicated cystitis and pyelonephritis includes organisms associated with uncomplicated UTIs (mainly Escherichia coli, with occasional other species of Enterobacteriaceae, such as Proteus mirabilis and Klebsiella pneumoniae) as well as Pseudomonas, Serratia, Providencia, enterococci, staphylococci, and fungi. In addition, organisms causing complicated cystitis are more likely to be resistant to commonly used oral antimicrobials recommended for uncomplicated cystitis. (See 'Microbiology' above.)
●In addition to clinical manifestations observed with uncomplicated urinary tract infection, patients with complicated infection may present with sepsis, multiple organ system dysfunction, and/or acute renal failure. In some cases, complicated pyelonephritis may be associated with weeks to months of insidious, nonspecific signs and symptoms such as malaise, fatigue, nausea, or abdominal pain. (See 'Clinical manifestations' above.)
●A urine culture and antimicrobial susceptibility testing should be performed to guide treatment. Patients with persistent or recurrent symptoms within a few weeks of treatment for acute complicated urinary tract infection should also have reevaluation for other conditions that might be causing the symptoms. In addition, patients with pyelonephritis should undergo radiographic imaging if they are severely ill or have symptoms of or risk factors for complications of infection. Computed tomography (CT) scan and ultrasonography are useful modalities to evaluate for the presence of an underlying anatomic abnormality, to detect a process that may delay response to therapy (such as calculus, papillary necrosis, or obstruction), or to diagnose a complication of infection such as a renal or perinephric abscess. (See 'Diagnostic evaluation' above and 'Radiographic imaging'above.)
●For patients with complicated cystitis who can tolerate oral therapy we suggest empiric treatment with an oral fluoroquinolone such as ciprofloxacin (500 mg orally twice daily or 1000 mg extended release once daily) orlevofloxacin (750 mg orally once daily) (Grade 2B). The duration range is generally 5 to 10 days. Parenteral therapy may be warranted for treatment of patients who cannot tolerate oral therapy or for patients with infection that is suspected to be due to resistant organisms; reasonable regimens that may be administered once daily include levofloxacin (500 mg), ceftriaxone (1 g), ertapenem (1 g) (drug of choice for known or suspected infection with an extended-spectrum beta-lactamase producing organism), or an aminoglycoside (3 to 5 mg/kg of gentamicin or tobramycin). Empiric treatment choice should also take into account previous antimicrobial use and results of any recent urine cultures. After clinical improvement is observed, parenteral therapy can be switched to oral therapy, guided by antimicrobial susceptibility data, for a total of 5 to 14 days, depending upon the severity of infection. (See 'Cystitis' above.)
●Patients with complicated pyelonephritis should be managed initially as inpatients. Broad-spectrum parenteral antimicrobials should be used for empiric treatment of complicated pyelonephritis as outlined in the table (table 1). Previous antimicrobial use and results of any recent urine cultures should inform the choice of an empiric regimen. If antimicrobial susceptibility data and clinical circumstances permit, treatment may be completed with oral therapy; acceptable agents include levofloxacin, ciprofloxacin, or trimethoprim-sulfamethoxazole. Antibiotics are generally administered for 5 to 14 days; depending on patient circumstances, a longer duration of therapy may be warranted. (See 'Pyelonephritis' above.)
Ultrasonography of acute pyelonephritis
Renal ultrasonography in a patient with acute pyelonephritis showing a hypodense mass with internal echoes (outlined by the arrows).
Courtesy of Alain Meyrier, MD.
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Computed tomography scan of acute pyelonephritis
Contrast-enhanced CT scan in a patient with acute pyelonephritis showing a large, hypodense region in the right kidney. There is no discrete abscess formation in this setting.
Courtesy of Alain Meyrier, MD.
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Computed tomography scan of bilateral acute pyelonephritis
Contrast-enhanced CT scan in bilateral acute pyelonephritis showing triangular hypodense streaks spreading from the pelvis to the renal cortex (arrows).
Courtesy of Alain Meyrier, MD.
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Parenteral regimens for empiric treatment of complicated pyelonephritis
| Antimicrobial agent | Dose, interval |
| Mild to moderate pyelonephritis* | |
| Ceftriaxone | 1 g every 24 hours |
| Ciprofloxacin | 400 mg every 12 hours |
| Levofloxacin | 750 mg every 24 hours |
| Aztreonam¶ | 1 g every 8 to 12 hours |
| Severe pyelonephritis | |
| Cefepime | 2 g every 12 hours |
| Piperacillin-tazobactamΔ | 3.375 g every 6 hours |
| Ceftolozane-tazobactam | 1.5 g every 8 hours |
| Ceftazidime-avibactam | 2.5 g every 8 hours |
| MeropenemΔ | 500 mg every 8 hours |
| Imipenem | 500 mg every 6 hours |
| Doripenem | 500 mg every 8 hours |
Previous antimicrobial use and results of any recent urine cultures should inform the choice of an empiric regimen.
Doses are for patients with normal renal function.
In the setting of pregnancy, the above agents are acceptable with the exceptions of ciprofloxacin, levofloxacin, and imipenem. The treatment of urinary tract infection due to enterococcus is discussed separately.
If methicillin-resistant S. aureus (MRSA) is known or suspected, see treatment regimens outlined separately in topics addressing MRSA management.
Doses are for patients with normal renal function.
In the setting of pregnancy, the above agents are acceptable with the exceptions of ciprofloxacin, levofloxacin, and imipenem. The treatment of urinary tract infection due to enterococcus is discussed separately.
If methicillin-resistant S. aureus (MRSA) is known or suspected, see treatment regimens outlined separately in topics addressing MRSA management.
*Broader therapy with one of the agents listed for severe pyelonephritis may be warranted if there is suspicion for infection with a resistant organism.
¶ Alternative in the setting of beta lactam allergy.
Δ If Pseudomonas aeruginosa is suspected, higher doses of piperacillin-tazobactam (4.5 g every 6 hours) or meropenem (1 g every 8 hours) can be used.
¶ Alternative in the setting of beta lactam allergy.
Δ If Pseudomonas aeruginosa is suspected, higher doses of piperacillin-tazobactam (4.5 g every 6 hours) or meropenem (1 g every 8 hours) can be used.
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Urinary tract infections in infants and children older than one month: Clinical features and diagnosis
Fever may be the only sign of urinary tract infection (UTI) in infants and young children. Older children may have urinary symptoms (eg, abdominal pain, back pain, dysuria, frequency, new-onset urinary incontinence). (See'Clinical presentation' above.)
●Important aspects of the history in a child with suspected UTI include features of the acute illness (eg, fever, urinary symptoms) and risk factors for UTI (table 1). (See 'History' above and "Urinary tract infections in children: Epidemiology and risk factors", section on 'Host factors'.)
●The examination of the child with suspected UTI should include measurement of blood pressure, temperature, and growth parameters; abdominal examination for tenderness or mass; assessment of suprapubic and costovertebral tenderness; examination of the external genitalia; evaluation of the lower back for signs of occult myelomeningocele; and a search for other sources of fever. (See 'Physical examination' above.)
●The laboratory evaluation for the child with suspected UTI includes obtaining a urine sample for a dipstick and/or microscopic evaluation and urine culture (table 2). Urine culture is necessary to make the diagnosis. (See'Laboratory evaluation' above.)
●We suggest that urine samples be obtained for urinalysis and culture in the following patients (algorithm 1A-C) (see 'Decision to obtain' above):
•Girls and uncircumcised boys younger than two years with at least one risk factor for UTI (history of UTI, temperature >39ºC, fever without apparent source [particularly if the child will be treated with antibiotics], ill appearance, suprapubic tenderness, fever >24 hours, or nonblack race).
•Circumcised boys younger than two years with suprapubic tenderness or at least two risk factors for UTI (history of UTI, temperature >39ºC, fever without apparent source, ill appearance, suprapubic tenderness, fever >24 hours, or nonblack race).
•Girls and uncircumcised boys older than two years with any of the following urinary or abdominal symptoms (abdominal pain, back pain, dysuria, frequency, high fever, or new-onset incontinence).
•Circumcised boys older than two years with multiple urinary symptoms (abdominal pain, back pain, dysuria, frequency, high fever, or new-onset incontinence).
•Febrile infants and children with abnormalities of the urinary tract or family history of urinary tract disease.
●Catheterization is the preferred method of urine collection for infants and children who are not toilet-trained. Clean catch is the preferred method of collection for toilet-trained children. We recommend that urine obtained in a sterile bag not be used for culture. (See 'How to obtain' above.)
●We suggest that urine culture be performed routinely for all children in whom UTI is a diagnostic consideration and in whom a sample for urinalysis or dipstick is collected. (See 'Urine culture' above.)
●The diagnosis of UTI requires laboratory confirmation. UTI is best defined as significant bacteriuria in a patient with pyuria on dipstick or microscopic urinalysis. We define significant bacteriuria as recovery of ≥100,000CFU/mL of a uropathogen from a clean catch specimen, ≥50,000 CFU/mL of a uropathogen from a catheterized specimen, and any uropathogenic bacteria from a suprapubic aspirate. If the urine culture demonstrates significant growth of Enterococcus, Klebsiella, or Pseudomonas aeruginosa in a child with symptoms of UTI, UTI may be diagnosed in the absence of pyuria. (See 'Significant bacteriuria' above and 'Pyuria' above.)
Prevalence of urinary tract infection in febrile* infants and children by demographic group
| Demographic group | Prevalence or pretest probability (95% CI) |
| 0 to 3 months | 7.2 percent (5.8-8.6) |
| Girls | 7.5 percent (5.1-10) |
| Circumcised boys | 2.4 percent (1.4-3.5) |
| Uncircumcised boys | 20.1 percent (16.8-23.4) |
| 3 to 6 months | 6.6 percent (1.7-11.5) |
| Girls | 5.7 percent (2.3-9.4) |
| Boys | 3.3 percent (1.3-5.3) |
| 6 to 12 months | 5.4 percent (3.4-7.4) |
| Girls | 8.3 percent (3.9-12.7) |
| Boys | 1.7 percent (0.5-2.9) |
| 12 to 24 months | 4.5 percent¶ |
| Girls | 2.1 percent (1.2-3.6) |
| Circumcised boys >1 year | <1 percent¶ |
| <19 years with urinary symptoms and/or feverΔ | 7.8 percent (6.6-8.9) |
* Temperature ≥38°C.
¶ 95% confidence interval not available.
Δ Most of these children were older than two years.
¶ 95% confidence interval not available.
Δ Most of these children were older than two years.
Data from: Shaikh N, Morone NE, Bost JE, Farrell MH. Prevalence of Urinary Tract Infection in Childhood: A Meta-Analysis. Pediatr Infect Dis J 2008; 27:302.
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Diagnostic algorithm for febrile male infants aged 3 to 24 months suspected of having a UTI
UTI: urinary tract infection; LR: likelihood ratio.
Reproduced with permission from: Shaikh N, Morone NE, Lopez L, et al. Does this child have a urinary tract infection? JAMA 2008; 298:2895. Copyright © 2008 American Medical Association.
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Diagnostic algorithm for febrile female infants aged 3 to 24 months suspected of having a UTI
UTI: urinary tract infection; LR: likelihood ratio.
Reproduced with permission from: Shaikh N, Morone NE, Lopez L, et al. Does this child have a urinary tract infection? JAMA 2008; 298:2895. Copyright © 2008 American Medical Association.
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Diagnostic algorithm for verbal children older than 24 months with urinary or abdominal symptoms
UTI: bacterial urinary tract infection; LR: likelihood ratio.
Reproduced with permission from: Shaikh N, Morone NE, Lopez L, et al. Does this child have a urinary tract infection? JAMA 2007; 298:2895. Copyright © 2008 American Medical Association.
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Test characteristics of tests used to diagnose urinary tract infections in children
| Sensitivity | Specificity | Positive likelihood ratio* | Negative likelihood ratio¶ | |
| Dipstick | ||||
| Leukocyte esterase (LE) | 84 percent | 78 percent | 4 | 0.2 |
| Nitrite | 50 percent | 98 percent | 25 | 0.5 |
| Nitrite or LE | 88 percent | 93 percent | 13 | 0.1 |
| Nitrite and LE | 72 percent | 96 percent | 18 | 0.3 |
| Microscopy | ||||
| Uncentrifuged | ||||
| Pyuria (>10/mm3) (all ages) | 77 percent | 89 percent | 7 | 0.4 |
| Pyuria (>10/mm3) (<2 years) | 90 percent | 95 percent | 18 | 0.1 |
| Bacteriuria (gram stained) | 93 percent | 95 percent | 19 | 0.1 |
| Overall (P+B) = enhanced | 85 percent | 99.9 percent | 85 | 0.1 |
| Overall (P or B) | 95 percent | 89 percent | 9 | 0.1 |
| Centrifuged | ||||
| Pyuria (>5/hpf) | 67 percent | 79 percent | 3 | 0.4 |
| Bacteriuria | 81 percent | 83 percent | 5 | 0.2 |
| Overall (P+B) | 66 percent | 99 percent | 7 | 0.4 |
P: pyuria; B: bacteriuria; hpf: high-power field.
* Positive likelihood ratio: The positive likelihood ratio is the probability that a child with a UTI will have a positive test divided by the probability that a child without a UTI will have a positive test (eg, true positive rate/false positive rate). The higher the positive likelihood ratio, the better the test.
¶ Negative likelihood ratio: The negative likelihood ratio is the probability that a child with a UTI will have a negative test divided by the probability that a child without a UTI will have a negative test (eg, false negative rate/true negative rate). The lower the negative likelihood ratio, the better the test (a perfect test has a negative likelihood ratio of zero).
* Positive likelihood ratio: The positive likelihood ratio is the probability that a child with a UTI will have a positive test divided by the probability that a child without a UTI will have a positive test (eg, true positive rate/false positive rate). The higher the positive likelihood ratio, the better the test.
¶ Negative likelihood ratio: The negative likelihood ratio is the probability that a child with a UTI will have a negative test divided by the probability that a child without a UTI will have a negative test (eg, false negative rate/true negative rate). The lower the negative likelihood ratio, the better the test (a perfect test has a negative likelihood ratio of zero).
References:
- Gorelick MH, Shaw KN. Screening tests for urinary tract infection in children: A meta-analysis. Pediatrics 1999; 104:e54.
- Huicho L, Campos-Sanchez M, Alamo C. Metaanalysis of urine screening tests for determining the risk of urinary tract infection in children. Pediatr Infect Dis J 2002; 21:1.
- Finnell SM, Carroll AE, Downs SM, the Subcommittee on Urinary Tract Infection. Technical Report--Diagnosis and Management of an Initial UTI in Febrile Infants and Young Children. Pediatrics 2011.
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Evaluation of the child with suspected urinary tract infection and initial urine with bacteriuria* but no pyuria
* With a pathogen other than Enterococcus, Klebsiella, or Pseudomonas aeruginosa.
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Urinary tract infections in infants older than one month and young children: Acute management, imaging, and prognosis
Most children with urinary tract infection (UTI) can be managed as outpatients. Indications for hospitalization may include age <2 months, clinical urosepsis, immunocompromised patient, vomiting or inability to tolerate oral medication, lack of outpatient follow-up, and failure to respond to outpatient therapy. (See 'Decision to hospitalize' above.)
●Empiric antimicrobial therapy immediately after appropriate urine collection is warranted in children with suspected UTI and a positive urinalysis. This is particularly true for young children with fever (especially if >39°C [102.2°F] or >48 hours), ill appearance, costovertebral angle tenderness, known immune deficiency, or known urologic abnormality. (See 'Empiric therapy' above.)
●We recommend that empiric therapy for UTI in children include an antibiotic that provides adequate coverage for Escherichia coli (Grade 1B). The agent of choice should be guided by local resistance patterns. Definitive therapy is based upon the results of urine culture and sensitivities. (See 'Choice of agent' above.)
•We suggest a cephalosporin (eg, cefixime, cefdinir, ceftibuten, cephalexin) as the first-line oral agent in the treatment of UTI in children without genitourinary abnormalities (Grade 2A). Amoxicillin or ampicillin should be added if enterococcal infection is suspected. (See 'Oral therapy' above.)
•Cephalosporins (eg, cefotaxime, ceftriaxone, cefepime) and aminoglycosides (eg, gentamicin) are appropriate first-line parenteral agents for empiric treatment of UTI in children. (See 'Parenteral therapy' above.)
●The duration of therapy depends upon the age of the child and the clinical scenario. (See 'Duration of therapy' above.)
•Febrile children are usually treated for 10 days
•Afebrile children are usually treated for shorter periods (3 to 5 days) (see 'Duration of therapy' above and "Acute cystitis: Clinical features and diagnosis in children older than two years and adolescents")
●The clinical condition of most patients improves within 24 to 48 hours of initiation of appropriate antimicrobial therapy. (See 'Clinical response' above.)
●In children whose clinical condition worsens or fails to improve as expected within 24 to 48 hours of initiation of antimicrobial therapy, broadening of empiric therapy may be indicated. Renal bladder ultrasonography (RBUS) should be performed as soon as possible to evaluate the presence of renal abscess or surgically correctable anatomic abnormalities or obstruction. (See 'Clinical response' above.)
●We obtain routine RBUS after first febrile UTI in children younger than two years who did not have normal prenatal ultrasonography at a reputable center at >30 to 32 weeks of gestation. We also obtain RBUS for children of any age with recurrent febrile UTIs and children of any age with a first UTI who have poor growth, hypertension, or a family history of renal or urologic disease. (See 'Ultrasonography' above.)
●We obtain voiding cystourethrogram (VCUG) to diagnose vesicoureteral reflux (VUR) in:
•Children of any age with ≥2 febrile UTIs, or
•Children of any age with a first febrile UTI and:
-Any anomalies on renal ultrasound, or
-The combination of temperature ≥39°C (102.2°F) and a pathogen other than E. coli, or
-Poor growth or hypertension. (See 'Voiding cystourethrogram' above.)
●The majority of children with UTI have no long-term sequelae. Prediction of long-term sequelae in children with UTI remains difficult. (See 'Prognosis' above.)
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