Table 2.
Summary recommendations from all included guidelines
| Title | Definition | Risk factors | Clinical presentation | Methods of urine specimen collection | Other laboratory test | Management | Imaging studies | Admission criteria | Prevention |
|---|---|---|---|---|---|---|---|---|---|
| 1 | To establish the diagnosis of UTI, clinicians should require both urinalysis results that suggest pyuria and/or bacteriuria and the present of at least 50,000 (CFUs/mL) of uropathogen cultured from urine specimen obtained through catheterization or SPA | If a clinical 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 if low likelihood then clinical follow up is sufficient If the infant not in a low-risk ether to collect urine by SPA and catheterization for UA and culture, or to collect urine for. UA and if turned out positive collect other ample by SPA or catheterization | Febrile infant with no apparent source for the fever requires antimicrobial therapy after obtaining urine specimen for both culture and urinalysis; the specimen needs to be obtained through catheterization or SPA, because the diagnosis of UTI cannot be established through culture of urine collected in a bag | When initiating treatment, the clinicians should base the choice of route; orally or parenterally both equally effective. The clinician should base the choice of agent on local antimicrobial sensitivity patterns and adjust according to sensitivity testing of the isolated uropathogen The duration should be between 7 and 14 days | Febrile infants with UTI should undergo RBUS VCUG should not be performed routinely after the first febrile UTI; VCUG is indicated if RBUS reveals hydronephrosis, scarring, high-grade VUR, or obstructive uropathy as well as atypical or complex circumstances | ||||
| 2 | For urine specimen from suprapubic bladder puncture; any number of CFU/mL Bladder catheterization >1000–50,000 CFU/mL Midstream no I’d >104 CFU/mL with symptom >105 CFU/mL | Neonate can percent with nonspecific symptoms (failure to thrive, jaundice, vomiting, hyperexcitability, lethargy, hypothermia, with or without fever In older children, lower urinary tract symptoms include dysuria, stranguria, frequency, urgency, incontinence, hematuria, and suprapubic pain And for the upper urinary tract fever and flank pain | Newborn, infants and nontoilet-trained children: A plastic bag if positive further clean catch or SPA or cather action to further confirm the diagnosis Toilet-trained children, CV midstream | Serum electrolytes and blood cell counts should be obtained for monitoring ill patient Creatinine CRP Procalcitonin | In febrile children with signs of UTI, antibiotic should be initiated as soon as possible Parental antibiotic is recommended in newborns and infant < 2 months Antibiotic should be given for 7–14 days | <1 year of age, exclusion of VUR >1 year of age girl exclusion of VUR >1 year of age boy; exclusion of VUR after recurrent febrile UTIs Toilet trained girl specific; exclusion of LUTS/BBD Toilet trained boy specific; exclusion of LUTS/BBD, exclusion of VUR f there is a suspicion | Prophylaxis antibiotics should be considered in cases of high susceptibility to UTI and risk-acquired renal damage Cranberry juice | ||
| 3 | Fever > 39 with no apparent source, age < 12 months, white race, temperature > 39 | Not toilet-trained: Urethral catheterization Bag specimen is used initial screen and subsequent specimen is obtained | Blood cultures need not be performed unless the child is hemodynamically unstable Renal function should be monitoring | Oral antibiotic should be between 10 and 14 days while IV for 3 days followed by 10 days oral | In case of complicated UTI a RBUS is recommended to look for obstruction and children <2 years | Antibiotic prophylaxis pending results of imaging is no longer advised routinely | |||
| by Catheterization or SPA For toilet-trained children, a mid-stream urine should be collected by CVU | has a complicated UTI | of age with first febrile UTI VCUG was recommended routinely for children between 2 months and 2 years but not anymore | |||||||
| 4 | Positive urine culture in the SPA and TUC urine. When a urine culture is positive (>105 CFU/mL) in SBC urine. UTI should be diagnosed only in children with both definite symptoms and abnormal urinalysis | Females First UTI commonly devolved in male infants, who are uncircumcised | High fever, flank pain, vomiting for pyelonephritis, dysuria, voiding dysfunction, turbid urine, suprapubic pain for cystitis Infants and children with toxic usually experience vomiting, poor feeding, dehydration, lethargy, or weak cry | The ideal methods for urine collection: SPA or TUC in nontoilet-trained children who are very ill. SBC fist in these who are not so ill and then SPA or TUC if urinalysis is abnormal | Febrile UTI children <3 months, toxic or unable to retain oral intake should receive antibiotic parenterally. Oral antibiotic as effective as the combination of oral and parenteral. The minimal duration 7 days | DMSA is a gold standard to diagnose pyelonephritis and renal scar VCUG is not routinely recommended RBUS is useful to detect urinary abnormalities and renal infections | Antibiotic prophylaxis is not recommended any more in children without or with VUR (Grade I–IV) For physiologic phimosis, topical steroids for 2–4 weeks will be a first-line treatment. Rather than neonatal circumcision Cranberry is a natural food to prevent recurrent UTI | ||
| 5 | Diagnosis of UTI only made by clinical symptoms in association with positive urine culture SPA: Any growth CSU: >108 CFU/L MSU or CCU >108 | Culture is recommended by the urine collected specimen Clean catch is recommended, mid-stream urine, or in-out catheter specimen If positive culture was obtained by bag, its recommended to repeat the culture by SPA, CSU, CCU, MSU | If the positive urine culture and absent of clinical symptoms does not warrant treatment or further investigation for UTI Recommended to start treatment for presumed UTI in children who have clinical symptoms suggestive of UTI and who have positive leukocyte or nitrate on urinary dipstick or microscopy The optimal duration is unknown, but 7–10 days is currently recommended | Routine renal tract imaging following first UTI is not recommended except children <3 months, have a urine culture with atypical organism, concurrent bacteremia renal impairment, abdominal mass or poor urinary stream MCUG is recommended if VUR is suspected And prophylactic antibiotics should be given at the time of MCUG DMSA is not recommended in the acute phase | In children who are younger than 1 month of age or children older than 1 month who appear septic, dehydrate or unable to retain oral intake, initial anti-microbial therapy | Routine circumcision for boys after first UTI is not recommended only for boys with recurrent UTI or hi-grade fever Cranberry concentrate is recommended not to be used for UTI prevention Avoidance of constipation, increase fluid intake, avoiding bubble bath | |||
| 6 | A UTI is defined by a combination of clinical features and the present of bacteria in the urine | Unexplained. Fever of 38° C Most common symptom in infants <3 months; fever, vomiting, lethargy, irritability And in infant and children 3 months or more; fever, frequency, dysuria | A clean catch urine sample is the recommended method for urine collection. If a clean catch urine sample is unobtainable: Other noninvasive methods such as urine collection pads should be used In infants and children When it is not possible or practical to collect urine by noninvasive methods, catheter Sam-plus, or SPA should be used | Infants younger than 3 months with a possible UTI should be referred immediately to the care of a pediatric specialist. Treatment should be with IV antibiotics For infants and children 3 months or older Treat with oral antibiotics for 7–10 days. The use of an oral antibiotic with low resistance patterns is recommended If oral antibiotics cannot be used, treat with an IV antibiotic agent | I ultrasound during acute infections only recommended to atypical UTI infants and children Ultrasound within 6 weeks recommended for infants and children with UTI DMSA 4–6 months following the acute attack recommended to infant with a typical UTI and recurrent UTI infants and children MCUG not recommended to infant and children | Antibiotic prophylaxis should not be routinely used in children and infants following first-time UTI Drink adequate amount of fluid Have an access to clean toilets Antibiotic prophylaxis may consider in infants and children with recurrent UTI | |||
| 7 | A combination of clinical symptoms, pyuria, and positive urine culture with > 50,000 CFU/mL | Recurrent UTIs, GU anomaly, high-grade VUR, recent catheterization, recent GU instrumentation | Nonspecific: Fever without source, abdominal pain, vomiting without diarrhea, focal symptoms: Dysuria, flank pain, suprapubic tenderness | Infants <6 months: catheter for UA and culture Children >6 months: Clean catch for UA and culture Children > 6-month nontoilet-trained: Send bag or catheter specimen for UA Bag specimen not be sent to culture | Blood culture for febrile infants < 3 months LP: All febrile neonates Metabolic panel, electrolyzes, lactate, CBC, or CRP not routinely recommended | Antibiotics recommended in children < 3 months with positive UA 3 months–1 year is febrile with positive UA Any child with positive UA who is toxic-appearing 3 months–12 years who are a febrile and well-appearing with holding empiric treatment till the result | Renal and bladder ultrasound: Sever clinical course, recurrent UTI, complicated UTI in children <2 years, infants <6 months of age with first febrile UTI VCUG: not routinely recommended after first UTI DMSA: Not routinely recommended in evaluation of UTI | Clinically ill Severe dehydration Neonates with fever Positive blood culture Urine culture positive for multi-drug resistant Unable to tolerate oral medication Failure to respond to outpatient therapy | |
| 8 | SPA: Any growth Transurethral BC: 50,000 CFU/mL CVU: >100,000 CFU/mL Bag: >100,000 | Pathogen other than E. coli Abnormal RBUS Abnormal prenatal ultrasound Male younger than 6 months at UTI attack | 2–3 months: Lethargy, irritability, fever, and vomiting In older children: Frequency, dysuria, abdominal pain, loin tenderness, and fever | Initially UA if abnormal urine culture Bag not recommended CVU recommended in primary care lefts Transurethral sample in hospital sitting or circul ill patients SPA gold stander but not feasible | Blood test is not necessary, but recommended in infants < 3 months | In a febrile child unwell appearing, <3 months, severely ill, persisting fever, or low compliance: Start IV treatment switch to oral as soon as the clinical condition allow Febrile + well appearing: Oral route Treatment should be between oral 10 and 14 days Or IV | RBUS: All children 2–4 weeks after the first febrile UTI Scintigraphy is not routinely recommended VCUG is recommended after fist UTI or abnormal RBUS or if the bacterial organism other that E. coli | Circumcision is conceivable is recommended in selective cases Antibiotic prophylaxis: Not routinely recommended after the first febrile UTI. It may be considers in children with reflux Grade IV and V | |
| 9 | Classifications | Nonspecific symptoms such fever, lethargy, vomiting and failure to thrive | In neonate, infants and nontoilet-trained: Plastic bag, CCU, transurethral bladder catheter, or SPA It is recommended to use two-step procedure which may lead to less invasive procedure In toilet-trained children; clean catch, I dream | The choice between oral or parental therapy should be based on patient age; clinical suspicion of urosepsis; illness severity; refusal of fluid; noncompliance Treatment febrile UTI with 4–7 days course of oral or parental therapy | Renal and bladder ultrasound within 24 h is advised in infant with febrile UTI to exclude obstruction VCUG is the gold standers diagnostic test for VUR is VCUG | Long-term antibacterial prophylaxis in case of high susceptibility to UTI and risk of acquired renal damage and lower urinary symptoms | |||
| 10 | Significant bacteriuria of a urinary pathogen in a symptomatic patient SPA: Any number of CFUs/mL Catheter: 50,000 CFUs/mL Clean catch: >100,000 CFU/mL | Female > male Febrile female <12 months uncircumcised male infant with fever children with obstructive urological abnormalities VUR BBD | In infant: Fever, irritability, lethargy, poor feeding or GI symptom In older children: Fever, urinary symptom, vomiting, abdominal pain, or suprapubic tenderness | For neonates: SPA for infant: Transurethral BC For toilet-trained: CVS Against the use of sterile urinary bag | CBC, inflammatory markers, serum creatinine, blood culture or LP Not routinely obtained in infant older that 3 months who appear healthy | Febrile + urinary symptom: Start empiric antibiotic for UTI while waiting for urine culture result Afebrile + urinary symptom: Check dipstick if positive start empiric antibiotic If negative wait for urine culture | RBUS and VCUG is recommended in first febrile UTI in <3 years old, recurrent UTI, complicated UTI, or Hx of VUR RBUS should be performed between 2 and 6 weeks where VCUG last days of antimicrobial therapy DMSA is only recommended in impaired renal function or UTI with severe VUR between 4 and 6 months | Antibiotic prophylaxis is recommended for Moderate to high-grade reflux Uncircumcised males with VUR Children with BBD and VUR Nitrofurantoin: 1–2 mg/kg/day Trimethoprim/sulfamethoxazole: 2 mg/kg/day | |
| 11 | The cutoff for defining UTI by catheterization is always considered 10,000 CFU/mL | Labia adhesion, BBD, phimosis, vaginal reflux, short VA distance Diaper; entrance of bacteria BBD, neurogenic bladder, anatomical BOO; retention and multiplication of bacteria in UB BBD, young age, short tunnel Hutch’s, diverticulum; VUR | Your female children with UTI present with nonspecific symptom; fever, sepsis, lethargy, prolonged jaundice, hematuria, poor feeding, vomiting diarrhea, abdominal pain, irritability, failure to thrive, cloudy malodorous urine In older children; the symptoms and sign are more specific; fever, chill mess, vomiting, back and abdominal pain, lower urinary tract symptoms Include suprapubic pain, dysuria, urinary frequency, urgency, day wetting and cloudy urine | Urine culture is gold standard SPA or TUC are strongly recommended For toilet-trained children, urine specimens for culture can be obtained by midstream Plastic bag not recommended For nontoilet-trained; bag specimen can be used initial urinalysis subsequent culture is obtained by cauterization or SPA In young children, urine is usually collected by catheterization or SPA | Oral antibiotics cab be used effectively on an outpatient >3 months of age <3 months it is recommended initial hospitalization and parental antibiotic after complete septic workup Or severely ill children immunocompromised, intolerance to oral intake, urinary tract | Imaging studies are done to identify risk factors RBUS serve an ideal for initial screening for anatomical abnormalities on infant because it’s noninvasive DMSA is gold standard for identifying acute pyelonephritis or renal scarring It is preferred for infants with febrile UTI VCUG is the gold-slandered classifying grade of VUR Can detect bladder dysfunction, posterior urethras valves, ureterocele, utricle cyst or neurogenic bladder | Significant urinary tract obstruction Trimethoprim or cotrimoxazole and nitrofurantoin have been substances mostly used | ||
| 12 | A positive urine culture in urine obtained by catheterization, the growth of a single uropathogen >10,000 CFU/mL and in MSU sample, the growth of a single uropathogen >100,000 are highly suggestive of UTI | Congenital anomalies of kidney or urinary tract Family history of VUR or renal disease Uncircumcised male infant Abnormal urine flow or dysfunctional voiding Constipation | In neonates and infants; fever, poor feeding, failure to thrive, lethargy, irritability, pyuria, bacteriuria | In infants and toddlers, bladder catheterization and SPA are recommended methods of urine collection and are considered the gold standard | In case of parental therapy is indicated, blood culture should always be obtained In neonates, a sepsis workup | Treatment of UTI (choice of antimicrobial, route of administration) should be based on age and clinical presentation, as well as risk factors from the patient’s past medical history. In children <60 days, consider always starting with parenteral treatment. In children >60 days in | All children, regardless of age, should have an ultrasound of the urinary tract performed after the first episode of pyelonephritis Micturition cystourethrogram should only be planned under certain circumstances | In general antibiotic prophylaxis is not recommended | |
| History suggesting previous UTI or confirmed recurrent UTI | good general condition initiating treatment orally or parenterally is equally efficacious (evidence quality: High recommendation: strong). Local antimicrobial sensitivity patterns (if available) should be considered when choosing an empirical agent. Adjustment of the initial treatment should be done according to AST of the isolated uropathogen (evidence quality: High recommendation: Strong). The clinician should choose 7–10 days as the total duration of antimicrobial therapy for upper UTI | ||||||||
| 13 | Unexplained fever of 38 C or higher Infant <3 months; most common to least common; fever, vomiting, lethargy, irritability, poor feeding, failure to thrive, abdominal pain, jaundice, hematuria, offensive urine Infant and children >3 months Fever, frequency, dysuria Loin tenderness Dysfunctional voiding | A clean catch urine sample is the recommended methods for urine if clean catch unobtainable urine collection pads When it is not possible or practical to collect by noninvasive, catheter sample or SPA should be used Before SPA is attempted ultrasound guidance should be used to demonstrate the presence of urine in the bladder | CRP should not be used to differentiate acute pyelonephritis/upper UTI from cystitis/lower UTI in infants and children | Infants <3 months with possible UTI should receive parenteral antibiotics For infants and children >3 months or older with acute pyelonephritis/upper UTI Should be treated with antibiotics As well as asymptomatic bacteriuria | Infants and children with atypical UTI should have ultrasound of the urinary tract For infants <6 months with first time UTI, ultrasound should be carried out within 6 weeks of the UTI A DMSA scan 4–6 months following the acute infection Routine imaging to identify VUR is not recommended, except in specific circumstances | Drink an adequate amount of fluid Should have ready access to clean toilets when required and should not be expected to delay voiding Antibiotic prophylaxis should NOT be routinely recommended in in infant ad children following first-time UTI |
1. UTI: Clinical practice guideline for the diagnosis and management of the initial UTI in febrile infants and children 2–24 months, 2. UTI in children: EAU/ESPU guidelines, 3. UTI s in infants and children: Diagnosis and management, 4. Clinical guideline for childhood UTI (second revision), 5. KHA-CARI guideline: Diagnosis and treatment of UTI in children, 6. UTI in children diagnosis, treatment, and long-term management, 7. Consensus guidelines for management of pediatric UTI: Northern California Pediatric Hospital Medicine Consortium, 8. Updated Italian recommendations for the diagnosis, treatment, and follow-up of the first febrile UTI in young children, 9. Update of the EAU/ESPU guidelines on UTI in children, 10. Diagnosis and management of community-acquired UTI in infants and children: Clinical guidelines endorsed by the SPIDS, 11. Asian guidelines for UTI in children, 12. Swiss consensus recommendation on UTI in children, 13. UTI in under 16 s: Diagnosis and management. KHA-CARI: Kidney Health Australia-Caring for Australasians with Renal Impairment, EAU: European Association of Urology, ESPU: European Society of Pediatric Urology, SPA: Suprapubic aspiration, TUC: Transurethral catheterization, SBC: Sterile bag collection, CSU: Catheter specimens of urine, MSU: Midstream urine, CCU: Clean-catch urine, BC: Bladder catheterization, CVU: Clinical vaccinology update, UTI: Urinary tract infection, GU: Genitourinary, VUR: Vesicoureteric reflux, E. coli: Escherichia coli, RBUS: Renal and bladder ultrasonography, BBD: Bowel and bladder dysfunction, UB: Ureolytic bacteria, CRP: C-reactive protein, CBC: Complete blood count, LP: Lumbar puncture, IV: Intravenous, AST: Antimicrobial sensitivity testing, VCUG: Voiding cystourethrography, DMSA: Dimercapto succinic acid, MCUG: Micturating cystourethrogram, CV: Clean void, CCS: Clean catch sample, CFUs: Colony-forming units, VA: Vaginoanal or anovaginal, BOO: Bladder outlet obstruction