Its all in the Urine... or not

​By Dr. Kathleen Bryant
 
CC: Fever
 
HPI: A 19 month old AA female presents with fever (Tmax 38.7*C) for 36 hours. Mom reports giving Tylenol/Motrin for fever control. Mom denies N/V/D, change in PO intake or change in UOP. Mom reports mild cough and nasal congestion. Immunizations UTD, no sick contacts.
 
Physical Exam:
VS: T: 38.7*C                      RR 16                     HR 110  BP 110/80           
Gen: well appearing, sitting in NAD
HEENT: bilateral TMs clear, no middle ear effusion, mild nasal congestion, posterior oropharynx clear, no cervical lymphadenopathy
CV: mild tachycardia, no M/G/R, capillary refill brisk, 2+ peripheral pulses
Resp: CTAB, no W/R/R
Abd: NTND, +BS, soft
GU: normal genitalia, no rashes
 
Discussion:
No source of infection is identified in this patient.
 
Do we need to obtain an urinalysis to rule out an UTI? Why do we care about UTIs? What is the significance of missed or delayed treatment of UTIs in this patient population?
 

• Concern for recurrent UTIs and renal damage from scarring

 

• AAP updated guidelines from 2011:
  • Population: Children 2-24months with fever (defined as > 38*C)
    • Overall risk for UTI is 5% in this population
  • Children should be identified as low or high risk by criteria determined by this guideline:
    • Risk factors for girls:
      • Caucasian
      • Less than 12 months old
      • Temperature > 39*C
      • Fever for 2 or more days
      • Absence of another source of infection
    • Risk factors for boys:
      • Ethnicity other than African descent  
      • Temperature > 39*C
      • Fever for more than 1 day
      • Absence of another source of infection
  • Probability of UTI increases as increasing number of risk factors are present
    • Girls with 1 risk factor has a <1% probability of UTI
    • Uncircumcised boys with no risk factors already have greater than 1% probability of UTI  
    • Circumcised boys with 2 risk factors have a <1% probability of UTI
  • Diagnosis of an UTI is only confirmed by both a cathetered (or suprapubic aspiration) urinalysis suggestive of UTI AND a positive urine culture
    • Leukocyte esterase 94% sensitive for suspected UTI in not toilet trained children
    • Nitrites not sensitive in not toilet trained children
      • Patients do not hold urine long enough for bacteria to produce nitrites
    • Presence of WBCs or bacteria
    • Positive urine culture defined as at least 50,000 CFUs/mL
  • Oral antibiotics are as effective as intravenous antibiotics
  • All children in this age group with first time confirmed UTIs should undergo a renal and bladder ultrasound (RBUS)
    • VCUG nolonger indicated for initial UTI
      • Should only be considered if RBUS positive for hydronephrosis, scarring or other abnormal findings suggesting reflux

• Back to this patient:
  • This patient is an AA female, older than 1 year, fever less than 39*C for less than 48hours. This patient’s only risk factor is absence of another source of infection making her have <1% probability of UTI. In this patient, you can hold on obtaining an UA and instead have the patient follow-up with her Pediatrician in 1 day for re-evaluation.

 
Clinical Pearls for ED:

• Children 2-24 months old should be evaluated for risk of UTI
• If patient at increased risk of UTI a catheterized or SPA urine sample should be obtained
  • Clean catch or peroneal bag urine not acceptable in this age group
• Both an urinalysis and urine culture should be obtained for confirmed diagnosis of UTI
  • In the ED if urinalysis suggestive of UTI oral antibiotics should be started and are as effective as IV antibiotics
• Patients should be instructed to follow-up with Pediatrician in 1-2 days for urine culture results
  • If urine culture negative they may stop antibiotics if urine culture negative
  • If urine culture positive and UTI confirmed, patient should have a RBUS scheduled

 
Author: Dr. Kathleen Bryant
 
References:
1.            Roberts, K.B., Revised AAP Guideline on UTI in Febrile Infants and Young Children. Am Fam Physician, 2012. 86(10): p. 940-6.
2.            Subcommittee on Urinary Tract Infection, S.C.o.Q.I., Management, and K.B. Roberts, Urinary tract infection: clinical practice guideline for the diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months. Pediatrics, 2011. 128(3): p. 595-610.