Society for Pediatric Urgent Care

Warning: Your Internet Explorer TLS settings may not be updated with the latest security settings. To fix this issue and resolve any connection errors,

Society for Pediatric Urgent Care

We are currently experiencing a Verizon outage that is impacting our servers and telephones. As a result, some of the website is not functioning. Verizon says that the problem will be resolved within 48 hours. We apologize for the inconvenience and will remove this notice when service is restored.

Urinary Tract Infection

ALERTS

  • Urosepsis
  • Pyelonephritis
  • STI’s
  • Renal abnormality
  • Testicular Torsion
  • Inguinal Hernia
  • Infants < 2 months
  • Female > male incidence

AGE OR PREGNANCY CONSIDERATIONS

  • Infants < 1yr – Urosepsis risk
  • Adolescents – STI risk

DIFFERENTIAL DIAGNOSIS

  • Occult bacteremia in febrile infant without source
  • Non-specific vulvovaginitis
  • Urethritis
  • STI – Urethritis/Epididymitis
  • Constipation
  • Vaginal foreign body
  • Group A strep
  • Kawasaki’s disease
  • Appendicitis
  • Dysfunctional elimination

EVALUATION

HISTORY

  • Onset and timing of dysuria, presence of frequency and/or urgency, discharge, gross hematuria, associated symptoms (fever, abdominal pain, vomiting, back pain).
  • History of UTI
  • Irritability, poor feeding – Infants/young children
  • Sexual history – Adolescents

PHYSICAL EXAM

  • Abdomen
  • Genitalia
  • Back – CVA
  • Cardiovascular – HR, perfusion
  • Neuro – mental status, irritability

Diagnostic findings

  • Abdomen: suprapubic tenderness
  • Genitalia: urethral meatus erythema, foul odor, assess for discharge
  • Back: tenderness, assess CVA
  • Cardiovascular: tachycardia, assess perfusion
  • Neuro: assess mental status and irritability

Concerning Findings

  • Pyelonephritis: CVA tenderness, vomiting, fever, tachycardia
  • Urosepsis: Fever, tachycardia, decreased perfusion, irritability, altered mental status
  • STI (epididymitis/cervicitis): Urethral or vaginal discharge, scrotal pain/swelling, pelvic pain

DIAGNOSTIC TESTS & INTERPRETATION

Lab Tests

  • Urinalysis
  • Urine Culture
  • GC/Chlamydia
  • CBC
  • Blood Culture

Imaging/ Diagnostic Procedures

  • Renal Ultrasounds
  • VCUG

MANAGEMENT

TRANSFER/ADMISSION CONSIDERATIONS

  • Age < 2months
  • Urosepsis/Bacteremia
  • Immunocompromise
  • Dehydration
  • Testicular torsion

URINARY TRACT INFECTION

TREATMENT

First Line

  • Oral
  • Cefixime
  • Trimethoprim-Sulfamethoxazole
  • Augmentin
  • Ciprofloxacin if >15years
  • Parenteral
  • Third and fourth generation cephalosporins and aminoglycosides.
  • Indications for IV: sepsis, < 3-6 months, vomiting/unable to tolerate oral medications, known resistant pathogen

Second Line

  • Amoxicillin
  • Nitrofurantoin
  • Macrodantin

Supportive

  • Fever and/or pain relief
  • Push fluids

Complementary & Alternative Therapies

  • Cranberry juice
  • Sitz baths for pain with urination

FOLLOW UP

Outpatient Referral

  • PCP in 24-48 hours
  • Urology/nephrology
  • Age <2yr with first febrile UTI
  • Recurrent febrile UTI at any age
  • Family hx of renal or urologic disease

Written instructions should include:
Anticipatory Guidance

  • Importance of increased fluids
  • Importance of completion of abx
  • May take 48-72 hours for dysuria and fever to stop

Activity, Diet

  • Activity as tolerated
  • Increase fluids

Signs and Symptoms to return

  • Persistent fever or new onset of fever
  • Persistent urinary symptoms (dysuria, hematuria, frequency/urgency)
  • Vomiting, decreased urine output
  • Lethargy

PROGNOSIS, COMPLICATIONS

  • Typically responds well to antibiotics
  • Can progress to pyelonephritis
  • Can progress to urosepsis/bacteremia
  • Can result in renal scarring if recurrent

URETHRITIS

TREATMENT

Supportive

  • Pain relief
  • Push fluids

Complementary & Alternative Therapies

  • Cranberry juice
  • Sitz baths for pain with urination

FOLLOW UP

Outpatient Referral

  • PCP in 24-48 hours

Written instructions should include:
Anticipatory Guidance

  • Avoid bubble baths and soaps in water
  • Good hygiene

Activity, Diet

  • Activity as tolerated
  • Increase fluids

Signs and Symptoms to return

  • Persistent urinary symptoms (dysuria, hematuria, frequency/urgency)
  • Fever
  • Vomiting

PROGNOSIS, COMPLICATIONS

  • Typically self-resolves
  • Can be related to constipation
  • Can be related to behavioral issues and withholding

VULVOVAGINITIS

TREATMENT

Supportive

  • Sitz baths
  • Gentle cleansing
  • Cool compresses
  • Wet wipes

FOLLOW UP

Outpatient Referral

  • PCP

Written instructions should include:
Anticipatory Guidance

  • Loose fitting pants/cotton underwear
  • Avoid bubble baths
  • Soak in clean water and wash body immediately before getting out of bath
  • Proper hygiene after toileting

Activity, Diet

  • As tolerated

Signs and Symptoms to return

  • Persistent pain
  • Purulent discharge
  • Fever

PROGNOSIS, COMPLICATIONS

  • Typically self-resolves
  • Vulvar edema with longer duration
  • Vaginal polyps with chronic discharge

EPIDIDYMITIS

TREATMENT

First Line

  • If likely STI etiology
    • Ceftriaxone plus Doxyxycline (>age 8yrs)
  • If r/t UTI or more typical urinary pathogens
    • See above UTI Treatment Guidelines

Supportive

  • Scrotal support
  • Pain relief

FOLLOW UP

Outpatient Referral

  • PCP in 24-48 hours
  • Urology if bacterial etiology in pre-pubertal patient

Written instructions should include:
Anticipatory Guidance

  • Cool packs/Ice packs
  • Jock strap for scrotal support
  • NSAIDs for pain

Activity, Diet

  • Activity as tolerated
  • Increase fluids

Signs and Symptoms to return

  • Increased pain
  • Fever

PROGNOSIS, COMPLICATIONS

  • Typically self-resolves in pre-pubertal children with supportive care
  • Responds well to antibiotics if bacterial in origin
  • Often related to STI’s in pubertal patients

REFERENCES

Fleisher G, Ludwig S. (Eds.). Textbook of Pediatric Emergency Medicine. 6th ed. Philadelphia, PA: Lippincott, 2010.

Hay, W., Levin, M., Deterding, R., Abzug, M. (Eds.). Current Diagnosis & Treatment – Pediatrics. 22nd ed. New York: McGraw Hill, 2014.

Engorn, B. & Flerlage, J. (Eds.). (20th ed., 2015). The Harriet Lane Handbook. Philadelphia: Saunders.

Pais, P., Avner, E. Infectious Causes of Cystitis and Urethritis. In: Kliegman RM, Behrman RE, Schorr NF, Stanton BF, St. Geme, J. (Eds.). Nelson Textbook of Pediatrics. 19th ed. Philadelphia, PA: Saunders Elsevier, 2011.

SEE ALSO (TOPIC, ALGORITHM, ELECTRONIC MEDIA ELEMENT)

  • Sexually Transmitted Infections

CODES

ICD9

PUBLISHER WILL ENTER

Snomed

PUBLISHER WILL ENTER

  • Sexually Transmitted Infections

CME/REVIEW QUESTIONS

  1. What are the referral recommendations for pediatric UTI?
  2. Name 2 first line antibiotic agents in the treatment of pediatric UTI.
  3. Give one criteria for transfer or admission when treating pediatric UTI.