jurnal untuk adit

8/10/2019 Jurnal Untuk Adit

1/18

DOI: 10.1542/peds.2011-1330; originally published online August 28, 2011;2011;128;595Pediatrics

Improvement and ManagementSubcommittee on Urinary Tract Infection, Steering Committee on Quality

Management of the Initial UTI in Febrile Infants and Children 2 to 24 MonthsUrinary Tract Infection: Clinical Practice Guideline for the Diagnosis and

http://pediatrics.aappublications.org/content/128/3/595.full.htmllocated on the World Wide Web at:

The online version of this article, along with updated information and services, is

of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.Boulevard, Elk Grove Village, Illinois, 60007. Copyright 2011 by the American Academypublished, and trademarked by the American Academy of Pediatrics, 141 Northwest Point

publication, it has been published continuously since 1948. PEDIATRICS is owned,PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

at Indonesia:AAP Sponsored on June 22, 2014pediatrics.aappublications.orgDownloaded from at Indonesia:AAP Sponsored on June 22, 2014pediatrics.aappublications.orgDownloaded from
http://pediatrics.aappublications.org/content/128/3/595.full.htmlhttp://pediatrics.aappublications.org/content/128/3/595.full.htmlhttp://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/content/128/3/595.full.html


2/18


3/18

INTRODUCTIONSince the early 1970s, occult bactere-mia has been the major focus of con-cern for clinicians evaluating febrileinfants who have no recognizablesource of infection. With the introduc-

tion of effective conjugate vaccinesagainst Haemophilus inuenzae typeb and Streptococcus pneumoniae (which have resulted in dramatic de-creases in bacteremia and meningi- tis), there has been increasing appre-ciation of the urinary tract as the mostfrequent site of occultandserious bacterial infections. Because the clinicalpresentation tends to be nonspecic ininfants and reliable urine specimens

for culture cannot be obtained withoutinvasive methods (urethral catheterization or suprapubic aspiration[SPA]), diagnosis and treatment maybe delayed. Most experimental andclinical data support the concept thatdelays in the institution of appropriate treatment of pyelonephritis increase the risk of renal damage. 1,2

This clinical practice guideline is a re-vision of the practice parameter pub-lished by the American Academy of Pediatrics (AAP) in 1999. 3 It was devel-oped by a subcommittee of the Steer-ing Committee on Quality Improvementand Management that included physi-cians with expertise in the elds of ac-ademic general pediatrics, epidemiol-ogy and informatics, pediatricinfectious diseases, pediatric nephrol-ogy, pediatric practice, pediatric radi-ology, and pediatric urology. The AAP

funded the development of this guide-line; none of the participants had anynancial conicts of interest. Theguideline was reviewed by multiplegroups within the AAP (7 committees, 1council, and 9 sections) and 5 externalorganizations in the United States andCanada. The guideline will be reviewedand/or revised in 5 years, unless newevidence emerges that warrants revi-sion sooner. The guideline is intended

for use in a variety of clinical settings(eg, ofce, emergency department, orhospital) by clinicians who treat in-fants and young children. This text is asummary of the analysis. The data onwhich the recommendations are

based are included in a companion technical report. 4

Like the 1999 practice parameter, thisrevision focuses on the diagnosis andmanagement of initial urinary tract in-fections (UTIs) in febrile infants andyoung children (224 months of age)who have no obvious neurologic or an-atomic abnormalities known to be as-sociated with recurrent UTI or renaldamage. (For simplicity, in the remain-der of this guideline the phrase fe-brile infants is used to indicate febrileinfants and young children 224months of age.) The lower and upperage limits were selected because stud-ies on infants with unexplained fevergenerally have used these age limitsand have documented that the preva-lence of UTI is high ( 5%) in this agegroup. In those studies, fever was de-ned as temperature of at least 38.0C

( 100.4F); accordingly, this denitionof fever is used in this guideline. Ne-onates and infants less than 2months of age are excluded, because there are special considerations in this age group that may limit the ap-plication of evidence derived from the studies of 2- to 24-month-old chil-dren. Data are insufcient to deter-mine whether the evidence gener-ated from studies of infants 2 to 24

months of age applies to childrenmore than 24 months of age.

METHODS

To provide evidence for the guideline, 2literature searches were conducted, that is, a surveillance of Medline-listedliterature over the past 10 years forsignicantchanges since the guidelinewas published and a systematic re-view of the literature on the effective-

ness of prophylactic antimicrobial therapy to prevent recurrence of fe-brile UTI/pyelonephritis in childrenwith vesicoureteral reux (VUR). Thelatter was based on the new and grow-ing body of evidence questioning the

effectiveness of antimicrobial prophy-laxis to prevent recurrent febrile UTI inchildren with VUR. To explore this par- ticular issue, the literature search wasexpanded to include trials publishedsince 1993 in which antimicrobial pro-phylaxis was compared with no treat-ment or placebo treatment for chil-dren with VUR. Because all except 1 of the recent randomized controlled tri-als (RCTs) of the effectiveness of pro-

phylaxis included children more than24 months of age and some did notprovide specic data according tograde of VUR, the authors of the 6 RCTswere contacted; all provided raw datafrom their studies specically ad-dressing infants 2 to 24 months of age,according to grade of VUR. Meta-analysis of these data was performed.

Results from the literature searchesand meta-analyses were provided to

committee members. Issues wereraised and discussed until consensuswas reached regarding recommendations. The quality of evidence support-ing each recommendation and thestrength of the recommendation wereassessed by the committee membermost experienced in informatics andepidemiology and were graded ac-cording to AAP policy5 (Fig 1).

The subcommittee formulated 7 rec-ommendations, which are presentedin the text in the order in which a clini-cian would use them when evaluatingand treating a febrile infant, as well asin algorithm form in the Appendix. Thisclinical practice guideline is not intended to be a sole source of guidancefor the treatment of febrile infants withUTIs. Rather, it is intended to assist clini-cians in decision-making. It is not intended to replace clinical judgmentor to

596 FROM THE AMERICAN ACADEMY OF PEDIATRICS at Indonesia:AAP Sponsored on June 22, 2014pediatrics.aappublications.orgDownloaded from
http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/


4/18

establish an exclusive protocol for thecare of all children with this condition.

DIAGNOSISAction Statement 1

If a clinician decides that a febrileinfant with no apparent source for the fever requires antimicrobial therapy to be administered be-cause of ill appearance or anotherpressing reason, the clinicianshould ensure that a urine speci-men is obtained for both cultureand urinalysis before an antimicro-bial agent is administered; thespecimen needs to be obtained through catheterization or SPA, be-cause the diagnosis of UTI cannotbe established reliably through culture of urine collected in a bag(evidence quality: A; strongrecommendation).

When evaluating febrile infants, clini-cians make a subjective assessment of the degree of illness or toxicity, in ad-dition to seeking an explanation for thefever. This clinical assessment deter-mines whether antimicrobial therapyshould be initiated promptly and af-fects the diagnostic process regardingUTI. If the clinician determines that thedegree of illness warrants immediateantimicrobial therapy, then a urinespecimen suitable for culture shouldbe obtained through catheterization orSPA before antimicrobial agents are

administered, because the antimicro-bial agents commonly prescribed insuch situations would almost certainly

obscure the diagnosis of UTI.SPA has been considered the standardmethod for obtaining urine that is un-contaminated by perineal ora. Vari-able success rates for obtaining urinehave been reported (23%90%). 6 8

When ultrasonographic guidance isused, success rates improve. 9,10 The technique has limited risks, but tech-nical expertise and experience arerequired, and many parents and phy-

sicians perceive the procedure asunacceptably invasive, comparedwith catheterization. However, theremay be no acceptable alternative toSPA for boys with moderate or se-vere phimosis or girls with tight la-bial adhesions.

Urine obtained through catheterization for culture has a sensitivity of 95%and a specicity of 99%, comparedwith that obtained through SPA. 7,11,12

The techniques required for catheter-ization and SPA are well described. 13

When catheterization or SPA is beingattempted, the clinician should have asterile container ready to collect aurine specimen, because the prepara- tion for the procedure may stimulate the child to void. Whether the urine isobtained through catheterization or isvoided, the rst few drops should beallowed to fall outside the sterile con-

tainer, because they may be contami-nated by bacteria in the distal urethra.

Cultures of urine specimens collectedin a bag applied to the perineum havean unacceptably high false-positiverate and are valid only when they yieldnegative results. 6,1416 With a preva-lence of UTI of 5% and a high rate of false-positive results (specicity:

63%), a positive culture result forurine collected in a bag would be afalse-positive result 88% of the time.For febrile boys, with a prevalence of UTI of 2%, the rate of false-positive re-sults is 95%; for circumcised boys,with a prevalence of UTI of 0.2%, therate of false-positive results is 99%.Therefore, in cases in which antimicro-bial therapy will be initiated, catheter-ization or SPA is required to establish the diagnosis of UTI. Aggregate quality of evidence: A (diag-

nostic studies on relevantpopulations).

Benets: A missed diagnosis of UTIcan lead to renal scarring if left un- treated; overdiagnosis of UTI canlead to overtreatment and unneces-

sary and expensive imaging. Once antimicrobial therapyis initiated, theop-portunity to make a denitivediagnosis is lost; multiple studies of antimicrobial therapy have shown that the urine may be rapidlysterilized.

Harms/risks/costs: Catheterizationis invasive.

Benet-harms assessment: Prepon-derance of benet over harm.

Value judgments: Once antimicro-bial therapy hasbegun, the opportu-nity to make a denitive diagnosis islost. Therefore, it is important tohave the most-accurate test for UTIperformed initially.

Role of patient preferences:There isno evidence regarding patient pref-erences forbag versus catheterizedurine. However, bladder tap has

FIGURE 1AAP evidence strengths.

FROM THE AMERICAN ACADEMY OF PEDIATR

PEDIATRICS Volume 128, Number 3, Septemb er 2011 597 at Indonesia:AAP Sponsored on June 22, 2014pediatrics.aappublications.orgDownloaded from
http://localhost/var/www/apps/conversion/tmp/scratch_3/pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://localhost/var/www/apps/conversion/tmp/scratch_3/pediatrics.aappublications.org/


5/18

been shown to be more painful thanurethral catheterization.

Exclusions: None.

Intentional vagueness: The basis of the determination that antimicro-

bial therapy is needed urgently isnot specied, because variability inclinical judgment is expected; con-siderations for individual patients,such as availability of follow-upcare, may enter into the decision,and the literature provides only gen-eral guidance.

Policy level: Strong recommendation.

Action Statement 2

If a clinician assesses a febrile infantwith no apparent source for the feveras not being so ill as to require imme-diate antimicrobial therapy, then theclinicianshouldassessthelikelihoodof UTI (see below for how to assesslikelihood).

Action Statement 2a

If the clinician determines the febrileinfant to have a low likelihood of UTI

(see text), then clinical follow-upmonitoring without testing is suf-cient (evidence quality: A; strongrecommendation).

Action Statement 2b

If the clinician determines that thefebrile infant is not in a low-risk group (see below), then there are 2choices (evidence quality: A; strongrecommendation). Option 1 is to obtain a urine specimen through cath-eterization or SPA for culture andurinalysis. Option 2 is to obtain aurine specimen through the mostconvenient means and to perform aurinalysis. If the urinalysis resultssuggest a UTI (positive leukocyteesterase test results or nitrite testor microscopic analysis resultspositive for leukocytes or bacte-ria), then a urine specimen should

be obtained through catheterization or SPA and cultured; if urinaly-sis of fresh ( < 1 hour since void)urine yields negative leukocyte esterase and nitrite test results, thenit is reasonable to monitor the clin-ical course without initiating anti-microbial therapy, recognizing thatnegative urinalysis results do notrule out a UTI with certainty.

If the clinician determines that the de-gree of illness does not require imme-diate antimicrobial therapy, then thelikelihood of UTI should be assessed.As noted previously, the overall preva-lence of UTI in febrile infants who haveno source for their fever evident on thebasis of history or physical examination results is approximately 5%, 17,18

but it is possible to identify groupswith higher-than-average likelihoodand some with lower-than-averagelikelihood. The prevalence of UTIamong febrile infant girls is more than

twice that among febrile infant boys(relative risk: 2.27). The rate for uncir-cumcised boys is 4 to 20 times higher than that for circumcised boys, whoserate of UTI is only 0.2% to 0.4%.1924 Thepresence of another, clinically obvioussource of infection reduces the likeli-hood of UTI by one-half.25

In a survey asking, What yield is re-quired to warrant urine culture in fe-brile infants?, the threshold was less

than 1% for 10.4% of academicians and11.7% for practitioners 26; when the threshold was increased to 1% to 3%,67.5% of academicians and 45.7% of practitioners considered the yield suf-ciently high to warrant urine culture.Therefore, attempting to operational-ize low likelihood (ie, below a thresh-old that warrants a urine culture) doesnot produce an absolute percentage;clinicians will choose a threshold de-pending on factors such as their con-dence that contact will be maintained

through the illness (so that a specimencan beobtainedat a later time) and com-fort with diagnostic uncertainty. Fig 2 in-dicates the number of risk factors as-sociated with threshold probabilitiesof UTI of at least 1% and at least 2%.

In a series of studies, Gorelick, Shaw,and colleagues 2729 derived and vali-dated a prediction rule for febrile in-fant girls on the basis of 5 risk factors,namely, white race, age less than 12months, temperature of at least 39C,fever for at least 2 days, and absenceof another source of infection. Thisprediction rule, with sensitivity of 88% and specicity of 30%, permitssome infant girls to be considered ina low-likelihood group ( Fig 2). For ex-ample, of girls with no identiablesource of infection, those who are non-white and more than 12 months of agewith a recent onset ( 2 days) of low-

FIGURE 2Probability of UTI Among Febrile Infant Girls 28 and Infant Boys 30 According to Number of FindingsPresent. a Probability of UTI exceeds 1% even with no risk factors other than being uncircumcised.



6/18

grade fever ( 39C) have less than a1% probability of UTI; each additionalrisk factor increases the probability. Itshould be noted, however, that someof the factors (eg, duration of fever)may change during the course of the

illness, excluding the infant from alow-likelihood designation andprompting testing as described inaction statement 2a.

As demonstrated in Fig 2, the majorrisk factor for febrile infant boys iswhether theyarecircumcised. The prob-ability of UTI can be estimated on the ba-sis of 4 risk factors, namely, nonblackrace, temperature of at least 39C, feverfor more than 24 hours, and absence of another source of infection. 4,30

If the clinician determines that the in-fant does not require immediate anti-microbial therapy and a urine speci-men is desired, then often a urinecollection bag afxed to the perineumis used. Many clinicians think that thiscollection technique hasa lowcontam-ination rate under the following cir-cumstances: the patients perineum is

properly cleansed and rinsed beforeapplication of the collection bag, theurine bag is removed promptly afterurine is voided into the bag, and thespecimen is refrigerated or processedimmediately. Even if contaminationfrom the perineal skin is minimized,however, there may be signicant con- tamination from the vagina in girls or the prepuce in uncircumcised boys, the 2 groups at highest risk of UTI. A

positive culture result from a speci-men collected in a bag cannot be used to document a UTI; conrmation re-quires culture of a specimen collected through catheterization or SPA. Be-cause there may be substantial delaywaiting for the infant to void and a sec-ond specimen, obtained through cath-eterization, may be necessary if theurinalysis suggests the possibility of UTI, many clinicians prefer to obtain a

denitive urine specimen throughcatheterization initially. Aggregate quality of evidence: A (diag-

nostic studies on relevantpopulations). Benets: Accurate diagnosis of UTI

can prevent the spread of infection

and renal scarring; avoiding overdi-agnosis of UTI can prevent overtreatment and unnecessary and ex-pensive imaging.

Harms/risks/costs: A small proportion of febrile infants, considered atlow likelihood of UTI, will not receive timely identication and treatmentof their UTIs.


Value judgments: There is a risk of UTI sufciently low to forestall further evaluation.

Role of patient preferences: Thechoice of option 1 or option 2 and the threshold risk of UTI warrantingobtaining a urine specimen may beinuenced by parents preference to avoid urethral catheterization (if a bag urine sample yields negativeurinalysis results) versus timelyevaluation (obtaining a denitivespecimen through catheterization).

Exclusions: Because it depends on arange of patient- and physician-specic considerations, the precise threshold risk of UTI warranting obtaining a urine specimen is left to the clinician but is below 3%.

Intentional vagueness: None. Policy level: Strong recommendation.

Action Statement 3

To establish the diagnosis of UTI,clinicians should require both uri-nalysis results that suggest infection (pyuria and/or bacteriuria)and the presence of at least 50 000

colony-forming units (CFUs) per mLof a uropathogen cultured from aurine specimen obtained throughcatheterization or SPA (evidencequality: C; recommendation).

Urinalysis

General Considerations

Urinalysis cannot substitute for urineculture to document the presence of UTI but needs to be used in conjunctionwith culture. Because urine culture re-sults are not available for at least 24hours, there is considerable interestin tests that may predict the results of the urine culture and enable presumptive therapy to be initiated at the rstencounter. Urinalysis can be per-formed on any specimen, includingone collected from a bag applied to theperineum. However, the specimenmust be fresh ( 1 hour after voidingwith maintenance at room temperature or 4 hours after voiding with re-frigeration), to ensure sensitivity andspecicity of the urinalysis. The tests that have received the most atten- tion are biochemical analyses of leu-kocyte esterase and nitrite through arapid dipstick method and urinemicroscopic examination for whiteblood cells (WBCs) and bacteria(Table 1) .

TABLE 1 Sensitivity and Specicity of Components of Urinalysis, Alone and in Combination

Test Sensitivity (Range), % Specicity (Range), %

Leukocyte esterase test 83 (6794) 78 (6492)Nitrite test 53 (1582) 98 (90100)Leukocyte esterase or

nitrite test positive93 (90100) 72 (5891)

Microscopy, WBCs 73 (32100) 81 (4598)

Microscopy, bacteria 81 (1699) 83 (11100)Leukocyte esterase test,

nitrite test, ormicroscopy positive

99.8 (99100) 70 (6092)




7/18

Urine dipsticks are appealing, because they provide rapid results, do not re-quire microscopy, and are eligible fora waiver under the Clinical LaboratoryImprovement Amendments. They indi-cate the presence of leukocyte es-

terase (as a surrogate marker forpyuria) and urinary nitrite (which isconverted from dietary nitrates in thepresence of most Gram-negative entericbacteria in the urine). The conversion of dietarynitrates to nitrites by bacteria re-quires approximately 4 hours in thebladder. 31 The performance characteris- tics of both leukocyte esterase and nitrite tests vary according to the denition used for positive urine culture

results, the age and symptoms of thepopulation being studied, and themethod of urine collection.

Nitrite Test

A nitrite test is not a sensitive markerfor children, particularly infants, whoempty their bladders frequently.Therefore, negative nitrite test resultshave little value in ruling out UTI. More-over, not all urinary pathogens reducenitrate to nitrite. The test is helpfulwhen the result is positive, however,because it is highly specic (ie, thereare few false-positive results). 32

Leukocyte Esterase Test

The sensitivity of the leukocyte esterase test is 94% when it used in thecontext of clinically suspected UTI.Overall, the reported sensitivity in var-ious studies is lower (83%), because the results of leukocyte esterase tests

were related to culture results withoutexclusion of individuals with asymptomatic bacteriuria. The absence of leukocyte esterase in the urine of indi-viduals with asymptomatic bacteriuriais an advantage of the test, rather thana limitation, because it distinguishesindividuals with asymptomatic bacte-riuria from those with true UTI.

The specicity of the leukocyte esterase test (average: 72% [range:

64%92%]) generally is not as good as the sensitivity, which reects the non-specicity of pyuria in general. Accord-ingly, positive leukocyte esterase testresults shouldbe interpreted with cau- tion, because false-positive results are

common. With numerous conditionsother than UTI, including fever result-ing from other conditions (eg, strepto-coccal infections or Kawasaki dis-ease), and after vigorous exercise,WBCs may be found in the urine. There-fore, a nding of pyuria by no meansconrms that an infection of the uri-nary tract is present.

The absence of pyuria in children with true UTIs is rare, however. It is theoret-ically possible if a febrile child is as-sessed before the inammatory re-sponse has developed, but theinammatory response to a UTI pro-duces both fever andpyuria; therefore,children who are being evaluated be-cause of fever should already haveWBCs in their urine. More likely expla-nations for signicant bacteriuria inculture in the absence of pyuria in-clude contaminated specimens, insen-

sitive criteria for pyuria, and asymptomatic bacteriuria. In most cases,when true UTI has been reported to oc-cur in the absence of pyuria, the de-nition of pyuria has been at fault. Thestandard method of assessing pyuriahas been centrifugation of the urineand microscopic analysis, with a threshold of 5 WBCs per high-powereld ( 25 WBCs per L). If a countingchamber is used, however, the nding

of at least 10 WBCs per L in uncentri-fuged urine has been demonstrated tobe more sensitive 33 and performs wellin clinical situations in which the stan-dard method does not, such as withvery young infants. 34

An important cause of bacteriuria in the absence of pyuria is asymptomaticbacteriuria. Asymptomatic bacteriuriaoften is associated with school-agedand older girls, 35 but it can be present

during infancy. In a study of infants 2 to24 months of age, 0.7% of afebrile girlshad 3 successive urine cultures with105 CFUs per mL of a single uropatho-gen. 26 Asymptomatic bacteriuria canbe easily confused with true UTI in a

febrile infant but needs to be distin-guished, because studies suggest thatantimicrobial treatment may do moreharm than good. 36 The key to distin-guishing true UTI from asymptomaticbacteriuria is the presence of pyuria.

Microscopic Analysis for Bacteriuria

The presence of bacteria in a fresh,Gram-stained specimen of uncentri-fuged urine correlates with 10 5 CFUs

per mL in culture.37

An enhanced uri-nalysis, combining the countingchamber assessment of pyuria notedpreviously with Gram staining of dropsof uncentrifuged urine, with a thresh-old of at least 1 Gram-negative rod in10 oil immersion elds, has greater sen-sitivity, specicity, and positive predictive value than does the standard urinal-ysis 33 and is the preferred method of urinalysis when appropriate equipmentand personnel are available.

Automated Urinalysis

Automated methods to perform uri-nalysis are now being used in manyhospitals and laboratories. Image-based systems use ow imaginganalysis technology and software toclassify particles in uncentrifugedurine specimens rapidly. 38 Resultscorrelate well with manual methods,especially for red blood cells, WBCs,and squamous epithelial cells. In thefuture, this may be the most commonmethod by which urinalysis is per-formed in laboratories.

Culture

The diagnosis of UTI is made on the ba-sis of quantitative urine culture re-sults in addition to evidence of pyuriaand/or bacteriuria. Urine specimensshould be processed as expediently as



8/18

possible. If the specimen is not pro-cessed promptly, then it should be re-frigerated to prevent the growth of or-ganisms that can occur in urine atroom temperature; for the same rea-son, specimens that require transpor-

tation to another site for processingshould be transported on ice. A prop-erly collected urine specimen shouldbe inoculated on culture medium thatwill allow identication of urinary tractpathogens.

Urine culture results are consideredpositive or negative on the basis of thenumber of CFUs that grow on the culture medium. 36 Denition of signicantcolony counts with regard to themethod of collection considers that the distal urethra and periurethralarea are commonly colonized by thesame bacteria that may cause UTI; therefore, a low colony count may bepresent in a specimen obtained through voiding or catheterizationwhen bacteria are not present in blad-der urine. Denitions of positive andnegative culture results are operational and not absolute. The time theurine resides in the bladder (bladderincubation time) is an importantdeter-minant of the magnitude of the colonycount. The concept that more than100 000 CFUs per mL indicates a UTIwas based on morning collections of urine from adult women, with compar-ison of specimens from women with-out symptoms and women consideredclinically to have pyelonephritis; the transition range, in which the propor-

tion of women with pyelonephritis ex-ceeded the proportion of women with-out symptoms, was 10 000 to 100 000CFUs per mL.39 In most instances, anappropriate threshold to considerbacteriuria signicant in infants andchildren is the presence of at least50 000 CFUs per mL of a single urinarypathogen. 40 (Organisms such asLactobacillus spp, coagulase-negativestaphylococci, and Corynebacterium

spp are not considered clinically rele-vant urine isolates for otherwisehealthy, 2- to 24-month-old children.)Reducing the threshold from 100 000CFUs per mL to 50 000 CFUs per mLwould seem to increase the sensitivity

of culture at the expense of decreasedspecicity; however, because the pro-posed criteria for UTI now include evi-dence of pyuria in addition to positiveculture results, infants with positiveculture results alone will be recog-nized as having asymptomatic bacteri-uria rather than a true UTI. Some labo-ratories report growth only in thefollowing categories: 0 to 1000, 1000 to10 000, 10 000 to 100 000, and more

than 100 000 CFUs per mL. In suchcases, results in the 10 000 to 100 000CFUs per mL range need to be evalu-ated in context, such as whether theurinalysis ndings support the diagno-sis of UTI and whether the organism isa recognized uropathogen.

Alternative culture methods, such asdipslides, may have a place in the of-ce setting; sensitivity is reported tobe in the range of 87% to 100%, and

specicity is reported to be 92% to98%, but dipslides cannot specify theorganism or antimicrobial sensitivi- ties. 41 Practices that use dipslidesshould do so in collaboration with acertied laboratory for identicationand sensitivity testing or, in the ab-sence of such results, may need to per-form test of cure cultures after 24hours of treatment.

Aggregate quality of evidence:C (ob-

servational studies). Benets: Accurate diagnosis of UTI

can prevent the spread of infectionand renal scarring; avoiding overdi-agnosis of UTI can prevent overtreatment and unnecessary and ex-pensive imaging. These criteriareduce the likelihood of overdiagno-sis of UTI in infants with asymptom-atic bacteriuria or contaminatedspecimens.

Harms/risks/costs: Stringent diag-nostic criteria may miss a smallnumber of UTIs.


Value judgments: Treatment of asymptomatic bacteriuria may beharmful.

Role of patient preferences: We as-sume that parents prefer no actionin the absence of a UTI (avoidingfalse-positive results) over a verysmall chance of missing a UTI.

Exclusions: None. Intentional vagueness: None. Policy level: Recommendation.

MANAGEMENT

Action Statement 4

Action Statement 4a

When initiating treatment, the clini-cian should base the choice of route of administration on practi-cal considerations. Initiating treat-ment orally or parenterally isequally efcacious. The clinician

should base the choice of agent onlocal antimicrobial sensitivity pat- terns (if available) and should ad- just the choice according to sensitivity testing of the isolateduropathogen (evidence quality: A;strong recommendation).

Action Statement 4b

The clinician should choose 7 to 14days as the duration of antimicrobial

therapy (evidence quality: B;recommendation).

The goals of treatment of acute UTI are to eliminate the acute infection, to pre-vent complications, and to reduce thelikelihood of renal damage. Most chil-dren canbe treated orally. 4244 Patientswhom clinicians judge to be toxic orwho are unable to retain oral intake(including medications) should re-ceive an antimicrobial agent parenter-




9/18


10/18

mester, and was performed and inter-preted by qualied individuals. 47

The timing of RBUS depends on theclinical situation. RBUS is recom-mended during the rst2 days of treat-ment to identify serious complications,such as renal or perirenal abscessesor pyonephrosis associated with ob-structive uropathy when the clinical ill-ness is unusually severeor substantialclinical improvement is not occurring.For febrile infants with UTIs who dem-onstrate substantial clinical improve-ment, however, imaging does not need to occur early during the acute infection and can even be misleading; ani-mal studies demonstrate that Esche-

richia coli endotoxin can producedilation during acute infection, whichcould be confused with hydronephro-sis, pyonephrosis, or obstruction. 48

Changes in the size and shape of thekidneys and the echogenicity of renalparenchyma attributable to edemaalso are common during acute infection. The presence of these abnormal-ities makes it inappropriate to con-sider RBUS performed early during

acute infection to be a true baselinestudy for later comparisons in the as-sessment of renal growth.

Nuclear scanning with technetium-labeled dimercaptosuccinic acid hasgreater sensitivity for detection of acute pyelonephritis and later scar-ring than does either RBUS or voidingcystourethrography (VCUG). The scan-ning is useful in research, because itensures that all subjects in a study

have pyelonephritis to start with and itpermits assessment of later renalscarring as an outcome measure. Thendings on nuclear scans rarely affectacute clinical management, however,and are not recommended as part of routine evaluation of infants with theirrst febrile UTI. The radiation dose to the patient during dimercaptosuccinicacid scanning is generally low ( 1mSv),49 although it maybe increased in

children with reduced renal function.The radiation dose from dimercapto-succinic acid is additive with that of VCUG when both studies are per-formed. 50 The radiation dose fromVCUG depends on the equipment thatis used (conventional versus pulseddigital uoroscopy) and is related di-rectly to the total uoroscopy time.Moreover, the total exposure for thechild will be increased when bothacute and follow-up studies are obtained. The lack of exposure to radi-ation is a major advantage of RBUS,even with recognition of the limitations of this modality that were de-scribed previously. Aggregate quality of evidence:C (ob-

servational studies). Benets: RBUS in this population

will yield abnormal results in 15%of cases, and 1% to 2% will have ab-normalities that would lead to action (eg, additional evaluation, re-ferral, or surgery).

Harms/risks/costs: Between 2%and 3% will be false-positive results,leading to unnecessary and invasiveevaluations.


Value judgments: The seriousnessof the potentially correctable abnor-malities in 1% to 2%, coupled with the absence of physical harm, was judged sufciently important to tip the scales in favor of testing.

Role of patient preferences: Be-cause ultrasonography is noninva-sive and poses minimal risk, we as-sume that parents will prefer RBUSover taking even a small risk of missing a serious and correctablecondition.

Exclusions: None.

Intentional vagueness: None.

Policy level: Recommendation.

Action Statement 6

Action Statement 6a

VCUG should not be performedroutinely after the rst febrileUTI; VCUG is indicated if RBUS re-

veals hydronephrosis, scarring,or other ndings that would sug-gest either high-grade VUR or ob-structive uropathy, as well as inother atypical or complex clinicalcircumstances (evidence qualityB; recommendation).

Action Statement 6b

Further evaluation should be con-ducted if there is a recurrence of fe-brile UTI (evidence quality: X;recommendation).

For the past 4 decades, the strategy toprotect the kidneys from further dam-age after an initial UTI has been to detect childhood genitourinary abnor-malities in which recurrent UTI couldincrease renal damage. The most com-mon of these is VUR, and VCUG is used to detect this. Management includedcontinuous antimicrobial administration as prophylaxis and surgical inter-vention if VUR was persistent or recur-rences of infection were not preventedwith an antimicrobial prophylaxis reg-imen; some have advocated surgicalintervention to correct high-grade re-ux even when infection has not re-curred. However, it is clear that thereare a signicant number of infantswho develop pyelonephritis in whomVUR cannot be demonstrated, and theeffectiveness of antimicrobial prophy-

laxis for patients who have VUR hasbeen challenged in the past decade.Several studies have suggested thatprophylaxis does not confer the de-sired benet of preventing recurrentfebrile UTI.5155 If prophylaxis is, in fact,not benecial and VUR is not requiredfor development of pyelonephritis, then the rationale for performingVCUG routinely after an initial febrileUTI must be questioned.




11/18

RCTs of the effectiveness of prophy-laxis performed to date generally in-cluded children more than 24 monthsof age, and some did not provide com-plete data according to grade of VUR.These 2 factors have compromised

meta-analyses. To ensure direct com-parisons, the committee contacted the6 researchers who had conducted themost recent RCTs and requested rawdata from their studies. 5156 All com-plied, which permitted the creation of a data set with data for 1091 infants 2 to 24 months of age according to gradeof VUR. A 2 analysis (2-tailed) and aformal meta-analysis did not detect astatistically signicant benet of pro-

phylaxis in preventing recurrence of febrile UTI/pyelonephritis in infantswithout reux or those with grades I, II,III, or IV VUR (Table 4 and Fig 3). Only 5infants with grade V VUR were in-cluded in the RCTs; therefore, data for those infants are not included in Table4 or Fig 3.

The proportion of infants with high-grade VUR among all infants with fe-brile UTIs is small. Data adapted fromcurrent studies ( Table 5) indicate that,of a hypothetical cohort of 100 infantswith febrile UTIs, only 1 has grade VVUR; 99 do not. With a practice of wait-ing for a second UTI to perform VCUG,only 10 of the 100 would need to un-dergo the procedure and the 1 withgrade V VUR would be identied. (Italso is possible that the 1 infant withgrade V VURmight have been identiedafter the rst UTI on the basis ofabnor-

mal RBUS results that prompted VCUG to be performed.) Data to quantify ad-ditional potential harm to an infantwho is not revealed to have high-gradeVUR until a second UTI are not precisebut suggest that the increment is in-sufcient to justify routinely subject-ing all infants with an initial febrile UTI to VCUG (Fig 4). To minimize any harmincurred by that infant, attempts havebeen made to identify, at the time of

the initial UTI, those who have thegreatest likelihood of having high-grade VUR. Unfortunately, there are noclinical or laboratory indicators thathave been demonstrated to identify in-fants with high-grade VUR. Indicationsfor VCUG have been proposed on the

basis of consensus in the absence of data 57; the predictive value ofany oftheindications for VCUG proposed in thismanner is not known.

The level of evidence supporting routine imaging with VCUG was deemedinsufcient at the time of the 1999practice parameter to receive a rec-ommendation, but the consensus of the subcommittee was to strongly en-courage imaging studies. The position

of the current subcommittee reects the new evidence demonstrating anti-microbial prophylaxis not to be effective as presumed previously. More-over, prompt diagnosis and effective treatment of a febrile UTI recurrencemay be of greater importance regard-less of whether VUR is present or thechild is receiving antimicrobial pro-phylaxis. A national study (the Ran-domized Intervention for Children WithVesicoureteral Reux study) is cur-rently in progress to identify the ef-fects of a prophylactic antimicrobialregimen for children 2 months to 6years of age who have experienced aUTI, and it is anticipated to provide ad-ditional important data 58 (see Areasfor Research).

Action Statement 6a

Aggregate quality of evidence: B(RCTs).

Benets: This avoids, for the vastmajority of febrile infants with UTIs,radiation exposure (of particularconcern near the ovaries in girls),expense, and discomfort.

Harms/risks/costs: Detection of asmall number of cases of high-

grade reux and correctable abnor-malities is delayed.


Value judgments: The risks associ-ated with radiation (plus the ex-pense and discomfort of the proce-dure) for the vast majority of infantsoutweigh the risk of delaying the detection of the few with correctableabnormalities until theirsecond UTI.

Role of patient preferences: The judgment of parents may come intoplay, because VCUG is an uncomfort-able procedure involving radiationexposure. In some cases, parentsmay prefer to subject their children to the procedure even when thechance of benet is both small anduncertain. Antimicrobial prophy-laxis seems to be ineffective in pre-

venting recurrence of febrile UTI/py-elonephritis for the vast majority of infants. Some parents may want toavoid VCUG even after the secondUTI. Because the benet of identify-ing high-grade reux is still in somedoubt, these preferences should beconsidered. It is the judgment of thecommittee that VCUG is indicated after the second UTI.

Exclusions: None.

TABLE 4 Recurrences of Febrile UTI/Pyelonephritis in Infants 2 to 24 Months of Age With andWithout Antimicrobial Prophylaxis, According to Grade of VUR

ReuxGrade

Prophylaxis No Prophylaxis P

No. of Recurrences

Total N No. of Recurrences

Total N

None 7 210 11 163 .15I 2 37 2 35 1.00II 11 133 10 124 .95III 31 140 40 145 .29IV 16 55 21 49 .14



12/18

Intentional vagueness: None. Policy level: Recommendation.

Action Statement 6b

Aggregate quality of evidence: X (ex-

ceptional situation). Benets: VCUG after a second UTI

should identify infants with veryhigh-grade reux.

Harms/risks/costs: VCUG is an un-comfortable, costly procedure thatinvolves radiation, including to theovaries of girls.


Value judgments: The committee judged that patients with high-grade reux and other abnormalities may benet from interventions to prevent further scarring. Furtherstudies of treatment for grade VVUR are not underway and are un-likely in the near future, because thecondition is uncommon and ran-domization of treatment in thisgroup generally has been consid-ered unethical.

FIGURE 3A, Recurrences of febrile UTI/pyelonephritis in 373 infants 2 to 24 months of age without VUR, with andwithout antimicrobial prophylaxis (based on 3 studies; data provided by Drs Craig, Garin, and Mon- tini). B, Recurrences of febrile UTI/pyelonephritis in 72 infants 2 to 24 months of age with grade I VUR,with and without antimicrobial prophylaxis (based on 4 studies; data provided by Drs Craig, Garin,Montini, and Roussey-Kesler). C, Recurrences of febrile UTI/pyelonephritis in 257 infants 2 to 24months of age with grade II VUR, with and without antimicrobial prophylaxis (based on 5 studies; dataprovided by Drs Craig, Garin, Montini, Pennesi, and Roussey-Kesler). D, Recurrences of febrile UTI/pyelonephritis in 285 infants 2 to 24 months of age with grade III VUR, with and without antimicrobialprophylaxis (based on 6 studies; dataprovided by Drs Brandstrm, Craig, Garin, Montini, Pennesi, andRoussey-Kesler). E, Recurrences of febrile UTI/pyelonephritis in 104 infants 2 to 24 months of age withgrade IV VUR, with and without antimicrobial prophylaxis (based on 3 studies; data provided by DrsBrandstrm, Craig, and Pennesi). M-H indicates Mantel-Haenszel; CI, condence interval.

TABLE 5 Rates of VUR According to Grade inHypothetical Cohort of Infants AfterFirst UTI and After Recurrence

Rate, %

After FirstUTI

(N 100)

AfterRecurrence

(N 10)

No VUR 65 26Grades IIII VUR 29 56Grade IV VUR 5 12Grade V VUR 1 6

FIGURE 4Relationship between renal scarring and num-ber of bouts of pyelonephritis. Adapted fromJodal. 59




13/18

Role of patient preferences: As men- tioned previously, the judgment of parents may come into play, be-cause VCUG is an uncomfortableprocedure involving radiation expo-sure. In some cases, parents may

prefer to subject their children to the procedure even when thechance of benet is both small anduncertain. The benets of treatmentof VUR remain unproven, but thepoint estimates suggest a small potential benet. Similarly, parentsmay want to avoid VCUG even after the second UTI. Because the benetof identifying high-grade reux isstill in some doubt, these prefer-

ences should be considered. It is the judgment of the committee thatVCUG is indicated after the secondUTI.

Exclusions: None. Intentional vagueness: Further eval-

uation will likely start with VCUG butmay entail additional studies de-pending on the ndings. The detailsof further evaluation are beyond thescope of this guideline.

Policy level: Recommendation.

Action Statement 7

After conrmation of UTI, the cli-nician should instruct parents orguardians to seek prompt medicalevaluation (ideally within 48hours) for future febrile ill-nesses, to ensure that recurrentinfections can be detected and treated promptly (evidence qual-

ity: C; recommendation).Early treatment limits renal damagebetter than late treatment, 1,2 and therisk of renal scarring increases as thenumber of recurrences increase ( Fig4).59 For these reasons, all infants whohave sustained a febrile UTI shouldhave a urine specimen obtained at theonset of subsequent febrile illnesses,so that a UTI can be diagnosed and treated promptly.

Aggregate quality of evidence:C (ob-servational studies).

Benets: Studies suggest that early treatment of UTI reduces the risk of renal scarring.

Harms/risks/costs: There may beadditional costs and inconvenience to parents with more-frequent visits to the clinician for evaluation of fever.


Value judgments: None. Role of patient preferences:Parents

will ultimately make the judgment toseek medical care.

Exclusions: None. Intentional vagueness: None. Policy level: Recommendation.

CONCLUSIONS

The committee formulated 7 key actionstatements for the diagnosis and treatment of infants and young chil-dren2 to24 monthsof age withUTIandunexplained fever. Strategies for diag-nosis and treatment depend onwhether the clinician determines thatantimicrobial therapy is warranted im-mediately or can be delayed safely until urine culture and urinalysis resultsare available. Diagnosis is based on the presence of pyuria and at least50 000 CFUs per mL of a single uro-pathogen in an appropriately collectedspecimen of urine; urinalysis alonedoes notprovide a denitivediagnosis.After 7 to 14 days of antimicrobial treatment, close clinical follow-upmonitoring should be maintained, withevaluation of the urine during subse-quent febrile episodes to permitprompt diagnosis and treatment of re-current infections. Ultrasonography of the kidneys and bladder should be per-formed to detect anatomic abnormalities that require further evaluation(eg, additional imaging or urologicconsultation). Routine VCUG after the

rst UTI is not recommended; VCUG isindicated if RBUS reveals hydrone-phrosis, scarring, or other ndings that would suggest either high-gradeVUR or obstructive uropathy, as well asin other atypical or complex clinical

circumstances. VCUG also should beperformed if there is a recurrence of febrile UTI.

AREAS FOR RESEARCH

One of the major values of a compre-hensive literature review is the identi-cation of areas in which evidence islacking. The following 8 areas are pre-sented in an order that parallels theprevious discussion.

1. The relationship between UTIs in in-fants and young children and re-duced renal function in adults hasbeen established but is notwell characterized in quantitative terms. The ideal prospective cohortstudy from birth to 40 to 50 years of age has not been conducted and isunlikely to be conducted. There-fore, estimates of undesirableoutcomes in adulthood, such as

hypertension and end-stage renaldisease, are based on the mathe-matical product of probabilitiesat several steps, each of which issubject to bias and error. Otherattempts at decision analysis and thoughtful literature review haverecognized the same limitations.Until recently, imaging tools avail-able for assessment of the effectsof UTIs have been insensitive. With

the imaging techniques now avail-able, it may be possible to identify the relationship of scarring to re-nal impairment and hypertension.

2. The development of techniques thatwould permit an alternative to inva-sive sampling and culture would bevaluable for general use. Special at- tention should be given to infantgirls and uncircumcised boys, be-cause urethral catheterization may



14/18

be difcult and can produce contaminated specimens and SPA nowis not commonly performed. Incu-bation time, which is inherent in theculture process, results in delayed treatment or presumptive treat-

ment on the basis of tests that lack the desired sensitivity and specic-ity to replace culture.

3. The role of VUR (and therefore of VCUG) is incompletely understood.It is recognized that pyelonephritis(dened through cortical scintigra-phy) can occur in the absence of VUR (dened through VCUG) and that progressive renal scarring(dened through cortical scintigra-

phy) can occur in the absence of demonstrated VUR. 52,53 The pre-sumption that antimicrobial pro-phylaxis is of benet for individualswith VUR to prevent recurrences of UTI or the developmentof renalscarsis not supported by the aggregate of data from recent studies and cur-rently is the subject of the Random-ized Intervention for Children WithVesicoureteral Reux study. 58

4. Although the effectiveness of anti-microbial prophylaxis for the pre-vention of UTI has not been demon-strated, the concept has biologicalplausibility. Virtually all antimicro-bial agents used to treat or to pre-vent infections of the urinary tractare excreted in the urine in highconcentrations. Barriers to the ef-fectiveness of antimicrobial pro-phylaxis are adherence to a daily

regimen, adverse effects associ-ated with the various agents, and the potential for emergence of anti-

microbial resistance. To overcome these issues, evidence of effective-ness with a well-tolerated, safeproduct would be required, andparents would need sufcient edu-cation to understand the value and

importance of adherence. A urinaryantiseptic, rather than an antimi-crobial agent, would be particularlydesirable, because it could be takenindenitely without concern thatbacteria would develop resistance.Another possible strategy might be the use of probiotics.

5. Better understanding of the ge-nome (human and bacterial) mayprovide insight into risk factors

(VUR and others) that lead to in-creased scarring. Blood specimenswill be retained from children en-rolled in the Randomized Interven- tion for Children With Vesi-coureteral Reux study, for futureexamination of genetic determinantsof VUR, recurrent UTI, and renal scar-ring. 58 VUR is recognized to run infamilies, 60,61 and multiple investiga- tors are currently engaged in re-

search to identify a genetic basis forVUR. Studies may also be able to dis- tinguish the contribution of congeni- tal dysplasia from acquired scarringattributable to UTI.

6. One of the factors used to assess the likelihood of UTI in febrile in-fants is race. Data regarding ratesamong Hispanic individuals are lim-ited and would be useful for prediction rules.

7. This guideline is limited to the initialmanagementof the rst UTI in febrileinfants 2 to24 monthsof age.Some of

the infants will have recurrent UTIs;some will be identied as having VURor other abnormalities. Further re-search addressing the optimalcourseof management in specicsit-uations would be valuable.

8. The optimal duration of antimicro-bial treatment has not been deter-mined. RCTs of head-to-head com-parisons of various duration wouldbe valuable, enabling clinicians tolimit antimicrobial exposure towhat is needed to eradicate the of-fending uropathogen.

LEAD AUTHORKenneth B. Roberts, MD

SUBCOMMITTEE ON URINARY TRACTINFECTION, 20092011Kenneth B. Roberts, MD, ChairStephen M. Downs, MD, MSS. Maria E. Finnell, MD, MSStanley Hellerstein, MDLinda D. Shortliffe, MDEllen R. Wald, MDJ. Michael Zerin, MD

OVERSIGHT BY THE STEERINGCOMMITTEE ON QUALITYIMPROVEMENT AND MANAGEMENT,20092011

STAFFCaryn Davidson, MA

ACKNOWLEDGMENTSThe committee gratefully acknowl-edges the generosity of the research-ers who graciously shared their data to permit the data set with data for1091 infants aged 2 to 24 months ac-cording to grade of VUR to be com-piled, that is, Drs Per Brandstrm,

Jonathan Craig, Eduardo Garin, Gio-vanni Montini, Marco Pennesi, andGwenaelle Roussey-Kesler.

REFERENCES

1. Winter AL, Hardy BE, Alton DJ, Arbus GS,Churchill BM. Acquired renal scars in chil-dren. J Urol . 1983;129(6):11901194

2. Smellie JM, Poulton A, Prescod NP. Retro-spective study of children with renal scar-ring associated with reux and urinary in-fection. BMJ . 1994;308(6938):11931196

3. American Academy of Pediatrics, Commit- tee on Quality Improvement, Subcommitteeon Urinary Tract Infection. Practiceparameter: the diagnosis, treatment, andevaluation of the initial urinary tract infection in febrile infants and young children.Pediatrics . 1999;103(4):843 852

4. Finnell SM,Carroll AE,DownsSM, etal.Technicalreport: diagnosis and management of an initialurinary tract infection in febrile infants andyoungchildren. Pediatrics . 2011;128(3):e749

5. American Academy of Pediatrics, SteeringCommittee on Quality Improvement andManagement. Classifying recommenda-




15/18

tions for clinical practice guidelines. Pedi- atrics . 2004;114(3):874 877

6. Leong YY, Tan KW. Bladder aspiration fordiagnosis of urinary tract infection in in-fants and young children. J Singapore Pae- diatr Soc . 1976;18(1):43 47

7. Pryles CV, Atkin MD, Morse TS, Welch KJ.

Comparative bacteriologic study of urineobtained from children by percutaneoussuprapubic aspiration of the bladder andby catheter. Pediatrics . 1959;24(6):983991

8. Djojohadipringgo S, Abdul Hamid RH, ThahirS, Karim A, Darsono I. Bladder puncture innewborns:a bacteriologicalstudy. Paediatr Indones . 1976;16(1112):527534

9. Gochman RF, Karasic RB, Heller MB. Use of portable ultrasound to assist urine collection by suprapubic aspiration. Ann Emerg Med . 1991;20(6):631635

10. Buys H, Pead L, Hallett R, Maskell R. Supra-

pubic aspiration under ultrasound guid-ance in children with fever of undiagnosedcause. BMJ . 1994;308(6930):690 692

11. Kramer MS, Tange SM, Drummond KN, MillsEL. Urine testing in young febrile children: arisk-benet analysis. J Pediatr . 1994;125(1):613

12. Bonadio WA. Urine culturingtechnique in fe-brileinfants. Pediatr Emerg Care . 1987;3(2):7578

13. Lohr J. Pediatric Outpatient Procedures.Philadelphia, PA: Lippincott; 1991

14. Taylor CM, White RH. The feasibility of

screening preschool children for urinary tract infection using dipslides. Int J Pediatr Nephrol . 1983;4(2):113114

15. Srensen K, Lose G, Nathan E. Urinary tractinfections and diurnal incontinence in girls.Eur J Pediatr . 1988;148(2):146147

16. Shannon F, Sepp E, Rose G. The diagnosis of bacteriuria by bladder puncture in infancyand childhood. Aust Pediatr J . 1969;5(2):97100

17. Hoberman A, Chao HP, Keller DM, Hickey R,DavisHW, Ellis D. Prevalence ofurinarytractinfection in febrile infants. J Pediatr . 1993;

123(1):172318. Haddon RA, Barnett PL, Grimwood K, Hogg

GG. Bacteraemia in febrilechildren present-ing to a paediatric emergency department.Med J Aust . 1999;170(10):475 478

19. Wiswell TE, Roscelli JD. Corroborative evi-dence for the decreased incidence of uri-nary tract infections in circumcised maleinfants. Pediatrics . 1986;78(1):96 99

20. To T, Agha M, Dick PT, Feldman W. Cohortstudy on circumcision of newborn boys andsubsequent risk of urinary-tract infection.Lancet . 1998;352(9143):18131816

21. Wiswell TE, Hachey WE. Urinary tract infections and the uncircumcised state: an up-date. Clin Pediatr (Phila) . 1993;32(3):130134

22. Wiswell TE, Smith FR, Bass JW. Decreasedincidence of urinary tract infections in cir-cumcised male infants. Pediatrics . 1985;

75(5):90190323. Ginsburg CM, McCracken GH Jr. Urinary

tract infections in young infants. Pediatrics .1982;69(4):409 412

24. Craig JC, Knight JF, Sureshkumar P, MantzE, Roy LP. Effect of circumcision on inci-dence of urinary tract infection in pre-school boys. J Pediatr . 1996;128(1):2327

25. Levine DA, Platt SL, Dayan PS, et al. Risk of serious bacterial infection in young fe-brile infants with respiratory syncytial vi-rus infections. Pediatrics . 2004;113(6):17281734

26. Roberts KB, Charney E, Sweren RJ, et al. Uri-nary tract infection in infants with unex-plained fever: a collaborative study. J Pedi- atr . 1983;103(6):864 867

27. Gorelick MH, Hoberman A, Kearney D, WaldE, Shaw KN. Validation of a decision ruleidentifying febrile young girls at high riskfor urinary tract infection. Pediatr Emerg Care . 2003;19(3):162164

28. Gorelick MH, Shaw KN. Clinical decision rule to identify febrile young girls at risk for uri-nary tract infection. Arch Pediatr Adolesc Med . 2000;154(4):386 390

29. Shaw KN, Gorelick M, McGowan KL, YakscoeNM, Schwartz JS. Prevalence of urinary tract infection in febrile young children in the emergency depar tment . Pediatrics .1998;102(2). Available at: www.pediatrics.org/cgi/content/full/102/2/e16

30. Shaikh N,Morone NE,Lopez J,et al.Doesthischild have a urinary tract infection? JAMA.2007;298(24):28952904

31. Powell HR, McCredie DA, Ritchie MA. Urinarynitrite in symptomatic and asymptomaticurinary infection. Arch DisChild . 1987;62(2):138140

32. Kunin CM, DeGroot JE. Sensitivity of a nitriteindicator strip method in detecting bacteri-uria in preschool girls. Pediatrics . 1977;60(2):244245

33. Hoberman A, Wald ER, Reynolds EA, Pen-chansky L, Charron M. Is urine culture nec-essary to rule out urinary tract infection inyoung febrile children? Pediatr Infect Dis J .1996;15(4):304309

34. Herr SM, Wald ER, Pitetti RD, Choi SS. En-hanced urinalysis improves identicationof febrile infants ages 60 days and youngerat low risk for serious bacterial illness. Pe- diatrics . 2001;108(4):866 871

35. Kunin C. A ten-year study of bacteriuria inschoolgirls: nal report of bacteriologic,urologic, and epidemiologic ndings. J In- fect Dis . 1970;122(5):382393

36. Kemper K, Avner E. The case against screen-ing urinalyses for asymptomatic bacteri-uria in children. Am J Dis Child . 1992;146(3):

34334637. Wald E. Genitourinary tract infections: cysti-

tis and pyelonephritis. In: Feigin R, CherryJD, Demmler GJ, Kaplan SL, eds. Textbook of Pediatric Infectious Diseases. 5th ed. Phila-delphia, PA: Saunders; 2004:541555

38. Mayo S, Acevedo D, Quiones-Torrelo C,Cans I, Sancho M. Clinical laboratory auto-mated urinalysis: comparison among auto-mated microscopy, ow cytometry, two teststrips analyzers, and manual microscopicexamination of the urine sediments. J Clin Lab Anal . 2008;22(4):262270

39. Kass E. Asymptomatic infections of the uri-nary tract. Trans Assoc Am Phys . 1956;69:5664

40. Hoberman A, Wald ER, Reynolds EA, Pen-chansky L, Charron M. Pyuria and bacteri-uria in urine specimens obtained by catheter from you ng chi ldr en wi th fever. J Pediatr . 1994;124(4):513519

41. DownsSM.Technical report: urinary tract infections in febrileinfants and young children. Pedi- atrics . 1999;103(4).Availableat: www.pediatrics.org/cgi/content/full/103/4/e54

42. Hoberman A, Wald ER, Hickey RW, et al. Oral

versus initial intravenous therapy for uri-nary tract infections in young febrile chil-dren. Pediatrics . 1999;104(1):79 86

43. Hodson EM, Willis NS, Craig JC. Antibioticsfor acute pyelonephritis in children. Co- chrane Database Syst Rev . 2007;(4):CD003772

44. Bloomeld P, Hodson EM, Craig JC. Antibiot-ics for acute pyelonephritis in children. Co- chrane Database Syst Rev . 2005;(1):CD003772

45. Hoberman A, Charron M, Hickey RW, BaskinM, Kearney DH, Wald ER. Imaging studies af-

ter a rst febrile urinary tract infection inyoung children. N Engl J Med . 2003;348(3):195202

46. Jahnukainen T, Honkinen O, Ruuskanen O,Mertsola J. Ultrasonography after the rstfebrile urinary tract infection in children.Eur J Pediatr . 2006;165(8):556559

47. Economou G, Egginton J, Brookeld D. Theimportance of late pregnancy scans for re-nal tract abnormalities. Prenat Diagn . 1994;14(3):177180

48. Roberts J. Experimental pyelonephritis in the monkey, part III: pathophysiology of ure-

http://www.pediatrics.org/cgi/content/full/102/2/e16http://www.pediatrics.org/cgi/content/full/102/2/e16http://www.pediatrics.org/cgi/content/full/103/4/e54http://www.pediatrics.org/cgi/content/full/103/4/e54http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://www.pediatrics.org/cgi/content/full/103/4/e54http://www.pediatrics.org/cgi/content/full/103/4/e54http://www.pediatrics.org/cgi/content/full/102/2/e16http://www.pediatrics.org/cgi/content/full/102/2/e16


16/18

teral malfunction induced by bacteria. In- vest Urol . 1975;13(2):117120

49. Smith T, Evans K, Lythgoe MF, Anderson PJ,G o r do n I . R a d i at i o n d o s i m e tr y o f technetium-99m-DMSA in children. J Nucl Med . 1996;37(8):13361342

50. Ward VL. Patient dose reduction during

voiding cystourethrography. Pediatr Radiol .2006;36(suppl 2):168 172

51. Pennesi M, Travan L, Peratoner L, et al. Isantibiotic prophylaxis in children with vesi-coureteral reux effective in preventing py-elonephritis and renal scars? A random-ized, controlled trial. Pediatrics . 2008;121(6). Available at: www.pediatrics.org/cgi/content/full/121/6/e1489

52. Garin EH, Olavarria F, Garcia Nieto V, Valen-ciano B, Campos A, Young L. Clinical signi-cance of primary vesicoureteral reux andurinary antibiotic prophylaxis after acutepyelonephritis: a multicenter, randomized,controlled study. Pediatrics . 2006;117(3):626632

53. Montini G, Rigon L, Zucchetta P, et al. Pro-phylaxis after rst febrile urinary tract in-fection in children? A multicenter, random-ized, controlled, noninferiority trial.Pediatrics . 2008;122(5):10641071

54. Roussey-Kesler G, Gadjos V, Idres N, et al.Antibiotic prophylaxis for the prevention of

recurrent urinary tractinfection in childrenwith low grade vesicoureteral reux: re-sults from a prospective randomized study.J Urol . 2008;179(2):674 679

55. Craig J, Simpson J, Williams G. Antibioticprophylaxis and recurrent urinary tract in-fection in children. N Engl J Med . 2009;361(18):17481759

56. Brandstrm P, Esbjorner E, Herthelius M,Swerkersson S, Jodal U, Hansson S. TheSwedish Reux Trial in Children, part III: uri-nary tract infection pattern. J Urol . 2010;184(1):286 291

57. National Institute for Health and Clinical Ex-cellence. Urinary TractInfection in Children: Diagnosis, Treatment, and Long-term

Management: NICE Clinical Guideline 54 .London, England: National Institute forHealth and Clinical Excellence; 2007. Avail-able at: www.nice.org.uk/nicemedia/live/11819/36032/36032.pdf. Accessed March14, 2011

58. Keren R, Carpenter MA, Hoberman A, et al.

Rationale and design issues of the Random-ized Intervention for Children With Vesi-coureteral Reux (RIVUR) study. Pediatrics .2008;122(suppl 5):S240 S250

59. Jodal U.The natural history ofbacteriuriainchildhood. Infect Dis Clin North Am . 1987;1(4):713729

60. EcclesMR, BaileyRR, AbbottGD, Sullivan MJ.Unravelling the genetics of vesicouretericreux: a common familial disorder. Hum Mol Genet . 1996;5(Spec No.):14251429

61. Scott JE, Swallow V, Coulthard MG, LambertHJ, Lee RE. Screening of newborn babies forfamilial ureteric reux. Lancet . 1997;350(9075):396400


http://www.pediatrics.org/cgi/content/full/121/6/e1489http://www.pediatrics.org/cgi/content/full/121/6/e1489http://www.nice.org.uk/nicemedia/live/11819/36032/36032.pdfhttp://www.nice.org.uk/nicemedia/live/11819/36032/36032.pdfhttp://localhost/var/www/apps/conversion/tmp/scratch_3/pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://pediatrics.aappublications.org/http://localhost/var/www/apps/conversion/tmp/scratch_3/pediatrics.aappublications.org/http://www.nice.org.uk/nicemedia/live/11819/36032/36032.pdfhttp://www.nice.org.uk/nicemedia/live/11819/36032/36032.pdfhttp://www.pediatrics.org/cgi/content/full/121/6/e1489http://www.pediatrics.org/cgi/content/full/121/6/e1489


17/18

APPENDIX Clinical practice guideline algorithm.



18/18

DOI: 10.1542/peds.2011-1330; originally published online August 28, 2011;2011;128;595Pediatrics

Improvement and ManagementSubcommittee on Urinary Tract Infection, Steering Committee on Quality

Management of the Initial UTI in Febrile Infants and Children 2 to 24 MonthsUrinary Tract Infection: Clinical Practice Guideline for the Diagnosis and

ServicesUpdated Information &

mlhttp://pediatrics.aappublications.org/content/128/3/595.full.htincluding high resolution figures, can be found at:

References

ml#ref-list-1http://pediatrics.aappublications.org/content/128/3/595.full.htat:This article cites 53 articles, 20 of which can be accessed free

Citations

ml#related-urlshttp://pediatrics.aappublications.org/content/128/3/595.full.htThis article has been cited by 51 HighWire-hosted articles:

Rs)3Peer Reviews (PPost-Publication

http://pediatrics.aappublications.org/cgi/eletters/128/3/595Rs have been posted to this article33 P

Subspecialty Collections

_on_quality_improvementhttp://pediatrics.aappublications.org/cgi/collection/committeeCommittee on Quality Improvementthe following collection(s):This article, along with others on similar topics, appears in

Permissions & Licensing

mlhttp://pediatrics.aappublications.org/site/misc/Permissions.xhttables) or in its entirety can be found online at:Information about reproducing this article in parts (figures,

Reprints http://pediatrics.aappublications.org/site/misc/reprints.xhtml

Information about ordering reprints can be found online:

rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.Grove Village, Illinois, 60007. Copyright 2011 by the American Academy of Pediatrics. Alland trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk publication, it has been published continuously since 1948. PEDIATRICS is owned, published,PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly
http://pediatrics.aappublications.org/content/128/3/595.full.htmlhttp://pediatrics.aappublications.org/content/128/3/595.full.htmlhttp://pediatrics.aappublications.org/content/128/3/595.full.htmlhttp://pediatrics.aappublications.org/content/128/3/595.full.htmlhttp://pediatrics.aappublications.org/content/128/3/595.full.html#ref-list-1http://pediatrics.aappublications.org/content/128/3/595.full.html#ref-list-1http://pediatrics.aappublications.org/content/128/3/595.full.html#ref-list-1http://pediatrics.aappublications.org/content/128/3/595.full.html#ref-list-1http://pediatrics.aappublications.org/content/128/3/595.full.html#related-urlshttp://pediatrics.aappublications.org/content/128/3/595.full.html#related-urlshttp://pediatrics.aappublications.org/content/128/3/595.full.html#related-urlshttp://pediatrics.aappublications.org/content/128/3/595.full.html#related-urlshttp://pediatrics.aappublications.org/cgi/eletters/128/3/595http://pediatrics.aappublications.org/cgi/eletters/128/3/595http://pediatrics.aappublications.org/cgi/eletters/128/3/595http://pediatrics.aappublications.org/cgi/collection/committee_on_quality_improvementhttp://pediatrics.aappublications.org/cgi/collection/committee_on_quality_improvementhttp://pediatrics.aappublications.org/cgi/collection/committee_on_quality_improvementhttp://pediatrics.aappublications.org/cgi/collection/committee_on_quality_improvementhttp://pediatrics.aappublications.org/site/misc/Permissions.xhtmlhttp://pediatrics.aappublications.org/site/misc/Permissions.xhtmlhttp://pediatrics.aappublications.org/site/misc/Permissions.xhtmlhttp://pediatrics.aappublications.org/site/misc/Permissions.xhtmlhttp://pediatrics.aappublications.org/site/misc/reprints.xhtmlhttp://pediatrics.aappublications.org/site/misc/reprints.xhtmlhttp://pediatrics.aappublications.org/site/misc/reprints.xhtmlhttp://pediatrics.aappublications.org/site/misc/reprints.xhtmlhttp://pediatrics.aappublications.org/site/misc/Permissions.xhtmlhttp://pediatrics.aappublications.org/site/misc/Permissions.xhtmlhttp://pediatrics.aappublications.org/cgi/collection/committee_on_quality_improvementhttp://pediatrics.aappublications.org/cgi/collection/committee_on_quality_improvementhttp://pediatrics.aappublications.org/cgi/eletters/128/3/595http://pediatrics.aappublications.org/content/128/3/595.full.html#related-urlshttp://pediatrics.aappublications.org/content/128/3/595.full.html#related-urlshttp://pediatrics.aappublications.org/content/128/3/595.full.html#ref-list-1http://pediatrics.aappublications.org/content/128/3/595.full.html#ref-list-1http://pediatrics.aappublications.org/content/128/3/595.full.htmlhttp://pediatrics.aappublications.org/content/128/3/595.full.html

jurnal untuk adit

Documents