Diagnosis and Treatment of Urinary

Tract Infections in Children

BRETT WHITE, MD, Oregon Health and Science University, Portland, Oregon

Acute urinary tract infections are relatively common in children, with 8 percent of girls and 2
percent of boys having at least one episode by seven years of age. The most common patho-gen is
Escherichia coli, accounting for approximately 85 percent of urinary tract infections in children.
Renal parenchymal defects are present in 3 to 15 percent of children within one to two years of
their first diagnosed urinary tract infection. Clinical signs and symptoms of a urinary tract
infection depend on the age of the child, but all febrile children two to 24 months of age with no
obvious cause of infection should be evaluated for urinary tract infection (with the exception of
circumcised boys older than 12 months). Evaluation of older children may depend on the clinical
presentation and symptoms that point toward a urinary source (e.g., leu-kocyte esterase or nitrite
present on dipstick testing; pyuria of at least 10 white blood cells per high-power field and
bacteriuria on microscopy). Increased rates of E. coli resistance have made amoxicillin a less
acceptable choice for treatment, and studies have found higher cure rates with
trimethoprim/sulfamethoxazole. Other treatment options include amoxicillin/clavulanate and
cephalosporins. Prophylactic antibiotics do not reduce the risk of subsequent urinary tract
infections, even in children with mild to moderate vesicoureteral reflux. Constipation should be
avoided to help prevent urinary tract infections. Ultrasonography, cystography, and a renal
cortical scan should be considered in children with urinary tract infections. (Am Fam Physi-cian.
2011;83(4):409-415. Copyright © 2011 American Academy of Family Physicians.)

▲ Patient information:
A handout on UTIs in
chil-dren, written by the
G uidelines regarding the diag-nosis,
treatment, and follow-up of urinary
colony-forming units per mL; catheter spec-
imen, greater than 10,000 colony-forming
units per mL; or clean-catch, midstream
author of this article, is tract infections (UTIs) in children
provided on page 416. continue to specimen, 100,000 colony-forming units per
evolve. Although a somewhat less aggres- mL or greater.3-5 Use of lower colony counts
sive approach to evaluation is now recom- in symptomatic patients has been advo-
mended, it is important for primary care cated,6 although this has not been included
physicians to appropriately diagnose and in established guidelines.
treat UTIs in children. Some underlying eti- Common uropathogens include Esch-erichia
ologies, including renal scarring and renal coli (accounting for approximately 85 percent
disease, can lead to considerable morbidity of UTIs in children), Klebsiella, Proteus,
later in life. Enterobacter, Citrobacter, Staphy-lococcus
Acute UTIs are relatively common in saprophyticus, and Enterococcus.7 A
children. By seven years of age, 8 percent of systematic review found that renal paren-
girls and 2 percent of boys will have at least chymal defects are identified in 3 to 15 per-
one episode.1 In a study of infants present-ing cent of children within one to two years of
to pediatric emergency departments, the their first diagnosed UTI.8 Long-term com-
prevalence of UTI in infants younger than 60 plications of UTI associated with renal scar-
days with a temperature greater than 100.4°F ring include hypertension, chronic renal
(38°C) was 9 percent.2 The reference standard failure, and toxemia in pregnancy. Long-term
for the diagnosis of UTI is a single organism follow-up data are limited, although one
cultured from a specimen obtained at the Swedish study found that among patients who
following concentrations: suprapu-bic had renal scarring from pyelonephri-tis during
aspiration specimen, greater than 1,000 childhood, 23 percent developed
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February 15, 2011 ◆ Volume 83, Number 4 www.aafp.org/afp American Family Physician 409

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UTIs in Children
SORT: KEY RECOMMENDATIONS FOR PRACTICE

Evidence
Clinical recommendation rating References

UTI should be suspected in patients with leukocyte esterase and nitrite present on dipstick testing, or C 13, 16
with pyuria of at least 10 white blood cells per high-power field and bacteriuria on microscopy.
In young children, urine samples collected with a bag are unreliable in the evaluation of UTI. C 17
The recommended initial antibiotic for most children with UTI is trimethoprim/sulfamethoxazole C 10
(Bactrim, Septra). Alternative antibiotics include amoxicillin/clavulanate (Augmentin) or cephalosporins,
such as cefixime (Suprax), cefpodoxime, cefprozil (Cefzil), or cephalexin (Keflex).
A two- to four-day course of oral antibiotics is as effective as a seven- to 14-day course in children A 19-21
with a lower UTI. A single-dose or single-day course is not recommended.
Children with acute pyelonephritis can be treated effectively with oral antibiotics (e.g., amoxicillin/ A 24
clavulanate, cefixime, ceftibuten [Cedax]) for 10 to 14 days or with short courses (two to four days)
of intravenous therapy followed by oral therapy.
Prophylactic antibiotics do not reduce the risk of recurrent UTIs, even in children with mild to B 25-27
moderate vesicoureteral reflux.
Routine circumcision in boys does not reduce the risk of UTI enough to justify the risk of surgical B 32
complications.

UTI = urinary tract infection.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented
evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.xml.

hypertension and 10 percent developed end- may include suprapubic tenderness or costo-
stage renal disease.9 However, more recent vertebral angle tenderness.
studies question the association between
DIAGNOSTIC TESTS
pyelonephritis and end-stage renal disease.10
Baseline abnormalities of the urogenital Dipstick tests for UTI include leukocyte
tract have been reported in up to 3.2 percent esterase, nitrite, blood, and protein. Leuko-cyte
of healthy, screened infants.11 Additionally, esterase is the most sensitive single test in
obstructive anomalies are found in up to 4 children with a suspected UTI. The test for
percent and vesicoureteral reflux in 8 to 40 nitrite is more specific but less sensitive. A
percent of children being evaluated for their negative leukocyte esterase result greatly
first UTI. Children younger than two years reduces the likelihood of UTI, whereas a
may be at greater risk of parenchymal positive nitrite result makes it much more
defects than older children.12 likely; the converse is not true, however. Dip-
stick tests for blood and protein have poor
Diagnosis sensitivity and specificity in the detection of
HISTORY AND PHYSICAL EXAMINATION UTI and may be misleading. Accuracy of
Clinical signs and symptoms of a UTI positive findings is as follows (assumes a
depend on the age of the child. Newborns 10 percent pretest probability)13:
with UTI may present with jaundice, sepsis, • Nitrite: 53 percent sensitivity, 98 percent
failure to thrive, vomiting, or fever. In specificity, 75 percent probability of UTI
infants and young children, typical signs and
symp-toms include fever, strong-smelling
• Bacteria on microscopy: 81 percent sen-
sitivity, 83 percent specificity, 35 percent
urine, hematuria, abdominal or flank pain, probability of UTI
and new-onset urinary incontinence. School-
aged children may have symptoms similar to
• Leukocytes on microscopy: 73 percent
sensitivity, 81 percent specificity, 30 percent
adults, including dysuria, frequency, or probability of UTI
urgency. Boys are at increased risk of UTI if
younger than six months, or if younger than
• Leukocyte esterase: 83 percent sensitiv-
ity, 78 percent specificity, 30 percent prob-
12 months and uncircumcised. Girls are ability of UTI
generally at an increased risk of UTI, par-
ticularly if younger than one year.3 Physical
• Leukocyte esterase or nitrite: 93 percent
sensitivity, 72 percent specificity, 27 percent
examination findings can be nonspecific but probability of UTI

410 American Family Physician www.aafp.org/afp Volume 83, Number 4 ◆ February 15, 2011
 UTIs in Children
Urine Testing in Children with Suspected Urinary Tract Infection
Children < 3 months of age Children 3 months to 3 years of age

Urine sample should be sent for

urgent microscopy and culture
Specific urinary symptoms Symptoms nonspecific for UTI

Initiate treatment
Initiate antibiotic treatment, and
send urine sample for urgent
microscopy and culture High risk of serious illness Intermediate or low
risk of serious illness

Initiate antibiotic treatment,

and send urine sample for Urine sample should be sent
urgent microscopy and culture for microscopy and culture

Initiate treatment if microscopy

or culture results are positive

Children > than 3 years of age

Perform urine dipstick test

Positive for leukocyte Negative for leukocyte esterase Positive for leukocyte esterase Negative for leukocyte
esterase and nitrite and positive for nitrite and negative for nitrite esterase and nitrite

Diagnose UTI Initiate antibiotic Send urine sample for Explore other
treatment, and send microscopy and culture; initiate causes of illness
urine sample for culture antibiotic treatment only if there
Initiate antibiotic treatment; is good clinical evidence of UTI
send urine sample for culture
only if patient is at intermediate Treat depending on
or high risk of serious illness or urine culture results Treat depending on
has a history of UTI urine culture results

Figure 1. Algorithm for urine testing in children with suspected urinary tract infection (UTI).
Information from reference 15.

• Blood: 47 percent sensitivity, 78 percent instead of dipstick testing. The presence of

specificity, 19 percent probability of UTI pyuria of at least 10 white blood cells per high-
• Protein: 50 percent sensitivity, 76 percent power field and bacteriuria are recom-mended
specificity, 19 percent probability of UTI as the criteria for diagnosing UTI with
All febrile children between two and 24 microscopy.16 In young children, urine
months of age with no obvious cause of samples collected with a bag are unreliable
infection should be evaluated for UTI, with compared with samples collected with a
the exception of circumcised boys older catheter.17 Therefore, in a child who is unable
than 12 months.14 Older children should be to provide a clean-catch specimen, catheter-
evaluated if the clinical presentation points ization should be considered. If urine cannot
toward a urinary source. The National Insti- be cultured within four hours of collection, the
tute for Health and Clinical Excellence in sample should be refrigerated.
the United Kingdom endorses incorporat-ing Imaging procedures with the highest rat-ings
specific strategies for urine testing based from the American College of Radiology
on the child’s age (Figure 1).15 In this model, Appropriateness Criteria for further evalua-
microscopy and urine culture should be per- tion of select children with UTIs are renal and
formed in children younger than three years bladder ultrasonography, radionuclide

February 15, 2011 ◆ Volume 83, Number 4 www.aafp.org/afp American Family Physician 411
UTIs in Children

Imaging in Children with Urinary Tract Infection

Boys Girls

≤ 3 years of age > 3 years of age < 3 years of age 3 to 7 years of age > 7 years of age

Cystography and Ultrasonography with Cystography and Observation without

ultrasonography cystography or renal cortical ultrasonography imaging; involve family
scan (either option acceptable); in imaging decisions
cystography needed if positive
Body temperature Body temperature
findings on renal cortical scan
≥ 101.3°F (38.5°C) < 101.3°F

Ultrasonography with cystography Observation without

or renal cortical scan (either option imaging; involve family
acceptable); cystography needed if in imaging decisions
positive findings on renal cortical scan

Figure 2. Algorithm for imaging decisions in children with urinary tract infection.
Information from reference 3.

cystography or voiding cystourethrography, especially those older than three years, is to

and renal cortical scan.18 Renal and bladder first perform ultrasonography and a renal
ultrasonography is effective for evaluating cortical scan. This strategy avoids bladder
anatomy, but is unreliable for detecting vesi- catheterization with cystography and mini-
coureteral reflux. Radionuclide cystography or mizes radiation exposure if the results of the
voiding cystourethrography is effective for scan are normal. However, if pyelonephritis
screening and grading vesicoureteral reflux, or cortical scarring is found on the renal cor-
but involves radiation exposure and tical scan, cystography is indicated.3
catheterization. Although voiding cystoure- Observation without imaging should be
thrography is suggested for either girls or boys, considered in girls three years or older with
radionuclide cystography is suggested only for a temperature less than 101.3° F and in all
girls because voiding cystourethrog-raphy is girls older than seven years.3 The fam-ily
needed for adequate anatomic imag-ing of the should share in the decision to perform
urethra and bladder in boys. A renal cortical imaging with the first UTI or delay imaging
scan (also called scintigraphy or DMSA scan) until the second UTI, if it occurs. Figure 2 is
uses technetium and is effec-tive for assessing an algorithm for imaging strategies in chil-
renal scarring, but requires intravenous dren with UTI.3
injection of radioisotope.
DIFFERENTIAL DIAGNOSIS
Long-term outcome studies have not been
performed to determine the best initial Although fever may be the sole present-ing
imaging study in children diagnosed with symptom in children younger than 24
UTI. Guidelines based on observational months, physical examination findings may
studies and expert opinion recommend that point toward an alternative diagno-sis,
all boys, girls younger than three years, and including otitis media, gastroenteritis, or
girls three to seven years of age with a upper respiratory tract infection. Occult
temperature of 101.3°F (38.5°C) or greater bacteremia should always be considered,
receive cystography and ultrasonography although the probability of this diag-nosis is
with a first-time UTI.3 An optional imag-ing much lower than UTI (less than 1 versus 7
strategy for febrile children with UTI, percent) in fully immunized

412 American Family Physician www.aafp.org/afp Volume 83, Number 4 ◆ February 15, 2011
 UTIs in Children

children with no other identifiable potential relative risk = 0.95; 95% confidence interval,
source for fever on physical examination.4 0.70 to 1.29). There was also no significant
Urinary calculi, urethritis (including a sexu- difference between short- and standard-
ally transmitted infection), dysfunctional duration therapies in the development of
elimination, and diabetes mellitus must be resistant organisms at the end of treatment.19
considered in verbal children with urinary Thus, a two- to four-day course of oral anti-
tract problems. biotics appears to be as effective as a seven-to
14-day course in children with lower UTIs.19
Treatment A single-dose or single-day course may be less
Although amoxicillin has traditionally been effective than longer courses of oral antibiotics
a first-line antibiotic for UTI, increased rates and is not recommended.20,21
of E. coli resistance have made it a less When the presenting symptoms are non-
acceptable choice, and studies have found specific for a UTI or the urine dipstick test is
higher cure rates with trimethoprim/ nondiagnostic, there may be a delay in
sulfamethoxazole (Bactrim, Septra). Other treatment while culture results are pend-ing.
choices include amoxicillin/clavulanate Parents can be reassured that antibiotics
(Augmentin) or cephalosporins, such as initiated 24 hours after the onset of fever are
cefixime (Suprax), cefpodoxime, cefprozil not associated with a higher risk of paren-
(Cefzil), or cephalexin (Keflex).10 Table 1 chymal defects than immediate antibiotics in
lists commonly used antibiotics, with dosing children younger than two years.22 How-ever,
information and adverse effects. Physicians delaying antibiotics by four days or more may
should be aware of local bacterial resistance increase the risk of renal scarring.8
patterns that might affect antibiotic choices. Fluoroquinolones are not usually used in
A Cochrane review analyzing short- children because of potential concerns about
duration (two to four days) versus standard- sustained injury to developing joints, although
duration (seven to 14 days) oral antibiotics there is no compelling evidence supporting the
in 652 children with lower UTIs found no occurrence of this phenom-enon.
sig-nificant difference in positive urine Fluoroquinolones may be useful when
cultures between the therapies immediately infection is caused by multidrug-resistant
after treatment (eight studies: relative risk = pathogens for which there is no safe and
1.06; 95% confidence interval, 0.64 to 1.76) effective alternative, parenteral therapy is not
or 15 months after treatment (10 studies: feasible, and no other effective oral agent

Table 1. Antibiotics Commonly Used to Treat Urinary Tract Infections in Children

Antibiotic Dosing Common adverse effects

Amoxicillin/clavulanate 25 to 45 mg per kg per day, Diarrhea, nausea/vomiting, rash

(Augmentin) divided every 12 hours
Cefixime (Suprax) 8 mg per kg every 24 hours Abdominal pain, diarrhea, flatulence, rash
or divided every 12 hours
Cefpodoxime 10 mg per kg per day, Abdominal pain, diarrhea, nausea, rash
divided every 12 hours
Cefprozil (Cefzil) 30 mg per kg per day, Abdominal pain, diarrhea, elevated results
divided every 12 hours on liver function tests, nausea
Cephalexin (Keflex) 25 to 50 mg per kg per day, Diarrhea, headache, nausea/vomiting, rash
divided every 6 to 12 hours
Trimethoprim/ 8 to 10 mg per kg per day, Diarrhea, nausea/vomiting, photosensitivity,
sulfamethoxazole divided every 12 hours rash
(Bactrim, Septra)

February 15, 2011 ◆ Volume 83, Number 4 www.aafp.org/afp American Family Physician 413
UTIs in Children

is available. Guidelines from the American subsequent UTI, even in children with mild to
Academy of Pediatrics recommend limiting moderate vesicoureteral reflux.26 Another
fluoroquinolone therapy to patients with randomized controlled trial of children and
UTIs caused by Pseudomonas aeruginosa or adolescents with pyelonephritis found that
other multidrug-resistant, gram-negative antibiotic prophylaxis did not prevent
bacteria.23 Ciprofloxacin (Cipro) is subsequent UTIs in patients with no docu-
approved by the U.S. Food and Drug mented vesicoureteral reflux or with mild to
Administration for complicated UTIs and moderate vesicoureteral reflux.27 Anti-biotic
pyelonephri-tis attributable to E. coli in prophylaxis may be more beneficial in children
patients one to 17 years of age.23 with more severe vesicoureteral reflux,
A Cochrane review concluded that chil- however.28 The most recent Cochrane review
dren with acute pyelonephritis can be treated on the subject concluded that large, properly
effectively with oral antibiotics (e.g., randomized, double-blind studies are needed to
amoxicillin/clavulanate, cefixime, ceftibu- determine the effectiveness of long-term
ten [Cedax]) for 10 to 14 days or with short- antibiotics for the prevention of UTI in
courses (two to four days) of intravenous susceptible children.1 Additionally, continuous
therapy followed by oral therapy. If intra- antibiotic prophylaxis in chil-dren younger
venous therapy is used, single daily dosing than two and a half years with vesicoureteral
with aminoglycosides is safe and effective. reflux may not decrease the risk of
Studies are needed to determine the optimal pyelonephritis or renal damage.29
duration of intravenous therapy in children Constipation should be addressed in infants
with acute pyelonephritis, but 10 to 14 days and children who have had a UTI to help
is typical.24 Hospitalization should be prevent subsequent infections.30 There is some
consid-ered for any child that is unable to evidence that cranberry juice decreases
tolerate oral intake or when the diagnosis is symptomatic UTIs over 12-months, particu-
uncer-tain in a markedly ill child. larly in women with recurrent UTIs.31 The
Follow-up assessment to confirm an effectiveness of cranberry juice in children is
appropriate clinical response should be per- less certain, and the high dropout rate in
formed 48 to 72 hours after initiating anti- studies indicates that cranberry juice may not
microbial therapy in all children with UTI. be acceptable for long-term prevention. A
Culture and susceptibility results may indi- systematic review concluded that routine
cate that a change of antibiotic is necessary. circumcision in boys does not reduce the risk
If expected clinical improvement does not of UTI enough to justify the risk of surgical
occur, consider further evaluation (e.g., lab- complications.32
oratory studies, imaging, consultation with
subspecialists). Referral to a subspecialist is
The Author
indicated if vesicoureteral reflux, renal scar-
BRETT WHITE, MD, is an assistant professor in the
ring, anatomic abnormalities, or renal cal-
Depart-ment of Family Medicine at Oregon Health and
culi are discovered, or if invasive imaging Science University in Portland. He is medical director of
procedures are considered. the uni-versity’s Family Health Center and associate
director of the university’s Family Medicine Residency.
Prevention Address correspondence to Brett White, MD, Oregon
In an observational study of otherwise healthy Health and Science University, 4411 SW Vermont St.,
children with a first UTI, antibi-otic Portland, OR 97219 (e-mail: [email protected]).
Reprints are not available from the author.
prophylaxis was not associated with a reduced
risk of recurrent UTI and increased the risk of Author disclosure: Nothing to disclose.
treatment-resistant pathogens.25 A randomized
controlled trial of children two months to REFERENCES
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414 American Family Physician www.aafp.org/afp Volume 83, Number 4 ◆ February 15, 2011
 UTIs in Children

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February 15, 2011 ◆ Volume 83, Number 4 www.aafp.org/afp American Family Physician 415