Febrile Urinary Tract Infections in Children

From Medscape Medical News

Laurie Barclay, MD

July 20, 2011 — The management of febrile urinary tract infections in children is changing, according to the results of a clinical review published in the July 21 issue of the New England Journal of Medicine.

"Acute pyelonephritis is the most common serious bacterial infection in childhood; many affected children, particularly infants, have severe symptoms," write Giovanni Montini, MD, from the Department of Pediatrics, Azienda Ospedaliero–Universitaria Sant'Orsola-Malpighi in Bologna, Italy, and colleagues.
"Most cases are readily treated, provided diagnosis is prompt, though in some children fever may take several days to abate.
Approximately 7 to 8% of girls and 2% of boys have a urinary tract infection during the first 8 years of life."

In boys as well as girls, febrile urinary tract infections occur most often during the first year of life, unlike nonfebrile urinary tract infections, which occur mostly in girls older than 3 years.
After infancy, urinary tract infections involving only the bladder usually present with localized symptoms and are easily treated.
When fever accompanies urinary infection, risk is greater for kidney involvement, and underlying nephrourologic abnormalities are more common, resulting in a higher risk for renal scarring and associated substantial long-term morbidity.
The sensitivity of fever to predict renal involvement is 53% to 84%, and specificity is 44% to 92%.

Management approaches for children with proven kidney infections have involved intensive workup and treatment, often including surgery and/or long-term antibiotic prophylaxis.
Because experts have questioned the need for such strategies, various recent or ongoing trials are investigating optimal strategies for the evaluation and treatment of a first febrile urinary tract infection, as well as the best options for subsequent interventions.
In most children, oral and intravenous antibiotics appear to be equally effective in treating febrile urinary tract infections.
Current recommendations of the American Academy of Pediatrics are that parenteral antibiotic therapy and hospitalization be considered for children who appear to be severely ill or dehydrated, or who cannot retain oral intake.
Although antibiotic choice depends on resistance patterns in a given institution or region, cephalosporins and amoxicillin–clavulanic acid are the oral antibiotics most often used, and cephalosporins and aminoglycosides are often recommended for intravenous treatment.
Thanks to advances in prenatal ultrasonography, it is now known that significant renal damage in children is often associated with the presence of hypodysplasia and other urologic abnormalities.
In some children, renal scarring associated with infection results in additional damage to dysplastic kidneys or late effects in kidneys that previously were normal.
"The value of antibiotic prophylaxis has been questioned in recent studies," the review authors write. "Further data are needed to determine which children might benefit from antibiotic prophylaxis. Studies in progress may help to answer these questions."


N Engl J Med. 2011;365:239-250.