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Urinary tract infections in children: EAU/ESPU guidelines
Raimund Stein1, Hasan S Dogan2, Piet Hoebeke3
1Division of Paediatric Urology, Department of Urology, Mainz University Medical Centre, Johannes Gutenberg University, Mainz, Germany.
Insights
Urinary tract infections (UTIs) in children require prompt diagnosis and treatment to prevent kidney damage. Guidelines emphasize early antibiotic intervention and appropriate imaging to identify at-risk patients.
Area of Science:
- Pediatric Nephrology
- Infectious Diseases
- Urology
Background:
- Urinary tract infection (UTI) is a common childhood illness, often presenting as the first sign of underlying urinary tract anomalies in up to 30% of cases.
- Delayed diagnosis and treatment of pediatric UTIs can lead to irreversible upper urinary tract damage.
Purpose of the Study:
- To establish evidence-based recommendations for the diagnosis, treatment, and imaging of urinary tract infections in children.
- To guide clinicians in identifying children at risk for severe UTI complications and upper tract damage.
Main Methods:
- A comprehensive literature review of PubMed and Embase databases.
- Consensus-based decision-making was employed for areas with limited or low-quality evidence.
Main Results:
- UTIs are classified by site, episode, symptoms, and complicating factors, with site and severity guiding acute treatment.
- Diagnostic methods include suprapubic aspiration, catheterization, clean-voided midstream samples (for toilet-trained children), and urine dipstick/microscopy.
- Prompt antibiotic treatment for febrile UTI is crucial to prevent bacteremia and renal involvement; ultrasound is recommended to rule out obstructive uropathy, with further imaging for vesicoureteral reflux based on clinical factors.
Conclusions:
- High-level evidence supports the diagnosis and treatment recommendations for pediatric UTIs.
- Evidence for imaging modalities to identify children at risk for upper urinary tract damage is less robust.
- Guidelines advocate for prompt exclusion of obstructive uropathy and, when indicated, vesicoureteral reflux.
Context:
In 30% of children with urinary tract anomalies, urinary tract infection (UTI) can be the first sign. Failure to identify patients at risk can result in damage to the upper urinary tract.
Objective:
To provide recommendations for the diagnosis, treatment, and imaging of children presenting with UTI.
Evidence Acquisition:
The recommendations were developed after a review of the literature and a search of PubMed and Embase. A consensus decision was adopted when evidence was low.
Evidence Synthesis:
UTIs are classified according to site, episode, symptoms, and complicating factors. For acute treatment, site and severity are the most important. Urine sampling by suprapubic aspiration or catheterisation has a low contamination rate and confirms UTI. Using a plastic bag to collect urine, a UTI can only be excluded if the dipstick is negative for both leukocyte esterase and nitrite or microscopic analysis is negative for both pyuria and bacteriuria. A clean voided midstream urine sample after cleaning the external genitalia has good diagnostic accuracy in toilet-trained children. In children with febrile UTI, antibiotic treatment should be initiated as soon as possible to eradicate infection, prevent bacteraemia, improve outcome, and reduce the likelihood of renal involvement. Ultrasound of the urinary tract is advised to exclude obstructive uropathy. Depending on sex, age, and clinical presentation, vesicoureteral reflux should be excluded. Antibacterial prophylaxis is beneficial. In toilet-trained children, bladder and bowel dysfunction needs to be excluded.
Conclusions:
The level of evidence is high for the diagnosis of UTI and treatment in children but not for imaging to identify patients at risk for upper urinary tract damage.
Patient Summary:
In these guidelines, we looked at the diagnosis, treatment, and imaging of children with urinary tract infection. There are strong recommendations on diagnosis and treatment; we also advise exclusion of obstructive uropathy within 24h and later vesicoureteral reflux, if indicated.
