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Urinary Tract Infection in Children: A Review

Urinary Tract Infection in Children: A Review

Introduction

Urinary tract infection (UTI) is defined as bacteriuria in the presence of symptoms1Heffner V, Gorelick M. Pediatric Urinary Tract Infection Pediatric Urinary Tract Infection. Clin Ped Emerg Med 2008; 9:233-237.  . UTI in children is a commonly encountered problem by healthcare providers. UTIs are increasingly gaining importance over the recent decades as they are recognised as an occult cause of 2febrile illness in children.2Zorc J, Kiddoo D, Shaw K. Diagnosis and Management of Pediatric Urinary Tract Infections. Clinical Microbiology Reviews 2005; 18 (2): 417-422.  

By the age of six years, 7% girls and 2% boys have had a symptomatic culture positive UTI. Below the age of one year, UTIs are more common in boys than girls. However, after the age of one year, it is commonly seen in girls. Although children recover promptly without any long-term complications post UTI, infections occurring in the upper urinary tract can cause irreversible damage to the renal parenchyma which is evident as renal scarring.

Following a single UTI, 15-41% children are thought to develop scarring. Long term renal scarring can also include chronic kidney 3disease, proteinuria, hypertension and complications in pregnancy . Untreated UTI may cause immediate and long-term morbidity including hypertension, renal scarring, pre-eclampsia and end-stage renal disease.1Heffner V, Gorelick M. Pediatric Urinary Tract Infection Pediatric Urinary Tract Infection. Clin Ped Emerg Med 2008; 9:233-237.  

Causative Organism

The causative organism for UTIs originates from the gut flora. Although large number of organisms can cause UTI, gram-negative bacteria are most frequently identified.

The most common type of bacteria causing UTIs are uropathogenic Escherichia coli (UPEC) which accounts for 70-90% of community acquired infections. Other causative bacteria such as Klebsiella and other organisms like Proteus mirabilis, Pseudomonas, coagulase negative Staphs, Streptococci (e.g. Group B strep, Enterococci), Staph Aureus and occasionally Haemophilus influenza are also known to cause UTIs. (Refer Table 1 for commonly causative pathogens.)1Heffner V, Gorelick M. Pediatric Urinary Tract Infection Pediatric Urinary Tract Infection. Clin Ped Emerg Med 2008; 9:233-237.  4Jadresic L. Diagnosis and management of urinary tract infections in children. Paediatrics And Child Health; 20(6): 274-278.  

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Risk Factors

A variety of risk factors can cause UTI. Females are more prone to UTI than males due to the short urethra which is in close proximity with anus and wiping from back to front. Uncircumcised males have a higher chance of developing UTI (4-20 times). Other risk factors include:

  • Obstructive uropathy
  • Urolithiasis
  • Voiding dysfunction
  • Lack of toilet training
  • Urethral instrumentation
  • Tighyt clothing
  • Pinworm infestation

Based on the clinical situation, the route of administration of the medication should be chosen. Patients appearing toxic, dehydrated or are vomiting, are suitable candidates for parenteral treatment as their oral compliance would be low. However, they should be transitioned to oral route when possible. A Cochrane 2014 review compared oral and intravenous antibiotics and found no difference in

time to fever resolution, rate of bacteriuria recurrence, or risk for persistent UTI at 72 hours between the routes of administration. As the efficacy of intravenous and oral routes is similar, the American Academy of Paediatrics (AAP) recommends the use of oral antibiotics when feasible.5Espinosa C, Bryant K, Bosley K. Therapeutics of Pediatric Urinary Tract Infections. Archives of Medicine 2015; 7(5):4    Neonates, children less than 3 months and children having complicated UTI need hospitalization and parenteral

Signs and Symptoms

Babies under 3 months of age can intermittently present with dehydration, hyponatraemia and hyperkalaemia mimicking the findings in congenital adrenal hyperplasia. In young children the symptoms of UTI are often nonspecific and fever is commonly the only presenting complaint.1Heffner V, Gorelick M. Pediatric Urinary Tract Infection Pediatric Urinary Tract Infection. Clin Ped Emerg Med 2008; 9:233-237.4Jadresic L. Diagnosis and management of urinary tract infections in children. Paediatrics And Child Health; 20(6): 274-278.    

Children less than two years can present as ‘Fever without focus’ and in Neonates it can be part of Septicemia. Young children can present with Recurrent fever, not gaining weight, vomiting and pain in abdomen. Older children can present having urinary symptoms like dysuria, frequency and/or urgency of micturition.

The clinical signs of UTI can be divided into two types and are presented in Table 2.

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Diagnosis

Urine Testing

Urine testing is advised in patients with signs and symptoms of UTI and with unexplained fever of 38℃ or higher. The specimen for urinanalysis can be collected in 4 ways:

  • Midstream clean catch specimen (most widely used)
  • Suprapubic aspiration from the bladder
  • From bag applied to the perineum (not a preferred method)
  • Temporary transurethral catheterisation

After collection, the specimen should be transported to the laboratory within 30 minutes to two hours or stored at 40℃ which would be utilised for dipstick microscopy and for culture and sensitivity test.

The gold standard for diagnosis of UTI is urine culture and sensitivity test which is mandate to confirm UTI.6Laila K, Roy E, Rahman H, et al. Urinary Tract Infection in Children : An Update. Bangladesh J Child Health 2012; 36(2): 90-97.   A urine culture is considered positive in children if there are ≥ 50,000 CFU/ml of a single pathogen from a reliable specimen.5Espinosa C, Bryant K, Bosley K. Therapeutics of Pediatric Urinary Tract Infections. Archives of Medicine 2015; 7(5):4    Urine culture from a good midstream sample >105 CFU is considered positive by Indian society of Ped Nephrology.

For children less than 3 years of age with fever (>39℃ rectal), urinalysis and urine culture is necessary. For children greater than 3 years of age, urinanalysis and urine culture can be obtained in case of urinary symptoms like dysuria, urinary frequency, haematuria, abdominal pain, back pain or new daytime incontinence.

Urine dipstick test is preferred as they provide rapid results without microscopy, is inexpensive and does not require extensive training. In the dipstick test, a colour change on chemically coated colour strips due to production of esterase by neutrophils or conversion of nitrate to nitrite is detected.7Robinson J, Finlay J, Lang M, et al. Urinary tract infection in infants and children: Diagnosis and management. Paediatr Child Health 2014; 19(6):315-19.  

Dipstick test have a specificity and sensitivity of 92% and 82% respectively.5Espinosa C, Bryant K, Bosley K. Therapeutics of Pediatric Urinary Tract Infections. Archives of Medicine 2015; 7(5):4    In a child suspected with UTI, Leucocytes esterase test is the most sensitive single test. A negative leucocytes esterase test greatly reduces the chances of UTI. The test for nitrate is also specific but less sensitive.8White B. Diagnosis and Treatment of Urinary Tract Infections in Children. Am Fam Physician. 2011;83(4):409-415.   The strategies for urine dipstick test for children are mentioned in table 3. The algorithm for urine testing in children suspected with UTI is shown in figure 1.

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Imaging procedures

The major objective to perform diagnostic imaging studies during or after a febrile UTI is to confirm pyelonephritis and to identify whether severe vesicoureteral reflux (VUR) or structural anomalies are present in children. Imaging is not required in children suspected with cystitis. Imaging should only be performed if it is likely to modify the management.

The imaging technique should be chosen keeping in mind the safety, cost and accuracy of the procedure to be performed. A voiding cystourethrogram (VCUG) was recommended in all children with febrile UTI between 2 months and 2 years of age in the past. However, it is no longer recommended.7Robinson J, Finlay J, Lang M, et al. Urinary tract infection in infants and children: Diagnosis and management. Paediatr Child Health 2014; 19(6):315-19.   The algorithm for imaging decisions in children with UTI is shown in figure 2.

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Others

Some markers like elevated white blood cell counts (WBC), Creactive protein (CRP) and erythrocyte sedimentation rate (ESR) are associated with bacterial infection in young children. However, they are not the perfect markers for diagnosis of UTI. 5Espinosa C, Bryant K, Bosley K. Therapeutics of Pediatric Urinary Tract Infections. Archives of Medicine 2015; 7(5):4   

Treatment Options

Once the diagnosis of UTI is confirmed, the initial goal is to prevent the acute infection to further spread and to prevent permanent damage to the renal system. antibiotics. Children above 3 months of age and children having simple UTI can be treated with oral antibiotics.

Antimicrobial therapy

At present preferred oral antibiotics will be as per local susceptibility pattern. However Amoxiclav and third generation Cephalosporin (Cefixim) are preferred 1st line oral antibiotics and Ceftriaxone and aminoglycoside are preferred parenteral drugs. Once child settles after 48 to 72 hrs he can be shifted to oral antibiotics. Treatment needs to be modified as per culture report especially in children less than 3 months and in complicated UTI. The introduction of antimicrobial agents is probably the most profound advance in the management of UTIs. Although the choice of antibiotics will largely depend on the antimicrobial susceptibilities of urinary pathogens 10National Collaborating Centre for Women’s and Children’s Health. Urinary tract infection in children diagnosis, treatment and long-term management. Clinical Guidelines; 2007.  ; in this context, the growing problem of antimicrobial resistance to antibiotics, such as norfloxacin, ampicillin and ciprofloxacin, is a cause of major concern which has led to the out patient management of UTIs challenging.11Renuart AJ, Goldfarb DM, Mokomane M, et al. Microbiology of Urinary Tract Infections in Gaborone, Botswana Plos One 2013;8(3):e57776.  

Nitrofurantoin

Amidst the concerns of rising resistance for most antimicrobials, demonstration of efficacy with minimal drug resistance makes nitrofurantoin an attractive agent for uncomplicated UTI and prophylaxis. The recommendation appears consistent with the guidelines from various international organisations, such as the Infectious Diseases Society of America (IDSA) and the European Society for Microbiology and Infectious Diseases (ESMI) which show Nitrofurantoin as an appropriate choice for therapy for UTIs, owing to the minimal overall resistance and favorable side-effect profile seen with this drug.11Renuart AJ, Goldfarb DM, Mokomane M, et al. Microbiology of Urinary Tract Infections in Gaborone, Botswana Plos One 2013;8(3):e57776.   12Gupta K, Hooton TM, Naber KG, et al. Executive Summary: International Clinical Practice Guidelines for the Treatment of Acute Uncomplicated Cystitis and Pyelonephritis in Women: A 2010 Update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases Clin Infect Dis. 2011;52(5): 561-564.   13Rijal A, Ghimire G, Gautam K, et al. Antibiotic susceptibility of organisms causing urinary tract infection in patients presenting to a teaching hospital. J Nepal Health Res Counc. 2012;10(1):24-7.   14Gupta K, Hooton TM, Naber KG, et al. International Clinical Practice Guidelines for the Treatment of Acute Uncomplicated Cystitis and Pyelonephritis in Women: A 2010 Update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious DiseasesClinical Infectious Diseases 2011;52(5):e103- e120.  

In this context, a study conducted by Edlin RS et al. characterised the patterns of antibiotic resistance in 25,418 outpatient urinary isolates. It was observed that resistance among E. coli was highest for Trimethoprim-Sulphamethoxazole (24%) but lower for Nitrofurantoin (less than 1%). Thus, the study suggested that Nitrofurantoin is an appropriate narrow-spectrum alternative due to its low resistance rate.15Edlin RS, Shapiro DJ, Hersh AL, et al. Antibiotic resistance patterns of outpatient pediatric urinary tract infections. J Urol. 2013; 190(1):222-7.   Likewise, a study conducted by Kashanian J et al. re-evaluated the first- and second-line therapies for treating uncomplicated urinary tract infection. The study involved 10,417 cultures that grew E. coli from 2003 to 2007. It was observed that Nitrofurantoin was bactericidal to a mean of 95% of E. coli UTIs. Nitrofurantoin also had a resistance rate of 2.3% as compared with quinolones (Ciprofloxacin and Levofloxacin), which had resistant rates of approximately 24%, and Co-trimoxazole, which had resistant rate of 29%. The study concluded that Nitrofurantoin is an acceptable treatment for uncomplicated UTIs and can now be considered the first-line treatment.16Kashanian J ,Hakimian P, Blute M Jr, et al. Nitrofurantoin: the return of an old friend in the wake of growing resistance. BJU International 2008; 102:1634-1637.  

Various other studies have demonstrated the efficacy of nitrofurantoin in the treatment and prophylaxis of UTI. Brendstrup L et al. compared the efficiency of Nitrofurantoin and Trimethoprim prophylaxis in preventing recurrent UTI by means of actuarial percentage recurrence-free curve involving 130 children. It was observed that Nitrofurantoin was the most efficient prophylactic drug in patients with abnormal urography and/or reflux as evaluated by actuarial percentage recurrence-free analysis (p = 0.0025). It was also observed that patients on Trimethoprim prophylaxis had 76% Trimethoprim resistant bacteria while Nitrofurantoin prophylaxis neither altered the pattern of resistance nor the bacteriological constellation.17Brendstrup L, Hjelt K, Petersen KE, et al. Nitrofurantoin versus trimethoprim prophylaxis in recurrent urinary tract infection in children. A randomized, double-blind study. Acta Paediatr Scand. 1990;79(12):1225-34.   Brumfitt W et al. evaluated the long-term efficacy and safety profile of Nitrofurantoin in urinary infections. The study involved 219 female patients (8-89 years) on long-term prophylaxis (1 year) with Nitrofurantoin for the prevention of recurrent urinary infection. It was observed that macrocrystalline Nitrofurantoin 50 mg at bedtime is appropriate for long-term (12 months) prophylaxis of recurrent urinary infections, in view of its efficacy and favourable safety and tolerability profile.18Brumfitt W, Hamilton-Miller JM. Efficacy and safety profile of long-term nitrofurantoin in urinary infections: 18 year’s experience. J Antimicrob Chemother. 1998; 42(3):363-71.   A review by Munoz-Davila M J. also showed that Nitrofurantoin has been used successfully for long term prophylaxis and treatment of acute lower urinary tract infections in adults, children and pregnant women. The overall experience after more than three decades of extensive use showed a very low reported side-effect incidence of less than 0.001 per cent based on total courses of therapy. Due to the increased emergence of antibiotic resistance, Nitrofurantoin has also been a suitable candidate for the treatment of infections caused by multidrug-resistant pathogens.19Munoz-Davila M J. Role of old antibiotics in the era of antibiotic resistance. Highlighted Nitrofurantoin for the treatment of lower urinary tract infections. Antibiotics 2014; 3: 39-48.  

R. C. Spencera et al. compared Nitrofurantoin modified release (MR) tablets with Trimethoprim or Co-trimoxazole in the treatment of uncomplicated urinary tract infection. It was observed that Nitrofurantoin MR showed fewer drug-related adverse events compared with Co-trimoxazole or Trimethoprim. The study also suggested that nitrofurantoin MR should be considered as one of the agents of choice for acute, uncomplicated lower UTI, particularly in view of its urinary tract specificity and the fact that Nitrofurantoin continues to show such low in-vitro resistance.20Spencer RC, Moseley DJ, Greensmith MJ. Nitrofurantoin modified release versus Trimethoprim or CoTrimoxazole in the treatment of uncomplicated urinary tract infection in general practice. J Antimicrob Chemother.1994 ;33 (Suppl A):121-9.  

The clinical advantages of Nitrofurantion may be further increased by using a sustained release formulation in favor of attenuation of adverse effects, fewer fluctuations in plasma drug concentration, and .enhanced patient compliance.21Bhatt N, Goyal S. Int. Sustained-Release Matrix Tablets of Nitrofurantoin: Formulation and Evaluation J. ChemTech Res. 2013;5(1):491-501.  

The US Food and Drug Administration has listed Nitrofurantoin as a Category B drug (probably safe). The Canadian Compendium of Pharmaceuticals and Specialties continues to state that Nitrofurantoin use is contraindicated in pregnancy only when patients are close to delivery.22Cimolai N, Cimolai T. Nitrofurantoin and pregnancy. CMAJ. 2007 Jun 19; 176(13): 1860-1861.  

Nelson textbook of paediatrics, recommends Nitrofurantoin as the first line of treatment for the effective management of UTI in children.23Kliegman RM, Behrman RE, Jenson HB, Stanton BF. Nelson Textbook of Pediatrics, 19th edition.  

Nitrofurantoin with low overall resistance and favorable side-effect profile is thus safe and effective, and should now be considered the best first-line choice of antibiotic for uncomplicated UTIs.

Ampicillin

Ampicillin is a Beta – Lactum antibiotic that has similar mode of activity as Benzylpenicillin, but its amino group-chain helps it to penetrate the membrane of some gram-negative which is responsible for its broader spectrum of activity. It has bactericidal activity. The management of UTI depends on individual against gram-positive and some gram negative organisms like E. coli, Proteus species and Staphylococcus. However it is ineffective against Klebsiella and penicillinase-producing organisms. The resistance of E. coli to ampicillin is 20-40%; accordingly, this agent is no longer considered optimal for treatment of UTIs caused by this organism.

Amoxicillin-Clavulanate

Amoxicillin – Clavulanate has been commonly used for the treatment of UTI. It is also effective against enterococci. Amoxicillin-Clavulanate is used orally and intravenously. The most common adverse effect of Amoxicillin-Clavulanate is diarrhoea of the clavulanate part. Amoxicillin – Clavulanate is not preferred for uncomplicated UTIs. E. coli with acute uncomplicated UTIs have shown high levels of resistance to Amoxicillin-Clavulanic acid.

Aminoglycoside

Aminoglycosides have broad spectrum of activity. Aminoglycosides are given by injection for very serious bacterial infections. They can be given only in combination with other antibiotics. Gentamicin is the most commonly used aminoglycoside for severe UTIs. They can have very serious side effects, including damage to hearing, sense of balance and kidneys.

Fluoroquinolones

Flouroquinolones are broad spectrum oral antibiotics with activity against Pseudomonas aeruginosa. This drug should not be taken during pregnancy. Of note, Infectious Diseases Society of America (IDSA) guidelines on the treatment of UTIs discourage use of fluoroquinolones for acute, uncomplicated UTI. Experts are concerned about overuse of fluoroquinolones leading to increased prevalence of fluoroquinolone-resistant pathogens that has major implications for the treatment of more serious infections.24Ramlakhan S, Singh V, Stone J Ramtahal A. Clinical Options for the Treatment of Urinary Tract Infections in Children. Clinical Medicine Insights: Pediatrics; 2014; 8: 31-37.   25Espinosa C, Bryant K, Bosley K. Therapeutics of Pediatric Urinary Tract Infections. Archives of Medicine 2015; 7(5):4.   In paediatric UTI management. Flouroqunilones are usually not recommended because of concerns regarding induction of arthropathy.26Jonhnson JR. Flouroquinolones in urinary tract infections. In:Ronald AR, Low DE(eds) Fluoroquinolone antibiotics . Germany. Springer 2003 : 107-119.  

Trimethoprim-Sulphamethoxazol

Trimethoprim-Sulphamethoxazole combination is used in UTI with ampicillin resistant E.coli. For many years, TrimethoprimSulfamethoxazole was the preferred antibiotic for the treatment of UTI, given its efficacy and low cost. However, development of a high prevalence of Trimethoprim-Sulphamethoxazole resistance among uropathogens has discouraged use of this drug in communities.

Cephalosporins

Depending on the clinical situation, cephalosporins can be useful for the treatment of UTI. They are effective against most Enterobacteriaceae but not against Enterococcus.24Ramlakhan S, Singh V, Stone J Ramtahal A. Clinical Options for the Treatment of Urinary Tract Infections in Children. Clinical Medicine Insights: Pediatrics; 2014; 8: 31-37.   25Espinosa C, Bryant K, Bosley K. Therapeutics of Pediatric Urinary Tract Infections. Archives of Medicine 2015; 7(5):4.   Collateral damage, a term describing ecological adverse effects of antimicrobial therapy, such as the selection of drug-resistant organisms and colonisation or infection with multi-drug resistant organisms, has been associated with use of broadspectrum cephalosporins and fluoroquinolones. Broad-spectrum cephalosporins, in particular, have been associated with collateral damage, the most concerning of which is ESBL resistance among gram-negative bacteria.

Alkalising agent: Role of Potassium Citrate

Acute symptoms of dysuria, such as burning micturition, stinging, or itching are usually diagnosed with an acute uncomplicated lower 26Jonhnson JR. Flouroquinolones in urinary tract infections. In:Ronald AR, Low DE(eds) Fluoroquinolone antibiotics . Germany. Springer 2003 : 107-119.  UTI. Amongst these manifestations, burning micturition may be the most common distressing feature. These bothersome experiences may draw attention towards the goal of subsidence of these symptoms first.28Shaikh N, Morone NE, Lopez J, et al. Does this child have a urinary tract infection?JAMA. 2007 26;298 (24):2895-904.   29Shah G, Upadhyay. Controversies in the diagnosis and management of urinary tract infections in children. J. Paediatr Drugs. 2005;7(6):339-46.   Therefore, such affected patients can be offered a choice of urinary alkalinisers prior to or concomitantly with an appropriate antibiotic therapy so as to provide symptomatic relief.30Mifsud I. Treatment of lower urinary tract infections in an era of increased antimicrobial resistance.Journal of the Malta College of Pharmacy Practice 2013;19:8-11.   31Scottish Intercollegiate Guidelines Network (SIGN). Edinburgh:SIGN; 2012. (SIGN publication no. 88). [July 2012]. Available from URL: http://www.sign.ac.uk. [Accessed on 17/1/2014]   In light of the above requirement, potassium citrate demonstrates superior efficacy in alkalising urine.32Sakhaee K, Nicar M, HillK, Pak CYC. Contrasting effects of potassium citrate and sodium citrate therapies on urinary chemistries and crystallization of stone-forming salts Kidney International 1983;24:348- 352.   This citrate preparation provides an alkali load and increases the urinary citrate, thereby maintaining a urinary pH of 6.0-6.5.33Gargan RA, Hamilton-miller JMT, Brumfitt W. Effect of pH and Osmolality on In Vitro Phagocytosis and Killing by Neutrophils in Urine. Infection and Immunity 1993;61(1):p.8-12   This process makes the urine less acidic, which may serve to improve the condition of painful and burning micturition in patients with UTIs.32Sakhaee K, Nicar M, HillK, Pak CYC. Contrasting effects of potassium citrate and sodium citrate therapies on urinary chemistries and crystallization of stone-forming salts Kidney International 1983;24:348- 352.   34McNally MA, Pyzik PL, Rubenstein JE, et al. Empiric use of potassium citrate reduces kidney-stone incidence with the ketogenic diet. Pediatrics 2009;124(2):e300-4   Besides alleviating symptoms, achievement of alkaline pH may also augment the natural defense mechanisms, including enhancement of phagocytosis, thereby destroying the infecting organisms, such as E. coli and S. saprophyticus.33Gargan RA, Hamilton-miller JMT, Brumfitt W. Effect of pH and Osmolality on In Vitro Phagocytosis and Killing by Neutrophils in Urine. Infection and Immunity 1993;61(1):p.8-12   Moreover, it may also assist in preventing later onset of UTI. Corroborating to this fact was a study performed by Lopez and colleagues, which illustrated that children experiencing ≥ 2 episodes of UTI with a normal urinary tract and hypercalciuria, showed significant improvement with absence of further episodes of UTI on treatment with potassium citrate.35Lopez MM, Castillo LA, Chávez JB, Ramones C. Hypercalciuria and recurrent urinary tract infection in Venezuelan children. Pediatr Nephrol. 1999;13(5):433-7   The absorbed citrate ions possess another beneficial property. These induce negative charge, which may increase the susceptibility of bacterial strains to certain antibiotics.While being an effective urinary alkaliniser, potassium citrate displays an acceptable tolerability profile as well.34McNally MA, Pyzik PL, Rubenstein JE, et al. Empiric use of potassium citrate reduces kidney-stone incidence with the ketogenic diet. Pediatrics 2009;124(2):e300-4   It neither neutralises the gastric juice nor alters the digestion.36Sweetman S. Martindale: The Complete Drug Reference. Edition London:pharmaceutical press; 2011   Other advantages of potassium citrate include high palatability, pleasant taste, and tolerable even on prolonged use, which make it suitable to be considered as a first line urine alkalising agent.32Sakhaee K, Nicar M, HillK, Pak CYC. Contrasting effects of potassium citrate and sodium citrate therapies on urinary chemistries and crystallization of stone-forming salts Kidney International 1983;24:348- 352.  

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Conclusion

The main objective of the treatment of UTI in children is to improve the symptoms along with short and long term benefits. It is necessary to have a rationalised utilisation of antibiotics as per local susceptibility pattern while treating UTI in children. It is necessary to consider the type of organism involved, the age of the child, the route of administration and the resistant profile of the drug before choosing the antibiotic of choice for the treatment. It is suggested that Nitrofurantoin be considered as the first line treatment in uncomplicated children older than 3 months and as prophylaxis as it exhibits the best resistance profile and favourable tolerability. Evaluation after 1st UTI is also important especially in children less than 1 year old.To provide symptomatic relief, patients can be offered a choice of urinary alkalinisers prior to or concomitantly with an appropriate antibiotic therapy, especially for burning micturation.

References

  1. Heffner V, Gorelick M. Pediatric Urinary Tract Infection Pediatric Urinary Tract Infection. Clin Ped Emerg Med 2008; 9:233-237.
  2. Zorc J, Kiddoo D, Shaw K. Diagnosis and Management of Pediatric Urinary Tract Infections. Clinical Microbiology Reviews 2005; 18 (2): 417-422.
  3. Ramlakhan S, Singh V, Stone J et al. Clinical Options for the Treatment of Urinary Tract Infections in Children. Clinical Medicine Insights: Pediatrics; 2014:8 31-37.
  4. Jadresic L. Diagnosis and management of urinary tract infections in children. Paediatrics And Child Health; 20(6): 274-278.
  5. Espinosa C, Bryant K, Bosley K. Therapeutics of Pediatric Urinary Tract Infections. Archives of Medicine 2015; 7(5):4
  6. Laila K, Roy E, Rahman H, et al. Urinary Tract Infection in Children : An Update. Bangladesh J Child Health 2012; 36(2): 90-97.
  7. Robinson J, Finlay J, Lang M, et al. Urinary tract infection in infants and children: Diagnosis and management. Paediatr Child Health 2014; 19(6):315-19.
  8. White B. Diagnosis and Treatment of Urinary Tract Infections in Children. Am Fam Physician. 2011;83(4):409-415.
  9. National Collaborating Centre for Women’s and Children’s Health. Urinary tract infection in children diagnosis, treatment and long-term management. Clinical Guidelines; 2007.
  10. Ochoa Sangrador C, Brezmes Raposo M; Grupo Investigador del Proyecto. Recommended antibiotic therapy in episodes of urinary tract infection. An Pediatr (Barc). 2007;67(5):485-97.
  11. Renuart AJ, Goldfarb DM, Mokomane M, et al. Microbiology of Urinary Tract Infections in Gaborone, Botswana Plos One 2013;8(3):e57776.
  12. Gupta K, Hooton TM, Naber KG, et al. Executive Summary: International Clinical Practice Guidelines for the Treatment of Acute Uncomplicated Cystitis and Pyelonephritis in Women: A 2010 Update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases Clin Infect Dis. 2011;52(5): 561-564.
  13. Rijal A, Ghimire G, Gautam K, et al. Antibiotic susceptibility of organisms causing urinary tract infection in patients presenting to a teaching hospital. J Nepal Health Res Counc. 2012;10(1):24-7.
  14. Gupta K, Hooton TM, Naber KG, et al. International Clinical Practice Guidelines for the Treatment of Acute Uncomplicated Cystitis and Pyelonephritis in Women: A 2010 Update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious DiseasesClinical Infectious Diseases 2011;52(5):e103- e120.
  15. Edlin RS, Shapiro DJ, Hersh AL, et al. Antibiotic resistance patterns of outpatient pediatric urinary tract infections. J Urol. 2013; 190(1):222-7.
  16. Kashanian J ,Hakimian P, Blute M Jr, et al. Nitrofurantoin: the return of an old friend in the wake of growing resistance. BJU International 2008; 102:1634-1637.
  17. Brendstrup L, Hjelt K, Petersen KE, et al. Nitrofurantoin versus trimethoprim prophylaxis in recurrent urinary tract infection in children. A randomized, double-blind study. Acta Paediatr Scand. 1990;79(12):1225-34.
  18. Brumfitt W, Hamilton-Miller JM. Efficacy and safety profile of long-term nitrofurantoin in urinary infections: 18 year’s experience. J Antimicrob Chemother. 1998; 42(3):363-71.
  19. Munoz-Davila M J. Role of old antibiotics in the era of antibiotic resistance. Highlighted Nitrofurantoin for the treatment of lower urinary tract infections. Antibiotics 2014; 3: 39-48.
  20. Spencer RC, Moseley DJ, Greensmith MJ. Nitrofurantoin modified release versus Trimethoprim or CoTrimoxazole in the treatment of uncomplicated urinary tract infection in general practice. J Antimicrob Chemother.1994 ;33 (Suppl A):121-9.
  21. Bhatt N, Goyal S. Int. Sustained-Release Matrix Tablets of Nitrofurantoin: Formulation and Evaluation J. ChemTech Res. 2013;5(1):491-501.
  22. Cimolai N, Cimolai T. Nitrofurantoin and pregnancy. CMAJ. 2007 Jun 19; 176(13): 1860-1861.
  23. Kliegman RM, Behrman RE, Jenson HB, Stanton BF. Nelson Textbook of Pediatrics, 19th edition.
  24. Ramlakhan S, Singh V, Stone J Ramtahal A. Clinical Options for the Treatment of Urinary Tract Infections in Children. Clinical Medicine Insights: Pediatrics; 2014; 8: 31-37.
  25. Espinosa C, Bryant K, Bosley K. Therapeutics of Pediatric Urinary Tract Infections. Archives of Medicine 2015; 7(5):4.
  26. Jonhnson JR. Flouroquinolones in urinary tract infections. In:Ronald AR, Low DE(eds) Fluoroquinolone antibiotics . Germany. Springer 2003 : 107-119.
  27. Zalmanovici Trestioreanu A, Green H, Paul M, et al. Cochrane Database of Systematic Reviews 2010, Issue 10. Art. No.: CD007182. DOI:10.1002/14651858.CD007182.pub2
  28. Shaikh N, Morone NE, Lopez J, et al. Does this child have a urinary tract infection?JAMA. 2007 26;298(24):2895-904.
  29. Shah G, Upadhyay. Controversies in the diagnosis and management of urinary tract infections in children. J. Paediatr Drugs. 2005;7(6):339-46.
  30. Mifsud I. Treatment of lower urinary tract infections in an era of increased antimicrobial resistance.Journal of the Malta College of Pharmacy Practice 2013;19:8-11.
  31. Scottish Intercollegiate Guidelines Network (SIGN). Edinburgh:SIGN; 2012. (SIGN publication no. 88). [July 2012]. Available from URL: http://www.sign.ac.uk. [Accessed on 17/1/2014]
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