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INTRODUCTION

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Urinary tract infections (UTIs) are relatively common in children, from infancy through adolescence. The incidence and clinical presentation of pediatric UTI vary by age and gender.

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CLINICAL FEATURES

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There are several age-specific clinical presentations for pediatric UTI. Neonates present with a clinical syndrome indistinguishable from sepsis, and may often have nonspecific symptoms such as fever, jaundice, poor feeding, vomiting, irritability, or lethargy. Older infants and young children typically present with gastrointestinal symptoms such as abdominal pain, vomiting, or decreased appetite. School-age children and adolescents present similarly to adults, and often, but not always, complain of specific urinary symptoms such as dysuria, frequency, urgency, or hesitancy. Infants and young children are more likely to have fever and upper tract disease, necessitating longer courses of antibiotic treatment. Adolescents without fever, flank pain, or vomiting may be treated similarly to adults with shorter course antibiotic regimens.

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DIAGNOSIS AND DIFFERENTIAL

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The gold standard for the diagnosis of pediatric UTI is the growth of a single urinary pathogen from a properly obtained urine culture. For infants and children in diapers, urine obtained by sterile transurethral catheterization is preferred. Ultrasound-guided suprapubic bladder aspiration is an acceptable alternative, but is more invasive and rarely performed. For toilet-trained children who can void on command (usually ascertained by asking a parent, but generally at around 3 years old), urine may be collected as a clean catch specimen. Bagged urine specimens have virtually no role in diagnosis of pediatric UTI, and are never appropriate for urine culture.

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Urine microscopy and chemical test strips (dipstick) have similar test characteristics in terms of sensitivity and specificity; however, dipstick is usually faster and more convenient, and a finding of positive nitrites is highly specific for the presence of gram-negative bacteriuria, obviating the need for urine microscopy. In cases where dipstick is indeterminate (i.e., “trace” leukocyte esterase), subsequent urine microscopy may be helpful in increasing diagnostic certainty. Microscopy is typically considered positive if more than five white blood cells per high-power field or bacteria are seen. Because young infants void frequently, and often do not store urine in the bladder long enough to accumulate leukocytes or nitrites, urinalysis is less sensitive in this age group, and culture should be sent regardless of negative urinalysis result.

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Young children may also experience urinary symptoms from urethritis secondary to irritant soaps, clothing, or poor hygiene. Physical exam should assess for vaginitis in girls, or meatitis or balanitis in boys. Adolescents may have urinary symptoms as a manifestation of a sexually transmitted disease such as Chlamydia trachomatis. An appropriate sexual history should be obtained in teenagers, and a pelvic examination may be indicated for sexually active females (for a discussion of sexually transmitted diseases, see Chapter 87).

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EMERGENCY DEPARTMENT CARE AND DISPOSITION

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The treatment and disposition of infants and children with ...

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