ARTICLE

New Advances in Childhood Urinary Tract Infections

Candice E. Johnson, MD, PhD*
HOST FACTORS
OBJECTIVES Host factors remain the most per-
After completing this article, readers should be able to: plexing area of pathogenesis. The
short urethra of the female is an
1. List the primary factor that differentiates cystitis from pyelonephritis. obvious risk factor, as is the easily
2. Determine the appropriate empiric antibiotic before culture sensitivity
results are known and make necessary modifications in treatment colonized foreskin of the male infant
when results become available. younger than 1 year of age. There is
3. Explain the circumstances when a child who has pyelonephritis no substantiation for the hypothesis
should be admitted to the hospital. that “wiping back to front” causes
4. Describe how to evaluate preschool and school-age children following urinary infection or that tub bathing
urinary tract infections. or bubble bath are causes of UTI.
5. Delineate the natural history of reflux nephropathy and the proce-
dure for detecting renal scars radiologically.
Bubble bath and other harsh deter-
gents certainly can cause dysuria,
but not infection. It is now estab-
lished that sexual intercourse and
Introduction but only certain organisms cause the use of diaphragms for contracep-
Today’s clinicians know much more UTI, implying that virulence factors tion are risk factors for UTI. A use-
about the causes and prevention of allow colonization to become ful prophylaxis strategy is to have
urinary tract infections (UTIs) than a infection.
the woman void after sexual rela-
decade ago, thanks to studies by tions. For women who have frequent
pediatric urologists on vesicoureteral UTIs, a single dose of trimethoprim-
reflux (VUR) and investigations by BACTERIAL VIRULENCE
FACTORS sulfamethoxazole after intercourse
molecular biologists on virulence has proven to be effective
factors of coliforms. Advances in In the late 1980s, studies at Dr prophylaxis.
techniques of urinalysis have made Svanborg-Eden’s laboratory in Gote-
The critical role of urine and
more accurate diagnosis possible, borg, Sweden, demonstrated that
stool withholding in UTI among
thereby decreasing the incidence of adhesive molecules on the tip of pili
younger children is being studied.
misdiagnosis and allowing the clini- in some Escherichia coli strains
Investigations in Great Britain and
cian to evaluate only proven UTIs bind to human uroepithelial cells.
radiologically. New evidence shows the United States have shown that
These pili were named “P pili”
that the radiologic studies may be constipation is associated with large
because they also bound to P anti-
performed during a brief hospital residual urine volumes after voiding
gens on red blood cells. Further
admission or as soon as practical on and that the treatment of constipa-
studies have shown that P pili func-
an outpatient basis, eliminating the tion leads to a reduction in UTIs.
tion as “ladders” that enable bacteria
previously recommended 4- to “Voiding dysfunction” or an “unsta-
to climb the ureters of normal hosts
6-week waiting period during which ble bladder” refers to involuntary
and avoid being washed out by the
many children were lost to detrusor contractions against a vol-
normal flow of urine (Fig. 1). How-
follow-up. ever, bacteria without such pili also untarily clamped sphincter. Children
can reach the kidneys if the person who have this problem are observed
has retrograde urine flow from to “squat” or “curtsy,” and some
Pathogenesis of UTIs VUR. In fact, most infections in void as rarely as twice daily. Treat-
The goal of research on UTIs is to children who have VUR are due to ment plans that include scheduled
understand how normal flora of the nonpiliated strains of E coli. voiding both at home and school or
human intestine invade the bladder Many other recognized virulence oxybutynin (an anticholinergic)
and ascend to infect the kidneys. factors in E coli have been well- often can often cure this problem.
This may permit development of a reviewed. These factors often are The final risk factor for UTIs is
vaccine for high-risk individuals. found together and may cause addi- the inheritance of VUR. In 1982,
The coliform bacteria isolated from tive virulence. One study docu- Jerkins and Noe (see Suggested
urine can be shown to have colo- mented a 50% treatment failure rate Reading) reported that one third of
nized the perineum of women and in cystitis caused by P-piliated asymptomatic siblings of children
the prepuce of male infants for sev- strains compared with 100% success who had VUR had the same prob-
eral weeks before causing infection, among infections caused by nonP- lem. More concerning is a recent
piliated strains. Research is being report that 30% of such asymptom-
conducted in animal models and in atic siblings show renal scarring on
*Professor of Pediatrics, University of
Colorado School of Medicine, Child Health humans to develop a vaccine against isotopic renal scans. All siblings of
Clinic, The Children’s Hospital, Denver, pyelonephritis, using the knowledge patients who have VUR should
CO. of virulence factors. undergo isotopic cystography, partic-

Pediatrics in Review Vol. 20 No. 10 October 1999 335

 INFECTIOUS DISEASE
Urinary Tract Infections

Diagnosis of UTI
Although bacterial infection is the
most common cause of dysuria,
there are many other potential diag-
noses, which are beyond the scope
of this article. It has been docu-
mented that bacterial colony counts
of 100/mL or less can cause dysuria
in adult women, which makes initial
cultures unnecessary in those who
have typical cystitis because the
woman usually is well before cul-
ture results are known. In contrast, a
positive culture in children deter-
mines whether a radiologic evalua-
tion is necessary. Fortunately, it has
been established that 80% of infants
and children who have catheter-
proven UTIs have bacterial colony
counts of 105/mL or greater (see
Pylkkanen et al in Suggested
Reading).
FIGURE 1. Pili on Escherichia coli are seen on electron microscopy as straight The method of collecting the
white extracellular markings on a dark-stained background. urine specimen in children is very
important in distinguishing contami-
nants from low-colony count infec-
ularly if they are younger than Taken together, these two studies tions. Although urinary collection
5 years of age. The mode of inheri- suggest that early identification of bags may be convenient for urinaly-
tance is unclear, but it seems advis- VUR and long-term prophylaxis can sis and determination of specific
able to screen such families by pre- prevent development of new scars. gravity, they are not suitable for
natal ultrasonography. In a similar long-term study from culture. Instead, a catheterized speci-
Stockholm, Sweden, 30 patients men or suprapubic puncture is
were followed for a mean of needed. A clean-void specimen is
Long-term Outcome of 27 years after childhood pyelone- adequate in toilet-trained children
Childhood UTI phritis. A total of 53 patients who unless the child is to be hospitalized
had nonobstructive scarring were for intravenous therapy. In that case,
To understand the need for uncom- identified from 1,000 intravenous a catheterized specimen will prevent
fortable radiologic studies among later diagnostic confusion. Two col-
pyelograms performed in children
children at risk of renal scarring, it
between 1951 and 1967. Thirty of
is necessary to examine the natural
these patients agreed to be evaluated
history of pyelonephritis. Until this TABLE 1. Definition
decade, such information was for glomerular filtration rate (GFR)
and blood pressure. Three of the 30 of Terms
unavailable. The most convincing
data on prevention of renal scarring had end-stage renal disease, seven ● UTI: Cystitis, urethritis,
by early diagnosis and treatment had undergone renal surgery, seven pyelitis, and pyelonephritis
comes from Dr Jean Smellie, who had treated hypertension, and all had
significantly depressed GFR. Marti-
● Urethritis: Dysuria, frequency,
has published 30-year studies from or enuresis with pyuria, but
Great Ormond Street Hospital in nell et al showed good preservation
of renal function when girls who colony count of ,104/mL of
London. Intravenous pyelography urine
documented no new renal scars in had renal scars received close super-
adults 18 to 39 years of age whom vision to prevent UTIs over a ● Cystitis: Dysuria 6 frequency
she had treated as children with 15-year period. with colony count of .104/mL
antibiotic prophylaxis for UTI and Women who have VUR or renal of urine. Hematuria may be
VUR. She also reviewed the charts scars should receive prophylaxis present, but no casts, flank
of 52 children who were identified during pregnancy, a time when UTIs pain, fever, or systemic
as having severe bilateral VUR and may recur. Pre-eclampsia and hyper- toxicity are seen
renal scarring. Virtually all of these tension occur at a higher rate among ● Pyelonephritis: Febrile UTI,
children had had either untreated those who have elevated creatinine. often with flank and
febrile pyelonephritis for more than It is suggested that adolescents who abdominal pain and cystitis.
5 days or an inadequate radiologic have VUR and elevated creatinine The colony count may be
evaluation (no cystogram or no eval- levels undergo surgical correction of ,105/mL of urine
uation at all until a recurrence). VUR before pregnancy.

336 Pediatrics in Review Vol. 20 No. 10 October 1999

 INFECTIOUS DISEASE
Urinary Tract Infections

FIGURE 2. Algorithm for diagnosing and treating UTIs in children younger than 13 years.

lection options are available for chil- plasia or neurogenic bladders that missing 15% of UTIs. The positive
dren who have cystitis: obtain two are colonized chronically may predictive value of a positive dip-
clean-void urines before treatment require an isotopic renal scan for stick test for nitrites or leukocyte
(usually impractical) or obtain one accurate diagnosis of UTI (see sec- esterase is much lower at 34%,
specimen and delay treatment until tion on Radiology). although the nitrite test has an
results are known. In practice, many After a child has been found to excellent specificity for UTI that
clinicians treat any child who has be afebrile and without flank pain or approaches 100%.
positive findings on urinalysis after toxicity, the urinalysis is the best Infants younger than 3 years of
obtaining only one specimen. tool to determine if outpatient ther- age who have fever of unknown
Table 1 defines the terms cur- apy should be started or withheld origin are an important group to
rently used in classifying UTIs. The pending culture results. Microscopic screen by urinalysis and urine cul-
algorithm in Figure 2 initially cate- examination of unspun urine in a ture. Results of a recent survey con-
gorizes children as having clinical hemacytometer is a simple, rapid, ducted by the American Academy of
symptoms of pyelonephritis or and practical diagnostic method. Its Pediatrics (AAP) documented that
symptoms suggesting less serious use was described in children in urine cultures were obtained in only
infections. Despite many excellent 1982, and it was combined with a 50% of febrile infants in this age
studies, no diagnostic test except the Gram stain in 1993 and called an group, with 12% of such cultures
radionuclide renal scan has been “enhanced urinalysis.” The positive being positive. A study of infants
shown to distinguish cystitis conclu- predictive value of a white blood younger than 1 year of age who had
sively from pyelonephritis. The pres- cell count of at least 10 x 109/L temperatures of 38.3°C or greater
ence of fever in a child who has (.10 x 103/mcL) and any bacteria (Ä100.9°F) demonstrated an inci-
bacteruria and pyuria is as effective on Gram stain of urine is 93% for a dence of UTI of 8.8% in females
in identifying pyelonephritis as an UTI, which would allow immediate and 2.5% in males. It is prudent to
elevated erythrocyte sedimentation initiation of treatment. However, the obtain cultures for all children
rate or serum C-reactive protein sensitivity of “enhanced urinalysis” younger than 3 years of age who
concentration or leukocytosis. How- is only 84.5%, indicating that urine have fever of unknown origin, even
ever, patients who have myelodys- cultures should be obtained to avoid if the urinalysis is negative.

Pediatrics in Review Vol. 20 No. 10 October 1999 337

 INFECTIOUS DISEASE
Urinary Tract Infections

In conclusion, urine cultures is whether it is safe to send home develop symptomatic UTIs, there is
should be obtained in all children febrile patients who have UTI. Only no value to identifying or treating
who have dysuria, frequency, hema- one study has examined this ques- them while they are asymptomatic.
turia, or recent onset of enuresis or tion systematically, although some In fact, treatment causes emergence
who are younger than 3 years of age managed care companies are behav- of resistant strains of bacteria. It is
and have unexplained fever. Urinal- ing as if it were a settled issue. It is best not to look for asymptomatic
ysis by dipstick and the “enhanced incorrect to state that febrile chil- bacteriuria in the first place because
urinalysis” both are helpful in decid- dren who have only mild systemic it takes a strong will not to treat a
ing whether to begin antibiotics symptoms have a “UTI” and not “positive” culture!
immediately. Most importantly, a “pyelonephritis.” All febrile children
catheterized or suprapubic aspiration who have UTIs have the potential
urine specimen should be obtained for renal scarring if mismanaged Prophylaxis of UTIs
from all children before initiating and, therefore, deserve close VUR is an indication for long-term
intravenous antibiotics. follow-up by parental report and by antibiotic prophylaxis. Children
urine culture if they are sent home awaiting a radiologic evaluation
on oral therapy. Furthermore, our should be assumed to have VUR
Treatment of UTIs experience has been that a single and receive prophylaxis temporarily.
Table 2 summarizes how results of a intramuscular (or intravenous) dose Children who have recurrent UTIs
Gram stain of the urine can aid in of ceftriaxone followed by oral ther- either can receive 6 months of pro-
selecting a single antibiotic for ini- apy for 10 days will prevent later phylaxis or be instructed in the use
tial inpatient treatment of pyelone- admissions because vomiting on the of daily nitrite test strips on a first
phritis. Except in geographic areas first day may prevent absorption of morning urine. Dipsticks cost $15
that have a high level of aminogly- oral antibiotics. The algorithm (Fig. per month compared with $2 to $4
coside resistance, two drugs should 2) recommends that children who per month for low-dose prophylaxis.
not be needed. Inexpensive generic are younger than 1 year, vomiting, A third indication for prophylaxis is
drugs such as amoxicillin, or likely to be noncompliant (many a single episode of pyelonephritis in
trimethoprim-sulfamethoxazole, or adolescents) be admitted for intrave- infants younger than 1 year of age.
nitrofurantoin are the preferred ther- nous antibiotic therapy until afebrile A neurogenic bladder that is being
apy for cystitis, although resistance for 24 hours. All children treated on managed with clean intermittent
of E coli to amoxicillin in some an outpatient basis should return at catheterization is not an indication
areas makes the other two drugs 24 hours for reassessment and to for prophylaxis because such ther-
preferable. A 10-day course is rec- obtain a second urine specimen. apy usually is not successful.
ommended for presumed cystitis Pyuria and hematuria may persist The drugs of choice for prophy-
unless the child is known to have no for several days, but motile rods laxis are shown in Table 3 and are
radiologic abnormalities. If the child should be absent, and the culture limited to those that do not select
has a normal radiologic evaluation should be sterile. At this time, a resistant fecal flora. There is longer
and is plagued by recurrent cystitis, prescription should be provided for experience with trimethoprim-
3-day therapy with trimethoprim- a prophylactic antibiotic to start sulfamethoxazole and nitrofurantoin,
sulfamethoxazole (8 mg/kg per day after 10 days, with enough drug to but a Danish study found trimetho-
divided in two doses) is an inexpen- last until VUR can be ruled out. prim alone to be equally effective in
sive option. Beta-lactams such as Renal ultrasonography and cystogra- children who had no urologic abnor-
amoxicillin and cephalosporins are phy should be performed as soon as malities. Theoretically this approach
not recommended for short-course practical (see section on Radiologic should cause fewer side effects
therapy or for the outpatient man- Studies). without the sulfa component, but
agement of febrile patients because Several prospective studies have this agent is not available as a
of high failure rates. shown that although children who suspension.
The central treatment controversy have asymptomatic bacteriuria often “Double prophylaxis” has been

TABLE 2. Initial Antibiotic Treatment of Pyelonephritis

BACTERIA ON GRAM STAIN ANTIBIOTIC CHOICES
Cocci (enterococci or Staphylococcus Ampicillin 100 to 200 mg/kg per day divided q 6 h
saprophyticus)
Gram-negative rods (coliforms) Gentamicin 6 mg/kg per day divided q 8 h
OR
Trimethoprim-sulfamethoxazole 8 mg trimethoprim/kg per day
divided q 12 h
OR
Ceftriaxone 100 mg/kg per day divided q 12 h

338 Pediatrics in Review Vol. 20 No. 10 October 1999

 INFECTIOUS DISEASE
Urinary Tract Infections

TABLE 3. Prophylactic Antibiotics for Childhood Urinary Infections

MONTHLY
COST OF
DOSE TIMING SIDE EFFECTS ADULT DOSE
Trimethoprim- 2 mg/kg of trimethoprim Bedtime Skin rash, rare Stevens- $2.00
sulfamethoxazole component (up to 40 mg, Johnson syndrome
(.3 months of age) which is 1/2 tablet)
Nitrofurantoin 1 to 2 mg/kg per day up to Bedtime Nausea, stomach ache, bad $4.00
(Macrodantint 50 mg taste, pulmonary fibrosis
preferred) reported in adults
(.1 month of age) receiving it .6 mo
Trimethoprim 2 mg/kg up to 50 mg Bedtime Nausea $9.00
(.3 months of age) (1/2 tablet) (Only tablet
form is available)

recommended in one study for girls were diagnosed prenatally and cor- 5 years of age and younger receive
who experience breakthrough infec- rected in the immediate postnatal ultrasonography and cystography as
tion while receiving a single agent. period. The significant finding is soon as possible after the first UTI.
This should be the last resort, how- that up to the sixth birthday, uro- Because afebrile children younger
ever, because it would be difficult to logic problems were common in than age 5 years have an increased
ascribe an allergic reaction to either children of both genders. risk of renal scarring compared with
trimethoprim-sulfamethoxazole or Figure 4 demonstrates that 33% older afebrile children, we also rec-
nitrofurantoin. of febrile children 5 years of age ommend imaging of these children,
and younger had treatable abnormal- but with less insistence. The mothers
ities compared with 9.6% of afebrile of these children frequently have
Radiologic Studies children of the same age. Among had cystitis that did not require
Recommended After UTIs children age 6 years and older, with radiographic evaluation, and they
Tremendous strides have been made or without fever, 6% to 12.5% had often are opposed to imaging studies
in improving the comfort, safety, abnormalities. Based on these find- unless the pediatrician counsels
and clinical value of radiologic eval- ings, we recommend that children wisely. All boys and all children
uations of UTIs in the past decade.
An excellent, detailed review of this
subject has been published (see
Auringer in Suggested Reading).
This article will cover only those
studies most useful in children.
Parents often ask about the likeli-
hood of finding a treatable problem
with radiologic studies. In 1975, 215
children between 3 months and 13
years of age were studied in a non-
referral setting by using renal ultra-
sonography accompanied by voiding
cystography. In the first 64 children
enrolled, intravenous pyelography
also was performed, but it did not
detect any problems that were not
seen on renal ultrasonography. Sev-
eral other studies found the same
results, and intravenous pyelography
no longer is recommended for initial
evaluation in children. Figure 3
shows the age and gender distribu-
tion of children who had UTI, which
was similar to data from studies per-
formed in Sweden. The most com- FIGURE 3. Age, gender, and number of children who had abnormalities among 215
mon treatable problem was VUR cases of UTI from 1979 to 1990 (Metro Health Medical Center, Cleveland, Ohio,
because obstructive lesions usually unpublished data).

Pediatrics in Review Vol. 20 No. 10 October 1999 339

 INFECTIOUS DISEASE
Urinary Tract Infections

TABLE 4. Radionuclide
Scans
Renal scans for UTIs
● Glucoheptonate-Tc-99m scan

visualizes both cortical scars

and the collecting system,
although the calcyes are
seen better on ultrason-
ography or intravenous
pyelography
● Dimethylsuccinic acid-Tc-

99m scan (DMSA)

visualizes only the cortex
and cortical scars
FIGURE 4. Age, gender, and presence of treatable abnormalities in 215 children Renal scans for obstruction
● MAG-3
who had UTIs.
● DTPA-Tc-99m—These two

isotopes are excreted rapidly

who have encopresis or urine with- be the first radiologic study per- and differentiate anatomic
holding should have an immediate formed because it rapidly rules out from functional obstruction.
evaluation. obstruction or perinephric abscesses Furosemide usually is
Renal ultrasonography is the least (Fig. 6). The second study should be administered during the scan
painful method for studying the kid- a voiding cystogram, initially per- Radionuclide voiding
ney and involves no radiation. It formed fluoroscopically, despite the cystography
evaluates the collecting system well higher radiation, because this
for both dilation and obstruction, but approach defines small structures
its sensitivity for parenchymal scar- and grades VUR more accurately ble strategy is to examine the child
ring is very limited. Intravenous than radionuclide studies. Subse- monthly, while continuing antibiotic
pyelography, once the gold standard quent cystograms should be radionu- prophylaxis, for 4 months, then
for assessing renal scarring, now is clide studies because of the lower schedule the imaging.
used less frequently than radionu- dose of radiation to gonads (Fig. 7). Children who have marked renal
clide scans. It remains useful Whether to perform a radionu- scarring, especially if it is bilateral,
because it can be interpreted by clide renal scan remains controver- should be referred to a pediatric
urologists without input from a radi- sial, as does its
ologist. It surpasses renal ultra- timing. Children
sonography in detecting renal scars, who have VUR
and it demonstrates dilation of the or calyceal dila-
ureter. There are two radionuclide tion should
scans to evaluate pyelonephritis undergo either
(Table 4). Dimethylsuccinic acid intravenous
(DMSA) and glucoheptonate both pyelography or
are coupled to technetium-99m and renal ultrasonog-
injected intravenously. The renal raphy to look for
tubular cells take up the isotope, and renal scarring.
within 90 to 120 minutes, defects Because perma-
can be seen wherever there is acute nent scars are
inflammation of the parenchyma or not established
pre-existing scars (Fig. 5). Image for 4 to 5
quality is improved if computed months, it seems
tomography is performed, but this is reasonable to
more expensive ($450 versus $350 perform the
for a regular DMSA scan) and often study 4 months
requires sedation of the child. Table after the infec-
5 shows the radiation doses of vari- tion. However,
ous studies. Intravenous pyelography parents may be
delivers substantial radiation to the reluctant to
gonads, and radionuclide scans return for an
deliver more to the kidneys, which expensive study
are more resistant to radiation. on a “well FIGURE 5. Left upper pole renal perfusion defect in a child
Ultrasonography generally should child.” A possi- who has pyelonephritis.

340 Pediatrics in Review Vol. 20 No. 10 October 1999

 INFECTIOUS DISEASE
Urinary Tract Infections

TABLE 5. Radiation Dosimetry During Urinary Tract Imaging in a 20-kg Child*

BLADDER FLUOROSCOPIC VCUG NUCLEAR VCUG
Kidney NG NG
Bladder 2,000 to 3,000 mR 20 mR
Ovary 1,000 to 1,500 mR 10 mR
Testes 2,000 to 3,000 mR 10 mR
Tc99m Tc99m Tc99m
KIDNEY DTPA DMSA GLUCOHEPTONATE INTRAVENOUS PYELOGRAPHY
Kidney 385 mR 3,200 mR 3,200 MR 300 mR (2,000 mR with tomography)
Bladder NG 300 mR NG 300 mR
Ovary NG 150 mR NG 300 mR
Testes NG 30 mR NG 600 mR (100 mR with shielding)
*From Kuhns L. Reflux nephropathy. Pediatr Clin North Am. 1987;34:747.

urologist. Children who have grade appeared, they proceed to surgery. Conclusion
III, IV, or V reflux (“dilating An endoscopic injection of Teflon® UTIs remain a common problem in
reflux”) also deserve a referral, particles rapidly is replacing the childhood. It has been documented
unless the primary care provider is reimplantation of ureters by an that 7.8% of girls and 1.6% of boys
experienced with this condition. Pro- abdominal route. The best news have had one or more UTIs by age
phylaxis should be continued indefi- about VUR comes from a 1998
nitely in children who have VUR, 7 years in Sweden. However, we
study in Sweden of 231 children now know to concentrate radiologic
and blood pressure and creatinine followed prospectively. Only 21
measured annually in addition to evaluations on children 5 years of
required surgery, and 75% of the age and younger who have fever or
ultrasonography or radionuclide cys- remainder were free of VUR after
tography. If breakthrough infection flank pain. We also know that
10 years of prophylaxis (see Wen- although one third of these children
occurs, most urologists repeat a
nerstrom et al in Suggested have VUR, fewer than 10% ever
renal scan or intravenous pyelogra-
Reading). will need surgery. The remainder
phy, and if new scars have

FIGURE 6. An algorithm for radiologic evaluation of a child who has a UTI. * Trimethoprim-sulfamethoxazole (1 to 2 mg/kg
per day at bedtime). From Johnson CE. Dysuria. In: Kliegman RM, Nieder M, Super D, Fletcher J. Practical Strategies in
Pediatric Diagnosis & Therapy. Philadelphia, Penn: WB Saunders; 1996.

Pediatrics in Review Vol. 20 No. 10 October 1999 341

 INFECTIOUS DISEASE
Urinary Tract Infections

Jerkins GR, Noe HN. Familial vesicoureteral

reflux: a prospective study. J Urol. 1982;
128:774 –777
Johnson CE, Maslow JN, Fattlar DC, Adams
KS, Arbeit RD. The role of bacterial adhe-
sions in the outcome of childhood urinary
tract infections. AJDC. 1993;147:
1090 –1093
Johnson CE, Shurin PA, Marchant CD, et al.
Identification of children requiring radio-
logic evaluation for urinary infection. Ped
Infect Dis J. 1985;4:656 – 663
Loening-Baucke V. Urinary incontinence and
urinary tract infection and their resolution
with treatment of chronic constipation of
childhood. Pediatrics. 1997;100:228 –232
Lohr JA. Use of routine urinalysis in making
a presumptive diagnosis of urinary tract
infection in children. Pediatr Infect Dis J.
1991;10:646 – 650
Lomberg H, Hanson L, Jacobsson B, et al.
Correlation of P blood group, vesico-
ureteral reflux, and bacterial attachment in
patients with recurrent pyelonephritis.
FIGURE 7. Radionuclide (isotopic) cystogram showing VUR of moderate severity to N Engl J Med. 1983;308:1189 –1192
the left kidney, as visualized during voiding, reading left to right in the top row, then Martinell J, Lidin-Janson G, Jagenburg R,
the bottom row. Sivertsson R, Claesson I, Jodal U. Girls
prone to urinary infections followed into
adulthood. Indices of renal disease. Pedi-
in children. Acta Paediatr Scand. 1990;79: atr Nephrol. 1996;10:139 –142
can be kept free of infection by 1225–1234 Newman TB, Pantell RH, Bernzweig J, et al.
follow-up by primary practitioners Bukowski TP, Betrus GG, Aquilina JW, Per- Frequency and yield of tests for urinary
working closely with pediatric urol- lmutter AD. Urinary tract infections and tract infection in young febrile infants.
pregnancy in women who underwent anti- Amb Child Health. 1997;3:213–214
ogists. On the horizon is the hope reflux surgery in childhood. J Urol. 1998; Pylkkanen J, Vilska J, Koskimies O. Diag-
for a vaccine for UTI-prone chil- 159:1286 –1289 nostic value of symptoms and clean-
dren, probably based on the P-pilus. Corman LI, Harbison RW, Kotchmar GS, voided urine specimen in childhood uri-
In the meantime, doctors must con- Harbison RW. Simplified urinary micros- nary tract infection. Acta Paediatr Scand.
vince parents of young children who copy to detect significant bacteriuria. 1979;68:341–344
Pediatrics. 1982;70:133–135 Rushton HG. Urinary tract infections in chil-
have pyelonephritis that radiologic Elder JS, Smith EM. Double antimicrobial dren. Pediatr Clin North Am. 1997;44:
evaluation is neither invasive nor prophylaxis in girls with breakthrough uri- 1133–1169
futile. nary tract infections. Urology. 1994;43: Schlager TA, Anderson S, Trudell J, Hendley
Editor’s Note: Kenneth B. Rob- 708 –712 JO. Nitrofurantoin prophylaxis for bacteri-
Fernandes E, Vernier R, Gonzalez R. The
erts, MD, summarizes the practice uria and urinary tract infection in children
unstable bladder in children. J Pediatr. with neurogenic bladder on intermittent
parameter on urinary tract infection 1991;118:831– 836 catheterization. J Pediatr. 1998;132:
on page 344 of this issue of Pediat- Hansson S, Jodal U, Noren L, Bjure J.
704 –708
rics in Review. This practice param- Untreated bacteriuria in asymptomatic girls
Smellie JM. Technetium-99m-dimercapto-
eter (Pediatrics. 1999;103:843– with renal scarring. Pediatrics. 1989;84:
succinic acid studies and urinary tract
964 –968
852) addresses children ages Hoberman A, Chao H-P, Keller DM, Hickey
infection in childhood. Acta Paediatr.
2 months to 2 years, and this article R, Davis HW, Ellis D. Prevalence of uri- 1998;87:132–133
emphasizes new advances. Taken nary tract infection in febrile infants. Smellie JM, Poulton A, Prescod NP. Retro-
J Pediatr. 1993;123:17–23 spective study of children with renal scar-
together, they bring us the latest ring associated with reflux and urinary
Hoberman A, Wald ER, Penchansky L,
thinking on UTIs.—RJH infection. BMJ. 1994;308:1193–1196
Reynolds EA, Young S. Enhanced urinaly-
sis as a screening test for urinary tract Stamm WE, Counts GW, Running KR, et al.
infection. Pediatrics. 1993;91:1196 –1199 Diagnosis of coliform infection in acutely
SUGGESTED READING Hoberman A, Wald ER, Reynolds EA, Char- dysuric women. N Engl J Med. 1982;307:
Auringer ST. Pediatric uroradiology update. ron M, Penchansky L. Oral vs. intravenous 462– 468
Urol Clin North Am. 1997;24:673– 681 therapy for acute pyelonephritis in children Todd JK. Prevention of urinary tract infec-
Belman AB. A perspective on vesicoureteral 1–24 months. Pediatr Res. 1994;37:143A tions in children. Report on Pediatric
reflux. Urol Clin North Am. 1995;22: Jacobson SH, Eklof O, Ericksson CG, Lins Infectious Diseases. 1997;7:29 –30
139 –150 L-E, Tidgren B, Winberg J. Development Wennerstrom M, Hansson S, Jodal U, Stok-
Brendstrup L, Hjelt K, Petersen KE, et al. of hypertension and uraemia after pyelone- land E. Disappearance of vesicoureteral
Nitrofurantoin versus trimethoprim pro- phritis in childhood: 27 year follow up. reflux in children. Arch Pediatr Adolesc
phylaxis in recurrent urinary tract infection BMJ. 1989;299:703–706 Med. 1998;152:879 – 883

342 Pediatrics in Review Vol. 20 No. 10 October 1999