Scenario: A 32-day-old female presents with vomiting and jaundice, and the mother reports that the child is irritable and not eating as well as usual. The pediatric hospitalist suspects a UTI and orders a dipstick/urinalysis and urine culture. The dipstick/urinalysis results are positive for nitrite and leukocyte esterase, indicating antibiotic therapy for presumed UTI.
UTI is one of the most common bacterial infections in infants and young children. To prevent progression to pyelonephritis and avoid potential renal scarring or failure, early recognition and prompt treatment are critical.
Clinical signs and symptoms of UTI in newborns include jaundice, sepsis, failure to thrive, poor feeding, vomiting, and fever. In infants and preschoolers, hospitalists should also suspect UTI in the presence of diarrhea, strong-smelling urine, abdominal or flank pain, and new onset urinary incontinence.1
Treatment recommendations, which are age-dependent, include antibiotic therapy initiated upon an abnormal dipstick/urinalysis. If a urine culture is positive, a seven- to 14-day course of antibiotic therapy is recommended, followed by prophylactic antibiotics until results of imaging studies are available.1 According to a study by Hoberman and Wald, treatment of UTI with oral antibiotics alone is generally effective, even for young children with pyelonephritis.2
Imaging recommendations for a first UTI include ultrasound, cystogram, and renal cortical scan.
Up to this point, there’s been very little disagreement about the management of UTI. However, the question of whether the one-month-old patient in our scenario should be admitted or sent home with strict instructions on the administration of antibiotics remains controversial. The pediatric UTI guideline from Cincinnati Children’s Hospital Medical Center recommends routine hospital admission if the infant is under 30 days old.1 On the other hand, Santen and Altieri, among others, recommend, “Sick children and infants less than three months should be treated as inpatients, and healthy children and older infants may be treated as outpatients.”3,4
—Jeffrey M. Simmons, MD
We asked several pediatric hospitalists across the country—including an instructor of pediatrics at Cincinnati Children’s Hospital Medical Center—to respond to this simple scenario, posing the following questions: “What recommendation would you follow? Would you admit the one-month-old infant in our scenario or send her home? Why?”
Predictably, admission criteria varied, but most agreed that this infant should be admitted. No one based their response on age.
Automatic Admission Cut-off Not Well Supported
Jeffrey M. Simmons, MD, instructor of pediatrics, Division of General and Community Pediatrics, Cincinnati Children’s Hospital Medical Center, responds: “My perspective on the UTI scenario is that the only dogma that applies is that the infant needs antibiotics. Because [the scenario] mentions vomiting, I would, therefore, most likely give parenteral antibiotics and admit.
“An issue within this scenario that I don’t believe the literature answers clearly is once a UTI is identified by the U/A, what risk remains of bacteremia or meningitis in the over 30-day-old infant? We are taught that infants don’t ‘localize’ infections well (i.e., a serious bacterial infection in one place can rapidly lead to disseminated infection). I sense a growing consensus that after 30 days or so this concern is less at issue. However, for clarity, I would prefer to obtain blood and CSF cultures on this infant prior to initiating antibiotic therapy. Without those cultures, and the screening tests that go with them (i.e., serum WBC count, CSF cell count, and glucose), I would be uncomfortable sending the infant home.
“However, if the WBC count was between 5 and 15, the CSF reassuring, the parents in agreement and reliable with good primary care follow-up the next morning, I think such an infant could be managed with one dose of IV/IM antibiotics after cultures are obtained and sent home. The following day, depending on culture results and the clinical situation, this infant might either be admitted, given another dose of parenteral antibiotics pending final blood culture, or switched to oral antibiotics.