“The urinalysis in this infant is suggestive of a urinary tract infection, although infants may have no abnormalities noted on initial urinalysis.7,8 The risk of bacteremia in infants under 60 days with documented urinary tract infection is significant. A number of studies support the need to treat infants less than 30 days with parenteral antibiotics.9-14 Addition of C-reactive protein testing at this time does not aid in distinguishing those who are bacteremic in this age group.15 The often quoted study by Hoberman of 306 children included only 13 under the age of two months.16 Of the 13 reported positive blood cultures, 10 were in children under age six months. Daily intramuscular ceftriaxone treatment would cover a majority of the typical neonatal UTI organisms, can be administered in the outpatient setting, and is proven to be as effective as intravenous delivery. The clinical response to bacteremia is, however, unpredictable in young infants. The sepsis potential in this infant requires admission for physiologic monitoring and support as needed.
“Final, but not inconsequential, concerns are barriers to follow-up. These include parental experience and coping skills with feeding and monitoring an ill infant, ability to educate on the illness and reasons for follow-up, transportation, and operational issues, such as weekend clinic hours or holiday office closures. For the index patient these issues are overshadowed by the clinical criteria for admission but would be of great importance for discharge.”
Based on these responses, admitting a suspected UTI patient on the basis of age alone, as suggested by Santen and Altieri, is likely inappropriate. Many other factors must be weighed and would likely indicate admission for the patient in the scenario, regardless of the infant’s age. In short, until there’s better evidence for age-based admission criteria, clinical judgment based on the individual patient presentation must continue to drive care and treatment decisions.
Keri Losavio is a medical journalist with more than 10 years’ experience.
- UTI Guideline Team, Cincinnati Children’s Hospital Medical Center. “Evidence based clinical practice guideline for children 12 years of age or less with acute first time urinary tract infection.” www.cincinnatichildrens.org/svc/dept-div/health-policy/ev-based/uti.htm. Guideline 7, pages 1–20, April 2005.
- Hoberman A, Wald ER. Treatment of urinary tract infections. Pediatr Infect Dis J. 1999;18(11):1020–1021.
- Santen SA, Altieri MF. Pediatric urinary tract infection. Emerg Med Clin North Am. 200119(3):675–690.
- Egland AG, Egland TK. Pyelonephritis. eMedicine. www.emedicine.com/emerg/topic769.htm. Accessed Oct. 16, 2005.
- No authors listed. Practice parameter: the diagnosis, treatment, and evaluation of the initial urinary tract infection in febrile infants and young children. American Academy of Pediatrics. Committee on Quality Improvement. Subcommittee on Urinary Tract Infection. Pediatrics. 1999;103(4):843–852.
- Pitetti RD, Choi S. Utility of blood cultures in febrile children with UTI. Am J Emerg Med. 2002;20:271–274.
- Dayan PS, Bennett J, Best R, et al. Test characteristics of the urine Gram stain in infants 60 days of age with fever. Pediatr Emerg Care. 2002;18(1):12–14.
- Huicho L, Campos-Sanchez M, Alamo C. Meta-analysis of urine screening tests for determining the risk of urinary tract infection in children. Pediatr Infect Dis J. 2002;21 (1):1-11.
- Byington C L, Enriquez F, Hoff C, et al. Serious bacterial infections in febrile infants 1 to 90 days old with and without viral infections. Pediatrics. 2004; 113(6):1662–1666.
- Baraff L. Management of fever without source in infants and children. Ann Emerg Med. 2000;36(6):602–614.
- Baraff LJ, Oslund SA, Schriger DL, Stephen ML. Probability of bacterial infections in febrile infants less than three months of age: A meta-analysis. Pediatr Infect Dis J. 1992;11(4):257–264.
- Klein JO. Management of the febrile child without a focus of infection in the era of universal pneumococcal immunization. Pediatr Infect Dis J. 2002;21(6):584–588.
- Syrogiannopoulos G, Grieva I, Anastassiou E, et al. Sterile cerebrospinal fluid pleocytosis in young infants with urinary tract infections. Pediatr Infect Dis J. 2001;20(10):927–930.
- Jaskiewicz JA, McCarthy CA, Richardson AC, et al. Febrile infants at low risk for serious bacterial infection—an appraisal of the Rochester criteria and implications for management. Febrile Collaborative Study Group. Pediatrics. 1994;94(3):390–396.
- Malik A, Hui C, Pennie RA, Kirpalani H. Beyond the complete blood cell count and C-reactive protein: A systematic review of modern diagnostic tests for neonatal sepsis. Arch Pediatr Adolesc Med. 2003;157(6):511–516.
- Hoberman A, Wald ER, Hickey RW, et al. Oral versus intravenous therapy for urinary tract Infections in young children. Pediatrics.1999;104:79–86