Pediatric urologist Ming-Hsien Wang recalls a 7-year-old patient with recurring urinary tract infections (UTIs) referred by a pediatrician who became increasingly frustrated with further management. Should the pediatrician manage the patient alone? Refer her to a pediatric urologist? Treat with antibiotics first and then order imaging? Start prophylactic antibiotics? Order a workup for vesicoureteral reflux (VUR)? Enroll the patient in a behavioral voiding program? What?

“The literature on treatment and further workup on UTI is very controversial, there is no protocol,” Wang says. “Some say treat them with one dose of antibiotics, other seven doses or more. When do you go ahead with further imaging studies, such as renal bladder ultrasound or more invasive studies such as voiding cystourethrogram? Nobody knows this for certain either.”

The course of management in such cases is far from crystal clear, even for pediatric urologists, Wang says. Therapeutic approaches vary because clinical guidelines and research findings vary, too. But one thing is certain, Wang adds – UTIs are becoming increasingly common in infants and young children, accounting for 1 million visits to pediatricians annually. The incidence of UTIs in children under age 6 is 3 to 7 percent for girls and 1 to 2 percent for boys. Even after treatment, 26 percent of infants with symptomatic UTIs suffer recurrent infection, and the rate can be as high as 40 to 60 percent in girls.

So, how best to manage these patients and when should you refer to a pediatric urologist? Wang recommends that pediatricians put patients with recurring UTI on preventive antibiotics. Infants under three months of age with high-grade fever should be seen immediately to rule out a serious infection and treated promptly, stresses Wang, noting that UTIs in infancy and early childhood carry the potential for long-term problems like renal scarring, hypertension and renal insufficiency. Following treatment, tests should be ordered to detect abnormalities such as VUR, the backflow of urine from the bladder to the ureter and the kidneys.

Wang adds that pediatricians should refer the UTI patient to a pediatric urologist when –

• The child with a bladder infection has a fever greater than 102 – a sign that the kidneys are affected.
• The child has three or more recurring infections, or
• Ultrasound shows something anatomically incorrect.

“I would recommend a non-invasive ultrasound of the kidney and bladder to make sure there’s nothing else going on, such as kidney stones, which we’re seeing an increasing incidence of in children,” Wang says. “Start patients with recurrent infections with low-dose prophylaxis antibiotics, and work with families, emphasizing the importance of perineal hygiene, bladder emptying and hydration. Seek further consultation with a pediatric urologist especially when you see abnormal ultrasound, recurring infections or babies with high fever.”

Ongoing research such as the multi-center Randomized Intervention for Children with Vesicoureteral Reflux (RIVUR) trial – designed to clarify outcomes and whether antibiotic prophylaxis therapy has any benefit – will provide some of the answers for pediatricians, notes Wang, co-principal investigator of the trial. Also, at the Johns Hopkins pediatric urology clinic, Wang is gathering data on UTI patients to determine how many on further workup have VUR or other anatomical findings that increase a child’s risk of infection.

For now, Wang says, best practices require parental education and a team approach involving the pediatrician, pediatric urologist, and most importantly, the parents. For more information, call 410-955-6100.

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Literature Check
The September 2011 issue of Pediatrics features a commentary on the AAP UTI guidelines, as well as clinical practice guidelines for UTI in febrile children 2 to 24 months. Also, the July 21, 2011 issue of the New England Journal of Medicine covers the latest on febrile urinary tract infections in children.