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Urinary tract infections in children: Long-term management and prevention

Urinary tract infections in children: Long-term management and prevention
Authors:
Nader Shaikh, MD
Alejandro Hoberman, MD
Section Editors:
Tej K Mattoo, MD, DCH, FRCP
Sheldon L Kaplan, MD
Deputy Editor:
Mary M Torchia, MD
Literature review current through: Dec 2022. | This topic last updated: Jan 31, 2022.

INTRODUCTION — Urinary tract infection (UTI) is a frequently occurring clinical problem in childhood. Upper UTIs (ie, acute pyelonephritis) may lead to renal scarring, hypertension, and end-stage renal dysfunction. Although children with pyelonephritis tend to present with fever, it is often difficult on clinical grounds to distinguish cystitis from pyelonephritis, particularly in young children (aged <2 years) [1]. Thus, we have defined UTI broadly here without attempting to distinguish cystitis from pyelonephritis. Acute cystitis in older children is discussed separately. (See "Acute infectious cystitis: Clinical features and diagnosis in children older than two years and adolescents".)

The long-term management and prevention of UTI in children will be reviewed here. The epidemiology, risk factors, clinical features, diagnosis, acute management, and prognosis of UTI in children and UTI in newborns are discussed separately. (See "Urinary tract infections in children: Epidemiology and risk factors" and "Urinary tract infections in infants and children older than one month: Clinical features and diagnosis" and "Urinary tract infections in infants older than one month and young children: Acute management, imaging, and prognosis" and "Urinary tract infections in neonates".)

LONG-TERM MANAGEMENT

Children without vesicoureteral reflux

Monitor for recurrent symptoms — Approximately 8 to 30 percent of children with UTI experience one or more symptomatic reinfections [2-6]. Breakthrough UTI are most common in females [7].

Progression of renal scarring is associated with recurrent episodes of pyelonephritis [8-11]. Accordingly, prompt diagnosis and treatment of these infections is critically important in reducing renal scarring [2,12-15].

Caregivers of young children with UTI should receive instruction about the risk of recurrent UTI and be advised to seek medical attention promptly for fever and/or urinary symptoms. The evaluation of these episodes should include urinalysis, urine culture, or both [1,16,17]; a delay in the treatment of febrile UTIs is associated with increased risk for renal scarring [18]. (See "Urinary tract infections in infants and children older than one month: Clinical features and diagnosis", section on 'Laboratory evaluation and diagnosis'.)

Children without vesicoureteral reflux (VUR) or who have not been evaluated for VUR who have recurrent UTI may warrant additional evaluation for VUR, renal scarring, and/or bladder and bowel dysfunction (BBD). These evaluations are discussed separately. (See "Evaluation and diagnosis of bladder dysfunction in children" and "Urinary tract infections in infants older than one month and young children: Acute management, imaging, and prognosis", section on 'Imaging'.)

Children without VUR who have had frequent, recurrent UTI (ie, three febrile UTIs in six months or four total UTIs in one year) also may warrant antimicrobial prophylaxis. (See 'Antimicrobial prophylaxis' below.)

Identify and treat bowel and bladder dysfunction — An important task in the management of children with UTI, especially those with recurrent UTI, is to identify underlying BBD, which is an important risk factor for recurrent UTI [6,19,20]. Female sex and dilating VUR (ie, grade III to V) are risk factors for BBD [21]. In a multicenter cohort of children 2 to 71 months of age with a history of UTI who did not receive prophylactic antibiotics, BBD at baseline was associated with increased risk of two-year recurrence (adjusted hazard ratio 2.07, 95% CI 1.09-3.93) [6]. In combined analysis of data from two studies of children at risk for recurrent UTI, toilet-trained children with BBD and VUR were at greater risk for recurrent UTI than children with either BBD or VUR alone [19]. (See "Urinary tract infections in children: Epidemiology and risk factors", section on 'Bladder and bowel dysfunction' and "Etiology and clinical features of bladder dysfunction in children".)

Treatment of BBD reduces the likelihood of UTI recurrences and, in some studies, is associated with faster resolution of VUR [22-24]. Treatment of BBD should be initiated by the primary care provider. The first steps in the treatment of bladder and bowel dysfunction include timed voiding (scheduled voids every two to three hours), "double" voiding (asking children to sit and urinate again right after they voided), avoidance of C's (carbonated drinks, caffeine, citrus, chocolate, and food colorants), and/or the use of laxatives for children with constipation [20,25]. In chronically constipated children, treatment with laxatives has been shown to significantly reduce recurrences of UTI [26]. (See "Management of bladder dysfunction in children", section on 'Conservative management' and "Chronic functional constipation and fecal incontinence in infants, children, and adolescents: Treatment".)

Referral to an urologist, gastroenterologist, or multidisciplinary team for further management (pelvic floor muscle training with biofeedback, anticholinergics) is recommended if the patient's symptoms do not respond to the initial management [20].

Children with vesicoureteral reflux — The long-term management and follow-up of children with vesicoureteral reflux are discussed separately. (See "Management of vesicoureteral reflux".)

PREVENTION OF RECURRENT UTI IN CHILDREN WITHOUT VESICOURETERAL REFLUX — To prevent renal scarring, risk factors for subsequent infection must be addressed. The discussion below focuses on prevention of recurrent UTI in children who do not have vesicoureteral reflux (VUR), urinary obstruction, or bladder and bowel dysfunction (BBD). The management of VUR and BBD are discussed elsewhere. (See "Management of vesicoureteral reflux" and "Management of bladder dysfunction in children".)

Antimicrobial prophylaxis — We suggest antimicrobial prophylaxis in children without VUR who have frequent recurrent UTIs (three febrile UTIs in six months or four total UTIs in one year). Antimicrobial prophylaxis may reduce the risk of recurrent UTI [27].

When prescribing antimicrobial prophylaxis, we generally suggest either:

Trimethoprim-sulfamethoxazole (TMP-SMX) 2 mg TMP/kg as a single daily dose for six months, or

Nitrofurantoin 1 to 2 mg/kg as a single daily dose for six months

Antimicrobial prophylaxis can be discontinued if no infection occurs during the period of prophylaxis; if infection recurs, resumption of prophylaxis may be warranted. The management of children with VUR is discussed separately. (See "Management of vesicoureteral reflux".)

Antimicrobial prophylaxis appears to be effective in reducing recurrent UTIs but not renal scarring. With regard to reinfections, a 2019 systematic review of randomized trials evaluating prophylactic antibiotics for the prevention of recurrent UTIs in children included 16 studies (2036 children), but only one was judged to be at low risk of bias. In meta-analysis of the two trials (914 participants) with adequately concealed treatment allocation [27,28], prophylactic antibiotics modestly reduced the risk of recurrent symptomatic UTI compared with placebo or no treatment (11 versus 16 percent, risk ratio [RR] 0.68, 95% CI 0.48-0.95) [29]. The greatest risk of repeat symptomatic infection occurred within three to six months of the initial UTI. With regard to renal scarring, a meta-analysis of seven randomized trials including 1427 children ≤18 years (with and without VUR) did not detect a benefit of prophylactic antibiotics in preventing renal scarring (5 versus 7 percent, RR 0.83, 95% CI 0.55-1.26) [30].

Antimicrobial prophylaxis for the prevention of recurrent UTI is well-tolerated [29,31,32]. In the systematic review described above, few adverse effects from antibiotic treatment occurred [29]. However, an increased risk for bacterial resistance to the antibiotic used for prophylaxis was apparent in subsequent infections. Similarly, in a multicenter randomized trial comparing prophylactic antibiotics and placebo in 607 children with VUR, no differences in the rates of adverse effects (eg, including fever, diarrhea, rash, otitis media, skin and soft tissue infection, pharyngitis, otitis media, other sinopulmonary infections) were detected [31,32]. Among children with a first recurrence caused by Escherichia coli, the proportion of isolates resistant to trimethoprim-sulfamethoxazole was greater in the prophylaxis group than in the placebo group (63 versus 19 percent) [31].

Unproven interventions

Surveillance cultures — Routine surveillance cultures should not be performed in asymptomatic children after their first UTI [33]. In a study comparing oral and intravenous antibiotics for UTI in children, routine surveillance of asymptomatic children did not enhance identification of true UTI episodes [2]. Further, treatment of patients who have bacteriuria without symptoms is unproven and may be harmful [34]. (See "Urinary tract infections in infants and children older than one month: Clinical features and diagnosis", section on 'Differential diagnosis'.)

Cranberry juice — We do not routinely suggest cranberry juice for the prevention of recurrent UTI in children. In a meta-analysis of 13 studies including children and adults (n = 2462), cranberry products did not reduce the occurrence of symptomatic UTI compared with placebo, water, or no treatment [35]. Meta-analysis of two studies limited to children with recurrent UTI [36,37] also found no benefit. Although cranberry juice in moderation is unlikely to be harmful, excessive intake may contribute to dental caries, diarrhea, and obesity.

Probiotics — We do not suggest probiotics for the prevention of recurrent UTI. In a 2015 meta-analysis of six trials (352 participants) comparing probiotics with placebo, probiotics did not prevent recurrent UTI [38]. The most commonly reported adverse effects included diarrhea, nausea, vomiting, constipation, and vaginal symptoms, although most of the included studies did not systematically collect information about adverse effects.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Urinary tract infections in children".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or email these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient education" and the keyword[s] of interest.)

Basics topic (see "Patient education: Urinary tract infections in children (The Basics)")

Beyond the Basics topic (see "Patient education: Urinary tract infections in children (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

Caregivers of young children with urinary tract infection (UTI) should receive instruction about the risk of recurrent UTI and be advised to seek medical attention promptly for fever and/or urinary symptoms. (See 'Monitor for recurrent symptoms' above and "Urinary tract infections in children: Epidemiology and risk factors", section on 'Risk factors for renal scarring'.)

The evaluation for episodes of fever and/or urinary symptoms should include a properly collected urine specimen (using bladder catheterization in children who are not toilet trained) which is then sent for urinalysis, urine culture, or both. (See "Urinary tract infections in infants and children older than one month: Clinical features and diagnosis", section on 'Laboratory evaluation and diagnosis'.)

The treatment of bladder and bowel dysfunction may include timed voiding, "double voiding," the use of laxatives, and/or referral to a subspecialist (eg, pediatric urologist or gastroenterologist). (See 'Identify and treat bowel and bladder dysfunction' above.)

Routine surveillance cultures in asymptomatic children after their first UTI are unnecessary. (See 'Surveillance cultures' above.)

For children without vesicoureteral reflux (VUR) who have frequent recurrent UTIs (three febrile UTIs in six months or four total UTIs in one year), we suggest antimicrobial prophylaxis (Grade 2B). Antimicrobial prophylaxis also may be warranted for children with more severe initial UTI episodes or those with additional UTI risk factors (eg, bladder and bowel dysfunction). Trimethoprim-sulfamethoxazole or nitrofurantoin may be used for prophylaxis. (See 'Antimicrobial prophylaxis' above.)

Prophylactic antibiotics are usually continued for six months. They can be discontinued if no infection occurs during the period of prophylaxis. Resumption of prophylaxis may be warranted if infection recurs. (See 'Antimicrobial prophylaxis' above.)

We do not routinely offer cranberry juice or probiotics for the prevention of recurrent UTI in children. (See 'Cranberry juice' above and 'Probiotics' above.)

The long-term management and follow-up of children with vesicoureteral reflux are discussed separately. (See "Management of vesicoureteral reflux".)

  1. Hoberman A, Charron M, Hickey RW, et al. Imaging studies after a first febrile urinary tract infection in young children. N Engl J Med 2003; 348:195.
  2. Hoberman A, Wald ER, Hickey RW, et al. Oral versus initial intravenous therapy for urinary tract infections in young febrile children. Pediatrics 1999; 104:79.
  3. Conway PH, Cnaan A, Zaoutis T, et al. Recurrent urinary tract infections in children: risk factors and association with prophylactic antimicrobials. JAMA 2007; 298:179.
  4. Peters CA, Skoog SJ, Arant BS Jr, et al. Summary of the AUA Guideline on Management of Primary Vesicoureteral Reflux in Children. J Urol 2010; 184:1134.
  5. Shaikh N, Ewing AL, Bhatnagar S, Hoberman A. Risk of renal scarring in children with a first urinary tract infection: a systematic review. Pediatrics 2010; 126:1084.
  6. Keren R, Shaikh N, Pohl H, et al. Risk Factors for Recurrent Urinary Tract Infection and Renal Scarring. Pediatrics 2015; 136:e13.
  7. Goldraich NP, Goldraich IH. Followup of conservatively treated children with high and low grade vesicoureteral reflux: a prospective study. J Urol 1992; 148:1688.
  8. Panaretto K, Craig J, Knight J, et al. Risk factors for recurrent urinary tract infection in preschool children. J Paediatr Child Health 1999; 35:454.
  9. Martinell J, Hansson S, Claesson I, et al. Detection of urographic scars in girls with pyelonephritis followed for 13-38 years. Pediatr Nephrol 2000; 14:1006.
  10. Wennerström M, Hansson S, Jodal U, Stokland E. Primary and acquired renal scarring in boys and girls with urinary tract infection. J Pediatr 2000; 136:30.
  11. Merrick MV, Notghi A, Chalmers N, et al. Long-term follow up to determine the prognostic value of imaging after urinary tract infections. Part 2: Scarring. Arch Dis Child 1995; 72:393.
  12. Hiraoka M, Hashimoto G, Tsuchida S, et al. Early treatment of urinary infection prevents renal damage on cortical scintigraphy. Pediatr Nephrol 2003; 18:115.
  13. Smellie JM, Poulton A, Prescod NP. Retrospective study of children with renal scarring associated with reflux and urinary infection. BMJ 1994; 308:1193.
  14. Coulthard MG, Lambert HJ, Vernon SJ, et al. Does prompt treatment of urinary tract infection in preschool children prevent renal scarring: mixed retrospective and prospective audits. Arch Dis Child 2014; 99:342.
  15. Oh MM, Kim JW, Park MG, et al. The impact of therapeutic delay time on acute scintigraphic lesion and ultimate scar formation in children with first febrile UTI. Eur J Pediatr 2012; 171:565.
  16. Subcommittee on Urinary Tract Infection, Steering Committee on Quality Improvement and Management, Roberts KB. Urinary tract infection: clinical practice guideline for the diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months. Pediatrics 2011; 128:595.
  17. SUBCOMMITTEE ON URINARY TRACT INFECTION. Reaffirmation of AAP Clinical Practice Guideline: The Diagnosis and Management of the Initial Urinary Tract Infection in Febrile Infants and Young Children 2-24 Months of Age. Pediatrics 2016; 138.
  18. Shaikh N, Mattoo TK, Keren R, et al. Early Antibiotic Treatment for Pediatric Febrile Urinary Tract Infection and Renal Scarring. JAMA Pediatr 2016; 170:848.
  19. Shaikh N, Hoberman A, Keren R, et al. Recurrent Urinary Tract Infections in Children With Bladder and Bowel Dysfunction. Pediatrics 2016; 137.
  20. Yang S, Chua ME, Bauer S, et al. Diagnosis and management of bladder bowel dysfunction in children with urinary tract infections: a position statement from the International Children's Continence Society. Pediatr Nephrol 2018; 33:2207.
  21. Gaither TW, Cooper CS, Kornberg Z, et al. Risk Factors for the Development of Bladder and Bowel Dysfunction. Pediatrics 2018; 141.
  22. Koff SA, Lapides J, Piazza DH. Association of urinary tract infection and reflux with uninhibited bladder contractions and voluntary sphincteric obstruction. J Urol 1979; 122:373.
  23. Koff SA, Murtagh DS. The uninhibited bladder in children: effect of treatment on recurrence of urinary infection and on vesicoureteral reflux resolution. J Urol 1983; 130:1138.
  24. Seruca H. Vesicoureteral reflux and voiding dysfunction: a prospective study. J Urol 1989; 142:494.
  25. Feldman AS, Bauer SB. Diagnosis and management of dysfunctional voiding. Curr Opin Pediatr 2006; 18:139.
  26. Loening-Baucke V. Urinary incontinence and urinary tract infection and their resolution with treatment of chronic constipation of childhood. Pediatrics 1997; 100:228.
  27. Craig JC, Simpson JM, Williams GJ, et al. Antibiotic prophylaxis and recurrent urinary tract infection in children. N Engl J Med 2009; 361:1748.
  28. Montini G, Rigon L, Zucchetta P, et al. Prophylaxis after first febrile urinary tract infection in children? A multicenter, randomized, controlled, noninferiority trial. Pediatrics 2008; 122:1064.
  29. Williams G, Craig JC. Long-term antibiotics for preventing recurrent urinary tract infection in children. Cochrane Database Syst Rev 2019; 4:CD001534.
  30. Hewitt IK, Pennesi M, Morello W, et al. Antibiotic Prophylaxis for Urinary Tract Infection-Related Renal Scarring: A Systematic Review. Pediatrics 2017; 139.
  31. RIVUR Trial Investigators, Hoberman A, Greenfield SP, et al. Antimicrobial prophylaxis for children with vesicoureteral reflux. N Engl J Med 2014; 370:2367.
  32. Desai S, Fisher B. Impact of Trimethoprim-sulfamethoxazole Urinary Tract Infection Prophylaxis on Non-UTI Infections. Pediatr Infect Dis J 2019; 38:396.
  33. American Academy of Pediatrics. Ten things physicians and patients should question. www.choosingwisely.org/doctor-patient-lists/american-academy-of-pediatrics/ (Accessed on March 18, 2014).
  34. Hansson S, Jodal U, Norén L, Bjure J. Untreated bacteriuria in asymptomatic girls with renal scarring. Pediatrics 1989; 84:964.
  35. Jepson RG, Williams G, Craig JC. Cranberries for preventing urinary tract infections. Cochrane Database Syst Rev 2012; 10:CD001321.
  36. Salo J, Uhari M, Helminen M, et al. Cranberry juice for the prevention of recurrences of urinary tract infections in children: a randomized placebo-controlled trial. Clin Infect Dis 2012; 54:340.
  37. Ferrara P, Romaniello L, Vitelli O, et al. Cranberry juice for the prevention of recurrent urinary tract infections: a randomized controlled trial in children. Scand J Urol Nephrol 2009; 43:369.
  38. Schwenger EM, Tejani AM, Loewen PS. Probiotics for preventing urinary tract infections in adults and children. Cochrane Database Syst Rev 2015; :CD008772.
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