May 02, 2012, Optimal management of urinary tract infections in

older people
Urinary Tract Infection FREE
Janet M. Torpy, MD; Laura A. Schwartz, MS; Robert M. Diagnosis
Golub, MD
Clinical findings
JAMA. 2012;307(17):1877. doi:10.1001/jama.2012.3885.

DIAGNOSIS AND TESTING The diagnosis of infection in an older patient is often

In addition to a medical history and a physical complicated by the lack of typical symptoms and a clear
examination, your doctor may order a urinalysis, which
history. Up to one-third of elderly patients do not present
examines a urine sample for the presence of white blood
cells and bacteria. Urine may be sent for culture to see pyrexia in response to infection.12 The presence of
what kind of bacteria is present. If bacteria grow in the
specimen, those bacteria are then tested to see which kind cognitive impairment and communication difficulties can
of antibiotics will be most effective. A blood count and
blood chemistries may be ordered, especially if fever is make it difficult to obtain an accurate history. Many
present or there are signs of a serious infection, such as older patients have chronic genitourinary symptoms and
when UTI affects the kidneys (pyelonephritis).
it is important to recognize that this is not synonymous
PREVENTION AND TREATMENT
with infection.8
 A 3-day course of antibiotics is sufficient to treat
most UTIs.
Many clinicians incorrectly attribute factors such as
 For individuals who have recurrent UTIs (3 or functional decline, increased confusion, and nonspecific
more per year), drinking lots of fluid is important
to maintain good urine flow. signs and symptoms to urinary tract infections and start

 Urinating after sexual intercourse may reduce the treatment on this basis.2,13,14 In the absence of clear
risk of UTIs, especially when the UTIs often occur
urinary tract localizing symptoms and signs, older
after sexual activity.
patients should be systematically assessed with a full
 The use of spermicide foams for birth control can
increase the risk of UTIs, so women who have clinical evaluation performed to arrive at a differential
recurrent UTIs may want to use a different form of
contraception. diagnosis.2

 In postmenopausal women, the use of low-dose
vaginal estrogen replacement may reduce the risk
of UTIs. However, not all women can safely take
estrogen, so this should be discussed with the
physician.
Juthani-Mehta et al conducted a prospective cohort study
of nursing home residents in Connecticut to ascertain
which clinical features are associated with bacteriuria

and pyuria in uncatheterized nursing home

 Urinary catheters may be a source of UTI. They
should be left in place only as long as they are residents.15 Dysuria, change in character of urine and
needed for medical purposes.
change in mental status were significantly associated
 If the bladder does not empty properly, the retained
urine can be an environment that encourages with bacteriuria plus pyuria in patients with suspected
bacteria to grow. The bladder emptying problem
UTI. Absence of these clinical features identified
may need to be corrected, possibly requiring a
catheter to drain the bladder or treatment of residents at low risk of having bacteriuria plus pyuria
underlying medical conditions, including prostate
problems in men or uterine prolapse (protrusion (25.5%), whereas the presence of dysuria plus one or
through an opening like the vagina) in women.
both of the other clinical features identified residents at
 If a structural problem within the urinary tract is
found, surgical correction may be necessary. This high risk of having bacteriuria plus pyuria (63.2%).
includes operations on the ureters, the pelvic floor,
the urethra, or the bladder itself. Participants had a high prevalence of dementia (63.3%)

Published online 2011 June 22. and given the high prevalence of bacteriuria in patients
with cognitive impairment, altered mental status may not

be a useful criterion for commencing antibiotics. This

study reinforced that nonspecific signs, such as change in
function, malaise, falls, and change in voiding pattern
were not significantly associated with bacteriura plus
pyuria.
Recognizing the diagnostic challenges in this population,
Loeb et al attempted to develop criteria for initiating
antibiotics in patients with bacteriuria in a long-term care
setting.16 This consensus paper suggested that antibiotics
should be initiated for residents without a urinary
catheter with acute dysuria alone or fever (defined as
temperature above 37.9°C or rise of 1.5°C above
baseline) and one of the following symptoms: new or
worsening urgency, frequency, suprapubic pain, frank
hematuria, costovertebral angle tenderness, or urinary
incontinence.
Some older patients may have UTI without localizing
urinary symptoms and these patients cannot always be
identified. The approach suggested by Nicolle is simply
to closely monitor such patients and regularly reassess
clinical features.14
Urine dipstick testing
Few studies have looked specifically at the role of
dipstick urinalysis in the older population. Most studies
on urine dipstick testing discuss the sensitivity and
specificity of the tests.17 While these characteristics are
relevant to the performance of tests in a population, they
are rarely helpful for making decisions about individual
patients.18 In contrast, the positive predictive value
(PPV) and negative predictive value (NPV) of a test are
helpful in estimating the probability of disease in patients
with positive and negative tests. Bent et al used
likelihood ratios to express the post-test probability of a
female patient having an uncomplicated UTI.19 In a
systematic review based on studies in young women,
nitrite and leucocyte esterase positive urinalysis had a
positive likelihood ratio of 4.2. A negative urinalysis
result had a likelihood ratio of UTI of 0.3. However this
review was not specific to older people so the
conclusions may not be transferable.
Sundvall and Gunnarsson evaluated the NPV of
combined nitrite and leucocyte esterase dipstick analysis
in predicting the presence of pathogenic bacteria in
elderly nursing home patients.20 They addressed
shortcomings in previous studies by including both visual
and analyzer reading of dipsticks as well as providing
data about the separate performance of tests for nitrites
and leukocytes in the identification of specific bacteria in
addition to any bacteria. However, an important
weakness of the study is its failure to provide separate
data for symptomatic versus asymptomatic patients, and
the case definition for significant bacteriuria implies that
symptomatic patients were included.
According to their statistical analysis, ruling in or ruling
out bacteriuria was considered possible where the point
estimate of PPV/NPV was ≥85% with a lower confidence
interval (CI) of ≥80%. The authors concluded that the
most reliable way to rule out bacteriuria was to identify
patients in whom both tests were negative. However, the
authors concede that no combination of dipstick test
results can be used to rule in bacteriuria. The
combination of negative leukocyte and nitrite test had a
NPV of 88% (CI: 84%–92%), however the results show
interpretation is further influenced by the definition of a
negative test because the PPV is only 51% if a positive
test is defined as >0 (Figure 1). Our interpretation of
these results is that dipstick testing is likely to add little if
anything to clinical diagnosis. With a positive test, the
probability of bacteriuria was between 51% and 73%,
and with a negative test it was between 9% and 21%.
These results are similar to the positive and negative
predictive value of clinical symptoms and signs without
stick testing.
 symptomatic women with the two latter species, the cut-

off level was >104”

Sundvall and Gunnarsson20

Figure 1
Obtaining urine cultures can be difficult in some older
Negative predictive value (NPV) and positive predictive people. Guidelines suggest that an in-and-out catheter
value (PPV) for dipstick urine testing for diagnosis of may be the most reliable way of obtaining a urine sample
bacteriuria in a nursing home population. Test in the female population if a voided sample cannot be
characteristics of a positive leukocyte esterase and/or a obtained.21 Urine culture by needle aspiration of the
positive nitrite dipstick were compared ... bladder is the gold standard method for diagnosing

bacteriuria, but is rarely used in older people.10 Urine

In the study by Juthani-Mehta et al, dysuria – change in
cultures should not be sent in individuals who are
character of urine – and change in mental status were
asymptomatic.10,21 Urine should also not be sent for
significantly associated with the combined outcome of
culture on the basis of positive urine dipsticks if no
bacteriuria plus pyuria.15 Absence of these clinical
symptoms are evident.22
features identified residents at low risk of having

bacteriuria plus pyuria (25.5%), whereas the presence of Asymptomatic bacteriuria

dysuria plus one or both of the other clinical features
Asymptomatic bacteriuria is defined as the presence of
identified residents at high risk of having bacteriuria plus
bacteria in urine on microscopy or quantitative culture in
pyuria (63.2%). Supporters of dipstick testing need to
a specimen obtained from a patient who does not have
provide evidence that these tests meaningfully improve
typical symptoms of a urinary tract infection.10 This
clinical prediction of bacteriuria in symptomatic patients.
requires confirmation by two consecutive samples.
Urine culture Studies have suggested a prevalence rate of 25%–50% of

women and 15%–40% of men without catheters amongst

Significant bacteriuria is commonly defined as greater
nursing home residents.22 Risk factors associated with
than 105 colony forming units/mL of a single bacterial
asymptomatic bacteriuria include institutionalization,
species in a freshly voided sample of urine.10 However,
presence of a urinary catheter, female sex, increasing
case definitions in studies of UTI are often much more
age, and diabetes.10
complex, for example:

It is widely recognized that asymptomatic bacteriuria

“A culture with growth of potentially pathogenic bacteria
should not be treated with antibiotics in the elderly
was normally considered positive if the number of colony
population.10,22 Treating asymptomatic bacteriuria does
forming units per liter (CFU/mL) was >105. In case of
not reduce mortality and can cause
specific signs of possible UTI such as positive nitrite
harm.23,24 Guidelines suggest that for every three
dipstick, leukocyte esterase dipstick >1, fever, frequency,
people treated with antibiotics, one will come to harm
urgency or dysuria, the cut-off point was >103 for
(CI: 2–10).10 Evidence also suggests that treating
patients harbouring Escherichia coli and male patients
asymptomatic bacteriuria in nursing home patients who
withKlebsiella species and Enterococcus faecalis. For
have chronic stable incontinence does not improve

incontinence in the short-term.25

Catheter-associated UTI
that it is a sample of catheter urine. The severity of

Catheter-associated UTIs account for a high proportion infection and underlying comorbidities should be taken

of health care associated infection and are common into consideration prior to prescribing antibiotics.

among the older population in long-term care. In

The Infectious Diseases Society of America (IDSA)
ambulatory patients, single catheter insertion is
published international clinical practice guidelines in
associated with urinary tract infection in 1%–2% of
2009 on the diagnosis and management of catheter-
patients. Indwelling urinary catheters lead to almost
associated UTI.26 These apply to adults over 18 years of
universal bacteriuria within 3–4 days of catheterization.
age and are not specific to older people. Similar clinical
Catheterization allows for the formation of a biofilm
criteria to Loeb’s were identified for diagnosis of catheter
between the catheter and urethral mucosa. A biofilm is
associated UTI. New or worsening fever, rigors, altered
the aggregation of microorganisms that form a structure
mental state, general malaise, or lethargy without other
on solid surfaces.26,27 The greatest risk factor for
identified causes were identified as possible signs and
catheter-associated UTI is duration of catheterization.8
symptoms.

The diagnosis of catheter associated UTI in the older

Guidelines suggest that catheters should be replaced prior
population is difficult and clinical signs and symptoms
to commencing antibiotic therapy in symptomatic
are often absent. Guidelines suggest symptoms or signs
catheterized patients if it has been in situ for longer than
alone should not be relied upon for predicting the
1 week.10,22,26 IDSA guidelines recommend that
likelihood of catheter associated UTI.10 Catheter
catheters that have been in use for more than 2 weeks
samples of urine should only be sent if the patient shows
should be changed to try and lead to quicker resolution of
signs of sepsis, recognizing that most catheterized
symptoms and prevent UTI recurrence.26 The optimal
patients will have bacteriuria.10,22Urinary catheters
method of decreasing catheter associated UTI is to
should ideally be removed and a culture then acquired
reduce indwelling catheter use and remove catheters the
from a freshly inserted catheter prior to commencing
moment they are no longer clinically necessary.
antimicrobials.26
Go to:
Loeb et al recommended minimum criteria for initiating
Management of UTI
antibiotics in older patients in long-term care with

catheters.16 These criteria included presence of fever Antimicrobial prescribing

>37.9°C or 1.5°C above baseline temperature, new
In an era of antibiotic stewardship, the prescribing of
costovertebral tenderness, rigors without obvious cause,
antibiotics is the subject of much scrutiny.28 The trend
or new onset of delirium. SIGN (Scottish Intercollegiate
until recently of increasing cases of Clostridium difficile
Guidelines Network) guidelines advocate that in patients
diarrhea has led to a shift from broad to narrow spectrum
with indwelling urinary catheters who are pyrexial, the
antibiotics.4 The prevalence of trimethoprim resistance
clinician should exclude other sources of infection and
in the Tayside population in Scotland has been reported
look for any localizing signs such as supra-pubic
as 27%–28%.29 Given the increased problems with
tenderness or loin pain.10 A sample of urine should be
resistance and health care associated infection, the use of
cultured to isolate the infective organism and to obtain
narrow spectrum agents where possible is now strongly
antibiotic sensitivities stating clearly on the request form
encouraged.30 The use of narrow spectrum agents
highlights the necessity for accurate diagnosis and the growing concern over fluoroquinolone use and

importance of obtaining cultures in the elderly prior to resistance, a group reviewed the recommendations for

commencing antibiotics.31 Local guidelines are now empiric treatment of UTI.34 They agreed that

widely utilized for prescribing antimicrobials based on trimethoprim-sulfamethoxazole should continue to be

local resistance patterns and available agents. used as first-line treatment in uncomplicated UTI if the

patient has not received any antibiotics in the past 3

The most common organism isolated depends on
months, had no hospitalizations, and there is <20%
populations studied. E. coli is the most frequent organism
resistance to trimethoprim-sulfamethoxazole locally.
isolated in the older population.1,11,32 Gram-negative
They recommended considering nitrofurantoin or
agents such as Klebsiella pneumoniaeand Proteus
fosfomycin if these criteria were not fulfilled.
mirabilis are also common.
Fluoroquinolones were recommended only if severe
The management of uncomplicated symptomatic UTI in symptoms were present and the patient had received
the female population has been the subject of several previous antibiotic therapy in the last 3 months and lived
randomized controlled trials. Most studies exclude the in an area with >20% resistance to trimethoprim-
very elderly and focus on the younger adult population. sulfamethoxazole. These guidelines were not specific to
UK guidelines advocate that trimethoprim should be used the older population.
as the first-line antibiotic in uncomplicated symptomatic
A 3-day course of trimethoprim is recommended for
UTI in females.10,23,30 Nitrofurantoin is an alternative,
women and a 7-day course for men.22 A Cochrane
although it should not be used in those with renal
review examined evidence for duration of antibiotic
impairment due to the inability to achieve necessary
therapy for uncomplicated, symptomatic lower UTIs in
concentrations in the urine and possibility of toxic levels
older women.35 Fifteen randomized controlled studies
in the plasma.10 European guidelines are now moving
(1644 elderly females) were reviewed and the authors
towards fosfomycin trometamol or nitrofurantoin as first-
concluded that short course antibiotics of 3–6 days could
and second-line agents with trimethoprim or
be adequate for treating uncomplicated UTI in older
cotrimoxazole advised only in areas where resistance
women. A need for more studies looking at optimum
rates for E. coli are less than 20%.8
duration of narrow spectrum agents was highlighted.
The Infectious Disease Society of America published
Most published guidelines for management of upper
guidelines on the management of UTIs in females, which
UTIs still recommend using quinolones as first-line
are currently under review.33 Trimethoprim-
agents.10 The need to review such guidelines has been
sulfamethoxazole was advocated as the first-line agent
highlighted.4 The IDSA guidelines recognized that there
for acute symptomatic lower urinary tract infection in
were few good, recent clinical studies of treatment in
females for 3 days. Trimethoprim and ofloxacin were
pyelonephritis and upper UTIs.33 They advised that
proposed as suitable alternatives. Fluoroquinolones were
severe pyelonephritis should be treated with intravenous
not recommended as first-line therapy unless there was a
fluoroquinolones or an aminoglycoside with or without
high level (>10%–20%) of trimethoprim or
ampicillin or an extended spectrum cephalosporin with or
trimethoprim-sulfamethoxazole resistance. They also
without an aminoglycoside. These guidelines again were
identified that nitrofurantoin and fosfomycin use may be
not specific to the elderly population.
more prominent if increasing resistance emerged. With
Our local guidelines in Tayside, Scotland advocate that
lower UTIs in females should be managed with
trimethoprim for 3 days and males should receive 14
days of trimethoprim. Complicated UTIs, including
upper UTI and bacteremic UTI, are treated with
intravenous amoxicillin and gentamicin. Co-trimoxazole
is used as an alternative in penicillin allergic patients in
conjunction with gentamicin.
Problems with antimicrobial resistance can also be
tackled with more judicious use of antibiotics. Research
has sought to uncover why doctors treat asymptomatic
bacteriuria and also to identify ways of reducing
antimicrobial prescribing in the older
population.13,36 Loeb et al conducted a cluster
randomized controlled trial to assess whether the use of
an algorithm to aid diagnosis and management of urinary
tract infections could reduce antimicrobial prescribing in
nursing home residents in Canada.36 This used
educational material aimed at nurses and physicians
working in nursing homes and set out a diagnostic
algorithm based on previous consensus criteria for
diagnosing UTIs in catheterized and noncatheterized
long-term care patients.16 The study was underpowered
to assess significant differences in hospital admission and
death between the group randomized to intervention and
the usual care group. It did however demonstrate that
using an algorithmic approach reduced antimicrobial
prescribing for suspected UTI.36
If patients do not have systemic signs there is no need to
start antibiotics immediately. In a randomized trial of
five management strategies for uncomplicated UTI in
nonpregnant women delaying antibiotics to see if
symptoms resolved spontaneously did not increase
duration or severity of symptoms and significantly
reduced antibiotic use. Symptom score was 2.11 for
delayed antibiotics vs 2.15 for immediate antibiotics but
there was a 20% reduction in antibiotic use. This trial
was done in younger women (mean age 40) but the
results are relevant to older women, especially in care
homes where they can be observed closely.37
Prevention of UTI
Cranberry products
Cranberries have long been considered to have a role in
reducing UTIs. The exact mechanism has been disputed.
Cranberries contain tannins called proanthocyanidins,
which prevent adherence of P-fimbriated E. coli to
uroepithelial cells on the bladder wall.38
A Cochrane review examined the evidence for the use of
cranberry in the prevention of UTI in susceptible
populations.39 This identified ten randomized controlled
trials using cranberry for the prevention of UTI. Four
studies were included in the meta-analysis and
demonstrated that cranberry significantly reduced the
incidence of UTI at 1 year compared to placebo. Studies
included a variety of populations examined and cranberry
was more effective in younger adult females with
recurrent UTI than in older people.
McMurdo et al conducted a randomized, placebo-
controlled double-blind trial examining whether
cranberry juice reduced UTI in elderly hospitalized
patients in Scotland.40 The primary outcome was time to
onset of first symptomatic UTI. 376 patients were
randomized making this one of the largest available
randomized controls examining the effect of cranberry
juice. This study had a lower symptomatic infection rate
than that observed during the pilot phase and so was
underpowered to demonstrate a significant difference
between cranberry and placebo. The number of E.
coli UTI was significantly lower in the cranberry group
compared to placebo.
SIGN guidelines recommended that females with
recurrent UTI should take cranberry products to decrease
frequency of recurrence.10 Capsules were advocated as
easier to take than juice. Cranberry products are not incidence of asymptomatic bacteriuria in catheterized

recommended for patients taking warfarin as cranberry is patients, it increases the risk of antimicrobial resistance.

thought to potentiate the effects of warfarin. The United

Go to:
Kingdom Committee on Safety of Medicines issued an

alert in 2004 about this based on a series of case Conclusion

reports.41 However, subsequent work suggests that there

Urinary tract infections present a significant problem in
is no significant interaction between warfarin and high-
both hospital medicine and general practice. The burden
dose cranberry juice.42
of infection is high and there are many challenges in

Prevention of catheter associated UTI diagnosis and management. Several studies have

identified the need for better education on asymptomatic

Catheter associated UTI is the most common health care
bacteriuria and presentation of UTI in the elderly
associated infection throughout the world and is common
population. Symptomatic infections are often difficult to
in long-term care facilities. Urinary catheterization
diagnose in older populations where there are high levels
should be avoided unless there is a clear clinical
of cognitive impairment and communication difficulties,
indication. Catheters should be avoided where possible
such as amongst residents of institutional care.
for the management of incontinence. Staff should also be

trained on indications for catheterization and written A strategy of observing patients for possible symptoms

protocols should be put in place.26,27 Catheters should before initiating antibiotics have been advocated,

also be removed the moment that they are no longer although recognizing this may not always be practical in

required. a primary care setting. Reducing inappropriate

prescribing of antibiotics for asymptomatic bacteriuria is

Alternatives to indwelling urethral catheters should be
likely to reduce antimicrobial resistance.
considered. Condom catheters are associated with a

lower incidence of bacteriuria, however their use is With emerging knowledge on antibiotic resistance and

sometimes difficult in confused patients.27 A Cochrane health care-associated infection, guidelines need to be

review on short-term urinary catheterization in adults updated to reflect the need to prescribe narrow spectrum

found that suprapubic catheterization was associated with agents when available and avoid empirical use of broad

less bacteriuria than urethral spectrum antibiotics.

catheterization.43 Suprapubic catheterization does carry

Cranberry juice for urinary tract infection in children
a small risk of visceral injury on insertion through the

abdominal wall. Intermittent catheterization was also Can Fam Physician. 2012 April;

associated with a lower risk of bacteriuria when

Ran D. Goldman, MD FRCPC
compared to indwelling catheterization in this review,
Cranberry juice for prevention of UTI
however studies included were mainly in an elective

orthopedic setting.43 A Cochrane review of 10 trials with more than 1000

patients17 showed that good-quality randomized

Guidelines suggest that antibiotic prophylaxis should not
controlled trials in women found that cranberry juice
be used to prevent catheter associated UTI in catheterized
decreased the number of symptomatic UTIs over a 12-
patients.10 Although prophylaxis may decrease the
month period, especially among women with recurrent

UTIs. No such evidence was provided for the
effectiveness of cranberry juice or cranberry-lingonberry
juice in children.
In an earlier randomized controlled trial from Finland,
respiratory tract bacterial composition and fecal fatty
acid composition (as a measure for colonic bacterial
flora) did not change significantly using cranberry juice
in 342 children in day-care centres over a 3-month
period.18 Unlike in other studies, the cranberry juice was
well accepted by the children, which might suggest that
its concentration might have been too low to affect them.
It is also possible that colonic flora do not correlate well
with the incidence of UTI.
Two randomized studies on prophylaxis against bacterial
UTI in a pediatric neuropathic bladder population were
conducted. In 40 patients, drinking 15 mL/kg of
cranberry cocktail daily for 6 months did not have any
effect compared with water on preventing UTI.19 In
another study, 3-month consumption of cranberry
concentrate in 15 children had no effect on bacteriuria in
this population.20In a study from Italy, 84 girls divided
into 3 groups were randomized to receive 50 mL of
cranberry juice, Lactobacillus GG drink, or placebo;
there were 5 of 27 (18.5%), 11 of 26 (42.3%), and 18 of
27 (48.1%) episodes of symptomatic UTI, respectively
(P < .05). Withdrawal was minimal in all groups.3
In a recent double-blind randomized placebo-controlled
trial in 7 Finnish hospitals, 255 children treated for UTI
were given cranberry juice or placebo for 6 months. The
investigators found no differences in timing between first
recurrences of UTI (P = .32), but UTI incidence per
person-year at risk was 0.16 episodes lower in the
cranberry group (P = .035). The number of days on
antibiotic therapy was much lower in children receiving
cranberry (−6 days per patient-year; P < .001). This
suggests a potential for cranberry juice to reduce
recurrent UTIs in children.16
Cranberry for treatment of UTI
Randomized trials of cranberry products for the treatment
of UTI have not been performed yet. However, in one
uncontrolled study, more than 50% of patients had a
positive clinical response after drinking 450 mL of
cranberry juice daily for 3 weeks.21 Another
study22 found that 2 to 3 glasses of cranberry juice a day
reduced white cell counts to 500 per mm3 or less in
children with neuropathic bladders, although urine
cultures continued to be positive for E coli.
Conclusion
Some evidence suggests that cranberry juice might be
beneficial to prevent recurrence of UTI in children.
Further studies with robust methodology are needed.
However, palatability of cranberry juice is a challenge in
children, and the optimal dose has yet to be determined.
Highlights for Management of a Child with a Urinary
Tract Infection
Int J Pediatr. 2012; 2012: 943653.
Published online 2012 July 19.
Sabeen Habib *
. Clinical Presentation
5.1. History and Physical Examination
Signs and symptoms vary greatly by age of the patient
becoming more specific as the child grows older. Even in
the absence of specific signs, a UTI should be included in
the differential diagnosis of high-grade fever.
Asymptomatic bacteriuria is present in about 3% of
preschool age children, as mentioned in the previous
section. About a third of these patients will have some
symptoms of urinary tract eventually.
In young infants, symptoms are usually nonspecific and
may include lethargy, decreased feeding, increased sleep,
vomiting, and decreased urinary output [16, 17]. Occult
UTI in neonates can be presented with late-onset
jaundice especially if conjugated fraction is elevated too
[18].
In younger children, presence of upper respiratory
infections, otitis media, or gastroenteritis does not
eliminate the possibility of a UTI [19, 20]. In one study
of febrile infants, those testing negative for RSV also had
a positive urine culture 10.1% of the time, whereas those
that tested positive for RSV had a positive urine culture
5.4% of the time [21]. Even the presence of varicella,
herpangina, croup has been found to decrease the risk of
UTI by 2.6% [5, 21]. In this age group, recurrent
abdominal pain could be a symptom of recurrent UTI and
should be evaluated promptly.
In older children, fever is usually the presenting
symptom of UTI. A fever of greater than 38°C without a
source has a positive likelihood ratio of 3.6 and with
temperatures greater than 39°C have a positive likelihood
ratio of 4 [11]. Besides fever, children may have
vomiting, loose stools, and abdominal pain [17]. This age
group could present with more specific symptoms of
either cystitis or pyelonephritis. These may include
dysuria, frequency, new onset incontinence flank pain,
and fever. Sometimes, however, younger children may
have short periods of urgency not associated with UTI.
Adolescent girls may have urethritis from an STD.
Hence, for proper diagnosis, laboratory evaluation is
mandatory [5].
The recurrence rate for UTI is 12% after a first time UTI
[10].
5.2. Lab Investigation
5.2.1. Urine Culture
Urine in the bladder is usually sterile; thus any bacteria
growing in should be considered an infection. Pryles
reviewed the existing pediatric data in 1960 defined UTI
in children [22]. This definition is still valid today. He
stated that urine cultures with fewer than 103 colony-
forming units per mL were almost always contamination,
those with between 104 and 105 colony-forming units per
mL were suspicious and should be repeated, and those
with more than 105 colony-forming units per mL were
indicative of infection [3].
Unfortunately, oftentimes the culture will grow a
bacterium that is obviously a contaminant, either from
the skin or from other parts of the genital tract. Such
culture often has multiple organisms and colony count
less than 105. Thus, most investigators define a UTI as
the presence of single organism in the urine combined
with signs or symptoms of UTI in the patient [3, 23, 24].
The traditional cutoff for urine obtained by noninvasive
collection methods (bag or clean catch) has been 105
CFU/mL [5]. For suprapubic aspiration, 102 CFU/mL is
regarded as the cut off [5, 25]. Some people have used
50,000 CFU/mL from catheterized sample [26–28].
When there are multiple organisms, or low colony count,
there is a higher chance of contamination [29].
5.2.2. Obtaining a Urine Sample
Culture of the urine remains the gold standard for
diagnosing UTIs [3,15]. The significance of bacterial
growth from a urine sample depends largely on the
method by which urine is obtained and the number of
colonies harvested. The culture results from a bagged
urine specimen have are only helpful if negative [30, 31].
Hence, a positive urine culture from a bagged specimen
cannot diagnose UTI. Suprapubic specimen remains the
gold standard [27]. This method is difficult to exercise
beyond infancy. Transurethral catheterization is preferred
in older children. Catheterization of the urethra is
occasionally difficult in patients with phimosis or labial
adhesions. Also, the contamination chances although
small are still higher than suprapubic aspiration.
Significant bacterial (>105) colony count is highly
suggestive of UTI.
As children get older and become toilet trained, mid-
stream clean catch sample of urine is commonly used
[32, 33]. The contamination rates are within limits if
obtained the urethral area is cleansed with soap and
water. With improper cleaning, the incidence of
contamination increases by three folds [32]. Again, the
value of this method is in ruling out rather than
diagnosing UTI.
5.2.3. Urine Dipstick
Urine dipstick is helpful for rapid screening till the
culture result comes back. The dipstick gives information
about nitrites and leukocyte esterase (LE). Nitrites are
generated from the breakdown of dietary nitrate by
bacteria [34] and leukocyte esterase is the breakdown
product of white cells.
LE alone has a positive predictive value of about 35.8%
meaning that it has a false-positive rate of about 64.7%
[35]. Nitrites on the other hand, when present, are highly
suggestive of UTI. Their absence does not rule out an
infection as not all organisms produce nitrites (e.g.,
Gram-positive and Acinatobacter spp.). Nitrites may not
be of significance in infants and small children as the
conversion requires 3-4 hours and these children urinate
much more frequently [36, 37].
5.2.4. Urine Microscopy
Definition of pyuria is not clear in the literature. Multiple
studies and a few meta-analyses [36–38] found the cutoff
of 5 WBC per HPF being used, the sensitivity being 74%
and specificity being 86%.
5.2.5. Blood Tests
When the child appears sick, a CBC, CRP, blood culture,
and procalcitonin should be obtained to evaluate for
sepsis. The first two do not have reliability in
differentiating upper from lower urinary tract infection
[39]. Blood culture is usually done for sick-looking
children and younger infants. About a tenth of young
infants have bacteremia with UTI [40]. Bacteremia
usually clears within 24 hours with appropriate
antibiotics, regardless, or route [5, 13]. Procalcitonin, a
proinflammatory marker, is newer and promising but
further studies are needed [5, 7, 41].
In infants younger than 8 weeks, lumbar puncture is still
recommended as there is lack of evidence to omit this
step. There is usually CSF pleocytosis, although
meningitis and UTIs are rare together [42].
5.2.6. Imaging
All males and females with well-documented UTIs
should be imaged for the presence of urological
anomalies associated with UTI. The extent of evaluation
varies depending on the age of presentation with the first
UTI and severity of the episode. The younger the child,
the higher the likelihood of anatomical abnormality,
hence all children younger than 2 years. of age with well-
documented UTI should be evaluated with a renal
ultrasound. Beyond 8 yrs of age, boys with UTIs still
warrant a renal ultrasound. Girls with a first time simple
UTI can likely be observed [27].
5.2.7. Renal Ultrasound
Renal ultrasound is helpful in delineating anatomic
abnormalities [43]. It can also be helpful in detecting
renal abscesses and stones [44]. For infants younger than
6 months with first-time UTI that responds to treatment,
ultrasound should be carried out within 6 weeks of the
UTI. A normal ultrasound does rule out hydronephrosis
which when present can suggest either vesicoureteral
reflux or obstruction of the urinary tract.
5.2.8. DMSA (Dimercaptosuccinic Acid) Renal Scan
A DMSA is a nuclear scan that is often used either to
diagnose pyelonephritis or permanent renal scars [9, 45].
During an acute UTI DMSA shows photopenic areas in
the kidney. These lesions are either permanent (scars) or
represent focal area of infection that eventually resolve.
DMSA scan may be needed in 6 months to confirm
scarring [46].
5.2.9. Voiding Cystourethrogram (VCUG)
All vesicoureteric reflux is diagnosed by VCUG. VCUG
does not need to be performed for every febrile UTI. It
should, however, be performed if renal ultrasound shows
hydronephrosis or any other sign of VUR [27].
It requires catheterization. The radiation exposure can be
reduced by performing a radionucleotide
cytourethrogram but this study does not help detect
anatomical abnormalities and only grades the reflux into
mild–moderate and severe [44]. We use contrast VCUG
as the first study for male. Nuclear VCUG is used in all
females with UTI and for followup of positive contrast
VCUG in females.
6. Management
6.1. Acute Treatment
The goal of the acute treatment is to decrease morbidity,
and to prevent long-term renal damage. Depending on
patient's clinical symptoms and tolerance, therapy can be
oral or parenteral as they have both been found equally
efficacious. If intravenous antibiotics are used, they can
usually be changed to oral in 24 to 48 hours. Parenteral
administration of an antimicrobial agent also should be
considered when adherence to oral regimen is uncertain
The usual antibiotic choices are cephalosporins,
amoxicillin plus clavulanic acid, or trimethoprim
sulfamethoxazole. It is also important to be aware local
pathogens and antibiotic susceptibility [27]. The total
duration of therapy should be 7–14 days [47]. Recurrence
rate is high with antibiotic regimen administered for
shorter than 7 days [48].
Asymptomatic bacteriuria in infants and children should
not be treated with antibiotics [47]. Studies have shown
that it disappears over time [12].
6.2. Long-Term Management
6.2.1. Bowel and Voiding Habits
Dysfunctional voiding syndromes and constipation
should be considered in young children and adolescents
with UTI. Symptoms include recurrent UTI, constipation,
encopresis, and day-time enuresis. Dysfunctional voiding
if unrecognized and not managed properly could lead to
reflux nephropathy. This later syndrome is associated
with renal scars, hypertension, and chronic kidney
disease. Children should be encouraged to void
frequently and hydrate well. Children should have ready
access to clean toilets when required and should not be
expected to delay voiding [47]. We often start
prophylactic antibiotics for at least 6 months or until
proper voiding habits are regained. There have been no
trials to support this practice.
6.2.2. Antibiotic Prophylaxis
In the recent years, the rule of vesicoureteric reflux in
UTIs and the role of prophylactic antibiotics in
preventing UTIs have been controversial. There have
been a few trials in younger children that found no
benefit of antibiotic prophylaxis [49, 50]. Antibiotic
prophylaxis may be considered in infants and children
with recurrent UTI [27]. If needed, the common
antimicrobials used are trimethoprim sulfamethoxazole,
trimethoprim, nitrofurantoin, and first generation
cephalosporins in a one nightly dose. In children less
than two months of age, amoxicillin is generally used as
prophylaxis [44].
6.2.3. Surgical Treatment of VUR
VUR often undergoes spontaneous resolution. The time
from first UTI to resolution of VUR is 6-7 yrs.
Comparison of medical and surgical treatment of VUR is
 6.4. Parent Education
hard as different studies use various outcomes. Hodson et

al. [51] reported decreased febrile UTIs as the only Healthcare professionals should ensure that when a child
benefit of surgical management. There was no difference or young person has been identified as having a
in renal scars or UTIs in general [51]. Surgical treatment suspected UTI, they and their parents are given
for vesicoureteric reflux is reserved for patients with high information about the need for treatment, the importance
grade and unilateral reflux, recurrent UTIs despite of completing any course of treatment and advice about
antibiotic prophylaxis, and noncompliance with prevention and possible long-term management [47].
antibiotics persistence beyond 9 yrs of age [44].
Parents should be made aware of the possibility of a UTI
Endoscopic management involves subureteral or
recurring and understand the need to be vigilant and to
intraureteral injection of bulking agent with
seek prompt treatment from a healthcare professional for
dextranomer/hyaluronic acid is suggested as first line
any suspected reinfection.
treatment [52].

Parents should be educated about healthy voiding and

6.3. Long Term Followup
stooling habits as means of preventing UTIs.
Infants and children with uncomplicated UTIs who do
Go to:
not undergo imaging investigations do not require follow

up by a subspecialist. Infants and children who have 7. Summary: The Disease from a GP Perspective

recurrent UTI or abnormal imaging results should be

Urinary tract infections are common in children. If
assessed by a pediatric specialist. Assessment of infants
recurrent or severe, they do have the potential to cause
and children with renal parenchymal defects should
renal scarring. All younger infants with fever of
include height, weight, blood pressure, and routine
unexplained origin should have their urine tested and
testing for proteinuria. Infants and children with a minor,
older children with symptoms should also be evaluated
unilateral renal parenchymal defect do not need long-
for UTIs. The gold standard for testing for UTI is
term followup unless they have recurrent UTI or family
suprapubic aspiration but a urinalysis and a urine culture
history or lifestyle risk factors for hypertension [47].
(catheterized/clean catch depending on age) is

Infants and children who have bilateral renal acceptable. Once diagnosed, prompt and appropriate

abnormalities, impaired kidney function, raised blood antibiotic treatment can prevent long-term complications

pressure, and/or proteinuria should receive monitoring and scarring. All younger infants with UTI and older

and appropriate management by a pediatric nephrologist children with complicated UTI should get a renal

to slow the progression of chronic kidney disease. ultrasound. This should be followed by VCUG only if

there is evidence of reflux on ultrasound. A DMSA scan

Infants and children who are asymptomatic following an
can help evaluate renal scarring. Prophylactic antibiotics
episode of UTI should not routinely have their urine re-
are reserved for recurrent UTIs and do not seem to
tested for infection. Asymptomatic bacteriuria is not an
benefit patients with low-grade VUR. Preventative
indication for followup [47].
measures include treating constipation and voiding

dysfunction.