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Pediatrics: General Medicine

Pediatric Urinary Tract Infection Differential Diagnoses

Updated: Oct 18, 2018
  • Author: Donna J Fisher, MD; Chief Editor: Russell W Steele, MD  more…
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Sections
Pediatric Urinary Tract Infection
  • Sections
    Pediatric Urinary Tract Infection
  • Overview
    • Practice Essentials
    • Background
    • Pathophysiology
    • Etiology
    • Epidemiology
    • Prognosis
    • Show All
  • Presentation
    • History
    • Physical Examination
    • Show All
  • DDx
  • Workup
    • Approach Considerations
    • Urine Collection and Analysis
    • Ultrasonography
    • Voiding Cystourethrography or Nuclear Cystography
    • Show All
  • Treatment
    • Approach Considerations
    • Hospital Admission Criteria
    • Infants Younger Than 8 Weeks With a Febrile UTI
    • Inpatient Treatment of Children With Complicated Pyelonephritis
    • Children With Cystitis
    • Prevention of Urinary Tract Infections
    • Consultations
    • Show All
  • Medication
    • Medication Summary
    • Antibiotics, Other
    • Analgesics, Other
    • Analgesics, Urinary
    • Show All
  • Questions & Answers
  • Tables
  • References

DDx

Diagnostic Considerations

Conditions that can produce the symptoms of urinary tract infection (UTI), along with those listed in the Differentials section, include the following:

  • Epididymitis

  • Orchitis

  • Prostatitis

  • Urethritis

  • Pregnancy

  • Urolithiasis

  • Bladder and bowel dysfunction

Children with uninhibited detrusor contractions may experience symptoms of voiding dysfunction (eg, urgency, frequency, hesitancy, dribbling, or incontinence) in the absence of infection or local irritation. In attempts to prevent incontinence during a detrusor contraction by voluntarily increasing outlet resistance, however, these children may promote the development of a UTI. One theory is that bacteria-laden urine in the distal urethra may be milked back into the urinary bladder (urethrovesical reflux).

Increased outlet resistance may be achieved by using various posturing maneuvers, such as the following:

  • Tightening of the pelvic-floor muscles

  • Applying direct pressure to the urethra with the hands

  • Performing the Vincent curtsy, which consists of squatting on the floor and pressing the heel of one foot against the urethra

Voiding dysfunction is not usually encountered in a child without neurogenic or anatomic abnormality of the bladder until the child is in the process of achieving daytime urinary control.

Adolescent girls are more likely to have vaginitis (35%) than UTI (17%).Adolescent girls who are diagnosed with cystitis frequently have a concurrent vaginitis. Pregnancy must be considered in adolescent girls who present with symptoms of UTI and/or vaginitis and who are sexually active.

Differential Diagnoses

  • Emergent Management of Pediatric Patients with Fever

  • Fever in the Neonate and Young Child

  • Nephrolithiasis

  • Pediatric Appendicitis

  • Pediatric Gastroenteritis in Emergency Medicine

  • Pinworms

  • Urinary Obstruction

  • Vaginitis

  • Vulvovaginitis

Workup

 
References

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  3. [Guideline] Subcommittee on Urinary Tract Infection; Steering Committee on Quality Improvement and Management. 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 Aug 28. [Medline] .

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  26. Michael M, Hodson EM, Craig JC, Martin S, Moyer VA. Short versus standard duration oral antibiotic therapy for acute urinary tract infection in children. Cochrane Database Syst Rev. 2003. CD003966. [Medline] .

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  28. Smolkin V, Koren A, Raz R, Colodner R, Sakran W, Halevy R. Procalcitonin as a marker of acute pyelonephritis in infants and children. Pediatr Nephrol. 2002 Jun. 17(6):409-12. [Medline] .

  29. Nikfar R, Khotaee G, Ataee N, Shams S. Usefulness of procalcitonin rapid test for the diagnosis of acute pyelonephritis in children in the emergency department. Pediatr Int. 2009 Jul 6. [Medline] .

  30. Bressan S, Andreola B, Zucchetta P, Montini G, Burei M, Perilongo G, et al. Procalcitonin as a predictor of renal scarring in infants and young children. Pediatr Nephrol. 2009 Jun. 24(6):1199-204. [Medline] .

  31. Wan J, Skoog SJ, Hulbert WC, Casale AJ, Greenfield SP, Cheng EY, et al. Section on Urology response to new Guidelines for the diagnosis and management of UTI. Pediatrics. 2012 Apr. 129(4):e1051-3. [Medline] .

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  34. Lin DS, Huang SH, Lin CC, Tung YC, Huang TT, Chiu NC, et al. Urinary tract infection in febrile infants younger than eight weeks of Age. Pediatrics. 2000 Feb. 105(2):E20. [Medline] .

  35. Kazi BA, Buffone GJ, Revell PA, Chandramohan L, Dowlin MD, Cruz AT. Performance characteristics of urinalyses for the diagnosis of pediatric urinary tract infection. Am J Emerg Med. 2013 Sep. 31(9):1405-7. [Medline] .

  36. Reuters Health. Point-Of-Care Urinalysis Lacks Accuracy in Pediatric UTIs. Medscape [serial online]. Available at http://www.medscape.com/viewarticle/809965 . Accessed: September 30, 2013.

  37. Tseng MH, Lin WJ, Lo WT, Wang SR, Chu ML, Wang CC. Does a normal DMSA obviate the performance of voiding cystourethrography in evaluation of young children after their first urinary tract infection?. J Pediatr. 2007 Jan. 150(1):96-9. [Medline] .

  38. Merguerian PA, Sverrisson EF, Herz DB, McQuiston LT. Urinary tract infections in children: recommendations for antibiotic prophylaxis and evaluation. An evidence-based approach. Curr Urol Rep. 2010 Mar. 11(2):98-108. [Medline] .

  39. Carpenter MA, Hoberman A, Mattoo TK, Mathews R, Keren R, Chesney RW, et al. The RIVUR Trial: Profile and Baseline Clinical Associations of Children With Vesicoureteral Reflux. Pediatrics. 2013 Jul. 132(1):e34-45. [Medline] . [Full Text] .

  40. Spencer JD, Bates CM, Mahan JD, Niland ML, Staker SR, Hains DS, et al. The accuracy and health risks of a voiding cystourethrogram after a febrile urinary tract infection. J Pediatr Urol. 2012 Feb. 8(1):72-6. [Medline] .

  41. McDonald A, Scranton M, Gillespie R, Mahajan V, Edwards GA. Voiding cystourethrograms and urinary tract infections: how long to wait?. Pediatrics. 2000 Apr. 105(4):E50. [Medline] .

  42. Mahant S, To T, Friedman J. Timing of voiding cystourethrogram in the investigation of urinary tract infections in children. J Pediatr. 2001 Oct. 139(4):568-71. [Medline] .

  43. Paschke AA, Zaoutis T, Conway PH, Xie D, Keren R. Previous antimicrobial exposure is associated with drug-resistant urinary tract infections in children. Pediatrics. 2010 Apr. 125(4):664-72. [Medline] .

  44. Hodson EM, Willis NS, Craig JC. Antibiotics for acute pyelonephritis in children. Cochrane Database Syst Rev. 2007 Oct 17. CD003772. [Medline] .

  45. Hoberman A, Wald ER, Hickey RW, Baskin M, Charron M, Majd M, et al. Oral versus initial intravenous therapy for urinary tract infections in young febrile children. Pediatrics. 1999 Jul. 104(1 Pt 1):79-86. [Medline] .

  46. Schnadower D, Kuppermann N, Macias CG, et al. Febrile infants with urinary tract infections at very low risk for adverse events and bacteremia. Pediatrics. 2010 Dec. 126(6):1074-83. [Medline] .

  47. Shaikh N, Mattoo TK, Keren R, Ivanova A, Cui G, Moxey-Mims M, et al. Early Antibiotic Treatment for Pediatric Febrile Urinary Tract Infection and Renal Scarring. JAMA Pediatr. 2016 Jul 25. [Medline] .

  48. Garcia J. Febrile UTI: Early Treatment Lowers Risk for Renal Scarring. Medscape Medical News. Available at http://www.medscape.com/viewarticle/866819 . July 29, 2016; Accessed: August 1, 2016.

  49. Weisz D, Seabrook JA, Lim RK. The Presence of Urinary Nitrites Is a Significant Predictor of Pediatric Urinary Tract Infection Susceptibility to First- and Third-Generation Cephalosporins. J Emerg Med. Jul 2010. 39(1):6-12.

  50. Hoberman A, Keren R. Antimicrobial prophylaxis for urinary tract infection in children. N Engl J Med. 2009 Oct 29. 361(18):1804-6. [Medline] .

  51. Montini G, Rigon L, Zucchetta P, Fregonese F, Toffolo A, Gobber D, et al. Prophylaxis after first febrile urinary tract infection in children? A multicenter, randomized, controlled, noninferiority trial. Pediatrics. 2008 Nov. 122(5):1064-71. [Medline] .

  52. Garin EH, Olavarria F, Garcia Nieto V, Valenciano B, Campos A, Young L. Clinical significance of primary vesicoureteral reflux and urinary antibiotic prophylaxis after acute pyelonephritis: a multicenter, randomized, controlled study. Pediatrics. 2006 Mar. 117(3):626-32. [Medline] .

  53. Pennesi M, Travan L, Peratoner L, Bordugo A, Cattaneo A, Ronfani L, et al. Is antibiotic prophylaxis in children with vesicoureteral reflux effective in preventing pyelonephritis and renal scars? A randomized, controlled trial. Pediatrics. 2008 Jun. 121(6):e1489-94. [Medline] .

  54. Mattoo TK. Are prophylactic antibiotics indicated after a urinary tract infection?. Curr Opin Pediatr. 2009 Apr. 21(2):203-6. [Medline] . [Full Text] .

  55. Craig JC, Simpson JM, Williams GJ, Lowe A, Reynolds GJ, McTaggart SJ, et al. Antibiotic prophylaxis and recurrent urinary tract infection in children. N Engl J Med. 2009 Oct 29. 361(18):1748-59. [Medline] .

  56. Williams G, Craig JC. Long-term antibiotics for preventing recurrent urinary tract infection in children. Cochrane Database Syst Rev. 2011 Mar 16. 3:CD001534. [Medline] .

  57. American Academy of Pediatrics Task Force on Circumcision. Circumcision policy statement. Pediatrics. 2012 Sep. 130(3):585-6. [Medline] .

  58. Ferrara P, Romaniello L, Vitelli O, Gatto A, Serva M, Cataldi L. Cranberry juice for the prevention of recurrent urinary tract infections: a randomized controlled trial in children. Scand J Urol Nephrol. 2009. 43(5):369-72. [Medline] .

  59. Jepson RG, Williams G, Craig JC. Cranberries for preventing urinary tract infections. Cochrane Database Syst Rev. 2012 Oct 17. 10:CD001321. [Medline] .

  60. Bryce A, Hay AD, Lane IF, Thornton HV, Wootton M, Costelloe C. Global prevalence of antibiotic resistance in paediatric urinary tract infections caused by Escherichia coli and association with routine use of antibiotics in primary care: systematic review and meta-analysis. BMJ. 2016 Mar 15. 352:i939. [Medline] .

  61. The RIVUR Trial Investigators. Antimicrobial Prophylaxis for Children with Vesicoureteral Reflux. N Engl J Med. 2014 May 4. [Medline] .

  62. Hewitt IK, Pennesi M, Morello W, Ronfani L, Montini G. Antibiotic Prophylaxis for Urinary Tract Infection-Related Renal Scarring: A Systematic Review. Pediatrics. 2017 May. 139 (5):762-6. [Medline] .

  63. Tzimenatos L, Mahajan P, Dayan PS, Vitale M, Linakis JG, Blumberg S, et al. Accuracy of the Urinalysis for Urinary Tract Infections in Febrile Infants 60 Days and Younger. Pediatrics. 2018 Feb. 141 (2): [Medline] .

  64. Selekman RE, Shapiro DJ, Boscardin J, Williams G, Craig JC, Brandström P, et al. Uropathogen Resistance and Antibiotic Prophylaxis: A Meta-analysis. Pediatrics. 2018 Jul. 142 (1): [Medline] .

Media Gallery
  • Application of low-risk criteria for and approach to the febrile infant: A reasonable approach for treating febrile infants younger than 2 months who have a temperature of greater than 38°C.

of
1

Tables

  • Table 1. Urinalysis for Presumptive Diagnosis of Urinary Tract Infection*
  • Table 2. Quantitative Urine Culture for the Diagnosis of Urinary Tract Infection*
  • Table 3. Antibiotic Agents for Parenteral Treatment of a Urinary Tract Infection
  • Table 4. Antibiotic Agents for the Oral Treatment of Urinary Tract Infection
  • Table 5. Antibiotic Agents to Prevent Reinfection

Table 1. Urinalysis for Presumptive Diagnosis of Urinary Tract Infection*

Method

Findings

Bright-field or phase-contrast microscopy of centrifuged urinary sediment

Bacteria

Gram stain of uncentrifuged or centrifuged urinary sediment

Bacteria

Nitrite and leukocyte esterase test

Positive = UTI likely

Nitrite test

Positive = UTI probable

Leukocyte esterase test

Positive = UTI probable

*Negative microscopic findings for bacteria do not rule out a UTI, nor do negative results of dipstick testing for nitrite and leukocyte esterase. False-negative nitrite readings are especially common in children.

Table 2. Quantitative Urine Culture for the Diagnosis of Urinary Tract Infection*

Method

Finding

Suprapubic aspiration

If a UTI is present, bacteria are likely to be proliferating in bladder urine with growth of any organism except 2000-3000 CFU/mL coagulase-negative staphylococci.

Catheterization in a girl or midstream, clean-void collection in a circumcised boy

Febrile infants and children with UTI usually have >50,000 CFU/mL of a single urinary pathogen; however, UTI may be present with 10,000-50,000 CFU/mL of a single organism.*

Midstream, clean-void collection in a girl or uncircumcised boy

UTI is indicated when >100,000 CFU/mL of a single urinary pathogen is present in a symptomatic patient. Pyuria usually present. A UTI may be present with 10,000-50,000 CFU/mL of a single bacterium.*

Any method in a girl or boy

If the patient is asymptomatic, bacterial growth is usually >100,000 CFU/mL of the same organism on different days. If pyuria is absent, this result probably indicates colonization rather than infection.

*Patients with urinary frequency (ie, decreased bladder incubation time) are those most likely to have bacteria proliferating in the urinary bladder in the presence of low colony counts.

Table 3. Antibiotic Agents for Parenteral Treatment of a Urinary Tract Infection

Drug

Dosage and Route

Comment

Ceftriaxone

50-75 mg/kg/day IV/IM as a single dose or divided q12h

Do not use in infants < 6 wk of age; parenteral antibiotic with long half-life; may displace bilirubin from albumin

Cefotaxime

150 mg/kg/day IV/IM divided q6-8h

Safe to use in infants < 6 wk of age; used with ampicillin in infants aged 2-8 wk

Ampicillin

100 mg/kg/day IV/IM divided q8h

Used with gentamicin in neonates < 2 wk of age; for enterococci and patients allergic to cephalosporins

Gentamicin

Term neonates < 7 days: 3.5-5 mg/kg/dose IV q24h

Infants and children < 5 years: 2.5 mg/kg/dose IV q8h or single daily dosing with normal renal function of 5-7.5 mg/kg/dose IV q24h

Children ≥5 y: 2-2.5 mg/kg/dose IV q8h or single daily dosing with normal renal function of 5-7.5 mg/kg/dose IV q24h

Monitor blood levels and kidney function if therapy extends >48 h

Note: IM = intramuscular; IV = intravenous; q = every.

Table 4. Antibiotic Agents for the Oral Treatment of Urinary Tract Infection

Protocol

Daily Dosage

Sulfamethoxazole and trimethoprim (SMZ-TMP)

30-60 mg/kg SMZ, 6-12 mg/kg TMP divided q12h

Amoxicillin and clavulanic acid

20-40 mg/kg divided q8h

Cephalexin

50-100 mg/kg divided q6h

Cefixime

8 mg/kg q24h

Cefpodoxime

10 mg/kg divided q12h

Nitrofurantoin*

5-7 mg/kg divided q6h

*Nitrofurantoin may be used to treat cystitis. It is not suitable for the treatment of pyelonephritis, because of its limited tissue penetration.

Table 5. Antibiotic Agents to Prevent Reinfection

Agent

Single Daily Dose

Nitrofurantoin *

1-2 mg/kg PO

Sulfamethoxazole and trimethoprim (SMZ-TMP) *

5-10 mg/kg SMZ, 1-2 mg/kg TMP PO

Trimethoprim

1-2 mg/kg PO

*Do not use nitrofurantoin or sulfa drugs in infants younger than 6 weeks. Reduced doses of an oral first-generation cephalosporin, such as cephalexin at 10 mg/kg, may be used until the child reaches age 6 weeks. Ampicillin or amoxicillin are not recommended because of the high incidence of resistant E coli.

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Contributor Information and Disclosures

Author

Donna J Fisher, MD Assistant Professor of Pediatrics, Tufts University School of Medicine; Chief, Division of Pediatric Infectious Diseases, Baystate Children’s Hospital

Donna J Fisher, MD is a member of the following medical societies: American Academy of Pediatrics , Society for Healthcare Epidemiology of America , American Society for Microbiology , Infectious Diseases Society of America , Pediatric Infectious Diseases Society

Disclosure: Nothing to disclose.

Chief Editor

Russell W Steele, MD Clinical Professor, Tulane University School of Medicine; Staff Physician, Ochsner Clinic Foundation

Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics , American Association of Immunologists , American Pediatric Society , American Society for Microbiology , Infectious Diseases Society of America , Louisiana State Medical Society , Pediatric Infectious Diseases Society , Society for Pediatric Research , Southern Medical Association

Disclosure: Nothing to disclose.

Acknowledgements

Leslie L Barton, MD Professor Emerita of Pediatrics, University of Arizona College of Medicine

Leslie L Barton, MD is a member of the following medical societies: American Academy of Pediatrics , Association of Pediatric Program Directors , Infectious Diseases Society of America , and Pediatric Infectious Diseases Society

Disclosure: Nothing to disclose.

Ann G Egland, MD Consulting Staff, Department of Operational and Emergency Medicine, Walter Reed Army Medical Center

Ann G Egland, MD is a member of the following medical societies: American College of Emergency Physicians , American Medical Association , Association of Military Surgeons of the US , Medical Society of Virginia , and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Terrance K Egland, MD Director, Business Planning and Development, Bureau of Medicine and Surgery

Disclosure: Nothing to disclose.

Stanley Hellerstein, MD (Retired) Pediatric Nephrologist, Children’s Mercy Hospital of Kansas City; (Retired) Ernest L Glasscock, MD Chair in Pediatric Research, Professor of Pediatrics, University of Missouri School of Medicine at Kansas City

Disclosure: Nothing to disclose.

David S Howes, MD Professor of Medicine and Pediatrics, Section Chief and Emergency Medicine Residency Program Director, University of Chicago Division of the Biological Sciences, The Pritzker School of Medicine

David S Howes, MD is a member of the following medical societies: American Academy of Emergency Medicine , American College of Emergency Physicians , American College of Physicians-American Society of Internal Medicine , and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Stephen L Thornton, MD Assistant Professor of Emergency Medicine, University of Kansas Hospital

Stephen L Thornton, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Grace M Young, MD Associate Professor, Department of Pediatrics, University of Maryland Medical Center

Grace M Young, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Emergency Physicians

Disclosure: Nothing to disclose.

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  • Sections
    Pediatric Urinary Tract Infection
  • Overview
    • Practice Essentials
    • Background
    • Pathophysiology
    • Etiology
    • Epidemiology
    • Prognosis
    • Show All
  • Presentation
    • History
    • Physical Examination
    • Show All
  • DDx
  • Workup
    • Approach Considerations
    • Urine Collection and Analysis
    • Ultrasonography
    • Voiding Cystourethrography or Nuclear Cystography
    • Show All
  • Treatment
    • Approach Considerations
    • Hospital Admission Criteria
    • Infants Younger Than 8 Weeks With a Febrile UTI
    • Inpatient Treatment of Children With Complicated Pyelonephritis
    • Children With Cystitis
    • Prevention of Urinary Tract Infections
    • Consultations
    • Show All
  • Medication
    • Medication Summary
    • Antibiotics, Other
    • Analgesics, Other
    • Analgesics, Urinary
    • Show All
  • Questions & Answers
  • Tables
  • References

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