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A 10 year-old girl presents to the ER at 8 PM with a brief history of mid-abdominal crampy pain which started during her school day. She has no diarrhea but has vomited twice. She has had no fever or chills. She ate breakfast and a little lunch, but had no appetite for supper. She is continent of urine and stool and denies having urinary frequency, urgency, or dysuria. She has no previous hospitalizations or significant illnesses. She has not been known to have had a UTI.
T 98.8 BP 108/68
WD WN schoolgirl who appears uncomfortable with abdominal discomfort.
HEENT - WNL
Neck - Supple w/o masses
Chest - Symmetrical, no CVA tenderness, Clear to auscultation
Cor - No M/G
Abd - Soft, BS active. Liver edge at RCM, spleen non-palpable. No Masses noted. No tenderness elicited.
Genit - Tanner I-II, 'normal'
Extrem - full ROM at all joints w/o effusion/tenderness
Skin - warm hands/feet, CR <3 sec, good elasticity and perfusion. No rash.
Labs:
WBC 10,200 Hgb 11.6 UA (voided)1.020 pH 6 +1 Alb +1 Blood (+) LE (-) Nitrite
Micro: 150 WBC (+) 'bacteria' 3-5 RBC
Treatment is offered.
Urine culture returns in 48 hr: >100,000 S. epidermidis
| Test | Sensitivity % (Range) |
Specificity % (Range) |
| Leukocyte esterase | 83 (67-94) | 78 (64-92) |
| Nitrite | 53 (15-82) | 98 (90-100) |
| Leukocyte esterase or nitrite positive | 93 (90-100) | 72 (58-91) |
| Microscopy: WBCs | 73 (32-100) | 81 (45-98) |
| Microscopy: bacteria | 81 (16-99) | 83 (11-100) |
| TABLE 2 -- Criteria for the Diagnosis of UTI | ||
| Method of Collection | Colony Count (Pure Culture) | Probability of Infection (%) |
| SPA | Gram-negative bacilli: any number | >99% |
| Gram-positive cocci: more than a few thousand | >99% | |
| Transurethral catheterization | >10*5 | 95%; |
| 10*4 -10*5 | Infection likely | |
| 10*3 -10*4 | suspicious; repeat | |
| <10*3 | infection unlikely | |
| Clean void | Boy | |
| >10*4 | Infection likely | |
| Girl | ||
| 3 Specimens 10*5 | 95% | |
| 2 Specimens 10*5 | 90% | |
| 1 Specimen 10*5 | 80% | |
| 5 × 10*4 - 10*5 | Suspicious, repeat | |
| 10*4 - 5 × 10*4 | Symptomatic: suspicious, repeat | |
| Asymptomatic: infection unlikely | ||
| <10*4 | infection unlikely | |
The published studies reviewed in this report are observational, and the children studied are a selected group of the sickest children with UTI. With these caveats in mind, the meta-analysis supports the contentions that: (1) primary VUR is neither sufficient on its own, nor is it essential for the development of renal damage in the presence of a UTI; (2) the pathogenesis of renal damage should be reconsidered in the light of finding UTI with no VUR; (3) most important clinically, in individuals who have been hospitalized with UTI, cystography should not be used as a screening tool to exclude renal defects.
J Am Soc Nephrol 14: 739–744, 2003
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Accordingly, the only really low-risk category of febrile children are those with a well-defined other focus of infection (ie, varicella, meningitis, osteomyelitis, pneumonia) and circumcised boys >12 months of age. In these children, the strategy recommended by McGillivray seems reasonable. On the other hand, it is worth emphasizing that a catheterized specimen for urinalysis (with pyuria expressed as the number of WBC/mm3) and urine culture should be obtained on all febrile children (1) with a previous history of UTI, (2) with known abnormalities of the urinary tract, (3) with a family history of urinary tract disease, (4) who are uncircumcised boys, (5) who are less than 3 months of age, (6) who appear ill, and (7) who are female with fever and without a well-defined focus of infection. In addition, a catheterized specimen should be obtained in nontoilet-trained children with symptoms of UTI (frequency, urgency, dysuria, suprapubic discomfort).
J Pediatr 2005;147:418-20.
Images
VCUG 1 VCUG 2 VCUG 3 VUR Tracings Papillae Scars/Reflux
DMSA/Pyelo Pyelo Biopsy Chronic Pyelo Pyelo Scars
SPA TUBC Boy TUBC Girl TUBC Labia UA Sensitivity
References
Genitourinary Imaging Techniques
Pediatric Urinary Tract Infections
Emergency Medicine Clinics - UTI Pediatric Clinics - UTI
J. Peds Urine Bag Collection Technique AAP Practice Parameter - UTI