Pediatric UTIs
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þ UTIs in infants
 - When to consider in febrile infant?
  + Guidelines: > 38.3 (39), <36 months get urine
  + Equivocal fever: URI, OM, GE, RSV: decrease likelihood of UTI in
    blacks, but not in others.
  + If have RSV, do we need to check for UTI? Fever 9% + UTI, but 4.6%
    with RSV
 - Risks for UTI?
  + even verbal kids don't tend to have UTI sx
  + fever, dysuria, incontinence, flank or suprapubic pain
  + From JAMA study: "does this patient have a UTI?"
   - Hx of UTI
   - > 40
   - > 39 x 48h
   - lack of circumcision
   - nonblack race
 - Vesicoureteral reflux is common in infants and is essentially normal
   up to school age, mostly grade 2-3, usually down to grade 1 by school
   age
 - "enhanced UA" - as sensitive as a culture if not more.
 - nitrites: requires bacterial conversion in bladder, so if urinating
   frequently, nitrite may be false negative
 - sterile pyuria: in Kawasaki Disease, bad diaper rash
 - asymptomatic bacteriuria in kids? yes. but less frequent than older
   patients. 0.6% incidence in kids, up to 20% in elderly nursing home 
   patients. 
 - do you have to do a cath? Al Orifi from J Pediatr 2000; 137:221 says
   bagged cultures very bad, but UA from a bag not unreasonable
 - + culture with negative UA? 
 - sick vs. well?
  + oral if loocks well
    Omnicef 14 mg/kg divided BID or QD for 10-14 days.
    e coli, proteus, rarely klebsiella
    ceftriaxone 50 mg/kg divided q12 OR
    Claforan 50 mg/kg divided Q8 AND if < 60 days old:
    + ampicillin (risk for enterococcus in that age)
 - short course in infants?
  + no good. Keren Pediatrics 20002; 109:e70
  + if adolescent and no hx of UTIs, can use short-Rx
  + adolescent with hx of UTIs or had a VCUG: long treatment, followup
    with pediatrician.
 - followup: 48 hours, always. Fever gone? Eating and drinking? Culture
   shows it's senstivive? 
 - bag urine as good as cath for UA, if not for culture

þ Catheterization is much better than suprapubic aspiration
 - [Pollack CV. Suprapubic bladder aspiration vs. urethral catheterization in
   ill infants: Success, efficiency, and complication rates. Ann Emerg Med
   1994;23:255.]
 - It's a good idea to use U/S to check to make sure the bladder is 2 cm
   across before cathing. [Abstract SAEM 2004]