1. Introduction
2. Obtaining Urine Samples for Culture
3. Urinary Tract Evaluation
4. Empiric Treatment
5. Interval Evaluation
6. Length of Therapy
7. Prophylaxis

These guidelines are intended for the management of previously healthy neonates without known underlying urologic abnormalities for whom urinary tract infection (UTI) is the primary diagnosis. Unfortunately, specific data are not available on the optimum management of neonatal UTI's (1).

Neonates do not localize infection well and the ability to make the diagnosis of a UTI in this age group may be affected by the lack of specific symptomatology (2). In addition, the immature immune system of neonates may result in an increased susceptibility to spread of the infection beyond the urinary tract (3) and the incidence of bacteremia may be as high as 30% (4). For these reasons, neonates with UTI's should be managed as though they had systemic sepsis and this is reflected in the recommended antibiotic course.

Young children with UTI's have a relatively high incidence of anatomic abnormalities (5,6). In addition, renal scarring in common in the pediatric age group, most frequently in the subpopulation with reflux (7,8). For these reasons, anatomic evaluation by ultrasound and evaluation for reflux by voiding cystourethrogram (VCUG) is recommended for all pediatric patients with their first episode of UTI.

In neonates (0-6 weeks), the preferred culture source is urine obtained by suprapubic aspiration (bladder tap) (9,10,11). Criteria for diagnosis of UTI from suprapubic aspiration culture is >10 cfu/mL. An alterative method of urine sampling for culture is bladder catheterization with criteria for diagnosis of UTI traditionally set at >1000-10000 cfu/mL (12) of a single organism.

An ultrasound (US) of the urinary tract should be obtained initially to evaluate for major anomalies and obstruction.

A voiding cystourethrogram (VCUG) should be obtained at a later time to evaluate for reflux. The timing of VCUG is controversial (13). If performed after 4 weeks, it is likely to be the most accurate. It should be delayed until a normal urinalysis and/or sterile urine culture has been documented. If delayed, the patient should remain on prophylactic antibiotics until performed. In a male in whom posterior urethral valves are suspected, VCUG should be obtained as soon as urine is sterile

Ampicillin plus gentamicin are recommended initially until urine culture results are available (if meningitis is diagnosed on lumbar puncture, coverage should include a third generation cephalosporin such as ceftriaxone or cefotaxime). Antibiotic Dosages

Repeat urinalysis and/or culture should be obtained at 24-48 hours into therapy.

Therapy should be 2-3 weeks in duration given parenterally. Parenteral therapy does not imply the need for hospitalization throughout the course of treatment.

Amoxicillin once daily until VCUG completed.

1. Dick PT, Feldman W: Routine diagnostic imaging for childhood urinary tract infections: A systematic overview. J Pediatr 128:12, 1996.
2. Crain EF, Gershel JC: Urinary tract infections in febrile infants younger than 8 weeks of age. Pediatr 86:363, 1990.
3. Wilson CB: Immunologic basis for increased susceptibility of the neonate to infection. J Pediatr 108:1, 1986.
4. Ginsberg CM, McCracken GH jr.: Urinary tract infections in young infants. Pediatr 69:409, 1982.
5. Drew JH, Acton CM: Radiologic findings in newborn infants with urinary infection. Arch Dis Child 51:628, 1976.
6. Saxena SR, Laurance BM, Shaw DG: The justification for early radiological investigations of urinary tract infections in children. Lancet ii:403, 1975.
7. Winberg J, Bollgren I, Kallenius G, Mollby R, Svenson SB: Clinical pyelonephritis and focal renal scarring. Pediatr Clin N Am 29:801, 1982.
8. Lerner GR, Fleischmann LE, Perlmutter AD: Reflux nephropathy. Pediatr Clin N Am 34:747, 1987.
9. McCarthy JM, Pryles CV: Clean voided and catheter neonatal urine specimens. Am J Dis Child 106:473, 1963.
10. Hardy J, Furnell P, Brumfitt W: Comparison of sterile bag, clean catch and suprapubic aspiration in the diagnosis of urinary infection in early childhood. Br J Urol 48:279, 1976.
11. Nelson JD, Peters PC: Suprapubic aspiration of urine in premature and term infants. Pediatr 36:132, 1965.
12. Hellerstein S: Recurrent urinary tract infections in children. Pediatr Infect Dis 1:271, 1982.
13. Lebowitz RL, Mandell J: Urinary tract infection in children: putting radiology in its place. Radiology 165:1, 1987.

The above recommendations represent a concensus opinion authored by Dr. Jane Burns.
Adapted for this Web page by Dr. Dennis E. Mayock.

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