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  • DOI: 10.1542/peds.2011-1330; originally published online August 28, 2011; 2011;128;595Pediatrics

    Improvement and ManagementSubcommittee on Urinary Tract Infection, Steering Committee on Quality

    Management of the Initial UTI in Febrile Infants and Children 2 to 24 MonthsUrinary Tract Infection: Clinical Practice Guideline for the Diagnosis and

    http://pediatrics.aappublications.org/content/128/3/595.full.htmllocated on the World Wide Web at:

    The online version of this article, along with updated information and services, is

    of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.Boulevard, Elk Grove Village, Illinois, 60007. Copyright 2011 by the American Academy published, and trademarked by the American Academy of Pediatrics, 141 Northwest Pointpublication, it has been published continuously since 1948. PEDIATRICS is owned, PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

    at Indonesia:AAP Sponsored on November 29, 2013pediatrics.aappublications.orgDownloaded from at Indonesia:AAP Sponsored on November 29, 2013pediatrics.aappublications.orgDownloaded from

  • CLINICAL PRACTICE GUIDELINE

    Urinary Tract Infection: Clinical Practice Guideline forthe Diagnosis and Management of the Initial UTI inFebrile Infants and Children 2 to 24 Months

    abstractOBJECTIVE: To revise the American Academy of Pediatrics practiceparameter regarding the diagnosis and management of initial urinarytract infections (UTIs) in febrile infants and young children.

    METHODS: Analysis of the medical literature published since the lastversion of the guidelinewas supplemented by analysis of data providedby authors of recent publications. The strength of evidence supportingeach recommendation and the strength of the recommendation wereassessed and graded.

    RESULTS: Diagnosis is made on the basis of the presence of bothpyuria and at least 50 000 colonies per mL of a single uropathogenicorganism in an appropriately collected specimen of urine. After 7 to 14days of antimicrobial treatment, close clinical follow-up monitoringshould be maintained to permit prompt diagnosis and treatment ofrecurrent infections. Ultrasonography of the kidneys and bladdershould be performed to detect anatomic abnormalities. Data from themost recent 6 studies do not support the use of antimicrobial prophy-laxis to prevent febrile recurrent UTI in infants without vesicoureteralreux (VUR) or with grade I to IV VUR. Therefore, a voiding cystoure-thrography (VCUG) is not recommended routinely after the rst UTI;VCUG is indicated if renal and bladder ultrasonography reveals hydro-nephrosis, scarring, or other ndings that would suggest either high-grade VUR or obstructive uropathy and in other atypical or complexclinical circumstances. VCUG should also be performed if there is arecurrence of a febrile UTI. The recommendations in this guideline donot indicate an exclusive course of treatment or serve as a standard ofcare; variations may be appropriate. Recommendations about antimi-crobial prophylaxis and implications for performance of VCUG arebased on currently available evidence. As with all American Academy ofPediatrics clinical guidelines, the recommendations will be reviewedroutinely and incorporate new evidence, such as data from the Ran-domized Intervention for Children With Vesicoureteral Reux (RIVUR)study.

    CONCLUSIONS: Changes in this revision include criteria for the diag-nosis of UTI and recommendations for imaging. Pediatrics 2011;128:595610

    SUBCOMMITTEE ON URINARY TRACT INFECTION, STEERINGCOMMITTEE ON QUALITY IMPROVEMENT AND MANAGEMENT

    KEY WORDSurinary tract infection, infants, children, vesicoureteral reux,voiding cystourethrography

    ABBREVIATIONSSPAsuprapubic aspirationAAPAmerican Academy of PediatricsUTIurinary tract infectionRCTrandomized controlled trialCFUcolony-forming unitVURvesicoureteral reuxWBCwhite blood cellRBUSrenal and bladder ultrasonographyVCUGvoiding cystourethrography

    This document is copyrighted and is property of the AmericanAcademy of Pediatrics and its Board of Directors. All authorshave led conict of interest statements with the AmericanAcademy of Pediatrics. Any conicts have been resolved througha process approved by the Board of Directors. The AmericanAcademy of Pediatrics has neither solicited nor accepted anycommercial involvement in the development of the content ofthis publication.

    The recommendations in this report do not indicate an exclusivecourse of treatment or serve as a standard of medical care.Variations, taking into account individual circumstances, may beappropriate.

    All clinical practice guidelines from the American Academy ofPediatrics automatically expire 5 years after publication unlessreafrmed, revised, or retired at or before that time.

    www.pediatrics.org/cgi/doi/10.1542/peds.2011-1330

    doi:10.1542/peds.2011-1330

    PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

    Copyright 2011 by the American Academy of Pediatrics

    COMPANION PAPERS: Companions to this article can be foundon pages 572 and e749, and online at www.pediatrics.org/cgi/doi/10.1542/peds.2011-1818 and www.pediatrics.org/cgi/doi/10.1542/peds.2011-1332.

    FROM THE AMERICAN ACADEMY OF PEDIATRICS

    PEDIATRICS Volume 128, Number 3, September 2011 595 at Indonesia:AAP Sponsored on November 29, 2013pediatrics.aappublications.orgDownloaded from

  • INTRODUCTIONSince the early 1970s, occult bactere-mia has been the major focus of con-cern for clinicians evaluating febrileinfants who have no recognizablesource of infection. With the introduc-tion of effective conjugate vaccinesagainst Haemophilus inuenzae typeb and Streptococcus pneumoniae(which have resulted in dramatic de-creases in bacteremia and meningi-tis), there has been increasing appre-ciation of the urinary tract as the mostfrequent site of occult and serious bac-terial infections. Because the clinicalpresentation tends to be nonspecic ininfants and reliable urine specimensfor culture cannot be obtained withoutinvasive methods (urethral cathe-terization or suprapubic aspiration[SPA]), diagnosis and treatment maybe delayed. Most experimental andclinical data support the concept thatdelays in the institution of appropriatetreatment of pyelonephritis increasethe risk of renal damage.1,2

    This clinical practice guideline is a re-vision of the practice parameter pub-lished by the American Academy ofPediatrics (AAP) in 1999.3 It was devel-oped by a subcommittee of the Steer-ing Committee on Quality Improvementand Management that included physi-cians with expertise in the elds of ac-ademic general pediatrics, epidemiol-ogy and informatics, pediatricinfectious diseases, pediatric nephrol-ogy, pediatric practice, pediatric radi-ology, and pediatric urology. The AAPfunded the development of this guide-line; none of the participants had anynancial conicts of interest. Theguideline was reviewed by multiplegroups within the AAP (7 committees, 1council, and 9 sections) and 5 externalorganizations in the United States andCanada. The guideline will be reviewedand/or revised in 5 years, unless newevidence emerges that warrants revi-sion sooner. The guideline is intended

    for use in a variety of clinical settings(eg, ofce, emergency department, orhospital) by clinicians who treat in-fants and young children. This text is asummary of the analysis. The data onwhich the recommendations arebased are included in a companiontechnical report.4

    Like the 1999 practice parameter, thisrevision focuses on the diagnosis andmanagement of initial urinary tract in-fections (UTIs) in febrile infants andyoung children (224 months of age)who have no obvious neurologic or an-atomic abnormalities known to be as-sociated with recurrent UTI or renaldamage. (For simplicity, in the remain-der of this guideline the phrase fe-brile infants is used to indicate febrileinfants and young children 224months of age.) The lower and upperage limits were selected because stud-ies on infants with unexplained fevergenerally have used these age limitsand have documented that the preva-lence of UTI is high (5%) in this agegroup. In those studies, fever was de-ned as temperature of at least 38.0C(100.4F); accordingly, this denitionof fever is used in this guideline. Ne-onates and infants less than 2months of age are excluded, becausethere are special considerations inthis age group that may limit the ap-plication of evidence derived fromthe studies of 2- to 24-month-old chil-dren. Data are insufcient to deter-mine whether the evidence gener-ated from studies of infants 2 to 24months of age applies to childrenmore than 24 months of age.

    METHODS

    To provide evidence for the guideline, 2literature searches were conducted,that is, a surveillance of Medline-listedliterature over the past 10 years forsignicant changes since the guidelinewas published and a systematic re-view of the literature on the effective-

    ness of prophylactic antimicrobialtherapy to prevent recurrence of fe-brile UTI/pyelonephritis in childrenwith vesicoureteral reux (VUR). Thelatter was based on the new and grow-ing body of evidence questioning theeffectiveness of antimicrobial prophy-laxis to prevent recurrent febrile UTI inchildren with VUR. To explore this par-ticular issue, the literature search wasexpanded to include trials publishedsince 1993 in which antimicrobial pro-phylaxis was compared with no treat-ment or placebo treatment for chil-dren with VUR. Because all except 1 ofthe recent randomized controlled tri-als (RCTs) of the effectiveness of pro-phylaxis included children more than24 months of age and some did notprovide specic data according tograde of VUR, the authors of the 6 RCTswere contacted; all provided raw datafrom their studies specically ad-dressing infants 2 to 24 months of age,according to grade of VUR

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