Source: Manual of Ambulatory Pediatrics 2010
SOAP Note – Urinary Tract Infection
A bacterial infection of any portion of the urinary tract. It may be limited to asymptomatic bacteriuria or may progress to involve the renal pelvis and parenchyma, causing pyelonephritis.
I. Etiology: E. coli is the most common causative organism in up to 80% of cases. Other organisms include Klebsiella, Proteus, Pseudomonas, Enterobacteriaceae, Staphylococcus saprophyticus, and less commonly,
S. aureus.
II. Incidence
A. Most commonly seen between 2 months and 2 years; more frequent in girls than in boys. The recurrence rate after the first infection is estimated at about 40%. UTI is seen in the neonate in 1% to 2% of both females and males (generally uncircumcised). There is a higher occurrence in premature infants (approximately 4%). Approximately 1% of school-age girls have symptomatic infections per year. UTI is found in 5% of febrile infants and young children.
B. Often related to sexual activity in adolescent females and the incidence increases as females become sexually active.
III. Subjective data
A. Classic signs
1. Elevated temperature; may be as high as 104.5F (40.3C)
2. Chills
3. Anorexia
4. Urinary frequency and urgency
5. Dysuria
6. Incontinence
7. Enuresis, nocturnal and diurnal
8. Costovertebral angle tenderness (flank pain)
9. Suprapubic pain
10. Back pain
B. Typical symptoms
1. Infants
a. Failure to thrive
b. Fever of unknown origin
c. Irritability
d. Strong odor to urine
e. Hematuria
f. Gastrointestinal symptoms—vomiting or diarrhea
g. Jaundice
2. Preschool-age children
a. Abdominal pain
b. Vomiting
c. Fever
d. Strong odor to urine
e. Enuresis
f. Urinary frequency and urgency
g. Dysuria
h. Vaginal discharge
i. Hematuria
3. School-age and older children
a. Symptoms as for preschool children
b. Costovertebral angle tenderness
C. Pertinent subjective data to obtain
1. Character of urinary stream
2. History of previous urinary tract infection or symptoms
3. History of possible causes of urethral irritation
a. Use of bubble bath or feminine sprays
b. Vaginitis
c. Pinworms
d. Masturbation
e. Sexual activity
4. Personal hygiene practices
5. Change in urinary habits
6. History of constipation
7. Family history of urological abnormalities
D. Note: Urinary tract infection should be suspected in all children who present with failure to thrive, fever of unknown origin, or recurrent abdominal pain.
IV. Objective data
A. Obtain accurate weight and blood pressure.
B. Poor growth rate
C. Fever of up to 104.5F (40.3C)
D. Abdominal examination may reveal suprapubic or costovertebral angle tenderness.
E. Child may appear toxic with acute infection.
F. Laboratory tests: Urinalysis and urine culture
1. Because infection may be completely asymptomatic, urinalysis is recommended by the AAP at age 5 and once between 11 and
21 years of age. Approximately 2% of females screened are found to have significant bacteriuria.
2. Proteinuria may be present.
3. Criteria for diagnosis by urine culture in a symptomatic child
a. More than 5 WBCs per high-power field (HPF) in centrifuged sediment (trace color changes on the leukocyte esterase strip indicates 5 WBCs/HPF)
b. More than 50,000 bacteria/mL of the same type of microorganism in a culture of a catheterized specimen and more than 100,000 bacteria/mL in a culture of a clean-voided specimen. Growth of more than one organism is usually indicative of contamination, not infection.
c. Any pathogens in a suprapubic aspirate (if first 10 mL is excluded) indicate infection.
d. Presence of nitrites indicates the presence of nitrate splitting bacteria. Nitrate test is most accurate when urine is not dilute and has been in bladder for 4 hours. Absence of nitrites does not rule out UTI.
4. Order sensitivity studies and urine culture if specimen is to be taken to the laboratory (results will take 24 to 48 hours).
5. Ideally, two or more urine cultures should be done unless the specimen is obtained by suprapubic aspiration or sterile catheterization.
6. If child is not toxic or does not have severe symptoms, postpone treatment and request a first-morning clean-voided specimen the next day.
7. Repeat any culture with a count between 10,000 and 50,000/mL.
8. In newborns, blood culture should be drawn (one third of newborns with UTI also have bacteremia).
V. Assessment
A. Diagnosis is established by positive urine culture.
B. Differential diagnosis
1. Vaginitis: Pyuria of >10 WBCs/HPF; urine culture nonspecific. Symptoms may be those of “cystitis”—frequency, burning, urgency.
2. Urethritis: Normal urine culture; symptoms may be those of cystitis—frequency, burning, urgency.
3. Urethritis related to sexually transmitted infection (particularly Chlamydia): Urethral culture positive; urine culture negative
VI. Plan
A. Pharmacologic therapy: Culture results may necessitate a change in antibiotic therapy. Empirical treatment is based on most likely pathogen and also regional patterns or resistance.
1. Children less than 2 months:
a. Amoxicillin: 40 mg/kg/d in 2 divided doses for 10 days
2. Children more than 2 months:
a. Bactrim or Septra (TMP/SMX): 6 to 12 mg/kg/d TMP and 30 to 60 mg/kg/d SMX in two divided doses for 10 days (>40 kg, one DS tablet every 12 hours)
or
b. Amoxicillin: 40 mg/kg/d in 2 divided doses; up to 50% of
E. coli may be resistant to penicillins (maximum 500 mg/dose) or
c. Cephalexin: 25 to 50 mg/kg/d in 3–4 divided doses for 10 days; more than 15 years, 500 mg bid for 10 days (maximum 1 g/dose) or
d. Cefixime (Suprax): 100 mg/5 mL; 10 mg/kg/d in 2 divided doses for 10 days (maximum 200 mg/dose)
3. Children over 2 years of age, afebrile, with no history of structural abnormalities or previous UTI may be treated for 5 days.
4. Acetaminophen for fever and discomfort: 10 to 15 mg/kg every 4 hours.
B. Repeat urine culture in 48 hours if still febrile or ill.
C. Encourage fluids.
D. Plan should include attempts to determine mechanism causing infection; consult physician for referral for urologic evaluation.
E. Indications for voiding cystourethrogram (VCUG) and ultrasound
1. All children age 2 months to 2 years who do not demonstrate the expected clinical response within 2 days of antimicrobial therapy; with the expected response, at the earliest convenience
2. First infection in male
3. Girls with UTI occurring at less than 3 to 5 years
4. Child with pyelonephritis or more than one urinary tract infection
5. Child with febrile UTI
F. Renal scintigraphy with dimercaptosuccinic acid (DMSA) can be useful in detecting pyelonephritis and renal scarring but its role in management of pediatric UTI is controversial.
1. DMSA is injected intravenously and the uptake in the urinary system is measured after 2–4 hours.
G. Vesicoureteral reflux generally resolves with time: 20% to 30% reflux resolves in 2 years. (As the child grows, the longitudinal muscle develops.) Grades I and II reflux (nondilated ureters) resolve spontaneously. Prophylactic antibiotic therapy is controversial but may be used until reflux proved normal by repeat VCUG (done every 6 to 12 months). Refer grades III to V to urologist.
VII. Education
A. Urine collection
1. Do not force fluids before collecting specimen.
2. Collection of clean-voided, midstream specimen
a. Use sterile container; boil thoroughly washed jar and cover for 10 minutes.
b. Female: Clean labia from front to back, using 3 antiseptic wipes. Spread labia and cleanse from clitoris to anus.
c. Male: Retract foreskin and cleanse glans with 3 antiseptic wipes.
d. Have child initiate voiding and then stop. Obtain specimen when child commences voiding again.
e. Take specimen to the office immediately; if a delay of more than a few minutes is expected, refrigerate specimen at 4C.
3. U-bag collection (difficult to obtain an uncontaminated specimen using this method)
a. Female
(1) Clean genitalia as above.
(2) Dry genitalia thoroughly.
(3) Remove protective covering from bag; apply first to perineum, pressing firmly to ensure adherence; then apply pressure from perineum forward. Be sure seal is tight.
b. Male
(1) Clean external genitalia.
(2) Dry thoroughly.
(3) Apply bag with firm pressure to ensure a tight seal.
c. Seal edges of bag once infant has voided and take to the office or laboratory immediately.
B. Encourage fluids during treatment.
C. Give all medication as prescribed
D. Call back immediately if child develops a rash or has nausea, vomiting, diarrhea, or headache.
E. Expect child to improve within 24 to 48 hours.
F. Teach parent and child to be alert to signs and symptoms of urinary tract infection.
G. Do not use bubble baths or feminine sprays.
H. Use showers instead of baths if child is old enough.
I. Do not use deep water for baths.
J. Stress perineal hygiene—wiping from front to back after toileting.
K. Encourage child to void at regular intervals and not to stall voiding.
L. For sexually active adolescent, encourage voiding after intercourse.
M.Minimize constipation (see protocol, p. 269).
VIII. Follow-up
A. Repeat urine culture in 48 hours if there is no clinical response within 2 days of antibiotic therapy.
IX. Complications
A. Recurrent urinary tract infection
B. Pyelonephritis
C. Failure to thrive in undiagnosed or untreated cases
D. Renal scarring
X. Consultation/referral
A. Infants and children up to 2 years of age
B. Males with first urinary tract infection
C. Immunocompromised patient
D. If patient is symptomatic 2 to 3 days after initiation of therapy
E. Vesicoureteral reflux for long-term prophylaxis. Dosage should be half the standard treatment dose, given at night to ensure concentration in the urine.