Evaluation and management of recurrent urinary tract infections in children: state of the art

Abstract

Urinary tract infections (UTIs) represent an important cause of febrile illness in young children and can lead to renal scarring and kidney failure. However, diagnosis and treatment of recurrent UTI in children is an area of some controversy. Guidelines from the American Academy of Pediatrics, National Institute for Health and Clinical Excellence and European Society of Paediatric Radiology differ from each other in terms of the diagnostic algorithm to be followed. Treatment of vesicoureteral reflux and antibiotic prophylaxis for prevention of recurrent UTI are also areas of considerable debate. In this review, we collate and appraise recently published literature in order to formulate evidence-based guidance for the diagnosis and treatment of recurrent UTI in children.

Keywords:

• antibiotic prophylaxis
• cystitis
• pyelonephritis
• urinary tract anomalies
• urinary tract infection
• vesicoureteral reflux

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• Urinary tract infection (UTI) is a leading cause of febrile illness in young children and is most prevalent in uncircumcised boys and girls under the age of 1 year.

• Diagnostic imaging algorithm after a febrile UTI, treatment of vesicoureteral reflux (VUR) and routine antibiotic prophylaxis are areas of some controversy. Consequently, an individualized approach for the evaluation and management of children with recurrent UTIs is necessary.

• A paradigm shift has occurred from identifying children with VUR and prescribing antimicrobial prophylaxis to prompt management of UTIs and identifying children at risk of developing renal scars.

• Antibiotic prophylaxis is associated with a modest reduction in the frequency of recurrent UTIs, although the risk of renal scarring may remain unchanged. Bladder–bowel dysfunction in children with VUR or recurrent UTIs should be identified and treated promptly.

• Benefit of cranberry juice (or other products) for the prevention of recurrent UTIs in children remains unclear.

• Circumcision significantly reduces the risk of UTIs, but 110 circumcisions need to be performed to prevent a single UTI.

• Definitive intervention (surgical or endoscopic) should be considered for children who develop frequent breakthrough infections despite antibiotic prophylaxis.

• Risk–benefit analysis with data from the Randomized Intervention for Children with Vesicoureteral Reflux (RIVUR) study will help to determine if the benefits of routine antibiotic prophylaxis outweigh any risks involved.

• Focus of future research on antibiotic prophylaxis should be changed from whether antibiotics prevent UTIs to which children would benefit the most from them.

Notes

AAP: American Academy of Pediatrics; ce-VUS: Contrast-enhanced voiding urosonography; DMSA: Dimercaptosuccinic acid; ESPR: European Society of Paediatric Radiology; NICE: National Institute of Health and Clinical Excellence; RNC: Radionuclide cystography; UTI: Urinary tract infection; VCUG: Voiding cystourethrography; VUR: Vesicoureteral reflux.

RIVUR: Randomized Intervention for Children with Vesicoureteral Reflux; TMP–SMX: Trimethoprim–sulfamethoxazole; UTI: Urinary tract infection.

AUA: American Urological Association; EAU: European Association of Urology; UTI: Urinary tract infection; VCUG: Voiding cystourethrography; VUR: Vesicoureteral reflux.