Recent evidence, controversies and emerging evidence
| RECENT EVIDENCE | |
| Urine bag collection | High contamination rates ≈50%.15 17 Least cost-effective collection method.47 Useful for dipstick screening but unreliable for culture. |
| Voiding stimulation methods | Improves the speed, success and cost-effectiveness of clean catch urine collection in precontinent children16 18 |
| Antibiotic prophylaxis | Not recommended after first or second UTI in otherwise healthy children. Modest effect on recurrence, does not reduce scarring and increases antibiotic resistance.44–46 |
| CONTROVERSIES | |
| What colony counts on culture represent true UTI? | Historical: 100 000 CFU/mL.30 NICE: no specific recommendation.16 AAP: 50 000 CFU/mL from catheter/SPA sample with pyuria.21 Proposed: 10 000 CFU/mL with symptoms/pyuria.29 |
| Duration of antibiotic therapy? | Short-course therapy for lower tract UTI (cystitis) may be as effective as longer courses.33 NICE: 7–10 days for pyelonephritis and 3 days for children >3 months with cystitis16 AAP: 7–14 days for all UTI.2 |
| Choice of antibiotic agent? | Must be guided by local guidelines and sensitivity patterns, as susceptibility can vary significantly between regions.21 |
| Does uncomplicated UTI predispose to risk of chronic kidney disease? | Children with structurally normal kidneys appear not at significant risk of long term renal morbidity.9 13 |
| Imaging tests following UTI: who, what and when to image? | Historical: aggressive imaging to identify VUR and scarring. NICE: age and risk based approach.16 AAP: ultrasound for all children <2 years old with febrile UTI, VCUG if ultrasound is abnormal.21 |
| EMERGING EVIDENCE | |
| Antibiotic resistance | Increasing globally, highest in resource-limited settings.6 37 Increases healthcare costs.38 |
| Urinary biomarkers to differentiate between UTI and asymptomatic bacteriuria | For example, interleukin-6, neutrophil gelatinase-associated lipocalin: further research needed to establish clinical utility.28 |
| Point-of-care PCR to identify presence of uropathogens | Can identify common uropathogens but only specified targets so may miss uncommon bacterial species. Cannot differentiate between contamination, asymptomatic bacteriuria and infection.9 |
National Institute for Health and Care Excellence (NICE) UK Clinical Guideline 54: UTI in under 16s: diagnosis and management 2017.
American Association of Paediatrics Clinical Practice Guideline: the diagnosis and management of the initial UTI in febrile infants and young children 2–24 months of age 2016.
PCR, Polymerase Chain Reaction; SPA, suprapubic needle aspiration; UTI, urinary tract infection; VCUG, Voiding Cystourethrogram; VUR, vesicoureteric reflux.