Urinary tract infection in children: diagnosis, treatment, and long term management - in association with NICE

1 . A 4 yea r old boy h a s h a d rec u rren t UTIs a n d is rec eivin g proph yla c t ic t rea t m en t wit h t rim et h oprim . He develops a n ot h er UTI. W h ic h of t h e followin g st a t em en t s is c orrec t ?
P r e -t e s t an s we r a. b. c. d. Y o u r an s we r Co r r e ct an s we r

You should double the dose of trimethoprim You should refer him for intravenous antibiotics You should start him on a prophylactic dose of a new antibiotic You should start him on a treatment dose of a new antibiotic

Th a t 's n ot righ t . Th e c orrec t a n swer is d. If an infant or child is receiving prophylactic medication and develops an infection, treatment should be with a different antibiotic, not a higher dose of the same antibiotic.

2 . A m ot h er brin gs h er 1 1 yea r old da u gh t er t o see you a s sh e h a s a h ist ory of rec u rren t UTIs. B ot h m ot h er a n d da u gh t er a re refu gees a n d h a ve poor En glish . Y ou n ot ic e t h a t t h e da u gh t er h a s da rk st a in in g of h er t eet h . W h ic h of t h e followin g dru gs do you t h in k m igh t h a ve been respon sible for t h is?
P r e -t e s t an s we r a. b. c. Y o u r an s we r Co r r e ct an s we r

Amoxicillin Trimethoprim Cefradine

d. e.

Nalidixic acid Tetracyclines

Th a t 's righ t . Tetracyclines are deposited in growing teeth (by binding to calcium) and can cause staining and, occasionally, dental enamel hypoplasia. You should NOT give them to children under 12 years. Tetracyclines should also not be given to pregnant or breastfeeding women.

3 . A 2 yea r old boy h a s a c u t e pyelon eph rit is. W h ic h of t h e followin g st a t em en t s is c orrec t ?

P r e -t e s t an s we r a. b. c. Y o u r an s we r Co r r e ct an s we r

You should treat him with antibiotics for three to four days Treatment with an oral cephalosporin or co-amoxiclav is often suitable If a child starts on intravenous antibiotics then they should nish the course of intravenous antibiotics

Th a t 's righ t . For infants and children 3 months or older with acute pyelonephritis or an upper UTI: Con sider referra l t o a pa edia t ric spec ia list Trea t wit h ora l a n t ibiot ic s for seven t o 1 0 da ys. Th e u se of a n ora l a n t ibiot ic wit h low resist a n c e pa t t ern s is rec om m en ded, for ex a m ple a c eph a losporin or c o-a m ox ic la v If ora l a n t ibiot ic s c a n n ot be u sed, u rgen t ly refer for t rea t m en t wit h a n in t ra ven ou s a n t ibiot ic a gen t su c h a s c efot a x im e or c eft ria x on e for t wo t o fou r da ys, followed by ora l a n t ibiot ic s for a t ot a l du ra t ion of 1 0 da ys.

4 . A 4 yea r old girl h a s a t ypic a l lower UTI. Her t em pera t u re is 3 7 .5 C. Sh e is a c c om pa n ied by h er m ot h er. W h ic h of t h e followin g st a t em en t s rega rdin g t rea t m en t is c orrec t ?
P r e -t e s t an s we r a. Y o u r an s we r Co r r e ct an s we r

You should treat her with oral antibiotics for seven to 10 days

b.

You should treat her with oral antibiotics and advise the mother to return if the child is still unwell after seven days You should treat her with oral antibiotics for three days and advise the mother to return if the child is still unwell after 24 to 48 hours

c.

Th a t 's righ t . You should treat her with oral antibiotics for three days and advise the mother to return if the child is still unwell after 24 to 48 hours.

5 . A 1 0 yea r old girl h a s a UTI. It is c a u sed by Esc h eric h ia c oli a n d t h e growt h is sign ic a n t . Th e sen sit ivit y pa t t ern is a s follows: Trim et h oprim R Ciproox a c in S Am ox ic illin R Ceph a lex in S. W h ic h of t h e followin g a n t ibiot ic s wou ld you st a rt ?
P r e -t e s t an s we r a. b. c. d. Y o u r an s we r Co r r e ct an s we r

Trimethoprim Ciprooxacin Amoxicillin Cephalexin

Th a t 's n ot righ t . Th e c orrec t a n swer is d. Cephalexin is appropriate in this circumstance. E coli is resistant to trimethoprim and amoxicillin.

Lea rning bite: prevention of recurrence

D ysfu n c t ion a l elim in a t ion syn drom es a n d c on st ipa t ion sh ou ld be a ddressed in in fa n t s a n d c h ildren wh o h a ve h a d a UTI

Ch ildren wh o h a ve h a d a UTI sh ou ld be en c ou ra ged t o drin k a n a dequ a t e a m ou n t Ch ildren wh o h a ve h a d a UTI sh ou ld h a ve rea dy a c c ess t o c lea n t oilet s, wh en requ ired, a n d sh ou ld n ot be ex pec t ed t o dela y voidin g

6 . W h ic h of t h e followin g c h ildren h a s a n a t ypic a l UTI?

P r e -t e s t an s we r a. b. c. d. Y o u r an s we r Co r r e ct an s we r

A 4 year old boy with a Proteus infection A 6 year old girl who responds to antibiotics within 36 hours A 7 year old boy with a temperature of 37.7C and a normal creatinine A 7 year old boy with both bacteriuria and pyuria

Th a t 's n ot righ t . Th e c orrec t a n swer is a . Children with an atypical UTI: Are seriou sly ill Ha ve poor u rin e ow Ha ve a n a bdom in a l or bla dder m a ss Ha ve a ra ised c rea t in in e Ha ve sept ic a em ia Fa il t o respon d t o su it a ble a n t ibiot ic s wit h in 4 8 h ou rs Ha ve n on - E c oli orga n ism s.

7 . A m ot h er brin gs h er 4 m on t h old ba by boy t o see you a s sh e is worried t h a t h e h a s h a d a fever for t wo da ys. Y ou m ea su re h is t em pera t u re - it is 3 9 .5 C.

W h a t level of risk of seriou s illn ess wou ld you pla c e t h e c h ild in ?

P r e -t e s t an s we r a. b. c. Y o u r an s we r Co r r e ct an s we r

Low risk Intermediate risk High risk

Th a t 's righ t . This child is at high risk as he has one very serious sign at his age - a temperature equal to or greater than 39C. The following are red signs (signs of a potentially serious underlying illness): Age 0 t o 3 m on t h s, temperature 3 8 C Age 3 t o 6 m on t h s, temperature 3 9 C. There is a link to the guideline on feverish illness in childhood at the end of this module.

8 . A. Ult ra sou n d du rin g t h e a c u t e in fec t ion B . Ult ra sou n d wit h in six week s C. D MSA 4 -6 m on t h s followin g t h e a c u t e in fec t ion

D . Mic t u ra t in g c yst ou ret h rogra m E. CT a bdom en a n d pelvis F. MR I a bdom en a n d pelvis G. No in vest iga t ion Th e followin g pa t ien t s h a ve a ll h a d a UTI. P lea se c h oose t h e m ost a ppropria t e in vest iga t ion in t h e c irc u m st a n c e from t h e list a bove. i. A 2 yea r old girl h a s h a d t h ree UTIs. Sh e h a d a n u lt ra sou n d six week s a ft er h er la st in fec t ion - t h is wa s n orm a l. Y ou r P re Test An swer : CT abdomen and pelvis Y ou r P ost Test An swer : Ultrasound during the acute infection Th a t 's n ot righ t . Th e c orrec t a n swer is D MSA 4 -6 m on t h s followin g t h e a c u t e in fec t ion . The guidance recommends that children of this age with recurrent UTIs should have an ultrasound within six weeks of the acute infection and then a DMSA 4-6 months later. ii. A 2 yea r boy h a s a t ypic a l UTI a n d respon ds well t o t rea t m en t wit h in 4 8 h ou rs. Y ou r P re Test An swer : No investigation Y ou r P ost Test An swer : No investigation Th a t 's righ t . Children of this age who respond promptly to treatment do not need further tests. iii. An 1 8 m on t h old girl h a s a n a t ypic a l UTI. Sh e h a s a n u lt ra sou n d du rin g t h e a c u t e in fec t ion Y ou r P re Test An swer : Ultrasound within six weeks Y ou r P ost Test An swer : Ultrasound within six weeks Th a t 's n ot righ t . Th e c orrec t a n swer is D MSA 4 -6 m on t h s followin g t h e a c u t e in fec t ion . Children of this age with an atypical UTI should have an ultrasound during the acute infection and then a DMSA 4-6 months later. iv. A 2 yea r old girl h a s rec u rren t UTIs. Th ere is a fa m ily h ist ory of vesic ou ret eric reu x a n d on on e oc c a sion sh e h a d a

P rot eu s in fec t ion . Sh e h a s a n u lt ra sou n d a n d a D MSA. Th e u lt ra sou n d sh owed dila t ion of t h e u ret ers. Y ou r P re Test An swer : Micturating cystourethrogram Y ou r P ost Test An swer : Micturating cystourethrogram Th a t 's righ t . While micturating cystourethrogram should not be performed routinely it should be considered if the following features are present: D ila t ion on u lt ra sou n d P oor u rin e ow Non - E c oli in fec t ion Fa m ily h ist ory of vesic ou ret eric reu x . When a micturating cystourethrogram is performed, prophylactic antibiotics should be given orally for three days with MCUG taking place on the second day.

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