CLINICAL PATHWAY URINARY TRACT INFECTION (UTI) ALGORITHM- UTI Testing Suspicion of UTI Intended for: • Patients with presumed UTI • Greater than 60days of age Age Age NOT intended for: Age 60days- >36months or • Known urologic anomalies <60days • 36months Toilet Trained Chronic/complex conditions (ie. spinabifida, self cath, hardware, etc.) • Recent urinary tract instrumentation Clean Catch UA placement Cath UA • Critical Illness Refer to CCG Consider • Immunocompromised Fever? NO “Fever, infant (less Alternative Dx than 28days or 28- 90days)” Index of UA Result? Neg Low Consider Suspicion* Alternative Dx Yes Pos/Equiv High *Index of Suspicion • Febrile Culture Culture • Dysuria • Frequency • Flank Pain • Hx of UTI History of No Gender? Male Circumcised? YES UTI? Male Female Risk Factors Yes NO Female Risk Factors • Temp ≥ 39°C • Age <12mo • Fever ≥2 days • Temp ≥ 39°C • No source of • ≥ 3 Risk Fever ≥ 2 days infection • No source of ≥ 3 Risk • Non-black Factors? <1yr? No infection Factors? Race • White Race Yes Yes No Yes No Cath UA Consider Cath Cath UA + Cath UA Consider Cath + Culture Cath UA based on Culture + Culture based on ! + Culture clinical clinical Bag Specimen presentation presentation NOT Preferred Neg Neg (consider with labial adhesions, or failed catheterizations) Consider Consider NEVER send culture Alternative Dx Alternative Dx Imaging Recommendations for patients >2months after 1st Febrile UTI No imaging required o Prompt response to therapy (afebrile in 72 hrs) o Reliable outpatient follow up o Normal voiding pattern o No abdominal mass o Normal (≤5mm pelvic dilation) 3rd trimester (>28 week) prenatal ultrasound Consider Renal Ultrasound: o At clinical discretion in patient under 2 years o Bowel/bladder dysfunction Renal Ultrasound recommended o Patient does not have adequate clinical response to appropriate treatment o Urosepsis/Severe infection associated with UTI o Recurrent UTIs o Unusual pathogens o Hypertension Strongly consider Voiding Cystourethrogram (VCUG) o Renal U/S reveals hydronephrosis, scars, or findings of high grade VUR or obstructive uropathy o Urosepsis/Severe infection associated with UTI (postpone until infection has cleared) o Recurrent UTIs (especially if family hx) Page 1 of 12 CLINICAL PATHWAY ALGORITHM- UTI Empiric Therapy Urinalysis Result? Micro (if available) Positive= Neg Neg or Consider Positive= Any nitrite, 1+ Leuc, or >5 WBCs or Equiv Equiv Alternative Dx WBCs, or gram stain positive Positive Positive Send Culture + First Line Empiric Therapy ! <36 ≥ 12yrs 36m-11yr If Prior months UTI, refer to (Adolescent) sensitivities First Line First Line- First Line- First Line- First Line- (10 days total therapy) Cystitis Pyelonephritis Cystitis Pyelonephritis (3 days total therapy) (10 days total therapy) (3 days total therapy) (10 days total therapy) • Cephalexin (Keflex) 12.5-25 mg/kg/dose (4 • Cephalexin (Keflex) • Cephalexin (Keflex) • Cephalexin (Keflex) • Cephalexin (Keflex) times/day, max 500mg/ 12.5-25 mg/kg/dose (3- 25 mg/kg/dose (4 times/ 12.5 mg/kg/dose (3-4 25 mg/kg/dose (4 times/ dose) 4 times/day, max day, max 1000mg/dose) times/day, max 500mg/ day, max 1000mg/dose) OR 500mg/dose) OR dose) OR • Ceftriaxone (if initial • Ceftriaxone (if initial • Ceftriaxone (if initial parental therapy needed) ------------------------------- parental therapy ------------------------------- parental therapy needed) 50mg/kg/dose IV or IM (1 Alternate Oral Option: needed) Alternate Oral Option: 50mg/kg/dose IV or IM (1 dose/day, max 2000mg/ • Sulfamethoxazole/ 50mg/kg/dose IV or IM (1 • Sulfamethoxazole/ dose/day, max 2000mg/ dose) trimethoprim dose/day, max 2000mg/ trimethoprim dose) (Bactrim, Septra) dose) (Bactrim, Septra) ------------------------------------- 5-6 mg/kg/dose (TMP) 5-6 mg/kg/dose (TMP) ------------------------------------- Alternate Oral Option: (2 times/day, max ----------------------------------- (2 times/day, max Alternate Oral Option: • Sulfamethoxazole/ 160mg/dose (TMP)) Alternate Oral Option: 160mg/dose (TMP)) • Sulfamethoxazole/ trimethoprim (Bactrim, • Sulfamethoxazole/ trimethoprim (Bactrim, Septra) trimethoprim (Bactrim, Septra) 5-6 mg/kg/dose (TMP) (2 Septra) 5-6 mg/kg/dose (TMP) (2 times/day, max 160mg/dose 5-6 mg/kg/dose (TMP) (2 times/day, max 160mg/dose (TMP)) times/day, max 160mg/ (TMP)) dose (TMP)) Page 2 of 12 CLINICAL PATHWAY ALGORITHM- UTI Culture Results Culture Culture Culture >100K CFU 10-100K CFU ! Typical <10K CFU Single Organism or Mixed Organism pathogen + “other gram- positive” usually reflects infection **Pre-test Probability Collection Clean Cath (Consider the following Catch Method? findings) Nitrite + Leuk Esterase 1+ or greater **Pre-test WBCs >5 High Bacteria > “rare” Probability Low Febrile Dysuria Frequency Severe/ Severe/ Flank Pain NO On-going On-going History of UTI illness? illness? NO YES YES • Phone Assessment • Phone Assessment • Call back to stop • Consider obtaining • Phone Assessment • Consider possibility treatment (if pre- repeat (carefully • Initiate, Continue, or of false positive treated) obtained) specimen Escalate Treatment • Consider alternate • Consider call back if • Initiate, Continue, or diagnoses concerned Escalate Treatment Second Line Therapy If resistant, phone follow-up is warranted. If patient is not improving, change to susceptible antimicrobial <36 36m- ≥ 12yrs months 11yrs (Adolescent) Second Line- Second Line- Second Line Second Line- Second Line- Cystitis Pyelonephritis (10 days total therapy) Cystitis Pyelonephritis • Nitrofurantoin monohydrate/ (10 days total therapy) • Cefixime (or equivalent • Nitrofurantoin - (10 days total therapy) macrocrystals • Cefixime (or equivalent cephalosporins if unavailable, *expensive, not to be used • Cefixime (or equivalent (MACROBID)– *expensive, not cephalosporins if Expensive) with pyelonephritis cephalosporins if unavailable, to be used with pyelo/pregnancy unavailable, Expensive) 4 mg/kg/dose (2 times/ Expensive) 1.25-1.75 mg/kg/dose ( 4 100mg/dose (2 times/day, max 4 mg/kg/dose (2 times/ day, max 200mg/dose) 4 mg/kg/dose (2 times/day, times/day, immediate 100mg/dose, 5 day course) day, max 200mg/dose) max 200mg/dose) release formulation, max • Nitrofurantoin macrocrystals • Ciprofloxacin- *only if 100mg/dose, 5 day (MACRODANTIN)– • See others don’t work- ! See • Ciprofloxacin- course) Ciprofloxacin- *last choice *expensive, not to be used with FDA warning in growing children, See FDA warning below! pyelonephritis/pregnancy 10 mg/kg/dose (2 times/ 10 mg/kg/dose (2 times/ • FDA warning! Cefixime (or equivalent 100mg/dose (4 times/day, max day, max 500mg/dose) day, max 500mg/dose) cephalosporins if unavailable, 10 mg/kg/dose (2 times/ 100mg/dose, 5 day course) Expensive) day, max 500mg/dose) 4 mg/kg/dose (2 times/ • Cefixime (or equivalent day, max 200mg/dose, 3 cephalosporins if unavailable, day course) Expensive) 8mg/kg/dose (1 times/day, • Ciprofloxacin- See FDA max 400mg/dose, 3 day ! warning! ! course) ! FDA 10 mg/kg/dose (2 times/ Certain NItrofurantoin day, max 500mg/dose, 3 • Ciprofloxacin- See FDA Warning less common Do not use with Ciprofloxacin day course) bacteria may not be warning pyelonephritis or Risk of Tendon covered by suggested 10 mg/kg/dose (2 times/day, pregnancy Rupture antibiotics (e.g. Proteus, max 500mg/dose, 3 day Enterococcus, etc.) course) Page 3 of 12 CLINICAL PATHWAY TABLE OF CONTENTS Algorithm – UTI Testing Algorithm – UTI Empiric Therapy Algorithm – UTI Culture Results Target Population Background Initial Evaluation Clinical Management Laboratory Studies | Imaging Therapeutics References Clinical Improvement Team TARGET POPULATION Inclusion Criteria • Patients with presumed or documented UTI • Patients aged >60 days old Exclusion Criteria • Need for immediate critical care/toxicity • Known urologic anomalies • Chronic/Complex conditions (ex. Spinabifida, self-cath, hardware, etc.) • Immunocompromised BACKGROUND • UTIs are the most common cause of serious bacterial illness in children • Recurrent UTI is a known cause chronic kidney disease in children • Inappropriate management may result in severe or invasive illness • Knowledge of risk factors and appropriate testing and interpretation of the results in proper clinical context is necessary for accurate diagnosis and treatment of UTI Page 4 of 12 CLINICAL PATHWAY Probability of UTI based on Number of Risk Factors Male Female Risk Factors Risk Factors • Temp ≥ 39°C • Age <12mo • Fever ≥2 days • Temp ≥ 39°C • No source of • Fever ≥ 2 days infection • No source of • Non-black infection Race • White Race INITIAL EVALUATION Signs and Symptoms1 CLINICAL MANAGEMENT Consider Urology Consult • Urologic anomalies • Recurrent UTI unresponsive to routine preventative measures • Any questions or concerns regarding imaging, management, or prophylaxis LABORATORY STUDIES | IMAGING Laboratory Studies Urinalysis (UA) • Dipstick2, 3 or Standard Page 5 of 12 CLINICAL PATHWAY Table 2. Urinalysis Methods Urine Culture (UC) • Gold standard for diagnosis of UTI • Most definitive result is >100,000 cfu of a single uropathogen • CHCO lab does not report colony counts above or below 50,000 (only 10,000 or 100,000) • However, multiple organisms and lower colony counts can reflect true UTI, particularly if: o The culture comes from a catheter specimen o There is high pre-test probability of UTI based on clinical history and urinalysis results (particularly if urine was nitrite positive) o One organism is a typical/common pathogen, e.g. E.coli and second organism is “other gram positive” o The patient