AMERICAN ACADEMY OF PEDIATRICS Committee on Quality Improvement Subcommittee on Urinary Tract Infection Practice Parameter: The Diagnosis, Treatment, and Evaluation of the Initial Urinary Tract Infection in Febrile Infants and Young Children

Objective. To formulate recommendations for health care professionals about the diagnosis, treatment, and evaluation of an initial urinary tract infection (UTI) in febrile infants and young children (ages 2 months to 2 years). Design. Comprehensive search and analysis of the medical literature, supplemented with consensus opinion of Subcommittee members. Participants. The American Academy of Pediatrics (AAP) Committee on Quality Improvement selected a Subcommittee composed of pediatricians with expertise in the fields of epidemiology and informatics, infectious diseases, nephrology, pediatric practice, radiology, and urology to draft the parameter. The Subcommittee, the AAP Committee on Quality Improvement, a review panel of office-based practitioners, and other groups within and outside the AAP reviewed and revised the parameter. Methods. The Subcommittee identified the population at highest risk of incurring renal damage from UTI— infants and young children with UTI and fever. A comprehensive bibliography on UTI in infants and young children was compiled. Literature was abstracted in a formal manner, and evidence tables were constructed. Decision analysis and cost-effectiveness analyses were performed to assess various strategies for diagnosis, treatment, and evaluation. Technical Report. The overall problem of managing UTI in children between 2 months and 2 years of age was conceptualized as an evidence model. The model depicts the relationship between the steps in diagnosis and management of UTI. The steps are divided into the following four phases: 1) recognizing the child at risk for UTI, 2) making the diagnosis of UTI, 3) short-term treatment of UTI, and 4) evaluation of the child with UTI for possible urinary tract abnormality. Phase 1 represents the recognition of the child at risk for UTI. Age and other clinical features define a prevalence or a prior probability of UTI, determining whether the diagnosis should be pursued. Phase 2 depicts the diagnosis of UTI. Alternative diagnostic strategies may be characterized by their cost, sensitivity, and specificity. The result of testing is the division of patients into groups according to a relatively higher or lower probability of having a UTI. The probability of UTI in each of these groups depends not only on the sensitivity and specificity of the test, but also on the prior probability of the UTI among the children being tested. In this way, the usefulness of a diagnostic test depends on the prior probability of UTI established in Phase 1. Phase 3 represents the short-term treatment of UTI. Alternatives for treatment of UTI may be compared, based on their likelihood of clearing the initial UTI. Phase 4 depicts the imaging evaluation of infants with the diagnosis of UTI to identify those with urinary tract abnormalities such as vesicoureteral reflux (VUR). Children with VUR are believed to be at risk for ongoing renal damage with subsequent infections, resulting in hypertension and renal failure. Prophylactic antibiotic therapy or surgical procedures such as ureteral reimplantation may prevent progressive renal damage. Therefore, identifying urinary abnormalities may offer the benefit of preventing hypertension and renal failure. Because the consequences of detection and early management of UTI are affected by subsequent evaluation and long-term management and, likewise, long-term management of patients with UTI depends on how they are detected at the outset, the Subcommittee elected to analyze the entire process from detection of UTI to the evaluation for, and consequences of, urinary tract abnormalities. The full analysis of these data can be found in the technical report. History of the literature review along with evidence-tables and a comprehensive bibliography also are available in the report. This report is published in Pediatrics electronic pages and can be accessed at the following URL: http://www.pediatrics.org/ cgi/content/full/103/4/e54. Results. Eleven recommendations are proposed for the diagnosis, management, and follow-up evaluation of infants and young children with unexplained fever who are later found to have a diagnosed UTI. Infants and young children are of particular concern because UTI in this age group (approximately 5%) may cause few recognizable signs or symptoms other than fever and has a higher potential for renal damage than in older children. Strategies for diagnosis and treatment depend on the clinician’s assessment of the illness in the infant or The recommendations in this statement do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate. “Practice Parameter: The Diagnosis, Treatment, and Evaluation of the Initial Urinary Tract Infection in Febrile Infants and Young Children” was reviewed by the appropriate committees and sections of the American Academy of Pediatrics (AAP), including the Committee on Infectious Diseases, the Committee on Medical Liability, and the Committee on Practice and Ambulatory Medicine; the Sections on Infectious Diseases, Nephrology, Radiology, and Urology; and the Chapter Review Group, a focus group of office-based pediatricians representing each AAP District: Gene R. Adams, MD; Charles S. Ball, MD; Robert M. Corwin, MD; Diane Fuquay, MD; Barbara M. Harley, MD; Michael J. Heimerl, MD; Thomas J. Herr, MD; Kenneth E. Matthews, MD; Robert D. Mines, MD; Lawrence C. Pakula, MD; Howard B. Weinblatt, MD; and Delosa A. Young, MD. The COQI and Subcommittee on UTI greatly appreciate the expertise of Richard N. Shiffman, MD, Center for Medical Informatics, Yale School of Medicine, for his input and analysis in the development of this practice guideline. Comments also were solicited and received from the American Academy of Family Physicians, the American College of Emergency Physicians, and the American Urological Association. PEDIATRICS (ISSN 0031 4005). Copyright © 1999 by the American Acad-