del tracto urinario
2000 Sep 5;163(5):523-9
Evaluating the benefits of antimicrobial prophylaxis to prevent urinary
tract infections in children: a systematic review.
Le Saux N, Pham B, Moher D
Thomas C. Chalmers Centre for Systematic Reviews, Children's Hospital of
Eastern Ontario Research Institute, Ottawa. firstname.lastname@example.org
BACKGROUND: The recurrence rate for urinary tract infections in children
is estimated at between 30% and 40%. The use of low doses of antibiotics
as prophylaxis for recurrent urinary tract infections is common clinical
practice. However, prolonged antimicrobial therapy has the potential to
contribute to problems of bacterial resistance and antimicrobial side
effects. The aim of this review was to systematically examine the
available evidence for the effectiveness of this intervention. METHODS: We
conducted a literature search of 3 electronic databases for the period
1966 to 1999. We also searched bibliographies from conference proceedings
and contacted content experts to ensure completeness of our database. Each
trial was evaluated on the basis of the following inclusion criteria:
target population (children), intervention (antibiotic v. no antibiotic),
outcome (number of urinary tract infections) and study design (randomized
controlled trial). Quality was assessed for the studies that met these
criteria. RESULTS: Most of the studies identified were case series and
cohort studies. Only 6 randomized trials fulfilled the inclusion criteria.
All were of low quality (median 2, range 0 to 2 [maximum quality score
5]). Three trials dealt with children who had anatomically normal urinary
tracts, and three included children with neurogenic bladder. The rate of
infections for patients with normal urinary tracts ranged from 0 to 4.0
per 10 patient-years for the treatment groups and from 4.0 to 16.7 for the
control groups. The recurrence rates for patients with neurogenic bladders
in 2 trials were 2.9 and 17.1 per 10 patient-years for the treatment
groups and 1.5 and 33.0 for the control groups. INTERPRETATION: The
available evidence for using antimicrobial prophylaxis to prevent urinary
tract infection in children with normal urinary tracts or neurogenic
bladder is of low quality. This suggests that the magnitude of any benefit
should at best be questioned. The surprising lack of data for children
with reflux is of concern. Well-designed trials are needed to optimize the
use of antimicrobials in children with recurrent urinary tract infection.
Arch Dis Child 2000 Aug;83(2):135-7
Detrusor instability; day and night time wetting, urinary tract
Fisher R, Frank D
Royal Bristol Hospital for Sick Children, St Michael's Hill, Bristol BS2
Surg Clin North Am 2000 Jun;80(3):895-909, ix-x
Contemporary issues with bacterial infection in the intensive care
Reed RL 2nd
Department of Surgery, Loyola University Medical Center, Maywood,
Nosocomial infection in the critically ill results from defects in the
intrinsic barriers to microbial invasion. The diagnosis is complicated by
an inability to perform an adequate physical examination in a patient with
several compounding findings, usually necessitating sophisticated
technologies to aid in the diagnosis. Pneumonia, line sepsis, urosepsis,
sinusitis, endocarditis, peritonitis, and acalculous cholecystitis are the
more common infections that challenge the care of the critically ill.
Antibiotic therapy is adjunctive to efforts to preserve the barrier, but
should be started early, should be targeted as specifically as possible to
the offending organisms, and should be dosed adequately to ensure an
effective concentration in the infected tissue.
Clin Infect Dis 1999 Apr;28(4):723-5
Factors contributing to susceptibility of postmenopausal women to
recurrent urinary tract infections.
Stamm WE, Raz R
University of Washington School of Medicine, Seattle, USA.
Recurrent urinary tract infections (UTIs) account for substantial
morbidity, losses in work time, and medical costs. Recent studies suggest
that the major factors predisposing to recurrent UTIs differ by age and
functional status. In premenopausal women, sexual intercourse, spermicide
exposure, maternal history
of UTI, and a history of UTI in childhood have been associated with
recurrent infections. In postmenopausal women, lack of estrogen appears to
be an important factor predisposing to recurrent UTI, as does nonsecretor
status, a history of UTI in the premenopausal period, incontinence,
presence of a cystocele, and postvoid residual urine. In older women who
are institutionalized, catheterization, incontinence, antimicrobial
exposure, and functional status are most strongly related to risk of
recurrent UTI. Further research is needed to better identify measures for
prevention of recurrent UTI, which likely differ by age group.
West J Med 2000 Mar;172(3):201-5
Dysuria in adolescents.
Department of Emergency Medicine, Mattel Children's Hospital, UCLA
90095-1752, USA. email@example.com
Arch Esp Urol 2000 Jan-Feb;53(1):15-20
[Cystic pyeloureteritis and infection. Presentation forms and review of
Navas Pastor J, Morga Egea JP, Garcia Ligero J, Garcia Garcia F, Tomas
Ros M, Rico Galiano JL, Sempere Gutierrez A, Guzman Martinez Valls PL, Gil
Franco J, Fontana Compiano LO
Servicio de Urologia, Hospital General Universitario, Murcia, Espana.
OBJECTIVE: To present three illustrative cases of pyeloureteritis cystica
and review the literature. METHODS: Three illustrative cases diagnosed at
our department are described. Patient history, clinical features,
diagnostic procedures and treatment are analyzed and the literature is
reviewed. RESULTS: Our patients had no specific symptoms. All three
patients had urinary tract infection with pyeloureteral involvement, which
was bilateral in two cases. One of these patients had a long-indwelling
catheter. CONCLUSIONS: Pyeloureteritis cystica is a benign and uncommon
condition whose etiology is not well-known. It is generally associated
with chronic infection and inflammation, and may be difficult to
distinguish from other filling defects of the urinary tract. Due to its
benign nature, treatment must always be conservative and close follow-up
Review of reported cases
Am Fam Physician 2000 Feb 1;61(3):713-21[Texto
Published erratum appears in Am Fam Physician 2000 Jun 15;61(12):3567
Urinary tract infections during pregnancy.
Delzell JE Jr, Lefevre ML
Health Sciences Center, University of Missouri-Columbia School of
Medicine, 65212, USA.
Urinary tract infections are common during pregnancy, and the most common
causative organism is Escherichia coli. Asymptomatic bacteriuria can lead
to the development of cystitis or pyelonephritis. All pregnant women
should be screened for bacteriuria and subsequently treated with
antibiotics such as nitrofurantoin, sulfisoxazole or cephalexin.
Ampicillin should no longer be used in the treatment of asymptomatic
bacteriuria because of high rates of resistance. Pyelonephritis can be a
life-threatening illness, with increased risk of perinatal and neonatal
morbidity. Recurrent infections are common during pregnancy and require
prophylactic treatment. Pregnant women with urinary group B streptococcal
infection should be treated and should receive intrapartum prophylactic
Enferm Infecc Microbiol Clin 1999 Dec;17(10):521-6
[Urinary infection in the elderly].
[Article in Spanish]
Geriatria, Equipo de Valoracion Geriatrica, Hospital Nuestra Senora del
Prado, Talavera de la Reina, Toledo.
Hosp Pract (Off Ed) 2000 Jan 15;35(1):53-9; discussion 59-60; quiz 144 [Texto
Managing urinary tract infections in men.
University of Washington School of Medicine, USA.
Despite the obvious genitourinary differences between the sexes,
management of lower urinary tract infections in men is based largely on
standards developed from studies in women. This has helped foster
misconceptions that, among other problems, add needless complexity and
expense to diagnosis and treatment of male patients.
Pediatr Clin North Am 1999 Dec;46(6):1111-24, vi
Urinary tract infection in the pediatric patient.
Shaw KN, Gorelick MH
Department of Pediatrics, University of Pennsylvania School of Medicine,
Little attention has been focused on the identification of urinary tract
infection (UTI) in young febrile children in the emergency department,
despite recent information that suggests both a high prevalence and
significant associated morbidity in this population. Most UTIs that lead
to scarring or diminished kidney growth occur in children younger than age
4 years, especially babies in the first year of life. Overall, prevalence
rates of UTI in febrile infants in the emergency department are
approximately 3% to 5%, with higher rates for white girls, uncircumcised
boys, and those without another potential source for fever. Prevalence and
risk factors are given so that clinicians may identify those febrile
children at particularly high or low risk of UTI for selective management.
Culturing methods, urine screening tests, and culture interpretation are
reviewed and management strategies based on these results are suggested.
BMJ 1999 Oct 30;319(7218):1173-5 [Texto
Urinary tract infection in children.
Sedgefield, County Durham TS21 3BN. Jhlarcombe@aol.com
Urol Clin North Am 1999 Nov;26(4):779-87
Urinary tract infections in pregnancy.
Connolly A, Thorp JM Jr
Department of Obstetrics and Gynecology, University of North Carolina
School of Medicine, Chapel Hill, USA.
Although pregnancy does not increase the prevalence of ASB in women, it
does enhance the progression rate from asymptomatic to symptomatic
disease. Furthermore, ASB is associated with preterm delivery. Given the
fact that identification and eradication of ASB in pregnant women can
lower the likelihood of pyelonephritis and prevent preterm delivery, every
gravida should be systematically screened for ASB and appropriately
treated. In the authors' opinion, a first-trimester urine culture remains
the screening test of choice; reliance on symptoms to prompt screening is
inadequate because the state of pregnancy can provoke frequency and
nocturia. Multiple antibiotic regimens for ASB are safe during pregnancy
Urol Clin North Am 1999 Nov;26(4):753-63
Management of pyelonephritis and upper urinary tract infections.
Department of Urology, Tulane University School of Medicine, New Orleans,
The most frequent cause of upper urinary tract infection remains E. coli.
Other organisms are found in complicated infections associated with
diabetes mellitus, instrumentation, stone, and immunosuppression. The
pathogenesis of acute pyelonephritis is reviewed herein, with an emphasis
on the virulence factors responsible for its initiation, including
urothelial adhesion by P-fimbriae of E. coli and other common factors
including hemolysin and aerobactin. Renal damage does not always ensue
following such infection. It is seen when toxic oxygen radicals are
released during the ischemic episode and the respiratory burst of
phagocytosis is marked and prolonged. These events occur when effective
antibacterial treatment is delayed when the diagnosis is not made early or
when socioeconomic factors prevent treatment. The scarring of chronic
pyelonephritis leads to the loss of renal tissue and function and may
progress to end-stage renal disease. With effective antibacterial therapy,
the immune response by both T and B lymphocytes leads to antibodies that
assist in bacterial eradication Therapy must be both rapid and effective.
In many instances, antibacterial agents may be used as outpatient therapy.
If the Gram stain shows only gram-negative organisms and if the infection
is community acquired, oral outpatient therapy with
trimethoprim/sulfamethoxazole or a fluoroquinolone may suffice if the
patient has no nausea. When the patient is septic, hospitalization and
treatment with parenteral antibiotics are needed. Both ceftriaxone and
gentamycin are cost-effective parenteral therapy because only once-daily
dosing is needed. If gram-positive organisms are found, an enterococcus
should be suspected, and a beta-lactam penicillin such as piperacillin or
a third-generation cephalosporin such as ceftriaxone is indicated. If
penicillin allergy exists, vancomycin should be used. If the patient does
not improve rapidly, diagnostic studies including ultrasound and CT will
assist in the diagnosis of obstruction, abscess, or emphysematous
pyelonephritis. Most of these complications are now rapidly treated
percutaneously, with surgical therapy following as needed. Complicated
infections, such as those occurring in patients with anatomic
abnormalities, stone, or immunosuppression, are often caused by organisms
other than E. coli, and long-term antibacterial therapy often leads to
fungal infections such as candidiasis. A recrudescence of tuberculosis is
occurring, often with resistance to antituberculous drugs. The increased
incidence has been associated with the immunosuppression of AIDS but is
also occurring in intravenous drug users, perhaps because of poor
nutrition but also owing to noncompliance with treatment. The symptoms of
renal tuberculosis are usually limited to fever, frequency, urgency, and
dysuria. Hematuria with sterile pyuria is the usual laboratory finding.
The young urologist should remember this renal disease in the differential
diagnosis of hematuria, because medical therapy can provide a cure.
Urol Clin North Am 1999 Nov;26(4):729-35, viii
Management of lower urinary tract infections and cystitis.
Department of Urology, Stanford University School of Medicine, California,
It is possible to understand the pathophysiology, diagnostic laboratory
methodology, and appropriate medical and surgical management of urinary
tract infections in today's modern medical world. The foundation of
success lies within an appropriate determination of the presence of
mitigating complications, careful documentation of invading organisms, and
judicious selection and administration of modern antimicrobial agents.
Virtually all urinary tract infections begin in the lower system through
bacterial exposure and adherence phenomena, creating simple uncomplicated
infections in otherwise healthy hosts and serious complicated infections
in others. Not all bacteriuria should be treated, and not all infections
should be treated equally; knowing the difference is the secret.
Pediatrics 1999 Nov;104(5):e54
Screening tests for urinary tract infection in children: A
Gorelick MH, Shaw KN
Division of Emergency Medicine, A. I. duPont Hospital for Children,
Wilmington, Delaware 19899, USA. firstname.lastname@example.org
OBJECTIVE: To review systematically and to summarize the existing
literature regarding performance of rapid diagnostic tests for urinary
tract infection (UTI) in children. DESIGN: Systematic review and
meta-analysis. METHODS: Published articles reporting the performance of
urine dipstick tests (leukocyte
esterase [LE] and/or nitrite), Gram stain, or microscopic analysis of spun
or unspun urine in the diagnosis of UTI in children </=12 years of age.
Articles were identified through a comprehensive MEDLINE search, and those
articles meeting a priori inclusion criteria were selected. Eligibility
criteria included the use of urine culture as the reference standard,
independent comparison of urine culture with the results of one of the
screening tests, definition of positive screening test results provided,
only pediatric patients included or evaluable separately, and both gold
standard and screening test performed on all patients. For each test,
heterogeneity of reported sensitivity and specificity of all studies was
determined. The subgroups of studies with similar definitions of UTI and
age of study subjects were analyzed separately to account for some of the
differences in reported results. When significant unexplained
heterogeneity among studies precluded simple combining of results, a
summary receiver-operator characteristic curve was fitted for each
screening test, from which pooled estimates of true-positive rate (TPR;
ie, sensitivity) and false-positive rate (FPR; 1-specificity) were
calculated. PRIMARY RESULTS: A total of 1489 titles were identified by the
MEDLINE search; 26 articles met all criteria for inclusion. There was
significant heterogeneity among studies for nearly all tests for both TPR
and FPR, which was explained only partially by the stringency of the
definition of UTI or age of subjects studied. Based on the pooled
estimates, the presence of any bacteria on Gram stain on an uncentrifuged
urine specimen had the best combination of sensitivity (0.93) and FPR
(0.05). Urine dipstick tests performed nearly as well, with a sensitivity
of 0.88 for the the presence of either LE or nitrite and an FPR of 0.04
for the presence of both LE and nitrite. Pyuria had lower TPR and higher
FPR: for presence of >5 white blood cells/high-power field in a
centrifuged urine sample, the TPR was 0.67 and the FPR was 0.21, whereas
for >10 white blood cells per mm(3) in uncentrifuged urine, the TPR was
0.77 and the FPR was 0.11. CONCLUSIONS: Both Gram stain and dipstick
analysis for nitrite and LE perform similarly in detecting UTI in children
and are superior to microscopic analysis for pyuria.
Am Fam Physician 1999 Mar 15;59(6):1472-8, 1485-6 [Texto
Pediatric urinary tract infection and reflux.
Ross JH, Kay R
Cleveland Clinic Foundation, Ohio 44195, USA.
Urinary tract infections in children are sometimes associated with
vesicoureteral reflux, which can lead to renal scarring if it remains
unrecognized. Since the risk of renal scarring is greatest in infants, any
child who presents with a urinary tract infection prior to toilet training
should be evaluated for the presence of reflux. Children who may be lost
to follow-up and those who have recurrent urinary tract infections should
also be evaluated. The preferred method for evaluation of urinary reflux
is a voiding cystourethrogram. Documented reflux is initially treated with
prophylactic antibiotics. Patients who have breakthrough infections on
prophylaxis, develop new renal scarring, have high-grade reflux or cannot
comply with long-term antibiotic prophylaxis should be considered for
surgical correction. The preferred method of surgery is ureteral
reimplantation. A newer method involves injection of the bladder trigone
Am J Med 1999 Mar;106(3):327-34
Prostatitis and urinary tract infection in men: what's new; what's
University of Washington School of Medicine, and Antibiotic Research
Clinic, Veterans Affairs Puget Sound Health Care System, Seattle 98108,
Urinary tract and prostatic infections are common in men, and most are
treated by primary providers. Acute bacterial prostatitis is caused by
uropathogens, presents with a tender prostate gland, and responds promptly
to antibiotic therapy. Chronic bacterial prostatitis is a subacute
infection, may present with a variety of pelvic pain and voiding symptoms,
and is characterized by recurrent urinary tract infections. Effective
treatment may be difficult and requires prolonged antibiotic therapy.
Nonbacterial prostatitis and chronic pelvic pain syndrome are more common
than bacterial prostatitis, and their etiologies are largely unknown.
Treatment for both nonbacterial disorders is primarily symptomatic. An
underlying anatomic or functional condition usually complicate urinary
tract infections in men, but uncomplicated infections occur, often related
to sexual activity. Gram-negative bacilli cause most urinary tract and
prostate infections. Therapy for prostatic infections requires an agent
that penetrates prostatic tissue and secretions, such as
trimethoprim-sulfamethoxazole or, preferably, a fluoroquinolone. Duration
of antibiotic therapy is typically 1 to 2 weeks for cystitis, 4 weeks for
acute bacterial prostatitis, and 6 to 12 weeks for chronic bacterial
prostatitis. Long-term suppressive antibiotic therapy and nonspecific
measures aimed at palliation may be useful in selected patients with
recurrent bacteriuria or persistent symptoms of chronic bacterial
Am Fam Physician 1999 Mar 1;59(5):1225-34, 1237
Urinary tract infections in adults.
Orenstein R, Wong ES
Hunter Holmes McGuire Veterans Affairs Medical Center, Richmond, Virginia
Urinary tract infections remain a significant cause of morbidity in all
age groups. Recent studies have helped to better define the population
groups at risk for these infections, as well as the most cost-effective
management strategies. Initially, a urinary tract infection should be
categorized as complicated or uncomplicated. Further categorization of the
infection by clinical syndrome and by host (i.e., acute cystitis in young
women, acute pyelonephritis, catheter-related infection, infection in men,
asymptomatic bacteriuria in the elderly) helps the physician determine the
appropriate diagnostic and management strategies. Uncomplicated urinary
tract infections are caused by a predictable group of susceptible
organisms. These infections can be empirically treated without the need
for urine cultures. The most effective therapy for an uncomplicated
infection is a three-day course of trimethoprim-sulfamethoxazole.
Complicated infections are diagnosed by quantitative urine cultures and
require a more prolonged course of therapy. Asymptomatic bacteriuria
rarely requires treatment and is not associated with increased morbidity
in elderly patients.
Urol Clin North Am 1998 Nov;25(4):685-701, x
Evaluation of and antimicrobial therapy for recurrent urinary tract
infections in women.
Engel JD, Schaeffer AJ
Department of Urology, Northwestern University Medical School, Chicago,
The problem with recurrent urinary tract infections in women is enormous
and contributes significantly to national health care costs. As the role
of office urology and the external "cost-effective" pressures
placed on the practicing urologist have heightened, a consistent, logical
approach towards diagnosis and management of urinary tract infection
becomes essential. This article briefly discusses the cause and
pathophysiology behind recurrent urinary tract infections in women. A
practical discussion of proper evaluation and treatment options will also
be provided in hopes of offering the clinician a simple, stepwise approach
to this sometimes difficult condition.
Drugs 1998 Nov;56(5):895-928
Ofloxacin. A reappraisal of its use in the management of genitourinary
Onrust SV, Lamb HM, Balfour JA
Adis International Limited, Auckland, New Zealand. email@example.com
Ofloxacin is an established fluoroquinolone agent which achieves good
concentrations in genitourinary tract tissues and fluids. It has good in
vitro activity against most Enterobacteriaceae, Staphylococcus
saprophyticus, methicillin-susceptible S. aureus, Neisseria gonorrhoeae,
Chlamydia trachomatis and Haemophilus ducreyi, intermediate activity
against Ureaplasma urealyticum and most enterococci, but limited or no in
vitro activity against enterococci, Serratia marcescens, Pseudomonas
aeruginosa and many anaerobes. However, high concentrations achieved in
the urine ensure its activity against most urinary tract pathogens.
Ofloxacin demonstrates consistent efficacy in a broad range of urinary
tract infections, achieving bacteriological response rates in excess of
80% in uncomplicated and 70% in complicated infections. The efficacy of
ofloxacin was similar to that of all comparators tested including other
fluoroquinolones, cephalosporins and cotrimoxazole
(trimethoprim/sulfamethoxazole). Ofloxacin is also effective as a
single-dose regimen in the treatment of uncomplicated gonorrhoea, as a
7-day regimen in uncomplicated C. trachomatis infections, and as
monotherapy in uncomplicated pelvic inflammatory disease (PID). Again,
ofloxacin demonstrated similar efficacy to alternative treatments in each
type of infection. The availability of an intravenous formulation and
near-complete oral bioavailability allow ofloxacin to be administered as a
sequential regimen without loss of activity. The tolerability and drug
interaction profile of ofloxacin is consistent with that of other
fluoroquinolones. The most commonly reported adverse events with ofloxacin
are gastrointestinal, neurological and dermatological. It was associated
with a lower incidence of photosensitivity and tendinitis and higher
incidence of some neurological events than some other fluoroquinolones.
Ofloxacin seems to have a lower propensity to interact with xanthines than
other fluoroquinolones. Conclusion: ofloxacin has established efficacy in
the treatment of a wide variety of urinary tract infections, although,
like other fluoroquinolones, it should be used rationally to preserve its
activity. Currently, ofloxacin also holds an important place among
fluoroquinolones in the treatment of C. trachomatis infections and
uncomplicated PID, although its acceptance as monotherapy in PID is likely
to depend on clarification of the causative role of anaerobic pathogens in
Clin Obstet Gynecol 1998 Sep;41(3):744-54
Urinary tract infections.
Faro S, Fenner DE
Rush-Presbyterian-St. Luke's Medical Center, Chicago, Illinois, USA.
Urinary tract infection in women has its origin, predominantly, via
ascending bacteria from the periurethral microflora. Asymptomatic
bacteriuria, except for the pregnant patient, need not be treated. E. coli
is the most common bacterium to cause UTIs, and is usually susceptible to
oral antibiotics. Patients who are hospitalized with an indwelling Foley
catheter or who have undergone instrumentation, tend to be infected with a
bacterium other than E. coli. Patients with uncomplicated cystitis can
effectively be treated with an oral antibiotic (Table 1) for 3 days.
Patients who do not respond to empiric therapy have a recurrence within 2
weeks of treatment, or who have a recurrence within the first week after
treatment, should have a pretreatment.
Am Fam Physician 1998 May 15;57(10):2440-6, 2452-4
Urinary tract infections in children: why they occur and how to prevent
University of Missouri-Kansas City School of Medicine, USA.
Urinary tract infections (UTIs) usually occur as a consequence of
colonization of the periurethral area by a virulent organism that
subsequently gains access to the bladder. During the first few months of
life, uncircumcised male infants are at increased risk for UTIs, but
thereafter UTIs predominate in females. An
important risk factor for UTIs in girls is antibiotic therapy, which
disrupts the normal periurethral flora and fosters the growth of
uropathogenic bacteria. Another risk factor is voiding dysfunction.
Currently, the most effective intervention for preventing recurrent UTIs
in children is the identification and treatment of voiding dysfunction.
Imaging evaluation of the urinary tract following a UTI should be
individualized, based on the child's clinical presentation and on clinical
judgment. Both bladder and upper urinary tract imaging with
ultrasonography and a voiding cystourethrogram should be obtained in an
infant or child with acute pyelonephritis. Imaging studies may not be
required, however, in older children with cystitis who respond promptly to
Comment in: Am Fam Physician 1998 May 15;57(10):2337-8, 2340
Am Fam Physician 1998 Apr 1;57(7):1573-80, 1583-4
Evaluation and treatment of urinary tract infections in children.
Ahmed SM, Swedlund SK
Wright State University School of Medicine, Dayton, Ohio, USA.
Urinary tract infections (UTIs) are among the most common bacterial
infections encountered by primary care physicians. Although UTIs do not
occur with as great a frequency in children as in adults, they can be a
source of significant morbidity in children. For reasons that are not yet
completely understood, a minority of UTIs in children progress to renal
scarring, hypertension and renal insufficiency. Clinical presentation of
UTI in children may be nonspecific, and the appropriateness of certain
diagnostic tests remains controversial. The diagnostic work-up should be
tailored to uncover functional and structural abnormalities such as
dysfunctional voiding, vesicoureteral reflux and obstructive uropathy. A
more aggressive work-up, including renal cortical scintigraphy, ultrasound
and voiding cystourethrography, is recommended for patients at greater
risk for pyelonephritis and renal scarring, including infants less than
one year of age and all children who have systemic signs of infection
concomitant with a UTI. Antibiotic prophylaxis is used in patients with
reflux or recurrent UTI who are at greater risk for subsequent infections