Opportunities to optimize use of antibiotics in pediatric practice have focused on targeted interventions in acute respiratory infections.
Practice based strategies to improve unnecessary or inappropriate antibiotic prescribing in pediatric urinary tract infection (UTI) are also necessary. Practitioners should develop a process in their practice to appropriately identify those with clinical features of UTI, to optimize specimen collection, to appropriately interpret urinalysis results and to target the initial antibiotic therapy.
Listen in as Mary Anne Jackson, MD explains that pitfalls that may result in injudicious testing and antibiotic use in the child with suspected UTI will be discussed and specific practice based interventions to improve outcomes will be reviewed.
Selected Podcast
Optimum Antibiotic Use for Pediatric Urinary Tract Infections
Featured Speaker:
Learn more about Dr. Mary Anne Jackson
Mary Anne Jackson, MD
Dr. Mary Anne Jackson is the Children’s Mercy Kansas City Division Director of Infectious Disease; Associate Chair of Community and Regional Provider Collaborations, Department of Pediatrics; and Professor of Pediatrics, University of Missouri-Kansas City School of Medicine. She completed her medical degree from University of Missouri-Kansas City School of Medicine, residency from Cincinnati Children's Hospital Medical Center, and fellowship from Pediatric Infectious Diseases at the University of Texas Southwestern Medical Center in Dallas, TX. Certified in pediatric infectious diseases and pediatrics, she specializes in bacterial resistance, including penicillin-resistant pneumococcus, emerging pathogens, hospital-acquired infection prevention, and new vaccines. She is the editor of the LINK, a monthly print and digital newsletter that provides education to an audience of local, regional and national pediatric providers on subjects related to current medical trends, developments in best practices and analysis of hot topics.Learn more about Dr. Mary Anne Jackson
Transcription:
Optimum Antibiotic Use for Pediatric Urinary Tract Infections
Dr. Michael Smith (Host): So, our topic today is optimum antibiotic use for pediatric urinary tract infections. My guest is Dr. Mary Anne Jackson. She is the division director of infectious disease at Children's Mercy Kansas City. Dr. Jackson, welcome to the show.
Dr. Mary Anne Jackson, MD, (Guest): Thank you so much for having me, Dr. Mike.
Dr. Smith: What a big topic, right, because we know there’s a lot of problems with overusing antibiotics and so really honing in on the diagnosis and the proper treatment is becoming critical really, and so just kind of -- what's your take on where we stand right now in treating infections specifically UTI in the pediatric population?
Dr. Jackson: Well, as you know, pediatric urinary tract infections are common. The estimates are there are about 1.6 million pediatric UTI visits every year in the United States –
Dr. Smith: Hmmm.
Dr. Jackson: -- and if infections are properly diagnosed and treated with antibiotics, the outcome is quite good, but what we've seen more recently is inappropriate diagnosis, unnecessary antibiotic use, and the whole issue here on antibiotic use is that antibiotics are great. They save lives. They should be used when they need to be used, but we want to be able to use them wisely. We're facing antibiotic resistance. We’re facing --
Dr. Smith: Right.
Dr. Jackson: -- children with adverse reactions to antibiotics and in terms of pediatric patients, you know, urinary tract infections are so common, and the scope of the problem is similar to dealing with ear infections and sinus infections and strep throat where we really need to make sure that we're making the diagnosis appropriately...
Dr. Smith: Right.
Dr. Jackson: ...and wisely use the antibiotics.
Dr. Smith: Well, let's do this. Let's kind of just walk through the different parts of dealing with a patient who comes in with symptoms of a UTI, and let's just talk about what you're doing and how you think we can improve on all these steps. So, like number one. How can we improve first on just identifying a true urinary tract infection?
Dr. Jackson: That is a great question, and the reason it's important to identify is if they're missed there are chances are that you could get renal scarring, scarring of the kidney or high blood pressure, even end-stage renal disease. So, first thing is who gets a urinary tract infection? These are common in the first couple years of life. They're more common in uncircumcised boys than in boys who have had a circumcision, and they're common in Caucasian girls, particularly those who are under 12 months of age with high fever and no other source. There are some features that might be tip off that pediatricians might target in talking with families where they bring in a child under the age of 2 with a fever and they want to talk about, you know, does the child have a normal urinary stream? Are they going frequently? If they're a little bit older, you know, could they tell do they have urgency, and certainly in the children who are being potty trained, there are some little girls in particular who have voiding dysfunction, and you can kind of identify those because these are the little girls who have the withholding behaviors where they cross their legs or squat down trying not to have to go to the bathroom. Usually, they're very interested in just continuing playing and so...
Dr. Smith: Right.
Dr. Jackson:...those are issues that you can certainly highlight, and then understanding that infants who have fever and vomiting, but have other features of a viral infection such as runny nose, cough, wheezing, rash or diarrhea...
Dr. Smith: Right...that's correct...right, right...
Dr. Jackson:...they don't even need to be evaluated, right?
Dr. Smith: Right...right.
Dr. Jackson:... and then for the older kids, those are the children who may have burning with urination, or you may have more with abdominal pain or back pain, or the child who’s been potty trained and is all of a sudden having a lot of accidents. So, there's a lot that goes into when should we think about it, and then the next step is what do we do about it?
Dr. Smith: Well, yeah, so the what do we do about it...do you feel that at least maybe in the community settings that a lot of healthcare practitioners, once they suspect it, you know, they really feel strongly this is a UTI that they're just starting to treat at that point, and that they're not collecting specimens? You think that's a problem?
Dr. Jackson: That is absolutely a problem, and the CDC has identified that. Occasionally, a urinalysis has been obtained, but no culture is done, and so the steps in confirming the urinary tract infection involve obtaining a proper specimen, sending a urinalysis, and if the urinalysis is abnormal, sending the urine culture so that can guide what type of antibiotics...
Dr. Smith: Right, right...
Dr. Jackson:...you use because you'd like to match the drug and the bug and use the best antibiotic, and that's not always being done, and so this starts with, you know, when you obtain a urinary specimen in a child, particularly who's not potty trained, how do you do that -- and that…
Dr. Smith: Yeah…
Dr. Jackson: … becomes a dilemma in practice.
Dr. Smith: Yeah, well it's a good...because it's not as simple as people maybe think, right? [chuckle] So, what are some of the techniques or hints or tips you can give to really improving that process of specimen collection?
Dr. Jackson: Well, as you might guess, the easiest way to obtain a urine specimen in a child who is not potty trained is to use a so-called bag, get a bag urine, and the bag urine is ok as long as you're not going to use it for the culture, and as long as you're not going to prescribe any antibiotic without getting a culture. So, a bag…
Dr. Smith: Okay.
Dr. Jackson: …urine is great. It's a great way to start the evaluation and so if the child has unexplained fever and is not severely ill, and you're not going to use an antibiotic, the first thing you do is put that bag urine on and then do the urinalysis and test it, and we can talk about testing in just a bit. But, if that urinalysis is abnormal, you must take the next step, and the next step is getting an appropriate specimen for culture which is a catheterized urine specimen, and the reason for this...
Dr. Smith: Right, right...
Dr. Jackson: ...is bag urines are notoriously contaminated...
Dr. Smith: Conta- yeah, yeah, yeah, right...
Dr. Jackson: ...with bacteria, and you may needlessly treat a child with an antibiotic.
Dr. Smith: That's right, that's right. So, that's probably one of the problems, too, is they're doing the bag collection but stopping at that point and just starting or initiating treatment. So, you mentioned about the urinalysis...what are...are we...do we get a little bit lazy in the community setting, and we're not interpreting the UAs correctly? Do you see that there's a problem at that interpretation level?
Dr. Jackson: Occasionally, I think that's the case, and so here's what I recommend that people look for. So, we want to make sure they look for nitrites, and nitrites that are positive -- this is on the dipstick -- the child is likely to have a urinary tract infection. Leukocyte esterase, possibly likely to have a urinary tract infection…
Dr. Smith: Right.
Dr. Jackson: …and if they look for white blood cells, they need to look for white blood cyells that are greater than five. Occasionally, you can be fooled in a child who's voiding frequently, and you might miss the nitrites, but there is a very reliable way to look at the urine, assuming that the child has not had the urine in the bladder for, you know, for a very short…
Dr. Smith: Okay.
Dr. Jackson: …period of time where you might get a negative finding.
Dr. Smith: Right.
Dr. Jackson:... but to use that urine and then to interpret the urinalysis and then decide about your next step, and let's just mention also that for the child who is potty trained, we do the so-called clean catch urine, and the only problem here is as many as 25% can be contaminated. So, folks do need to look at that, and I have some pearls for looking at your information once you get to the culture point, but my tip on using the clean catch is urines in little girls is there has to be some counseling for the parents for how to do this. I like to turn the little -- these are predominately little girls. Once you get over a year, urinary tract infections in boys are very uncommon.
Dr. Smith: Right, right.
Dr. Jackson: ...but with a little girl who’s potty trained, you need to clean them, parents need to be instructed -- I actually have them sit backwards on the toilet. Some people believe this is a better way to get a urine sample. They have to void first, and then you're going to collect the specimen, and so clean-catch specimens in little ones who are potty trained and bag specimens to start, but then using a catheterized urine specimen in the child who has a bag urine that is abnormal.
Dr. Smith: Ok. So, yeah, when we get to that specimen level, and we've done the appropriate way of collecting it based on the patient, what are some of the things you're looking for at that point with the specimen?
Dr. Jackson: So, we've talked about looking for so called nitrites and leukocyte esterase and white blood cells and bacteria. Those are going to be all indicators to tell you whether or not you need to proceed with the culture of the specimen, and then this is where the pearls really come in in interpreting a culture. So, there are three different factors that you want to look at. So, you have a child where -- oh I think this is a child with a urinary tract infection; I'm obtaining -- let's just say this is a 2 year old who's not potty trained. I got the bag specimen, and it looks like there may be infection. Now, I’ve obtained a catheterized specimen in that 2 year old, and again, the urinalysis is abnormal, and I’ve sent that for culture -- not all of the cultures come back. First question, is there a single organism? That's the first thing you look at.
Dr. Smith: Okay.
Dr. Jackson: The second thing would be is the organism a pathogen that causes urinary tract infection, and the third thing is -- is the organism present in a significant colony count, which is 50,000 colony…
Dr. Smith: Okay.
Dr. Jackson: …forming units per mL or greater. So, single organism, first off the bat, if you have, for instance, 5,000 colonies of E. coli and 25,000 colonies of a viridans streptococci, that is not an infection. Stop. There is no need for antibiotics in that particular patient, assuming they've not been exposed to antibiotics.
Dr. Smith: Okay.
Dr. Jackson: If they have greater than 100,000 colonies of Staphylococcus epidermidis, which is skin flora…
Dr. Smith: Right.
Dr. Jackson: …in a, you know, significant colony count, that's not a uropathogen in the vast majority of children -- and meaning a child who doesn't have some type of abnormality within the urinary tract. On the other hand, if you have three different organisms, that is a contaminated urine specimen. It is unevaluable, so, what you want to start with is -- is it an organism that's identified as a single organism, in high colony count, that's a uropathogen. What you're looking at and for is E. coli greater than 100,000 colony units per mL, single organism, and then you need to match up your drug and bug…
Dr. Smith: Right, right.
Dr. Jackson: …and so those are the keys there.
Dr. Smith: Well, let me ask you. So, in the bacteria that really aren’t uropathogens, or at least not common…
Dr. Jackson: Correct.
Dr. Smith: ...uropathogens…in those cases, it’s just better to watch and wait and see how the patient does and not start antibiotic therapy at that point?
Dr. Jackson: Absolutely, so, if a viridans streptococcus grows to 20,000 colony forming units per mL, that is not an infection, and you would not want to treat that child. You need to kind of go back to the drawing board and say, if this is a child with fever and an abnormal urinalysis, but the urine culture is negative, then you have to think about other causes of an abnormal urine, and so I'll give you a perfect example. If you have a six month old who has high fever and is fussy and has a urinalysis that you've checked that has white blood cells in it, but the urine culture is negative, and the child remains highly febrile, think about other things like Kawasaki Disease, for instance.
Dr. Smith: Oh, yeah, okay.
Dr. Jackson: In children six months and younger, they may not have any other clinical criteria, so that's the point that where you want to go back to the drawing board, where the culture does not align with what you are suspecting, and so I mentioned E. coli which is the most common. There are organisms, Klebsiella, Enterobacter, Pseudomonas aeruginosa, also common uropathogens. Enterococcus faecalis is the most common gram positive pathogen, and then occasionally, you'll see other organisms, Serratia, and Citrobacter are seen in children who have ana -- so if you find those in the urine, you might be thinking to yourself -- uh oh, I’m worried now that this child might have some type of anatomic issue with the kidney, too.
Dr. Smith: Right, okay. Well, let me ask you this, Dr. Jackson. You know, everything you just went through was really a good review and obviously, we need to really kind of hone in our approach to a possible UTI because of the overuse of antibiotics, and I think it's becoming really to a critical level, and so what a wonderful review you just did. Is there one more thing that you would just like to tell the practitioners listening to this show about handling pediatric UTIs?
Dr. Jackson: So, here is what I think is the final and most important issue here. If you've used your stringent rules for diagnosis -- so you've added in your clinical clues, you've made a laboratory diagnosis; you've determined that an antibiotic is needed, and now you're going to match your drug to the bug, what you -- using your susceptibility data, two things have to happen next. One, do not use a broad-spectrum agent when you have a narrow spectrum agent that is appropriate for that bug.
Dr. Smith: Right, very good.
Dr. Jackson: So, in our institution, cephalexin is a great antimicrobial in most cases, and you don’t need to use a third generation cephalosporin. Then, the last piece, which I think is very important and then you're going to counsel every time on what you think the expected course should be, and what the risk is with the antibiotics. So, you're going to say, your child does have a urinary tract infection. Looking at the germ, which is E. coli and the most common one we're going to start cephalexin. You should expect that your child's fever will be gone in 48 hours. Cephalexin is very well-tolerated in children, but if your child starts developing diarrhea, and I usually put some guidelines there or develops a rash, I want you to give me a call back, so we can talk...
Dr. Smith: Okay...
Dr. Jackson: ...about that and if the fever persists beyond 48 hours, I absolutely want to see you back.
Dr. Smith: Right, right.
Dr. Jackson: So, I think there are some things that downstream that have to happen once you've made your diagnosis, and you proceeded. Children still need a renal ultrasound -- the under 2 who have first-time UTI and what you're trying to do is look for anatomic abnormalities that are obvious there. They…
Dr. Smith: Right
Dr. Jackson: …do not need…cystograms, so for
Dr. Smith: Ok...
Dr. Jackson: ...for first time episodes.
Dr. Smith: Dr. Jackson, what a -- I felt like I was back in school again.
Dr. Jackson: [chuckle]
Dr. Smith: That was wonderful. Thank you so much.
Dr. Jackson: My pleasure!
Dr. Smith: I want to thank you, too, for the work that you’re doing at Children’s Mercy and for coming on the show. You’re listening to Transformational Pediatrics with Children’s Mercy Kansas City. For more information, you go to childrensmercy.org. That’s childrensmercy.org. I’m Dr. Mike Smith, thanks for listening.
Optimum Antibiotic Use for Pediatric Urinary Tract Infections
Dr. Michael Smith (Host): So, our topic today is optimum antibiotic use for pediatric urinary tract infections. My guest is Dr. Mary Anne Jackson. She is the division director of infectious disease at Children's Mercy Kansas City. Dr. Jackson, welcome to the show.
Dr. Mary Anne Jackson, MD, (Guest): Thank you so much for having me, Dr. Mike.
Dr. Smith: What a big topic, right, because we know there’s a lot of problems with overusing antibiotics and so really honing in on the diagnosis and the proper treatment is becoming critical really, and so just kind of -- what's your take on where we stand right now in treating infections specifically UTI in the pediatric population?
Dr. Jackson: Well, as you know, pediatric urinary tract infections are common. The estimates are there are about 1.6 million pediatric UTI visits every year in the United States –
Dr. Smith: Hmmm.
Dr. Jackson: -- and if infections are properly diagnosed and treated with antibiotics, the outcome is quite good, but what we've seen more recently is inappropriate diagnosis, unnecessary antibiotic use, and the whole issue here on antibiotic use is that antibiotics are great. They save lives. They should be used when they need to be used, but we want to be able to use them wisely. We're facing antibiotic resistance. We’re facing --
Dr. Smith: Right.
Dr. Jackson: -- children with adverse reactions to antibiotics and in terms of pediatric patients, you know, urinary tract infections are so common, and the scope of the problem is similar to dealing with ear infections and sinus infections and strep throat where we really need to make sure that we're making the diagnosis appropriately...
Dr. Smith: Right.
Dr. Jackson: ...and wisely use the antibiotics.
Dr. Smith: Well, let's do this. Let's kind of just walk through the different parts of dealing with a patient who comes in with symptoms of a UTI, and let's just talk about what you're doing and how you think we can improve on all these steps. So, like number one. How can we improve first on just identifying a true urinary tract infection?
Dr. Jackson: That is a great question, and the reason it's important to identify is if they're missed there are chances are that you could get renal scarring, scarring of the kidney or high blood pressure, even end-stage renal disease. So, first thing is who gets a urinary tract infection? These are common in the first couple years of life. They're more common in uncircumcised boys than in boys who have had a circumcision, and they're common in Caucasian girls, particularly those who are under 12 months of age with high fever and no other source. There are some features that might be tip off that pediatricians might target in talking with families where they bring in a child under the age of 2 with a fever and they want to talk about, you know, does the child have a normal urinary stream? Are they going frequently? If they're a little bit older, you know, could they tell do they have urgency, and certainly in the children who are being potty trained, there are some little girls in particular who have voiding dysfunction, and you can kind of identify those because these are the little girls who have the withholding behaviors where they cross their legs or squat down trying not to have to go to the bathroom. Usually, they're very interested in just continuing playing and so...
Dr. Smith: Right.
Dr. Jackson:...those are issues that you can certainly highlight, and then understanding that infants who have fever and vomiting, but have other features of a viral infection such as runny nose, cough, wheezing, rash or diarrhea...
Dr. Smith: Right...that's correct...right, right...
Dr. Jackson:...they don't even need to be evaluated, right?
Dr. Smith: Right...right.
Dr. Jackson:... and then for the older kids, those are the children who may have burning with urination, or you may have more with abdominal pain or back pain, or the child who’s been potty trained and is all of a sudden having a lot of accidents. So, there's a lot that goes into when should we think about it, and then the next step is what do we do about it?
Dr. Smith: Well, yeah, so the what do we do about it...do you feel that at least maybe in the community settings that a lot of healthcare practitioners, once they suspect it, you know, they really feel strongly this is a UTI that they're just starting to treat at that point, and that they're not collecting specimens? You think that's a problem?
Dr. Jackson: That is absolutely a problem, and the CDC has identified that. Occasionally, a urinalysis has been obtained, but no culture is done, and so the steps in confirming the urinary tract infection involve obtaining a proper specimen, sending a urinalysis, and if the urinalysis is abnormal, sending the urine culture so that can guide what type of antibiotics...
Dr. Smith: Right, right...
Dr. Jackson:...you use because you'd like to match the drug and the bug and use the best antibiotic, and that's not always being done, and so this starts with, you know, when you obtain a urinary specimen in a child, particularly who's not potty trained, how do you do that -- and that…
Dr. Smith: Yeah…
Dr. Jackson: … becomes a dilemma in practice.
Dr. Smith: Yeah, well it's a good...because it's not as simple as people maybe think, right? [chuckle] So, what are some of the techniques or hints or tips you can give to really improving that process of specimen collection?
Dr. Jackson: Well, as you might guess, the easiest way to obtain a urine specimen in a child who is not potty trained is to use a so-called bag, get a bag urine, and the bag urine is ok as long as you're not going to use it for the culture, and as long as you're not going to prescribe any antibiotic without getting a culture. So, a bag…
Dr. Smith: Okay.
Dr. Jackson: …urine is great. It's a great way to start the evaluation and so if the child has unexplained fever and is not severely ill, and you're not going to use an antibiotic, the first thing you do is put that bag urine on and then do the urinalysis and test it, and we can talk about testing in just a bit. But, if that urinalysis is abnormal, you must take the next step, and the next step is getting an appropriate specimen for culture which is a catheterized urine specimen, and the reason for this...
Dr. Smith: Right, right...
Dr. Jackson: ...is bag urines are notoriously contaminated...
Dr. Smith: Conta- yeah, yeah, yeah, right...
Dr. Jackson: ...with bacteria, and you may needlessly treat a child with an antibiotic.
Dr. Smith: That's right, that's right. So, that's probably one of the problems, too, is they're doing the bag collection but stopping at that point and just starting or initiating treatment. So, you mentioned about the urinalysis...what are...are we...do we get a little bit lazy in the community setting, and we're not interpreting the UAs correctly? Do you see that there's a problem at that interpretation level?
Dr. Jackson: Occasionally, I think that's the case, and so here's what I recommend that people look for. So, we want to make sure they look for nitrites, and nitrites that are positive -- this is on the dipstick -- the child is likely to have a urinary tract infection. Leukocyte esterase, possibly likely to have a urinary tract infection…
Dr. Smith: Right.
Dr. Jackson: …and if they look for white blood cells, they need to look for white blood cyells that are greater than five. Occasionally, you can be fooled in a child who's voiding frequently, and you might miss the nitrites, but there is a very reliable way to look at the urine, assuming that the child has not had the urine in the bladder for, you know, for a very short…
Dr. Smith: Okay.
Dr. Jackson: …period of time where you might get a negative finding.
Dr. Smith: Right.
Dr. Jackson:... but to use that urine and then to interpret the urinalysis and then decide about your next step, and let's just mention also that for the child who is potty trained, we do the so-called clean catch urine, and the only problem here is as many as 25% can be contaminated. So, folks do need to look at that, and I have some pearls for looking at your information once you get to the culture point, but my tip on using the clean catch is urines in little girls is there has to be some counseling for the parents for how to do this. I like to turn the little -- these are predominately little girls. Once you get over a year, urinary tract infections in boys are very uncommon.
Dr. Smith: Right, right.
Dr. Jackson: ...but with a little girl who’s potty trained, you need to clean them, parents need to be instructed -- I actually have them sit backwards on the toilet. Some people believe this is a better way to get a urine sample. They have to void first, and then you're going to collect the specimen, and so clean-catch specimens in little ones who are potty trained and bag specimens to start, but then using a catheterized urine specimen in the child who has a bag urine that is abnormal.
Dr. Smith: Ok. So, yeah, when we get to that specimen level, and we've done the appropriate way of collecting it based on the patient, what are some of the things you're looking for at that point with the specimen?
Dr. Jackson: So, we've talked about looking for so called nitrites and leukocyte esterase and white blood cells and bacteria. Those are going to be all indicators to tell you whether or not you need to proceed with the culture of the specimen, and then this is where the pearls really come in in interpreting a culture. So, there are three different factors that you want to look at. So, you have a child where -- oh I think this is a child with a urinary tract infection; I'm obtaining -- let's just say this is a 2 year old who's not potty trained. I got the bag specimen, and it looks like there may be infection. Now, I’ve obtained a catheterized specimen in that 2 year old, and again, the urinalysis is abnormal, and I’ve sent that for culture -- not all of the cultures come back. First question, is there a single organism? That's the first thing you look at.
Dr. Smith: Okay.
Dr. Jackson: The second thing would be is the organism a pathogen that causes urinary tract infection, and the third thing is -- is the organism present in a significant colony count, which is 50,000 colony…
Dr. Smith: Okay.
Dr. Jackson: …forming units per mL or greater. So, single organism, first off the bat, if you have, for instance, 5,000 colonies of E. coli and 25,000 colonies of a viridans streptococci, that is not an infection. Stop. There is no need for antibiotics in that particular patient, assuming they've not been exposed to antibiotics.
Dr. Smith: Okay.
Dr. Jackson: If they have greater than 100,000 colonies of Staphylococcus epidermidis, which is skin flora…
Dr. Smith: Right.
Dr. Jackson: …in a, you know, significant colony count, that's not a uropathogen in the vast majority of children -- and meaning a child who doesn't have some type of abnormality within the urinary tract. On the other hand, if you have three different organisms, that is a contaminated urine specimen. It is unevaluable, so, what you want to start with is -- is it an organism that's identified as a single organism, in high colony count, that's a uropathogen. What you're looking at and for is E. coli greater than 100,000 colony units per mL, single organism, and then you need to match up your drug and bug…
Dr. Smith: Right, right.
Dr. Jackson: …and so those are the keys there.
Dr. Smith: Well, let me ask you. So, in the bacteria that really aren’t uropathogens, or at least not common…
Dr. Jackson: Correct.
Dr. Smith: ...uropathogens…in those cases, it’s just better to watch and wait and see how the patient does and not start antibiotic therapy at that point?
Dr. Jackson: Absolutely, so, if a viridans streptococcus grows to 20,000 colony forming units per mL, that is not an infection, and you would not want to treat that child. You need to kind of go back to the drawing board and say, if this is a child with fever and an abnormal urinalysis, but the urine culture is negative, then you have to think about other causes of an abnormal urine, and so I'll give you a perfect example. If you have a six month old who has high fever and is fussy and has a urinalysis that you've checked that has white blood cells in it, but the urine culture is negative, and the child remains highly febrile, think about other things like Kawasaki Disease, for instance.
Dr. Smith: Oh, yeah, okay.
Dr. Jackson: In children six months and younger, they may not have any other clinical criteria, so that's the point that where you want to go back to the drawing board, where the culture does not align with what you are suspecting, and so I mentioned E. coli which is the most common. There are organisms, Klebsiella, Enterobacter, Pseudomonas aeruginosa, also common uropathogens. Enterococcus faecalis is the most common gram positive pathogen, and then occasionally, you'll see other organisms, Serratia, and Citrobacter are seen in children who have ana -- so if you find those in the urine, you might be thinking to yourself -- uh oh, I’m worried now that this child might have some type of anatomic issue with the kidney, too.
Dr. Smith: Right, okay. Well, let me ask you this, Dr. Jackson. You know, everything you just went through was really a good review and obviously, we need to really kind of hone in our approach to a possible UTI because of the overuse of antibiotics, and I think it's becoming really to a critical level, and so what a wonderful review you just did. Is there one more thing that you would just like to tell the practitioners listening to this show about handling pediatric UTIs?
Dr. Jackson: So, here is what I think is the final and most important issue here. If you've used your stringent rules for diagnosis -- so you've added in your clinical clues, you've made a laboratory diagnosis; you've determined that an antibiotic is needed, and now you're going to match your drug to the bug, what you -- using your susceptibility data, two things have to happen next. One, do not use a broad-spectrum agent when you have a narrow spectrum agent that is appropriate for that bug.
Dr. Smith: Right, very good.
Dr. Jackson: So, in our institution, cephalexin is a great antimicrobial in most cases, and you don’t need to use a third generation cephalosporin. Then, the last piece, which I think is very important and then you're going to counsel every time on what you think the expected course should be, and what the risk is with the antibiotics. So, you're going to say, your child does have a urinary tract infection. Looking at the germ, which is E. coli and the most common one we're going to start cephalexin. You should expect that your child's fever will be gone in 48 hours. Cephalexin is very well-tolerated in children, but if your child starts developing diarrhea, and I usually put some guidelines there or develops a rash, I want you to give me a call back, so we can talk...
Dr. Smith: Okay...
Dr. Jackson: ...about that and if the fever persists beyond 48 hours, I absolutely want to see you back.
Dr. Smith: Right, right.
Dr. Jackson: So, I think there are some things that downstream that have to happen once you've made your diagnosis, and you proceeded. Children still need a renal ultrasound -- the under 2 who have first-time UTI and what you're trying to do is look for anatomic abnormalities that are obvious there. They…
Dr. Smith: Right
Dr. Jackson: …do not need…cystograms, so for
Dr. Smith: Ok...
Dr. Jackson: ...for first time episodes.
Dr. Smith: Dr. Jackson, what a -- I felt like I was back in school again.
Dr. Jackson: [chuckle]
Dr. Smith: That was wonderful. Thank you so much.
Dr. Jackson: My pleasure!
Dr. Smith: I want to thank you, too, for the work that you’re doing at Children’s Mercy and for coming on the show. You’re listening to Transformational Pediatrics with Children’s Mercy Kansas City. For more information, you go to childrensmercy.org. That’s childrensmercy.org. I’m Dr. Mike Smith, thanks for listening.