Other measures:

• Management of fever

• Encourage fluid consumption

• Potassium citrate mixture or local application of zinc paste in children with acute dysuria.

Investigations:
Mandatory in ALL patients with bacteriologically proven urinary infection.

Principles:
(a) to detect or exclude obstructions
(b) to ascertain whether the kidneys are involved
(c) to discover any etiological factor.
During the acute infection ultrasonography of the abdomen is done. USG is a simple non invasive technique which can exclude obstruction, assess solid/cystic masses, bladder capacity, residual urine and renal size. But it does not provide information on kidney functions or inflammation. It is unreliable in detecting renal scaring or in demonstrating VUR. If pyelonephritis is strongly suspected a DMSA scan is indicated. 3 weeks after treatment of acute infection all children should have a voiding cystourethrography to assess reflux (found in 25% of all children < 10 years of age with asymptomatic or symptomatic bacteriuria). If vesicoureteral reflux is present an IVP with nephrotomography or radioisotopic renal scanning with DMSA or glucoheptanate to evaluate kidney size and detect renal scars is indicated.

Further management
1. Relief of obstruction.
2. Prevention of recurrence of infection.
(a) Low dose prophylaxis with antibiotics. A single dose is given at bed time to cover the longest period without voiding. (doses mentioned in previous table)

Indications:

• Repeated symptomatic UTI prophylaxis given (for 6-12 months)

• Obstructive uropathy/neurogenic bladder/calculi

• Medical management VUR GI-III

• After ureteric reimplantation

• Renal scarring

• After treatment of acute infection until radiologic evaluation.

(b) Plenty of fluids and frequent voiding with double voiding at bedtime.
(c) Correct constipation
(d) Circumcision to reduce periurethral bacterial colonization.

3. Follow up
(a) Clinical – Look for hypertension Monitor growth
(b)Urine culture and sensitivity – 3 monthly for at least one year even in the absence of anatomical abnormalities.
(c)Imaging – Once every year if VUR is present
(d)Renal function – If evidence of renal damage is present
(e) Monitoring for evidence of drug toxicity in patients on chemoprophylaxis (anemia ‘ leukopenia)

Conclusion
1. The signs of UTI may be nonspecific. Examine the urine in all ill children if the clinical diagnosis is uncertain even if nothing else suggests UTI.
2. The main objectives in the management are
(a) Prevention and limitation of renal scarring by early recognition and treatment of UTI with investigations of the urinary tract to identify those at risk of renal damage.
(b) To prevent recurrent symptomatic infection in those children with no structural abnormality by establishing good drinking, voiding and bowel habits under cover of low dose antibacterials.