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uro.uti.pediatric.v1

Pediatric UTI (neonate / infant / older child / adolescent; VUR, recurrent, dysfunctional voiding)

urologyacutepediatricneonataloutpatientacuteinpatient
Start encounter →Print handoutPRODUCTION

shard-3-neuro-sym Phase C wave-11 2026-05-15 — initial author at INTEGRATED with full §5.5 contract depth. 11 phenotypes encoded as severity_triggers covering full pediatric UTI spectrum: infant_under_2mo_with_fever_workup (routes to peds.febrile-infant.core.v1), febrile_uti_2_to_24_mo (AAP Bagga), afebrile_cystitis_older_child_adolescent, first_uti_in_male (always abnormal — PUV / VUR workup), VUR_grade_3_to_5_diagnosed (RIVUR / PRIVENT prophylaxis or surgery), congenital_anomaly_UTI, recurrent_pediatric_uti (DMSA + urology), dysfunctional_voiding_uti (routes to uro.urinary-incontinence-eval.v1), breakthrough_uti_on_prophylaxis, circumcision_status_male_UTI_risk, toilet_training_associated_uti. 5 setting playbooks span home (caregiver recognition + when to call) → outpatient (catheter/SPA collection + AAP imaging algorithm) → ed (STAT workup + IV ceftriaxone or amp+gent if <2 mo + sepsis workup) → inpatient (IV-to-PO step-down + US + VCUG planning) → icu (pediatric urosepsis SCC 2026 pediatric bundle). AAP 2011 algorithm: catheter or SPA UA + culture in <2 yo (bag urine NOT diagnostic); diagnostic threshold ≥50,000 CFU/mL (catheter) or ≥10,000 CFU/mL (SPA) with pyuria; renal + bladder US after first febrile UTI 2–24 mo; VCUG only if atypical / recurrent febrile / abnormal US; DMSA if recurrent. Empiric: <2 mo fever → IV amp + IV gent (full sepsis workup); 2–24 mo febrile UTI → IV ceftriaxone (admit) or oral cefixime / cefdinir (low-risk); older child afebrile cystitis → amoxicillin / cephalexin / TMP-SMX × 7–10 d per local resistance. VUR grade III–V → continuous low-dose prophylaxis (TMP-SMX 2 mg/kg/day or nitrofurantoin 1–2 mg/kg/day qhs) × 6–12 mo (RIVUR 2014 PMID 24795142; AAP 2011 PMID 21873693); surgery if failed prophylaxis or worsening anatomy. AVOID classes: fluoroquinolones (cartilage), tetracyclines <8 yo (teeth), sulfa <2 mo (kernicterus), nitrofurantoin in pyelo (no renal tissue penetration) and <1 mo (G6PD). Circumcision discussion (AAP 2012 — informed parental decision) for recurrent UTI in uncircumcised male infant; ~10× UTI risk in first year. Dysfunctional voiding / bowel-bladder dysfunction is a leading cause of recurrent pediatric UTI — routes to uro.urinary-incontinence-eval.v1 for behavioural + laxative pathway. Sibling pivots: uro.uti.uncomplicated.v1 (adult parallel), uro.uti.complicated.v1 (adult parallel with complicating factor), peds.febrile-infant.core.v1 (<2 mo workup leads) — all resolve to real engines in ALL_DOSSIERS. 2026-05-22 citation remediation — all PMIDs live-verified on PubMed; mis-attributed placeholders replaced with verified anchors; RxCUIs reverse-verified on RxNav. Schema-blocked downstream: peds.vur.v1, peds.posterior-urethral-valves.v1, calc.pediatric_uti_score, protocol.aap_uti_imaging_2011, workup.dmsa_scintigraphy, workup.vcug — none yet in clinical-tools-registry.ts. Tickets surfaced in depth brief §10. Dossier registered in _registry.ts as part of this commit (Phase C wave-11 commit-race v2; shard-3 explicit scope).

Entry points (8)

  • demographic
    Infant <2 mo with rectal temperature ≥38.0°C — UTI is on the differential; FULL workup pathway (peds.febrile-infant.core.v1) (AAP 2011)
    age_under_2mo_with_fever
  • symptom
    Febrile child 2–24 mo without clear source — UA + culture per AAP 2011 Bagga criteria (PMID 21873693)
    febrile_2_to_24mo_no_clear_source
  • symptom
    Verbal child / adolescent with dysuria + frequency + urgency (similar to adult uncomplicated cystitis)
    dysuria_in_older_child_or_adolescent
  • demographic
    First UTI in a male child — ALWAYS abnormal until proven otherwise (posterior urethral valves / VUR workup) (AAP 2011)
    first_uti_in_male_child
  • history
    ≥3 UTIs in 12 mo OR ≥2 febrile UTIs in 6 mo → DMSA + urology (AAP 2011; RIVUR 2014)
    recurrent_pediatric_uti
  • lab_abnormality
    Known vesicoureteral reflux grade III–V → prophylaxis or surgical pathway (RIVUR; PRIVENT)
    VUR_known_grade_3_to_5
  • history
    Known congenital anomaly (posterior urethral valves, ureteropelvic junction obstruction, neurogenic bladder) (AUA pediatric)
    congenital_anomaly_urinary_tract
  • history
    Dysfunctional voiding / encopresis / holding — predisposes to UTI (route to uro.urinary-incontinence-eval.v1 cross-engine)
    dysfunctional_voiding_pattern

Required inputs (23)

  • age_monthsrequired
    demographic • used at FRAME
    Age stratifies risk and workup intensity: <2 mo → full sepsis workup; 2–24 mo → AAP Bagga; >24 mo → similar to adult cystitis (AAP 2011 PMID 21873693)
  • sexrequired
    demographic • used at FRAME
    Male UTI is uncommon and ALWAYS abnormal until proven otherwise (PUV, VUR); female anatomy more permissive (AAP 2011)
  • weight_kgrequired
    demographic • used at TREATMENT
    All pediatric dosing is weight-based (mg/kg/day) (AAP 2011)
  • circumcision_status_malerequired
    history • used at CONTEXT
    Uncircumcised male infants have ~10× UTI risk in first year vs circumcised; counsel parents in recurrent cases (AAP 2011)
  • prior_uti_countrequired
    history • used at CONTEXT
    Recurrent ≥3 / 12 mo or ≥2 febrile / 6 mo → DMSA + urology referral (AAP 2011)
  • known_vur_graderequired
    history • used at CONTEXT
    Grade III–V → prophylaxis (RIVUR / PRIVENT) or surgical reimplantation; grade I–II usually conservative
  • known_congenital_anomalyrequired
    history • used at CONTEXT
    PUV, UPJ obstruction, neurogenic bladder, duplex system → urology co-management; expanded empirics
  • dysfunctional_voiding_or_constipationrequired
    history • used at CONTEXT
    Holding, encopresis, constipation → behavioural / bowel-bladder dysfunction; routes to uro.urinary-incontinence-eval.v1
  • recent_antibioticsrequired
    history • used at CONTEXT
    Recent abx → resistance pattern shift; avoid prior agent (AAP 2011)
  • prophylaxis_status
    history • used at CONTEXT
    On prophylaxis breakthrough → resistance pattern; switch agent (RIVUR)
  • toilet_training_status
    history • used at CONTEXT
    Recent toilet training → behavioural UTI risk window
  • temprequired
    vital • used at RED_FLAGS
    Fever ≥38.0°C drives febrile-UTI pathway (admission threshold lower in <2 mo)
  • sbprequired
    vital • used at RED_FLAGS
    Hypotension → urosepsis ICU pathway (id.sepsis.peds.v1 + SCC 2026 pediatric)
  • ill_appearancerequired
    symptom • used at RED_FLAGS
    Toxic / ill-appearing infant → admit + IV abx regardless of UA results
  • urinalysis_catheter_or_spa_under_2yorequired
    lab • used at INITIAL_WORKUP
    Children <2 yo (or non-toilet-trained) — catheter or SPA only (bag urine has false-positive rate too high for diagnosis) (AAP 2011)
  • urine_culture_catheter_or_spa_under_2yorequired
    lab • used at INITIAL_WORKUP
    Catheter culture ≥50,000 CFU/mL OR SPA ≥10,000 CFU/mL with pyuria — diagnostic threshold (AAP 2011)
  • cbc
    lab • used at INITIAL_WORKUP
    Leukocytosis / left shift → severity; thrombocytopenia → sepsis (pediatric SSC 2020)
  • bmprequired
    lab • used at INITIAL_WORKUP
    Renal function for dose adjustment + AKI staging (KDIGO 2026)
  • crp_pct
    lab • used at INITIAL_WORKUP
    CRP/PCT pediatric severity adjunct (panel.inflammation)
  • blood_culture
    lab • used at INITIAL_WORKUP
    STAT in <2 mo + ill-appearing + admitted patients (peds.febrile-infant.core.v1)
  • renal_bladder_us_after_first_febrile_utirequired
    imaging • used at BRANCHING_WORKUP
    AAP 2011 — renal + bladder ultrasound after first febrile UTI (2–24 mo) to rule out obstruction and anatomic anomaly
  • vcug_if_atypical_or_recurrent_or_abnormal_us
    imaging • used at BRANCHING_WORKUP
    AAP 2011 — VCUG only if recurrent febrile UTI OR abnormal US OR atypical organism; not first-line
  • current_meds_pediatricrequired
    medication • used at TREATMENT
    Family-shared meds; allergy history; recent abx (AAP 2011)

12-phase flow (12)

  1. 1FRAME
    Pediatric patient (neonate through adolescent) with possible UTI — age, sex, congenital anomaly status, dysfunctional voiding pattern, prior UTI history. <2 mo + fever → route to peds.febrile-infant.core.v1 for full sepsis workup; first UTI in male child → ALWAYS abnormal workup (AAP 2011)
    inputs: age_months, sex, circumcision_status_male, known_vur_grade, known_congenital_anomaly
    advance: engine scope confirmed
  2. 2ENTRY
    Fever in <2 mo / 2–24 mo without source / verbal dysuria in older child / first UTI in male / recurrent / known VUR / dysfunctional voiding (AAP 2011)
    advance: entry captured
  3. 3CONTEXT
    Age, sex, weight, circumcision, prior UTI count, prophylaxis status, dysfunctional voiding, constipation, congenital anomaly, recent abx, toilet training (AAP 2011; RIVUR; PRIVENT)
    inputs: weight_kg, prior_uti_count, dysfunctional_voiding_or_constipation, recent_antibiotics, prophylaxis_status, toilet_training_status, current_meds_pediatric
    advance: context complete
  4. 4RED_FLAGS
    <2 mo with fever → full sepsis workup + admit; ill / toxic appearance → admit + IV abx; hypotension / shock → ICU + pediatric sepsis bundle (peds.febrile-infant.core.v1; SCC 2026 pediatric)
    inputs: temp, sbp, ill_appearance
    advance: no red flags OR routes engaged
  5. 5INITIAL_WORKUP
    UA + urine culture via CATHETER or SPA in <2 yo (bag urine NOT acceptable for diagnosis); CBC + BMP; blood culture if admitting; CRP/PCT adjunct; LP if <2 mo + ill (peds.febrile-infant.core.v1) (AAP 2011)
    inputs: urinalysis_catheter_or_spa_under_2yo, urine_culture_catheter_or_spa_under_2yo, cbc, bmp, crp_pct, blood_culture
    actions: panel.ua, panel.renal, panel.cbc, panel.inflammation
    advance: workup tier selected
  6. 6BRANCHING_WORKUP
    AAP 2011 imaging algorithm: renal + bladder US after first febrile UTI (2–24 mo); VCUG only if recurrent febrile / abnormal US / atypical organism; DMSA scintigraphy if recurrent pediatric UTI (≥3/12 mo or ≥2 febrile/6 mo) — driven by AAP / RIVUR / PRIVENT (AAP 2011; RIVUR 2014; DMSA studies)
    inputs: renal_bladder_us_after_first_febrile_uti, vcug_if_atypical_or_recurrent_or_abnormal_us
    advance: imaging plan documented
  7. 7DIFFERENTIAL
    Pediatric UTI vs viral illness vs occult bacteremia vs vulvovaginitis (girls) vs balanitis (boys) vs appendicitis (often presents atypically with urinary symptoms in children) vs nephrolithiasis vs encopresis-related (AAP 2011)
    advance: differential narrowed
  8. 8RISK_STRATIFICATION
    Severity (ill-appearance, sepsis screen), age tier (<2 mo / 2–24 mo / >24 mo), sex, prior history, VUR grade if known, prophylaxis status (AAP 2011)
    advance: tier selected
  9. 9TREATMENT
    STEP 1 <2 mo fever → IV ampicillin + gentamicin OR IV ampicillin + cefotaxime + admit; STEP 2 febrile UTI 2–24 mo → IV ceftriaxone (admit) OR oral cefixime / cefdinir / cefpodoxime (low-risk + reliable follow-up); STEP 3 afebrile cystitis older child → amoxicillin / cephalexin / TMP-SMX × 7–10 d; STEP 4 known VUR grade III–V → continuous TMP-SMX or nitrofurantoin low-dose prophylaxis OR surgical correction; STEP 5 candiduria — only treat if symptomatic / IC; STEP 6 AVOID FQ (cartilage), tetracyclines <8 yo, sulfa in <2 mo (kernicterus) (AAP 2011; RIVUR)
    inputs: weight_kg, current_meds_pediatric
    advance: regimen prescribed
  10. 10DISPOSITION
    Admit if <2 mo / ill / toxic / non-PO / failed outpatient / pyelonephritis / known severe VUR with breakthrough; discharge with oral abx + 24–48 h follow-up otherwise (AAP 2011)
    advance: disposition documented
  11. 11MONITORING
    Symptom resolution at 48–72 h; culture results 24–48 h → tailor; recheck after course; imaging follow-up per AAP algorithm
    advance: monitoring plan documented
  12. 12FOLLOWUP
    Renal + bladder US in 2–24 mo after first febrile UTI; VCUG if atypical / recurrent / abnormal US; DMSA if recurrent; urology referral if VUR / anatomic anomaly / male / recurrent; prophylaxis discussion (RIVUR / PRIVENT); dysfunctional voiding pathway (uro.urinary-incontinence-eval.v1); circumcision discussion in recurrent uncircumcised (AAP 2011)
    advance: follow-up + imaging plan documented