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Urinary tract infections in children

Nature Reviews Urology (2026)Cite this article

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Abstract

Bacterial urinary tract infections (UTIs) are prevalent in childhood and adolescence. Paediatric UTIs present unique challenges with respect to diagnosis, prevention and management, and the potential for adverse sequelae. Uropathogenic Escherichia coli (UPEC) accounts for the majority of UTIs and is the best studied uropathogen. Novel discoveries have advanced our understanding of host–pathogen interactions, cellular and molecular mechanisms of host defence, and risk factors for UTI recurrence. Emerging evidence also highlights an association of the gut, vaginal and urinary microbiota in influencing UTI risk and recurrence. Yet, key knowledge gaps persist regarding UTI pathogenesis, host susceptibility, optimal diagnostic and management strategies and prevention of UTI recurrence and sequelae, especially in paediatric populations. The development of standardized clinical pathways offers an opportunity to improve care consistency and outcomes by integrating evidence-based practices into routine management. As technologies evolve and understanding deepens, future efforts must integrate host, microbial and clinical insights to optimize UTI prevention and treatment in paediatric populations.

Key points

  • The bladder presents a challenging niche for colonization; consequently, bacterial uropathogens have evolved strategies to establish infection and evade host immune defences.

  • Kidney immune cells operate within a complex environment in which urothelial cells produce antimicrobial peptides and chemokines, leading to neutrophil recruitment and formation of neutrophil extracellular traps.

  • The risk factors that contribute to urinary tract infection (UTIs) and renal scarring include congenital abnormalities, such as vesicoureteral reflux, along with bowel and bladder dysfunction and genetic polymorphisms.

  • Current strategies for UTI management include accurate diagnosis and judicious use of antibiotics for effective treatment as well as prophylaxis.

  • With increasing prevalence of paediatric UTIs, development and implementation of robust clinical pathways will be vital for improving patient care and outcomes.

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Fig. 1: Overview of major uropathogenic Escherichia coli virulence factors.
Fig. 2: Antimicrobial properties of urothelium.
Fig. 3: Roles of immune phagocytes during urinary tract infection.
Fig. 4: Immune defences of the kidney.
Fig. 5: Innate immune properties of kidney intercalated cells during urinary tract infection.

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Author information

Authors and Affiliations

  1. The Kidney and Urinary Tract Center, Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, OH, USA

    Preeti P. John, Juan de Dios Ruiz-Rosado, Laura Schwartz, Christina Ching, Denise Kimbrough & Brian Becknell

  2. Department of Medicine, Division of Infectious Diseases, University of Pittsburgh, Pittsburgh, PA, USA

    Laura Mike

  3. Department of Medicine, Section of Infectious Diseases and Department of Molecular Virology and Microbiology, Huffington Center of Aging, Baylor College of Medicine, Houston, TX, USA

    Indira U. Mysorekar

  4. Division of Nephrology and Hypertension, Nationwide Children’s Hospital, Columbus, OH, USA

    Juan de Dios Ruiz-Rosado, Laura Schwartz, Denise Kimbrough & Brian Becknell

  5. Cellular Genetics, Wellcome Sanger Institute, Hinxton, UK

    Menna Clatworthy

  6. Department of Medicine and Cambridge Institute of Therapeutic Immunology and Infectious Disease, University of Cambridge, Cambridge, UK

    Menna Clatworthy

  7. Department of Pediatric Urology, Nationwide Children’s Hospital, Columbus, OH, USA

    Christina Ching

  8. Division of General Academic Pediatrics, Children’s Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA

    Nader Shaikh

  9. Division of Urology, McMaster Pediatric Surgery Research Collaborative, Department of Surgery, and Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada

    Luis Braga

  10. Division of Pediatric Nephrology and Hypertension, Riley Hospital for Children, Indianapolis, IN, USA

    Evan Rajadhyaksha & David Hains

  11. Division of Infectious Diseases, Nationwide Children’s Hospital, Columbus, OH, USA

    Joshua Watson

Authors
  1. Preeti P. John
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  2. Laura Mike
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  3. Indira U. Mysorekar
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  4. Juan de Dios Ruiz-Rosado
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  5. Menna Clatworthy
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  6. Laura Schwartz
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  7. Christina Ching
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  8. Denise Kimbrough
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  9. Nader Shaikh
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  10. Luis Braga
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  11. Evan Rajadhyaksha
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  12. David Hains
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  13. Joshua Watson
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  14. Brian Becknell
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Contributions

The authors contributed equally to all aspects of the article.

Corresponding author

Correspondence to Brian Becknell.

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The authors declare no competing interests.

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Nature Reviews Urology thanks Stephen Shei-Dei Yang, Pankaj Hari and Jitendra Meena for their contribution to the peer review of this work.

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Related links

Nationwide Children’s: https://www.nationwidechildrens.org/for-medical-professionals/tools-for-your-practice/clinical-pathways

UTICalc: https://uticalc.pitt.edu

Glossary

Acute kidney injury

Rapid deterioration of renal excretory function.

Carbonic anhydrase II

(CAII). Enzyme that is essential for acid–base regulation.

Congenital anomalies of the kidney and urinary tract

(CAKUT). Group of developmental abnormalities that affect the kidneys, bladder, ureters and urethra.

Cystitis

Bladder inflammation commonly caused by bacterial infection. Symptoms include urinary urgency, frequency and lower abdominal pain.

Dimercaptosuccinic acid scan

(DMSA scan). Nuclear medicine test used to image kidneys to assess renal structure and function.

Dysbiosis

Imbalance of the microbiome potentially caused by infections, antibiotics, stress or poor diet.

Fusiform vesicles

(FVs). Intracellular compartments that transport urothelial plaques to the bladder epithelial surface.

Macrophage extracellular traps

(METS). Net-like structures produced by macrophages that are composed of DNA strands, histones and proteins, which entrap and kill pathogens.

Neutrophil extracellular traps

(NETs). Net-like structures composed of DNA strands, histones and proteins, produced by neutrophils, that entrap and kill pathogens.

Principal cells

Cell type in the kidney’s collecting duct that regulates electrolyte and water balance.

Promoter polymorphisms

Variation in a gene’s promotor region that may alter the expression of the gene.

Pyelonephritis

Kidney inflammation caused by bacterial infection with symptoms such as fever and flank pain.

Quiescent intracellular reservoirs

(QIRs). Persistent reservoirs of Escherichia coli in the bladder mucosa following initial invasion of bladder epithelial cells and infection of the bladder.

Renal scarring

Fibrosis of the kidney parenchyma caused by inflammation, infection and injury resulting in kidney disease.

Tamm–Horsfall glycoprotein

(THP or uromodulin). Major urinary protein that prevents Escherichia coli from binding to urothelium.

Tubulo-interstitial nephritis

Inflammation of the renal interstitium and tubules owing to autoimmune diseases, infections or drugs.

UTICalc

Paediatric UTI probability calculator based on clinical variables.

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John, P.P., Mike, L., Mysorekar, I.U. et al. Urinary tract infections in children. Nat Rev Urol (2026). https://doi.org/10.1038/s41585-026-01130-1

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