See also: NICE Guidelines These local guidelines are in conjunction with NICE UTI Algorithms Renal scarring and subsequent nephropathy are important causes of later hypertension and renal failure. Early diagnosis is essential, especially in infants, because this is the most vulnerable age for renal scarring. Healthcare professionals should ensure that when a child or young person has been identified as having a suspected UTI, they and their parents or carers as appropriate are given information about the need for treatment, the importance of completing any course of treatment and advice about prevention and possible long term management. NICE has recently provided comprehensive guidance on this topic, which largely seeks to minimize perceived unnecessary management and investigation, whilst maintaining good clinical governance. These guidelines should be followed. DIAGNOSIS Presenting symptoms and signs in infants and children with UTI Age group Symptoms and signs Infants younger than 3 months unexplained fever of 38 C or higher, Vomiting, Lethargy, Irritability, Poor feeding, Failure to thrive, Abdominal pain, Jaundice, Haematuria, Offensive urine Infants and children, 3 months or older Preverbal unexplained fever of 38 C or higher, Abdominal pain, Loin tenderness, Vomiting, Poor feeding, Lethargy, Irritability, Haematuria, Offensive urine, Failure to thrive Verbal Frequency, Dysuria Dysfunctional voiding, Changes to continence, Abdominal pain, Loin tenderness, unexplained fever of 38 C or higher, Malaise, Vomiting, Haematuria, Offensive urine, Cloudy urine Indications for urine examination (also see algorithm and NICE fever guidelines) All cases of: Urinary symptoms frequency, dysuria, Unexplained prolonged fever, Unexplained vomiting or abdominal pain or Enuresis, Haematuria, Hypertension, Prolonged neonatal jaundice, Faltering growth, Suspected sexual abuse
Other cases to be considered: Ill infants at home with a temperature above 38 ºC of uncertain cause Non specific illness Urine Specimens Older children clean catch (mid stream in later childhood) Infants CLEAN CATCH should be ROUTINE with help of the parents or carer. If a clean catch urine sample is unobtainable: Other non invasive methods such as urine collection pads should be used. Cotton wool balls, gauze and sanitary towels should not be used to collect urine in infants and children. When it is not possible or practical to collect urine by non invasive methods, catheter samples or SPA should be used. Before SPA is attempted, ultrasound guidance should be used to demonstrate the presence of urine in the bladder. In an infant or child with a high risk of serious illness it is highly preferable that a urine sample is obtained; however, treatment should not be delayed if a urine sample is unobtainable. If urine is to be cultured but cannot be cultured within 4 hours of collection, the sample should be refrigerated or preserved with boric acid immediately. Dipstix: If both leukocyte esterase and nitrite are positive: The child should be regarded as having UTI and antibiotic treatment should be started. If a child has a high or intermediate risk of serious illness and/or a past history of previous UTI, a urine sample should be sent for culture. If leukocyte esterase is negative and nitrite is positive: Antibiotic treatment should be started if the urine test was carried out on a fresh sample of urine. A urine sample should be sent for culture. Subsequent management will depend upon the result of urine culture. If leukocyte esterase is positive and nitrite is negative: A urine sample should be sent for microscopy and culture. Antibiotic treatment for UTI should not be started unless there is good clinical evidence of UTI (for example, obvious urinary symptoms). Leukocyte esterase may be indicative of an infection outside the urinary tract which may need to be managed differently. If both leukocyte esterase and nitrite are negative: The child should not be regarded as having UTI. Antibiotic treatment for UTI should not be started, and a urine sample should not be sent for culture. Other causes of illness should be explored.
Indications for culture Urine samples should be sent for culture: in infants and children who have a diagnosis of acute pyelonephritis/upper urinary tract infection in infants and children with a high to intermediate risk of serious illness in infants and children under 3 years in infants and children with a single positive result for leukocyte esterase or nitrite in infants and children with recurrent UTI in infants and children with an infection that does not respond to treatment within 24 48 hours, if no sample has already been sent When clinical symptoms and dipstick tests do not correlate. Remember! URINE DIPSTIX result in children under 1 year is unrelieable. Use RED TOPPED CONTAINERS (contain boric acid), which inhibits bacterial growth in the container and allows longer storage DOCUMENT VERY CLEARLY IN THE NOTES WHETHER (AND HOW) A URINE SAMPLE HAS BEEN OBTAINED AND ALSO WHEN SENT TO THE LAB. DOCTOR TO CONTACT MICROBIOLOGY TO ARRANGE URGENT MICROSCOPY when Appropriate Microscopy results and indications for culture : Interpretation of microscopy results Microscopy results Pyuria positive Pyuria negative Bacteriuria positive Bacteriuria negative Criteria for diagnosis of UTI The infant or child should be regarded as having UTI Antibiotic treatment should be started if clinically UTI The infant or child should be regarded as having UTI The infant or child should be regarded as not having UTI Relevant clinical suspicion plus: Pure growth of >10 5 bacteria / microlitre (=mm 3 ) Repeat culture if lower counts occur persistently, particularly in a boy. Dipstix see above. Microscopy Urgent for presumptive diagnosis of UTI in children under 3 years. Notes: Pyuria greater than 10 white cells / microlitre not diagnostic may be useful if child is on antibiotics or in absence of genital inflammation Absence of pus cells or presence of mixed bacterial growth UTI not demonstrated, but not excluded Sterile urine before treatment excludes UTI.
Proteinuria or haematuria very non specific. Any growth from catheter or SPA is significant. MANAGEMENT 1. Obtain urine specimen. (see above) 2. Commence treatment immediately in cases of: Toxic children with renal angle tenderness suggesting acute pyelonephritis. (IV antibiotics are indicated). Younger children if high clinical suspicion. Treatment can be delayed while awaiting culture results in some cases: If the child is not ill, and older, and the dipstix are not confirmatory. Do not treat asymptomatic bacteriuria with antibiotics. Infants younger than 3 months: those with a possible UTI should be referred as soon as possible to a paediatric specialist. Parenteral antibiotics should be given including a third generation cephalosporin (i.e. cefotaxime or ceftriaxone) AND amoxicillin. Treat for 7 10 days if severe infection Infants and children older than 3 months: Acute pyelonephritis or upper urinary tract infection Oral antibiotics for 7 10 days, either cephalosporin or co amoxiclav If oral antibiotics cannot be used, treat with IV antibiotics (i.e. cefotaxime or ceftriaxone) for 2 4 days followed by oral antibiotics for a total of 10 days. If IV is not possible, IM treatment should be considered Cystitis or lower urinary tract infection Oral antibiotics for 3 days with one of the following: either trimethoprim, nitrofurantoin, cephalosporin or amoxicillin If the infant or child is still unwell after 24 48 hours, the parents/carers should be advised to bring the child back for reassessment If UTI is the only possible diagnosis, then ensure a urine culture is sent to identify the organism and determine sensitivity if not already done so. Consider referral to paediatric specialist Antibiotic prophylaxis This is not routinely recommended in infants and children following first episode of UTI For infants or children already receiving prophylactic medication who develop an infection, treat with a different antibiotic not a higher dose of the same antibiotic. Suitable antibiotics for short, full dose oral therapy: Cephalexin 25 mg/kg/dose b.d. orally (particularly for systemically
unwell patients) Trimethoprim Nitrofurantoin 4 mg/kg/dose b.d. orally 0.75 mg/kg/dose q.d.s. orally For acute pyelonephritis/severe infection: Cefuroxime 33 mg/kg/dose t.d.s. IV followed by appropriate oral medication. Single initial dose of Gentamicin 2.5 mg/kg (then discuss daily dosing usually appropriate) Notes: Amoxicillin is unsuitable as a first line drug due to high resitance rates, even in the community. Community resistance may be higher to trimethoprim than to cotrimoxazole, but the sulphonamide component of co trimoxazole may cause more adverse effects. Doses of cephalosporins and co trimoxazole may need adjustment in the presence of renal impairment. Change antibiotic if necessary if no clinical response after 48 h according to cultures. Check blood urea, creatinine and electrolytes in ill patients. If these are deranged adjust antibiotic doses. STOP gentamicin until levels available. Blood pressure measurement is mandatory. Arrange imaging studies and follow up as per NICE guidance: Imaging studies See Appendix 1 Follow up See Appendix 2 References 1. NICE UTI GUIDELINES (CG54) 2007, reviewed 2013 http://pathways.nice.org.uk/pathways/urinary tract infection in children 2. Jadresic,L. et al. Management of urinary tract infection in childhood. BMJ 307;761 4 (1991) 3. Ed. Webb N and Postlethwaite R. Clin Paediatr Nephrology 3 rd Edition 2003 (Oxford) 4. Yzermans Joris C, van Duijn Nico P, et al. The urine dipstick test useful to rule out infections. A meta analysis of the accuracy. BMC Urolology 2004 (Jun) Vol 4, p4 Previous version: Peter Houtman, Andrew Rickett, Dr A Sridhar Peter Houtman UPDATED 2005 and 2007 Revision: October 2007, 2009, 2012, 2016
Appendix 1 Imaging in UTI Children with cystitis/ lower UTI should undergo ultrasound (within 6 weeks) ONLY if they are under 6 months age or have had recurrent UTI No other investigations are required for any child with cystitis/lower UTI unless they have recurrent UTI and /or abnormality on renal ultrasound, in which case late DMSA scan should be considered Children younger than 6 months Imaging Responds well to treatment within 48 hours without any features for atypical Ultrasound during the acute infection Atypical UTI No Yes b Yes Ultrasound within 6 weeks Yes a No No Recurrent UTI DMSA 4 6 months No Yes Yes following the acute infection MCUG No Yes Yes a. If abnormal consider MCUG b. In a child with a non E coli UTI, responding well to antibiotics and no other features of acute infection, the ultrasound can be requested on a nonurgent basis to take place within 6 weeks Children 6 months or older but younger than 3 years Imaging Responds well to Atypical Recurrent UTI treatment UTI within 48 hours without any features for atypical Ultrasound during the No Yes b No acute infection Ultrasound within 6 weeks No No Yes DMSA 4 6 months No Yes Yes following the acute infection MCUG No No a No a a. While MCUG should not be performed routinely it should be considered if the following features are present ; Dilatation on ultrasound, poor urine flow, non E coli infection, family history of VU reflux b. In a child with a non E coli UTI, responding well to antibiotics and no other features of acute infection, the ultrasound can be requested on a nonurgent basis to take place within 6 weeks
Children 3 years or older Imaging Responds well to treatment within 48 hours without any features for atypical Ultrasound during the acute infection Atypical UTI No Yes a b No Ultrasound within 6 weeks No No Yes a DMSA 4 6 months No No Yes following the acute infection Recurrent UTI MCUG No No No a. Ultrasound in toilet trained children should be performed with a full bladder with an estimate of bladder volume before and after micturition b. In a child with a non E coli UTI, responding well to antibiotics and no other features of acute infection, the ultrasound can be requested on a nonurgent basis to take place within 6 weeks Definitions Atypical UTI o Seriously ill o Poor urinary flow o Abdominal or bladder mass o Raised serum creatinine o Septicaemia o Failure to respond to treatment with suitable antibiotics within 48 hours o Infection with non E coli organisms Recurrent UTI o o o Two or more episodes of UTI with acute pyelonephritis/ upper UTI or One episode of UTI with acute pyelonephritis/ upper UTI plus one or more episode of UTI with cystitis/ lower UTI, or Three or more episodes of UTI with cystitis/lower UTI
Appendix 2 Follow up in UTI No routine follow up but ensure awareness of the possibility of recurrence of UTI and the need to be vigilant, and to seek medical help and prompt treatment if UTI is suspected Imaging tests If not indicated If Indicated No follow up Normal Imaging tests Abnormal Imaging tests First time UTI Recurrent UTI 1. Follow up 2. Refer to Paediatrician/ specialist No follow up 1. Follow up 2. Refer to Paediatrician/ specialist
Trust Approved by: Children s Clinical Governance Committee Last reviewed: October 2007, 2009, 2012, Policy No: C37/2005 2016 Next review: May 2019
Trust Approved by: Children s Clinical Governance Committee Last reviewed: October 2007, 2009, 2012, Policy No: C37/2005 2016 Next review: May 2019
Trust Approved by: Children s Clinical Governance Committee Last reviewed: October 2007, 2009, 2012, Policy No: C37/2005 2016 Next review: May 2019
Trust Approved by: Children s Clinical Governance Committee Last reviewed: October 2007, 2009, 2012, Policy No: C37/2005 2016 Next review: May 2019