Urinary Tract Infections ( UTI's ) in Childhood - Yorkshire Regional Management Guidelines

Publication: 01/08/2008  
Last review: 19/01/2018  
Next review: 19/01/2021  
Clinical Guideline
INTERIM REVIEW DATE 
ID: 1375 
Approved By:  
Copyright© Leeds Teaching Hospitals NHS Trust 2018  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Yorkshire Regional Guidelines for the Management of Urinary Tract Infections in Childhood

 Index: “How to use these guidelines”

Scope of Guidelines

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Theses guidelines are aimed for use by all health care practitioners in the management of urinary tract infections in all infants and children less than 16 years of age.

Introduction

3-5% of girls and 1-2% of boys will have a symptomatic UTI during childhood. Symptoms and signs of UTI are often non specific especially under 3 years. Infection not only causes troublesome and often recurrent symptoms but also may point to unsuspected abnormalities of the urinary tract. The most common of these is vesicoureteric reflux (VUR). In a minority of cases VUR in association with a UTI can result in reflux nephropathy and potentially chronic renal failure in late childhood or adult life. However current management, subjects a large number of children to often unpleasant investigations, antibiotic prophylaxis and prolonged follow up based on limited evidence. This has also placed a heavy burden on the NHS.
These Regional Guidelines are based upon NICE clinical guideline 54, “Urinary tract infection in children: diagnosis, treatment and long-term management.” www.nice.org.uk/CG054.
Any deviation from NICE will be clearly stated in text. The NICE Quick reference guide (QR) can also be used for supplementary information where referenced within this regional guideline.
This guideline also refers to NICE clinical guideline 47, “Feverish illness in children: assessment and initial management in children younger than 5 years.” www.nice.org.uk/CG047

Aims

The aim of these guidelines in conjunction with NICE is to achieve more consistent clinical practice, based on accurate diagnosis and effective management. However the clinician (having read the guideline) has to take responsibility for their clinical management and therefore may refer, investigate and treat as they feel appropriate for individual patients. This may be particularly applicable to infants < 1year who may warrant referral to local paediatric services.

Diagnosis

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Symptoms and signs:
UTI is a common bacterial infection causing illness in infants and children. It may be difficult to recognise UTI in children because the presenting symptoms and/or signs are non-specific, particularly in the youngest children.

Age groups

Most common Least common

Infants younger than 3 months

Fever
Vomiting
Lethargy
Irritability

Poor feeding
Failure to thrive

Abdominal pain
Jaundice
Haematuria
Offensive urine

> 3 months of age

Pre-verbal

Fever

Abdominal pain or abdominal/loin tenderness
Vomiting
Poor feeding

Lethargy
Irritability
Haematuria
Offensive urine
Failure to thrive

Verbal

Frequency
Dysuria

Dysfunctional voiding
Changes to continence
Abdominal/loin pain or tenderness

Fever
Malaise
Vomiting
Haematuria
Offensive urine
Cloudy urine

Any child can present with septic shock secondary to UTI, although this is more common in infants.
Fever defined as > 38°C

Test urine sample in infants and children: (QR p8) 

  • with symptoms and signs of UTI (from table above)
  • with unexplained fever of 38°C or higher
  • with an alternative site of infection but who remain unwell
  • All infants younger than 3 months with suspected UTI should be referred to paediatric specialist care and a urine should be sent for urgent microscopy and culture

Management

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Infants younger than 3 months

  • Urgent referral for admission to general paediatrician
  • Urine for urgent MC&S
  • Manage in line with ‘Feverish illness in children’ (NICE CG 47)

3 months - 3 years

Use urgent microscopy and culture (MC&S) to diagnose UTI

Specific urinary Symptoms

  • Urine for MC&S (urgent if available) 
  • Start antibiotics 

 

Non-Specific urinary symptoms

 

High risk of serious illness **

  • Urgent referral for admission to general paediatrician
  • Urine for urgent MC&S
  • Manage in line with ‘Feverish illness in children’

** For assessment of risk of serious illness

 

Intermediate risk of serious illness**

  • Consider urgent referral to general paediatrician
  • Urine for MC&S (urgent if available) 
  • Treat with antibiotics if urgent microscopy positive or if nitrites present on dipstick testing when urgent microscopy not available  

 

 

Low risk of serious illness**

  • Urine for MC&S (urgent if available) 
  • Treat with antibiotics if urgent microscopy positive or if nitrites present on dipstick testing when urgent microscopy not available

3 years and older

Use dipstick to diagnose UTI [Nitrite and Leucocytes (LE)]

Nitrite and LE positive 

  • UTI - treat with antibiotics
  • Send urine MC&S (differs in part from NICE which advocates only sending MC&S if high/intermediate risk of serious illness or recurrent UTI)

Nitrite positive and LE negative 

  • Probable UTI - treat with antibiotics
  • Send urine MC&S

Nitrite negative and LE positive 

  • May or may not be UTI - management should be based on clinical judgement
  • Send urine MC&S

Nitrite and LE negative

  • UTI very unlikely - no antibiotic treatment.

(if a there is still a strong clinical suspicion send urine for MC&S)

Method of collecting urine sample:

  • A clean catch urine sample is the recommended method for urine collection.

If a clean catch urine sample is unobtainable:

  • Other non-invasive methods such as urine bags/ urine collection pads should be used. It is important to follow the manufacturers’ instructions when using urine collection pads / bags.
  • 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 suprapubic aspiration (SPA) should be used. Before SPA is attempted, ultrasound guidance should be used when possible to demonstrate the presence of urine in the bladder.
  • In an acutely unwell child it is highly preferable that a urine sample is obtained; however, treatment should not be delayed if a urine sample is unobtainable.

Testing and preserving urine samples:

  • All urine should be collected in universal white top container first and then dipsticked for the presence of Nitrite and Leukocytes
  • All children should have urine sent for MC&S if there is strong clinical suspicion or any abnormalities on testing for leucocytes or nitrites
  • Before sending to the laboratory - Transfer urine from universal container (white topped) to boric acid container (red topped). Samples can be stored in a boric acid container for up to 48hrs at room temperature. There is no need to refrigerate. Ensure patient details are completed along with referring clinician to allow processing of sample and communication of results.

Microbiology results
A growth of 105organisms/ml of single bacteria on a CCU/MSU is the bacteriological criterion for UTI Diagnosis. Any growth on a SPA is considered significant.

Microscopy results

Pyuria positive

Pyuria negative

Bacteriuria positive

Should be regarded as having UTI

Should be regarded as having UTI

Bacteriuria negative

Antibiotic treatment should only be started if clinically UTI
(Could be partially treated UTI)

UTI excluded

Assessment of significant risk factors in children with UTI
The following risk factors for UTI and serious underlying pathology should be recorded:

  • Poor urine flow
  • Abdominal mass
  • History suggesting previous/ confirmed UTI
  • Evidence of spinal lesion
  • Recurrent fever of uncertain origin
  • Poor growth
  • constipation
  • high blood pressure
  • dysfunctional voiding
  • family history of VUR
  • enlarged bladder
  • antenatal renal anomalies

Treatment

  1. Infants younger than 3 months with a possible UTI and any child with a high risk of serious illness should be referred immediately to the care of a general paediatrician.
  2. The use of an oral antibiotic with low resistance patterns is recommended, for example cephalosporin. Adjust antibiotics if required once urine culture and sensitivity results available.
  3. If oral antibiotics cannot be used, treat with an intravenous (IV) antibiotic agent such as cefuroxime for 2-4 days followed by oral antibiotics for a total duration of 10 days.
  4. If an infant or child is receiving prophylactic medication and develops an infection, treatment should be with a different antibiotic, not a higher dose of the same antibiotic.

Infants younger than 3 months with a UTI

Minimum 2-4 Days IV antibiotics followed by oral

> 3 months of age

Systemically well
Children with no systemic features and absence of significant fever

Treat with 3 days oral antibiotics. Advised to return if no better at 24-48hrs for reassessment

Systemically Unwell

  • (Fever > 38 +/- loin pain / tenderness)

 

Treat with 7-10 days oral antibiotics
(Consider IV antibiotics according to clinical judgement. Use lower threshold for IV antibiotics in younger children, those with significant risk factors and severely ill.)

Imaging strategies

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Children < 6months

 Responds well to treatment within 48 hours

 Atypical UTI

 Recurrent UTI

Ultrasound during the acute infection

No

Yesb

Yes

Ultrasound within 6 weeks

Yesa

No

No

DMSA 4-6 months following the acute infection

No

Yes

Yes

MCUG

No

Yes

Yes

  1. if abnormal consider MCUG
  2. USS may be requested within 6 weeks in non E.coli infection if child responds well to antibiotics with no other features of atypical UTI

 

 Children > 6months
and < 3 years

 Responds well to treatment within 48 hours

 Atypical UTI

 Recurrent UTI

Ultrasound during the acute infection

No

Yesb

No

Ultrasound within 6 weeks

No

No

Yes

DMSA 4-6 months following the acute infection

No

Yes

Yes

MCUG

No

Noa

Noa

  1. Consider MCUG if non E.coli infection, dilatation on USS, poor urine flow, family history of VUR.
  2. USS may be requested within 6 weeks in non E.coli infection if child responds well to antibiotics with no other features of atypical UTI

 

 Children 3 years or older

 Responds well to treatment within 48 hours

Atypical UTI

Recurrent UTI

Ultrasound during the acute infection

No

Yesa b

No

Ultrasound within 6 weeks

No

No

Yesa

DMSA 4-6 months following the acute infection

No

No

Yes

MCUG

No

No

No

  1. USS in toilet trained children should be performed with a full bladder to allow estimation of bladder volume pre and post micturition
  2. USS may be requested within 6 weeks in non E.coli infection if child responds well to antibiotics with no other features of atypical UTI

Definitions:

Atypical UTI

Recurrent UTI

  • Septicaemia/ requires IV antibiotics
  • Non-E.coli UTI
  • Poor urine flow
  • Abdominal mass/ bladder mass
  • Raised creatinine
  • Failure to respond to treatment with suitable antibiotics within 48hrs
  • Two or more UTI episodes at least one episode with systemic symptoms or signs
  • Three or more UTI’s without systemic symptoms/ signs

Follow-up (QR p14)

Agree how to communicate the results of imaging tests with parents/ carers.

Infants and children who do not undergo imaging investigations should not be routinely followed up.

  • Antibiotic prophylaxis is not routinely recommended in children with their first UTI.
  • When MCUG is performed, prophylactic antibiotics should be given orally for 3 days with MCUG taking place on the second day
  • All parents/carers should be advised to be vigilant during illness for non specific symptoms of malaise and unexplained fevers which may be due to a further UTI and would need prompt investigation and treatment.
  • Parents/carers should have methods of collecting urine from child to get tested by local primary care doctor.

Indications for referral to Local General Paediatric Services:

  1. All children under the age of 3 months
  2. Children of any age who are systemically unwell
  3. Children with recurrent UTI

Assessment In General Paediatrics should:

  • Address dysfunctional elimination syndromes and constipation
  • Include height, weight, blood pressure and routine testing for proteinuria. This should be performed at least on a yearly basis in all infants and children with renal parenchymal defects.

Indications for referral to Tertiary Paediatric Nephrology:

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  1. Bilateral parenchymal abnormalities
  2. Impaired renal function
  3. Hypertension
  4. Proteinuria

Provenance

Record: 1375
Objective:

The aim of these guidelines in conjunction with NICE is to achieve more consistent clinical practice, based on accurate diagnosis and effective management. However the clinician (having read the guideline) has to take responsibility for their clinical management and therefore may refer, investigate and treat as they feel appropriate for individual patients. This may be particularly applicable to infants < 1year who may warrant referral to local paediatric services.

Clinical condition:

Urinary tract infections in childhood

Target patient group: Children less than 16 years
Target professional group(s): Secondary Care Doctors
Primary Care Doctors
Primary Care Nurses
Secondary Care Nurses
Adapted from:

Evidence base

These Regional Guidelines are based upon NICE clinical guideline 54, “Urinary tract infection in children: diagnosis, treatment and long-term management.” www.nice.org.uk/CG054.
Any deviation from NICE will be clearly stated in text. The NICE Quick reference guide (QR) can also be used for supplementary information where referenced within this regional guideline.
This guideline also refers to NICE clinical guideline 47, “Feverish illness in children: assessment and initial management in children younger than 5 years.” www.nice.org.uk/CG047

Document history

LHP version 1.0

Related information

Contact Address:

Dr KS Tyerman
Department of Paediatric Nephrology,
Level 4 Gledhow Wing,
St. James’s University Hospital,
Beckett Street,
Leeds,
West Yorkshire,
LS9 7TF

Suggested Audit Points:

  1. Are urine samples sent to microbiology in appropriate containers and in a timely fashion?
  2. Do radiological requests comply with the guidelines: Are indications for radiological investigations specified on request form and do they comply with guidelines (If not is reason specified).
  3. Are radiological investigations carried out within the recommended time interval.
  4. Is there clear documentation of height, weight, blood pressure and urinalysis in those patients with renal parenchymal defects who are reviewed in general paediatric or paediatric nephrology clinics.

Glossary:

  • VUR - Vesico- ureteric reflux: This is a back flow of urine from the bladder to the kidneys. It is can be graded I (minor) - V (severe). VUR can be familial and may be associated with underlying renal dysplasia and/ or the development of renal parenchymal defects.
  • Non - E. coli UTI - Non Escherichia coli urinary tract infection: Eschericha coli is the commonest cause of UTI in childhood. Non - E. coli UTI may point to an underlying renal tract malformation, VUR or renal calculi.
  • DMSA - Dimercaptosuccinic acid: Radioisotope scan used to demonstrate renal parenchymal defects / scars. Also provides information on relative split function between right and left kidney.
  • MCUG - Micturating cysto-urethrogram: This is an unpleasant invasive investigation performed in infants and occasionally young children to detect VUR and exclude an obstructive uropathy such as posterior urethral valves in boys.

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