Lower Urinary Tract Infection in children - Management of Infection Guidance for Primary Care

Publication: 30/09/2010  
Last review: 01/01/1900  
Next review: 31/01/2019  
Clinical Guideline
UNDER REVIEW 
ID: 2237 
Approved By:  
Copyright© Leeds Teaching Hospitals NHS Trust 2010  

 

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.

Lower UTI in children

Illness

Comments

Preferred option

Alternative

Lower UTI in children
HPA QRG
CKS
NICE54

Child  <3 months with suspected UTI:  ADMIT 1C
Child ≥ 3 months:
Always send pre-treatment MSU
Use dipstick to assist with diagnosis1A+
Treatment failures not resulting from antibiotic resistance should be admitted.

Trimethoprim1A
3 days 1A+

See BNF for dosage

If Trimethoprim is being given as prophylaxis:
Cefalexin electronic Medicines Compendium information on Cefalexin
See BNF for dosage

Principles of Treatment

  1. This guidance is based on the best available evidence but its application must be modified by professional judgement.
  2. A dose and duration of treatment is suggested. In severe or recurrent cases consider a larger dose or longer course
  3. Choices are given as Preferred option or Alternative for patients intolerant of the preferred option and 2nd Line for when an alternative is required because of treatment failure
  4. Only send microbiology specimens if there is a clinical suspicion of infection. Inappropriate specimens (e.g. routine ulcer swab or routine catheter specimen of urine) lead to inappropriate antibiotic prescribing.
  5. Prescribe an antibiotic only when there is likely to be a clear clinical benefit.
  6. Consider a no, or delayed, antibiotic strategy for acute self-limiting upper respiratory tract infections 1,A+
  7. Limit prescribing over the telephone to exceptional cases.
  8. Use simple generic antibiotics if possible. Avoid broad spectrum antibiotics (e.g. co-amoxiclav, quinolones and cephalosporins) when narrow spectrum antibiotics remain effective, as they increase risk of Clostridium difficile, MRSA and resistant UTI's.
  9. Avoid widespread use of topical antibiotics (especially those agents also available as systemic preparations).
  10. In pregnancy AVOID tetracyclines, aminoglycosides, quinolones, and high dose metronidazole. Short-term use of trimethoprim (unless low folate status or taking another folate antagonist such as antiepileptic or proguanil) or nitrofurantoin (at term, theoretical risk of neonatal haemolysis) is unlikely to cause problems to the foetus.
  11. We recommend clarithromycin as it has less side-effects than erythromycin, greater compliance as twice rather than four times daily & generic tablets are similar cost. In children erythromycin may be preferable as clarithromycin syrup is twice the cost.
  12. Where a ‘best guess’ therapy has failed or special circumstances exist, microbiological advice can be obtained from LTHT Microbiology (Mon-Fri 9am-5pm and Sat and Sun 9am-1pm: 0113 39 23962/28580; Otherwise via LTHT switchboard - ask for the On call Microbiology Registrar)

Note

Note: Doses are oral and for adults unless otherwise stated. Please refer to BNF for further information.
Letters indicate strength of evidence:
A+ = systematic review: D = informal opinion

Provenance

Record: 2237
Objective:
  • to provide a simple, empirical approach to the treatment of common infections
  • to promote the safe, effective and economic use of antibiotics
  • to minimise the emergence of bacterial resistance and reduce the incidence of Healthcare Associated Infections in the community
Clinical condition:

Lower Urinary Tract Infection in children

Target patient group: Children
Target professional group(s): Primary Care Doctors
Pharmacists
Adapted from:

This guidance was initially developed in 1999 by practitioners in South Devon, as part of the S&W Devon Joint Formulary Initiative, and Cheltenham & Tewkesbury Prescribing Group and modified by the PHLS South West Antibiotic Guidelines Project Team, PHLS Primary Care Co-ordinators and members of the Clinical Prescribing Sub-group of the Standing Medical Advisory Committee on Antibiotic Resistance. It was further modified following comments from Internet users. The guidance has been updated annually as significant research papers, systematic reviews and guidance have been published. The Health Protection Agency works closely with the authors of the Clinical Knowledge Summaries.


Evidence base

Grading of guidance recommendations

The strength of each recommendation is qualified by a letter in parenthesis.

Study design

Recommendation
grade

Good recent systematic review of studies

A+

One or more rigorous studies, not combined

A-

One or more prospective studies

B+

One or more retrospective studies

B-

Formal combination of expert opinion

C

Informal opinion, other information

D

Clinical Knowledge Summaries web http://www.prodigy.nhs.uk. BNF (No 55), SMAC report - The path of least resistance (1998), SDHCT Medical Directorate guidelines + GU medicine guidelines, Plymouth Management of Infection Guidelines project LRTI and URTI.

Urinary Tract Infections

Notes

  1. Abrutyn E, Mossey J, Berlin JA, Boscia J, Levison M, Pitsakis P, Kaye D. Does asymptomatic bacteriuria predict mortality and does antimicrobial treatment reduce mortality in elderly ambulatory women? Ann Int Med 1994:827-33. A cohort study and a controlled trial found that bacteriuria was not an independent risk factor for mortality in elderly women without catheters, and that its treatment did not lower the mortality rate.
  2. Grabe M, Bishop MC, Bjerkland-Johansen TE, Botto H, Cek M, Lobel B, Naber KG, Palou, J, Tenke, P, Wagenlehner F. Guidelines on Urological Infections. European Association of Urology 2009: 1-110. Asymptomatic bacteriuria is seldom associated with adverse outcomes in people with indwelling catheters. Treatment of bacteriuria causes harms: increased short-term frequency of symptomatic infection, and re-infection with organisms of increased antimicrobial resistance.

Children

  1. National collaborating centre for women’s and children’s health. NICE clinical guideline. Urinary tract infection in children. Diagnosis, treatment and long-term management. http://www.nice.org.uk/nicemedia/pdf/CG54fullguideline.pdf (Accessed 8th January 2009) Diagnosis and referral: expert opinion is that children under the age of 3 months with suspected UTI should be admitted; that imaging during the acute episode is only needed for atypical UTI or for children under the age of 6 months with UTI. Choice of antibiotics for lower UTI: NICE identified 3 RCTs comparing trimethoprim to other antibiotics for UTI in children, and one systematic review comparing short and long course of antibiotics for UTI in children that included studies assessing trimethoprim, nitrofurantoin and amoxicillin. The NICE guideline development group recommend trimethoprim, nitrofurantoin, amoxicillin, or cefalexin for empirical treatment of lower UTI in children. Duration of antibiotics for lower UTI: one systematic review found no difference in efficacy between short-courses (2-4 days) and longer courses (7-14 days) of antibiotics in children with lower UTI. Upper UTI: one systematic review combined two studies of co-amoxiclav treatment for 10-14 days compared with IV antibiotic treatment. No difference in efficacy was found.

Document history

LHP version 1.0

Related information

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