Urinary tract infection (UTI) - suspected in children


  • Diagnosis and primary management of urinary tract infection (UTI) in children less than 16 years

Out of scope

  • Children with established pathology of the renal tract
  • Children with immune deficiency including those on immunosuppressive drugs
  • Long-term management of repeated UTIs in sexually active girls



UTI is best defined as the presence of a significant level of bacteria in the urinary tract in the presence of an inflammatory response. Clinically, UTIs can be grouped into:

  • Cystitis (lower tract infection) –usually apyrexial with no systemic symptoms
  • Pyelonephritis (upper tract infection) – presents with fever, vomiting, loin pain & rigors
Atypical UTI is characterised by:
  • Seriously ill
  • Poor urine flow
  • Abdominal or bladder mass
  • Raised creatinine
  • Septicaemia
  • Failure to respond to antibiotic treatment within 48 hours
  • Infection with non-Escherichia coli organism
Recurrent UTI is characterised by:
  • 2 or more episodes of upper tract UTI
  • 1 episode of upper tract UTI plus 1 or more episode of lower tract UTI
  • 3 or more episodes of lower tract UTI

History and Examination

  • Signs and Symptoms of UTI (see table 1)
  • Cystitis (lower tract) or pyelonephritis (upper tract) infection? (seedefinitions above)
  • Red flags - signs suggesting 'high risk of serious illness' (see red flags)
  • Any features of atypical UTI (see definitions above)
  • Blood pressure (hypertension increases chance of underlying renal disease)
  • Associated constipation
  • Voiding pattern – dysfunctional voiding is major risk factor for UTI
  • Growth - see RCPCH growth chart
Signs and Symptoms of UTI
AgeMost commonLess commonLeast common
Less than 3 monthsUnexplained fever
Poor feeding
Faltering growth
Abdominal pain
Offensive urine
Preverbal (infants & toddlers)FeverAbdominal pain
Loin tenderness
Poor feeding
Offensive urine
Faltering growth
Verbal (older children)Frequency
Dysfunctional voiding
Deterioration in continence
Abdominal pain
Loin tenderness
Offensive/cloudy urine


  1. UTI may present in infants younger than age 3 months with non-specific symptoms
  2. Fever is the most common presentation of UTI in children under 1 year old

Differential Diagnoses

Other common sources of fever in children including serious bacterial or viral infections

Red Flags

Symptoms and signs consistent with a high risk of serious illness

Adapted from NICE fever in children guidelines


  • Pale
  • Mottled
  • Blue
  • Ashen


  • Unable to rouse or does not stay awake once roused
  • Weak
  • High-pitched or continuous cry
  • Appearing ill to a healthcare professional


  • Respiratory distress
    • Recession
    • Tachypnoea or
    • Grunting


  • Reduced skin turgor
  • Dry mucous membranes


  • Bile stained vomit
  • Bulging fontanelle
  • Convulsions (febrile or otherwise)
  • Abdominal mass


Collect urine sample for dipstick analysis if:
  • Unexplained fever greater than 38°C, in any age child, within 24 hours of onset
  • Symptoms/signs suggesting UTI (above)
  • Feverish illness due to apparent other cause, but not improving
Collect by:
  • 'Clean catch' recommended and best practice
  • If 'clean catch' not possible, use special collection pads
  • Bag specimens strongly discouraged (high incidence of contamination)
  • If neither possible then urine should be obtained by catheterisation (CSU), or supra-pubic aspiration (SPA), ideally under ultrasound guidance, in hospital.
  • If child very unwell (see 'high risk of serious illness'), do not delay antibiotic treatment while awaiting urine specimen.
Predictive value of dipstick (infants and children less than 3 years)
DipstickNitrate positiveNitrite negative
Leukocyte esterase
Likely UTI, send for MC&S,
start treatment
Treat if UTI clinically likely,
but may indicate infection
Leukocyte esterase
Suspect UTI if freshly
voided sample, send for
MC&S, start treatment

UTI unlikely


  1. Dipstick testing unreliable for children younger than 3 years old (frequent passage of urine doesn't allow time for nitrite formation)
  2. Use clinical criteria for decision-making in cases where urine dipstick testing does not support clinical findings
Indications for sending sample for MC&S:
  • Suspected pyelonephritis (upper tract infection)
  • Patient with red flag symptoms
  • All cases in children younger than 3 years where UTI is suspected even if the dipstick is negative for leucocytes and nitrites as dipstick is unreliable in this age group
  • Nitrite and/or Leukocyte esterase positive
  • Recurrent UTIs
  • Suspected UTI unresponsive to treatment after 24 - 48 hours
  • Clinical symptoms strongly suggest UTI but dipstick test doesn't correlate


BNFc for dose
Course lengthComments
Younger than 3 monthsRefer acutely to general paediatrics
Older than 3 months
Upper tract UTI
Oral Co-Amoxiclav7-10 days. Assess response
after 24-48 hours. Check
culture result in
Consider referral to
general paediatrics
for intravenous
treatment if severely
tolerating oral

Older than 3 months
Lower tract UTI
Oral Trimethoprim
Alternatives are
Nitrofurantoin or
3 days. Assess response
after 24-48 hours. Check
culture result in non-responders

Prevent further UTIs by

  • Treating constipation
  • Advising increased fluid intake
  • Discouraging delayed bladder voiding
  • Treat asymptomatic bacteriuria
  • Commence antibiotic prophylaxis after single UTI (consider if recurrent)

For treatment choices please refer to North and East Devon Formulary:
Joint Formulary - Chapter 5 - Urinary Tract Infections


Referral Criteria

Acute referral to paediatric specialist (who will follow up and imaging)
  • All infants younger than 3 months with suspected UTI
  • Aged greater than 3 months with any 'red flags' or atypical features
Referral for imaging and general paediatric outpatient review

3-6 months

  • Ultrasound kidneys and bladder within 6 weeks of infection
  • Refer to general paediatrics if abnormal ultrasound

6 months – 3 years

  • Responds well to treatment within 48 hours
    • No investigation or follow-up
  • Recurrent UTI
    • Ultrasound kidneys and bladder within 6 weeks of infection
    • Consider general paediatrics referral

Greater than 3 years

  • Responds well to treatment within 48 hours
    • No investigation or follow-up
  • Recurrent UTI
    • U/S within 6 weeks specifically requesting 'assessment of bladder emptying'
    • Consider general paediatrics referral

Referral Instructions

e-Referral Service details:

  • Specialty: Child & Adolescent Services
  • Clinic Type: Other Medical
  • Service: DRSS-Eastern-Paediatrics- Devon CCG-15N

Referral Forms

DRSS Referral forms

Supporting Information

Patient Information

Info KID – UTI

Info KID - Urinary tests>


NICE UTI in Children

NICE Feverish Illness in Children younger than 5

Pathway Group

This guideline has been signed off by the Eastern Locality on behalf of NHS Devon CCG.

Publication date: December 2016


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